Children struggling at school represent a very substantial segment of paediatric morbidity.1 Up to 20% of children have learning or behavioural problems that interfere with school functioning, which suggests this is a significant public health issue. There is evidence that persistent school problems can have a negative impact on a range of outcomes throughout the life course into adult
To provide an approach to the assessment of the child who presents with problems at school.
The reasons for children’s school problems are many and varied – there are a number of biological and environmental factors that can have a role. Sometimes the aetiology is clear but often it is obscure. A comprehensive assessment of these children is important and results in a management plan that addresses the child’s strengths and weaknesses. The general practitioner can play an important part in the early identification of these children, as well as providing informed, ongoing follow up and advocacy.
Scope of problem
Up to one in five children struggle at school; prevalence rates vary according to how the problem is defined. The sheer numbers of children with school problems would suggest that this be considered a significant children’s public health issue.3–4
The foundations for school success or failure are established in the early years before children start school. Recent Australian data indicate that, nationally, 22% of children starting school are rated as developmentally vulnerable or at risk; the percentages are even greater in disadvantaged communities.5 Some children arrive at school with previously diagnosed conditions, such as epilepsy, language disorder, autism spectrum disorder or a chronic medical condition, that may interfere with their school functioning. However, most children with vulnerable or delayed readiness for school do not have a clear-cut diagnosis; rather, their development is vulnerable because of the disadvantaged circumstances of their upbringing.6
There is a strong association between developmental vulnerability at school entry and academic achievement, behavioural problems and a well-documented series of parent and family risk factors, often linked to social disadvantage.6–8 Many children have not had the advantages of attending preschool9 or have not had opportunities to socialise with other children. In some instances, because they have not been observed in structured settings such as childcare or preschool, delays in development or problems with behaviour or social interaction have not been identified or addressed by parents. When the child attends more structured or formal educational settings, the teacher may become concerned about aspects of development and social behaviour. It is only when the child does not make expected progress or falls behind their peers in academic areas or shows problem behaviours in class or on the playground that concerns are acted on; sometimes this is not until after several years of schooling.
Children struggling at school may present to the general practitioner (GP) in myriad ways. Sometimes it is the parent who first becomes concerned about academic progress or behaviour at school, or because of the child’s social isolation – for example, not being invited to classmates’ birthday parties. Parents may notice that the child is slower or different when compared with an older sibling at the same age. Often it is the class teacher who has indicated to the parent that the child is struggling and this leads to a visit to the GP. In other instances it is suggested to parents that their child ‘should be assessed’. Sometimes children go to the GP with a diagnosis or label, such as attention deficit hyperactivity disorder (ADHD), dyslexia or Asperger syndrome, from the teacher or parents. Some parents are acutely aware and sensitive to the child’s difficulties at school; other parents are less well informed and seek help only because the school has suggested it.
The nature of difficulties the child experiences varies greatly. There can be concerns about learning, behaviour, socialisation or a combination. The issues may be straightforward; for example, a child of average or above average intelligence might have trouble with reading. On the other hand, a child may present with a complex constellation of difficulties – not keeping up academically, problems focusing and sustaining attention, disruptive classroom behaviour, low self-esteem and poor motivation. School difficulties can be associated with a range of symptoms including headache, recurrent abdominal pain, mood swings and manifestations of anxiety or depression. A small number of children have a chronic medical condition that affects their learning, whereas others have a history of developmental delay and/or challenging behaviour that can be traced back to the toddler years.
Assessment and management
Many children who struggle at school require a multidisciplinary specialist evaluation. Few GPs have the training or expertise to undertake detailed assessments; nevertheless, they can play a central part in their initial triaging of the issues, making informed referrals, providing ongoing follow up and coordination, and advocating for the child in obtaining appropriate and timely services. Because of their relationship with the child and family, the GP’s documentation of past medical and developmental history, their subjective observations of the child’s communication and behaviour in the consulting room, the social circumstances and relevant facts about the family structure, and any insights into the family dynamic are likely to be very helpful to the specialist and an important part of the assessment. The GP can organise for formal testing of hearing and visual acuity and document any medications, such as antihistamines or anticonvulsants, that may be impacting on attention. Obtaining information from the child’s school reports, test results (eg. the National Assessment Program – literacy and numeracy) and previous assessments helpS develop a profile of the child. Finally, thorough physical and neurological examinations are important parts of the assessment. This information will result in an informed referral for further evaluation.
Multidisciplinary specialist assessment is designed to obtain a detailed description of a child’s developmental strengths and weaknesses together with identifying possible biological and environmental pathways contributing to the child’s problems. For example, there is an emerging body of research documenting the relationship between sleep problems and learning and behavioural problems10, and evidence of improved functioning when the sleep problems are treated. In some cases there will be a clear-cut diagnosis, such as ADHD or a specific language disorder, or where it is apparent that a disadvantaged or dysfunctional home environment has prevented the establishment of solid foundations for learning and self-regulatory behaviour at school. Any and all assessments should include practical recommendations for intervention for the school and for the parents.
Some children may respond quickly – and even dramatically – to specific interventions, such as medications for ADHD or improvement in hearing with adenoidectomy or insertion of grommets, or a period of intensive remediation. However, there are usually no silver bullets for children who struggle at school; intervention may be needed for several years, results may take time to be evident, and parents – and the child – may experience frustration with the seemingly slow progress of the intervention. Parents and, unfortunately, some teachers are understandably vulnerable to the claims made for the benefits of alternative therapies. GPs have an important role in counselling parents against enrolling their child for dubious – and often expensive – therapies that have no basis in science.11–12
GPs are ideally placed to screen for school problems. Asking parents the simple question ‘how is your child doing at school?’ can elicit responses that indicate all is not well. This question can be asked during the course of a consultation for the child or parent. Many parents may think that the child’s progress at school is not an issue that is of interest to the GP or – wrongly – that the GP cannot help them. Even if at that point in time the child seems to be coping well, asking the question gives parents the opportunity to raise the issue if concerns arise at some future point in time. Parents should be encouraged to take interest in their child’s progress and communicate with the school on a regular basis. Where parents are engaged with the school, children’s outcomes tend to be better.
In addition, GPs can work with parents in the years before children start school to enhance children’s development and help ensure they build solid foundations for learning at school. For example, parents should be encouraged to read to their child on a daily basis from infancy; this is one of the most important things parents can do to build language skills and introduce young children to books and to print material.13 Virtually all children will benefit from participation in structured early learning.9 For children from disadvantaged or at risk environments attendance at early learning centres from a young age can be considered an effective form of early intervention. By virtue of their ongoing relationship with children and families, GPs are able to identify and address emerging problems in the child, or family issues that might impact on the child’s development and behaviour.14 Early identification of emerging problems and early intervention are generally more effective – and cost effective – than dealing with them later when they have become entrenched.
Children struggling at school present challenges for the healthcare and education systems. They cause stress and distress for children and parents and, if not identified, assessed and managed in a timely and appropriate manner, can lead to lifelong problems and an enormous waste of human potential. GPs can play a central part in helping these children and supporting their families, and make a measureable impact on improving outcomes.
Competing interests: None.
Provenance and peer review: Comissioned; externally peer reviewed.
- Hiscock H, Roberts G, Efron D, et al. Children attending paediatricians study: national prospective audit of office practice from the Australian Paediatric Research Network. Med J Aust 2011;194:392–97.
- Winters CA. Learning disabilities, crime, delinquency, and special education placement. Adolescence 1997;32:451–62.
- Snow PC, Powell MB. Developmental language disorders and adolescent risk: a public health advocacy role for speech pathologists? Int J Speech Lang Pathol 2004;6:221–29.
- Roberts G, Price A, Oberklaid F. Paediatrician’s role in caring for children with learning difficulties. J Paediatrics Child Health 2012;48:1086–90.
- Royal Children’s Hospital Melbourne, Centre for Community Child Health. A Snapshot of early childhood development in Australia: AEDI National Report 2009. Canberra: Australian Government 2009.
- Oberklaid F, Baird G, Blair M, Melhuish B, Hall D. Children’s health and development: approaches to early identification and intervention. Arch Dis Child 2013;98:1008–11.
- Kiernan KE, Mensah FK. Poverty, family resources and children’s educational attainment: The mediating role of parenting. Br Educational Research J 2011;37:317–36.
- Lynch JW, Law C, Brinkman S, Chittleborough C, Sayers M. Inequalities in child healthy development: some challenges for effective implementation. Soc Sci Med 2010;71:1244–48.
- Melhuish EC. Preschool Matters. Science 2011;333:299–300.
- Sung V, Hiscock H, Sciberras E, Efron D. Sleep problems in children with attention-deficit/hyperactivity disorder. Prevalence and the effect on the child and family. Arch Pediatr Adolesc Med 2008;162:336–42.
- Rojas NL, Chan E. Old and new controversies in the alternative treatment of attention-deficit hyperactivity disorder. Ment Retard Dev Disabil Res Rev 2005;11:116–30.
- American Academy of Pediatrics. Joint technical report – learning disabilities, dyslexia, and vision. Pediatrics 2011;127:e818–56.
- Zuckerman B. Promoting early literacy in pediatric practice: twenty years of Reach Out and Read. Pediatrics 2009;124:1660–65.
- Oberklaid F, Drever K. Is my child normal? Milestones/red flags for referral Aust Family Physician 2011;40:666–71.