Patient Presentation
A 6-year-old male came to clinic for a health supervision visit. He was healthy, had friends, and enjoyed swimming and playing soccer. He had struggled in kindergarten with pre-reading concepts and the school was going to have him repeat kindergarten. He had been tested for hearing and vision problems during the previous school year. The family history showed that the father saying that reading was a struggle for him and he still did not like to read. No family members had been retained or needed additional help in school. None had attentional issues.
The pertinent physical exam showed a healthy male with growth parameters in the 10-25% and normal development. His physical examination was unremarkable. The diagnosis of a healthy male who was going to be retained in kindergarten was made. During the interview the father said that the school had recommended him being retained because of his reading problem, that he was more immature than the other students and that he was physically small. He didn’t know if the school was going to give his son any special help with his reading and social skills. “I think they are just going to have him do it again,” he said. The pediatrician voiced her concern that there is little data to support holding a child back to begin kindergarten, nor for retaining in kindergarten, and noted that there was data which showed children who were retained had poorer school and psychosocial development as the children got older. The pediatrician encouraged the father to make an appointment at the school to clarify the reasons for the retention and what interventions the child would receive so he could be successful in kindergarten and/or first grade. The father said that he would think about it “but the school usually knows best.” The pediatrician again encouraged the father to work with the school to monitor his son’s progress over the year.
Discussion
Grade retention is often an emotionally charged discussion and decision. Unfortunately there is not a comprehensive body of research literature to draw upon to make these important decisions. Grade retention is common and costly. An estimated 9.6% of student were retained at least once before 9th grade. One estimate, in Texas in 2006-2007, had a yearly per student cost of $10,162 per retained student or over 2 billion dollars to the Texas school systems.
Research has shown that:
- Children who are retained have poorer academic achievement than promoted peers
- After retention, the academic gains from the retained year fade after 2-3 years.
- Retention often is associated with increased behavior problems – particularly as they get older (i.e. junior high, high school and young adulthood)
- “Retained students are more likely to have poorer educational and employment outcomes during late adolescence and early adulthood.”
- “Retention negatively impacts “…all areas of a child’s achievement (reading, math, and language) and socio-emotional adjustment (peer relationships, self-esteem, problem behaviors and attendance).””
- “Retention is more likely to have benign or positive impact when students are not simply held back, but receive specific remediation to address skill and/or behavioral problems and promote achievement and social skills.
The National Association of School Psychologists recommends alternatives to retention and social promotion (moving a child ahead to the next grade because of age discrepancy with peers without corresponding academic achievement) where the child is promoted with specific individual activities and interventions developed with the educational personnel and family together. These interventions should be put into place and actively monitored to assist the student to be successful in school. Examples include early reading programs, behavior management strategies, mental health programs, tutoring programs, extended school year, etc. The interventions should be multitiered with equal opportunities for students of all backgrounds to learn and “universal screening for academic, behavioral, and social-emotional difficulties.”
Questions for parents to consider when faced with this difficult decision can be found in the To Learn More section below.
Learning Point
Risk factors for grade retention include:
- Male
- African-American
- Hispanic
- Late birthday (i.e. close to cut off date for beginning school)
- Developmental delay or attentional issues
- Behavior problems including aggression and immaturity
- Living in poverty or single parent household
- Parents with low educational attainment
- Language problems including those learning English
- Inner city location
- Student mobility
Questions for Further Discussion
1. What are your local school district’s policy (official and unofficial) on grade retention?
2. What resources are available in the schools and community to help students with grade retention/school failure?
3. What is the differential diagnosis of grade retention/school failure?
Related Cases
- Disease: School Health | Learning Disorders | Child Mental Health
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Developmental Disabilities | General Pediatrics | Psychiatry and Psychology | School | Social Services
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: School Health and Learning Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Byrd RS, Weitzman ML. Predictors of early grade retention among child in the United States. Pediatrics. 1994;93:481-487.
Byrd RS, Weitzman ML, Auinger P. Increased behavior problems associated with delayed school entry and delayed school progress. Pediatrics. 1997;100:654-611.
Shea Stump, C. Repeating a grade: the pros and cons. GreatSchools.com.
Available from the Internet at http://www.greatschools.org/special-education/health/659-repeating-a-grade.gs?page=1 (cited 9/1/11).
National Association of School Psychologists. Grade retention and social promotion (White
Paper). Bethesda, MD.Available from the Internet at http://www.nasponline.org/about_nasp/positionpapers/WhitePaper_GradeRetentionandSocialPromotion.pdf (rev. 2/26/2011, cited 9/1/2011).
Cortiella, C. The State of Learning Disabilities. National Center for Learning Disabilities, NY, NY. 2011.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 