Tuesday, August 30, 2011

Treating Depression

wild grass and moths
Depressed mood or sadness lasting two weeks or more requires treatment. We all feel depressed, sad, or ‘blue’ occasionally. Moods and feelings change in response to events in our external environment. Usually depressive feelings or sadness last for a day or two; longer in case of loss or bereavement. However, if these feelings of sadness and hopelessness persist for more than 2 weeks and interfere with daily life, it indicates a clinical depression.
Depression is the fourth highest contributor to the global burden of disease. 
Clinical depression is a treatable illness. Many people never seek treatment due to lack of awareness, lack of access to mental health care, ignorance, or shame.

Signs and Symptoms

The hallmark of Clinical Depression is a pervasive depressed mood. This depressed mood is not responsive to positive events. There is associated slowness of thinking and movement; and there are thoughts related to guilt, self-blame, hopelessness and suicide . These features of constitute the classical triad of symptoms for the diagnosis of Clinical Depression. For a more formal diagnosis some or all of the symptoms below are used
  1. Persistent sadness. Frequent crying, irritability, ‘emotional outbursts’
  2. Slowing of movement and thoughts
  3. Feelings of guilt - ‘I shouldn’t have done that’, ‘it is all my fault’
  4. Worthlessness - ‘I haven’t achieved anything’, ‘I let my parents down’, ‘what I do has no value’
  5. Hopelessness - ‘What’s the point?’, ‘I don’t see things getting better’
  6. Thoughts of dying and suicide - ‘I would be better off dead’
  7. Loss of interest in activities and hobbies that were once pleasurable
  8. Difficulty concentrating, remembering details, making decisions
  9. Insomnia, early morning wakefulness, excessive sleeping.
  10. Change in appetite – appetite loss or overeating.
  11. Fatigue, lethargy, decreased energy
  12. Headache, cramps or digestive problems that are not relieved by treatment

How is depression treated?

The first step to treatment is to visit a psychiatrist. Your psychiatrist is the only mental health professional qualified to prescribe medication and provide psychotherapy. Your psychiatrist will take a detailed history of your symptoms, and will ask you to complete some questionnaires to assess their severity. He will also do a physical examination and may get some tests done (thyroid disorders and blood glucose related problems can cause similar symptoms).

The treatment of depression rests on two pillars
  1. Pharmacotherapy (medication)
  2. Psychotherapy (counselling, CBT)
Medication (pharmacotherapy) is required for moderate and severe depressions. Formal psychotherapy is started later once concentration and thinking improve. Your psychiatrist will prescribe an appropriate antidepressant. Antidepressants are not addicting. Side effects if any occur during the initial phase of treatment, they should not make you feel worse. Antidepressants must be taken for 4-6 weeks before they have a full effect. Later you should continue the medication even if you are feeling better to prevent a relapse. Suddenly stopping antidepressants can precipitate a relapse. Medication should be tapered gradually under your doctor’s supervision. If you follow your doctor's advice regarding follow up visits your treatment will be optimal.

Psychotherapy alone may be used in mild depression. Usually it is combined with medication for moderate and severe depressions. Psychotherapy is of two types:
  1. Cognitive Behaviour Therapy (CBT) identifies self-defeating, ‘negative thoughts’ and behaviours that perpetuate clinical depression in a vicious cycle. Your therapist then works with you to replace these thoughts and behaviours with ‘positive’ ones to help you recover from the illness.
  2. Interpersonal Therapy (IPT) helps people understand and work through troubled relationships that may be at the root of depression or making it worse.

How can I help a friend or family member who is depressed?

  1. Listen carefully.
  2. Offer support, understanding and encouragement.
  3. Never dismiss feelings, but point out realities and offer hope.
  4. Encourage them to go out for walks, outings and other simple activities. Don’t push too hard but keep trying.
  5. Make sure they keep appointments with the psychiatrist and stay in therapy.
  6. Never ignore suicide comments
    • Gently correct blatantly ‘negative’ thoughts. Help the person form an action plan to resolve the problem
    • DON'T LEAVE THEM ALONE until they OK the plan. 
    • Accompany them to a known responsible person or a doctor or mental health professional. You could save a life.

What can I do when I am depressed?

  1. Stay active. Exercise; go out for a movie, or any event you previously enjoyed.
  2. Eat regular meals. Don’t skip them even if you are not hungry.
  3. Go to bed at a regular time. Don’t wait until you are extremely tired so you can get sleep. Insomnia is the first symptom to respond to antidepressant medication
  4. Set realistic goals for yourself.
  5. Break up large tasks into smaller ones and do what you can.
  6. Spend time with others, confide in a trusted friend or relative.
  7. Postpone important decisions such as getting married/divorced, changing jobs until you are feeling better.
  8. Do not wait too long to get treatment.
  9. Expect your mood to improve gradually. Sleep and appetite will improve before your mood changes.
  10. Keep your appointments with your psychiatrist and do not stop your medication suddenly.

Monday, August 15, 2011

Rejection and aggression - the fury of the scorned male

rejection and aggression

Rejection experienced in an intimate relationship can trigger unexpected aggression with sometimes fatal consequences. A working woman in Pune was stabbed to death in her home when she spurned the marriage proposal of a good friend. Another 17 year-old girl from Hadapsar was stabbed in the stomach for rebuffing the overtures of a relative. Why would a man assault a woman after professing his love to her? Many instances of aggression arise from events where an individual perceives he is not sufficiently loved or valued in the context of an intimate relationship.

People differ in their readiness to perceive and react to rejection. The desire to belong is a basic human need. Some maintain equanimity while others over-react in ways that harm their relationships and their well-being. Hostility and aggression are among the most destructive reactions to rejection. Low self-esteem, depression, jealousy, self-neglect and a breakdown of daily routine are other painful outcomes of being rejected. Social rejection is the strongest predictor of violence in adolescents (Surgeon General 2001). This association between rejection and aggression is also repeatedly shown in social experiments.

Rejection triggers behaviours internalised during interactions with parents during infancy and early childhood. Based on these interactions children form certain expectations regarding the satisfaction or rejection of their needs. When childhood needs are met sensitively and consistently the child forms secure expectations. When childhood needs are met with rejection the child forms a pattern of insecure expectations involving doubts and anxieties. These repeated early interactions determine the individuals attachment style - the communication pattern exhibited in close relationships.

Aggression is first learned during infancy as a response to separation from the mother. The purpose is to reunite with the mother and discourage future separation. Adults who are socially immature respond to separation from a loved one with shouting, crying, and throwing or smashing objects. Again the purpose is to protect the relationship. Men with a fearful or preoccupied attachment style are more likely to be jealous, violent and abusive in intimate relationships. This tendency to violence increases when the relationship is threatened. Males with a fearful attachment style are anxious about gaining their partners approval and at the same time are fearful of being rejected by them. These males are more likely to attribute negative intent to their partners. This combination of internal conflict and external blame makes men with a fearful attachment style respond to rejection with aggression (Leary 2006).

Jealousy is the precursor of aggression in many close relationships. Jealousy occurs when people believe that another person does not sufficiently value their relationship because of the presence or intrusion of a third party. Men who are abusive have higher interpersonal jealousy. Abused women and the men who abuse them report jealousy as the most common precursor to violence. Among both men and women, intimate violence is often provoked by real or imagined infidelity (Leary 2006). We have already discussed jealousy in the context of the family.

Rejection-sensitivity is a personality characteristic associated with aggression elicited by rejection in love and romance. People high in rejection sensitivity (Downey 1996)
  1. Anxiously expect rejection by significant people in their lives.
  2. Readily perceive intentional rejection in the ambiguous or insensitive behaviour of their new partner.
  3. Over-react to rejection

Gender differences (Downey 1996) dictate that men with high rejection sensitivity manifest jealousy in the face of perceived rejection. Their consequent attempts to control their love object’s interactions with other males leads to further dissatisfaction in the relationship. When they are not successful in this they respond with rage - the common fallout of jealousy. Females react to perceived rejection with hostility and withdrawal of support. Both gender reactions lead to dissatisfaction with the partner and subsequent breakup of the relationship. If taken to an extreme, the jealousy in the rejection sensitive male can lead to fatal consequences for object of his affections.

Despite these negative experiences rejection sensitive people are repeatedly drawn to intimate relationships. The new relationship is viewed as an opportunity for acceptance. Initially they work hard to ingratiate themselves with their partner. However, the inevitable transient negativity, insensitivity, or preoccupation triggers the deeply ingrained anxieties and expectations of rejection. The person over-reacts to minor and ambiguous signals from the love object and starts the cycle of dissatisfaction in the relationship.

Rejection sensitivity is deeply ingrained in the personality. An intimate partner or a therapist can alter the expectancies and anxieties about rejection. It is possible for the rejection sensitive person to develop better conflict resolution skills. But only when there is a high degree of motivation in the rejection-sensitive person and a skilled, and nurturing partner.

  1. Özlem Ayduk, Anett Gyurak, and Anna Luerssen. Individual differences in the rejection-aggression link in the hot sauce paradigm: The case of Rejection Sensitivity. J Exp Soc Psychol. 2008 May 1; 44(3): 775–782. doi: 10.1016/j.jesp.2007.07.004
  2. Downey G, Feldman SI. Implications of rejection sensitivity for intimate relationships. J Pers Soc Psychol. 1996 Jun;70(6):1327-43.
  3. Leary MR, Twenge JM, Quinlivan E. Interpersonal rejection as a determinant of anger and aggression. Pers Soc Psychol Rev. 2006;10(2):111-32.
  4. Office of the Surgeon General. (2001). Youth violence: A report of the Surgeon General. U.S. Department of Health and Human Services. 

Sunday, July 31, 2011

Brain effects of cellular phone use

EEG changes with cellular phone radiation
Mobile phone induced EEG changes
Cellular phones affect the brain to cause injury and death through inattention and reaction time delays. Cellular phone radiations also induce abnormal changes in brainwaves. Here we are not concerned with the potential for death due to the cancer generating properties of GSM radiation. We are concerned with the direct and immediate adverse effects of cellular phone conversations.

Cellphones continue to kill their users in Pune. At least two people died crossing the Hadapsar railway tracks while engrossed in conversation. One of them was oblivious to shouting onlookers warning him of the oncoming train. Another cell-bewitched user fell off his eighth-floor balcony while conversing. And of course cellphone use while driving continues to kill despite the ban. All this is besides the cancer risk that the WHO (2011) is unable to disregard.

How distracting is a cellphone conversation?

Any extraneous demand on attention will distract from performance on an ongoing task. If the task itself is critical, as in driving, distractions can be lethal. Even hands-free cellphone conversations while driving cause attention lapses and slow down reaction time (McCartt 2006). These effects are seen in drivers across gender and age groups. The surest way to verify that a crash occurred during mobile phone use is to check billing records. Using this method crashes leading to personal or property damage are found to be four times more common during mobile phone use. When there is a higher mental load in the mobile phone conversation problems with attention and reaction time are magnified (Lin 2006).

The stream of media reported mobile phone related deaths during the performance of everyday tasks highlights the much neglected aspect of non-driving related mobile phone injuries. Pedestrians conversing on a mobile phone cross the road more slowly, are less likely to look for traffic, and take more risks in the face of oncoming traffic (Neider 2010). Pedestrians are less likely to cross a road successfully while using a mobile phone than while listening to music on an iPod. These effects are more pronounced in adolescents.

The risk of injury is related to the need to shift the focus attention from the task on hand to the conversation. Conversing on a mobile phone takes up a significant amount of mental processing ability. Mobile phone conversations increase reaction times and reduce accuracy on task performance. These impairments increase with increasing complexity of the task being interrupted. One can only imagine the effect of a mobile phone interruption on the outcome of an ongoing medical procedure.

Do cellular phone generated electromagnetic waves interfere with brainwaves?

Intriguingly, GSM microwave radiation interacts with and distorts brainwaves. This effect can be directly measured and recorded on an electro-encephalogram (EEG). Electromagnetic fields emitted by cellular phones cause a slowing of brain waves (delta waves) that is not seen in healthy adults during normal wakefulness. These changes persist for up to ten of minutes after the mobile phone is switched off. Children are more vulnerable to these effects as microwave absorption is greatest in an object the size of a child’s head. This radiation also penetrates the thinner skull of an infant with greater ease (Kramarenko 2003).

Brainwaves normally discharge asynchronously when attention is drawn to an event in the environment. This event related de-synchronisation is altered by mobile phone electromagnetic fields. This affects tasks involving memory, especially in children (Krause 2000, 2006). Cellphone radiofrequency waves have a dose dependent effect on tasks attention, concentration and short term memory. Reaction speed decelerates with increasing GSM field intensity. These effects are more pronounced when the responding hand and side of radiation exposure are taken into account (Luria 2009).

These dose dependent radiation effects are also seen when cellular phone use also alters brainwave patterns (spindle activity) during slow-wave sleep. These effects are long lasting, and indicate a non-thermal effect. The thalamus, a part of the brain that processes sensation, is responsible for generating sleep spindle activity and may be especially susceptible to cellphone radiation (Regel 2007).

Walk and talk is a bad idea

  1. Robert Baan, Yann Grosse, Béatrice Lauby-Secretan, Fatiha El Ghissassi, Véronique Bouvard, Lamia Benbrahim-Tallaa, Neela Guha, Farhad Islami, Laurent Galichet, Kurt Straif, on behalf of the WHO International Agency for Research on Cancer Monograph Working Group. Carcinogenicity of radiofrequency electromagnetic fields. The Lancet Oncology, Volume 12, Issue 7, Pages 624 - 626, July 2011 doi:10.1016/S1470-2045(11)70147-4
  2. Kemker BE, Stierwalt JA, LaPointe LL, Heald GR. Effects of a cell phone conversation on cognitive processing performances. J Am Acad Audiol. 2009 Oct;20(9):582-8.
  3. Kramarenko AV, Tan U. Effects of high-frequency electromagnetic fields on human EEG: A brain mapping study. Intern. J. Neuroscience, 113:1007–1019, 2003 DOI: 10.1080/00207450390220330
  4. Krause CM, Sillanmäki L, Koivisto M, Häggqvist A, Saarela C, Revonsuo A, Laine M, Hämäläinen H.  Effects of electromagnetic fields emitted by cellular phones on the electroencephalogram during a visual working memory task. Int J Radiat Biol. 2000 Dec;76(12):1659-67.
  5. Krause CM, Björnberg CH, Pesonen M, Hulten A, Liesivuori T, Koivisto M, Revonsuo A, Laine M, Hämäläinen H. Mobile phone effects on children's event-related oscillatory EEG during an auditory memory task. Int J Radiat Biol. 2006 Jun;82(6):443-50.
  6. Lin CJ, Chen HJ. Verbal and cognitive distractors in driving performance while using hands-free phones. Percept Mot Skills. 2006 Dec;103(3):803-10.
  7. Luria R, Eliyahu I, Hareuveny R, Margaliot M, Meiran N. Cognitive effects of radiation emitted by cellular phones: the influence of exposure side and time. Bioelectromagnetics. 2009 Apr;30(3):198-204.
  8. McCartt AT, Hellinga LA, Bratiman KA. Cell phones and driving: review of research. Traffic Inj Prev. 2006 Jun;7(2):89-106.
  9. Mark B. Neider, Jason S. McCarley, James A. Crowell, Henry Kaczmarski, Arthur F. Kramer. Pedestrians, vehicles, and cell phones. Accident Analysis and Prevention 42 (2010) 589–594
  10. Regel SJ, Tinguely G, Schuderer J, Adam M, Kuster N, Landolt HP, Achermann P. Pulsed radio-frequency electromagnetic fields: dose-dependent effects on sleep, the sleep EEG and cognitive performance. J Sleep Res. 2007 Sep;16(3):253-8.

Tuesday, July 26, 2011

Discrimination of psychiatrically ill persons by hospitals

Healthcare discrimination of mentally ill persons
Discrimination of mentally ill persons by hospitals
A young woman with psychiatric illness was refused admission at a leading tertiary care hospital in Pune. The reason - “mentally unstable patients are known to cause harm not only to themselves but to others as well. The hospital lacks facilities and infrastructure for catering to psychiatric patients.” A similar unwritten policy of denying inpatient care on grounds of psychiatric illness exists in at least one other large corporate hospital in Pune.

We have already stressed the importance of access to healthcare for persons with mental illness. We will now further explore the stereotype of harm in mental illness. The stigma associated with this stereotype has an adverse impact on timely delivery of healthcare to persons with psychiatric illness.

Are mentally ill persons likely to harm other hospital inpatients?

Hospital and healthcare settings have the highest levels workplace related violence across all industry sectors (CDC 2002).  The place where patient perpetrated violence is most likely to occur is the Emergency or Casualty department not the wards (Farooq 2009). Patients of all categories mostly attack staff or junior doctors - the ones they are in regular and direct contact with. In most cases violence is perpetrated by arrogant patient attendants not the patients themselves, whatever their diagnosis. For the rest violence is a result of unacceptable staff behaviour, and dissatisfied patients or attendants. It is rare for patients of any diagnosis to physically attack and harm each other in a hospital. Even in acute inpatient psychiatry units violence towards other patients or staff is less than 3% of total incidents of violence (Biancosino 2009). So much for psychiatric illness being “known to cause harm”.

Are patients with psychiatric illnesses the only ones that harm other patients? At the height of the swine-flu scare in 2009 no patient suspected of having the disease was denied treatment or admission. Yet swine-fly is known to be highly contagious and lethal. Special protocols and facilities were drawn up and earmarked overnight. So the potential for harm is not the overriding factor in denial of treatment.

Patients with psychiatric illness require minimal investigation, and respond rapidly to cheap and effective medication. Return on investment may be what it is all about. Psychiatrically ill pateintsdo not make much money for a hospital. It is more lucrative to provide skewed facilities for a liver transplant that would require weeks of ICU care, extensive investigation and invasive procedures. It would also make news for all the right reasons.

Mental illness accounts for 80-90% of completed suicides. Serious suicide attempts by poisoning or jumping result in emergency hospital admissions. Treatments would entail stay in the Intensive Care Unit, utilisation of the Operation Theatre, mechanical ventilation, and extensive monitoring and investigations. All this translates into large cash transactions over a short period of time. No hospital administrator would deny admission to these critically ill patients - ethical considerations, policy and stigma not withstanding.

Is it really possible to exclude patients with psychiatric illness from the hospital healthcare system?

The dichotomy between soma and psyche, physical and mental is artificial. This was formally enunciated in Para 1 of the WHOs Alma-Ata declaration (1978) and is the accepted definition of health for medical students since decades. Psychiatric and somatic illnesses coexist with and impact eachother. Ignoring this interaction is adversely affecting the outcomes of chronic illnesses like diabetes, heart disease, cancer and respiratory disease. The World Mental Health Day 2010 document specifically evaluates the evidence and stresses the urgent need to integrate mental heatlhcare for these chronic illnesses which account for 60% of the worlds deaths.

Walk into any hospital ICU and you will see at least one delirious patient strapped to the bed with physical restraints. Psychological aspects of critical illness are given the short shrift only because the mindset is one of discrimination and disrespect for the individual. Psychiatric and physical health problems do not exist in isolation. Their physical basis and vice versa cannot be excluded by artificial dichotomies.

Is it desirable to treat persons with mental illness in a general hospital setting?

Integration of mental healthcare delivery with existing facilities is a major thrust of the WHO (2008). Hospitals need to provide an accessible and acceptable location for treatment of acute exacerbations of mental health disorders in the same way that they currently do for physical health disorders. This would also enable access to services for physical health problems that arise during the inpatient stays of persons with mental health problems.

Deinstitutionalisation of psychiatric and mental health care has been stressed as a human right since the mid 20th century. A step in this direction for Pune's hospitals would be to draw up and implement guidelines to prevent and manage hospital violence. These guidelines already exist (CDC 2002, OSHA 2004).

  1. Biancosino B, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, de Girolamo G; PROGRES-Acute Group. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009 Oct;197(10):772-82.
  2. CDC. Violence - occupational hazards in hospitals.  DHHS (NIOSH) Publication No. 2002–101. April 2002
  3. J Farooq, A Mustafa, D Singh, GH Yattoo, A Tabish, GJ Qadiri. Violence in hospitals. Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009; 16-20
  4. Occupational and Safety Health Administration. Guidelines for preventing workplace violence for health care and social service workers. 2004. Publication no. OSHA 3148-01R
  5. Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001 Jan;52(1):75-80.
  6. World Federation for Mental Health (WFMH). Mental health and chronic physical illness - the need for continued and integrated care. World mental health day. 10 October 2010.
  7. World Health Organisation (WHO) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
  8. WHO/Wonca.  Integrating mental health into primary care: a global perspective. World Health Organisation and World Organization of Family Doctors (Wonca). 2008.

Saturday, July 16, 2011

Inclusive education for children with autism in Pune

inclusive education for children with autism and developmental disabilities
Inclusive Education
Inclusive education for children with autism and other developmental disabilities is now approaching reality in Pune. Nine children with autism appeared for the Maharashtra 10th standard (SSC) board exam. The accommodations and waivers granted to these students reflect an infusion of the fresh breath of inclusion into the corridors of the board of education .

Sarva Shiksha Abhiyan (SSA) in Maharashtra

The Education for All Movement, the central government’s flagship SSA, seeks to ensure that every child, including those with special needs, is provided an elementary education. As far as disability is concerned the SSA has adopted a zero rejection policy. It provides for universal access to infrastructure and curricula in schools. Maharashtra is at the forefront of this scheme. In all 380000 teachers from Maharashtra attended workshops on inclusive education through the SSA. 414277 children with special needs were identified and 380723 enrolled under the SSA in Maharashtra as of Jun-2009, . Of these about 9000 children were provided a home-based education.

Beyond elementary school it is up to the state education boards to ensure access to further education. For this the Central Board of Secondary Education (CBSE) initiated accommodations and waivers in 2009. This year for the first time, 9 students with autism from Pune division and 10 students from Mumbai appeared for the Maharashtra SSC 10th standard board exams. Lets look at why this is a significant social event.

Modern education of children with disability traces its history to Jean-Marc Itard a French physician. On the cusp of the 18th and 19th centuries Itard attempted to educate Victor, a feral child discovered in the forests of Aveyron. Although Itard himself judged his work with Victor a failure, this renowned experiment marked the first time that anyone considered the possibility that persons with disabilities could be educated.

Edouard Seguin (mid 1800s), a French educator, developed a method for teaching children with intellectual disability in order for them to take their rightful place in the societies of their day. The early training schools were based on these concepts. The schools were small and homelike with 8 to 10 residents. The original goal was the return of children to their families after a period of intervention.


Despite these early efforts, it was later concluded that educational and therapeutic approaches had failed. Persons with intellectual disability were scapegoated and regarded as the root cause of many social problems. Institutionalisation and segregation into special schools became the principal means of ‘protecting’ intellectually disabled persons from society and also for ‘safeguarding’ society against the social ill thought to be caused by an expanding population of defectives (Jackson 1999).


Lloyd Dunn (1968), a special educator, declared that most children with mental retardation could be "mainstreamed" in classes with typically developing age-mates. He questioned the need for segregated special education classes for most children with mental retardation. He highlighted the lack of evidence to show that children with mild mental retardation learn any better in special education classes than in regular classes. Lloyd Dunn pointed out that educational techniques had advanced sufficiently to allow the effective schooling of most children with retardation alongside other typical children.


Wolf Wolfensberger (1972), a scholar, activist and prolific author in the field of development disabilities extended the idea of normalization to the service delivery system itself. He called on all residences, schools, and other services for persons with retardation to be as normative as possible. Parent and professional advocacy groups also fought hard for legislative and legal victories to decrease the size of large institutions.


Inclusive education seeks to overcome every barrier - physical and academic- to ensure the child is educated with their peers (Sigafoos 2003). It stresses the importance of peer interaction in the final outcome for the child who is to enter into the adult world on a level playing field. To this end academics is given a secondary role. The child is supported for all physical needs to enable participation in the classroom experience with their peer group. Academic difficulties are addressed by a remedial teacher or special educator attached to the class who helps the child in parallel with the regular curriculum. The child may be learning at a level many grades below the rest of the class but has the benefit of meaningful social interaction.

It has taken 200 years for the vision of Itard to reach the SSA, the national inclusive education program. The universal principles of justice, fraternity, and equality secured for all citizens by the constitution are driving us to ensure children with autism and other disabilities are educated alongside their peers. That is why nine children with autism have appeared for a board exam in Pune. That is why this is a significant social event.

  1. CBSE. Amendments/Additions in Examination Bye Laws. 2009
  2. Dunn L M. Special education for the mildly retarded—is much of it justifiable? Except. Child. 35:5-22, 1968.
  3. Jackson, Mark. Mental Retardation In: A century of Psychiatry. Ed. Hugh Freeman. London: Harcourt Publishers, 1999.
  4. Sigafoos, Jeff, Michael Arthur, and Mark O'Reilly. Challenging Behaviour and Developmental Disability. London: Whurr Publishers, 2003.
  5. SSA, Inclusive education. Accessed 04-Jul-2011
  6. SSA. Kolkotta National Workshop. Accessed 04-Jul-2011