Anticipatory Guidance

Evaluation of Children with School Difficulties

The parents of a 7 year-old boy bring their child to the office for evaluation of poor school performance in the 2nd grade. Their teacher wants to start "medication" but the family is hesitant.  His mother had "learning issues" as a child, and is a successful executive now.


How would you approach this problem?


Pediatricians are often viewed as trusted individuals who are familiar with the child and family. Therefore families will often approach the pediatrician with questions concerning their child who is doing poorly in school. It is important to help children because failure in school may lead to the development of poor self-esteem, which will further enhance failure. In addition, it is common for schools to refer the child to the pediatrician for evaluation. The pediatrician should be knowledgeable about how to evaluate children who are doing poorly and where to refer patients to for a complete workup.

Common Causes of School Difficulties

  1. Low intelligence/intellectual disability
  2. Learning disability-defined as impaired ability not expected based on intelligence and developmental level. Potential not consistent with achievement. Often described as relating to processing and perceptual difficulties.
  3. Emotional problems, family problems, behavioral problems.  Bullying at school can push students who are perceived aas "different" into truancy and drug abuse at a young age with resultant academic difficulties.
  4. Attention deficit disorder
  5. Medical problems.
  6. Poor attendance secondary to multiple reasons.

Evaluation of Children with School Difficulties

  1. Complete history
    • perinatal and neonatal
    • previous school performance
    • family history including developmental delay, other family member's performances
    • social history
    • medical history
    • developmental history
  2. Physical examination
    • height, weight, and head circumference
    • neurological exam
    • skin lesions consistent with neurocutaneous syndromes.
    • hearing and vision
  3. Discussion with the school
    • talk to the child's teacher
    • review previous report cards
    • get results of any formal testing that has been done at the school
    • may have teacher fill out questionnaires about child's behavior and performance
  4. Recommend formal testing.
  • This will often help get to a diagnosis if there is intellectual disability, learning disabilities or perceptual problems, attention deficit disorder, and emotional/psychological problems.
  • Testing may be done through the school system or may use an outside resource, although this may be expensive.


  1. Therapy is dependent on what your evaluation has found
    1. Some children cannot do the work and special arrangements for tutoring and special resource rooms may be necessary. Parents need to realize that the child has limited abilities.
    2. If there are physical or medical reasons, these need to be addressed.
    3. Learning disabilities may be helped by alternative means of teaching
    4. ADD and ADHD may respond to stimulant medications, behavior modification, and special tutoring
    5. Emotional problems and family issues may be aided by counseling, as well as teaching parents how to deal with behavioral problems
    6. Speech, physical, and occupational therapy
  2. Encouraging parents to be advocates for their children. The government under PL 94-142 guarantees a free education to all handicapped children
  3. All children should have an Individual Educational Plan (IEP) which describes the child's particular problem and remedial activities including goals and objectives for the school year. Early grade retention can be a warning sign that physicians can use as an opportunity to help families advocate for their children to receive IEPs and appropriate academic assistance.

Treating children who are having problems in school often takes a great deal of time. The pediatrician who helps a child and his or her family will get a great deal of satisfaction. Often parents are lost and the pediatrician is the only individual interested. The pediatrician must be an advocate for the child and if he/she doesn't have the clinical knowledge to diagnose and treat, he/she must refer the child to someone who does.


  1. McInerny,Thomas Children Who Have Difficulty in School: A primary Pediatrician's Approach. Pediiatrics in Review. Sept. 1995
  2. Silverstein,M et al. Receipt of special education servisec following elementary school grade retention.  Archives of Pediatrics and Adolescent Medicine.  June 2009
  3. Birkett M et al.  LGB and questioning students in schools: the moderating effects of homophobic bullying and school climate on negative outcomes.  Journal of Youth and Adolescence.  August 2009.