Paediatrician’s role in the assessment of children with school problems

A new handbook entitled Children with School Problems: A Physician’s Manual (1) has been published by the Canadian Paediatric Society (CPS). It replaces the book Learning Disabilities: A Practical Office Manual, 2nd Edition (2). The new book was written by a group of developmental paediatricians from the Canadian Paediatric Society Developmental Paediatrics Section. The focus of the book is an approach to assessing children in trouble at school, rather than on diagnosing children with a learning disability. Many children assessed do not have a specific learning disability as their main problem. As well, an approach incorporating a synthesis of the child’s biological and psychological make-up in the context of environmental factors helps develop appropriate descriptions of the child’s needs and possible solutions.

Increasingly, community paediatricians and family physicians need to respond to parents’ requests for help when a child is experiencing difficulties in school. The requests may be related to the child’s academic progress, or ability to attend and concentrate or to interact and respond appropriately at school. Parents frequently look to their physician for help, guidance and advice. Schools often request assessment of underlying medical, family and/or emotional problems, or request further referrals regarding a child who is experiencing difficulty concentrating or learning. Many physicians are not sure how best to respond to these requests due to lack of training and experience. Because these assessments involve the integration of information from a variety of sources, it is necessary to set aside considerable time to focus on what are often complex problems. Allocating appropriate time within a busy office schedule can be difficult.

Although the traditional medical approach forms the foundation for the assessment of school problems, there is a need to extend the process to collect enough information to reach a clear formulation and make effective recommendations. It is often useful to meet with the family initially to discuss the agenda and indicate what the physician can offer. Detailed family and psychosocial histories are invaluable for understanding the perceptions and expectations of parents and past experiences of the child, as well as genetic risk factors. An individual interview with the child is critical for understanding how the child is feeling and how he or she perceives the problem. Children often come to the office reluctantly and need to be given confidence that the doctor’s role is positive and supportive. Children with School Problems provides an excellent discussion of how to interview children, with practical suggestions. The examination may need to include a screening or sampling of the child’s neuromaturational markers of developmental dysfunctions, selected areas of development and academic skills. The handbook contains many materials for doing this and guidelines for their interpretation.

The book suggests three levels of assessment depending on the available time and experience of the physician. The first level is a screening assessment to identify the key areas in which the child or family needs help. The level two assessment examines the key areas in greater detail. The third level is usually completed by a developmental paediatrician working with a multidisciplinary team. Because these problems arise out of an interplay of factors, it is important to integrate this information into a formulation for the family. Explaining this formulation to the child and family naturally leads to a plan of action that may include further consultation or investigations.

A psychological assessment is usually needed to diagnose a learning disability because some measure of intelligence or aptitude is required in most operational definitions. Developing a good referral network and knowledge of local resources is critical to helping these families. Many of these difficulties are long term, and ongoing support and reformulation is often necessary. It is important that the physician communicates his or her commitment to the family to work with them through this process.

Children with School Problems meets a critical need for paediatricians and family doctors who are asked to assess children experiencing difficulties learning in school. It is also hoped that provincial governments will acknowledge the amount of time, knowledge and expertise required, and support physicians appropriately.

For details on how to order Children with School Problems, see page 172.