School Underachievement and Academic Failure
School Underachievement and Academic Failure: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
School underachievement and academic failureare important problems that require evaluation. There may be seriousphysical or psychologic disorders underlying these problems.
Principal Causes of School Underachievement and AcademicFailure
- Environmentaldisadvantage
- Impaired intellectual ability
- Impaired hearing, language, or vision
- Specific learning disabilities
- Medical illness in the absence of psychosis
- Psychologic disorders
- Anxiety
- Depression
- Attention deficit hyperactivity disorder
- School phobia
- Adjustment reaction of childhood andadolescence
- Disruptive behavior disorders
- Bipolar disorder
- Pervasive developmental disorders
- Autism
- Childhood disintegrative disorder
- Asperger disorder
- Rett syndrome
- Pervasive developmental disorder nototherwise specified
- Psychosis
- Substance use
Clinical Features and Diagnosis
Environmental Disadvantage
Unfavorable environmental factors often playrole in school underachievement and academic failure. They includepoverty, lack of family support and encouragement, long or frequentschool absences, disturbed home situation, and poor teaching. Lackof motivation and unwillingness to work are also major factors contributingto poor school performance.
Impaired Intellectual Ability
Childrenwith moderate-to-severe mental retardation usually are recognizedbefore school age because of developmental delay. Some childrenwith borderline intelligence (IQ of 70–85) or mild mentalretardation (IQ of 55–69) who have deficits in cognitiveability and adaptive behavior may not be recognized until they beginschool.Short attention span, poor memory,and difficulty in understanding and expressing simple concepts arecommon manifestations of impaired intellectual ability.Intelligence testing should be performedto assess intellectual strengths and weaknesses. 2 commonly usedtests to evaluate a child's intellectual ability are WechslerIntelligence Scale for Children–Third Edition (WISC-III)and Stanford-Binet Intelligence Scale–Fourth Edition. Impaired Hearing, Language, or Vision
Impaired hearing, language, or vision oftenresults in academic underachievement. See Chap. 26, Hearing Loss and Deafness; Chap. 72, Verbal Communication Difficulty;and Chap. 74, Vision Disturbances.
Specific Learning Disabilities
By definition,children with a specific learning disability have normal intelligencebut have deficits in acquisition of reading, spelling, writing,or mathematic skills. Such children may have problems understandingor using spoken or written language, with difficulty listening,thinking, remembering, sequencing, and abstracting.History, physical exam, observationof child, and school report provide useful information for evaluatingthese problems.Intelligence, achievement, psychologic,and special educational testing confirm diagnosis. Medical Illness in Absence of Psychosis
Chronic medical illness may impair child'sability to concentrate and learn.
Psychologic Disorders
Some children have psychologic problems thatprevent them from achieving normally in school. History (includingparent and teacher reports), physical exam (including mental statusexam), and clinical observation are diagnostic in many cases. Psychologictesting also can contribute important information in certain circumstances.
Anxiety
Chronicanxiety is symptomatic of an underlying problem.Clinical manifestations of anxietyinclude restlessness, irritability, anorexia, insomnia, nightmares,under- or overeating, lack of interest and withdrawal from usualactivities, frequent crying, poor school performance, and truancy. Depression
Mood swingsare normal in children and seldom last long.Major depressive disorder is characterizedby depressed or irritable mood or loss of pleasure in activitiesalong with changes in sleep, appetite, concentration, and energythat persist for ≥2 wks. Feelings of guilt or thoughts of deathalso may occur.Children with dysthymic disorder havedepressed or irritable mood that lasts >1 yr but do nothave enough other symptoms to be considered to have major depression.Children and adolescents also can experiencepsychotic symptoms as part of depressive episode. Depressed youngchildren frequently have somatic complaints, acting out or destructivebehavior, and school difficulties. Adolescents with depression candemonstrate promiscuous behavior, substance abuse, and other antisocialacts. Attention Deficit Hyperactivity Disorder
Core featuresof attention deficit hyperactivity disorder are motor restlessness,inattention, and impulsivity. At least some of these symptoms mustoccur before 7 yrs of age and persist for ≥6 mos.Children who are restless and alwaysmoving are termed hyperactive. Inattention refers to difficultyin maintaining attention, organizing tasks, remembering things necessaryfor activities, and following through on instructions. Examplesof impulsivity are interrupting or intruding on others and difficultyin waiting one's turn.Children with this disorder have difficultygetting along with others and often have few friends. As a result,they have low self-esteem and self-confidence. Some have learningdisabilities, and many are anxious and even depressed.There is no single test for this disorder.History, physical exam, and clinical observation of child, usinginformation from parents and teachers, are diagnostic. School Phobia
Intenseseparation anxiety usually exists in children with school phobia.Such children usually fear that something destructive will happenat home or school, and this fear may be actual or unconscious.Common complaints are headache, abdominalpain, tiredness, chest pain, cough, sore throat, nausea, vomiting,leg pain, dizziness, and painful menses.Because of underlying anxiety and timespent away from school, academic performance suffers. Adjustment Reaction of Childhood and Adolescence
Consists of emotional or behavioral symptomsthat occur in reaction to some stress and are in excess of whatwould be expected. Examples of common stresses are loss of parentthrough death or divorce, enrolling in new school, or increasedpeer pressure.
Disruptive Behavior Disorders
Conductdisorder is persistent behavior pattern that violates societal normsor rules and infringes on rights of others. Behavior may involveaggression to people or animals, property destruction, deceitfulnessor theft, and severe violation of rules.Oppositional defiant disorder refersto a pattern of hostile and defiant behavior. Bipolar Disorder
Typical cycling of mania and depression thatoccurs in adolescents with this disorder may not occur in youngerchildren. In childhood presentation may be mania or depression,mood disturbance may be dysphoric rather than euphoric, and coursemay be chronic and not episodic. School performance can be severelyaffected.
Pervasive Developmental Disorders
Several disorders are included under pervasivedevelopmental disorders: autism, childhood disintegrative disorder,Asperger disorder, Rett syndrome, and pervasive developmental disordernot otherwise specified.
Autism
Onset is before 30 mos of age, although itcan occur after this age in atypical cases. Autistic children lackability to relate to other people in normal ways. They play alone,use objects in bizarre ways, and have absent or impaired languageskills.
Childhood Disintegrative Disorder
Children with this disorder develop normallyuntil 2–4 yrs of age and then regress in social and communicationskills. Age of onset is most important criterion to distinguishthis disorder from autism.
Asperger Disorder
Children with this disorder have normal languagedevelopment, but their social interactions are abnormal. Do notseem to know how to relate to others. Some of these individualsmay have high intelligence.
Rett Syndrome
This X-linked dominant disorder is causedby mutations in gene encoding methyl-CpG–binding protein-2.Onset is 4 mos–5 yrs of age, with deceleration of headgrowth, loss of hand skills, and appearance of stereotypic hand-wringingmovements. Deterioration of language development and social skills alsooccurs.
Pervasive Developmental Disorder Not Otherwise Specified
Children with this disorder present at 30mos–12 yrs of age. In addition to autistic features, they haveimpaired reality testing, poor self-concept, and poor impulse control.
Psychosis
Severe disturbancein mental functioning that includes changes in cognition, perception,mood, impulse control, and reality testing.Characteristic manifestations includeinappropriate affect, impaired reality testing, a thought disorder,poor behavioral control, disturbed social relating ability, andauditory or visual hallucinations.Schizophrenia is common type of psychosisthat usually presents in adolescence. These individuals are withdrawnand fail to communicate normally with other people. They have impairedreality testing, distorted illogical thoughts, poor impulse control,sudden unpredictable mood changes, inappropriate affect that isflat or bizarre, delusions, and hallucinations. Substance Use
Alcohol, marijuana, cocaine, methylenedioxymethamphetamine(ecstasy), and inhalants are some common substances used by individualsin pediatric population. Dropping out of school, delinquency, and incarcerationare associated with use of these substances.
Diagnostic Approach
The physicianis in a unique position to help assess children and adolescentswith school underachievement and academic failure.History can determine presence of environmentaldisadvantage, adequacy of previous schooling, and existence of familyproblems. Developmental history and clinical observation enablephysician to decide whether mental retardation should be suspected.Detailed psychosocial and behavioral history with clinical observationindicate whether child is anxious, depressed, phobic, psychotic,or has attention deficit disorder.Clinician may screen for hearing, vision,and language problems during physical exam.Any child who is underachieving orfailing in school should have intelligence testing. This shouldbe followed by achievement testing, first with norm-referenced tests,which compare performance of child with others, and then with criterion-referencedtests, which reveal specific strengths and weaknesses. Purpose ofthis form of testing is to determine more precisely what childrenknow and what their problem areas are. For child with suspectedlearning disability, specific tests to detect specific learning problemsshould be given and interpreted by experienced teacher, educationalspecialist, or clinical psychologist who works with children withlearning disabilities.It is important to learn about child'semotional make-up to gain some understanding of major areas of concernor conflict that may influence school performance. Some tests giveinsight into particular problem areas and are usually administeredby clinical psychologists or psychiatrists who are experienced intheir interpretation.Goodnough-Harris Drawing Test can be used atall ages.Rorschach Psychodiagnostic Plates andThematic Apperception Test may be useful in children >3yrs of age.For older children and adolescents,Minnesota Multiphasic Personality Inventory can be used.These projective tests assess emotionaland cognitive style, specific feelings and fantasies, self-image,nature of relationships with others, and areas of conflict or concern. Physicians have the opportunity tolearn why a child is underachieving or failing in school and candevelop an appropriate plan to evaluate the problem. What they andother professional colleagues recommend is a function of their findingsand the resources that are available for appropriate help. References
- American Psychiatric Association. Diagnosticand statistical manual of mental disorders, 4th ed. Washington,DC: American Psychiatric Association, 1994.
- Amir RE, et al. Rett syndrome is caused by mutationsin X-linked MECP2, encoding methyl-CpG-binding protein 2. Nat Genet1999;23:185–188.
- Fleisher GR, Ludwig S, eds. Textbook of pediatric emergencymedicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins,2000.
- Green M. Pediatric diagnosis, 6th ed. Philadelphia:WB Saunders, 1998.
- Kinsbourne M, Caplan PJ. Children's learningand attention problems. Boston: Little, Brown, 1979.
- Klykylo WM, et al. Clinical child psychiatry. Philadelphia:WB Saunders, 1998.
- Sargent J, Hodas GR. Disturbed child. In: FleisherGR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4thed. Philadelphia: Lippincott Williams & Wilkins, 2000:209–216.
- Tanguey PE. Pervasive developmental disorders: a 10-yearreview. J Am Acad Child Adolesc Psychiatry 2000;39:1079–1095.
- Zamentkin AJ, Ernst M. Problems in the management ofattention-deficit-hyperactivity disorder. N Engl J Med 1999;340:40–46.
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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