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SCHOOL

FAILURE

Kurt Glaser, M.D., and Raymond L. Clemmens, M.D.

Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland

(Submitted April 13; revision accepted for publication September 10, 1964.)

Presented in part at the Thirty-second Annual Meeting of the American Academy of Pediatrics, Chicago, Illinois, October 8 and 9, 1963.

Dr. Glaser is Clinical Director, Rosewood State Hospital, Owings Mills, Maryland, and Dr. Clemmens

is Director, Central Evaluation Clinic for Children, University Hospital, Baltimore, Maryland.

PRESENT ADDRESS: (KG.), 6114 Biltmore Avenue, Baltimore, Maryland 21215.

SPECIAL

ARTICLE

128

PEDIATRICS, January 1965

T

HIS PAPER will concern itself with school

failure in its broadest sense: academic

failure or underachievement in one or more

subjects, with or without retention in the

grade.

Most parents expect the pediatrician to

counsel them in all phases of the child’s

development, including social and

psy-cllOlogical adjustment and educational

mat-tems. Early recognition and identification of

problems interfering with the child’s

sue-cessful schoOl career are essential for the

success of corrective 2

While the educator, psychologist, or

so-cial worker will recognize the existence of

learning problems in the child, the

pedi-atrician is frequently called upon to

deter-mine whether the disturbing factors are

causatively related, unrelated and

non-contributory, or themselves the result of

the educational handicap and/or

second-arily contributory.

In his attempt to grossly assess the

emo-tional and intellectual functioning of the

cilild, the pediatrician can avail himself of

a number of abbreviated psychological

34, 5 Korsch et a!. have shown that

pediatricians’ appraisals of children’s I.Q.

correlate vell VitIl the results of standard

psychological tests, except in the physically

ill child, who was underestimated, and the

retarded child, who was overrated.6 It must

be kept in mind, however, that these are

screening devices and to be used only as

such. Accurate assessment should be

re-femred to the experienced psychologist using

standardized tests.

A

screening test for the determination of

reading levels has been devised by the

Baltimore County Public School System

and is well applicable for physicians’ office

use (see Appendix).

Causes of underachievement and failure

in school are discussed in the following

pages.

LEARNING DIFFICULTIES AND

MATURATIONAL FACTORS

Problems in both academic achievement

and school adjustment are far more

corn-rnon in boys than in girls. It is commonly

held that social pressures and child-rearing

practices centering about the role of the

male in our society are the primary

causative factors for this predominance in

boys.

However, as Bentzen has pointed out,

organic factors may play at least an equally

important role.7 The human male organism

matures at a slower rate than the female.

Thus she advances the hypothesis that some

of the behavior disorders and learning

prob-lems among boys may be the result of the

stress response of an immature organism to

the demands of a society which fails to

make appropriate provision for this

biologi-cal age differential.

While direct methods of measuring

ma-turational rates of the central nervous sys-tern are lacking, other organ systems, such

as the secondary ossification centers, show

consistently earlier maturation in girls than

(2)

LEARNING DIFFICULTIES AND

PHYSICAL FACTORS

The importance of detecting possible

physical handicaps in a child with learning

difficulties must not be underestimated. For

instance, tile correction of sensory deficits

may be all that is needed to ameliorate the

learning difficulty and restore

self-con-fidence. However, the psychological

pat-temns resulting from the handicap may be

sufficiently ingrained to need specific

assist-ance. On the other hand, learning

diffi-culties and physical and psychological

prob-lems may not be causally related and each

may need treatment in its own right.

It is not always easy for a teacher to

me-late inappropriate behavior in school to the

presence of a physical defect. Lack of

in-terest, daydreaming, underachievement,

withdrawal-often interpreted as “laziness”

-may be the results of visual or hearing

defects, of anemia, glandular disturbances,

or many other causes. However, in the

mid-die and upper socioeconomic groups such

conditions are usually discovered earlier

and rarely represent signifcant contributing

factors to learning difficulties. Fatigue and

hunger can be found as a result of poor

living habits and inadequate supervision

in the child of well-to-do parents, whose

permissiveness and lack of organization

al-lows or even encourages the child to stay

up late at night or run to school without

breakfast.

The cause of a learning problem may be

difficult to pinpoint; for instance, mental

retardation and deafness may be confused,

or deafness may not be recognized in a

mentally retarded child.8

Neurological disorders in the form of

manifest brain damage, resulting in mental

retardation, cerebral palsy, or seizures, are

usually recognized without difficulty. These

may be associated with psychological

dis-turbances.9 But the realization that

be-havior, language, and learning problems

can be caused by minimal central nervous

system disorders in the absence of overt

evidence of mental retardation or

neuro-motor impairment has come about only

gradually in the recent past, and the

sub-ject still remains controversial.

Two categories of central nervous system

problems need to be examined : first, the

group with neurological damage or cellular

destruction as a result of some insult to the

brain; secondly, the group with

develop-mental or maturational deviation which

me-suits in marked unevenness of functioning

and which is thought to be constitutionally

determined and of genetic origin.

Minimal Brain Damage

Various terms have been used to

desig-nate this group of conditions, such as

or-ganic brain disordems,b0 brain damage,

minimal cerebral 2 hyperkinetic

impulse disomder,13 and minimal chronic

brain syndromes.14

Much of the current interest in this area

can be attributed to the contributions of

Goldsteinl3 and the more recent work of

Strauss and his associates who pioneered

in the educational habilitation of atypical

children.16 They called attention to a group

Of problem youngsters who demonstrated

hyperkinesis, motor inco-ordination,

dis-tractibility, perseveration, learning

disor-ders, and perceptual problems. These

chil-dren were temperamentally unstable,

ex-hibited little capacity to tolerate

environ-mental stress, and had marked difficulty in

adjusting to and achieving in a regular

classroom setting. Strauss believed that tileir

disturbed function resulted primarily from

organic neurological impairment. He

differ-entiated the syndrome from disorders of

psycho-social origin and called them

“brain-injured children.”

Pasamanick et 718 and 92

subsequently demonstrated that theme is a

high correlation between certain pregnancy

and perinatal complications, particularly

prematurity, and learning disorders as well

as behavior problems. Drillien states that

“obstetrical hazards may lower the child’s

resistance to adverse factors in the

post-natal environment.”#{176}

(3)

sent a picture of generalized motor

awk-wardness, principally manifest in fine motor

inco-ordination, difficulties in balance,

dys-diadochokinesis, hyperreflexia, mild

choreo-athetosis, and poor handwriting. These

mini-mal signs may go undetected in the

classi-cal neurological examination, but may be

noted in tile expanded neurological exam-ination and ill psychological testing.2’ The electroencephalogram may be abnormal.

Speech and language problems are common

and further testing may reveal problems in

auditory comprehension, reduced auditory

memory, and diminished auditory

discrim-ination and perception.

The restlessness, impulsivity, and

explo-sive nature of their responses make it

diffi-cult for these children to adjust in ordinary

classroom settings. The child’s behavior and

low achievement rate are a source of

annoy-ance to teachers. Psychological disturbances

may develop and may present the major

problem in later years.

In some instances drug therapy may be

of value in decreasing the hyperactivity,

distractibility, and extreme anxieties associ-ated with tile syndrome. Numerous

pharma-cologic agents have been used and

encour-aging results have been 2223, 24

al-though the opinions are far from unanimous.

If secondary emotional factors can be

avoided, the long-term outlook of the

hy-perkmnetic child with adequate intellectual

endowment is favorable. As he matures, the

child often develops the ability to

compen-sate for his perceptual distortions. In most

children, hyperactivity and impulsivity can

be expected to show significant resolution

near puberty, with or without medication.

Once the child’s organic difficulties have

been recognized, adjustment problems can

be better understood. The nature of the

psychological difficulty will vary depending

upon many factors, including family

sta-bility and other social relationships.

Percep-tual difficulties may cause problems in all

areas of learning; motor awkwardness can

make it difficult for the child to participate

in sports and other peer activities.

The diagnosis of minimal brain damage,

and subsequent reappraisal and

manage-ment of the child’s problems, will often

bring about a significant improvement in

the child’s performance, adjustment, and

acceptance. A simple explanation of the

clinical diagnosis, the symptoms, and the

prognosis may help parents and teachers in

their attitude and approach, and this in turn

may help these children in coping with the

environmental stresses at home, at play, and

in school.

A significant number of seemingly

organ-ically impaired children can be managed by

a combination of direct parent counseling,

psychotropic drugs, structured environ-ment, firm discipline, and educational

pro-23 24 Some of these children present

a generalized picture of immaturity to

vIlich the mother often responds

instinc-tively with overprotectiveness. Within

cer-tam limits, this may be helpful to the child

rather than detrimental. In cases where a

weakness in the capacity of the parents to

respond appropriately to the child’s needs

is the most important limiting factor, more

formal psychotherapeutic intervention is

required.

Specific Language Disability

The acquisition of language skills,

par-ticularly reading, serves as the pass key to academic progress. Children who encounter persistent difficulties in learning to read are

high-risk candidates for problems in

aca-demic achievement and school adjustment. Many investigators have tended to the

view that there is an identifiable group of

children with language and learning

dis-orders due to neurological dysfunction,

\vilich may be determined genetically. This

condition has been described under such

terms as specific dyslexia,?5 congenital word

blindness,26 specific developmental

dys-lexia,27 and strephosymbolia.28

The central issue of this thesis is that

there exists within the community of slow

learners, a specific group which has

par-ticular difficulty in learning the

conven-tional meaning of symbols, which is of

(4)

SPECIAL ARTICLE

and is often genetically determined. The

condition is much more common in boys

than in girls, and is frequently associated

with mixed laterality, delayed

determina-tion of handedness, motor awkwardness,

and directionality confusion. Detailed

fam-ily history frequently reveals a similar

read-ing, speech, or language disorder among

near relatives.

The acceptance of this entity is not

uni-versal. Those who are opposed to the

con-cept of specific language disability point

out that retarded readers constitute a

con-tinuum and that it is meaningless to single

out a group of special cases. They believe

that poor teaching, irregular school

attend-ance, social and cultural factors, and

emo-tional disorders rather than inheritance are

the causative factors. They also indicate

that an entity such as specific language

dis-ability or congenital language disorder

might suggest to the teacher that the child’s

problem could not be remedied. Such an

assumption is, of course, incorrect.

An exact definition of specific language

disability is not possible since it ranges in

degree from very mild to extremely severe.

The key point, however, is that reading and

other language skills are definitely out of

keeping with over-all intellectual capacities

and that this difference persists in spite of

competent instruction over adequate

pen-ods of time with pedagogic methods which

are successful in the majority of children.

It is of more than mere academic interest

to determine if learning disabilities might

be of genetic origin. If such an hypothesis

could be established, much of the

long-term frustration and failure resulting in

secondary emotional complications could

be alleviated by early identification,

spe-cial instruction, and appropriate parent

counseling.

An exhaustive epidemiologic study of

reading disabilities has been reported by

Hallgren.2 He studied 276 cases of

read-ing disability and their near relatives, as

well as 212 controls. He found reading

dis-abilities in 88% of the families of his index

cases and concluded that reading problems

are genetically determined and follow an

autosomal dominant mode of inheritance.

Valuable information in understanding

the contributing role of hereditary and

en-vinonmental factors may be gleaned from

studies of twins with reading problems.

Hemmann reported studies on 45 sets of

twins, in which at least one was found to

have a reading 29 Of 3 pairs of

non-identical twins, one of whom had reading

retardation, 33% of the co-twins were

simi-larly involved. Of 12 sets of identical twins,

however, 100% concordance was found.

Al-though the numbers are small, the findings

are of considerable interest and lend

sup-port to the hypothesis that genetic factors

may be involved.

Out of our study and experience0 we

have arrived at the following observations:

1. There exists a group of children of

adequate intelligence and apparently

ade-quate motivation who are seriously

me-tarded in reading and whose problem

can-not be readily accounted for on the basis

of demonstrable physical abnormalities,

emotional disorders, or environmental

fac-tors.

2. These problems are commonly

associ-ated with a family history of reading

dis-ability and language disorder in near rela-tives.

3. Reading problems are more common

in males than in females by a ratio of

be-tween four and eight to one.

4. There is no higher incidence of visual

refractive error among children with

read-ing problems than among children without

these problems.

5. Specific neurological signs are

uncom-mon in children with reading retardation.

However, they frequently are very

awk-wand in their body movements, especially

those involving fine motor co-ordination,

balance, and handwriting.

6. Psychological testing may show a wide

disparity between verbal and performance

scores on the WISC (Wechsler Intelligence

(5)

Scale for Children) and this disparity may

he in either direction.

7.

Psychological studies may reveal

prob-lems in spatial orientation and directional-ity. These children have unusual difficulty

in reproducing and synthesizing geometric

designs and show frank reversals and

rota-tions.

8. Speech problems and language

dis-orders are more common in children with

reading problems than among control

groups. These children have problems in

more than one area. They may be seen by a

psychiatrist and receive a psychiatric

diag-nosis; when studied by an educator, they

will be labeled with an educational

diag-nosis; and when seen by a neurologist, will

be given an additional label. The necessity

of close communication among these

disci-plines is obvious, but these professional

workers have often failed to cultivate

inter-professional communications and exchanges

of ideas necessary for the development of

optimal understanding of these complex

problems 24

The pediatrician, through early

recogni-tion of language difficulties, especially if

the history reveals a familial incidence, can

do much to encourage early remedial steps

and avoid handicapping personality and

school problems.3#{176}

LEARNING DIFFICULTIES

AND INTELLIGENCE

As with any laboratory test, I.Q. test

re-suits must be regarded with caution and in

the proper perspective. I.Q. tests were

standardized on the average American with

an average environmental and educational

background. While its purpose is to

meas-ure intellectual endowment it really

re-fleets the individual’s current functioning,

and the results are the product of

endow-ment, past learning experience, and current

motivation.

A child who has not had the average

in-tellectual stimulation and has not been

ex-posed to learning experiences usually

ex-pected for his age is apt to function below

the highly stimulated child who has been

SCHOOL FAILURE

exposed intensively to learning material.

Thus test results can be misleading as to

actual intellectual ability and future

p0-tential.

Since intellectual ability as measured by

I.Q. tests is relative to preconceived

stand-ards, its implication for a particular child

and his family, and for the child’s ability

to adapt adequately to the demands of his

society must be evaluated from a relative

vantage point and not in isolation. A child

vith an I.Q. of 100, coming from an

in-tellectually superior family, may be

con-sidered relatively retarded by his family

and peers. Unrealistic academic

expecta-tions and pressures on the part of parents

will be in conflict with the child’s ability,

leading to disappointment and defeatism.

The school personnel may or may not

rein-force the conflict by such statements as, “he

is average-just like all the other children,”

the parents wishfully interpreting this to

mean “like his siblings and some children.”

Conversely, relative brightness may stand

out if the child is born into an intellectually

dull family. In such an environment he may

not only suffer from undenstimulation but

may be actively discouraged in his

intellec-tual endeavors which may be embarrassing

and incomprehensible to the parents.

LEARNING DIFFICULTIES AND

PSYCHOSOCIAL FACTORS

Motivation and Stimulation

Basic to a positive learning experience

are eagerness to learn, incentive from the

environment, and exposure to learning

ma-terial.

Underprivileged minority groups often

view with suspicion and resentment the

educated person who has attained a higher

socioeconomic and educational status and

whom they meet in authority roles (teacher,

policeman, social worker, etc.). They equate

education with authority, which produces a

negative attitude toward learning in

par-ents and older children, and this is readily

transmitted to the child entering school. In

such a milieu it becomes undesirable

(6)

133

the academically successful child soon

earns the reputation of “apple polisher” and

“sissy,” and his positive educational desire is seen as non-conforming within the group

and unacceptable to peers.

Parallel with this lack of motivation often

goes absence of readily available books,

magazines, and newspapers, and a lack of

active stimulation and participation by the

parents. Pleasurable learning experiences,

such as trips to the library or museum

ex-hibits, are limited, language development is

constricted, and intellectual and academic

activities, if any, are passive and minimal.

While this does not necessarily hold to all

low socioeconomic minority groups, it is

found there much more frequently.31 32

In any therapeutic approach it must be

kept in mind that the foregoing is

essen-tially a social problem which must be

at-tacked by “feeding the hungry, educating

the ignorant, treating the emotionally

dis-turbed”-in that order. Economic

assist-ance, retraining of the breadwinner,

reloca-tion of the family may be the basic steps.

In addition, early educational experiences

to counteract the effects of deprivation are

being attempted through the establishment

of nursery school classes in the public

school systems in underprivileged areas.#{176}

Adjustment of the school curriculum to

meet the special needs of children in such

areas is another way to increase their

moti-vation to learn and remain in school. This

should not mean a deprived curriculum for

the deprived child, but a meaningful

cur-niculum geared to the practical need for

early tangible returns : early introduction of

vocational skills, with academic teaching as

meaningful adjunct to vocational training.

A psychotherapeutic approach is usually

not indicated in this group since their

prob-lem is not one of adjustment difficulties.

They are adjusted to their environment,

and a change of the environment is a

socio-0 The Baltimore city school system started such a pilot study in September, 1962, with funds pro-vided in part by the Ford Foundation under its “Gray Area Program.”

economic problem and basically not a

psychiatric one. In the emotionally

dis-tumbed child who is the product of a

dis-turbed family, treatment has to include the key member(s) of the family.

The mode of living in middle and upper

socioeconomic intellectual groups offers

motivation and stimulation to learning. The

higher educational background of parents

and peers, the high value placed upon

in-tellectual achievement, and the availability

of resources all tend to stimulate the child

to strive toward approval by acquisition of

knowledge and success in school.

Yet this does not always hold true. The

middle- or upper-class girl whose idea of

success is not a successful career or knowl-edge for knowledge’s sake, but a husband

who can provide all material comforts, may

lack the motivation necessary for good

school performance. Her ambivalent

feel-ings about education are often repressed,

but if the conflict can be lifted from the

subconscious level and expressed openly,

clarification and reorientation can occur

and the conffict can be solved.34

In materialistic-hedonistically oriented

families success in school and pursuit of intellectual achievements for the child may

be the expressed desire of the parents, but

their personal example conveys to the child

that father is lacking these attributes and

that his way of life had led him to success

through roads other than those professed

to be desirable. It is easy to see why a child

from such an environment would lack the

necessary motivation for academic success.

The therapeutic approach in these

chit-dren can be frustrating and difficult. At

times interpretation to the parents of how

the child sees them and their life can be an

eye-opener to the parents and lead to better

communication and understanding.

Discus-sions around a realistic appraisal of the

financial situation of the family, often not

as rosy as parents like to pretend in order

to “give the child all the things they have

missed in their youth,” and a review of

their uphill struggle in earlier years can

(7)

rein-forced by meaningful limits set with

con-sistency.

Parents often foster social preoccupations

and distractions such as clubs, sororities

and fraternities, and radio and television

sets in tile child’s room. Such competition with study time may be difficult to control

if the child’s school progress becomes

af-fected. Families with such conflicts may

need tactful guidance over longer periods

of time, and parental insigilt into the

coii-flict the’ created may be slow to come.

Negativism

In the process of normal emotional

growth the drive for independence is often

expressed through rebellious behavior,

antagonistic to parental wishes and

expec-tations.’5 What more effective way to

ex-press such feelings than through opposition

to successful schooling, the single most

ex-tensive process of molding youth into the

image of the adult?

This process can take the form of

aggres-sive, disruptive behavior in tile classroom,

defiant refusal to work, truancy or,

con-versely, compliant behavior with passive

resistance to learning. This may be on a

conscious level or, more often, the

resist-ance to learning is subconscious and the

child may sit for hours in front of the book

without absorbing the information, or “know all the work at home” and fail the test in school. Some early school dropouts

fall into this category. The choice of a

ca-reer is often determined by the

subcon-scions drive to assert his independence in

the form of opposition to father’s wishes

rather than by inclination, ability, or even

opportunity.

The child is not aware of the dynamics,

is not responsive to direct interpretation,

and the parents are helpless, and furious

in their helplessness, in the face of

“illogi-cal” behavior. They cannot comprehend

that the child’s actions are guided by

sub-conscious motives rather than by logical,

intellectual considerations.

At times, counseling can change the

par-ents’ pushing, demanding, and punitive

at-titude and can help the youngster to gain enough insigllt into the dynamics of his

ac-tions to enable him to change his course.

Often, however, child-parent antagonism

has become a way of life, has expanded to

antagonism and hostility toward teachers

and any representative of authority, and

cannot be altered by short-term counseling.

This is particularly true when deeper psy-chosexual conflicts are disturbing the

child-parent relationship. Then prolonged

analyt-ically oriented psychotherapeutic efforts will

be necessary, associated with intensive

par-ental counseling or treatment, or even

re-moval of the child from his environment

into an intensive therapeutic setting.36

Inner Conflicts

Inner conflicts can be energy absorbing,

cause insomnia, inability to concentrate,

daydreaming, and can interfere with

ade-quate functioning in learning activities.

Worry about precocious or delayed

sex-ual development, about actual or imaginary

parental rejection, about parental discord,

fear or anguish caused by illness or death

in the family, frustrating competition with

academically superior siblings, to mention

just a few, can seriously affect a youngster’s

physical and emotional well-being and

aca-demic performance.

Deeper probing into the nature of the

conflicts often reveals psychosexual

dis-tunbances in need of correction via

pro-longed therapy. Reading difficulties may be

regarded as a manifestation of anxiety over

inadequately resolved hostile, destructive

sexual fantasies, whereby the patient seeks

relief of the guilt over his hostile fantasies

through self-punishment by exposure to

criticism at home and in school.

Psychoanalysts have pointed out the

analogy between sexual aggressiveness and

looking, reading, and learning. If sexual

aggressiveness is “bad,” so would be

look-ing, reading, and “Repression

of sexual curiosity may block the normal

interest in knowing and thinking. . . . The

‘stupidity’ may represent simultaneously an

(8)

parents from whom the patient had

suffered frustrations for his curiosity.”40

A negative conditioning to learning can

be effected early in life through an

un-pleasant experience connected with first reading efforts and their association with a

hated, severe, or punitive teacher on

par-ent.4’

In another study on learning impotence,

the author attributes a negatively charged

pathological attachment to mother as

lead-ing to difficulties in achieving a separate

identity. These children see “non-learning” as a successful form of separation from the mOtller.42

Whatever the underlying cause, it is

im-portant that the emotional conflict leading

to the learning difficulty be recognized and

treated before it produces a pattern of

aca-demic failure with ramifications beyond the

causative factors. Eventually the

complica-ting factors in behavior, grade retardation,

and parental, teachers’, and peers’

reac-tions may hide the original causes.

PROBLEMS OF SCHOOL ATFENDANCE

School Phobia

For the physically ill child, homebound

for a prolonged time, provisions exist in the

school system for help through home

teach-ens, tape recordings, or other technical

an-rangements. Less adequate provisions are

usually available for absences due to

psy-chological causes, often because they are

not well understood. The pediatrician’s role

in this situation involves not only the

evalu-ation and treatment of the child, but

guid-ance for the parents and school personnel.

School phobia, a neurotic behavior

mani-344 may occur with or without

psychophysiologic reactions or personality

disorders. In adolescence, it can be a

mani-festation of a serious character disorder.45

Probably the most frequent cause of early

school phobia is a separation anxiety

mutu-ally shared by mother and child. Maternal

rejection with resulting guilt and

overpro-tection may make separation difficult for

the mother, and this feeling is readily

con-veyed to the child.

Overdependence as a result of

overpro-tection may evoke hostility in the child

to-ward the mother from whom he cannot

de-velop independence. This hostility with

resulting guilt can lead to fear of

abandon-ment,46 fear of death of mother, and a need

for not leaving her side. Childhood

de-pression may also cause school phobia,47

and there are still other causes43 which

cannot be discussed within the frame of

tllis paper.

The therapeutic approach to school

phobia consists of two phases: an

immedi-ate attempt to return the child to school,

usillg verbal pressure, physical assistance,

and environmental maneuvers in order to

avoid secondary effects due to prolonged

absence, such as academic retardation,

shame upon returning, ridicule, etc.

See-ondly, the underlying problem must be

treated. Depending on its depth and

dura-tion, this may in some cases be resolved

quickly or resolve itself, or may require

prolonged psychotherapy for child and

mother.

Truancy

Another cause for absenteeism is truancy,

found usually among the older school

pop-ulation and closely related to delinquency.

This is a deliberate absence from school, on a rational basis, with or without the

knowl-edge of the parents. In many of these

youngsters lack of academic achievement is

a secondary manifestation, although the

lack of intellectual ability or a reading

dis-ability may produce indifference and lack

of motivation for learning, and may be the

forerunners to truancy.

Delinquency

Primary low academic achievement may

lead to delinquent acts as a means of

at-taming recognition and acceptance by

peers, or delinquent behavior as an

adapta-tion to a subcultural mode of living may

lead to refusal-to-learn as part of

group-accepted mores. A vicious cycle often

de-velops which becomes more difficult to

(9)

SCHOOL FAILURE

Special sciloOl programs, requiring close

collaboration of staff teams, have been

de-‘eloped to cope with this pmoblem.

In a child whose delinquent behavior is

overtly or covertly supported by his parents

and rewarded by his peers, thus a

socio-logical problem, neither individual

psycho-therapy nor tutoring or remedial reading

can be expected to beam fruit unless they

are part of a corrective process attacking

the social problem.

In many cases of delinquent behavior the

child derives little if any academic benefit

from his physical presence in school, and

is better served by the experience of

me-moval as a result of his behavior, a

conse-quence he is apt to face in later

employ-ment if his conduct is not acceptable.

Training scilool, early employment, special

foster homes, or group homes may be of

more help to this type of ease for his future

adjustment.

In order to prevent such extreme

meas-ures, it is of course important to discover

the potential delinquent as early as possible

and to institute preventive and therapeutic

measures. In some school systems serious

attempts are made to detect children with

potentially disturbed or delinquent

be-havior. Among the programs which have

been in progress for some time are the

Early Identification and Prevention

Pro-gram in New York City49 and the

Chil-dren’s Guild in Baltimore (a nursery school

for emotionally disturbed preschool

chil-dren).

Drop-outs

Closely related to juvenile delinquency

is the problem of the “drop-out,” which in

recent years has assumed such proportions

that it has become of major concern not

only to the educator but also to industry,

labor, and law enforcement on state and

federal levels.

A statistical evaluation of the extent,

causes, and ways toward correction,

na-tionally and by states, was published in a

recent issue of School Life,5#{176} the official

journal of the Office of Education of the

U.S. Department of Health, Education, and

Welfare. It shows that of all ninth graders

in the United States in 1958/9 only 69.7%

graduated from high school four years

later. Table I lists the various causes for

dropping out.

TABLE I

REASONS FOR WITHDRAWAL Civ:x ny PUPILS Wno

DROPPED OUT OF MARYLAND PuBLIC hIGh ScI1ooIs

DURING THE \FAR ENDING JUNE 30, 196110

Reasons Percentage of Total

Lack of interest

Lack of scholastic success Economic reasons r.rarriage Pregnancy Allother

35 .3’53

17Sf I I.1

9.2

5.3 21.3

A recently completed exhaustive study’

points out that the majority of drop-outs

had been retained in some grade at least

one year and were often two or more years

below grade level in reading. But it also

produces evidence that “in a great majority

of cases, lack of mental ability is probably

not the major cause of failure to finish

school.”

Prevention must start before the negative

attitude toward school has become fixed,

and certainly while school attendance is

still legally obligatory. For any such

pro-gram to be effective, close co-operation

be-tween agencies is essential. Schools will

have to adjust their curriculum to be

mean-ingful to youngsters whose immediate goal

is early earning ability and financial

inde-pendence. Teachers need special training

and understanding of the psychology of the

child and his background. Industry will be

called upon to provide training and job

op-portunities, and industry’s needs in turn

must be correlated with vocational

prepana-tion during the school years. Facilities have

to be adjusted to local conditions in the

community, which might change in the

course of years, complicating the task of

long-range co-ordinated planning.

(10)

137

to identify at an early age those who seek,

by escape from school, solutions to their

inner conflicts which are often centered

around parental relationships. Many of

these youngsters can be helped by

psychi-atnic intervention, but again early

identifi-cation and early corrective measures are

till

LEARNING DIFFICULTIES AND

EDUCATIONAL FACTORS

One of the most basic approaches toward

the prevention of potential learning

diffi-culties and drop-outs is the adaptation of

the school curriculum to the needs of

youngsters according to their ability,

mo-tivation and orientation, social customs, and

patterns of society.

The basic school program is geared to

the “average” child with an “average”

back-ground, and that is as it should be. Great

strides have been made to provide

school-ing, within the public school systems, for

physically and mentally handicapped

chil-dren. More progressive communities are

providing special educational classes for

brain-injured children, for educable and

trainable retardates, for children with

corn-munication disorders, and for children with

severe reading problems. School facilities

for the emotionally disturbed, for the

eul-turally deprived, for borderline intelligent,

and for the intellectually gifted children

are at this point woefully inadequate.

In low motivational, low socioeconomic

groups and in those with borderline

intelli-genee, which constitute the bulk of failures

and drop-outs, the general academic

cur-riculum is not meaningful or practical since

orientation and economic needs often

de-mand that school experience be translated

into early earning capacity. Postponement

of early gratffication of hedonistic desires

(

dates, car, clothes) in favor of delayed but

higher economic, social, and intellectual

goals is too great a frustration for the

im-mature youngster. The lack of parental

ex-ample and supervision and the desire for

group acceptance through achievement in

non-scholastic activities condition the child

against school. For this group, introduction

of vocational training with tangible goals

and early financial returns must take place

before the child is conditioned against

school and the social structure it represents,

and before he has acquired delinquent

pat-terns of behavior.

The bright child who does not perform

“according to his ability,” the child who

fails when there should be no reason

be-cause “his I.Q. is so high,” or the child who

could do so well “if he would only apply

himself,” is being recognized more and

more as a child who can be helped.

Educa-tors have been making efforts at early

iden-tification of learning difficulties and their

physical or emotional 455 and

diag-nostic services within some school systems

have been established. However, with

in-creasing frequency the pediatrician is

con-suited by the parents, or he may be the first

to recognize the existence of a problem if

he extends his inquiry into the area of

social and academic functioning.

It is estimated that about 2.2% of the

pop-ulation have an I.Q. over 13056 (about 1-3%’

are considered mentally retarded), hut the

approaches toward teaching these gifted

children have been haphazard and

spo-758

These children are apt to get bored in

the “average” class situation. They will look

for diversion in unacceptable ways, often

inducing others to join in the fun, and their

academic performance may decline to tile

point of failure. Theme is a tendency to look

for the solution by changing to an even

slower moving class or by employing a

tutor, while overlooking the seemingly

paradox alternative of moving a poorly

per-forming child to an accelerated, more

chal-lenging class. Here the pediatrician can be

of assistance in the recognition of the

situa-tion and in the choice and timing of

ap-propriate remedial moves.

The child with behavior disturbances is

apt to continue the acquired behavior even

after a change in class situation, unless he

is given additional help at the appropriate

(11)

treatment, counseling by the school

eounse-br or social worker, and/or tutoring in a

specific subject. While some of the

counsel-ing can be done by the pediatrician, his

main function is the pivotal position he

en-joys with the child and his family, which

places him in the strategic role to

eo-ordinate the various corrective endeavors

and to prepare and motivate child and

family for the remedial procedures.

The pediatrician may not always be

pre-pared to handle such situations, either for

lack of time or lack of familiarity with

school facilities and auxiliary resources. In

this case referral to tile child psychiatrist

should be made early, after careful

prepa-ration of the family.

There are a number of educational

fac-tors which may be related to school failure,

which are primarily of a pedagogic nature,

or directly the responsibility of the school

authorities. Some of these are the teacher’s

personality and competence, frequent

teacher changes, grading systems, and the

widely discussed teaching methods in early

reading 61 While the

pedia-trician is rarely requested to intervene in

such problems, he should be sufficiently versed in them to be able to differentiate

them from other causes of school failure.

SUMMARY

Modern preventive pediatrics recognizes

that the scilool life of the child is one of the

important environmental forces affecting

his total well-being. Learning difficulties, or

any problems interfering with adequate

functioning in school, thus enter within the

province of pediatric care.

While the cause of a learning difficulty

may be purely educational, to be handled

adequately by the school authorities, the

problem is frequently more complex and

involves a variety of physical, emotional,

or social factors. The pediatrician, through

llis close acquaintance with tile child, his

family, and their environment, is in the

strategic position to seek and co-ordinate

the services needed for the correction of

these multi-faceted problems. In order to

do so he must be thoroughly acquainted

with the many factors which may interfere

with a child’s school performance so that

he can correctly evaluate the problem and

find the appropriate avenue for help in the

individual child.

REFERENCES

1. Bennholdt-Thomsen, C. : Failure in school-and the doctor. Muenchen. Med. Wschr.,

102:1, 1959 (in German).

2. Mousees, E. K. : Aphasia and deafness in

children. Exceptional Child., 25:395, 1959.

3. Kanner, L., and Eisenberg, L. : Childhood

problems in relation to the family.

PEDI-ATIUCS, 20:155, 1957.

4. Coleman, J. M., Iscoe, I., and Brodsky, M.: The “Draw-a-Man Test” as a predictor of

school readiness and as an index of

emo-tional and physical maturity. PEDIATRICS, 24:275, 1959.

5. Office Evaluation of Intelligence and Special Senses (Symposium). Bordley, J. E. : Hear-ing; Costenbader, F. D. : Vision; Bakwin, R. M. : Intelligence; Eisenberg, L. : Reading.

PEDIATRICS, 23:980, 1959.

6. Korsch, B., et al.: Pediatricians’ appraisals of patients’ intelligence. PEDIATRICS, 27:990, 1961.

7. Bentzen, F. : Sex ratios in learning and

be-havior disorders. Amer. J. Orthopsychiat., 23:92, 1963.

8. De Schweinitz, L., Miller, A., and Miller,

J. B.: Delays in diagnosis of deafness among preschool children. PEDIATRICS, 24:462, 1959.

9. Taylor, E. M. : Psychological appraisal of chil-dren with cerebral defects. Cambridge,

Massachusetts : The Commonwealth Fund,

Harvard University Press, 1959.

10. Bender, L. : Psychopathology of Children with Organic Brain Disorders. Springfield, Illinois: Charles C Thomas, 1956.

1 1. Eisenberg, L. : Psychiatric implications of brain damage in children. Psychiat. Quart., 31:72, 1957.

12. Knobloch, H., and Pasamanick, B. : Syndrome of minimal cerebral damage in infancy. J.A.M.A., 170:1384, 1959.

13. Laufer, NI. N., Denhoff, E., and Solomons, C.: The hvperkinetic impulse disorder in chii-dren’s behavior problems. Psychosom. Med., 19:38, 1957.

(12)

NOTE: The child is expected to be able to read each column at the end of the grade indicated. The test is

un-timed and the results can be expressed in percentages.

APPENDIX

WORD RECOGNITION TEST

. Pre-Przmer Level . Primer Level . First Grade

Second Grade Third Grade

i’irst half Second half First 1hz/f Second half

1. a 2. ball 3. blue 4. come 5. father 6. get 7. have 8. house 9. in 10. it

(13)

140

SCHOOL

FAILURE

15. Goldstein, K.: The Organism-A Holistic

Ap-proach to Biology. New York : American

Book Company, 1939.

16. Strauss, A. A., and Lehtinen, E. L. : Psycho-pathology and Education of the Brain-In-jured Child. New York: Crunc and Stratton,

1950.

17. Pasamanick, B., and Lilienfeld, A. M. :

Preg-nancy experience and the development of

behavior disorders in children. Amer. J. Psychiat., 112:8, 1956.

18. Kawi, A., and Pasamanick, B. : Prenatal and Paranatal Factors in Children with Reading Disorders. Monogr. Soc. Research Child Develop., 24:4, 1959.

19. Drillien, C. M. : Obstetric hazard, mental re-tardation and behaviour disturbance in

primary school. Develop. Med. Child.

Neurol., 5:3, 1963.

20. Drillien, C. M. : A longitudinal study of the growth and development of prematurely and maturely born children. Arch. Dis.

Child., 36:233, 1961.

21 . Rabinovitch, R. D., Drew, A. L., et al: A

Research Approach to reading retardation.

Res. PubI. Ass. Res. Nerv. Ment. Dis.

34:363, 1954.

22. Bradley, C.: Characteristics and management

of children with behavior disorders

associ-ated with organic brain damage. Pediat.

Clin. N. Amer., 4:1049, 1957.

23. Clements, S. D., and Peters, J. E. : Minimal brain dysfunction in the school age child.

Arch. Gen. Psychiat., 6:185, 1962.

24. Clemmens, R. L. : Minimal brain damage in

children : An interdisciplinary problem, medi-cal, paramedical and educational. Children,

8:179, 1961.

25. Haligren, B. : Specific dyslexia: A clinical and genetic study. Acta Psychiat. Neurol. Suppl., Vol. 65, 1960.

26. Drew, A. C. : A neurological appraisal of familial congenital word-blindness. Brain, 29:440, 1956.

27. Ingram, T. T. : Pediatric aspects of specific developmental dysphasia, dyslexia and dysgraphia. Cereb. Palsy Bull., 2:248, 1960. 28. Orton, S. T. : Specific reading

disability-strephosymbolia. J.A.M.A., 90: 1095, 1928. 29. Hermann, K., and Norrie, E. : Is congenital

world-blindness a hereditary type of Gerstmann’s syndrome? Psychiat. Neurol.

(Basel), 136:59, 1958.

30. Gallagher, J. R. : Medical Care of the Ado-lescent. New York: Appieton-Century-Crofts, Inc., 1960.

31. Friedman, NI. : Some aspects of cultural

dep-rivation. Pathways Child CUid., Board Ed.

New York City, 4:1, June, 1962.

32. Jones, H. : The Environment and Mental

De-velopment. Manual in Child Psychology. New York: Wiley, 1954.

33. Simmons, J. E. : The impact of the family and home environment on the performance of the school child. J. Indiana Med. Ass., June, 1959, p. 963.

34. Liss, E. : Learning difliculties. Amer. J. Ortho-psychiat., 11 :522, 1941.

35. Glaser, K. : Conflicts and rebellion during

adolescence. PEDIATRICS, 26: 839, 1960.

36. Newman, R. G. : Assessment of progress in the treatment of hperaggressive children with learning disturbance within a school setting. Amer. J. Orthopsychiat., 29:633, 1959.

37. Harper, P. : Preventive Pediatrics (Child

Health and Development). New York:

Ap-pleton-Century-Crofts, Inc., 1962.

38. Silverman, J. S., Fite, M. W., and Mosher,

M. M. : Learning problems: (1) Clinical

findings in reading disability children-spe-cial cases of intellectual inhibition. Amer. J.

Orthopsychiat., 29:298, 1959.

39. Sperry, B. NI., et a!.: Dstmctive fantasies in certain learning difficulties. Amer. J. Ortho-psychiat., 22:356, 1952.

40. Fenichel, 0. : The Analytic Theory of Neurosis.

New York: Norton, 1945, p. 181.

41. Pearson, C. H. J.: A Survey of Learning Diffi-culties in Children. Psychoanal. Study

Child., 7:322, 1952.

42. Rubenstein, B. 0., et al.: Learning impotence: A suggested diagnostic category. Amer. J. Orthopsychiat., 29:315, 1959.

43. Glaser, K. : School phobia and related condi-tions. PEDIATRICS, 23:371, 1959.

44. Eisenberg, L. : School phobia : A study in the communication of anxiety. Amer. J.

Psy-chiat., 114:712, 1958.

45. Coolidge, J. C., et al.: School phobia in ado-lescence: A manifestation of severe character

disturbance. Amer. J. Orthopsychiat.,

30:599, 1960.

46. Kagan, J.: Psychological studies of a school

phobia in one of a pair of identical twins.

J. Projec. Techn., 20:78, 1956.

47. Agras, S. : The relationship of school phobia to childhood depression. Amer. J. Psychiat., 116:533, 1959.

48. Goldsmith, J. M., et al: Changing the

delin-quent’s concept of school. Amer. J.

Ortho-psychiat., 29:249, 1959.

49. Early identification and prevention program,

kindergarten through 3rd grade-New York

City. See N.E.A.J., 51:50, 1962, and Path-ways Child Guid., 4:3, June, 1962. 50. Miller, L. M. : The dropout: Schools search

for clues to his problems. School Life, May,

(14)

51. Schreiber, D. (Project Director): School

drop-outs-A symposium. N.E.A.J., 51:O, 1962.

52 Josselyn, I. M. : The problem of school drop-outs. Children, 9: 194, 1962.

53. Lichter, S., et al.: The Dropouts: A Treatment Study of Intellectually Capable Students

who Drop Out of High School. New York: Free Press of Glencoe, 1962.

54. DeHirsch, K. : Tests designed to discover po-tential reading difficulties at the six-year-old level. Amer. J. Orthopsychiat., 27:566, 1957.

55. Bower, E. M. : The emotionally handicapped child and the school-present research plans and directions. Exceptional Child., 26:232, 1960.

56. Silverman, S. S. : A bureau for children with accelerated mental development. Pathway’s Child Guid., Board. Ed. New York City, 4:2, June, 1962.

57 Newland, T. E. : Programs for the superior:

Flappenstansical or conceptual? Teacher’s College Rec., 62:513, 1961.

58. Cutts, N., and Moseley, N. : Teaching the

Bright and Gifted. New York: Prentice-Hall, Inc., 1957.

59. Flesch, R. : Why Johnny Can’t Read-And

What To Do About It. New York: Harper

Bros., 1955.

60. Gates, A. I. : Why Mr. Flesch is wrong.

N.E.A.J., September, 1955.

61. Brown, S. : Dr. Flesch’s cure for reading troubles. Commentary, August, 1955, p. 152.

Acknowledgment

The authors wish to express their sincere ap-preciation to Dr. Gilbert B. Schiffman of the

Balti-more County Department of Education for his

(15)

1965;35;128

Pediatrics

Kurt Glaser and Raymond L. Clemmens

SCHOOL FAILURE

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Pediatrics

Kurt Glaser and Raymond L. Clemmens

SCHOOL FAILURE

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