Patient Presentation
A 10-year-old female came to clinic for her health supervision evaluation. She was having problems in school (getting D’s and F’s with an occasional C) and was struggling in all her subjects but especially reading. She was particularly vocal that she did not like school and didn’t understand why she had to go to school. “I don’t really want to do anything when I grow up so why should I go to school,” she said. Her mother was not concerned about her learning and thought that she was doing “just fine. She’s like the rest of us.” The family had moved multiple times within one location and between locations to live with relatives and friends while the mother tried to maintain employment. The past medical history was positive for mild persistent asthma that was not well-controlled and she did not have any of her medications available. The family history was positive for asthma, diabetes, attention problems and school problems. Her mother and maternal aunt had dropped out of school and her father had struggled but finished high school.
The pertinent physical exam showed a pleasant but vocal school-ager. Her vital signs were normal and her growth parameters were at the 25-50% but there were no previous visits for comparison. She had mild rhinorrhea and her lungs had some mild wheezing. The rest of her examination was normal.
The diagnosis of of a child with uncontrolled, mild persistent asthma who was struggling in school, and with social problems of home insecurity and poverty was made. The pediatrician worked with the clinic’s social worker to help secure asthma medication for the family to go home with and refills at the local pharmacy. The social worker also offered to help the mother to work with the school but the mother refused. She did accept help in finding more permanent housing and child care for other children though. The family did not followup for their asthma appointment 2 months later. The social worker contacted the cellphone and the mother said they had moved again out of the area.
Discussion
“Literacy is traditionally meant as the ability to read and write. The modern term’s meaning has been expanded to include the ability to use language, numbers, images, computers, and other basic means to understand, communicate, gain useful knowledge, solve mathematical problems and use the dominant symbol systems of a culture.”
The earliest written communication was in 3500-3000 BCE, with the earliest alphabet being from 1200-750 BCE. Although the percentage of the world’s adult literacy rate is increasing each decade by ~5%, “…from 55.7 per cent in 1950 to 86.2 per cent in 2015,…” the total number of adults who are illiterate is increasing because of increased population. Universal, compulsory education is viewed as the mainstay of developed and developing nations to building a literate population. However there are many reasons that children, teenagers and adults may not succeed in a school including individual and family issues, the general social and community environment, and specific school issues.
School failure is defined as grade retention (i.e. repeating a grade, 10% of Kindergarten-8th grade students), expulsion (0.2% of students) and dropping out of school (i.e. 16-24 year old not enrolled and do not have a general equivalency degree, 9% which is a decline but total number of students is increasing because of increased enrollment). Even students that graduate from high school may not be sufficiently literate in the broader sense. Some studies cite, 80% of high school students graduating but only50% are ready for the world and only 50% are proficient in math and reading.
Students with learning disabilities (LD) make up ~10% of enrolled students (about the same % as those who have asthma). Reading disability accounts for ~6.5% which is the most common form of LD. LD is often thought to cause relatively low morbidity but students with LDs often struggle in school and have school failure. Early signs may be students struggling and putting in more time than peers or acting out in some way. Students may be completing homework and performing academically appropriately, but to do this may be expending a great deal of time and mental effort to keep up. Other signs of LD include class clown behavior, school anxiety, frequent failing grades, frequent absences or detention/suspension, and aggressive and bullying behaviors.
Co-morbidities are common with students with LD having more than 1 LD, attention or other problem. Students with LDs may also be intelligently gifted too and are sometimes called “twice-exceptional.”
Students who are struggling or failing in school should be appropriately evaluated which may include an assessment of their academic problems, behavior and mental health evaluation, general intelligence testing, social evaluation, hearing and vision testing and other testing as appropriate. Students may be evaluated by a “RTI or response to intervention” evaluation with students having specific educational interventions started with them and then the outcome of the intervention is part of the student’s evaluation. Students may qualify for special education through an Individualized Education Plan or a 504 plan.
A review of special education can be found here.
A review of how gifted children present can be found here.
A review of risk factors for grade retention can be found here.
A review of causes of school absenteeism can be found here.
A review of causes of attentional problems can be found here.
Learning Point
Causes of school failure include:
- Child and Family
- Absenteeism
- Attention problem
- Cognitive problem
- English as a second language
- Health issues – acute or chronic
- Anemia
- Allergies
- Asthma
- Autism
- Brain injury – traumatic, infectious or other
- Crohn’s disease
- Cystic fibrosis
- Genetics – Fragile X
- Hypo- or hyperthyroid
- Obstructive sleep apnea
- Prematurity
- In-utero drug exposure
- Phenylketonuria
- Seizures
- Home environment
- Low level of family support for student/attitudes toward school
- Inadequate study space/time
- Not interested in the classes
- Don’t have specific study skills/ Behind and can’t catch up
- Perceived inadequate rewards for effort expended
- Competing priorities / excessive extramural activities
- Divorce/separation/conflict
- Neglect/abuse/violence
- Low level of family support for student/attitudes toward school
- Learning disabilities
- Language disorder – oral or listening
- Reading disorder
- Mathematics disorder
- Writing disorder
- Others or combination
- Mental health problems
- Anxiety
- Conduct disorder
- Depression
- Excessive gaming
- Mood disorder
- Oppositional defiant disorder
- Obsessive compulsive disorder
- Panic attacks
- Phobia
- Separation anxiety disorder
- Shyness
- Sensory impairment – vision, hearing
- Sleep problems
- Social/Community
- Food
- Housing including frequent moves
- Substance abuse
- Violence
- Poverty
- Peer pressure for low performance
- School
- Under-resourced learning environment
- Inadequate overall funding, facilities, books, materials, personnel, etc.
- Classroom size
- Environmental hostility, prejudice, or bullying, violence, safety issues
- Under-, not-appropriately educated teachers
- Mismatch between student/teacher
- Curriculum inadequate or unrealistic expectations
- Curriculum inadequate for specific individual’s needs
- Excessive testing
- Increased testing standards without increased educational support
- School transitions
- Under-resourced learning environment
Questions for Further Discussion
1. What are the potential causes of school problems for this student?
2. What are the social and economic impacts of school failure?
3. What are the health impacts of school failure?
4. How many students end up in prison who have school failure and what are the health impacts of prison? A review can be found here.
5. What are the health impacts of homelessness? A review can be found here.
Related Cases
- Disease: Asthma in Children | School Health | Homeless Health Concerns
- Symptom/Presentation: Health Maintenance and Disease Prevention
| Wheezing | Developmental Delay
- Specialty: School | General Pediatrics | Allergy / Pulmonary Diseases
- 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, and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: School Health and Asthma in Children and Homeless Health Concerns.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Byrd RS. School failure: assessment, intervention, and prevention in primary pediatric care. Pediatr Rev. 2005 Jul;26(7):233-43.
Kamal M, Bener A. Factors contributing to school failure among school children in very fast developing Arabian Society. Oman Med J. 2009 Jul;24(3):212-7.
Bradshaw CP, O’Brennan LM, McNeely CA. Core competencies and the prevention of school failure and early school leaving. New Dir Child Adolesc Dev. 2008 Winter;2008(122):19-32.
Rimrodt SL, Lipkin PH. Learning disabilities and school failure. Pediatr Rev. 2011 Aug;32(8):315-24.
Klein, J. The Failure of American Schools. The Atlantic June 2011. Available from the Internet at: https://www.theatlantic.com/magazine/archive/2011/06/the-failure-of-american-schools/308497/ (cited 6/4/18)
Welsh EC, Appana S, Anderson HA, Zierold KM. The association between school-to-work programs and school performance. J Adolesc Health. 2014 Feb;54(2):221-7.
Ibabe I. Academic Failure and Child-to-Parent Violence: Family Protective Factors.
Front Psychol. 2016 Oct 7;7:1538.
Chacon Fuertes F, Huertas Hurtado CA.
The Causes of School Failure in Secondary School Students: Validation of a Psychosocial Model with Structural Equations. Span J Psychol. 2017 Nov 20;20:E62.
Literacy. Wikipedia. Available from the Internet at: https://en.wikipedia.org/wiki/Literacy (cited 6/4/18).
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 