How appropriate are referral letters written by school principals to a learning disability clinic? A retrospective audit

ABSTRACT

This retrospective study analyzed the quality of 1069 referral letters written by school principals to our learning disability clinic. Utilizing a self-devised checklist having four domains (with 26 items), the audit revealed that in only nine (34.6%) items, the necessary information was available in >90% of referral letters.

It is generally noticed that at least 20% of children in a classroom get poor marks – they are “scholastically backward.”[1,2,3] There are many reasons for children to underperform at school, such as medical problems, below-average intelligence, specific learning disabilities, attention deficit hyperactivity disorder, emotional problems, a poor sociocultural home environment, psychiatric disorders, or even environmental causes.[1,2,3] Poor school performance (PSP) should be seen as a “symptom” reflecting a larger underlying problem in children. It is essential that this symptom be scientifically analyzed to discover its underlying cause(s) and find a remedy.[1,2,3]

School principals play an important role as they are responsible for drafting the referral letter of afflicted students to our learning disability (LD) clinic for assessment. In general, the quality of information provided by referral letters is a crucial element in the effective diagnosis and management of any illness or condition.[4] Hence, we conducted the present study to analyze the quality of referral letters written by school principals to our clinic.

After taking permission from our institutional ethics committee (EC/12/2021 dated April 29, 2021), we extracted the referral letters of all students assessed in our clinic over 4 years and 8 months (January 2018 to August 2022). Since there is no gold standard to assess referral letters,[4] we audited these referral letters utilizing a self-devised checklist [Table 1]. This checklist was formulated based on our experience in assessing students with PSP since the last 25 years, and each referral letter was analyzed under four domains (with 26 items) [Table 1] for adequacy of information (both clinical and administrative) mandatory for assessing a student with PSP and issuing the certificate for educational purpose. The study protocol was registered with the clinical trials registry of India (CTRI/2021/05/033872) prospectively.

Table 1.

Domains and their items for quality assessment of referral letters (n=1069) in the present study

Domain	Item	n (%)
I. Configuration of school referral letter and school characteristics
	i. Letter written on an official school letterhead paper	1051 (98.3)
	ii. School address mentioned	1053 (98.5)
	iii. Contact number of school mentioned	980 (91.7)
	iv. Email address of school mentioned	571 (53.4)
	v. Typed letter	993 (92.9)
	vi. Handwritten letter (but legible)	73 (6.8)
	vii. Date of referral mentioned	1002 (93.7)
	viii. Outward number mentioned on letter	429 (40.1)
	ix. Address of LD clinic correctly mentioned	369 (34.5)
	x. Principal’s name, signature, and stamp mentioned	390 (36.5)
	xi. Medium of instruction mentioned	184 (17.2)
	xii. School ownership (private or public) mentioned	229 (21.4)
	xiii. School educational board mentioned	386 (36.1)
II. Student characteristics
	i. Name mentioned correctly	1015 (94.9)
	ii. Age/date of birth mentioned correctly	107 (10.0)
	iii. Gender mentioned correctly	1069 (100.0)
	iv. Class standard mentioned	974 (91.1)
	v. Both parents’ names mentioned	5 (0.5)
	vi. Comorbid chronic medical illnesses/condition mentioned	46 (4.3)
III. Information about student’s academic performance
	i. Academic problems mentioned superficially	881 (82.4)
	ii. Academic problems mentioned comprehensively	150 (14.0)
	ii. Duration of academic problems mentioned	36 (3.4)
	iii. Classroom teacher notes attached along with	199 (18.6)
	iv. School counselor notes attached along with	63 (5.9)
	v. Behavior in classroom mentioned	522 (48.8)
IV. Reason for referral
	i. Poor school performance or equivalent words mentioned	1069 (100.0)
	ii. Provisional diagnosis or clinical impression mentioned	538 (50.3)

LD=Learning Disability

A total of 1069 referral letters were analyzed. Under the domain “configuration of school referral letter and school characteristics,” our analyses revealed that most (>90%) of the referral letters were typed on the official school letterhead paper, with the school’s address and contact number, and date of referral mentioned. However, important information such as address of our LD clinic, school principal’s name (with signature and official stamp), medium of instruction, type of school ownership, and school educational board were rarely mentioned [Table 1].

Under the domain “student characteristics,” in most (>90%) of the referral letters, the student’s name, gender, and class standard were mentioned correctly. However, important information, namely, age/date of birth of the student, names of parents, and presence or absence of comorbid chronic medical illnesses, were rarely stated. In the present study, 483/1069 (45.2%) students were suffering from a comorbid chronic illness/condition (e.g., bronchial asthma, epilepsy, thalassemia major, malignancy, cerebral palsy, congenital heart disease, hypothyroidism, juvenile diabetes mellitus, Down syndrome, hearing deficit, visual deficit, etc.), which impacts the school performance; and of these, 123/1069 (11.51%) students were on chronic medication. But only 46/483 (9.52%) referral letters had mentioned the student’s chronic illness/condition.

Under the domain “information about student’s academic performance,” the academic problems faced by the student in reading, writing, and doing math were described superficially in 82.4% letters and comprehensively in only 14% letters. Important information, such as behavior (hyperactive, inattentive, aggressive, disruptive, or reclusive), was mentioned in only 48.8% of letters. Other important information, such as duration of academic problems, classroom teacher and school counselor’s notes, were hardly ever available.

Under the domain “reason for referral,” all (100%) letters mentioned PSP or equivalent words (such as not doing well in school, underperforming). Only 50.3% letters mentioned a provisional diagnoses of the student’s PSP.

In the present study, in only 9/26 (34.6%) items of the checklist, the necessary information was available in >90% of the referral letters. In contrast, in 15/26 (57.7%) items, the necessary information was not mentioned in >50% of the referral letters.

To our knowledge, no study has analyzed the quality of referral letters written by school principals to an LD clinic. Our results indicate that most referral letters do not include important information (both clinical and administrative). Poor quality of referral letters, however, does not impair our assessment of the student’s PSP, as we eventually get the required information by contacting the school, or during the student’s clinical and neurologic examination, by screening each student for ADHD, and getting relevant family/socioeconomic information during the counseling session with the parent(s). However, a comprehensively drafted referral letter mentioning all necessary information would surely be helpful in assessing the referred students.

There are a few limitations to the present study. Firstly, this is a single-center study and our results cannot be generalized. Secondly, some aspects of referral were not examined, especially whether even poorly drafted letters might have correctly stated the cause of PSP preassessment. Thirdly, as academic problems were mentioned comprehensively in only 14% of referral letters, we did not make any attempt to correlate this information with the final diagnoses made in these students.

In conclusion, the present study highlights the immediate need to: (i) develop a standardized referral template, with inclusion of all required information (clinical and administrative), for school principals to refer students with PSP for their evaluation; and, (ii) conduct local educational workshops in schools for school principals, classroom teachers, and school counselors to improve awareness about the causes of PSP, so that academic problems, behavior, and comorbid chronic medical illnesses of students are comprehensively mentioned in referral letters. These two steps would significantly improve the quality of referral letters in future.

Financial support

The learning disability clinic at our institute is partially funded by a research grant from MPS Ltd., Noida, Uttar Pradesh, India.

Conflict of interest

Dr. Sunil Karande is the Editor of the Journal of Postgraduate Medicine.