EditorialPublication Exclusive

Back to school: The underachiever and the slow learner

Your young patients have begun their annual trek back to school. Some gladly, some ruefully. Some children and teenagers with educational problems may be brought into your office specifically for that particular evaluation. Others with educational problems will often be uncovered in your office by routinely obtaining a history, specifically asking, How are your grades in school? I suggest avoiding the too-generic inquiry, How is school going? as this will often lead to a monosyllabic answer such as fine, even when the grades are Ds or Fs. Beauty is in the eye of the beholder, it seems. Another valuable question for the mother of an elementary-age child who is struggling: What age do you think that your child functions, relative to his peers?

Whenever a student answers that he received more than one D or F letter grade, or a needs improvement, this should send up major red flags for you to obtain a more detailed educational and social history. You should also obtain any available recent report cards, achievement tests, and the rarely already performed psycho-educational tests. A recent vision and auditory evaluation is prudent as well.

Stan L. Block

Thus, educational problems are an area where the resourceful pediatrician can be very helpful to the child's overall academic and emotional health. Let me explain.

ADHD follow-up leads to a discovery

This autumn, a 6-year-old boy is in your office for his biannual follow-up for a diagnosis of attention-deficit/hyperactivity disorder given by your office last year. You re-examine his initial ADHD checklists from early first grade, where he was noted by his parents and teachers to have significant issues with focusing and completing tasks, along with problems of disorganization and distractibility. At that time, his mother had no concerns about his level of work. Stimulant medication was prescribed, which improved his completion of schoolwork, and it also seemed to improve the amount of time spent on tasks. But during the year, he was still observed as struggling with his schoolwork.

At his 1-year medication follow-up near the end of first grade, the teacher commented on his ADHD checklists: Puts anything down on assignments. Does not take time to try to figure things out. Does not ask for help. When asked about his grades, the mother admitted that the teachers mostly evaluated his work as unsatisfactory or needs improvement. She also said he seems to be unable to keep up with his peers academically.

Being a perceptive and pro-active pediatrician, you subsequently requested more formal psycho-educational testing due to his poor academic progress. You know that nearly 23% of students may be categorized as slow learners, or with a borderline cognitive disability, according to Voight and colleagues. Although much inattention and distractibility was observed during his psychological testing, his intelligence testing revealed that he was functioning in the lower academic range, receiving an overall or full-scale IQ score of 75. But what the heck does this mean to anybody but the psychologist? This is where you as a pediatrician are a key player translating the techno-babble to parents.

Thus, this child was likely affected not only with a mild version of inattentive ADD, but also he could be categorized as a slow learner. This latter problem is among the most perplexing for the child, the parents and the school. No formal educational avenues, programs or remedial courses are readily available for the slow learner.

Definition of slow learners

The slow learner is generally considered as a student who achieves a full-scale score between 70 to 85 (or 89) on formal IQ testing. This range of IQ is thus considered as a borderline intellectual disability (cognitive impairment) or low average intellectual capability. These IQ scores are not low enough (less than 70) to place them in the mild cognitive impairment group (old term=mild mental retardation). Nor is there usually enough discrepancy between their IQ and academic ability to place them in the learning disabled group, as well. Surprisingly, this group of children may represent about 23% of the entire student population, compared with a rate of 5% to 10% for remediable learning disabilities in the population. Yet, you likely may not have observed such a high rate of slow learners in your private general pediatric practice.

The worrisome aspect of being a slow learner is the fact that he usually will not qualify for any special services, special education, or even a helpful individualized educational plan (IEP).

In the typical classroom setting, most teachers aim their academic course work for the average learner, who has a mean IQ of 90 to 110. These slow learner children are destined to struggle here.

Thus, it is incumbent upon you as the pediatrician to help the family interpret what these lower IQ scores mean for the child's projected academic achievement. Note that IQ scores have been shown to be also predictably stable over time. However, in some areas of academics, the child may show major scatter and spikes in different subjects. Meaning for instance, that he may perform much better or much worse in verbal than in math or performance-type skills.

Critical interpretation of full-scale IQ scores

To further simplify it: An IQ of 75 means that an 8-year-old child will function intellectually overall at 75% of the average 8-year-old's intellectual functioning ie, at an average of a 6-year-old level. As he ages, he will commensurately function intellectually as a 12-year-old at age 16 years. This correlation continues to the assumed intelligence peak of an 18-year-old. Furthermore, it is important to remind parents that often times the mental age will correlate well with the social maturity age as well. This lack of age-appropriate maturity, too, can lead to major problems in the classroom, with a lot of acting out, acting up and acting unfocused.

Like most experts, I also think it is important to attempt to diagnose the slow learner before second grade.

The first reason early diagnosis is best is because it really helps parents to acknowledge the slower learning pace and to take the pressure off the child for not maintaining high academic achievement. In addition, one school tactic can be used. A controversial stopgap remedy may buy the child some vital extra time to gain some early additional academic and social competence and an early positive school experience. You may have the parents strongly consider holding back or retaining the child in kindergarten or first grade. However, any later grade retention is considered counterproductive by most experts.

At this younger age, I have rarely seen self-esteem issues with very early grade retention. And yet, the parents must be reminded that the child with an IQ of 75 will never fully catch up to his same-age peers. Thus, the discrepancy in academics with the early addition of 1 year chronologically (eg, cognitively a 7- vs. an 8-year-old) will eventually become more difficult to overcome and more noticeable (cognitively a 13-year-old vs. a 16-year-old).

Corroborating this approach during the early academic career, Zoëga and colleagues recently published data showing that students with later birthdays ie, the younger one-third of the classroom tended to have more long-term academic struggles (language arts and mathematics) at age 9 years. The study also found that these children were 50% more likely to be placed on medication for ADHD. This usually results from their inability to perform their grade level work and their social immaturity in the classroom.

Note that a mild cognitive disability or social immaturity can both manifest as distractibility and motor over activity, as was the case of the 6-year-old boy I discussed.

But remember, one distinct limitation of formal psychometric testing before third grade: it will uncommonly uncover or diagnose remediable learning disabilities in reading or math. The younger child is still undergoing major cognitive maturing of earlier speech and language disorders that will commonly spontaneously remit. Thus, he frequently resolves many of his previous early-on prima facie learning issues, if global intelligence seems to be or has been tested as average or above.

On an anecdotal note, of my four daughters, two of them with late summer birthdays were retained in kindergarten. Despite their above-average cognitive ability, this truly afforded them a major boost academically (decades ago). They evolved from being timid, sitting back, and always struggling academically early on, to becoming class leaders and eventually obtaining a post-graduate Pharm D degree and a master's degree in education, respectively.

Adolescent ADHD and ramification of school failure

You are seeing this very pleasant and articulate, previously healthy 15-year-old female for the first time in 2 years for a sore throat. As part of your routine generic review of systems at this age, you briefly inquire not only about her menses, home life, boyfriends and mood, but also about her schoolwork. You specifically ask about her grades, to expedite your process in this limited amount of time. You receive some hesitancy from her, and a monosyllabic reply of OK. You ask her: What specifically were your grades? And she just looks at her mother, and says You tell him.

You discover that she had two failing grades last year as a freshman, and that she has been struggling since high school began. But, she did very well in middle school with an A/B average. Her mother says that now she is always irritable and angers easily. She mopes around a lot, and tries to avoid the family by going into her room alone most evenings. Your patient admits that she cries many days of the week.

However, you are actually quite impressed at her lofty goals for the future (physical therapist), and by her insightfulness and diction, and her articulateness. And her spaciness.

How can this bright girl be barely surviving high school academically?

You now conjure up your quick and salient differential diagnoses for academic failure in high school that includes:

  • Inattentive ADD;
  • Drug abuse, particularly marijuana;
  • Slow learner;
  • Severe mood disorder or anxiety;
  • Home life chaos;
  • Adolescent adjustment reaction (severe rebellion).

You arrange for a follow-up visit the following week for further evaluation and discussion of the academics and mood issues. By then you will have received her recent report cards, ACT/SAT standardized test scores, and achievement tests, along with some current ADHD checklists from a few teachers (an onerous task in itself during high school). Today, along with your streptococcal testing, you also will have obtained a current urine drug screen in your office (negative).

As you peruse her achievement scores, you are perplexed that most of her achievement scores were in the upper quartile for her grade, her ACT scores were 26 as a freshman, and her freshman grades were mostly Cs and Ds with an A in chemistry. Her teachers ADHD checklists were markedly positive for inattention, and daydreaming and even some defiance and sadness in the classroom.

After further discussion with the teenager, you surmise that she is afflicted with a moderately severe case of inattentive ADHD, along with some mild reactive depression and adolescent adjustment reaction issues.

In your experience, inattentive ADHD is the most common cause for school failure or underachievement in high school among students who have otherwise average or above intelligence. Their academic potential may be commonly readily gleaned just by evaluating annual school achievement test scores, and somewhat by your attention to the student's diction and language.

Furthermore, ADHD has been linked to low academic achievement as the following two recent reports show.

These reports also seem to corroborate your observations about ADHD as a leading culprit in these cases of massive underachievement. Zoëga and colleagues reported that among children with much later-treated ADHD vs. ADHD treated by fourth grade, test performance scores from fourth grade to seventh grade declined by 73% in mathematics and by 43% in language arts. And the math decline was even worse among girls than boys.

Furthermore, Scheffler and colleagues reported that a notable positive influence of ADHD medication upon mathematics and reading test scores during elementary school. With medication use, the academic gains were 0.19 and 0.29 school years, respectively, as early as the fifth grade alone. The authors pushed for the need for long-term studies regarding the influence of medication use in children with ADHD upon academic achievement.

Treatment

After you discussed your appraisal of the 15-year-old's condition with both the patient and her mother, you felt quite comfortable that with successful ADHD medication treatment, her grades would show a profound improvement, likely into the A-B-C range. You also thought her reactive depression would abate soon, as her academic struggles subsided school was the unhappy situation where she spent the majority of her waking hours.

You discussed the implications of treatment, and the more common possible adverse effects, in particular weight loss, appetite suppression, headaches, abdominal discomfort and insomnia.

Regarding your medication selection, you told them that you did not want to be policeman for drug diversion or prescription theft, a common problem for many stimulant drugs that you have observed for teen patients, even in good households. Therefore, you never prescribed the easily on-the-street-marketed Adderall products or short-acting methylphenidate. You were going to use only longer-acting, difficult-to-divert stimulant drugs such as Concerta (Janssen), Vyvanse (Shire) or Focalin XR (Novartis), which would last 8 to 12 hours and could be used intermittently; or non-stimulant drugs such as atomoxetine (Strattera, Eli Lilly), which would last all day but require daily usage.

A urine drug screen would need to be obtained every 4 to 6 months or so. Any positive tests for illicit drugs would require you to abandon any further use of stimulant therapy. You also require follow-up every 3 to 4 months to monitor for dosage adjustments, pill usage, academic performance, and weight loss, etc.

Course

Within 3 months of initiating Concerta 36 mg daily, her grades have risen to the A-B honor roll category. Her irritability and bad moods have mostly subsided.

You have just experienced one of the more rewarding aspects of adolescent medicine helping to totally turn around a bright young lady's academic and emotional life.

References:

Accardo PJ, Accardo JA, Capute AJ. In: Accardo PJ, ed. Capute and Accardo's Neurodevelopmental Disabilities in Infancy and Childhood: Vol. I. Neurodevelopmental Diagnosis and Treatment. 3rd ed. Baltimore: Paul H Brookes Publishing; 2008:3-25.
Myers SM, Challman TD. In: Voigt RG, Macias MM, Myers SM, eds. Developmental and Behavioral Pediatrics. USA: American Academy of Pediatrics; 2011:249-291.
Scheffler RM. Pediatrics. 2009;123:1273-1279.
Zoëga H. Pediatrics. 2012;130;e53-62.
Zoëga H. Pediatrics. 2012;130(6):1012-8.

For more information:

Stan L. Block, MD, FAAP, is Professor of Clinical Pediatrics, University of Louisville, and University of Kentucky; President, Kentucky Pediatric and Adult Research Inc.; and General Pediatrician, Bardstown, Ky. Block can be reached at slblockmd@hotmail.com. He is also a member of the Infectious Diseases in Children Editorial Board.

Disclosure: Block reports no relevant financial disclosures.

Your young patients have begun their annual trek back to school. Some gladly, some ruefully. Some children and teenagers with educational problems may be brought into your office specifically for that particular evaluation. Others with educational problems will often be uncovered in your office by routinely obtaining a history, specifically asking, How are your grades in school? I suggest avoiding the too-generic inquiry, How is school going? as this will often lead to a monosyllabic answer such as fine, even when the grades are Ds or Fs. Beauty is in the eye of the beholder, it seems. Another valuable question for the mother of an elementary-age child who is struggling: What age do you think that your child functions, relative to his peers?

Whenever a student answers that he received more than one D or F letter grade, or a needs improvement, this should send up major red flags for you to obtain a more detailed educational and social history. You should also obtain any available recent report cards, achievement tests, and the rarely already performed psycho-educational tests. A recent vision and auditory evaluation is prudent as well.

Stan L. Block

Thus, educational problems are an area where the resourceful pediatrician can be very helpful to the child's overall academic and emotional health. Let me explain.

ADHD follow-up leads to a discovery

This autumn, a 6-year-old boy is in your office for his biannual follow-up for a diagnosis of attention-deficit/hyperactivity disorder given by your office last year. You re-examine his initial ADHD checklists from early first grade, where he was noted by his parents and teachers to have significant issues with focusing and completing tasks, along with problems of disorganization and distractibility. At that time, his mother had no concerns about his level of work. Stimulant medication was prescribed, which improved his completion of schoolwork, and it also seemed to improve the amount of time spent on tasks. But during the year, he was still observed as struggling with his schoolwork.

At his 1-year medication follow-up near the end of first grade, the teacher commented on his ADHD checklists: Puts anything down on assignments. Does not take time to try to figure things out. Does not ask for help. When asked about his grades, the mother admitted that the teachers mostly evaluated his work as unsatisfactory or needs improvement. She also said he seems to be unable to keep up with his peers academically.

Being a perceptive and pro-active pediatrician, you subsequently requested more formal psycho-educational testing due to his poor academic progress. You know that nearly 23% of students may be categorized as slow learners, or with a borderline cognitive disability, according to Voight and colleagues. Although much inattention and distractibility was observed during his psychological testing, his intelligence testing revealed that he was functioning in the lower academic range, receiving an overall or full-scale IQ score of 75. But what the heck does this mean to anybody but the psychologist? This is where you as a pediatrician are a key player translating the techno-babble to parents.

Thus, this child was likely affected not only with a mild version of inattentive ADD, but also he could be categorized as a slow learner. This latter problem is among the most perplexing for the child, the parents and the school. No formal educational avenues, programs or remedial courses are readily available for the slow learner.

Definition of slow learners

The slow learner is generally considered as a student who achieves a full-scale score between 70 to 85 (or 89) on formal IQ testing. This range of IQ is thus considered as a borderline intellectual disability (cognitive impairment) or low average intellectual capability. These IQ scores are not low enough (less than 70) to place them in the mild cognitive impairment group (old term=mild mental retardation). Nor is there usually enough discrepancy between their IQ and academic ability to place them in the learning disabled group, as well. Surprisingly, this group of children may represent about 23% of the entire student population, compared with a rate of 5% to 10% for remediable learning disabilities in the population. Yet, you likely may not have observed such a high rate of slow learners in your private general pediatric practice.

The worrisome aspect of being a slow learner is the fact that he usually will not qualify for any special services, special education, or even a helpful individualized educational plan (IEP).

In the typical classroom setting, most teachers aim their academic course work for the average learner, who has a mean IQ of 90 to 110. These slow learner children are destined to struggle here.

Thus, it is incumbent upon you as the pediatrician to help the family interpret what these lower IQ scores mean for the child's projected academic achievement. Note that IQ scores have been shown to be also predictably stable over time. However, in some areas of academics, the child may show major scatter and spikes in different subjects. Meaning for instance, that he may perform much better or much worse in verbal than in math or performance-type skills.

Critical interpretation of full-scale IQ scores

To further simplify it: An IQ of 75 means that an 8-year-old child will function intellectually overall at 75% of the average 8-year-old's intellectual functioning ie, at an average of a 6-year-old level. As he ages, he will commensurately function intellectually as a 12-year-old at age 16 years. This correlation continues to the assumed intelligence peak of an 18-year-old. Furthermore, it is important to remind parents that often times the mental age will correlate well with the social maturity age as well. This lack of age-appropriate maturity, too, can lead to major problems in the classroom, with a lot of acting out, acting up and acting unfocused.

Like most experts, I also think it is important to attempt to diagnose the slow learner before second grade.

The first reason early diagnosis is best is because it really helps parents to acknowledge the slower learning pace and to take the pressure off the child for not maintaining high academic achievement. In addition, one school tactic can be used. A controversial stopgap remedy may buy the child some vital extra time to gain some early additional academic and social competence and an early positive school experience. You may have the parents strongly consider holding back or retaining the child in kindergarten or first grade. However, any later grade retention is considered counterproductive by most experts.

At this younger age, I have rarely seen self-esteem issues with very early grade retention. And yet, the parents must be reminded that the child with an IQ of 75 will never fully catch up to his same-age peers. Thus, the discrepancy in academics with the early addition of 1 year chronologically (eg, cognitively a 7- vs. an 8-year-old) will eventually become more difficult to overcome and more noticeable (cognitively a 13-year-old vs. a 16-year-old).

Corroborating this approach during the early academic career, Zoëga and colleagues recently published data showing that students with later birthdays ie, the younger one-third of the classroom tended to have more long-term academic struggles (language arts and mathematics) at age 9 years. The study also found that these children were 50% more likely to be placed on medication for ADHD. This usually results from their inability to perform their grade level work and their social immaturity in the classroom.

Note that a mild cognitive disability or social immaturity can both manifest as distractibility and motor over activity, as was the case of the 6-year-old boy I discussed.

But remember, one distinct limitation of formal psychometric testing before third grade: it will uncommonly uncover or diagnose remediable learning disabilities in reading or math. The younger child is still undergoing major cognitive maturing of earlier speech and language disorders that will commonly spontaneously remit. Thus, he frequently resolves many of his previous early-on prima facie learning issues, if global intelligence seems to be or has been tested as average or above.

On an anecdotal note, of my four daughters, two of them with late summer birthdays were retained in kindergarten. Despite their above-average cognitive ability, this truly afforded them a major boost academically (decades ago). They evolved from being timid, sitting back, and always struggling academically early on, to becoming class leaders and eventually obtaining a post-graduate Pharm D degree and a master's degree in education, respectively.

Adolescent ADHD and ramification of school failure

You are seeing this very pleasant and articulate, previously healthy 15-year-old female for the first time in 2 years for a sore throat. As part of your routine generic review of systems at this age, you briefly inquire not only about her menses, home life, boyfriends and mood, but also about her schoolwork. You specifically ask about her grades, to expedite your process in this limited amount of time. You receive some hesitancy from her, and a monosyllabic reply of OK. You ask her: What specifically were your grades? And she just looks at her mother, and says You tell him.

You discover that she had two failing grades last year as a freshman, and that she has been struggling since high school began. But, she did very well in middle school with an A/B average. Her mother says that now she is always irritable and angers easily. She mopes around a lot, and tries to avoid the family by going into her room alone most evenings. Your patient admits that she cries many days of the week.

However, you are actually quite impressed at her lofty goals for the future (physical therapist), and by her insightfulness and diction, and her articulateness. And her spaciness.

How can this bright girl be barely surviving high school academically?

You now conjure up your quick and salient differential diagnoses for academic failure in high school that includes:

  • Inattentive ADD;
  • Drug abuse, particularly marijuana;
  • Slow learner;
  • Severe mood disorder or anxiety;
  • Home life chaos;
  • Adolescent adjustment reaction (severe rebellion).

You arrange for a follow-up visit the following week for further evaluation and discussion of the academics and mood issues. By then you will have received her recent report cards, ACT/SAT standardized test scores, and achievement tests, along with some current ADHD checklists from a few teachers (an onerous task in itself during high school). Today, along with your streptococcal testing, you also will have obtained a current urine drug screen in your office (negative).

As you peruse her achievement scores, you are perplexed that most of her achievement scores were in the upper quartile for her grade, her ACT scores were 26 as a freshman, and her freshman grades were mostly Cs and Ds with an A in chemistry. Her teachers ADHD checklists were markedly positive for inattention, and daydreaming and even some defiance and sadness in the classroom.

After further discussion with the teenager, you surmise that she is afflicted with a moderately severe case of inattentive ADHD, along with some mild reactive depression and adolescent adjustment reaction issues.

In your experience, inattentive ADHD is the most common cause for school failure or underachievement in high school among students who have otherwise average or above intelligence. Their academic potential may be commonly readily gleaned just by evaluating annual school achievement test scores, and somewhat by your attention to the student's diction and language.

Furthermore, ADHD has been linked to low academic achievement as the following two recent reports show.

These reports also seem to corroborate your observations about ADHD as a leading culprit in these cases of massive underachievement. Zoëga and colleagues reported that among children with much later-treated ADHD vs. ADHD treated by fourth grade, test performance scores from fourth grade to seventh grade declined by 73% in mathematics and by 43% in language arts. And the math decline was even worse among girls than boys.

Furthermore, Scheffler and colleagues reported that a notable positive influence of ADHD medication upon mathematics and reading test scores during elementary school. With medication use, the academic gains were 0.19 and 0.29 school years, respectively, as early as the fifth grade alone. The authors pushed for the need for long-term studies regarding the influence of medication use in children with ADHD upon academic achievement.

Treatment

After you discussed your appraisal of the 15-year-old's condition with both the patient and her mother, you felt quite comfortable that with successful ADHD medication treatment, her grades would show a profound improvement, likely into the A-B-C range. You also thought her reactive depression would abate soon, as her academic struggles subsided school was the unhappy situation where she spent the majority of her waking hours.

You discussed the implications of treatment, and the more common possible adverse effects, in particular weight loss, appetite suppression, headaches, abdominal discomfort and insomnia.

Regarding your medication selection, you told them that you did not want to be policeman for drug diversion or prescription theft, a common problem for many stimulant drugs that you have observed for teen patients, even in good households. Therefore, you never prescribed the easily on-the-street-marketed Adderall products or short-acting methylphenidate. You were going to use only longer-acting, difficult-to-divert stimulant drugs such as Concerta (Janssen), Vyvanse (Shire) or Focalin XR (Novartis), which would last 8 to 12 hours and could be used intermittently; or non-stimulant drugs such as atomoxetine (Strattera, Eli Lilly), which would last all day but require daily usage.

A urine drug screen would need to be obtained every 4 to 6 months or so. Any positive tests for illicit drugs would require you to abandon any further use of stimulant therapy. You also require follow-up every 3 to 4 months to monitor for dosage adjustments, pill usage, academic performance, and weight loss, etc.

Course

Within 3 months of initiating Concerta 36 mg daily, her grades have risen to the A-B honor roll category. Her irritability and bad moods have mostly subsided.

You have just experienced one of the more rewarding aspects of adolescent medicine helping to totally turn around a bright young lady's academic and emotional life.

References:

Accardo PJ, Accardo JA, Capute AJ. In: Accardo PJ, ed. Capute and Accardo's Neurodevelopmental Disabilities in Infancy and Childhood: Vol. I. Neurodevelopmental Diagnosis and Treatment. 3rd ed. Baltimore: Paul H Brookes Publishing; 2008:3-25.
Myers SM, Challman TD. In: Voigt RG, Macias MM, Myers SM, eds. Developmental and Behavioral Pediatrics. USA: American Academy of Pediatrics; 2011:249-291.
Scheffler RM. Pediatrics. 2009;123:1273-1279.
Zoëga H. Pediatrics. 2012;130;e53-62.
Zoëga H. Pediatrics. 2012;130(6):1012-8.

For more information:

Stan L. Block, MD, FAAP, is Professor of Clinical Pediatrics, University of Louisville, and University of Kentucky; President, Kentucky Pediatric and Adult Research Inc.; and General Pediatrician, Bardstown, Ky. Block can be reached at slblockmd@hotmail.com. He is also a member of the Infectious Diseases in Children Editorial Board.

Disclosure: Block reports no relevant financial disclosures.

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