Patient Presentation
A 5-year-old female came to clinic for her health supervision visit. Her mother was concerned because she had recently taken a kindergarten readiness test which showed lower achievement for mathematical skills because she would identify 3 numbers and wrote only 2 numbers. At home, her mother described her as being able to count to 10 with 1:1 correspondence, she understood “bigger and smaller, “more and less” and could group items by color. She also seemed interested in numbers in her environment such as street signs, addresses, cash registers, and household items. Her parents had been working with her on letters and thought she knew most of her numbers. She had not been in daycare or a formal preschool setting. Her mother said she was interested in things around her, did well at her play group a couple days a week and in playing with siblings and cousins daily. Her extended family members had no concerns about her development. She knew most letters by sight and could write her name, colors, liked to build with household items, and draw and paint. She could do personal care such as feeding and toileting.

The past medical history was positive for pressure equalizing tubes but with normal audiology testing. The family history was negative for school problems. Both parents had finished high school and the father was consistently employed. The mother worked a few hours a week while extended family provided child care.

The pertinent physical exam showed a smiling child with normal vital signs. Her growth parameters were 75% and tracking appropriately. Her vision testing was normal as was the rest of her physical examination.

The diagnosis of a healthy female was made. The pediatrician counseled the mother that she was probably ready to go to school but that the lower math testing may be something to monitor. “She hasn’t really been in a school environment yet and maybe she didn’t feel as comfortable when they asked her to tell or write the numbers. It seems that she understands many things about math like the idea of “more or less” and you tell me that she can count toys at home,” the pediatrician said. She went on, “You might want to talk with the school again about if they have concerns about her starting and if she does, how they are going to watch her and help her. They should have a plan about how to talk with you about the progress she is making too. See how worried they are about this, but my guess is that she will be fine with more practice on the numbers and being more comfortable in the classroom.” The patient’s clinical course showed that the family worked with her to learn her numbers before starting school in the fall. At a parent-teacher conference 4 weeks into the school year, the teacher had no concerns about her specific skills but reported that she was a very friendly girl who is making friends and was learning the classroom routines. She was slower with the routines than others probably because she hadn’t done them as much and felt she was making good progress. The parent said that she was learning when she had to raise her hand to talk or not and sometimes she did it at funny times like during dinner.

Discussion
For parents there can be a lot of pressure to “get it right” when deciding to send their child to school. Positive adult life outcomes such as employment, physical and mental health, and prosocial relationships are associated with higher educational attainment. Higher educational attainment such as finishing high school and potentially an advanced degree is associated with positive school experiences and domain specific skill attainment (e.g. reading, writing, math skills) and is also associated with readiness to begin school. Therefore if a child is “not ready” to start school, then the parent can feel that they are setting their child up for potentially poorer outcomes for their entire life. Especially as children spend a significant amount of their time in school over many years, the quality of that education is important. Which also means that starting children in school when they have the knowledge, skills and attitudes to successfully learn is important.

Risk factors for poor school readiness includes:

• Poverty – one of the most important, this is across ethnic and racial groups, most likely because of lack of resources, less parental education, poorer health, etc.
• Living foster or kinship care – especially foster care, most likely because of unstable living arrangements
• Maternal depression – potentially being less available to the child
• Developmental disability
• Prenatal/natal factors such as tobacco or alcohol exposure, and low birthweight

Obviously some of these factors cannot be readily changed for the individual child or family, but others can be mitigated.
Some measures which enhance school readiness and school success include:

• Access to preschool
• Reading to the child at home – review of risk factors for grade retention can be found here
• Positive parenting by adults who are supported themselves – A review of parenting styles can be found here
• Consistent living situation – A review of health problems in the homeless population can be found here
• Access to resources at home including reading and writing materials
• Access to resources in the community including physical and mental health resources

Learning Point
The answer to when a child is ready to start school is multifactorial with some group characteristics being helpful in making the decisions.
Remembering that the school readiness decision is not the only determiner of if a child succeeds in school. The child and parent will have almost 13 years of schooling to help them to be successful before high school graduation.

According to the American Academy of Pediatrics, school readiness in the child includes:

• “[P]hysical well-being and sensory motor development, including health status and growth;
• [S]ocial and emotional development, including self-regulation, attention, impulse control, capacity to limit aggressive and disruptive behaviors, turn-taking, cooperation, empathy and the ability to communicate one’s own emotions; identification of feelings facilitates accurate communication of these feelings;
• [A]pproaches to learning, including enthusiasm, curiosity, temperament, culture and values;
• [L]anguage development including listening, speaking, and vocabulary, as well as literacy skills, including print awareness, story sense, and writing and drawing processes;
• [G]eneral knowledge and cognition, including early literacy and math skills”

Some non-academic skills that sometimes are overlooked but are important life skills include being able to follow instructions (i.e. responding to name, complying with simple or multi-step instructions), functionally communicating (e.g. requesting assistance or attention from peers or adults), and social skills (e.g. tolerating delays, offering/sharing with others, comforting others, etiquette such as saying “please” or “thank you”). These skills can be taught. A list of some more specific skills for school readiness can be found here.

School readiness testing often may look mainly or only at the academic skills of the child. These types of tests can be helpful as part of the decision making process but by themselves usually should not be a reason to exclude an otherwise “ready” child. They can be helpful for monitoring a child particularly in an area of weakness or to provide instruction in those areas.

For an individual child the parents should look at the child holistically and make an assessment. Family members, childcare, school and healthcare professionals can help with the decision by providing insights and guidance about the individual child and family situation, but it is ultimately the parent’s decision. Most children are “ready” around age 5 years. Data supports that over the last 20-30 years in the US children are now more ready for school. Parents should consider if they do not send their child, what will the child do during that year that will make them “ready” the following year. Will they have access to specific educational interventions for example. Does that intervention need to be for a whole year, or would additional intervention in the kindergarten classroom still provide the necessary opportunities for the child. Parents can consider if the child had been in a classroom type setting before and for how long. Is the child succeeding in that setting or are their major problems. Some parents are worried about their child with a summer birthday who will be “younger” that some of the other children. In general, if the child is developmentally appropriate in the social/emotional area, the child usually is ready for school.

A review of school failure can be found here
A review of risk factors for grade retention can be found here

Questions for Further Discussion
1. What is the pediatrician’s role in helping families get their child ready for school or being successful in school?
2. What resources are available in your local community to support school readiness and success?
3. How common is dyscalculia? A review can be found here
4. How do gifted children present? A review can be found here

Related Cases

Disease: School Readiness | Child Behavior Disorders | Developmental Disabilities

Symptom/Presentation: Health Maintenance and Disease Prevention | Developmental Delay

Specialty: Developmental Disabilities | School

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: Child Behavior Disorders and Learning Disabilities.

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.

Shah PE, Kaciroti N, Richards B, Lumeng JC. Gestational Age and Kindergarten School Readiness in a National Sample of Preterm Infants. J Pediatr. 2016;178:61-67. doi:10.1016/j.jpeds.2016.06.062

Pinto G, Bigozzi L, Tarchi C, Vezzani C, Accorti Gamannossi B. Predicting Reading, Spelling, and Mathematical Skills: A Longitudinal Study From Kindergarten Through First Grade. Psychol Rep. 2016;118(2):413-440. doi:10.1177/0033294116633357

Fahmie TA, Luczynski KC. Preschool life skills: Recent advancements and future directions. Journal of Applied Behavior Analysis. 2018;51(1):183-188. doi:https://doi.org/10.1002/jaba.434

Williams PG, Lerner MA, Council on Early Childhood, Council on School Health. School Readiness. Pediatrics. 2019;144(2). doi:10.1542/peds.2019-1766

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa