Am Fam Physician. 1999;59(10):2816-2824
Children with school problems pose a challenge for the family physician. A multidisciplinary team of professionals can most appropriately assess and manage complex learning problems, which are often the cause of poor school performance. The family physician's primary role in this process is to identify or exclude medical causes of learning difficulties. An understanding of the complicated nature of school problems, the methods used to assess, diagnose and treat them, and the resources available to support the child and family are essential to successful management. Various references and resources are helpful for a more in-depth study of specific school problems.
The reasons for school problems in children are usually multifaceted, numerous and overlapping. The etiologies and their prevalence in the total population are: learning disabilities, 7 to 10 percent; emotional disturbances, 5 to 10 percent; attention-deficit/hyperactivity disorder (ADHD), 5 percent; chronic illness, 5 percent; and mental retardation, 2 to 3 percent. The family physician should have a general understanding of these common problems and other, more elusive factors, including the personality characteristics of the patient and the expectations of teachers and parents.1
Diagnosis and treatment of school problems depend on the collaboration of a multidisciplinary team of experts, which may consist of the family physician, school psychologist, classroom teacher, special educator, school nurse, school administrator, school counselor, social worker and other specialists. The child and the parents or guardians should also assume an active role on the team. The roles and responsibilities of each team member are outlined in Table 1.
|Team member||Roles and responsibilities|
|Family physician||Assesses child for medical problems that affect child's ability to learn.|
|Provides consultation with regard to medical condition or medication.|
|Parents/guardians||Act as advocates for the child.|
|Provide historical, genetic, medical and environmental information.|
|Manage child's behavior at home.|
|Child||Presents his or her unique perception of the problem.|
|School psychologist||Administers and interprets academic and behavioral assessments.|
|Often serves as leader of multidisciplinary team.|
|School teacher||Identifies specific behaviors that interfere with learning.|
|Implements curricular modifications and behavioral interventions.|
|Special educator||Acts in a wide variety of roles—may assist with evaluation; designs and implements curriculum or behavior modifications.|
|School nurse||Dispenses medications prescribed by physicians.|
|Consults with teachers regarding effects of medication.|
|School administrator||Ensures that child is receiving appropriate education regardless of disabilities.|
|School counselor||Acts in a wide variety of roles—may provide vocational, individual or family counseling.|
|School social worker||Provides case management services to child and family.|
|Speech and language specialist||Assesses child's ability to formulate, transmit or receive information; treats speech and language impairments.|
|Medical specialist||Conducts specialized assessments on referral from family physician.|
Family Physician's Role
The family physician can help children with school problems reach their full potential by obtaining the medical, social and family history and performing a physical assessment of the child. It is also helpful for the physician to be familiar with the community school system and the child's rights to appropriate education.
When assessing a child with school problems, the family physician should consider five areas of potential difficulty: intelligence, academic achievement, attention/concentration, perceptual (visual/motor) function and behavior.2 Deficits in any of these areas can lead to achievement or behavior problems. Difficulties in achievement may manifest themselves as discrepancies in basic reading skills, reading comprehension, mathematical reasoning, oral and written expression or listening comprehension. Behavioral or emotional difficulties range from low self-concept to aggression and motivational issues.3 Table 2 presents a guide to assessing school resources that can help a child who is performing poorly.
|Mechanisms for referrals|
|Roles and availability of multidisciplinary school team:|
|School's philosophy with regard to:|
|Classroom environment (inclusion, pull-out, self-contained)|
|Standard assessment techniques and tools|
The family physician's primary role is to identify or exclude medical causes for inadequate school performance. The physician should place special emphasis on the child's family, social and academic histories, which may provide essential clues to the origin of school problems. Questions should be formulated to detect any unusual occurrences, trauma or evidence of slow mental development or adverse perinatal event. Maternal alcohol or drug intake may also contribute to cognitive deficits in children.4
A thorough family history should include questions about learning disabilities, school failures, mental illness, behavioral problems, and substance abuse or emotional disturbances in parents or other family members. Health problems that are of special relevance to learning should also be identified, including chronic disease, seizures, recurrent or persistent otitis media, lead poisoning and iron deficiency anemia.5 Other specific risk factors for school performance problems include delay in reaching developmental milestones; impaired vision or hearing; poverty; adverse perinatal events; and personal or family trauma.5
The physical examination should be complete enough to identify or exclude illnesses or conditions that might contribute to poor performance. The physician should evaluate the child's overall well-being, level of energy and alertness, cooperation and ability to communicate. Vision and hearing tests are essential to rule out sensory deficits. Standard measurements of height, weight and head circumference are important indicators of developmental delay. Any congenital anomaly should be noted and evaluated. Neurologic impairments may also be detected during the physical examination.
Only if the physical examination or history suggests a medical condition such as iron deficiency, lead toxicity or thyroid dysfunction would laboratory tests (e.g., complete blood cell count, determination of serum lead level or thyroid function) be warranted. Other laboratory tests are generally not helpful.5
The physician should also obtain reports from the school psychologist, including intelligence tests, academic achievement records and assessments of attention, concentration and perceptual, behavioral and emotional functioning. Family physicians should become familiar with the tests used in local school districts and make an effort to understand their interpretation. A comprehensive review and an explanation of psychologic and psychoeducational tests are available in Aylward's Practitioner's Guide to Developmental and Psychological Testing.2 This book includes numerous algorithms to help the family physician address concerns about developmental delays, poor school performance or behavior problems. The multidisciplinary team should decide which tests to use. Table 3 lists the psychometric tests that are commonly used in assessing school problems.
|Wechsler Intelligence Scale for Children—revised and third editions (WISC–R, WISC–III)|
|Kaufman Assessment Battery for Children (KABC)|
|Wide Range Achievement Test–Revised (WRAT–R)|
|Kaufman Test of Educational Academics (KTEA)|
|Attention/concentration rating scales|
|Conners Parent Rating Scales (CPRS) and Conners Teacher Rating Scales (CTRS)|
|ADD-H Comprehensive Teachers Rating Scale (ACTeRS)|
|Perceptual (visual/motor) tests|
|Bender-Gestalt Test (B-G)|
|Developmental Test of Visual/Motor Integration (VMI)|
|Behavioral rating scales|
|Child Behavior Checklist (CBCL)|
|Behavioral Assessment System for Children (BASC)|
|Aggregate Neurobehavioral Student Health and Education Review (ANSER)|
To help parents advocate for their child, the physician also needs to be familiar with federal and state laws governing the child's educational rights. Schools are required to provide parents with written information about their rights at the time of evaluation. Table 4 summarizes the public laws that affect the education of children with disabilities.
|Public law no. 94-142: Education for Handicapped Children Act (1975)|
|Guarantees that all children who require special education receive it.|
|Assures fairness in assessing and educating students with disabilities.|
|Establishes standards of accountability for appropriate services.|
|Provides federal funds to assist state and local governments in meeting provisions of the law.|
|Public law no. 99-457: Amendments to the Education for all the Handicapped Act (1986)|
|Mandates early intervention services for at-risk children aged 3 to 5 years through Preschool Grant Program.|
|Provides incentive grants to initiate programs for high-risk children from birth to 3 years of age (Part H—The Handicapped Infants and Toddlers Program).|
|Public law no. 102-119: Individuals with Disabilities Education Act Amendment of 1991 (IDEA)|
|Reauthorizes family-centered programs for children from birth to 3 years of age (Part H), specifically targeting minority, low-income, inner-city and rural populations.|
|Mandates improved cooperation between health care and special education disciplines.|
|Assures, consequently, that physicians will be integrally involved in the early identification of developmental delays and of children at biologic or environmental risk. Physicians will actively participate in the formulation of “individualized family service plans” (IFSPs) and interpret results of screenings and evaluation for parents.|
|Public law no. 105-117: Individuals with Disabilities Education Act Amendment of 1997 (IDEA ‘97)*|
|Enhances early intervention and multidisciplinary services for toddlers and infants with disabilities.|
|Provides for participation of children and youth with disabilities in state- and district-wide assessment programs.|
|Addresses discipline and behavior issues of children with disabilities.|
|Includes added emphasis on the participation of children with disabilities in the general education classroom and general curriculum.|
Common Diagnostic Outcomes
School problems are often caused by mulitiple overlapping factors. A brief synopsis of the most common reasons for school failure follows. Table 5 lists groups that may provide additional resources to the family physician and offer support to the families of children with these problems.
|General||Clearinghouse on Disability Information, Office of Special Education and Rehabilitative Services (OSERS), U.S. Department of Education, Room 3132, Switzer Bldg., 3130 C St., S.W., Washington, D.C. 20202-2524; telephone: 202-205-8241||Specializes in providing responses to questions about funding, federal legislation and federal programs that serve persons with disabilities on national, state and local levels.|
|National Information Center for Children and Youth with Disabilities (NICHCY), P.O. Box 1492, Washington, D.C. 20013; telephone: 800-695-0285||Provides services to assist those involved in helping children: responses to questions, referrals to other sources, patient education, etc.|
|Genetics||National Society of Genetic Counselors, 233 Canterbury Dr., Wallingford, PA 19086-6617; telephone: 610-872-7608||Provides referrals for genetic counseling and services.|
|Mental retardation||American Association on Mental Retardation (AAMR), 444 N. Capitol St., N.W., Suite 846, Washington, D.C. 20001; telephone: 202-387-1968||Promotes cooperation with those involved in services, training and research in mental retardation.|
|The Arc of the United States, 500 E. Border St., Suite 300, Arlington, TX 76010; telephone: 800-433-5255||Serves persons with mental retardation (national advocacy organization).|
|Learning disabilities||Learning Disabilities Association of America, 4156 Library Rd., Pittsburgh, PA 15234; telephone: 412-341-1515||Encourages research and works on behalf of persons with learning disabilities.|
|National Center for Learning Disabilities (NCLD), 381 Park Ave. S., Suite 1401, New York, NY 10016; telephone: 212-545-7510; 888-575-7373||Promotes public awareness of learning disabilities.|
|International Dyslexia Association, 8600 LaSalle Rd., Chester Bldg., Suite 382, Baltimore, MD 21286-2044; telephone: 410-296-0232; 800-ABCD-123||Promotes the study and treatment of dyslexia.|
|Council for Exceptional Children (CEC), 1920 Association Dr., Reston, VA 20191; telephone: 703-620-3660||Provides information about the education of gifted children and children with disabilities.|
|ADHD||ADD Warehouse, 300 N.W. 70th Ave., Suite 102, Plantation, FL 33317; telephone: 954-792-8944; 800-233-9273||Compiles catalog of ADHD materials.|
|CH.A.D.D. National, 499 N.W. 70th Ave., Suite 101, Plantation, FL 33317; telephone: 954-587-3700; 800-233-4050||Provides information about support groups for parents of children and adults with ADHD.|
|Behavioral and emotional problems||Autism Society of America, 7910 Woodmont Ave., Suite 650, Bethesda, MD 20814-3015; telephone: 301-657-0881; 800-3AUTISM||Provides information about autism to affected persons and their families.|
|Autism Services Center, 605 9th St., Prichard Bldg., P.O. Box 507, Huntington, WV 25710-0507; telephone: 304-525-8014||Provides direct-care services for persons with autism and developmental disorders.|
|Chronic illness||Parents of Chronically Ill Children, 1527 Maryland St., Springfield, IL 62702||Provides information about rare disorders, including special education options.|
|Epilepsy Foundation of America, 4351 Garden City Dr., Suite 406, Landover, MD 20785-2267; telephone: 301-459-3700; 800-EFA-1000||Provides information to persons with epilepsy and their families.|
Learning disabilities are characterized by difficulties in listening, speaking, writing, reasoning or computing. The term “learning disabilities” encompasses a variety of specific disabilities that are presumed to stem from some brain or central nervous system dysfunction.6
The diagnostic criteria for the different types of learning disabilities are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).7 The family physician usually relies on the expertise of the school psychologist to determine the presence of a learning disability. The school system should undertake specific curricular and classroom modifications to enhance the function of a student with a learning disability.
EMOTIONAL AND BEHAVIOR DISORDERS
Emotional and behavior disorders can also affect school performance. It is estimated that 14 to 20 percent of students experience some form of behavior disorder during their school-age years.8 These problems can range from minor disturbances to the dramatic symptoms displayed by children with oppositional defiant disorder or conduct disorder.
Emotional problems in children are often overlooked or minimized as a reason for poor performance. The family physician must not fail to evaluate the patient for the presence of emotional or psychiatric disorders. When the physician discovers an emotional or behavior problem, referral to and reciprocal communication with a social worker, counselor or other mental health professional are appropriate.
An excellent reference offered by the American Academy of Pediatrics, The Classification of Child and Adolescent Mental Diagnoses in Primary Care,9 describes the differences between normal developmental variations in behavior and more severe emotional and behavioral disorders.
As the interdisciplinary assessment progresses, the diagnosis of mental retardation should be evident, if present. Mental retardation is characterized by significant cognitive impairment in intellectual functioning and adaptive life skills. Approximately 11.5 percent of all students with disabilities who are six to 21 years of age are mentally retarded.6 Mental retardation is diagnosed in people with significantly below average intellectual functioning and related limitations in two or more of the following adaptive skill areas: communication, home living, self-care, social skills, community use, self-direction, health and safety awareness, functional academics, and leisure and work skills.
The role of the family physician, in addition to assuring that the patient is physically healthy, is to support the parents and advocate for the patient. This may involve becoming familiar with educational laws concerning least restrictive environments and classroom inclusion,1 and communicating with school officials when necessary.
CHRONIC ILLNESS AND PHYSICAL DISABILITIES
Chronic illness affects learning when students experience sensory, physical or other health-related impairments that may require specific modifications in educational programming. These impairments include permanent medical conditions such as brain injury, autism, convulsive disorders and cerebral palsy. Chronic illness also encompasses medical conditions that may interfere with school (e.g., asthma, allergies, type 1 diabetes mellitus, repeated otitis media, thyroid disorders, cancer). The physician's role is to help the child stay as healthy as possible and to explain to the school staff how this condition and any required medication may affect learning.
Physical disabilities may also hinder learning. These include hearing and visual impairments and orthopedic problems that affect mobility. Obviously, most, if not all, of these conditions require physician assessment in addition to classroom and curricular adaptations.
Attention problems affect a child's ability to concentrate and learn. Situational stress, family discord or dysfunction, depression, anxiety, medication or illicit drug use, and illness may all cause attention problems. ADHD is characterized by developmentally inappropriate degrees of inattention and impulsiveness, with or without hyperactivity.
ADHD affects 3 to 5 percent of school-age children. Of those with ADHD, more than 50 percent have at least one comorbid condition.10 Highlights of six “guideposts” to an ADHD diagnosis are given in Table 6.11 By combining these guideposts with the DSM-IV diagnostic criteria for ADHD, family physicians should be able to make an informed diagnosis. Figure 1 presents an algorithm that, when used with a thorough assessment of school performance, may also be helpful in determining the presence of ADHD.
If ADHD is diagnosed, the physician must decide if medications should be used in addition to educational and behavioral interventions. Family physicians should be familiar with the commonly used medications, the standard monitoring guidelines for these drugs and their adverse effects. Some family physicians decide not to take a primary role in treating ADHD with medication and refer patients to a developmental pediatrician. Nevertheless, because these physicians may later treat the child for an acute illness, they must be aware of the common ADHD medications and their effects. A more complete review of the evaluation and management of ADHD can be found in the literature.12
OPPOSITIONAL DEFIANT AND CONDUCT DISORDERS
Criteria for diagnosis of oppositional defiant disorder and conduct disorder are presented in Tables 7 and 8. Estimates of the prevalence of ADHD coexisting with oppositional defiant disorder or conduct disorder range from 30 to 50 percent.10 Family physicians should be familiar with the diagnostic criteria for these disorders, and each should be diagnosed if the criteria are met. The existence of oppositional defiant disorder or conduct disorder in conjunction with ADHD necessitates a much different management from that required for ADHD alone.
Other disorders, including childhood depression, separation anxiety and adjustment disorders, can also cause poor school performance and may be mistaken for laziness, poor attitude or lack of parental guidance or discipline. The physician should refer again to the DSM-IV for diagnostic criteria. Mild, transitory forms of depression, anxiety or oppositional behaviors should be distinguished from more severe, chronic disorders.
|A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:|
|1. Often loses temper.|
|2. Often argues with adults.|
|3. Often actively defies or refuses to comply with adults' requests or rules.|
|4. Often deliberately annoys people.|
|5. Often blames others for his or her mistakes or misbehavior.|
|6. Is often touchy or easily annoyed by others.|
|7. Is often angry and resentful.|
|8. Is often spiteful or vindictive.|
|note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.|
|The disturbance in behavior causes significant impairment in social, academic, or occupational functioning.|
|The behaviors do not occur exclusively during the course of a psychotic or mood disorder.|
|Criteria are not met for conduct disorder, and, if the individual is age 18 years or older, criteria are not met for antisocial personality disorder.|
|A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:|
|Aggression to people and animals|
|1. Often bullies, threatens or intimidates others.|
|2. Often initiates physical fights.|
|3. Has used a weapon that can cause serious physical harm to others (e.g., bat, brick, broken bottle, knife, gun).|
|4. Has been physically cruel to people.|
|5. Has been physically cruel to animals.|
|6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).|
|7. Has forced someone into sexual activity.|
|Destruction of property|
|8. Has deliberately engaged in fire setting with the intention of causing serious damage.|
|9. Has deliberately destroyed others' property (other than by fire setting).|
|Deceitfulness or theft|
|10. Has broken into someone else's house, building, or car.|
|11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).|
|12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).|
|Serious violations of rules|
|13. Often stays out at night despite parental prohibitions, beginning before age 13 years.|
|14. Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period).|
|15. Is often truant from school, beginning before age 13 years.|
|The disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning.|
|If the individual is 18 years or older, criteria are not met for antisocial personality disorder.|