School Failure—Evaluation and Treatment

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School

Failure.-

Evaluation

and Treatment

Elena Boder, M.D.

From the Departments of Pediatrics, University of California at Los Angeles and Cedars-Sinai Medical Center, and the Division of Neurology, Childrens Hospital of Los Angeles. Los Angeles, California

Children who are failing in school have multiple problems and are clearly a

heteroge-neous group, both etiobogically and clinically.

They have a wide variety of neurodevelopmental deviations-in behavior, motor function,

percep-lion, language, and learning-which has led to the

concept of maturational lag, commonly referred to as “minimal brain dysfunction” (MBD).

Nevertheless, these children present initially with

problems either in behavior or scholastic

under-achievement, or-by far the largest group-as a

combination of both. The most common

behav-ioral problem leading to school failure in the early

grades is the hyperkinetic syndrome, inasmuch as

this behavioral manifestation is one of the least

likely to be tolerated in the school. In my

experi-ence, the most common and least recognized

cause of chronic underachievement at all grade

levels is specific learning disability, notably

devel-opmental

The purpose of this paper is to outline an

overall neuropsychoeducational approach to the

diagnosis and management of children referred

for school failure that I have found useful in a

private neuropediatric consultation practice.

THE OVERALL DIAGNOSTIC APPROACH

The essentials of the neuropsychoeducational

approach, in which the interdependence of

neurological, psychological, and educational

fac-tors is accepted as fundamental, are: orderly,

comprehensive diagnostic evaluation, utilizing a

multidisciplinary team of consultants as a basis for coordinated total management; close

communi-cation with key school personnel for diagnostic

interpretation and special educational planning;

parent and child counseling for diagnostic and

therapeutic interpretation, emphasizing the need

for a structured home routine; and psychotropic

drug therapy and psychotherapy as indicated.

If the child presents with a behavioral problem,

with or without concomitant scholastic

under-achievement, the initial diagnostic objective is to

determine whether the behavioral problem is

primarily neurological (neurodevelopmental),

primarily psychiatric, or both neurogenic and

psychogenic.

The next objective is to determine whether the

learning problem underlying the

underachieve-ment is a primary, specific learning disability or is

nonspecific and secondary to behavioral, mental,

emotional, motivational, sociocultural, and other

factors.

A third objective in the comprehensive

evalua-tion is to rule out all physical, neurological, and

peripheral sensory factors that may be causative

or contributory in the child’s school problems.

Most commonly, the presenting complaint of a

child referred for school failure is a behavioral

problem. The child’s underachievement, when

mentioned, is usually regarded as secondary to the

behavioral problem or to poor motivation.

Although it is generally recognized that the

#{176}Theterms dyslexia, specific dyslexia, and specific develop-mental dyslexia are used here interchangeably with

develop-mental dyslexia and specific, or primary, reading disability.

None is used as a broad term encompassing nonspecific reading disorders.

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hyperkinetic syndrome is frequently associated

with

secondary, nonspecific learning disabilities,

it

has

not been sufficiently recognized that it is

also frequently associated with primary or

specific learning disabilities, notably

develop-mental dyslexia. Systematic screening for

devel-opmental

dyslexia is therefore an integral part of

my expanded neurological examination of every

child referred for school failure, especially a child

with the hyperkmnetic syndrome.

It is taken for granted that the child failing in

school will invariably have a secondary, reactive

emotional overlay, and an attempt is made to

assess its severity. It is also important to ascertain

whether a primary emotional problem exists as a

causal or contributory factor in the child’s

under-achievement. However, the presence of an

emotional problem, whether primary or

second-ary or both, does not exclude the possibility that

the

child may also have developmental dyslexia.

Therefore, sorting out the primary and secondary

emotional factors, though essential in developing

a therapeutic program for the child’s emotional

problems, is not essential in making a diagnosis of

developmental dyslexia or any other specific

learning disability.

OFFICE PROCEDURES

Children

referred for neuropediatric evaluation

of school failure often have had a number of

previous diagnostic work-ups. A preliminary step

therefore is to obtain through the parents,

prefer-ably before the child’s first office visit, reports on

previous medical and psychological evaluations,

as well as past and present school reports,

includ-fig reports from the child’s current teacher on his

classroom behavior, scholastic achievement, and peer group interaction.

My evaluation ordinarily requires two or at

most three extended office visits, at which both

parents are asked to be present. Their presence at

the first visit is important not only to obtain a

more complete history and to observe family

interactions, but also to explore what each

parent’s main concerns about the child are, what

each believes to be the causes of the child’s

problems, and what they hope to gain from the

present consultation. The special advantage of

both

parents being present at the second visit is

that each can have a first-hand interpretation of

the

diagnosis and the proposed plan of

manage-ment, which helps to ensure optimum

coopera-tion.

The first office visit begins with a brief

inter-view with the child in the presence of his parents,

based on a few simple questions about his

reac-tions to school. This provides an opportunity to

observe his general pattern of behavior and

reveals whether he recognizes his school

problems or denies them. Next, while the history

is being obtained from the parents, the child goes

to another room where the office assistant

admin-isters a set of paper-pencil tests and my diagnostic

screening procedure for developmental dyslexia,

which is outlined later.

The review of past records is supplemented by

a detailed medical, developmental, and family

history, giving emphasis to events which are

potential causative factors of brain damage,

noting any significant delays in speech and

language

and

motor skills, and inquiring about

dyslexia and speech or language impairments in

siblings and other members of the family. It is

often difficult to elicit a positive history of

dyslexia in the parents; they will admit much

more readily to being poor spellers than slow

readers, probably because the irregularity of

English orthography makes poor spelling socially

acceptable.

Unless the child’s school problems are

rela-tively uncomplicated, the physical and

neurolog-ical examination usually is scheduled for the

second visit. It has been found advantageous to

have the parents present during the examination.

Their presence, which is reassuring to a younger

child, gives the examiner a chance to point out

the child’s assets and to let the parents see for

themselves some of the deficits in performance.

Later interpretation of the neurological findings

becomes more meaningful when it is related to

the parents’ own observations.

A

complete

physical examination is considered

an essential preliminary step to the expanded

neurological examination. Especially important

to rule out are physical defects, including gross

visual and auditory impairments, congenital

anomalies, abnormal somatic growth and

devel-opment,

allergic or endocrine disorders, chronic

illness, and malnutrition.

Because of the variety of “soft” signs pointing

to maturational lags in children with school

difficulties, each child is given an expanded

neurological examination. Space does not permit

discussion of the growing number and variety of

special neurological tests designed to elicit soft

signs. The reader is referred to the other

discus-sions in this section. In expanding the routine

neurological examination, I limit myself as

required by the time available to tests I have

found especially valuable in eliciting precisely

those signs, soft or hard, which are directly

(3)

relevant to school performance or point to the

other neurodevelopmental disorders frequently

associated with the hyperkinetic syndrome or

with developmental dyslexia.

Among the tests in my expanded neurological

examination are standard tests of fine and gross

motor coordination and manual praxis, including

dressing and undressing; tests for cerebellar

func-tion, lateral dominance, including Schilder’s

arm-extension test, finger gnosia, and stereognosis;

Benton

right-left discrimination test;

color-naming test; reciting the days of the week as a test

for auditory sequential memory;

sentence-repeti-tion test for articulation and short-term memory;

and the paper-pencil tests administered at the

first office visit along with my diagnostic

screen-ing procedure for development dyslexia. The last

is repeated at the second visit to check the

consistency of the results.

The paper-pencil tests include copying of

geometric designs to point up visual-perceptual

and visuomotor coordination impairments;

draw-ing “a house, a man, and a tree,” a picture of the

child’s own family, the face of a clock from

memory, and spontaneous drawings, which may

disclose immature performance, bizarre

dispro-portions, distorted body-image, and visual-spatial

deficits. The family drawing may also provide

valuable clues to family interactions and the

child’s self-image.

The child’s general pattern of behavior has also

been noted by the end of the neurological

exami-nation, along with the presence of involuntary

movements, such as choreiform movements,

tremors, or tics, and the stereotyped movements

typical of the schizophrenic child.

Diagnostic Screening Test for Developmental Dyslexia

An integral part of the expanded neurological

examination is my empirically evolved Diagnostic

Screening Test for Developmental Dyslexia.

Described in detail elsewhere,’-2 it provides an

approach to differentiate specific dyslexia from

nonspecific reading retardation. Such

differentia-tion has immediate practical bearing since

specific dyslexia calls for remedial reading

tech-niques that are not required in the management

of nonspecific reading disorders.

In the presence of significant reading

retarda-tion-usually two or more years below age-grade

level or mental age, although a retardation of

even one year may be regarded as diagnostically

significant-I make the diagnosis of

develop-mental dyslexia by analyzing reading and spelling

jointly as interdependent functions.’-2 My system

of analysis seeks to identify diagnostic

reading-spelling patterns not through errors alone, which

reflect only the dyslexic child’s functional deficits,

i.e., what he cannot do, but by means of the total

reading and spelling performance, which reflects

strengths as well as deficits.

It should be emphasized that my diagnostic

screening test is used in conjunction with the

main prevailing diagnostic criteria for

develop-mental dyslexia provided by (1) diagnosis by

exclusion, essentially a differential diagnosis, (2)

indirect diagnosis through neurological and

psychometric concomitants, and (3) direct

diag-nosis, based primarily on the frequency and

persistence of certain kinds of errors in reading

and writing. All of these standard approaches are

incorporated in the comprehensive diagnostic

work-up outlined in this paper.

The screening for atypical patterns begins with

the reading test, which consists of eight lists of 20

words each, both phonetic and nonphonetic, graded from pre-primer to sixth grade. These are

presented in two ways: “flash’ ‘ presentation

which determines the child’s reading level and

sight vocabulary, i.e., the words recognized

instantly as whole-word configurations, or

ge-stalts; and “untimed” presentation, which calls

upon the child’s ability to decode unfamiliar

words phonetically.

The spelling test, designed to parallel the

“flash” and “untimed” columns in the reading

test, is also given in two parts: “known” words

(

i.e., sight vocabulary) and “unknown” words (i.e.,

not in sight vocabulary). A simple scoring

proce-dure is used, relating the child’s performance to

that of normal readers. It is based on the

percent-age of correctly spelled words in the “known”

word list, which is an index to the child’s ability to

“revisualize” words in his sight vocabulary, and

the percentage of “good phonetic equivalents” in

the “unknown” word list, which is an index to the

child’s word-analysis skills. (In the spelling

pattern of normal readers, 70% to 100% of

“known” words are spelled correctly; 80% to

100% of “unknown” words are spelled

phoneti-cally.’2)

My observations indicate that strengths and

deficits in the gestalt and analytic functions of

dyslexic children-the two basic processes

under-lying reading-are reflected in three atypical

reading-spelling patterns, none of which are

found among normal readers and spellers. On the

basis of these three patterns, three subtypes of

dyslexic children are delineated-dysphonetic,

dyseidetic, and mixed dysphonetic-dyseidetic,

each with its own prognostic and remedial

impli-cations. .2

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PEDIATRICS

FOR THE CLINICIAN

397

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FIG. 1. Nonphonetic spelling in dysphonetic group 1. A 15-year-old boy, 10th grade, IQ 92 (Stanford-Binet LM). Reading level, fourth grade (sight vocabulary); word-analysis skills minimal even though he had been in a special reading class for three years. Known words: 25% correct, misspellings 67% dysphonetic. Unknown words: none correct, misspellings 100% dysphonetic. Note that some phonetic concepts are evident in his strikingly dysphonetic performance on the

unknown word list. (Reprinted with permission of Spastics International Medical Publications,

publishers of Developmental Medicine and Child Neurology.)

Croup 1 (dysphonetic), by far the largest of the

three subtypes, reflects a primary deficit in

symbol-sound integration, with inability to

devel-op word-analysis skills. These children read

globally, responding to whole words as

configura-tions, or gestalts. Lacking phonic skills, they are

unable to decode words not in their sight

vocabu-lary. Misspellings are typically nonphonetic and

unintelligible (Fig. 1). Their most striking errors,

primarily in reading but also in writing, are

semantic substitutions, e.g., reading “funny” for

“laugh” or “airplane” for “train.”

Croup 2 (dyseidetic) reflects a primary deficit

in the ability to perceive and recall whole words

as gestalts, without deficit in analytic function.

These children read primarily through a process

of phonetic analysis, sounding out most words as

if encountered for the firt time. Misspellings are

typically phonetic and intelligible (Fig. 2), e.g.,

“laf” for “laugh,” “lisn” fr “listen.”

Children who are both dysphonetic and

dysei-detic (Croup 3) are deficient both in the ability to

develop phonetic word-analysis skills and in

perceiving whole words as gestalts (Fig. 3).

Without remedial teaching, they tend to remain

virtually alexic-nonreaders and nonspellers.

ADDITIONAL DIAGNOSTIC STUDIES

At the conclusion of the first office visit, guided

by the review of past records, referrals for

addi-tional tests and diagnostic studies are made. The

regular consultants, described below, with each of

whom professional exchange by telephone is

readily available, constitute in effect a

multidisci-plmnary diagnostic team. The second office visit is

scheduled when reports on all the diagnostic

studies have been obtained.

Psychological Testing

Unless an adequate current report on

individ-ual psychometric testing is already available, the

child is referred to a clinical child psychologist for

a psychoeducational evaluation. When private

referral is not financially feasible, the cooperation

of the school psychologist can be invaluable. The

(5)

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FIG. 2. Phonetic spelling in dyseidetic group 2. A 10-year-old boy, fourth grade, IQ in bright normal range (Stanford-Binet LM), excels in arithmetic. Reading level, first grade (sight vocabulary); word analysis skills, third to fourth grade. Known words: 40% correct, misspellings 83% phonetic. Unknown words: none correct, misspellings 90% phonetic. Note that as in group 1 and 3 the total of correctly spelled words in the known words list is far below his reading

level.

evaluation is based on a minimum battery of

standard tests of intelligence and achievement,

supplemented with tests of visual and auditory

perception and memory and visuomotor

coordi-nation, and with projective tests, when possible,

to assess the emotional concomitants, primary

and secondary, of the child’s school failure.

Among the patterns of test performance upon

which I have come to rely for evidence of

cognitive deficits are certain characteristic WISC

profiles. These include a wide scatter in subtest

scores and a discrepancy of 15 IQ points or more

between the verbal and performance scales,

which are generally regarded as being diagnostic

of specific learning disabilities. A relatively low

verbal IQ and low scores on the digit-span and

coding subtests are especially significant in the

diagnosis of the genetic type of developmental

dyslexia, whereas a very low performance IQ is

frequently associated with overt neurological

evidence of brain damage.

Intelligence and achievement tests are key

instruments in assessing not only the degree of

underachievement but also the severity of a

specific learning disability. It is important to keep

in mind, however, that either the low

perform-ance IQ or the low verbal IQ and the wide subtest

scatter that are characteristic of children with

specific learning disabilities may bring their

frill-scale IQ on the WISC into the mentally retarded

range, rendering it meaningless as a measure of

overall intelligence and often leading to

misdiag-nosis and mismanagement.

A selective retardation in reading and spelling

on standard achievement tests, with normal

performance in arithmetic, justifying in such

cases the descriptive term “selective reading

disability,” is generally viewed as diagnostic of

developmental dyslexia. However,

developmen-tab dyslexia and dyscalculia can and frequently do

coexist in the same child. In my experience, it is a

reading-spelling discrepancy in achievement

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FOR THE CLINICIAN

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FIG. 3. Nonphonetic spelling of mixed dsphonetic-dyseidetic group 3. A 10-year-boy, fifth grade, IQ 87 (\VISC: verbal IQ 72, performance IQ 103). Reading level, pre-primer (sight

vocabulary); no word-analysis skills. Known words: 37% correct, misspellings 100% dysphonetic.

Unknown words: none correct, misspellings 100% dysphonetic. (Reprinted with permission of

Spastics International Medical Publications, publishers of Developmental Medicine and Child

Neurology.)

scores, with spelling at a much lower level, rather

than a reading-arithmetic discrepancy, that is the

more constant diagnostic sign of developmental dyslexia.

The visual memory, auditory memory, and

sound-blending subtests of the Illinois Test of

Psycholinguistic Abilities (ITPA) have proved to

be valuable supplements to my diagnostic

screen-ing procedure for developmental dyslexia, in that

they provide significant correlates with the three

identified dyslexic subtypes.

Additional Medical Diagnostic Studies

Since screening of vision and hearing in the

pediatrician’s office is usually inadequate for an

evaluation of a child with a learning disorder,

ophthalmobogical and oto-audiobogical

consulta-tions are routine, unless reports of recent

exami-nations are available.

The routine laboratory tests include a T, level

in addition to complete blood count and

urmnaly-sis, supplemented as indicated with selected

blood chemistries and special laboratory studies,

such as amino acid chromatography, cytogenetic

studies, skull X-ray films, and determination of

bone age. An EEC, taken during both the waking

and sleeping state, is obtained routinely on

chil-dren with intermittent inattention, severe

acting-out behavioral disorders, chronic brain

syn-dromes, mental retardation, or a history of seizures, but is not routine for children with

scholastic underachievement alone. Referral to a

speech pathologist or speech therapist is routine

for all children with speech impairment.

Psychiatric referral is made only for children

whose behavioral disorders suggest primary

emotional problems, borderline psychosis,

child-hood schizophrenia, or autism.

Since refractive errors that interfere with near

vision and reading comfort are easily missed in

routine visual screening, ophthalmobogical

evalu-ation with cycboplegic refraction is essential.

Although it is generally agreed that visual defects

are not a cause of specific reading disability, there

is a tendency to underestimate their importance

as a contributory factor or as a primary cause of

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nonspecific, secondary reading retardation.

Myo-pia, unless unusually severe, is not a factor in poor

reading, but even moderate hyperopia,

particu-larly if associated with astigmatism or

conver-gence insufficiency, may be a significant factor in

all reading disorders.

Oto-audiological evaluation is essential because

mid- and high-frequency hearing boss, which can

interfere with auditory discrimination sufficiently

to cause delay in speech and language

develop-ment, is usually missed except with pure-tone and

speech audiometry. Intermittent conductive

hy-poacusis due to recurrent or chronic serous otitis

mediacan also interfere with normal speech and language development and thereby result in a

secondary reading-spelling disability associated

with low scores on the WISC verbal scale similar

to those found in children with specific

language-learning disability.

TREATMENT

The multidisciplinary team approach essential

in the diagnosis of children presenting with school

failure is also the most effective approach to

treatment, provided that the pediatrician

contin-ues in the role of coordinator, implementing the

recommendations of the team and interpreting

them to the family and school personnel. The

recommendations must be coordinated into a

practical program of treatment in which all of the child’s multiple problems and correctable defects

are handled concurrently, taking into

considera-tion the whole child and the family’s actual

circumstances.

Despite the superficial similarities in the

symp-tomatology of children failing in school, each

child is found to have a distinctive cluster of

symptoms calling for a highly individualized

therapeutic approach. In my experience, unless

treatment is individualized, coordinated and

simultaneous, i.e., multifaceted, it is usually

unsuccessful. Drug therapy alone, for example, cannot take the place of needed educational

therapy

or psychotherapy. When a full

simulta-neous treatment program is not feasible, realistic

priorities according to the specific immediate

needs of the given child have to be assigned.

Parent and child counseling is of paramount

importance in dealing with children who are

failing in school. The psychotherapeutic impact

of a correct diagnosis, particularly of

develop-mental dyslexia, can be quite dramatic. Leading

to an improved self-image for the child and to

better parent-child and teacher-child

relation-ships, the diagnosis itself often proves to be a

turning point in the child’s emotional

develop-ment and school adjustment, even when remedial

facilities are not immediately available.

Interpreting the dysfunction of central

pro-cesses essential for reading in terms of visual and

auditory “channels” for learning that are “open”

or “closed” is easily grasped and accepted by

parents and child. Furthermore, the child’s

reading-spelling patterns, being readily

demon-strable, can be used effectively to help parents

gain a better understanding of the child’s problem

and the goals toward which remedial instruction

is to be directed.

The special value of a structured home

environ-ment and good health habits for children with the

hyperkinetic syndrome or learning disabilities is

also stressed. It is felt that a structured home

routine helps the child to become better

orga-nized and to develop, along with better health

habits, better work habits and self-discipline, thus

contributing to a better school adjustment.

Communication With Schools

Utilization of school personnel as an integral

part of the multidisciplinary team is especially

advantageous. Once the child’s behavioral and

learning problems have been properly diagnosed

andinterpreted to key school personnel, they can

begin to share in the management.

Awareness of community resources, both

public and private, enables the pediatrician to

guide the parents in obtaining the best and most

practical program available for their child.

School structuring or special education

pro-grams are indicated for most children with the

hyperkmnetic syndrome or learning disabilities.

For mild or moderate specific learning

disabili-ties, just as for nonspecific ones, school

structur-ing may suffice. Immediate classroom adaptations

to make allowances for the child’s limitations

include such simple measures as not requiring

oral reading and spelling before the class when

the child’s problem is one of dyslexia, giving oral

rather than written tests and providing

oppor-tunity for activities in which the child can

succeed. A year’s retention may be a valuable

adaptive measure at kindergarten or first-grade

level, though usually not later. Whenever

possi-ble, it is advisable to have the child remain in a

regular classroom, supplemented with the

appro-priate remedial programs at school or through

private

tutoring.

A full-time learning disability class within the

schools is recommended for children with severe

learning disabilities and for those who are not

making satisfactory progress in a part-time

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dial program. A specialized private school, for

which state funds may be obtainable, is indicated

for children with severe learning disabilities for

whom no effective public school program is

available.

In addition, children with general motor

clum-siness, who experience frustration on the

play-ground, can often be helped in a corrective

physical education class at school; children with

speech impairments or poor auditory

discrimina-tion may be able to benefit from the school’s

speech therapy program.

Educational Therapy

Special education is indispensible in the

reme-diation of specific learning disabilities. No other

measures, alone or in combination, can take its

place.

It is not, however, within the scope of this

paper to review the variety of remedial

tech-niques utilized by educators, although the

pedia-trician interested in learning disabilities should

have some familiarity with them. In general, the

techniques are multisensory, i.e., visual, auditory,

and tactile-kinesthetic, and often addressed

primarily to one sensory modality and reinforced

by another.

Although opinions differ on whether to teach

initially to the “open” or the “closed” channel,

that is, to the strength or to the weakness, my own

experience with the three dyslexic subtypes

supports the view that the initial approach should

be to teach to the strength, not only to ensure

initial successes for the child but also to prepare a

better foundation for teaching to the weakness

with remedial techniques.

Psychotropic Drug Therapy

Since hyperkinetic children are a

heteroge-neous group, only a careful differential diagnosis

can serve as a basis for determining whether drug

therapy is indicated.

The basic distinction is between neurogenic

hyperactivity, i.e., the classic hyperkinetic

syndrome, and psychogenic hyperactivity, i.e., a

behavioral response to anxiety. Though

psycho-stimulants are the drugs of choice for neurogenic

hyperactivity, tranquilizers or tricyclic

antide-pressants may be indicated for psychogenic

hyperactivity. When a diagnosis of hyperkinetic

syndrome is in doubt, a diagnostic trial of

psychostimulants is justified.

When a child with the hyperkinetic syndrome

has severe emotional concomitants, notably poor

self-image with depression or acting-out behavior,

a psychostimulant may be combined with a

tranquilizer or tricyclic antidepressant,

prefer-ably in conjunction with psychotherapy.

In mild developmental hyperactivity,

psycho-stimulants are not indicated; home structuring

and behavior modification techniques at home

and at school usually suffice. When the

hyperki-netic syndrome is associated with a specific

learn-ing disability, psychostimulants may be successful

initially in modifying the child’s school behavior

only to be followed by a recurrence of

hyperkmne-sis, the neurogenic hyperactivity being replaced

by anxiety-based hyperactivity. Thus, when

psychostimulants fail to ameliorate a true

hyper-kinetic syndrome, a coexisting specific learning

disability or a primary emotional problem must

be considered. A nonspecific learning disability

secondary to attentional deficit and hyperkinesis

usually resolves spontaneously with successful

psychostimulant therapy without special

educa-tion or individual tutoring.

In helping parents to accept a trial of

psycho-stimulant therapy, it is important to explain that

the objective is not to sedate or subdue the child

but rather to “normalize” his behavior, overcome

the attentional deficit, thus making the child

more accessible to learning, and improve school

adjustment. It is also helpful to explain that

developmental hyperactivity tends to diminish

with maturation, and that the medication can be

discontinued when the child develops better

ability to concentrate and achieves adequate

impulse control. Care is taken that the child on

medication is not deprived of a sense of

accomplishment for improved behavior by

point-ing out to him that medication can help his

behavior and learning only if he himself makes

the effort to improve.

When medication is prescribed, the need for

adult supervision is emphasized. Large dosages

are avoided because of their side effects. When

moderate dosage is not effective, trial of a

different medication is made. Anorexia and

insomnia, the most common side effects of

psychostimulants, may be minimized by limiting

the medication to the morning and noontime. In

selected cases in which the attentional deficit and

hyperkinesis create problems primarily at school,

I have found it reassuring to parents to suggest

that medication may be discontinued on

weekends and during school vacations.

Psychotherapy

Psychotherapy is usually not required for the

secondary, reactive emotional overlay invariably

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present in the child failing in school. In my

experience, like that of others, the overlay tends

to

clear up once the underlying problems have

been managed medically and educationally. In

older children, however, the emotional

concomi-tants of chronic school failure are frequently so

severe that referral to a child psychiatrist or

clinical psychologist experienced in dealing with

school problems or to a child guidance clinic

should be considered.

If parent counseling and behavior therapy do

not resolve the child’s primary or secondary

emotional and motivational problems, individual

psychotherapy or family therapy is indicated.

Croup therapy is usually preferable for

adoles-cents. Parents may be encouraged to participate

in an effective parent organization such as the

Association for Children with Learning

Disabili-ties (ACLD), as a means of increasing their insight

into the child’s problems and allaying their own

anxiety.

Follow-up

Follow-up on academic progress and the

effec-tiveness of psychotropic drug therapy, both

requiring close communication with school

personnel, is viewed as an essential aspect of

management. Before each office visit, a simple

questionnaire on behavior and achievement is

mailed directly to the school, so that a

confiden-tial report from the teacher, which is

indispens-ible as a guide to adjusting psychostimulant

medication, will be available.

The best evidence for the effectiveness of

management is relatively rapid behavioral or

academic improvement within the current

semes-ter or school year, especially if the child’s

problem has been chronic and has failed to

respond to previous therapeutic measures. Other

criteria for evaluating management include

improved parental attitudes toward the child and

the school, and improvement in the child’s

self-image and attitude toward school.

In assessing the effectiveness of a given dosage

of psychostimulant, I supplement the parents’ and

teacher’s reports periodically with an objective

before-and-after office test, for which the parents

are asked to bring the child to the office without

medication. A set of paper-pencil tasks is given.

This includes copying of geometric designs,

drawing the child’s own family, and writing to

dictation a selected list of words from the

diag-nostic screening procedure for developmental

dyslexia. The previously established dosage of

psychostimubantt is then administered; 30

mm-utes later the paper-pencil tasks are repeated.

When psychostimulant therapy is effective,

strik-mg improvement in test performance is usually

noted. Handwriting and drawings tend to be

smaller and neater, and hyperactivity and

dis-tractibility are diminished. For a quantitative

assessment of the effectiveness of the

psychostim-ulant, the Coodenough Draw-a-Person-Test and

the Bender Cestalt Test may be given as part of

the before-and-after office test and scored later by

a clinical psychologist.

For children receiving psychostimulant

medi-cation, it is important to follow the height and

weight curves, since anorexia and insomnia, the

most common side effects, may interfere with

so-matic growth.

SUMMARY AND CONCLUSIONS

A comprehensive multidisciplinary team

ap-proach

to the diagnosis and management of

school failure, with the pediatrician

knowledge-able in the field of behavioral and learning

disorders serving as coordinator, is outlined in

terms of actual office procedures. An integral part

of the expanded neurological examination is an

empirically evolved diagnostic screening test for

developmental dyslexia which identifies three

atypical reading-spelling patterns on the basis of

which dyslexic children can be classified into

three main subtypes: dysphonetic, dyseidetic, and

mixed dysphonetic-dyseidetic, each with its own

therapeutic and prognostic implications.

The approach outlined here is designed to

identify not only the specific educational needs of

a given child but all of the causative and

contrib-utory factors, physical, emotional, and

sociocultu-ral, that may impinge on the child’s ability to

learn. Though necessarily time-consuming, the

team approach appears in our present state of

knowledge to be the most practical and reliable

way to get at the roots of the child’s multifaceted

problem and to develop a coordinated program of

treatment-simultaneous insofar as feasible, and

sequential when required.

A child referred for school failure is a child in

crisis. The challenge to the pediatrician to whom

tSee Denhoff’s article in this issue for an outline of psycho-stimulant medication dosages.

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PEDIATRICS

Vol. 58 No. 3

September 1976 403

the parents turn for a solution is to find ways as

promptly as possible to help the child improve in

his school adjustment and self-esteem. It is

recog-nized that special education has a primary and

ultimate responsibility for remediating specific

learning disabilities. Nevertheless, the complexity

of the problem of school failure requires that

overall diagnosis and management be a

multidis-ciplmnary venture, in which the professionals

involved

are committed to working together to

ensure that the whole child is taken into

account.

REFERENCES

1. Boder E: Developmental dyslexia: Prevailing diagnostic concepts and anew diagnostic approach. In, Mykle-bust HR (ed): Progress in Learning Disabilities:

Volume II. New York, Grune & Stratton, 1971. 2. Boder E: Developmental dyslexia: A diagnostic approach based on three atypical reading-spelling patterns. Dev Med Child Neurol 15:663, 1973.

The

Assessment

of the

Child

at School

Entry

Martin C. 0. Bax, M.B.

From the Thomas Coran, Research Unit, London University, London, England

Most learning and behavior disorders in school

children present as “crisis situations,” when

anxious parents or exasperated teachers suddenly

call for medical or psychological help with a child

aged 9, 10, or 11 who is in severe difficulties. It is

not surprising that remedial efforts to help these

children are often unsuccessful. It seems likely

that if we could identify the children earlier and

try to help them before they get into difficulties,

the results would be much better. However, the

correlation between abnormalities found in

babies in the newborn period or in the early years

of life, although significant, are quite low, and we

cannot identify with any degree of reliability

children who may have school difficulties at this

earlier age. On the other hand, we have shown

that a thorough assessment of the child at school

entry will allow one to identify quite a large

proportion of the children who are going to get

into difficulties.’ A careful assessment, therefore,

of children at school entry is an essential part of

educational pediatrics.

There are a number of other reasons why

preschool assessments cannot identify potential

problems. The main one is that there are a

number of functions emerging about age 5 or 6

which cannot be adequately studied in the early

years. A further, and very important, reason for

putting a great deal of emphasis on the initial

examination at school is that whatever

adminis-trative arrangements, under the various systems

of medicine that operate in different countries,

are made in the preschool period to see children,

it is difficult to be certain of seeing all the

children. It is just those children who are not

brought by their parents for regular preschool

ADDRESS FOR REPRINTS: Thomas Coram Research Unit,

University of London, London, England.

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1976;58;394

Pediatrics

Elena Boder

Evaluation and Treatment

−−

School Failure

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