Pediatricians Should Help Recognize and Remediate Educational Problems, AAP Says
Rarely do school problems begin or end at the classroom door. Inadequate sleep, learning disabilities, and even food insecurity, among other factors, may help to explain a child’s poor report card. Primary care physicians, according to a new report by the American Academy of Pediatrics, are in a unique position to screen for and treat contributing conditions, and also offer support for the secondary challenges — often low self-esteem and social struggles — that follow school failures.
While academic success and progress has been traditionally relegated to the school system, the AAP, in a report released last month1, formally called on clinicians to assume a more involved role in their patients’ educational achievement. The organization argues that pediatricians, “as advocates for child health and well-being,” are in a unique position to help solve problems that manifest in the classroom, and that the issue should be regarded as seriously as any other in pediatric care.
“I’ve seen how miserable and hopeless kids feel when they’re falling behind or failing at school,” said Dr. Arthur Lavin, chair of the AAP Committee on Psychosocial Aspects of Child and Family Health, and one of the report’s lead co-authors, according to a release.2
To guide pediatricians, the report outlines tools to help evaluate psychological, neurological, or other medical problems that can hinder educational progress, and provides approaches to inform clinical decisions on a child’s academic challenges.
“Our goal is to use our resources as pediatricians to help identify why the child is struggling and provide realistic options to help them succeed in moving forward in their education,” said Dr. Lavin, whose pediatric practice experience extends 25 years.
How Many Children Have Academic Problems?
About 6.7 million students, representing 13.2 percent of total public-school enrollment, were served by federally supported special education programs between 2015 and 2016, according to federal data.3 The numbers represent a marked increase from the 3.7 million students served in 1976 — one year after the enactment of the Individuals with Disabilities Education Act (IDEA), which mandates that children and youth ages 3 to 21 with disabilities be provided a free and appropriate public school education.
The great majority of the children served by these programs — about 35 percent — have specific learning disabilities, defined by IDEA as “a disorder in one or more of the basic psychological processes involved in understanding or using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.”
How Can Pediatricians Help a Child Struggling in School?
A pediatrician’s role in this addressing academic problems, according to the AAP, encompasses several functions, ranging from prevention, treatment, advocacy, and monitoring.
Prevention and Recognition
To address academic underachievement, pediatricians should first attempt to prevent or mitigate factors, like brain injury, that could lead to it. Administering immunizations, screening for anemia and lead exposure, addressing psychosocial risks, and encouraging safe practices like using helmets and seat belts are all routine, preventative practices the AAP recommends that pediatricians employ.
The AAP also encourages pediatricians to identify specific risk factors that may interfere with typical academic progress. For early signs of language-based learning disabilities in preschool-age students, for instance, pediatricians can ask families about pre-reading language milestones. Other factors associated with academic difficulties include food insecurity, parental health and education levels, and even the amount of shared reading done at home.
Diagnosis and Referral
A new AAP resource that accompanies the report lists the range of conditions and situations that may contribute to academic dysfunction. Included on that list are attention deficits (like ADHD), emotional difficulties and disorders, adversity or trauma (hunger and child abuse, for example), social issues (truancy, bullying), and physical illnesses.
Central to the diagnosis process is a medical evaluation to determine why academic progress is compromised. Doctors may perform a host of evaluations on elements like perinatal and developmental history, sleep and behavioral patterns, and physical ailments.
Pediatricians should evaluate for delays in the development of motor coordination, for instance, as it often co-occurs with learning disabilities. Likewise, inadequate sleep, in quality and duration, is a known contributor to academic dysfunction of which doctors should be aware. Understanding a child’s family and social history can also point to gaps in educational achievement. A child in foster care, for example, may have changed schools many times — each school change, research shows, can result in a loss of four months’ worth of academic skills 4.
“Each child is a complex individual, and a lack of academic progress is often a symptom of complex issues that need to be approached with careful thought,” said Celiane Rey-Casserly, director of the Center for Neuropsychology at Boston Children’s Hospital and another lead co-author of the report. “They may show up as neurologic, emotional, or behavioral issues — or different combinations of them.”
Following initial evaluations, pediatricians can refer children to specialists — like child psychologists or neuropsychologists — if more information is needed to determine the source of the problems. The AAP also encourages pediatricians to develop familiarity with local community resources in an effort to provide comprehensive care.
Dr. Levin, in an interview with The New York Times5, recounted his experience with a 10-year-old patient who was struggling in school, especially in his math classes. A local mental health professional had diagnosed him with ADHD — reportedly based on a single test — and had started him on stimulant medication. But further testing, prompted by Dr. Levin, showed continued difficulties with mathematics, and eventually led to a diagnosis of dyscalculia, a math learning disability. “When we got him help with math, he went from struggling in school to succeeding,” Dr. Lavin told the Times.
Treatment, Advocacy, and Monitoring
Pediatricians are already expected to collaborate with schools when treatment extends to the classroom, but the AAP argues that doctors should also help families navigate school-based evaluations and intervention services. If a child with ADHD, for example, can benefit from classroom modifications, the pediatrician should consult with the family to ensure the accommodations are appropriate and of quality.
Periodic monitoring of a child’s academic progress can also help signal to pediatricians whether the school is appropriately working with the child and family. Ongoing monitoring is also critical because students with academic problems are known to be at risk for low self-esteem, lack of sense of efficacy, and other negative perceptions that can develop into conditions like depression and anxiety.
In securing treatment for academic problems, pediatricians essentially assume the role of advocate, the report says. After identifying the factors hindering a child’s academic progress, the pediatrician can make a request for an evaluation at the school to determine the child’s eligibility for an IEP or 504 Plan. The doctor can advocate for the most fitting plan for the child, and inform families of procedures related to education plans, like the fact that some school districts have physicians that, if requested with at least 72 hours notice, can attend IEP meetings.
To aid pediatricians, the AAP has included example templates, like a referral letter for a school evaluation, within the report’s supplemental information. The organization also encourages pediatricians to familiarize themselves with IDEA, so that they understand the rights and challenges of their school-age patients.
Outside of school, the organization stressed that pediatricians can and should help adults in the child’s life better understand the science of neurodevelopmental or mental health disorders, including a child’s innate strengths and challenges. “Children with these disorders may be perceived as lazy or willfully oppositional rather than as having neurocognitive deficits that preclude typical academic progress,” the report warns. Failing to do so can lead to lingering impacts not just in school, but in a child’s well-being for years to come.
“We’re leaving a huge sector of our population behind,” Dr. Laura McGuinn, a professor of pediatrics at the University of Alabama at Birmingham, and a lead co-author of the report, told the Times. “They’re told so many times how awful they are because the school measures them compared to kids who, neurologically, do it easily, and it destroys lives every day.”
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1 Rey-Casserly,C., McGuinn, L., Lavin, A. et.al. (2019). School-aged Children Who Are Not Progressing Academically: Considerations for Pediatricians. Pediatrics, 144 (4) e20192520. DOI: 10.1542/peds.2019-2520
2 New Report Helps Pediatricians Diagnose Causes Behind Stalled Academic Progress. (2019, October).Retrieved from: https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/New-Report-Helps-Pediatricians-Diagnose-Causes-Behind-Stalled-Academic-Progress.aspx
3 Fast Facts: Students with Disabilities. Retrieved from: https://nces.ed.gov/fastfacts/display.asp?id=64
4 Szilagyi, M., Rosen, D., Rubin, D., Zlotnik, S., et. al. (2015). Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics, 136 (4) e1142-e1166; DOI: 10.1542/peds.2015-2656
5 Klass, P. (2019). Is Your Child Struggling in School? Talk to Your Pediatrician. Retrieved from: https://www.nytimes.com/2019/10/07/well/family/is-your-child-struggling-in-school-talk-to-your-pediatrician.html