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Attention Deficit and Hyperactivity Disorder (ADHD) Buddhi Stories Dystonia Featured Neurodevelopmental Disability (NDD)

Deepak – Precious Child

Biography

Everything seemed against the birth, growth and development of Deepak, as if nature and nurture were conspiring against his very survival at every stage. However, he got past the onslaught of the catastrophic events around his birth, was diagnosed with Neurodevelopmental Disability (NDD) in his infancy, and associated conditions, namely ADHD in his childhood and Seizure Disorder in the adolescent phase. As a young adult he developed Dystonia (involuntary muscle spasm).

Deepak’s mother was an elderly primi at 32 years of age and conceiving for the first time 7 years after marriage and he was ‘a precious baby’. She was hypothyroid, on thyroid supplements, and was on psychiatric medication for 4 years prior to the delivery. The child was delivered by elective Caesarian section, and the mother suffered Post-Partum Haemorrhage (PPH) while the newborn had an Apgar score of 9, with some breathing difficulty.

Exploring the Condition

It was a non-consanguineous marriage. The father had a chronic health condition and his career never took off. It was thus a dysfunctional family, with an overanxious mother coping with a hyperkinetic child with NDD, the father shirking the responsibilities of fatherhood. Deepak’s father died when he was barely 6 years of age and the mother moved in with her parents with the child. There was a history of dementia on Deepak’s maternal side but no family history of suggestive of neurological, psychiatric or other general medical (including liver) condition to indicate Wilson’s disease (see box).

Motor milestones were delayed, and the child walked at 2 years. Unthinking TV viewing by the family saw Deepak at the same age jumping and clapping hands at every violent scene on the screen as if to cheer the hero and villain along! Language was delayed and he started saying a few meaningful words around 2½ years.  At school at age 4 years, he had poor attention span, would not sit in one place, and his learning ability was average. He did not mingle with his peer group in school, and this awkwardness in social interaction continued, into adolescence and adulthood. It is around 5-6 years that Deepak started showing significant aggression, especially aimed at his mother.

He had fears and phobias, and was reluctant to board the public bus to school with his mother, resulting in frequent tantrums. The mother sought a psychiatric consultation for Deepak and he was prescribed a mild tranquiliser. He managed to get through mainstream school (with only one change of school in the 5th grade). While in middle school, he was seen by a Neurologist and diagnosed to have ADHD  and was prescribed Dicorate ER (Divalproex) 250 mg – 1-0-1 and Modafinil (a stimulant drug) 100 mg – 1-0-0. In the 9th grade, he had difficulty coping with studies but managed to pass the 10th grade Board examination.

Before completing 12th grade examination, in 2009, Deepak had seizures manifesting as momentary loss of consciousness and stare. He had memory deficit following the seizure onset and could not cope with his studies.  He dropped out of school as a consequence and subsequently developed frequent minor involuntary movements of the limbs, later dystonic turning of head/neck to the right, with facial grimacing.  Lifting the arm spontaneously, without voluntary control, also followed. At this stage a Neurology Consultant  put him on Tab.Trihexiphenidyl 2mg – 1-0-1.

Our Healing Approach

After comprehensive assessment at TriMed-Neurokrish, at the age of 22 years, a diagnosis was arrived at of Neurodevelopmental Disability with Neurobehavioural Syndrome, borderline intelligence and Movement Disorder (MD). The management of the patient was planned carefully taking into account the multiple challenges that had to be dealt with effectively. The patient was on polypharmacy, and the first step was modification of the drug regimen to optimize benefit. He was on Tab.Divalproex ER 250 mg – 1-0-1 and Lamotrigine 50mg – 0-0-1 was added to this regimen, as effective mood stabilizing combinations in such conditions. Along with this, a novel antipsychotic, Clozapine 25 mg – 0-0-1½ was prescribed; later Atomoxetine 25 mg – 1 -0-0 was started to control ADHD features; to improve attention and concentration and to reduce hyperkinetic behaviour. Modifinil was eventually tapered and stopped as was Dicorate.

The patient did well on this new drug regimen with no further seizures and reduction in the frequency of involuntary motor disturbances. Multivitamin, Calcium Piracetam were added on at various stages of treatment. Deepak had severe musculo-skeletal pain all over the body with spasm of the limb muscles, and the trapezius muuscles in particular, bilaterally. Tab.Trigabantin (Gabapentin 300mg + Methylcobalamin 0.5 mg), Alpha Lipoic Acid 100 mg was added to the drug regimen, and with physiotherapy aimed at relaxing the muscle groups involved there was relief of spasms and with it, pain relief. He also received Podikizhi, an Ayurvedic massage therapy technique with dry herbal powder which is efficacious in the treatment of complaints associated with joints, musculoskeletal and neuromuscular pains in addition to rejuvenating, relaxing and strengthening the joints, muscles and soft tissues and as a result providing remarkable pain relief.

The integrated therapies of Neurorehabilitation and Cognitive Retraining sessions, combined Yogasana, Pranayama, Meditation 22 sessions, Acupuncture 10 sessions, Reflexology 20 sessions, ran parallel to the physiotherapy exercises and TENS 22 sessions. Following a few sessions of therapy, there was improvement in gait, involuntary movements were significantly reduced and ADL performance was returning to normal. The beneficial response to cognitive retraining was noteworthy, as his power of concentration and with it his retentive power and memory had stepped up remarkably with goal-directed cognitive activity. Behavioural problems were brought under control.

The NDD at birth with neurobehavioural problems, exaggerated neuropsychiatric symptoms with onset of the movement disorders/dystonia, the raised Aminotransferase, on LFT testing (indicative of disturbed liver function), the chronic constipation, and a high serum copper (196.4 micrograms/dL), suggested to the Neurokrish Consultant a drug challenge with Penicillamine (a chelating agent), even though the clinical and lab findings were atypical for Wilson’s disease. There was no KF ring, and serum caeruloplasmin and 24 hour urinary copper were normal. Penicillamine (250mg) was slowly increased from one to 2 tablets and was successful over weeks in     reducing dystonia considerably. Subsequently serum copper levels improved and LFT became normal. At the end of 6 months, the Penicillamine was tapered over a month and then stopped, with no return of the dystonia at monthly follow up, even at the end of 7 months.

Wilson’s Disease

Wilson’s disease is an autosomal recessive disorder of copper metabolism, characterised by excessive accumulation of copper in the brain, liver, kidney, cornea and other organs. The clinical manifestation of WD is due to the toxic accumulation of copper in these organs.

Copper is an essential metal that is an important cofactor for many proteins. The average diet contains adequate amounts of copper. The absorbed copper from the duodenum and small intestines enters the portal circulation and reaches the liver.  The liver utilizes some copper for its metabolic needs, synthesizes and secretes the copper-containing protein Ceruloplasmin, and excretes the excess copper via bile secretion. Defective excretion of copper (Roberts 2008)1, results in its deposition especially in the liver and brain.

Ceruloplasmin is the major carrier for copper in the blood, accounting for 90% of the circulating copper in normal individuals. In one series (Steindl 1997)2, 12 of 55 patients with WD and mainly liver involvement, had normal ceruloplasmin and no Kayser-Fleischer rings, though subjects in the same study with predominantly  neurological manifestation had  lowered serum caeruloplasmin and the presence of KF ring.

The gene for Wilson’s Disease ATP 7B, has been mapped to chromosome 13. There are multiple disease mutations of the gene described in proband with the disorder. Further, there are significant Indian studies (Mukherjee, 2014)3 on the genetics of WD, highlighting that some of the more frequently occurring mutations in Indians are different from those reported by  the West.

First-degree relatives of any patient newly diagnosed with WD must be screened. Serum aminotransferase activities are generally abnormal in WD except at a very early age. In many individuals, the degree of elevation of aminotransferase activity may be mild and does not reflect the severity of the liver disease. D-penicillamine (demethylcysteine) is an effective chelator of copper, well absorbed when taken orally , and it promotes the  urinary excretion of copper.

D-penicillamine – induced status dystonicus (Paliwal, 2010)4 is a unique but serious drug related complication in a subset of patients with Wilson disease  with good response to Gabapentin, but failing to respond to other antidystonia drugs.

References

  • Roberts E.A., Schilsky M.L. Diagnosis and Treatment of Wilson’s Disease: An Update (AASLD Guidelines) Hepatology, June (2008),47,(6)  : 2089-2111
  • Steindl P., Ferenci P., Dienes H.P., Grimm G., Pabinger I., Madl C., et al. Wilson’s disease in patients presenting with liver disease: a diagnostic challenge. Gastroenterology 1997;113:
  • Mukherjee S., Dutta S., Majumdar S., Biswas T. et al Genetic defects in Indian Wilson disease patients and genotype- phenotype correlation. Parkinsonism Relat Disord. 2014 Jan;20(1):75-81.
  • Paliwal V.K., Gupta P.K., Pradhan S. Gabapentin as a rescue drug in D-penicillamine-induced status dystonicus in patients with Wilson disease. Neurol India 2010;58:761-3.

Looking Ahead

Deepak has progressed well all round, much to the delight of the TriMed-Neurokrish team. The mother is thankful and has no words to express it. Deepak continues his follow up at Trimed-Neurokrish, is regular with his medication, and is advised short course of therapies if indicated. He continues his exercise regimen at home. He went through a short three-month computer course and is now employed for a computer data entry job, which he carries out efficiently, with all the concentration required. The  occasional flicker of involuntary movement is almost negligible. Behaviour problems have receded to the background, and he is less awkward socially though he continues to be introverted. Above all, there is an inner calm and peace that Deepak radiates, which tells the long story of pain and hardship of the past, and of the future which he knows will offer better hope and cheer. Life is good!

Categories
Anxiety Autistic Spectrum Disorder (ASD) Buddhi Stories Featured Neurodevelopmental Disability (NDD)

Surya – Conquering Anxiety

Biography

Surya was the first born, delivered full term by lower segment Caesarian section, the indication being a big baby weighing 3.4 kg with a large head and cephalo-pelvic disproportion. The Apgar score was 9/10 (excellent). There was no neonatal seizure or any other health-related event of significance in the neonatal period or in infancy. With the passage of a few months the parents noted that the infant’s response to familiar people, even to them, lacked spontaneity, and eye contact was sparing. He was preoccupied with repetitively examining one favourite toy over a long period of time and this form of restricted play continued into childhood. He did not walk till almost 2 years, and even when he did, he was awkward and had frequent falls in the early phase. It was, however, the delay in the speech/language milestones with the first few meaningful words expressed at 2 years, that caused greatest parental concern.

At this stage, a diagnosis under the broader umbrella of Autism Spectrum Disorder (ASD) – Pervasive Developmental Disability – not otherwise specified (PDD-NOS) was arrived at by the specialist in USA and early therapies were started. The parents stuck to the specialist advice to confine the child’s exposure to a single language and English served the school and home front. On joining school at three years, there was some improvement in his verbal expression, but by 4 years, with the family back in India, from abroad, he had achieved wider language and communication capability. This is the magic gift that Indian children born abroad receive on exposure to the Indian milieu, even short-term, where grandparents, aunts, uncles and cousins, chatter incessantly, not necessarily in English, but also in their child-focused affection, rally round to address the child face-to-face!

Exploring the Condition

Surya’s speech, which lacked clear enunciation, accent and prosody, and had a nasal quality, required special attention and the child had regular speech therapy from the age of 4 years, aside from occupational therapy and special education outside mainstream schooling. Surya manifested restlessness, easy distractibility, poor motivation, social anxiety and on occasions, impulsivity, which also required correction. When he was brought by his parents to TriMed-Neurokrish two years back, at age 9 years, they appeared as stressed as Surya himself. As a high performing ASD, he had managed to barely cope with mainstream schooling upto the primary grades (ICSE Board syllabus), with poor math skills and dyslexia. Anxiety was mounting as he progressed to high school level with its academic demands. To add to the displeasure at school, he was bullied by the other children, who did not let him join them in the ball games offered, as he was slow and clumsy. When this awkwardness was analyzed by the specialist, it pointed to poor hand-eye co-ordination as a main cause. School refusal started to set in and the parents recognized the red flag signal which called for more intensive professional attention. A close friend suggested TriMed-Neurokrish as a possible solution to the child’s learning disability and emotional  problems.

Surya had got this far academically, without major behavioural problems, as all along, the mother had dynamically participated in fulfilling his study requirements and emotional needs and the school had been supportive. His mother, a well educated, perceptive lady, continued to follow the special education methods at home, which she observed during the child’s sessions with the special educator. His spelling skills took a big leap forward when he was taught by the phonetic method. The mother spent long hours with Surya over his homework, partly by following rote learning methods, though by elaborating on the topics’ ramifications, she managed to bring in some conceptual learning, which ensured better retention and recall in him. Math skills were just picking up at a basic level, but Surya was happy to run up to the corner store to purchase some small items of grocery the mother requested, and managed every time to bring back the correct change.

Our Healing Approach

At TriMed-Neurokrish, a comprehensive assessment, by the team members was carried out with meticulous care. The child was thin built, with dysmorphic features, with a narrow face, low set ears, close set eyes, and a tendency to keep the lips parted slightly, the last due to a chronic sinusitis and nose block. No other abnormal systemic signs were observed and laboratory tests were unremarkable, except for low D3 levels, which was corrected with oral medication. We had a team meeting to formulate a list of priority moves to gain effective control in the management of Surya’s educational and psychosocial problems. A diagnosis under High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome (based on the Sohn Grayson Rating Scale) with Learning Disability (LD) was arrived at, and the broad management plan was discussed.

The immediate goal was:

  • To reduce Surya’s anxiety levels and get him to attend school regularly, a few hours initially, progressing to full day attendance
  • To overcome separation anxiety when the mother dropped him at school and left
  • To motivate him to engage in other activities than studies
  • To work on his fears and phobias of ‘robbed’, ‘kidnapped’, ‘killed’ which disturbed him
  • To offer caregiver support to the mother who was highly stressed

By way of medication, Surya was given Attentrol – (Atemoxitine) to improve his attention on tasks along with a anxiolytic.

The Clinical Psychologist found his academic performance adequate, based on the NIMHANS Battery (Specific Learning Disability Index). Regarding his special academic needs, with long term coaching outside school, Surya was able to cope with reading, writing (including spelling), at his 8th grade levels, with math ability at 5th grade levels. His handwriting skills were poor due partially to defective fine motor control and his focusing power on tasks required reinforcing with repetition. All these deficits put together made him very anxious regarding coping with studies.

Our intensive therapy for Surya followed our protocol for children with Neurodevelopmental Disorders (NDD) and included a combination of two Ayurveda treatments (Shirodhara & Abhyangam), Play Yoga, Neurodevelopmental Therapy (NDT, a combination of physical and occupational therapies, in his case with a handwriting focus) and psychological therapy (behavioral and family). Sessions of NDT and BT often continue for months in regular periodicity, and include weekend opportunities to meet with peers (also in therapy), socialize, and develop skills of emotional expression. Later, understanding his fondness for ‘gadgets’ we involved him in a cognitive enhancement program using structured computer based gaming to enhance specific cognitive skills.

Our team, after much deliberation, suggested to the parents, special education for Surya at a school of excellence, and with the Open School Examination system offered there, he settled to a comfortable pace of school work.

The special educators of the school, in dialogue with Surya’s parents, chose subjects for him that he would be able to comprehend and work out in a relaxed manner, and which would lead him to a future career as a high performing ASD. In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem. Day-to-day, moment-to-moment caregiver stress was significantly reduced in the mother, who decided to expose Surya to other activities than studies as suggested by the TriMed-Neurokrish team. Coaching in swimming and keyboard playing were chosen as two diverse activities (with the mother joining the coaching sessions as well) which would benefit physical fitness, cognitive ability, concentration, fine motor activity, musical sensitivity, sensory integration and many other finer aspects of development in the child.

Surya’s motivation and empathy to go with the mother did not last for long and the ASD trait of preference for routine and repetitive activity prevailed. He preferred to unobtrusively sit watching his mother, as she completed the courses successfully and went on to the next level of training with the hope that perhaps Surya would get back to these activities some day with gentle persuasion and the slow but sure outcome of goal-directed CBT! She brushed aside this wishful thought and got back to the present with its encouraging progress in Surya.

He was however, enjoying his Behaviour Therapy and Cognitive Enhancement sessions at Trimed-Neurokrish and the team members gave of their best to sustain Surya’s interest through the sessions. He continued to listen to music, most often a favourite tune and beat repeatedly. He responded positively to engage in a short-term novel activity for which he was rewarded. In a BT session to learn how to tie his shoe-lace, his motivation was that he would get new shoes, and sure enough he mastered the skill in two days! What worked towards motivating Surya without fail was the reward in the form of a car ride, to undergo any new learning process. So the team went through BT for activities of daily living, interaction with strangers, mentoring and token economy, in a graded manner, to more advanced cognitive enhancement paradigms of arithmetic tasks, logical reasoning and critical thinking. Incorporating the subject’s areas of special interests in therapy, using visual aids and including parents in therapy sessions, the benefits of cognitive behavior therapy and cognitive enhancement became apparent.

“In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem.”

Our Focus:

Autistic Spectrum Disorder

Autistic spectrum disorder (ASD) is a group of developmental disabilities that can cause significant social, communication and behavioral challenges. Autism represents an unusual pattern of development beginning in the infant and toddler years. Language  and communication, learning, thinking, problem solving, social interaction, stereotypy and other behavioural  patterns, lack of empathy and performance of activities of daily living may show varied levels of involvement. Neuropsychiatric and neuropsychological evaluations in Autism have revealed selective dysfunction of ‘social cognition’, with sparing of motor, perceptual and basic cognitive skills1. According to DSM IV the spectrum of autistic disorders comprise autistic disorder, Asperger’s syndrome, pervasive developmental disorder not otherwise specified, including atypical autism (PDD-NOS), Rett’s syndrome, and childhood disintegrative disorder. When full criteria of the five under this umbrella are not met, it falls under the category of PDD-NOS. High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome is diagnosed by employing an assessment questionnaire for the subject’s parents named the Sohn Grayson Rating Scale, a questionnaire for the subject’s parents, covering the academic, cognitive, psychosocial and other domains, which may indicate a higher performance and atypical pattern of the spectrum in the subject studied, as in our patient, Surya. Before this instrument is used, there are over seven diagnostic tools for ASD, including Autistic Behavioural Checklist, Autistic Spectrum Screening Questionnaire and observational tools which must be employed on subject to be tested.

Global prevalence of ASD is about 1.5 per 1000. There has been a 600% increase in prevalence over the last two decades. In a multinational study, the point prevalence of ASD was 7.6 per 1000 or 1 in 132 in 20102. In India more children with ASD are being identified, earlier than before and as a result, early intervention is possible with developmental disability institution being made available in the public sector as well. But these are few and far between. The average age at presentation to the clinic in India was 21.23 months (SD = 2.18)3. They present clinically in a manner similar to that reported internationally. Awareness among professionals and the public is increasing over less than a decade.4  As yet, there is no aetiology-based intervention for autistic spectrum disorders (ASD). However, symptomatic treatment and therapies with a cognitive-psychoeducational/behavioural approach  can be of value in moderate ASD5.   

References

  1. Vaghbatta. Shirodhara AshtangaMisra V. The social brain network and autism. Annals of neurosciences. 2014 Apr;21(2):69.Hridaya, Sutra Sasthana, Chapter 22
  2. Baxter AJ, Brugha TS, Erskine HE, Scheurer RW, Vos T, Scott JG. The epidemiology and global burden of autism spectrum disorders. Psychological medicine. 2015 Feb 1;45(03):601-13.Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1;  9 : 457–463
  3. Malhi P, Singhi P. A retrospective study of toddlers with autism spectrum disorder: Clinical and developmental profile. Annals of Indian Academy of Neurology. 2014 Jan;17(1):25.
  4. Malhotra S, Vikas A. Pervasive developmental disorders: Indian scene. Journal of Indian Association for child and adolescent mental health. 2005;1(5).
  5. Francis K. Autism interventions: a critical update. Developmental Medicine & Child Neurology. 2005 Jul 1;47(07):493-9.

Looking Ahead

Surya is relaxed in his new school, and stress and anxiety of school work has left him. He is catching up with many ADL, and is even more motivated to do so with a reward at the end of each novel learning process. With improved performance and by dispelling his fears and phobias through logical thinking taught to him at the CBT sessions, Surya has conquered many of his fears and phobias and to a considerable extent his social anxiety.

He continues his CBT/CET and follow up at Trimed-Neurokrish, twice a week and the team is more than pleased to receive him for his sessions, as there is good compliance and palpable progress with each visit to the clinic.

The parents are at peace and are relieved to have found a centre which offers a holistic approach towards Surya’s all round development.

Categories
Neurodevelopmental Disability (NDD)

Understanding Developmental Disability

Sad but true! One in five children, in a developing nation like India, emerge into this world with their innate human capital compromised. A range of neurodevelopmental disorders (NDD) are the outcome of such compromise: learning disability, childhood epilepsy, cerebral palsy, mental retardation, attention deficit and hyperactivity disorder, autistic spectrum disorder; conditions that strike early and leave lasting impact on the child. On the occasion of the International Day of People with Disabilities (3rd December) we delve further.

What is neurodevelopmental disability?A range of conditions that follow abnormal brain development and impact on motor function (strength, dexterity, coordination); or cognitive function (intelligence, learning, aptitude); or emotions & behavior (temperament, mood swings, emotionality, aggression, hyperactive-impulsive behaviours, socialization issues etc.). In all these instances, there are demonstrable changes in the brain and its development, either structural or in it’s functioning.

Why NDD? While some humans have NDD imprinted in their biological code (through genetic, hormonal, and other neurobiological factors), for many others, the causes lie in critical stages of development, with a range of factors causing compromise. Factors that affect maternal health around conception and through pregnancy; trauma through injury, drugs (both prescription and non-prescription), alcohol, smoking; exposure of the pregnant mother to infections or toxins; and maternal malnutrition, commonly compromise this desired state of “optimality”. Factors affecting the child include birth trauma and infection through poorly planned and executed deliveries, neonatal compromise (asphyxia, jaundice, early trauma through accidents or abuse, infections, malnutrition); untreated epilepsy; other progressive neuropsychiatric disorders etc. Contributory factors include late recognition of the problem, failure to be evaluated in formal medical settings, and the failure to seek and secure early interventions.

Who is at risk?The global lesson from the “Human Genome Project” was that about 10% of all neurological conditions are explained by abnormalities in a single gene. The majority of disorders were thus deemed to be multifactorial- more than one genetic abnormality being responsible, with strong contributions from environmental events that have impact. This probably holds good for NDD as well. In general, having a parent or first degree relative affected by a neuropsychiatric or developmental condition, may double the risk of NDD.

When should we suspect NDD?At the one end of the spectrum are children with overtly manifested disability with severe problems that are apparent early and demand medical interventions. They only form the tip of the iceberg. The larger group who go undetected, are children with minimal brain dysfunction. Typically, they are slow-learners in school, who find academic progress challenging; may be clumsy and lack dexterity, with poor handwriting; or indeed demonstrate a range of emotional and behavioral patterns.

Why should we take action early? These children are often the poor performers and/or perceived troublemakers in school. Rather than receiving special attention, they are at worst punished and at best ignored, in many mainstream schools. Without adequate help and support, these children will slowly and surely slide down the educational scale, out of mainstream schooling, into special schooling systems that cannot really tap their potential. Further, children who do not receive support are likely to feel stigmatized and lose their self-confidence.

Where should I take my child, when in doubt?Your pediatrician should be the first port of call. The class teacher may also have valuable inputs. When either pediatrician or class teacher (or both) suspect a problem, more specialized inputs become necessary. Problems in learning and intelligence are best assessed by a clinical psychologist; problems in motor or other brain function (like epilepsy) by a neurologist, sometimes with the assistance of an occupational therapist; problems in behavior by psychiatrists, often with the assistance of a counselor. When language development is affected, ENT doctors supported by speech and language therapists may need to be consulted. In many instances, comprehensive assessment requires a team approach. Depending on the problem the specialists consulted may require a range of laboratory tests- brain scans, brain wave (EEG) and other electrophysiological tests; blood and urine tests including hormonal assays and so on.

How should I progress once diagnosed?

  • Your pediatrician should be your primary support
  • Your child’s school needs to be briefed transparently and kept in the loop. Don’t worry about being asked to leave. If the school cannot accept the problem and work with you, it may not be the best place for your child.
  • Identify a team of professionals; be consistent in your interactions and regular in follow up. Make sustainable plans and set realistic goals. Prepare for the marathon, not a sprint.
  • Don’t focus only on the disability; your child may also have special interests and abilities. Put focus on them too.
  • Don’t be preoccupied by academic results; focus on overall development.
  • Caregiving is challenging and tiring; share the care as a family, develop your own support networks with other parents and keep your spirit up.