Ebook Developmental behavioral pediatrics (4th edition): Part 2

(BQ) Part 2 book Developmental behavioral pediatrics presents the following contents: Outcomes—school function and other task performance, outcomes—physical functioning, outcomes—developmental, assessment, management and treatment, legal, administrative, and ethical issues.

Lynn Mowbray wegner

SCHOOL ACHIEVEMENT AND UNDERACHIEVEMENT

51

Vignette

Alice, an 8-year-old third-grade student in an upper middle class public school, gets along very

well with all the other children in her class and her teacher Alice’s parents are concerned about her

classroom achievement Her teacher had Alice’s older sister as a student and she also wonders at

the difference in the two girls with respect to their academic attainment Alice’s sister consistently

mastered every classroom task with little effort and good humor Alice has a similar sunny disposition,

but her performance usually falls in the lower range of mid-average Alice’s parents, both attorneys,

requested a conference, and the three adults could not find a logical reason for this discrepancy

between the two siblings “Why don’t you discuss this with Alice’s pediatrician and see if there might

be a medical reason for Alice’s apparent underachievement?” suggested the teacher

On the first day of kindergarten, all children are poten-­

tial Rhodes scholars! Even if the child has been attend-­

ing daycare and preschool for several years, the first day

of “real school” is a milestone in every family The fam-­

ily anticipates sharing the child’s care and nurture with

teachers and other school personnel This care becomes

a combined responsibility The child must navigate the

transition between the primary influence of the home and

a larger world with different expectations, and each set-­

ting contributes uniquely and importantly to the child’s

educational experience Educating children is important

at many levels: to the child, the family, and society

In the medical home, pediatricians providing health

maintenance for children are often consulted before

school entry to help parents decide the “best” school

setting or “when” it is best for the child to enter formal

schooling Later, if children do not perform at levels ex-­

pected by their families or teachers, pediatricians again

often are consulted for recommendations about further

formal assessment and school placement Sometimes, chil-­

dren perform below parental expectations, and sometimes

their achievement clearly exceeds stated thresholds Pedia-­tricians who provide medical care for children are expected

to be child development experts Moreover, parents ex-­pect the pediatrician to be able to apply this knowledge to the acquisition of academic skills from the early primary through the secondary school years School achievement

is not merely “being smart enough.” Achievement is very dependent on a complex and interwoven system reflecting societal, familial, and child elements (e.g., cognition, tem-­perament, language, memory, attention, visual-­spatial, fine and gross motor) These factors contribute to the child’s ability to acquire information and new skills in the school setting The proficient pediatrician will consider the matrix of societal, familial, and individual elements when trying to discern the factors affecting a particular child’s academic achievement profile

The three areas (Fig 51-­1) are discussed individually and then considered as elements in “school achieve-­ment.” This discussion examines the factors affecting children to attain academic achievement commensurate with their cognitive level or those affecting children who

oUTCoMES—SCHooL FUNCTIoN AND oTHER TASK PERFoRMANCE

Part VI

do not “make the grade.” Finally, suggestions are offered

to help direct the pediatrician’s surveillance efforts to

avoid unexpected academic struggles

SOCIETAL FACTORS

Within each community, there are economic, political,

cultural, and even religious influences on the educational

system offered (Fig 51-­2) Whereas there are national

federal mandates, control of local schools often is left to

local officials with state oversight This can create pock-­

ets of inequality as more affluent communities may be

able to provide, and expect, more diversity of resources

and experiences for their children Communities with

larger tax bases can support larger school budgets

Teacher salaries may be greater, schools may be bet-­

ter maintained, and “perishable goods” such as books,

computers and software, and CD-­ROMS may be more

easily updated Innovative programs may be explored as

school personnel are able to attend professional trainings

to learn about these offerings Conversely, communities

with fewer economic resources may not be able to attract

teachers with advanced skills, more experience, or pro-­

fessional choices There may be inadequate or outdated

textbooks, fewer supplemental classes, and less ability to

address individual student differences as completely

Often interwoven with the economic forces are politi-­

cal agendas Although a community may need a larger

budget for school use, local politicians may be reluctant to

promote tax increases Their personal professional agen-­

das may directly compete with school needs Overarching

local concerns may be a higher influence on curriculum

because certain topics may be considered inappropriate

Restricting books in the school libraries is one example

of this Curriculum control is sometimes used as a means

of inserting political influence in school policies

Cultural and frequently associated religious influ-­

ences can be subtle when the school is located in a geo-­

graphic region populated by a preponderance of families

from a particular ethnic group with specific cultural

heritage and religious beliefs If the majority believe a

certain way, there is an assumption the schools will fol-­

low suit If, however, there are many religions repre-­

sented in the families, more strident and vocal groups

may exert undue influence, and dissention from the oth-­

ers may follow The dictum “separation of church and

state” is sometimes difficult to follow when community

political leaders represent a majority religious group in the community

School administrators reflect these larger societal fac-­tors as well as their personal values and beliefs Whereas school system administrators must follow federal and state mandates, most district systems are given signifi-­cant leeway to permit local mores to set local standards (e.g., sex education, traditional man-­woman marriage versus same-­gender marriage/union, evolution versus creationism) These local school officials may respond to influential local groups and individuals with strong opin-­ions about curriculum, policy, and procedures These administrators also have their individual perspectives about how things should be run, and they often have the ability to make school policies fit their perspectives.Teachers also bring their professional training and in-­dividual values to the classroom The variability of teacher preparation is staggering Some teachers have master’s degrees from extremely strong education programs; other teachers may have only a few education courses taken while they receive on-­the-­job training The length of the teaching career is variable also The teacher’s personal be-­liefs are brought to the classroom every day

It is clear that the educational experience being of-­fered to each child is complex and reflects many factors beyond the control of the child and family Some of these factors are readily apparent: an aging school facility can

be seen from the curb Other equally important factors are much more subtle and may not be discerned until a problem arises For example, a child who refuses to pray

or to say the Pledge of Allegiance because of religious reasons may uncover pervasive community values Both apparent and subtle factors are important

FAMILY FACTORS

Families are the first communities of which children are members It is safe to say that at this time (early 21st century), there are no “typical” families (see Chapter 9) Children may live with birth parents, adoptive parents, grandparents, other relatives, single parents, parents who are married but do not live together, same-­sex parents, or foster parents, or they may be truly raised

by paid caretakers while their actual parents are fre-­quently absent These arrangements may be variably

Achievement

Child

Family Society

Figure 51-1 Academic achievement: Interplay of individual profile,

family factors, and community characteristics.

Economic Political

Cultural Religious

Societal Factors

Figure 51-2 Societal factors that influence educational systems.

accepted by the community, and this acceptance may

affect the child’s functioning in the family Community

acceptance also may affect the child’s ability to func-­

tion as an “equal” citizen in the school community

(Fig 51-­3)

Families also have culture The family culture some-­

times is consistent with the larger community, and some-­

times there is lack of congruity If the family values are at

odds with the larger community, conflicts can arise, and

these may interfere with the child’s successful academic

achievement For example, a family with strict religious

adherence (e.g., Passover, Yom Kippur, Ramadan) may

require school absences not synchronous with the es-­

tablished attendance schedule The child may miss tests,

field trips, or special opportunities Depending on the

school and community acceptance, these absences may

be excused and the child allowed to make up the missed

time, or the child may be penalized There are laws pro-­

hibiting discrimination on the basis of religion, but dis-­

crimination can be subtle

This “subtle” discrimination may also occur when the

family does not meet community expectations Biracial

children may experience this Children whose parents

have unpredictable work schedules may not consistently

come for school open houses or teacher conferences

This may be perceived by school personnel or other par-­

ents as “lack of interest” in school matters Parents who

have legitimate but out of the ordinary occupations (e.g.,

bartenders, entertainment industry) may have their par-­

enting skills regarded more severely than those of more

“traditional” parents Children who live with relatives

and are not cared for by a parent whose career precludes

daily contact with the child may overhear adults make

assumptions about the parents’ affection and concern for

the child Children with parents in prison are often in-­

nocent victims of hostility directed at their absent parent

with secondary judgments of the child’s character

Sometimes, the culture of the family excludes the

community If the family perceives the larger commu-­

nity as being “hostile” or alien to its values, the child

may receive the message that only the family, or those of

whom the family approves, are “safe” and acceptable

In this manner, the child may reject acceptance from

the school community Reinforcement is accepted only

from the family The family standards of achievement are those only accepted

Family standards as the sole reference point for the child’s academic performance may create false impres-­sions If the child is perceived as having more capabil-­ity than he or she is able to demonstrate, the child may receive the message “You are lazy You are not work-­ing hard enough You could do better work if you tried harder You are capable of better performance in your school work.” Conversely, if the family has diminished expectations (e.g., “Girls in this family are not good at math.”), a child with weak academic performance may not be offered a careful assessment of why his or her performance is weak

The child’s parents or primary caretakers can have a tremendous impact on successful daily school function-­ing Parental disorganization and problems with time management and scheduling can upset the most consci-­entious student If the child has a primary developmen-­tal condition, such as attention deficit disorder, weak parental organizational skills compound problems with getting to school on time, completing homework assign-­ments and returning them to school, locating materials for extra projects, and even getting to bed on time so the child has adequate rest A parent with substance abuse habits can undermine the child’s sense of security and regularity Not only can parental mental illness make the child genetically vulnerable to similar conditions, but poor emotional regulation clearly can affect daily routines and habits supporting successful school participation.Parental learning disabilities can have a significant impact on the child’s ability to master academic tasks Not only is there an inherited pattern to some learning disabilities (Williams and O’Donovan, 2006), but many children rely on their parents to provide additional ex-­planation and help in the evenings with homework as-­signments The child whose parent struggles with basic reading, math, and written expression skills will not have the advantage of this additional home support Many adults have significant shame about their weak basic ac-­ademic skills and may try to hide this information from their children by “being too busy” to help them or telling them “You are just being lazy by asking for my help.”Finally, much has been written about socioeconomic status and the impact on child health and development Magnetic resonance imaging studies of normal brain development in children between 6 and 18 years of age and neuropsychological testing of children in low-­income families (<$35,000/year) showed significantly weaker performance on cognitive and achievement tasks emphasizing integrative skills (e.g., reading comprehen-­sion, written expression) (Waber et al, 2007) The au-­thors of that study interpreted these results to suggest that lower economic family conditions do not provide rich and stimulating experiences enhancing cognition and accompanying complex academic tasks

THE CHILD

Children are products of their families and the larger community, but foremost, each has a unique pro-­file of strengths and weaknesses (Fig 51-­4) Whereas

Community acceptance

Performance expectation

Family culture

Parental academic abilities

Family Factors

Figure 51-3 Family factors that influence student educational

achievement.

community and familial responses may mitigate and

enhance this profile, there are independent qualities

strongly predictive of academic success Success here

is loosely described as “successful attainment of skills

commensurate with the child’s cognitive profile.”

If the universal descriptor of “academic achievement”

is successfully passing all grades, then cognition is the

best predictor of academic success (Sattler, 1992) Stan-­

dardized measures of intelligence correlate most closely

with academic success (Lezak et al, 2004) These tests

were developed with the primary intention of identify-­

ing those children who were most likely, all other factors

aside, of successfully completing a formal educational

program (i.e., “school”) Children with “full-­scale” in-­

telligence scale scores in the “average” range or higher

(i.e., IQs > standard score 85) stand a better chance

of being able to acquire the academic skills requisite

to fluid reading speed and acceptable comprehension,

math calculation and understanding, and expression of

their ideas in written form

If “intelligence” is closely examined, there are de-­

velopmental skills clearly identifiable as contributing

to this measured intelligence Receptive and expres-­

sive language, selective attention, immediate and long-­

term recall, working memory, visual-­spatial skills, and

fluid processing all are potential domains of individual

strength on which to build (see Chapter 55)

These areas also can be individual weaknesses that

may be addressed for either remediation or bypass What

is important is that intelligence is perceived not as a com-­

posite but rather as a synergistic amalgam Every child has

an individual strength:weakness profile, and those chil-­

dren who are successful in school are taught to recognize

their individual areas of strength to use when their weaker

areas are emphasized during the school day

Another important characteristic of academically

successful children is resilience (see Chapter 50) Strongly

resilient children do not buckle when they fail, either

absolutely or relatively This resilience may reflect their

basal level of academic skills or their personal motiva-­

tion to succeed in school Some children are extremely

motivated to learn and are not dissuaded by “failure.”

These children persevere in the face of academic strug-­

gles They may possess a strong self-­concept as part of

their inherent temperament (see Chapter 7), or they have had their resilience “shaped” by the parenting style

in their homes

The classroom is a laboratory for social skills and in-­teraction abilities One of the most important skills a child needs to learn is how to be a “good citizen” in the classroom The child must have needs met and respect the needs of the other students and the teacher Children vary in their abilities to share, to take turns, to start and

to maintain conversations, to control their bodies, and

to request assistance They have to know when to listen and when to talk Children enter school with potentially very different abilities to be successful group members Some children have successfully attended daycare or preschool and have demonstrated this ability Other children have had home training that has made them ready to adapt to the classroom setting

Another important characteristic of children who succeed in school is their personal belief that educa-­tion is important to their present and future well-­being Young children have these feelings imparted to them by their families, who articulate the importance of educa-­tion to them As they become older, the personal ac-­ceptance of these beliefs is essential to help maintain the motivation to attend school and to give the best effort to assignments This personal “ownership” of education’s value becomes an integral part of the child’s resilience

to school struggles If the child does not receive ongoing support from the family with respect to the value of education, even a mild setback can lead the child to re-­ject school as important to him or her

THE PEDIATRICIAN’S ROLE IN ANTICIPATORY CARE

The pediatrician can play a central role and be a signifi-­cant agent in helping children to achieve school success from early childhood experiences in daycare or pre-­school through post-­secondary education (Levine, 2002)

Table 51-­1 shows the various points for medical moni-­toring and intervention

Genetic Elements

Certain genetic disorders have identified cognitive pat-­terns clearly affecting a child’s ability to master new information Many of these conditions (e.g., trisomy 21, fragile X and other “expansion disorders”) have variable expression in the child, and early intervention can fre-­quently be associated with relatively optimal school per-­formance Careful family history can alert the clinician to assess the infant for any physical features suggesting par-­ticular inheritance or supplemental newborn screening Prompt referral as soon as physical signs are identified can result in appropriate referral for supportive developmen-­tal interventions and family advocacy Malformations may suggest syndromes with subsequent developmental and cognitive effects (e.g., velocardiofacial syndrome)

Prenatal Factors

Maternal and paternal age at conception, maternal hab-­its such as alcohol use and cigarette smoking, maternal hypertension during pregnancy, and other indicators

Cognition Developmental

skills

Desires education Resilience

Child Factors

Figure 51-4 Individual characteristics of the child that affect

academic performance.

Table 51-1 Topics Related to School Achievement: What May Be Discussed at Anticipatory Care Visits

Age Considerations

Cognitive Fragile X Trisomy 21 Malformations Velocardiofacial Prenatal factors Parent age at conception Alcohol or tobacco use Hypertension during pregnancy Birth and perinatal events Intraventricular hemorrhage Secondary visual impairments Central nervous system infections Birth–3 years Child

Formal developmental screening Months 9, 18, and 30 or 36 New concerns by family or physician Regular developmental surveillance Parent

Maternal postpartum depression Referral to mental health programs Surveillance of family “wellness”

Parental literacy Referral to adult literacy groups

3 years–kindergarten

entry Child Continue formal developmental

screening Continue developmental surveillance Interaction with same-­age children Independent play

Sustained interest Interactive conversations with adults Variety of activities

Parent Discussion about early education Family ambitions

Community pressures Mistaken ideas Parent

Community expectations Family history

Child’s characteristics Parents’ personal school experiences Child

Factors affecting standardized test performance performance

Personal characteristics Personal characteristics Physical

Sensory deficits Medical conditions Motor skills Neuropsychological Attention Memory Reasoning Language Comprehension Temperament Stress and frustration

management management Emotional Previously diagnosed mental health conditions

Home Learning atmosphere Educational support Daily routine Parent and child expectations Peers

Acceptance in social group Peer attitudes toward achievement Parent

Review and explain testing reports Later elementary

years Child—continue developmental surveillance

Independence Initiates parental involvement Turns in assignments Asks specific questions to facilitate learning

Cognitive changes Reading at appropriate grade level Understanding peer humor Peer influence

Social hierarchies Attitudes toward academic achievement

Differences in physical development Strengths and weaknesses

identification Observation in the examination room Noting examples of stronger functioning by parents Parent

Encouragement toward independence Middle school Child and school

Chronic illness Educational and cognitive aspects Current research

Effects of treatment Use of offered accommodations School personnel support Peer acceptance Parent

Emphasize need for autonomy and individuation

Contact school Suggest classroom modifications High school Adolescent

Identification of personal areas of strength

Facilitate communication between child and parent

Parent Unresolved need for success Post-­secondary edu-­

cation/vocational training

Young adult

If previously received supplemental services: apprenticeships services: apprenticeships

of possible fetal hypoxemia (including maternal iron

deficiency anemia) and suboptimal fetal growth have

been associated with developmental conditions later

associated with school and behavior struggles

Birth and Perinatal Events

Significant adverse events during delivery and prolonged

neonatal complications, such as intraventricular hem-­

orrhage with subsequent hydrocephalus, secondary

visual and hearing impairments, central nervous system

infections, and other significant congenital abnormali-­

ties, potentially may affect cognition and educational

attainment in later childhood

Birth Through Three Years

Between birth and 3 years of age, expert opinion

recommends regular developmental surveillance as well

as formal developmental screening with standardized in-­

struments at 9 months, 18 months, and 30 or 36 months

of age

Identifying Infants and Young Children with

Developmental Disorders in the Medical

Home: An Algorithm for Developmental

Surveillance and Screening

Formal screening also may properly be offered at any

other time if the child’s family or the pediatrician has

new concerns All U.S states have early intervention

services for young children, and pediatricians may make

referral for formal developmental testing at any time

before 36 months of age (www.cdc.gov/ncbddd/child/

devtool.htm).

During these early years, formal screening for maternal

postpartum depression, surveillance for indicators of

family “wellness,” and careful but clear addressing of

parental literacy are important to help develop a strong

and supportive family home in which the child can grow

and be nurtured Referral to local mental health pro-­

grams and adult literacy groups can begin interventions

benefiting everyone in the family

Three Years Through Kindergarten Entry

Developmental support for children in this age range

is usually provided through the public school sys-­

tems Whereas referrals certainly can be made after 36

months of age, it can be more difficult to obtain formal

standardized assessment of the child’s cognitive, lan-­

guage, and motor skills if the family’s economic re-­

sources are limited It is for this reason that referral for

formal assessment before 3 years is emphasized None-­

theless, children with identified developmental delays

may enter the school system–sponsored structured

preschool programs For this reason, continued devel-­

opmental surveillance and screening with a standard-­

ized instrument is optimal care for children in this age

group

As part of the developmental surveillance, asking

the parent how the child interacts with other same-­age

children in paired situations as well as in larger group

settings is important As the child becomes older, there

should be more independent play, more sustained

interest in a preferred activity, and increasing length of interactive conversations with adults

Asking the parents if the child freely participates in many different types of activities—coloring, assembling puzzles, imaginative play, riding a scooter or tricycle, listening to books being read aloud, and reciting nursery rhymes—can point to areas of further discussion if the child routinely avoids certain areas

Pediatricians are often asked about the “best” preschools for their patients Many parents mistakenly believe that young children need to be taught to read and to count before they enter kindergarten The wise pediatrician will ask the parents what they think is im-­portant about attending preschool That query can open

a discussion about family ambitions, community pres-­sures, and possibly mistaken ideas about early education

A thoughtful conversation often can help the parents decide for themselves the best preschool setting for their child

Kindergarten Entry

The kindergarten physical examination appointment

is often a well-­attended visit because many school sys-­tems demand a school form completed by a physician The pediatrician can be very helpful in providing some common-­sense anticipatory suggestions Regular bed-­times, breakfast in the morning, time for exercise after school, and time and place for homework completion should be emphasized With respect to parenting, maybe the most important suggestion is to develop the habit of praising the child’s efforts and not the outcome This

is very important as reading and written expression of-­ten require repeated attempts to master a subskill, and children may become tired and want to give up their at-­tempts They need to know that their parents appreciate and value the hard work they are showing as they work

to master these skills

Parents may quickly perceive that the kindergarten their child is attending is much different from the experience they had as 5-­year-­olds Adults inspecting kindergarten curriculum may have the sense “We aren’t

in Kansas anymore, Toto!” As elementary curricula seem

to move more quickly and encourage the acquisition of more complex skills at a younger and younger level, skills that were once the purview of first grade are now expected by the end of the kindergarten year Some par-­ents, sensing the intensity of the kindergarten curriculum, want the pediatrician’s advice about not having the child enter kindergarten when the fifth birthday is reached Other parents may allow matriculation but then want

to retain the child for a second year of kindergarten for

“maturing” purposes Again, the community expecta-­tions, the family’s history, and the child’s characteristics all must be considered This is another excellent time for

a thoughtful explication of the parents’ personal school experiences and an emphasis on their decision making rather than taking the pediatrician’s expert opinion

Early Elementary Years

Grades 1 through 3 are the foundation for skills used throughout the remainder of the child’s school years Learning to read, to do arithmetic functions, and to express ideas in written form may be the first tasks in

which a child shows struggles Parents want to know if

early problems with classroom learning suggest more se-­

rious cognitive or processing problems, and this can be

difficult to discern Teachers are loathe to separate chil-­

dren in these early grades as being “deficient” and may

try a variety of informal interventions before requesting

formal psychoeducational testing either to identify or

to describe a “learning disability.” If the teacher does

not communicate concerns about the child’s progress to

the parents, many parents assume the child is meeting

expectations The news that the child is being referred

to the school’s student support team for further assess-­

ment either can come as a shock to the family or can be

welcomed that “finally something is being done.” Many

parents do not understand the testing process, the results

from standardized testing, and what appropriate inter-­

ventions should be offered if the child is found to meet

criteria for a learning disability The pediatrician can

be helpful by offering to review the test report and ex-­

plaining the standard scores in the context of a normally

distributed curve Seeing the information displayed in

this graphic manner sometimes makes the numbers more

understandable There also are books explaining psy-­

chological tests to nonpsychologists (Wodrich, 1997)

For the typical nonstruggling student, the third

grade is usually the first formal testing experienced,

when children are given the high-­stakes educational

achievement testing mandated by No Child Left Be-­

hind legislation Learning disabilities aside, Table 51-­2

illustrates many factors potentially affecting the child’s

ability to learn classroom material and also to dem-­

onstrate this acceptable mastery on these tests These

factors should be considered throughout the academic

course through college entry

When children do not pass these examinations,

additional testing will identify neuropsychological fac-­

tors; however, the environmental and temperamental

contributors are best assessed through interviews, obser-­

vations, and checklists By reviewing the medical record,

the pediatrician can find much of this other information

and can be a valuable member of the assessment team

Later Elementary School Years

As the child progresses in school, the demands increase

Not only does the complexity of the material increase,

with resulting emphasis on more adept integration of all

the neuropsychological elements described in Table 51-­2,

but there is an expectation the student will function

more independently This can create problems for the

child in several ways

First, if the parents are not also emphasizing more

independent management of school homework and proj-­

ects, the student is not practicing independence out of the

classroom This can be seen in children not remembering

to have parents sign forms brought home, not turning

in completed homework although the parent made sure

it was in the book-­bag, or needing the parent’s pres-­

ence as they do their assignments Second, teachers in

later grades may function more as “consultant” rather

than as teacher That is, they may present the content

in a lecture but then expect the students to ask specific

questions about what they do not understand There

certainly are independent learners who can proceed and handle assignments with only minimal questioning of the teacher Some children, however, cannot articulate what it is they do not understand; they need for the content to be presented in a slightly different manner This may be misperceived as being overly dependent on the teacher for help, and the teacher may refuse to help them Asking if the child shows independence at home can help resolve this confusion

Older elementary children are expected to be transi-­tioning into more conceptual and higher order language use and understanding Their reading material is less about concrete and tangible topics This change in lan-­guage use and understanding is developmental and may begin as early as 9 years and yet in other students may not be mastered until later middle school An informal

Table 51-2 Factors Affecting Standardized Test

Performance

Personal Characteristics

Physical Sensory deficits affecting acquisition of tested material (vision, hearing)

Medical conditions, acute and chronic (Brown, 1999) Fine motor and gross motor: precision, strength, and speed Neuropsychological factors

Attention Memory: short-­term, working, and long-­term retrieval Reasoning ability, possibly reflecting fluid processing, working memory, and processing speed (WISC Book)

Visual-­spatial skills Language

Comprehension (both aural and reading) affected by receptive skills and prior exposure to the “language” of the test (Leonard, 1998)

Personal experience Past exposure to material covered on the test Temperament

Perceived stress of the testing and internal coping style Past temperamental factors affecting learning Persistence

Frustration management Coping with both failure and success Emotional factors

Previously diagnosed mental health conditions: attention deficit disorder; depression

Anxiety-­related disorders Bipolar disorder

Environmental Factors

School Resources available for teaching and learning content:

teacher qualifications; current resources for content (books, computers, consultants)

Physical building conditions Temperament synchrony between the student and teacher Home

Availability for supplemental learning opportunities provided

in the home Support for consistent and complete homework mastery Predictable daily routine, including meals, physical exercise, and adequate sleep

“Good fit” between parents’ and child’s expectations for school performance

Peers Child’s acceptance by peers in the social group Peer attitudes toward school and academic achievement

sign that the child is not understanding more conceptual

language is the complaint that appropriate grade-­level

books are “boring.” When they are reading for plea-­

sure, they may choose books at a lower level than they

are capable of reading Similarly, they may not under-­

stand the humor of same-­age peers, although they used

to easily tell jokes and understand them

Peer relations also become increasingly more im-­

portant as children approach the middle school years

(see Chapter 15) The complex social hierarchies can

take a significant amount of emotional energy, and some

students will become internally distracted in the class-­

room as they mull over an unkind remark casually made

in the lunchroom by a former close friend Peer attitudes

toward academic achievement also can be a significant

factor in a student’s willingness to actively participate

in classroom discussions or enrichment after-­school

programs Concerns about their physical development

in comparison with peers also can significantly affect a

child’s social interactions in the classroom As more stu-­

dents are retained because of failure to pass high-­stakes

testing, there will be more “old for grade” students, and

the discrepancies between physical size and development

will likely increase

Finally, identification of the gifted student should

not be forgotten (see Chapter 52) As everyone has a

personal profile of strengths and weaknesses, there may

be students who clearly excel and are identified early

in their school years as intellectually bright There are

other students, however, who quietly do their work

and may show one area of significant talent These chil-­

dren should not be ignored as just showing a “splinter

strength.” It is possible they may fall in the designation

of “academically gifted and learning disabled.” That

is, they will show superior scores on standardized in-­

telligence testing, but their academic achievement test-­

ing falls in the average range of standard scores If no

one probes for more careful and formal scrutiny, the

child will be passed along as average This is a situation

in which the pediatrician can make a significant con-­

tribution by noting examples of stronger functioning

described by the parents or observed in the examina-­

tion room The pediatrician then can be the professional

requesting further assessment by the school

Middle School

The middle-­school years can be a maelstrom for children,

parents, and school personnel All the issues described

for the late elementary school-­age child are present and

made even more dramatic by the physical and cognitive

changes experienced by young adolescents Puberty en-­

compasses the physical and sexual changes; adolescence

demonstrates the enduring psychosocial and learning/

cognitive transitions between childhood and adult life

The content demands of middle-­school subjects increase

also, and concomitantly supports offered in the elemen-­

tary schools seem to fade More is expected in the abil-­

ity to organize their assignments, to maintain prolonged

focused attention, to understand increasingly more con-­

ceptual and higher order language, and quickly to shift

topics as they transition between classes and people with

whom they interact This appears to be true for both those

students who have identification as “specifically learning disabled” and those who receive support through “other health impaired” identification At the same time sup-­port is changed, the typical young and mid-­adolescent does not want to appear different from peers and may refuse any offered supplemental services The needs do not abate, but the intervention certainly changes Par-­ents may seek help from the pediatrician to advocate for the school to continue to honor accommodations offered in elementary school as they are clearly needed for the student to make academic progress When contact is made with the school for this purpose, a successful strat-­egy is to focus on the eventual goal of school attendance through the twelfth grade and high-­school graduation Asking how this student will successfully manage the content of middle-­school courses and develop the skills requisite for successful mastery of high-­school demands can help focus the discussion more on strengths of the middle-­school teachers to enhance development and less

on what will or will not be offered If the pediatrician makes suggestions about classroom modifications (pref-­erential seating, copies of class notes, after-­school as-­sistance in how to stage long-­term projects), the process may be viewed as less adversarial

Another manner in which the pediatrician can be helpful to both school personnel and the child is to act

as a resource for information about the educational and cognitive aspects of chronic illnesses Although most lay-­people understand that central nervous system disorders (e.g., seizure disorders, past history of meningitis or head trauma with prolonged loss of consciousness, congeni-­tal brain malformations) could have a clear impact on learning, they may not understand other conditions and the relationship to cognition This might include mid-­line heart defects, sickle cell anemia, insulin-­dependent diabetes, and asthma Discussions about chronic health conditions might include review of current research about cognition and the condition, effects of treatment, need for hospitalization, and reduced endurance once the child is in the classroom

Pediatricians also may be drawn into a discussion with the student to encourage the use of offered accom-­modations Whereas parents may have many directives about what they want their child to do, the pediatrician may be viewed as more neutral, and thus recommen-­dations made may be taken more seriously by the stu-­dent An especially important aspect to this discussion

is to acknowledge humiliation protection and how the student may accept the support and avoid as much as possible teasing by peers

High School

High school may begin in either the ninth or tenth grade, but high school is clearly different from all other school experiences, as parents and teachers remind the students that high-­school grades “count.” These are the courses and grades the colleges, technical schools, and special-­ized vocational programs will use to determine eligibility after the senior year If you ask middle-­class ninth-­grade students what they plan to do after high school, most will give an answer including further education It is important to try to ensure that all students leaving high

school have solid reading and reading comprehension,

practical math skills, and the ability to express their ideas

clearly in written form If a student’s parents did not have

a strong educational background, they may not have an

accurate understanding of their child’s ability level rela-­

tive to that expected by a graduating senior The pedia-­

trician may have to be the strong advocate for ensuring

that the student is offered assistance to graduate with as

much of the basic skills as possible Adults concerned

with adolescents must remember that this age also in-­

cludes first work experiences, social distractions and pre-­

occupations, excessive media consumption, and risks of

tobacco or alcohol and other substances for abuse

On the other end of the spectrum are those students

whose parents bought infant clothing for them with the

logo of an Ivy League college and who are determined

their child will matriculate into a “top” college This can

be a very difficult situation if the student does not have

the academic or personal profile consistent with this de-­

manding institution or if the student does not follow his

or her parents’ wishes Sometimes, the decision about

college can uncover the parents’ unresolved needs for

success and how these needs are being channeled through

the child The pediatrician can be helpful here by empha-­

sizing in the child’s early adolescent years the need for au-­

tonomy and individuation from the parents Encouraging

the adolescent to identify personal areas of strength and

to pursue these for a sense of mastery and accomplish-­

ment will provide a buffer for any academic setbacks It

is a rare child who completely ignores his or her parents’

suggestions, as the family messages can be incredibly

powerful, but emotionally healthy children may choose

a path in which they know they can find success rather

than temporarily appease the parent In this situation,

the pediatrician can use skills as both a child and parent

advocate to help facilitate communication between the

child and parent and meaningfully contribute to an ac-­

ceptable resolution to the differing needs of each

Planning for Post-Secondary Education

or Vocational Training

Ideally, these plans were being developed at the begin-­

ning of high school Certain factors can prevent the best

plan’s being followed An intervening serious health con-­

dition may change the student’s plans from going to col-­

lege in another state to attending a local and less stressful

community college Family disruption through the death

of a parent or divorce may change the financial support

available to the student, and the student may realistically

have to defer formal training or education to be self-­

supporting Emotional and mental health conditions can

change the academic trajectory of a promising student

Most high schools have guidance counselors to advise

students, but the services that these overextended pro-­

fessionals can offer are usually limited to developing the

letters of recommendation for the student If a student

is not planning to attend a post-­secondary technical

or academic program, and if the student ever received

supplemental school services as either learning dis-­

abled or “other health impaired,” it is very important

to see if that student would be eligible for vocational

rehabilitation consultation Whereas these resources

can be variable in the completeness of services offered, they should know about training centers and other community programs for individuals who do not have the educational background to enter a more advanced technical school Apprenticeships can be another avenue for more specialized training, and this can be invaluable for students who are not reading at a high-­school level and who learn best through on-­the-­job training

For all students, the pediatrician can be a strong ally in communicating with teachers and other school person-­nel, making suggestions about improving time manage-­ment and organizational skills, developing appropriate medication plans when indicated, facilitating family dialogue, and making evidence-­based suggestions about diet, sleep, and exercise The final years of secondary school can be tumultuous for students and parents The pediatrician can be the voice of calm for them all

SUMMARY

School performance is a multifaceted marker of a child’s development, and pediatricians can make significant con-­tributions to helping the child be as successful as he or she

is capable Knowledge of the community characteristics, the family background, and the child’s individual physical, developmental, and emotional strengths and weaknesses places the pediatrician in a position to help guide the child through preschool programs all the way

to high-­school graduation Actively soliciting informa-­tion at all appointments about school performance and showing a genuine interest in mastery of educational tasks demonstrate the pediatrician’s desire to be a part-­ner with the child and family in their common goal of helping the child manage the academic challenges as the child develops physically, emotionally, and socially

REFERENCES

American Academy of Pediatrics: Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening Pediatrics 118:405-­

Sattler JM: Assessment of Children, Revised and Updated, 3d ed San Diego, Jerome M Sattler, Publisher, 1992 , Jerome M Sattler, Publisher, 1992 Sattler, Publisher, 1992 , Publisher, 1992.

Waber DP, De Moor C, Forbes PW, et al: The NIH MRI study of normal brain development: Performance of a population based sample of healthy children aged 6 to 18 years on a neuropsycho-­ logical battery J Int Neuropsychol Soc 13:729, 2007.

Wehman P: Life Beyond the Classroom: Transition Strategies for Young People with Disabilities, 3rd ed Baltimore, MD, Paul Brookes, 2001.

Williams J, O’Donovan MC: The genetics of developmental dyslexia Eur J Hum Genet 14:681, 2006.

Wodrich DL: Children’s Psychological Testing: A Guide for Nonpsy-­ chologists Baltimore, MD, Paul Brookes, 1997.

THE GIFTED CHILD 52

Children who are gifted compose 5% to 20% of the

gen-eral school-age population, depending on how “gifted”

is defined or the criteria used to identify students who

are gifted (Pfeiffer and Stocking, 2000) Primary care

physicians may be the first line of professionals

con-sulted by parents of gifted children Is my preschooler

gifted? How can I nurture my child’s talents? What is

the best educational setting for my gifted child? Why is

my child not achieving at a level consistent with his or

her high ability? Primary care physicians are frequently

placed in the position of assisting parents with answers

to these questions and directing them to appropriate

re-sources and educational opportunities The following

summary of the current research on identification of,

appropriate educational programming for, and special

challenges faced by children who are gifted is provided

as a resource for the primary care provider

DEFINITIONS OF GIFTEDNESS

“Gifted” means different things to different people in

different contexts and cultures Some equate gifted with

high intelligence, others with high academic achievement

Still others highlight the domain-specific mastery

char-acteristic, for example, of musically or artistically gifted

individuals What constitutes giftedness in terms of

cog-nitive abilities, talents, personality traits, or

environmen-tal contributions is the source of ongoing investigation

and public debate Researchers and educators alike differ

in how they define giftedness, and the empiric literature

is characterized by the absence of a common vocabulary

or universally defined terms, making comparisons across

studies difficult Within the realm of education, there is

no federal definition recognized by all states—a child

who qualifies for gifted programs in one state may not

be eligible for similar programs in a different state

Historically, gifted has been equated with high

in-tellectual functioning In the early 20th century, Lewis

Terman defined gifted as an intelligence quotient (IQ)

at or above 150 on the Stanford-Binet Intelligence Scale

(Terman et al, 1926) Subsequently, the 98th percentile

(IQ = 130) has commonly been used as the cutoff for

giftedness More recently, some school districts

recog-nize students with IQs of 120 or above as eligible to

receive gifted programming

The problem with viewing exceptionally high IQ as synonymous with giftedness is that a fixed proportion

of the population is always selected (e.g., top 3% to 5%; Renzulli, 2005) Research suggests that herita-bility accounts for most of the variance in IQ among children in middle and upper socioeconomic classes However, for children from low-resource backgrounds

or minority groups, environment—not genes—makes a bigger difference (Turkheimer et al, 2003) As such, use

of an IQ cutoff as the criterion for gifted will ridentify children from low-resource backgrounds An additional problem with use of intelligence test scores

unde-to define giftedness is the limited predictive utility of these scores IQ correlates only modestly with academic achievement, and noncognitive factors also account for

a significant proportion of variance in academic ment, including but not limited to motivation, interest, self-efficacy, and self-regulation skills In addition, in-telligence test scores are poor predictors of real-world functioning, such as job performance (Neisser et al,

attain-1996) Finally, IQ scores do not capture the range of cognitive abilities Therefore, classifications that em-phasize IQ for placement will miss those children with

“uneven giftedness” (e.g., nonverbal intelligence > bal intelligence) For all of these reasons, IQ cutoff cri-teria frequently result in underidentification of gifted children

ver-Modern-day conceptualizations of giftedness ognize that general intellectual ability is an important component of giftedness but reject the notion that in-telligence is a unitary construct For example, Howard

rec-Gardner’s (1999) “multiple intelligences” highlights the multifactorial nature of giftedness by defining eight domain-specific intelligences: linguistic, logical- mathematical, musical, bodily-kinesthetic, spatial, in-terpersonal, intrapersonal, and naturalistic Similarly, Robert Sternberg suggests that intelligence is not a fixed entity but a flexible and dynamic one, a form of develop-ing expertise involving noncognitive and cognitive com-ponents Specifically, Sternberg’s WICS model (2005)

asserts that gifted individuals possess a synthesis of

wisdom (balancing intrapersonal, interpersonal, short-

and long-term goals), intelligence (ability to adapt to

one’s environment and to learn from experience), and

creativity (applying and balancing innovative, analytical,

and practical abilities) Joseph Renzulli (1978, 2005)

also emphasizes the confluence of multiple factors in

defining giftedness In his three-ring model, Renzulli

suggests that creative-productive people possess an

in-teraction among three basic traits: (1) above-average

ability, defined as high general intellectual functioning

or well above average domain-specific performance,

such as general verbal ability; (2) high levels of task

com-mitment, defined as perseverance, hard work, intrinsic

motivation, and self-efficacy; and (3) high levels of

cre-ativity, or original, unconventional, ingenious thinking

These three rings interact against a background of

per-sonality and environmental variables (e.g., educational

opportunities) to give rise to gifted products The

mul-tiple factors that give rise to gifted behaviors require

special attention from parents, primary care providers,

and educators

DEVELOPMENTAL ASPECTS OF GIFTEDNESS

Cognitive Development

The term giftedness often sparks the nature-nurture

de-bate Those assuming the nature side of the argument

emphasize the inborn, heritable ability and intrinsic

drive of the gifted child (e.g., high IQ), whereas those

assuming the nurture side of the argument suggest that

giftedness is the product of hard work or deliberate

practice (Bloom, 1985) According to modern-day

theo-rists, as detailed previously, high ability is a necessary

but not sufficient component of giftedness Opportunity

also plays a large role in the development of giftedness,

including family support, societal and cultural values,

educational opportunities, and resources

When considering their cognitive development, Winner

(1997) suggests that gifted children are qualitatively

dif-ferent from children of average ability Specifically, gifted

children excel at higher order reasoning, independent

solu-tion of abstract problems, and transfer of skills to novel

situations Gifted children also are characterized by an

in-trinsic drive to master specific domains of interest Signs

of giftedness may emerge early in development, including

early onset of language, excellent memory, intense

curios-ity, long attention span when engaged in activities of high

interest, metacognitive awareness of problem solving

strat-egies, and efficient use of learning strategies Many

chil-dren who are gifted acquire reading skills before entering

kindergarten, demonstrate facility with numbers, and excel

at abstract problem solving Although many gifted

chil-dren demonstrate evenly developed intellectual

function-ing, many evidence domain-specific gifts in language or

nonverbal/quantitative reasoning Finally, gifted children

may evidence uneven development that is characterized by

acquisition of cognitive skills in advance of social and

emo-tional development

Social-Emotional Development

In a review of the research, Neihart and colleagues

(2002) reported that most gifted children are socially

and emotionally well adjusted Contrary to myths

promoted by the media, rates of suicide or school

violence are not higher among students who are gifted

Rather, Neihart and colleagues report low rates of linquency among students who are gifted compared with average students In the National Education Longi-tudinal Study from the National Center for Educational Statistics, students placed in gifted programs reported higher self-perceptions of their social relationships and emotional development and tended to have fewer seri-ous school behavior problems compared with students enrolled in regular educational programming (Sayler and Brookshire, 1993) Similarly, Bain and Bell (2004)

de-reported that the majority of gifted elementary and middle-school students reported high self-concepts com-pared with a high-achieving group of students and had

a stronger tendency to attribute social success to ability and effort (internal locus of control) rather than to luck

or task difficulty

A number of steps have been suggested for the motion of healthy social and emotional development among children who are gifted First, the role of the family cannot be understated Three family characteris-tics have been shown to facilitate social and emotional resilience among gifted youth: parents who have high expectations of their gifted children and model high achievement, parents who give their children more in-dependence, and parents who provide stimulation and nurturance (Winner, 2000) Second, schools that set high expectations for achievement and provide appro-priate, individualized educational programming also promote social and emotional adjustment among gifted students Reis and Renzulli (2004) suggest that appro-priate educational programming for gifted students should include (1) accelerative learning experiences tar-geting areas of academic strength along with supports

pro-in areas of identified weakness (i.e., learnpro-ing disabilities

or attention-deficit/hyperactivity disorder), (2) ing that teaches students how to cope with the pressures and social stress associated with high academic abil-ity and early presentation of career information, and (3) integration of social-emotional curriculum appro-aches to help gifted children support one another, including social opportunities with peers of similar abil-ities, interests, and motivation

mentor-APPROACHES TO EDUCATING THE GIFTED CHILD

During the past 50 years, research and educational gramming focused on gifted students have grown At the federal level, although specific legislation recognizes the unique educational needs of students who are identi-fied as gifted and talented (e.g., the Jacob Javits Gifted and Talented Students Education Act, recently reau-thorized in 2001 as part of the No Child Left Behind Act), the federal government does not mandate services for gifted students Gifted and talented programming is not part of the Individuals with Disabilities Education Act Rather, the majority of programs and services that students receive are determined by state laws and poli-cies and funded at the state and local level State laws that define gifted and talented programming and teacher training requirements, along with available funding for gifted education, vary widely Most states and school

pro-districts use the following definition (U.S Department

of Education, 1993) :

Children and youth with outstanding talent

per-form or show the potential for perper-forming at

re-markably high levels of accomplishment when

compared with others of their age, experience, or

environment These children and youth exhibit

high capability in intellectual, creative, and/or

ar-tistic areas, possess an unusual leadership capacity,

or excel in specific academic fields They require

services or activities not ordinarily provided by the

schools Outstanding talents are present in children

and youth from all cultural groups, across all

eco-nomic strata, and in all areas of human endeavor

(p 26)

Most leaders in the field agree that cognitive ability

tests should constitute part but not all of the

iden-tification process They agree that other indicators

of potential also should be used in the identification

process and should be given equal consideration in

selecting those students eligible for special services

Most agree that the selection process should take

into consideration multiple variables, and in the

fi-nal afi-nalysis, the informed judgment of educators

should prevail over strict cutoff scores on

psycho-metric instruments Despite these ideals, in this era of

high-stakes testing, identification of students eligible

for special programs typically relies on test scores

(i.e., intelligence test cutoffs or performance on

aca-demic achievement tests)

Curriculum Alternatives

In general, research suggests that gifted students require

a differentiated curriculum that addresses their

learn-ing needs to maintain academic interest and high levels

of achievement The following is a brief introduction

to the various curriculum alternatives for gifted

educa-tion Empiric support for the effectiveness of each of

the following programs is limited There are three main

approaches to gifted education: ability grouping,

accel-eration, and enrichment

Ability grouping refers to the practice of using test

scores or other measures of achievement to assign

stu-dents to groups within the classroom This practice

may involve part-time assignment to both regular and

special classes or full-time grouping with students of

similar abilities within the classroom Magnet schools

are a good example of ability grouping for students

who are gifted and talented or students with special

interest areas (e.g., science and math or the arts)

Research suggests that gifted students who receive

a differentiated curriculum through flexible

group-ing practices evidence higher academic achievement

at all grade levels compared with those students who

do not receive a differentiated curriculum (Kulik and

Kulik, 1992)

Acceleration is an educational procedure that is

based on the assumption that gifted students learn at

an accelerated rate and generally master advanced-level

academic material Acceleration is a placement, not an

educational program Accelerative procedures may clude early entrance into kindergarten, grade advance-ment, early entry into college, and dual enrollment in high school and college Curriculum compacting is an-other example of accelerative programming, whereby a number of courses are “compressed” into one or stu-dents are exempt from instruction in an area in which they demonstrate mastery Opponents of acceleration suggest that this form of educational programming is detrimental to the social, emotional, or physical devel-opment of gifted students, and acceleration practices are not commonly used by most school districts How-ever, in a review of the research, Gross and van Vliet (2005) reported positive outcomes for exceptionally gifted students who were permitted radical accelera-tion (i.e., early entry into college), including sustained interest and involvement in academic activities, high levels of academic success, and transition into high- status careers Moreover, there was no evidence for social or emotional maladjustment when exceptionally gifted students participated in well-planned acceleration procedures Positive outcomes for students who partici-pate in radical acceleration procedures were associated with high achievement motivation, persistence, effective study skills, and involvement in educational decision making

in-Enrichment refers to additional or new curricular

material not delivered in regular education or tional strategies that supplement what is taught in the regular education classroom (e.g., pull-out programs) Advanced Placement (AP) courses, part-time college courses, and summer programs are examples of en-richment programs Gifted students report an increase

instruc-in social self-concept when they participate instruc-in summer enrichment programs (Rinn, 2006) However, pull-out programs have been criticized for not providing appro-priate educational programming throughout the school day or across all subject areas

CHALLENGES FACED BY SOME GIFTED CHILDREN

The Underachieving Gifted Child

The gifted child who does not evidence consistent academic achievement represents one of the most frustrating dilemmas for primary care provid-ers and parents alike Gifted underachievement, most commonly defined as a severe and persistent discrep-ancy between a student’s academic performance and actual ability, represents a significant problem for some children In a review of the research on gifted underachievement during the last 5 decades, Reis and colleagues (2005) reported that the beginning stages

ability-of academic underachievement among gifted students occur in elementary school, perhaps because of an un-challenging curriculum Subsequently, underachieve-ment appears to be periodic and episodic, occurring

in some years and not others and in some classes but not others Eventually, increasing episodes of under-achievement will result in a more chronic pattern for some students

Gifted underachievement is often a complex problem

involving multiple factors (Reis and McCoach, 2000,

2002):

• Curriculum factors: Gifted underachievers report

that they are bored or unchallenged by the regular

education curriculum In general, research suggests

that when given an appropriately stimulating

academic environment, gifted students perform at

more advanced levels than their peers

• Peer factors: Underachieving gifted students report

that the influence of peers is the single strongest

force undermining their achievement Specifically,

some gifted students succumb to the pressure to be

like their peers, hiding their abilities in an attempt

to be accepted by their typically developing peers

(Winner, 2000)

• Family factors: Parenting styles may interact with

the behaviors of some underachievers, yet no clear

pattern exists about the types of parental behaviors

that may influence or cause underachievement

(Reis et al, 2005) Such family characteristics

as inconsistent parenting styles (Rimm, 1995),

parents with less positive affect, parental

disinterest toward education, overly strict or

overly lenient parenting, and family conflict have

been correlated with gifted underachievement

• Child factors: Depression, anxiety, perfectionism,

rebellion, low motivation, low self-regulation,

or low self-efficacy can lead to academic

under-achievement among gifted students Academic

underachievement may be symptomatic of more

serious cognitive or emotional issues, such as

an unrecognized dual diagnosis (e.g.,

attention-deficit/hyperactivity disorder, learning disability,

or depression)

Solutions

Research documenting the effectiveness of specific

terventions for gifted underachievement has been

in-conclusive However, the growing literature on gifted

underachievement suggests that a focus on strengths

and interests is critical to reversing the pattern of

un-derachievement (Baum et al, 1995; Dole, 2000; Reis

et al, 2005) In addition, interventions that target

fam-ily, child, peer, and academic factors are recommended

Specifically, psychological interventions that target

family dynamics (e.g., increased positive parent-child

interactions, increased parental interest and investment

in their child’s education, and use of reward systems)

and characteristics of the student (e.g., cognitive and

emotional obstacles, such as low self-efficacy) are

rec-ommended Academic interventions should include

cur-ricular changes that tap areas of giftedness and high

interest and establish clear academic goals and

objec-tives with rewards for attainment of these goals There

is some evidence that more rigorous academic challenge

may actually have a positive impact on

underachieve-ment Peer groups that support achievement can be

an important part of preventing and reversing

under-achievement In this regard, busier adolescents who

are involved in clubs, extracurricular activities, sports, and religious activities are less likely to underachieve

in school Regular patterns of work and practice also seem to help talented students develop an achievement model in their own lives For example, scheduled time for extracurricular activities and regular time for homework and reading can help develop positive self- regulation strategies Finally, the coordinated efforts of caring adults, such as a mental health provider, coach,

or teacher, can help ensure that these areas are tively targeted (Baum et al, 1995; Callahan and Kyburg,

effec-2005)

The Socially Isolated Gifted Child

Among those gifted students who experience social or emotional difficulties, social isolation may result from

a number of factors Early investigations reported that the gifted adolescent who feels lonely may be expe-riencing stress and depression in reaction to the bur-dens of “success” (Kaiser and Berndt, 1985) Cornell (1990) reported that compared with popular students

of average ability, unpopular high-ability students are characterized by lower reported levels of social self-concept and academic self-efficacy Finally, Pfeiffer and Stocking (2000) have suggested that some gifted students become socially or emotionally maladjusted because of difficulties identifying a peer group with similar abilities; disparity between the instructional environment and the capabilities of the gifted child;

or unrealistic expectations on the part of parents or teachers that can lead to defiant behavior, depression/hopelessness, academic underachievement, or sub-stance abuse

Some gifted children may be the target of peer lying Peterson and Ray (2006) conducted a national survey of 432 eighth-grade students identified as gifted

bul-to determine the prevalence rates of bullying among gifted students The prevalence of being bullied at some time during kindergarten through the eighth grade was 67% Name-calling was the most prevalent type of bul-lying across all grades and was rated as the worst type

of bullying, followed by teasing about appearance and teasing about intelligence and grades Students reported that the greatest emotional impact of bullying occurred

in the fifth grade, although emotional distress related

to being bullied persisted between the fifth and eighth grades Boys were more likely than girls to be targets

or instigators of bullying, to think violent thoughts, or

to engage in violent behaviors at school Many victims told no one and suffered in silence The authors con-cluded that bullying of gifted children and adolescents occurs fairly universally and at higher rates than in some reports of the prevalence of bullying in the general school-age population As such, for the gifted child, peer bullying may contribute to difficulties incorporating in-telligence and academic accomplishments comfortably into an identity

Solutions

In addition to supporting and encouraging accelerative learning experiences, Neihart and colleagues (2002) sug-gest that educational programming for gifted students

should address social and emotional development In

this regard, educational programming for gifted students

should (1) ensure time to learn with others of similar

abil-ities, interests, and motivation; (2) supply opportunities

to explore areas of interest with a variety of peers;

(3) provide mentoring or coaching to cope with stress,

criticism, and the social demands associated with high

achievement; (4) present career information early; and

(5) develop approaches to help gifted students support

one another (e.g., group interventions that provide

di-rect instruction in conflict resolution, decision making,

and leadership) Because teasing and peer bullying

oc-cur fairly universally, primary care providers and

educa-tors should be attuned to the peak incidence of teasing

about appearance and intelligence in the middle-school

years and proactively work toward prevention of

bully-ing by buildbully-ing a positive, safe school culture (Peterson

and Ray, 2006) The most effective interventions are

comprehensive, involving the entire school, rather than

simply targeting the victim An excellent resource on the

subject is available through the American

Psychologi-cal Association and includes prevention strategies from

kindergarten through high school, school-wide

educa-tion programs, and guidelines for anti-bullying policies

(Orpinas and Horne, 2005)

The Perfectionistic Gifted Child

Perfectionism, holding excessively high standards for

performance, afflicts some students who are gifted

Re-search suggests that although adaptive levels of

perfec-tionism can fuel persistence and productivity for some

gifted students, excessive levels of perfectionism can

lead to immobilizing anxiety, avoidance behaviors, and

failure (Schuler, 2002) Dixon and coworkers (2004)

studied perfectionistic tendencies in a group of gifted

high-school students By use of cluster analysis of the

Multidimensional Perfectionism Scale, personality sures, and indicators of psychiatric symptoms, four ty-pologies were yielded (Table 52-1) Those adolescents with maladaptive types of perfectionism also reported high levels of self-doubt, excessive concern about mak-ing mistakes, excessively critical parents, poor self-image, and inadequate coping strategies Dixon and colleagues suggest that maladaptive perfectionism may become more differentiated in adolescence

mea-Solutions

Knowledge about the various types of perfectionism among gifted students can help primary care providers, parents, and educators understand the barriers to their success (Dixon et al, 2004) Important components of intervention include assisting the child in setting high yet realistic goals, encouraging effort rather than plac-ing undue emphasis on cognitive ability, and valuing the lessons learned from mistakes (Schuler, 2002) When excessively high standards lead to a crippling fear of failure and subsequent underachievement, psychological interventions are indicated Mental health professionals may assist in the identification of possible obsessive-compulsive tendencies or depression and provide effec-tive remediation of maladaptive perfectionism

The At-Risk Gifted Child

According to the National Research Center on the Gifted and Talented, gifted children from low-resource families

or minority groups are underidentified and resented in gifted and talented educational programs Moreover, a majority of gifted and talented students who drop out of school are from lower socioeconomic backgrounds or had reduced access to educational op-portunities or technology (e.g., computers) For many students from low-resource or minority groups, the

underrep-Table 52-1.  A Typology of Perfectionism in Gifted Adolescents

Perfectionism Type Perfectionism Profile Adjustment Profile

Mixed-adaptive This type is well organized and has few doubts

about his or her ability to complete tasks; sets high personal standards but does not overreact or respond negatively to mistakes Parents have high expectations but are not excessively critical.

This type reports few psychiatric symptoms but a strong sense of mastery coping and superior adjustment, perceptions of personal security, and academic competence.

Pervasive This type is well organized but has strong doubts

about his or her ability to complete tasks; sets high personal standards but overreacts and responds negatively to mistakes Parents have high expectations and are excessively critical.

This type reports more psychiatric symptoms (somatic complaints, obsessive-compulsive tendencies, depression, anxiety), a poorer self-image, a lower sense of personal security, and a pattern of dysfunctional coping.

Nonperfectionist This type is confident in his or her ability to complete

tasks but shows little preference for organization, order, or neatness; does not set very high personal standards and does not respond negatively to mistakes Parents do not have high expectations and are not excessively critical.

This type is substantially similar to the mixed-adaptive type on measures of psychiatric symptoms, personal security, and coping, although the nonperfectionist reports less academic competence and a weaker superior adjustment compared with the mixed- adaptive type.

Mixed-maladaptive This type is overly concerned about mistakes

and doubts his or her ability to complete tasks successfully; sets relatively lower personal standards and shows relatively little preference for organization, order, or neatness Parents set very high standards and are excessively critical.

This type reports more psychiatric symptoms (somatic complaints, obsessive-compulsive tendencies, interpersonal sensitivity), a poorer self-image, a lower sense of personal security, and a pattern of dysfunctional coping.

Adapted permission from Dixon FA, Lapsley DK, Hanchon TA: An empirical typology of perfectionism in gifted adolescents Gifted Child Q 48:95-106, 2004.

cultivation of giftedness is complicated by limited

“edu-cational capital,” including reduced financial means

and restricted access to cultural, health, and

educa-tional resources, in addition to psychological and social

pressures and racial and ethnic discrimination (Borland

and Wright, 1994; Gordan and Bridgall, 2005)

In a review of the literature, Neihart (2006) suggested

that many gifted students from low-resource families or

minority groups experience an “affiliation/achievement

conflict” when they perceive that the expression of their

giftedness would be in conflict with or not valued by

members of their cultural group Withdrawal from

aca-demic pursuits is a common reaction to the cognitive

dissonance that occurs when a student first becomes

aware of this conflict, usually during adolescence For

example, gifted African American students may

expe-rience peer pressure to underachieve for fear of acting

“white” (Ford, 1994) Peer influence and pressure in

working-class families to marry young and to secure a

job represent additional pressures faced by gifted

chil-dren from low-resource families or minority groups

Underachievement in at-risk populations should

there-fore be viewed as a sociocultural phenomenon (Ford,

1994; Grantham, 2004; Neihart, 2006)

In a review of the literature, Moore and colleagues

(2005) reported that “noncognitive” factors more

ef-fectively predict persistence among academically gifted

African American students than do achievement and

performance variables (e.g., tests and grades) These

noncognitive factors include self-confidence, realistic

self-appraisal, understanding of and ability to cope with

racism, preference for long-range goals over more

im-mediate short-term goals, support of academic pursuits

from others, successful leadership experience,

commu-nity service, and knowledge acquired in a field Similarly,

in a 3-year study of 35 economically disadvantaged,

eth-nically diverse, academically gifted high-school students,

Reis and associates (2005) reported that the presence of

at least one supportive adult, peer support, and

involve-ment in productive after-school or summer activities

dis-tinguished those students who excelled academically

Solutions

Mentoring or coaching has been promoted as one

strategy to cultivate academic giftedness among

stu-dents from low-resource families or minority groups

Callahan and Kyburg (2005) suggest that the greater

a gifted student’s distance from that expected in terms

of the typical professional (e.g., African Americans in

mainstream science), the greater the need for role

mod-els who are closely matched to the student in terms of

attitude, values, lifestyle, background experience, race,

and gender Neihart (2006) suggests that gifted students

from low-income families or minority groups must

mas-ter “code switching,” a process of deliberately changing

behaviors to accommodate the expectations of different

environments As such, at-risk gifted students need

“cul-tural brokers” or caring adults who understand gender,

class, racial, or ethnic factors and can identify these

fac-tors in a variety of contexts, mediate potential conflict,

and build bridges Finally, coaching may provide direct

instruction in the social skills necessary for leadership in

a variety of cultural contexts, including authority, control, and conflict resolution For instance, in some ethnic cultures, behaviors that are encouraged in acceler-ated educational programs (e.g., questioning authority, critical thinking) are discouraged at home because they are perceived as disrespectful of authority

self-Family and peers represent important moderators

of academic success among gifted students from income or minority groups Ford (1994) recommends building strong family-school-community relations for these students to nurture resilience Even among low-income families, conditions favoring high achievement are the same as those described in the general popula-tion: supportive families that value education and work, favorable educational and financial resources, positive and encouraging parenting practices, and higher degree

low-of stimulation (Robinson et al, 2002) Peer group works also may provide a forum for open discussions about the hidden and overt expectations regarding class, race, and achievement, including explicit labeling

net-of the unfairness some at-risk gifted students encounter (Neihart, 2006)

Finally, the curriculum must enable access to gifted and talented programming and academic resources for members of low-resource and minority groups (Swanson,

2006) Academic enrichment that incorporates a cultural curriculum to integrate ethnic identity and cul-tivation of academic giftedness is recommended (Ford,

multi-1994) Neihart (2006) describes optimal academic tings for at-risk gifted students as “welcoming learning environments” that address identity and learning goals concurrently and normalize the conflicts that some at-risk gifted students experience

set-The Twice Exceptional Gifted Child

Children who are gifted and also possess a second ceptionality are frequently misunderstood and often

ex-do not receive appropriate educational programming that addresses the range of their needs For example, education personnel are less likely to refer students with learning disabilities (Minner et al, 1987) or emotional- behavioral disorders (Minner, 1989) for gifted and talented programs However, the unidentified second exceptionality often impedes the academic success of the student who also is gifted Because gifted students who are underachieving may suffer from undiagnosed learning disabilities or attention-deficit/hyperactivity disorder, it is important to exclude the possibility that a dual diagnosis is responsible for the student’s underachievement (see also Chapter 51)

Solutions

Careful, professional evaluation, including sive psychological or neuropsychological evaluation, may assist the primary care provider with accurate diagnosis Intervention should include a differentiated curriculum that provides both enrichment and instructional sup-ports For example, a 504 Accommodation Plan may be required to help the gifted student with attention-deficit/hyperactivity disorder compensate for everyday behav-iors associated with executive dysfunction (e.g., poor or-ganizational skills, limited task initiation or persistence,

comprehen-deficits in working memory) In addition, several key

components that foster resilience among twice

excep-tional students have been highlighted: early

identifica-tion of both excepidentifica-tionalities, educaidentifica-tional programming

that targets strengths and weaknesses (i.e., enrichment

and remediation), direct instruction in compensatory

strategies, and provision of accommodations at an early

age to promote academic success Twice exceptional

students also may benefit from psychological

interven-tions that address their unique emotional needs, assist

in the development of awareness about their strengths

and weaknesses, and promote realistic goal setting

Fi-nally, supportive adults and extracurricular activities

that showcase the gifted child’s strengths promote

re-silience among twice exceptional students (Baum, 1990;

Dole, 2000)

THE ROLE OF THE PRIMARY CARE PROVIDER

Identification

The primary care provider is in an ideal position to first

identify potential giftedness early in development when

children present with precocious language/vocabulary

development or exceptional problem solving skills The

primary care provider also may recognize the signs of

unidentified gifted students (e.g., gifted underachievers)

as the child advances in school Referral for a

compre-hensive psychoeducational or neuropsychological

eval-uation may assist with accurate identification of high

ability and possible comorbid conditions, such as

learn-ing disabilities or attention-deficit/hyperactivity disorder

Finally, the primary care provider may be the first-line

professional to learn about the social or emotional

mal-adjustment of the gifted child and refer families for

ef-fective psychological or psychiatric intervention

Parenting

The primary care provider also is in an ideal position to

encourage appropriate parent-child interactions, to

pro-mote developmentally appropriate expectations for

be-havior, and to educate families about the unique social,

emotional, and academic needs of the gifted child

Par-ents may feel pressure to provide enriched experiences

and may feel the burden of time and financial investment

The primary care provider can alleviate these pressures

by educating the family about normal child development,

linking the families to resources such as the National

Re-search Center on the Gifted and Talented, and

recom-mending appropriate educational programming Research

suggests that family dynamics make a stronger

contribu-tion to the achievement outcomes of gifted children than

demographic variables Specifically, parents who set high

and clear expectations promote higher achievement in

their children Strong extended family relations also tend

to promote emotional health, social competence, and

self-efficacy Finally, an authoritative parenting style,

characterized by both flexibility and firmness,

contrib-utes to greater academic achievement in children who are

gifted (Neihart, 2006) The primary care provider may

coach parents from diverse backgrounds about these key

components of effective parenting (Table 52-2)

Educational Programming

The primary care provider should become familiar with state and local definitions guiding the provision of gifted programming Definitions may be obtained from state departments of education or the National Association for Gifted Children Because identification of students eligi-ble for gifted educational programming may vary from school district to school district, the primary care pro-vider also may consult with district school psychologists about identification procedures and gifted programming specific to a given school Research clearly indicates that gifted students require accelerated learning experiences

to maintain interest and high achievement Therefore,

in addition to educational programming, the primary care provider may become familiar with extracurricular opportunities, such as summer programs and weekend college courses

SUMMARY

Current conceptualizations of giftedness highlight the cognitive and noncognitive components necessary for gifted products, including, for example, high intellec-tual ability, creativity, persistence and motivation, and self-efficacy Although children who are gifted repre-sent a heterogeneous group from diverse backgrounds, those factors that promote healthy cognitive, social, and emotional development are largely the same and include supportive families that set high expectations for academic achievement; individualized, accelerative educational programs that address areas of strength and weakness; and opportunities to interact with peers who have similar abilities, interests, and motivation The primary care physician is in an ideal position to guide parents of gifted children by first recognizing the signs of gifted behavior early in development and refer-ring for comprehensive psychoeducational or neuropsy-chological evaluation when indicated The primary care physician also may provide families with guidance on

Table 52-2.  What Gifted Students Desire from

Their Parents

According to their survey of hundreds of children identified

as gifted and talented, Galbraith and Delisle suggest that the following are the top 10 things gifted students wish their parents would or would not do:

1 Be supportive and encouraging; be there for us; be on our side.

2 Don’t expect too much of us; don’t expect perfection 2 Don’t expect too much of us; don’t expect perfection.

3 Don’t pressure us, be too demanding, or push too hard 3 Don’t pressure us, be too demanding, or push too hard.

4 Help us with our schoolwork/homework 4 Help us with our schoolwork/homework.

5 Help us to develop our talents 5 Help us to develop our talents.

6 Be understanding 6 Be understanding.

7 Don’t expect straight As 7 Don’t expect straight As.

8 Allow us some independence; give us space; trust us, because 8 Allow us some independence; give us space; trust us, because chances are we know what we’re doing.

9 Talk to us; listen to us.

10 Let us try alternative education or special programs.

Adapted with permission from Galbraith J, Delisle J: The Gifted Kids’ Survival Guide: A Teen Handbook Minneapolis, Free Spirit Publishing, 2004.

developmentally appropriate expectations for behavior

and effective parenting strategies Finally, the primary

care physician may be the first to identify potential

social or emotional problems among children who are

gifted and direct families to appropriate psychological

interventions or mentoring

REFERENCES

Bain SK, Bell SM: Social self-concept, social attributions, and peer

relationships in fourth, fifth, and sixth graders who are gifted

com-pared to high achievers Gifted Child Q 48:166-178, 2004.

Baum S: Gifted but Learning Disabled: A Puzzling Paradox Reston, VA,

Council for Exceptional Children, 1990 ERIC Digest No E479.

Baum SM, Renzulli JS, Hébert TP: Reversing underachievement:

Cre-ative productivity as a systematic intervention Gifted Child Q

39:224-235, 1995.

Bloom B: Developing Talent in Young People New York, Ballantine,

1985.

Borland JH, Wright L: Identifying young, potentially gifted,

eco-nomically disadvantaged students Gifted Child Q 38:164-171,

1994.

Callahan CM, Kyburg RM: Talented and gifted youth In DuBois

DL, Karcher MJ (eds): Handbook of Youth Mentoring Thousand

Oaks, CA, Sage, 2005, pp 424-439.

Cornell DG: High ability students who are unpopular with their peers

Gifted Child Q 34:155-160, 1990.

Dixon FA, Lapsley DK, Hanchon TA: An empirical typology of

perfectionism in gifted adolescents Gifted Child Q 48:95-106,

2004.

Dole S: The implications of the risk and resilience literature for

gifted students with learning disabilities Roeper Rev 23:91-96,

2000.

Ford D: Nurturing resilience in gifted black youth Roeper Rev 17:

80-85, 1994.

Gardner H: Intelligence Reframed: Multiple Intelligences for the 21st

Century New York, Basic Books, 1999.

Gordon EW, Bridgall BL: Nurturing talent in gifted students of color

In Sternberg RJ, Davidson JE (eds): Conceptions of Giftedness,

2nd ed New York, Cambridge University Press, 2005, pp

120-146.

Grantham TC: Multicultural mentoring to increase black male

repre-sentation in gifted programs Gifted Child Q 48:232-245, 2004.

Gross MUM, van Vliet HE: Radical acceleration and early entry to

college: A review of the research Gifted Child Q 49:154-171,

McCoach DB, Kehle TJ, Bray MA, Siegle D: Best practices in the

iden-tification of gifted students with learning disabilities Psych Schools

38:403-411, 2001.

Minner S: Initial referral recommendations of teachers toward

gifted students with behavioral problems Roeper Rev 12:78-80,

1989.

Minner S, Prater G, Bloodworth H, Walker S: Referral and placement

recommendations of teachers toward gifted handicapped children

Roeper Rev 9:247-249, 1987.

Moore JL, Ford DY, Milner R: Recruitment is not enough:

Retain-ing African American students in gifted education Gifted Child Q

49:51-67, 2005.

Neihart M: Dimensions of underachievement, difficult contexts, and

perceptions of self Roeper Rev 28:196-202, 2006.

Neihart M, Reis S, Robinson N, Moon SM (eds): The social and

emo-tional development of gifted children What do we know? Waco,

DC, American Psychological Association, 2005.

Peterson JS, Ray KE: Bullying and the gifted: Victims, perpetrators, prevalence, and effects Gifted Child Q 50:148-168, 2006 Pfeiffer SI, Stocking VB: Vulnerabilities of academically gifted stu- dents Special Services Schools 16:83-93, 2000.

Reis SM, Colbert RD: Hébert TP: Understanding resilience in diverse, talented students in an urban high school Roeper Rev 27:110-120, 2005.

Reis SM, McCoach DB: The underachievement of gifted students: What do we know and where do we go? Gifted Child Q 44:152-

170, 2000.

Reis SM, McCoach DB: Underachievement in gifted and talented dents with special needs Exceptionality 10:113-125, 2002 Reis SM, Renzulli JS: Current research into the social and emotional development of gifted and talented students: Good news and fu- ture possibilities Psychol Schools 41:119-130, 2004.

stu-Renzulli JS: What makes giftedness? Reexamining a definition Phi Delta Kappan 60:180-184, 1978.

Renzulli JS: The three-ring conception of giftedness In Sternberg RJ,

Davidson JE (eds): Conceptions of Giftedness, 2nd ed New York, Cambridge University Press, 2005, pp 246-279.

Rimm S: Why Bright Kids Get Poor Grades and What You Can Do About It New York, Crown Trade Paperbacks, 1995.

Rinn AN: Effects of a summer program on the social cepts of gifted adolescents J Secondary Gifted Educ 17:65-75, 2006.

self-con-Robinson NM, Lanzi RG, Weinberg RA, et al: Family factors ated with high academic competence in former Head Start children

associ-at third grade Gifted Child Q 46:278-290, 2002.

Sayler MF, Brookshire WK: Social, emotional, and behavioral ment of accelerated students in gifted classes, and regular students

adjust-in eighth grades Gifted Child Q 37:150-154, 1993.

Schuler PA: Perfectionism and the gifted adolescent J Secondary Gifted Educ 12:183-196, 2002.

Sternberg RJ: The WICS model of giftedness In Sternberg RJ,

Davidson JE (eds): Conceptions of Giftedness, 2nd ed New York, Cambridge University Press, 2005, pp 327-342.

Swanson JD: Breaking through assumptions about low-income, nority gifted students Gifted Child Q 50:11-25, 2006.

mi-Terman LM, Baldwin BT, Bronson E, et al: Genetic Studies of Genius: Mental and Physical Traits of a Thousand Gifted Children, 2nd ed Stanford, Stanford University Press, 1926.

Turkheimer E, Haley A, Waldron M, et al: Socioeconomic status modifies heritability of IQ in young children Psychol Sci 14:623-

RESOURCES FOR PROFESSIONALS

Essential Readings in Gifted Education (Sally M Reis, series editor;

Thousand Oaks, CA, Sage Publications) is a collection of seminal

articles published in Gifted Child Quarterly, a lead journal in the

field of gifted and talented research.

National Research Center on the Gifted and Talented (NRC/GT) is

a collaborative effort between several academic institutions and state departments of education in an effort to plan and to conduct research about giftedness The NRC/GT can be accessed on the Internet at www.gifted.uconn.edu/nrcgt.html.

RESOURCES FOR PARENTS AND GIFTED

CHILDREN

National Association for Gifted Children (NAGC) is a national advocacy

group of parents, educators, and affiliate groups who have joined

together in an effort to promote appropriate gifted education The

NAGC has affiliates in nearly every state and publishes a quarterly

magazine, Parenting for High Potential The NAGC Web site ( www.

nagc.org) provides information about national and state policies on

gifted education, including state definitions, funding, and policies

about acceleration The Web site also includes information about

na-tional conventions, parent and teacher resources, and publications.

Judy Galbraith’s The Gifted Kids’ Survival Guide for Ages 10 and Under and Judy Galbraith and James R Delisle’s The Gifted Kids’ Survival Guide: A Teen Handbook (Minneapolis, Free Spirit

Publishing) offer guides to the myriad issues faced by children and adolescents who are gifted, including identification of appropriately challenging educational programs and the social and emotional as- pects of being gifted These guides also include extensive lists of resources (books and Web sites) for parents and children.

Terrill Bravender

ADAPTATION AND MALADAPTATION

TO SCHOOL 53

In the 21st century, the United States is an

information-driven, highly technologic society, and education is the

key to success The U.S Department of Labor estimates

that 12 of the 20 fast-growing jobs will require at least

a bachelor’s degree, and an additional five will require

other specialized training The importance of

educa-tion is also reflected in current unemployment

statis-tics In the second quarter of 2006, the unemployment

rate was 7.0% among those who have not completed

high school, 4.3% among high-school graduates, 3.7%

for those with some college, and 2.1% for those with

a college degree or higher (Bureau of Labor Statistics,

2006) For those who are employed, the differences in

salaries are even more pronounced In 2004, the

me-dian income was $22,000 per year for full-time workers

with less than a high-school diploma, $31,000 for those

with a high-school diploma, and $51,000 for those with

a bachelor’s degree (Internet Staff and Population

Di-vision) In addition, there are positive associations

be-tween income and health, and the level of education,

independent of income, also plays an important role in

determining overall health status

Adaptation to school is complex, and problems in

this area can result from a broad range of influences

Such problems may occur in conjunction with diagnoses

covered in other chapters, such as attention deficit

dis-order, specific learning disabilities, and psychiatric

diag-noses such as anxiety or depression, but these comorbid

diagnoses do not have to be present The term

maladap-tation to school refers to a spectrum of behaviors that

run from school disengagement to school avoidance and

ultimately to school dropout When school-related

be-havior problems do arise, parents may look to a variety

of health care providers for impartial evaluation and

guidance The clinician’s primary role is to identify or to

exclude medical, developmental, psychological, or other

issues that may have an impact on behavior in school,

although excluding a problem may be as important as

identifying a problem Even when a specific problem is

not identified, parents will often look to a trusted

clini-cian for help The provider’s role then is to act as an

impartial advocate for the child and to assist the

fam-ily in developing appropriate school attendance and

be-havior strategies Throughout the evaluation, it is useful

to remember that there are many influences on school

adaptation, including issues that are related not only to the child but also to the school itself, peers, and the fam-ily Too often, a frustrated parent focuses solely on the child without also examining these other domains

EVALUATION

The evaluation should begin by eliciting the specifics of the school problems, not just “he hates going to school.” One should assess whether these are new or persistent problems, whether the problems encompass all sub-jects or just specific classes or teachers, and whether the child is disruptive only at school or also at home Routine questions about past and current medical his-tory as well as a medication history may be important Family history is an important component of the assess-ment and should include questions about other family members’ school experiences and parental expectations about school and school attendance Attention should also be paid to histories of mental illness, incarceration, substance abuse, and discipline practices Assessments

of the home environment may be revealing ate sleep and media use are important determinants of school engagement and attendance, and these should be explored thoroughly Additional home environment as-sessments should include who lives in the home (perma-nently and transiently), how available the parents are to their children, and what sorts of family routines are es-tablished A succinct dietary history should be obtained

Appropri-If previous developmental or educational testing has been performed, the parents should be asked to provide copies of the evaluations for inclusion in the medical record A directed physical examination is important, with particular care paid to the child’s growth and de-velopmental parameters The child’s mood, affect, and behavior in the office should be assessed to help screen for depression, severe anxiety, or hyperactivity Routine hearing and vision screening should be performed

A variety of physical, developmental, and behavioral issues may have an impact on adaptation to school and are summarized in Table 53-1 Although hidden medi-cal diagnoses having an impact on school engagement are fairly rare, one must keep a broad differential diag-nosis in mind Some issues may be apparent, with the school-engagement effects hidden (such as with chronic

515

illnesses or medication side effects), whereas others may

truly be hidden medical diagnoses (such as absence

sei-zures or thyroid disorders) Between 10% and 20% of

school-age children have some sort of chronic illness

(Boekaerts and Roder, 1999) Any chronic illness, from

the severe (such as cancer) to the more benign (such as

allergic rhinitis), may affect school performance, and

children with lower school performance are at greater

risk for disengagement Up to one third of aggressive

and disruptive students may have at least one chronic

medical, nonpsychiatric illness (Rappaport et al, 2006)

Asthma clearly has an impact on children’s school

at-tendance and performance and is the most common

chronic illness of childhood Other chronic health issues

that should be considered include prematurity, chronic

hearing loss, visual impairment, absence seizures, lead

exposure, iron deficiency anemia, thyroid disease, and

somatization disorders Being overweight has been

linked to poor school performance but is likely to be a

marker for other issues, such as comorbid chronic health

problems or lower socioeconomic status

Behavioral and emotional disorders can

dramati-cally affect school performance Although both girls

and boys may experience any of these disorders, boys

are more likely to present with externalizing problems,

such as oppositional defiant disorder or conduct

disor-der, whereas girls are more likely to present with

inter-nalizing disorders such as depression or anxiety, both

of which are associated with school refusal Adolescent

substance use can clearly affect school engagement and

attendance in dramatic ways, but which comes first, the

school problems or the substance use, is less clear In

some instances, school problems and a lack of school

connectedness may actually precede academic problems

(Fothergill and Ensminger, 2006) The answer to which

comes first is likely to depend on the individual

Adoles-cents who are less engaged with school are more likely

to start using alcohol or drugs, and those who use these

substances are more likely to have worsened school

engagement and attendance Substance use by parents may also affect school connection Whereas the effect

of prenatal exposure to alcohol or drugs is well known, ongoing substance abuse by parents can have long-term effects on their children’s physical health, social and emo-tional development, and school performance (Conners

et al, 2004), which in turn are likely to have an impact

on school engagement Traumatic events, such as prior

or ongoing sexual or physical abuse, may affect school performance Traumatic experiences and post-traumatic stress disorder are not uncommon in children and ado-lescents; one population-based study noted that approxi-mately 40% of participants had experienced at least one

Diagnostic and Statistical Manual of Metal Disorders

trauma by the age of 18 years (Giaconia et al, 1995)

In this study, about 14% of those with trauma histories developed post-traumatic stress disorder and were more likely to exhibit academic failure in addition to other psychological and physical health problems Simply be-ing exposed to violence in the home, even when it is not directed at the children, is associated with worsened school performance (Hurt et al, 2001) Finally, children who must serve as caregivers for chronically ill parents

or other family members are at greater risk for school disengagement (Siskowski, 2006)

SCHOOL DISENGAGEMENT

There has been significant interest recently in the portance of children’s sense of connection to school Referred to varyingly as positive orientation to school, school attachment, school bonding, and, more recently, school connectedness, it has been studied by use of

im-Vignette

Jordan is a bright 15-year-old boy in ninth grade who presents to his pediatrician after his parents found marijuana in his bedroom He has not done well in school this year, failing three classes and barely passing the remainder Previously social and outgoing, he has recently been spending most of his time at home alone

in his room His parents became concerned, but their work demands had recently increased, and they had little time to investigate He had a successful middle-school experience, making good grades in advanced classes and participating on the school football and lacrosse teams Unfortunately, most of Jordan’s friends have gone to different high schools He was unable

to join the football team this past fall because his parents were not available to provide transportation When lacrosse season started in the spring, he felt that the transportation situation had not changed, so

he told his parents he was not interested in playing

In a conference with Jordan and his parents, Jordan agreed to cease using marijuana if he were able to join the lacrosse team at his high school His parents agreed that they would assist in finding appropriate transportation to and from practices as long as his grades improved and he remained drug free

Table 53-1.  Differential Diagnosis of Issues Related

Hearing or vision loss

Medication side effects

Substance abuse (in patient) Sleep disturbances Excessive media use

Family Issues

Chronic illness in family member Substance abuse (in family member)

Physical or sexual abuse Exposure to violence in home

School Issues

Poor fit for student’s temperament

different methods and definitions Despite these

differ-ences, some common themes have emerged A student

who feels a sense of belonging, likes school, has good

friends, is invested in current and future academic

prog-ress, and participates in extracurricular activities can

be considered to have a high level of connectedness

Schools that provide fair and effective discipline and

that have teachers who are perceived as caring and

sup-portive also promote school connectedness among their

students Each of these individual domains has

demon-strated relevance to grades, school participation, liking,

and belonging All of these factors are highly associated

with student outcomes (Libbey, 2004)

School disengagement can be manifested as either

dis-ruption or withdrawal When a child exhibits disruptive

behaviors, school disengagement must be differentiated

from oppositional and defiant behaviors, premeditated

aggressiveness, and impulsivity associated with

atten-tion deficit disorder These externalizing behaviors may

be associated with school disengagement, but they also

may be misdiagnosed in a child who is simply not

con-nected to his or her school, and the management

ap-proaches are likely to be quite different Students whose

disengagement is manifested as withdrawal may be

la-beled as having depression or the primarily inattentive

type of attention deficit disorder Again, although these

issues may be associated with academic disengagement,

making the proper diagnosis will aid in development of

appropriate interventions

The need to feel like one belongs in school and is

cared for in school is important not only for students’

academic performance and school behavior but also for

their emotional and physical well-being Students who

are disengaged are at greater risk for a variety of other

behavioral health problems and also view themselves

as less healthy than those students who are more

con-nected to their schools Indeed, this concept of school

connectedness has emerged as an important

interven-tion area for protecting adolescents from harm (Resnick

et al, 1997) School connectedness is influenced by

stu-dents’ perception of caring teachers as well as by high

performance expectations School policies designed to

influence adolescent behaviors (such as locker searches,

drug testing, and punitive threats) have been found to

have much less effect on adolescent behaviors than does

the promotion of school connectedness School

con-nectedness is not simply an inherent attribute; it can be

promoted through systematic interventions tions designed to promote school bonding and imple-mented in elementary school can have enduring effects

Interven-in reducInterven-ing risky adolescent health behaviors Interven-in high school (Hawkins et al, 1999) Other programs designed

to promote school connectedness have emphasized discipline (rather than external, punitive controls) and have been able to significantly reduce incidents of fight-ing and acting out in class while still maintaining class-room decorum (Freiberg, 1989; McNeeley et al, 2002) Interestingly, the more intensely the self-discipline measures were implemented, the better the students’ behavior

self-School connectedness is mediated by a number

of variables that can be divided into system variables and individual-level variables and are summarized in

Table 53-2

System Variables

Teachers who are empathetic, are consistent, age self-management for discipline issues, and allow students to make decisions can improve their classroom management and thus improve students’ feelings of connectedness Harsh discipline, such as “zero toler-ance” policies for alcohol infractions, have been shown

encour-to decrease connectedness These policies usually date expulsion for first offenses and are designed to improve school safety However, students who attend such schools are likely to report feeling less safe than those students who attend schools with more moder-ate discipline policies Smaller schools seem to promote more connectedness than larger schools do, yet class-room size does not show such consistent effects One explanation for this finding is that classroom sizes are rarely large enough to inhibit development of coherent social units When schools become too large, though,

man-it may become difficult for teachers to know all of the students and provide a warm, caring atmosphere for so many people School connectedness is higher in schools that are racially or ethnically segregated and lowest in schools that are integrated (McNeeley et al, 2002) It has been noted that when schools are integrated, friendships tend to self-segregate within individual racial and ethnic groups When friendship patterns are segregated in this manner, students of all racial and ethnic groups feel less connected to school Further compounding the prob-lem is that minority students may disproportionately

Table 53-2.  Factors Influencing School Connectedness

Positively Influence Negatively Influence

System variables Empathetic teachers

Consistent discipline Student self-management for discipline Students involved in decision making Smaller schools

Harsh discipline

“Zero tolerance” for minor infractions Difficult classroom management Larger schools

Individual variables Higher grades

Extracurricular activities Younger students Male students Nonminority students

Lower grades Skipping school Older students Female students Minority students

be assigned to lower-track classes together, thus

exac-erbating the segregated friendship patterns Whereas

some have advocated segregation of schools by race and

gender to enhance educational experiences for girls and

minorities, there is a potential danger in the fact that

an unequal distribution of resources typically follows

school segregation Further, the National Longitudinal

Study of Adolescent Health has demonstrated that some

schools that are highly integrated also have high levels

of school connectedness What differentiates these

par-ticular schools is an area ripe for future research

Individual Characteristics

Students who participate in extracurricular activities,

such as sports, clubs, or performing arts groups, feel

more connected to their schools, as do those who get

higher grades Lack of school connectedness is

associ-ated with higher rates of skipping school Female

stu-dents and members of minority groups demonstrate

lower levels of school connectedness Interestingly,

stu-dents’ school connectedness decreases as they get older,

and there seems to be a significant drop-off between

el-ementary and middle school This is clearly a critical

period for intervention and prevention efforts

Despite the best efforts of schools and students, there

occasionally is simply a poor fit between a particular

student and teacher A child’s individual temperament

may play a role in this and should be further

investi-gated, as discussed in detail in Chapter 7

Management

The goals of management include preventing further

dis-engagement (which can progress to truancy and dropout)

and promoting improved school connectedness Specific

interventions should be tailored to any underlying issues

identified and to each specific situation It is crucial that

any underlying comorbid conditions (such as attention

deficit disorder or depression) be treated appropriately

General intervention guidelines are as follows

Behavioral Interventions

For disruptive students, behavioral contracts between

teachers, parents, and the student can be effective

Positive reinforcement and consistency are essential for

success Children who are too disruptive to the other

students may need to be placed in a special classroom

with more structure

Developing Strengths

A lack of connectedness to school can significantly

af-fect children’s self-esteem, further alienating them from

participating in academic work and extracurricular

ac-tivities These children should be encouraged to develop

specialties in areas of strength or interest and

encour-aged to apply these areas of special strength to the

school environment

Educational Services

These services are important, particularly for students

with diagnosed learning disabilities Special education

focused on skill development as well as language,

occu-pational, and physical therapy may be indicated

Counseling

Individual counseling should be focused on a student’s gaining insight into the relationship between his or her behavior and possible underlying emotional difficulties

It may also assist with the underlying anxiety about school participation that often accompanies school disengagement

Social Skills Training

Some students are disengaged because of social skills difficulties, and those with attention deficit disorder may also benefit Social skills training should take place

in a group setting with children of similar age, and such programs are available in many communities and even within some schools

SCHOOL AVOIDANCE

School avoidance behaviors include school refusal (also referred to as school avoidance or school phobia) and truancy Both are manifested by a child’s resistance

or refusal to attend school, but the two terms are ten used to highlight differences in what is driving the behavior The literature includes various interpreta-tions and often overlapping meanings of these terms,

of-so appropriate definition of these terms is important

This chapter uses school avoidance to describe all

be-haviors involving repeated missing of school that is not due to physical illnesses, including simple truancy The

term school refusal is used in place of school phobia

and is differentiated from truancy, which implies a more volitional behavior

Vignette

Maggie, a 9-year-old healthy girl, presented to her pediatrician for abdominal pain and dizziness She had been seen by other members of the medical practice twice in the past month for similar problems, and her mother had taken her to a local urgent care for evaluation the week before Maggie indicated that pain was located near her bellybutton but could not describe it any further She had no history of vomiting, diarrhea, or constipation and had no ill contacts The pain tended to start soon after awakening and tended

to resolve by the time they sought medical attention The pain did not bother her on the weekends Further history revealed that Maggie’s parents had recently separated, and Maggie and her mother had moved to

a new apartment in a different school district When asked about school, Maggie stated that she wanted to

go to school but that she couldn’t because her stomach hurt too much She has missed so much school that her teacher has begun sending schoolwork home, and Maggie’s mother wonders if she should hire a tutor to teach Maggie at home

School Refusal

School refusal may be distinguished from truancy by the

following features:

1 Severe difficulty in consistently attending school,

often resulting in prolonged absences

2 Severe emotional distress when faced with having to

go to school This may be manifested by fearfulness,

temper tantrums, or complaints of physical illness

without an obvious organic cause

3 The child remains at home during school hours with

full knowledge of his or her parents

4 The child does not exhibit significant antisocial

behaviors, such as delinquency, substance abuse,

disruptiveness, or risky sexual activity (Berg et al,

1969)

School refusal affects boys and girls equally, and

chil-dren of all levels of socioeconomic status are equally

affected Although school avoidance may occur in

isolation, there are high rates of comorbid psychiatric

diagnoses Anxiety disorders are quite common, as is

depression, whereas conduct and oppositional defiant

disorders are uncommon There are three peak ages at

onset of school avoidance behaviors:

1 At school entry (ages 5 to 6), which is often related to

separation anxiety

2 At entry into middle school (ages 11 to 13), which is

the typical age for complex school avoidance

presen-tations that involve anxiety and affective

dysregula-tion

3 High school (ages 14 and older) is more associated

with truancy, and school avoidance at this age is

more likely to be associated with serious psychiatric

illnesses

Typically, children will begin complaining of vague

problems about school or sometimes will not even

men-tion school but will complain of physical symptoms

These physical complaints may include abdominal pain,

headaches, dizziness, or nausea for which no physical

cause can be found These vague complaints related to

going to school may then progress to complete refusal

to attend school or to remain at school despite the best

efforts of parents and school staff Most children will

state that they want to go to school but are unable to do

so because of their symptoms The child’s symptoms are

usually present on mornings before school and quickly

disappear if the child is allowed to remain at home

Some parents may find it difficult to accept that the

origins of the child’s physical complaints are rooted in

psychological distress Parental anxiety that there may

be a hidden, serious medical condition will only serve

to increase the child’s anxiety and worsen the problem

This emphasizes the importance that a full medical

ex-amination be conducted to rule out any organic cause

of the symptoms (Elliott, 1999) Some children may

ac-tually have a physical illness (such as gastritis) that is

related to school avoidance Treatment of such

medi-cal problems is important, but in many cases, simply

treating the medical problem may not actually affect school attendance

Further evaluation should begin by differentiating school avoidance behavior from truancy Although it

is possible for children to exhibit both behaviors, it is unusual for these problems to occur at a similar time in the same child Next, it is important to assess the child’s general functioning at home and at school as well as to assess for anxiety and depression The family’s reaction

to the school refusal as well as how the school is ing to the absences is important On occasion, a specific incident at school or at home will be noted as a precipi-tant of the behavior This incident may not seem signifi-cant to the clinician or parents (such as being scolded at school), but it may be enough in a sensitive child to start the school avoidance process More often, though, if the child does not exhibit an anxiety disorder or depression, the etiology is related to ongoing family or peer con-flict or academic difficulties Once begun, the process may become self-perpetuating because the more time the child spends away from school, the more anxious he or she may become about attending again

react-Management

Interventions should be tailored to each child A variety

of behavioral, psychodynamic, cognitive, or logic approaches may used separately or in combination This author’s bias is toward use of a strict behavioral approach that is mainly exposure based, but it should also include interventions designed to teach relaxation and self-calming techniques to affected children In most situations, an immediate return to school should

pharmaco-be emphasized to help reduce the reinforcement of pharmaco-being home If a child does develop a physical illness requiring school absence, the home should be made as unenter-taining as possible The child must remain in bed and may not watch television, read books, play games, or interact with a parent The reason given to the child is that if he or she is too sick to go to school, he or she is too sick for these other activities

In conjunction with behavioral interventions, the school day may need to be modified, particularly dur-ing the initial exposure phase Any modifications (such

as shortening the school day) should be written in a tract and agreed on by teachers, school administrators, clinicians, and parents Modifications may also include minimizing exposure to particularly stressful areas and should emphasize those aspects of school that the child finds to be positive Once the contract is in place, the stu-dent should not be allowed to negotiate the terms Home-bound tutoring, online class work, and home schooling should be avoided because these convey the message that staying home is an appropriate alternative If home schooling does become necessary, it should be conducted only in a time-limited manner, with a contract written that includes a date for school re-entry (Freemon, 2003).Other specific interventions for various clinical situa-tions are as follows

1 If a child is fearful of school for a good reason, such

as being bullied, or has legitimate fears of being harmed, these fears need to be taken seriously and

addressed appropriately Schools are required to

provide safe learning environments for all children,

and if a child is bullied or threatened, it becomes a

problem that the school legally must address

2 Somatic symptoms should not be minimized or

dismissed Just because a child has school

avoid-ance does not mean that the child cannot develop

organic causes of abdominal pain Similarly, even if

an organic cause of pain cannot be identified, it does

not mean that the child is not experiencing pain

The child should be told that you believe the pain

is real, and even though there is no medication that

will help, the parents and treatment team are going

to help him or her learn to cope with what he or she

is feeling so that the child can get back to school

3 On re-entering school, socially challenging and3 On re-entering school, socially challenging and

less structured areas such as the bus stop,

physi-cal education class, and the lunchroom may need

to be avoided until the child’s confidence is re-

established

4 Children who have a significant anxiety component4 Children who have a significant anxiety component

may benefit from psychotropic medications

Selec-tive serotonin reuptake inhibitors may be

consid-ered In addition, a low dose of a benzodiazepine

may be helpful for the anticipatory anxiety that may

occur on initially re-entering school

5 Concerns about explaining their absences to other5 Concerns about explaining their absences to other

students may worsen school avoidance Rehearsing

what to say when these inevitable questions arise

can alleviate some of this anxiety

6 Recruiting a friend or dependable peer to accom-6 Recruiting a friend or dependable peer to

accom-pany the child or even just to check in with the child

throughout the day may be helpful

7 Allowing the child to have a cell phone is a bit tricky.7 Allowing the child to have a cell phone is a bit tricky

Most schools have strict limits on cell phone use,

but cell phone communication may be able to be

worked into a behavioral contract A child may be

allowed to telephone the parents once or twice daily

at specific times to check in, but if the cell phone

is abused by the child making increasingly frequent

calls, the privilege will be lost

8 Social skills groups may be helpful for some chil-8 Social skills groups may be helpful for some

chil-dren with social cognitive deficits

9 Children with neurodevelopmental dysfunctions

will benefit from a variety of enhanced learning

opportunities, bypass strategies, and appropriate

behavioral and medication treatments

10 Children with chronic illnesses may present special

challenges These children often exhibit a rate of

absenteeism that is out of proportion to what would

be directly attributable to the specific chronic illness

Special considerations should be taken to ensure

that their medical appointments and medication

regimens do not interfere with school attendance,

disrupt the school experience, or call special

atten-tion to them

Truancy

Intentional, unauthorized absence from school, or

tru-ancy, is a problem that affects most school districts in

the United States The prevalence of truancy is difficult

to assess across different schools because of variations

in reporting, so most estimates are based on students’ self-reports As might be expected, the numbers of students skipping school increase as students get older One recent study found that nationwide, almost 11%

of eighth graders and 16% of tenth graders reported skipping at least 1 day of school in the past 4 weeks (Henry, 2007) Although the No Child Left Behind Act requires schools and districts to report attendance rates, differences in state definitions mean that there remain no aggregate national data on truancy The consequences of chronic truancy may be significant; skipping school has been associated with poor aca-demic performance, school dropout, teen pregnancy, and social maladjustment The effects of truancy also persist into adulthood and are associated with job in-stability, violence, marital problems, criminal behav-iors, and incarceration Although a main predictor of school truancy in adolescents is parental educational level, other predictors may help guide interventions These predictors include adolescent substance abuse, having unsupervised time after school, and school dis-engagement School disengagement variables include feeling unsafe in school, feeling unlikely to gradu-ate from high school, and feeling unlikely to attend college

Truant students may face direct legal consequences due to poor attendance Many schools will automati-cally fail students who miss a particular number of classes If the school files a truancy petition, the child

or parent may face legal sanctions Compulsory cation laws often hold parents responsible for their children’s school attendance, particularly for younger children Parents and their truant children may face fines or orders for parents to attend school with their children or to attend parenting classes In extreme and fortunately unusual cases, parents may face social ser-vices investigations or loss of custody of their children and even be sentenced to jail (Smink and Heilbrunn,

edu-2005)

Management

Truancy interventions are similar to those involved with school dropout because chronic truancy is a path that often leads to dropout Whereas individual behavioral management certainly plays a role (particularly involv-ing behavioral contracts developed by parents, school personnel, and other care providers), the most impor-tant interventions are programmatic in nature Truancy reduction programs vary as much as the schools and districts that they serve These programs may involve school attendance review boards, alternative schools, distance learning initiatives, individual case manag-ers, and even the court system in conjunction with so-cial services Although many of these programs have shown short-term success in reducing truancy rates, the long-term effects of these programs are unknown Un-fortunately, despite such ongoing efforts at decreasing truancy and its eventual outcome of school dropout, dropout rates in the United States have not changed in the past 2 decades

SCHOOL DROPOUT

Before the American Civil War, most elementary

edu-cation was offered in “common schools,” which,

al-though publicly operated, were not necessarily publicly

funded, and parents often paid some form of tuition

In the period after the mid-19th century, the majority

of the United States offered publicly funded primary

school education, usually serving children through the

age of 14 or 15 years The “high-school movement” of

the early 20th century dramatically improved access

to secondary schooling, and the number of publicly

funded high schools increased dramatically between

1910 and 1940 (Goldin, 1999) The first compulsory

education law in the United States was passed by

Mas-sachusetts in 1852 Mississippi was the last state in

the country to establish compulsory education laws

in 1918 Although the ages at which students are

re-quired by law to attend school vary by state, children

are required to begin school at the age of 5, 6, or

7 years and must attend through the age of 16, 17, or

18 years There are movements currently, in many

states that do not already require it, to extend

com-pulsory education to the age of 18 years Despite the

legal requirement to attend school, dropout is,

unfor-tunately, a frequent outcome of school maladaptation

There are numerous negative consequences to school

dropout, including higher rates of unemployment,

lower wages when employed, and lower general health

status regardless of income

Data on dropout rates must be reviewed with

cau-tion, realizing that differently defined rates are often

reported The event dropout rate refers to the

percent-age of students who left high school between the

begin-ning of one school year and the beginbegin-ning of the next

without earning a high-school diploma or its

equiva-lent, such as a Graduate Equivalency Degree (GED)

In 1972, the high-school event dropout rate was 6.1%

This rate slowly trended downward until 1990, when it

was 4.7% Despite small year-to-year fluctuations, this

rate has been essentially unchanged since that time, and

the event dropout rate in the 2004 was also 4.7% This

means that almost 1 of every 20 high-school students

who started high school in 2003 was no longer in school at the end of the academic year and translates to 486,000 dropouts There are wide variations in dropout rates from state to state, ranging from 1.9% in Wiscon-

sin to 10.5% in Arizona The freshman graduation rate

estimates the proportion of public high-school men who graduate with a regular diploma 4 years after starting ninth grade Nationally, approximately 75%

fresh-of freshman graduate on time The state-specific rates vary widely from a low of 57% in Nevada to a high of

88% in Nebraska The status completion rate refers to

the percentage of individuals in a given age range who are no longer in high school and who have completed a degree In 2004, approximately 80.5% of 18- to 24-year-olds in the United States held a high-school diploma, and 6.3% had passed the GED examination, giving a total status completion rate of 86.8% The converse of

this is, of course, the school dropout problem, the status

dropout rate This rate reflects the cumulative number

of dropouts within a given population Nationally, in

2004, there were approximately 3.8 million individuals aged 16 to 24 years who were classified as high-school dropouts, representing 10.3% of this age group (Laird

et al, 2007)

Those who drop out of school are at risk for a ber of adverse consequences Dropouts are more likely

num-to be unemployed, and those who are working are likely

to be underemployed In 2003, the median income cluding full-time and part-time workers) for high-school dropouts older than 18 years was $12,184, whereas the median for those who had either a high-school diploma

(in-or GED was $20,431 Dropouts are m(in-ore likely to be

in prison and even on death row The U.S ment of Justice reports that approximately 75% of state prison inmates and 59% of federal prison inmates did not complete high school More than half of death row inmates are high-school dropouts It has been estimated that even just a 1% increase in average education levels would save approximately $1.4 billion in incarceration costs and would reduce arrest rates by 11% (Center for Mental Health in Schools, 2000)

Depart-Management

Prevention efforts are critical, particularly given that individual-level interventions have shown little benefit

An examination of the reasons that youth drop out

of school can help guide such programs These sons are summarized in Table 53-3 The most common reason, given by more than half of dropouts, is that they simply did not like school Other more concrete reasons include failing school, being suspended, job conflicts, and having friends who also dropped out of school (U.S Department of Education, 1990) These reasons should be viewed as the final outcome of a long process of disengagement from school Academic failure, disengagement from extracurricular activities, and high numbers of school absences are all interre-lated, and such problems may begin to be manifested

rea-as early rea-as first grade (Kemp, 2006) Thus, ideal ventions should be seen as prevention efforts focused

inter-on these linter-onger term disengagement issues nately, programs that focus on individuals at risk are

Unfortu-Vignette

Bobby is a 17-year-old with a long history of attention

deficit disorder and academic difficulties His high

school recently instituted a 2-year foreign language

requirement for graduation Bobby has failed first-year

Spanish three times and is now refusing to take it yet

again in his senior year “Why should I bother?” he

asks “There’s no way I can graduate now, anyway,

since I have to have 2 full years.” Instead of starting

twelfth grade, he has been working at an automobile

repair shop near his house Bobby says that the owner

thinks Bobby would make a good mechanic, but there

is no way for him to get the training he needs without

a high-school diploma

likely to be less efficacious than systematic approaches

that emphasize flexible approaches to academics and

school structure For example, schools should be able

to have the autonomy and flexibility to offer

differ-ent curricula to studdiffer-ents with differdiffer-ent strengths, such

as vocational and technical training as well as

tradi-tional academic subjects Students who have difficulty

succeeding in these traditional academic areas would

then have the opportunity to receive training and find

success earlier in their education Many of these

at-risk students may eventually receive such training, but

only after having to experience failure and potentially

dropping out of a traditional school Success earlier in

schooling may also improve self-esteem as well as the

perception that these students have about education

Unfortunately, given many of the current policies in

place that require frequent testing and strict academic

benchmarks, few schools have the autonomy to

pro-vide needed vocational and technical training for their

most at-risk students

In the case noted in the vignette, Bobby was fortunate

enough to be able to enroll in a local community college’s

vocational high-school program He was able to

pur-sue his certified mechanics program while accumulating

credit toward a high-school diploma He graduated on

time, just after his 18th birthday Bobby earned a

me-chanics certificate a year later and decided to pursue a

specialized apprentice program He now is working as a

mechanic for a professional auto racing team

2 decades Regular screening for school adaptation and attendance is an important component of clinical interactions, and prevention of school dropout is criti-cal Although screening and management often focus

on individual students, prevention efforts should be focused on system variables, with particular attention paid to promoting school connectedness and offering alternative pathways to school completion, such as vocational education

Bureau of Labor Statistics: Labor Force Statistics from the Current Population Survey 2006 Available at: ftp://ftp.bls.gov/pub/suppl/ empsit.cpseed3.txt Accessed August 25, 2006.

Center for Mental Health in Schools: An Introductory Packet on Dropout Prevention School Mental Health Project, Department

of Psychology, UCLA, 2000 Available at: http://smhp.psych.ucla edu/qf/transition_tt/dropout.pdf Accessed June 1, 2007.

Conners NA, Bradley RH, Mansell LW, et al: Children of mothers with serious substance abuse problems: An accumulation of risks

Am J Drug Alcohol Abuse 30(1):85-100, 2004.

Elliott JG: School refusal: Issues of conceptualisation, assessment, and treatment Practitioner review J Child Psychol Psychiatry 40(7):1001-1012, 1999.

Fothergill KE, Ensminger ME: Childhood and adolescent antecedents

of drug and alcohol problems: A longitudinal study Drug Alcohol Depend 82(1):61-76, 2006.

Freemon WP: School refusal in children and adolescents Am Fam Physician 68(8):1555-1560, 2003.

Freiberg HJ: Turning around at-risk schools through consistency agement J Negro Educ 58:372-382, 1989.

man-Giaconia RM, Reinhertz HZ, Silverman AB, et al: Traumas and traumatic stress disorder in a community population of older ado- lescents J Am Acad Child Adolesc Psychiatry 34(10):1369-1380, 1995.

post-Goldin C: A Brief History of Education in the United States Cambridge,

MA, National Bureau of Economic Research, 1999.

Hawkins J, Catalano R, Kosterman R, et al: Preventing adolescent health-risk behaviors by strengthening protection during child- hood Arch Pediatr Adolescent Med 153(3):226-234, 1999 Henry KL: Who’s skipping school: Characteristics of truants in 8th and 10th grade J School Health 77(1):29-35, 2007.

Hurt H, Malmud E, Brodsky NL, Giannetta J: Exposure to violence: Psychological and academic correlates in child witnesses Arch Pediatr Adolesc Med 155(12):1351-1356, 2001.

Table 53-3.  Youth Reported Reasons for Dropping

Out of School

P ercentage e ndorsing r eason

Male Female

School related

Could not get along with

Could not keep up with

Could not get along with

Could not work and go to

Family related

Peer related

Internet Staff and Population Division: Educational Attainment in

the United States: 2004 U.S Census Bureau, Population Division,

Education and Social Stratification Branch Available at: http://

www.census.gov/population/www/socdemo/education/cps2004.

html Accessed August 25, 2006.

Kemp SE: Dropout policies and trends for students with and without

disabilities Adolescence 41(162):235-250, 2006.

Laird J, DeBell M, Chapman C: Dropout Rates in the United States:

2004 Washington, DC, U.S Department of Education, National

Center for Education Statistics, 2007 NCES 2007–024.

Libbey HP: Measuring student relationships to school:

Attach-ment, bonding, connectedness, and engagement J School Health

74(7):274-283, 2004.

McNeeley CA, Nonnemaker JM, Blum RW: Promoting school

connectedness: Evidence from the National Longitudinal Study of

Adolescent Health J School Health 72(4):138-146, 2002.

Rappaport N, Flaherty LT, Hauser ST: Beyond psychopathology: Assessing seriously disruptive students in school settings J Pediatr 149(2):252-256, 2006.

Resnick MD, Bearman PS, Blum RW, et al: Protecting adolescents from harm Findings from the National Longitudinal Study on Adolescent Health JAMA 278(10):823-832, 1997.

Siskowski C: Young caregivers: Effect of family health situations on school performance J School Nursing 22(3):163-169, 2006 Smink J, Heilbrunn JZ: Legal and Economic Implications of Truancy Clemson, SC, Clemson University, 2005.

U.S Department of Education: National Education Longitudinal Study of 1988, First Follow-up Study Washington, DC, National Center for Education Statistics, 1990.

Lisa aLbers Prock and Leonard raPPaPort

ATTENTION AND DEFICITS

OF ATTENTION 54

Attention is an elusive concept Research psychologists

often split attention into several apparently distinct

sub-components or abilities These sub-components are assessed

by careful experimental procedures However, they do

not necessarily correlate with a child’s typical approach

to schoolwork and homework in the real world

Devel-opmental-behavioral pediatricians, psychiatrists, and

clinical psychologists often lump the subcomponents

into a superordinate category Implicitly, they

empha-size the ability to concentrate over time in the face of

distraction They evaluate children’s ability to attend

primarily by asking teachers and parents to rate the

child on a variety of global behaviors However,

indi-viduals demonstrate varying degrees of attention as a

function of the specific task or stimuli, situation-specific

needs and expectations, and their level of motivation At

any age, from preschool through adulthood, individuals

may present with a complex and variable capacity to

regulate attention to function in a variety of settings

Intrinsic and extrinsic factors may affect an individual’s

ability “to attend” at any moment in time

An important controversy is whether variations in

at-tention (and a related construct, activity level) represent

a continuum of normal behavior or whether attentional

weaknesses represent a neurologically based behavioral

disorder Critics of the “disorder model” cite multiple

weaknesses in the theoretical construct of disorders of

attention and argue that performance one or two

stan-dard deviations from the average does not necessarily

imply a physiologic basis for a disorder (Carey, 2002)

(see also Chapter 7) Similar issues also can be found

in classifications of other behaviorally defined disorders

that do not have specific known causes or diagnostic

tests that identify disease

Some children and adults have severe, persistent, and

pervasive difficulties in sustaining attention, and these

difficulties adversely alter academic and social

func-tioning Under these circumstances, the diagnosis of

attention-deficit/hyperactivity disorder (ADHD) may

be appropriate The diagnosis is based on clinical

fea-tures without corroborating neurologic or laboratory

findings The diagnosis implies that other neurologic,

medical, and psychosocial explanations for attentional

weaknesses have been considered A difficulty in

estab-lishing the diagnosis of ADHD is that it may coexist

with other diagnoses, including learning disorders, tics,

seizures, lead intoxication, and child abuse However,

the diagnosis of ADHD implies that some conditions, such as seizure disorder, lead poisoning, and parent-child conflict, have been ruled out or appropriately addressed There are many analogies in medicine For example, fever is a continuum It exists in many differ-ent conditions Treatment with antipyretics normal-izes body temperature without treating the cause of the fever

Personal characteristics that have been associated with attentional deficits can also be viewed as strengths

in settings other than the traditional school For ple, distractibility may be a disadvantage in the class-room but an advantage for a soldier in the field Partial completion of multiple tasks may bring poor grades in school but good income for a salesman A high energy level may be quite problematic for the child during a long and sedentary school day but can be a wonderful asset on the playing field after school

exam-In this chapter, we adopt the nomenclature of nicians working in the field, with the knowledge that this may change as we gain more knowledge over time

cli-Throughout this chapter, following the Diagnostic and

Statistical Manual for Primary Care, we use the term attentional problems to describe individuals presenting

with attentional weakness We reserve ADHD for dren and adults who have severe and persistent prob-lems and have met specific clinical criteria for research purposes (Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision, 2000) These criteria require pervasive challenges, with modulation of one’s attention, activity, and behaviors leading to maladap-tive behaviors and functional limitations that are in-consistent with an individual’s developmental level and environmental expectations

chil-NEUROSCIENCE AND NEUROPSYCHOLOGY

OF ATTENTION AND ATTENTION DISORDERS Neuroimaging

Observations from the fields of neuroscience, psychology, and clinical medicine have contributed to our evolving understanding of the concept of attention and disorders of attention Recent studies have exam-ined the structure and function of neurologic structures associated with attention regulation through modern structural and functional neuroimaging These studies

neuro-provide a picture of an integrated network subserving

attention

Neuroscientists and neuropsychologists consider

multiple process components as composing attention

(Casey and Durston, 2006; Mirsky, 1996): focus

(iden-tification of a stimulus in the environment); encoding/

processing of the detected information; appropriately

sustained attention (including screening out of

nonrel-evant environmental stimuli); appropriate shifting of

attention; inhibition of involuntary shifting of attention

(distractibility); and orchestration of a response to the

incoming information There are anatomic correlates to

these components identified in studies of children and

adults with no attentional issues

• Focusing on a particular stimulus requires input

from the superior temporal and inferior parietal

cortices as well as striatal input as mediated via

the the basal ganglia

• Encoding of information to which one is

atten-ding requires the function of the hippocampus

and the amygdala

• Sustaining attention appears to be served by

rostral midbrain structures, including the pontine

reticular activation formation and thalamic

nuclei

• Shifting attention from one stimulus to another,

either voluntarily or involuntarily, requires

prefrontal cortex activity

At the same time, specific brain lesions have been

correlated with attentional problems associated with

the diagnosis of ADHD, providing additional

informa-tion about the complex networks required for atteninforma-tion

Dysfunction in the frontal-subcortical pathways is the

most commonly invoked theory for ADHD This theory

is supported by the finding that deficits associated with

ADHD are similar to the impaired functions of adults

with frontal lobe damage Another structure implicated

in ADHD is the locus ceruleus, a small nucleus of

nor-epinephrine neuronal cell bodies that originate in the

midline pontine tegmentum and then arborize

through-out the brain, including the cerebral cortex The role of

locus ceruleus neuron activation appears to be in

sup-porting attention to the environment and screening out

irrelevant details while supporting focus on the relevant

stimuli (Pliska, 1996)

More than 60 studies have found individual and

group differences in the size of numerous brain regions

between patients with and without ADHD symptoms

Consistent with neuroanatomic and neurochemical

find-ings, volumetric structural magnetic resonance imaging

studies comparing individuals diagnosed with ADHD

and controls suggest an important role of

frontostria-tal circuitry, fronfrontostria-tal cortex, and basal ganglia (caudate,

putamen, globus pallidus) Another group difference is

intracortical connections through the corpus callosum

Finally, differences in the cerebellum have also been

reported The findings of association between structural

differences and the behavioral profile of ADHD do not

determine whether local structural changes are the cause

of or secondary to ADHD symptoms In addition, group

differences are not of sufficient magnitude to allow use

of structural imaging in diagnosis

Functional neuroimaging studies (positron sion tomography and functional magnetic resonance imaging) have supported the importance of frontostri-atal pathways in attention A single-photon emission computed tomographic study has found differences in dopamine transporter density in adults with ADHD

emis-in comparison to adults without ADHD (Dougherty

et al, 1999) However, similar to structural imaging studies, functional imaging studies do not consistently agree on the locus or lateralization of brain findings

in individuals diagnosed with ADHD as opposed to those without ADHD Functional studies have the same logical limitation as structural studies do, leaving unanswered whether correlations between activations and symptoms are a cause or effect of the attentional problems

Developmental changes have also been seen in sponse to inhibition and other aspects of attention These changes are associated with differences in the number and identity of areas of activation on functional imaging In addition, adults with ADHD demonstrate a prominent decrease in metabolism in premotor cortex, superior frontal cortex, striatum, and thalamus com-pared with adults without ADHD The magnitude of the differences changes from childhood to adulthood

re-Neurochemistry

Evidence from studies examining brain structure imaging), brain function (neuropsychology, functional imaging studies), and responses to medications (psycho-pharmacology) suggest the importance of dopamine- and norepinephrine-mediated frontostriatal pathways

(neuro-in the pathophysiology of ADHD Psychostimulants commonly used to treat symptoms of ADHD have been found to influence both dopaminergic and noradrener-gic systems Nearly all medications effective in treating the symptoms of individuals diagnosed with ADHD have been demonstrated to directly or indirectly increase dopamine activity in frontostriatal pathways Neuro-pharmacologic studies support the concept of ADHD as

a disorder of hypodopaminergic function or dopamine insensitivity

DEVELOPMENTAL TRAJECTORY

OF ATTENTION SKILLS

Any individual’s ability to regulate her or his level of attention, activity, and impulses evolves from infancy through adulthood Both neurologic maturation and real-life experiences have an impact on the rate of change and the precision of these skills In addition, level of mo-tivation and intelligence also alter one’s ability to selec-tively attend to a specific environmental stimulus As a result, a child’s attention regulatory skills must be evalu-ated within the context of the child’s chronologic and developmental age With increasing neuromaturation, one’s ability to inhibit or to override routine or reflex-ive behaviors in favor of more controlled or situation- appropriate and adaptive behaviors generally improves

In some situations (e.g., inhibition tasks), young children

may use more brain regions than do adults to perform

similar tasks

Studies of children beginning in infancy have

de-scribed three core components integral to

demon-stration of one’s level of attention in any situation:

(1) alerting/arousal, (2) inhibition, and (3) attentional

control The developmental information integrates

with neural functions to provide a picture of this

com-plex function

Alerting/Arousal

To demonstrate attention to any specific

environmen-tal stimulus, an individual must maintain alertness to

detect salient stimuli in the environment A child’s

abil-ity to disengage, shift, and re-engage attention typically

develops throughout infancy For example, even at

3 months of age, parents report being able to distract

an upset child with exposure to a novel stimulus; but as

interest and attention wane, a child’s distress returns,

suggesting that distress reduction may be the result

of shifting of attention, not reduction in the noxious

stimulus

Regions of the right frontal and parietal cortices and

the norepinephrine system appear to be critical in

main-taining focus on a particular object or person (Posner

and Rothbart, 2005) Studies of individuals with

epi-lepsy have demonstrated that midline structures are also

necessary for arousal This model also suggests that

alertness (focus on one specific item) leads to “quieting”

of other brain activities by the release of norepinephrine,

resulting in an increased signal-to-noise ratio in specific

brain areas

Inhibition

A child’s ability to inhibit inappropriate behaviors

(response inhibition) typically increases with age One

common task thought to measure response inhibition in

the clinical setting is the go/no-go paradigm, in which

children are asked to respond to every stimulus except

one (e.g., respond to all letters except Z) A child’s

abil-ity to refrain from responding to the no-go stimulus is

used as a measure of response inhibition During the

preschool and school-age years, response inhibition

tends to improve for most children

Neuroimaging studies using the go/no-go paradigm

have demonstrated signal increases in several brain

re-gions (ventral prefrontal cortex, inferior frontal cortex,

and anterior cingulate gyrus) with development;

chil-dren show reduced brain activity on this task compared

with adults, although the brain activation in these same

regions increases when inhibition is required (Casey

et al, 2001; Vaidya, 2005) In children far more than

in adults, basal ganglia structures also appear to be

in-volved in response inhibition Children diagnosed with

ADHD who behaviorally show a high rate of errors of

commission, or false alarms, demonstrate significantly

lower activity than do control children in their basal

ganglia region activity during performance of a go/

no-go task (Durston, 2003) However, when children

diagnosed with ADHD took stimulant medication to

address symptoms of inattention and impulsivity, their

basal ganglia activity more closely resembled that of

control children as their behavioral performance proved (Vaidya, 2005)

im-Attentional Control

In the real world, children (and adults) are expected to selectively focus on relevant tasks while simultaneously suppressing information that is irrelevant or misleading

at that time One task used to study this component of attention is the Stroop paradigm In this task, partici-pants are asked to identify the color of ink in which a word is written The task requires inhibition of word reading because reading the word is a more automatic

response than saying the color (e.g., saying red when the word blue is printed in red ink requires inhibition of reading blue) Neuroimaging studies implicate that the

anterior cingulate cortex is particularly important for detecting and resolving this attentional conflict

Shifting attention is measured by tasks such as the Wisconsin Card Sorting Task This task requires parti-cipants to change the sorting rule they are using as a result of the positive and negative feedback they re-ceive on the basis of their responses Typically, healthy children learn to shift their behavior and their implicit categories when the rules change Adults adjust more quickly than do children Adults with dorsolateral pre-frontal cortex lesions have impaired performance on these tasks In addition, adults with frontal lobe lesions perform this task quite similarly to a typically developing 3-year-old child

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER AS A DIAGNOSIS

The core features required for diagnosis of ADHD have been revised during the past half-century with

each iteration of the Diagnostic and Statistical Manual

of Mental Disorders (Tables 54-1 and 54-2) ADHD

is currently diagnosed on the basis of the presence of behavioral symptoms of inattention or hyperactivity- impulsivity These domains are dissociable but fre-quently co-occur To ensure that the core symptoms are pervasive, clinical diagnostic criteria must be observed

in at least two settings To ensure that the symptoms

are profoundly disruptive, diagnostic criteria currently

require that an individual is functionally impaired

To ensure that the symptoms are persistent, the teria require that they have been present for at least

cri-6 months and began before the age of 7 years Finally,

the Diagnostic and Statistical Manual of Mental

Dis-orders, fourth edition, text revision (DSM-IV-TR),

requires that the symptoms are not attributable to

an-other primary disorder (DSM-IV-TR, 2000).

Most researchers and clinicians follow the framework outlined in the DSM-IV-TR (2000) in making the diag-nosis of ADHD (see Table 54-1) Four specific subtypes

of ADHD are outlined in the DSM-IV-TR:

1 ADHD, combined type (accounting for 85% of those with ADHD)

2 ADHD, predominantly inattentive type

3 ADHD, predominantly hyperactive-impulsive type

4 ADHD, not otherwise specified

Key components of the DSM-based diagnosis of all

ADHD subtypes include the following:

• symptoms of inattention or symptoms of

hyperactivity-impulsivity, often operationally

defined by a symptoms checklist;

• onset of symptoms in childhood (before 7 years

of age) and duration greater than 6 months; and

• functional impairments in two or more settings; not primarily attributable to other disorders (including pervasive developmental disorders, anxiety disorders, thought disorders)

The criteria do not specifically prevent individuals with underlying developmental or emotional disorders, such as an autism spectrum disorder or an anxiety

Table 54-1.  Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

A Either 1 or 2 (or both):

(1) inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is

maladaptive and inconsistent with developmental level:

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) often has difficulty sustaining attention in tasks or play activities

(c) often does not seem to listen when spoken to directly

(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

(e) often has difficulty organizing tasks and activities

(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

(h) is often easily distracted by extraneous stimuli

(i) is often forgetful in daily activities

(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for least 6 months to a

degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

(a) often fidgets with hands or feet or squirms in seat

(b) often leaves seat in classroom or in other situations in which remaining seated is expected

(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) often has difficulty playing or engaging in leisure activities quietly

(e) is often “on the go” or often acts as if “driven by a motor”

(f) often talks excessively

Impulsivity

(g) often blurts out answers before the question has been completed

(h) often has difficulty awaiting turn

(i) often interrupts or intrudes on others (e.g., butts into conversation or games)

B Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C Some impairment from symptoms is present in two or more settings (e.g., school or work and at home).

D Clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E Symptoms do not occur exclusively during the course of pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).

Based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision Washington, DC, American Psychiatric Association, 2000.

Table 54-2.  Evolution of Diagnosis of Attention-Deficit/Hyperactivity Disorder

1902 George Still published in Lancet Initial clinical description of 43 children with “moral impulse control” difficulties

related to neurologically based difficulties with sustaining attention 1930s Clinical use of “minimal brain damage”

and then “minimal brain dysfunction” Attribution of behavioral symptoms to “brain insults,” including infections, toxin, head trauma; use of stimulants began in 1930s 1960s “Hyperkinetic reaction of childhood” enters

the DSM-II (1968) Increased used of stimulants prescribed to address symptoms

1970s Central role of “attention” and focus on subtypes related to presence or absence

of impulsivity/activity and modulation of arousal, impulsive responses

1980 DSM-III (1980) “hyperkinetic syndrome”

changed to “attention deficit disorder ±

hyperactivity” in DSM-III-R (1987)

Consideration of core features of “primary inattention” to environment versus

“failure to inhibit appropriate response”; changed from ADD (attention deficit disorder) to ADHD (attention-deficit/hyperactivity disorder) on the basis of field trials using behavioral rating scales

1990s DSM-IV (1994) evidence-based redefinition of

ADHD criteria

National Institute of Mental Health (NIMH)

conference to review state of ADHD

diagnosis and treatment (1998)

Emphasizing pervasiveness and impairment caused by symptoms NIMH conference reviews ADHD diagnostic trends and practices, suggesting both inappropriate and inadequate diagnosis of ADHD

2000s American Academy of Pediatrics practice

guidelines for primary care providers

(2001)

American Academy of Pediatrics guidelines emphasize assessment in two or more settings with standardized questionnaires and consideration of comorbidities

disorder, from being diagnosed with ADHD The

cri-teria encourage clinicians to avoid use of ADHD as a

primary diagnosis if a child’s inattention or

distractibil-ity may be understood to reflect another disorder that

responds to another type of intervention

Differential Diagnosis of Attentional Problems

The differential diagnosis is extensive because attention is

easily perturbed Vision and hearing deficits should always

be considered in children with attentional problems

Seizures, both generalized, such as petit mal, and partial,

can cause significant deficits in attention Recently

in-creasing data are pointing to sleep disorders, such as sleep

apnea and narcolepsy, as significantly affecting attention

Recent studies provide evidence that snoring affects the

quality of sleep, with resultant decrements in attention

Insufficient normal sleep should also be considered

Thy-roid disease, such as hyperthyThy-roidism or hypothyThy-roidism,

has an impact on attention Toxins such as lead, alcohol,

and prescribed medications and illicit drugs have all been

associated with decreased attention

One should also consider environmental causes of

at-tentional problems, such as stress at home from illness,

death, or marital issues, in addition to the possibility of

physical and sexual abuse Poverty with an inadequate

diet or deficits in the availability of a place to sleep safely

or to do homework obviously has an impact on

atten-tion Finally, many genetic and medical problems have

been associated with an increased prevalence in

atten-tional problems, including but not limited to premature

birth, surgery for congenital heart disease,

neurofibroma-tosis, fetal alcohol syndrome, and prenatal and

postna-tal lead exposure Temperamenpostna-tal differences must also

be considered as part of the differential diagnosis (see

Chapter 7) Clearly, many children who have reduced

attentional focus and increased activity levels have

age-appropriate function In these cases, the characteristics

may represent a variation of normal

Clinicians also must consider other learning and

emotional issues as causes of attentional weakness

Children with language disorders often present with

at-tentional weakness Their problems may be due to

trou-ble understanding complex language in their classroom,

home, and social environment or may be a coexisting

issue with attentional weakness Children with reading

or math disabilities or problems with fine motor output

may try to obscure their academic or production

weak-nesses by disrupting class and may appear to have very

significant attentional problems Also, children with

cognitive impairment that is at the borderline or more

severe levels may show attentional problems when they

are presented with work beyond their ability However,

they may have attentional weakness as a coexisting

is-sue with cognitive limitations ADHD can coexist with

learning disabilities, language impairments, and

cogni-tive disorders The presence of one of these diagnoses

does not preclude the diagnosis of ADHD

Children with behavior consistent with an autism

spec-trum disorder can appear to have severe attentional

prob-lems because they are often not motivated to please their

family members, teachers, or even peers Finally, children

with depression often present with severe attentional

problems This list is not totally inclusive of all causes of attentional problems, but it highlights the many pitfalls

in the commonly exhibited headlong rush to make the diagnosis of ADHD and suggests that clinicians consider ADHD a diagnosis used after many other causes have been considered and always with caution Any suggestion

of other causes of attentional problems in the history and physical examination needs to be followed up by specific testing before the diagnosis of ADHD is made

Epidemiology of ADHD

There is considerable variation in the prevalence of nosis with ADHD between countries and even between different regions within the United States This variance

diag-is thought to stem from the differences in the ratio of physicians to people in the region and the differences in applying diagnostic criteria In the United States, ADHD

is estimated to affect 3% to 7% of school-age children (Rappley, 2005; Satcher, 1999) Boys are more often de-scribed as meeting criteria for ADHD, but the reported male-to-female ratio varies widely (Rappley, 2005).ADHD symptoms have their onset in preschool or early childhood Many symptoms persist through adult-hood In individuals identified with ADHD as children, the rate of persistence to adulthood has been reported

to be as high as 50% On occasion, a person who has underachieved throughout life reaches adulthood and

is then diagnosed with ADHD (Okie, 2006) A recent national survey in the United States found an estimated prevalence of ADHD of 4.4% of U.S adults The inves-tigators emphasized that adult ADHD symptoms often coexisted with a range of other mental health disor-ders The majority of adults were untreated for ADHD, although many were under treatment for the other co-morbid mental health or substance-related disorders (Kessler, 2006)

GENETICS, ENVIRONMENT, AND ATTENTION

Both genetic and environmental influences are generally accepted to have an impact on one’s attention abilities Determination of the relative contributions of each and the interplay between genes and environment continues

to be a significant research challenge

Genetics and Attention

ADHD has been shown to run in families, and therefore genetic factors are thought to play an important role in the severity of attentional problems This observation is based on analyses of the rates of the ADHD within fam-ilies relative to degrees of relatedness and the incidence

of ADHD in adopted children (Table 54-3) Multiple candidate genes have been suggested to contribute to symptoms of ADHD It remains unclear if the genetics

of ADHD may involve one or more genes acting vidually, particular alleles of several genes interacting,

indi-or a variety of genetic mechanisms contributing to the spectrum of ADHD symptoms

Our understanding of specific genes that may be volved in the presentation of attentional problems con-tinues to evolve Animal studies have suggested a role for genes controlling the dopaminergic and noradrenergic

in-systems Many specific genes have been implicated in

contributing to meeting criteria for ADHD in humans

For example, seven separate genes (in which the same

variant has been studied in three or more case-control

or family-based studies) show statistically significant

evi-dence of association with ADHD on the basis of pooled

odds ratios across studies: the dopamine D4 receptor gene

(DRD4), the dopamine D5 receptor gene (DRD5), the

dopamine transporter gene (SLC6A3, DAT), the

dopa-mine beta-hydroxylase gene (DBH), the serotonin

trans-porter gene (SLC6A4, 5-HTT), the serotonin receptor 1B

gene (HTR1B), and the synaptosomal-associated protein

25 gene (SNAP25) (Faraone et al, 2006)

Environmental Factors and Attention

Environment factors have also been implicated in the

ex-pression of attentional problems for any individual It is

unclear if environmental factors, including biologic and

social factors, may be causative of ADHD or if they lead

to gene expression in genetically predisposed individuals

Discrete prenatal and postnatal environmental risk factors

associated with children’s diagnosis with ADHD include

parental tobacco and substance use Whereas the prenatal

or postnatal exposure to toxins, including lead and

alco-hol, may lead to presentation with attentional problems,

the majority of children meeting criteria for ADHD do

not have a history of lead or prenatal alcohol exposure

Similarly, specific prenatal or perinatal complications

(toxemia, eclampsia, poor maternal health, and extremely

low birth weight) have been implicated in contributing to

later ADHD, but the majority of children with ADHD do

not have known prenatal or perinatal complications

Contemporary environmental influences for a child,

including parenting strategies, environmental

stress-ors, and parent-child temperament mismatches, may

also contribute to a child’s presentation with ADHD

symptoms It is unclear whether suboptimal parenting

is causative of ADHD, but clearly it may exacerbate

ex-pression of attentional problems and functional

impair-ment Environmental stressors, including trauma and

exposure to domestic violence, may also contribute to

a child’s presentation with vulnerable attention tion, which may improve in a different environment

regula-ASSESSMENT FOR POSSIBLE ATTENTION DISORDERS IN CLINICAL SETTINGS

Consensus documents from the National Institutes of Health, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics (Perrin, 2001)

as well as the DSM-IV-TR (2000) describe diagnostic criteria and treatment strategies for clinicians Evidence

of symptoms consistent with a diagnosis of ADHD must

be obtained from the affected individual (child, cent, adult) as well as from other observers including parents, teachers, and clinicians A variety of question-naires and checklists are available for children, parents, and teachers Recent American Academy of Pediatrics guidelines (Perrin, 2001) describe one approach to a clinical assessment for symptoms of ADHD in a primary care setting:

1 use of explicit diagnostic behavioral criteria (as lined in DSM-IV-TR);

2 elicitation of symptoms of impairment in more than one setting (home, school, office); and

3 consideration of coexisting conditions (diagnostic and treatment implications)

To consider “coexisting conditions” or a differential diagnosis, many experts suggest that a psychoeduca-tional or mental health evaluation may be required

Clinician’s Role

A major challenge for the clinician is that many medical, behavioral, and learning problems can present as weak-nesses of attention regulation A major task is quantifying the pervasiveness, persistence, and impact of inattention and overactivity It is important to identify treatable diag-noses for the cause of attentional problems (Table 54-4)

It is also important to determine whether medical or chotherapeutic treatment is necessary, whether there is or

psy-is not an identifiable cause Key components of a clinical assessment for ADHD include a comprehensive history, a thorough physical examination, and a review of collateral information, such as school performance and testing re-sults from other observers Gathering of a comprehensive history includes a review of prenatal, perinatal, early child-hood, extended family, and psychosocial factors This his-tory may also uncover possible comorbid conditions (Table 54-5) A thorough physical examination (see Chapter 76) should include a detailed neurologic examination and confirmation of a child’s normal vision and hearing No specific physical or laboratory findings are pathognomonic

of a diagnosis of ADHD; hence, recent clinical guidelines

do not suggest any particular routine medical assessment

to confirm or to rule out a diagnosis of ADHD

Parent and Teacher Questionnaires

Current ADHD diagnostic criteria require that an vidual present with functional impairments in at least two of the three settings including home, school, and

indi-Table 54-3.  Summary of Family Studies and

Diagnosis of Attention-Deficit/Hyperactivity

Disorder

Parents of children meeting criteria for ADHD have an increased

risk (2- to 8-fold increase) of meeting criteria for ADHD

themselves.

Siblings of children with ADHD, after controlling for effects of

social status, gender, and degree of genetic relatedness, also

demonstrate an increased risk of ADHD symptoms (2.1 to 3.5

times the risk).

On the basis of twin studies of ADHD symptoms, heritability data

pooled from 20 separate analyses suggest that approximately

80% of the heritability risk for ADHD diagnosis and symptoms

(hyperactivity, inattentiveness) is attributable to genetic factors.

Adoption studies demonstrate that adoptive relatives of

hyperactive children are less likely to meet criteria for ADHD,

whereas biologically related individuals are more likely to have

ADHD symptoms (suggesting a genetic rather than purely

environmental etiology of ADHD symptoms).

Sources: Nigg et al, 1999; Durston, 2003; Castellanos et al, 2002; Faraone

et al, 2006.

work Use of standardized rating scales (completed by

parents and teachers) as part of a diagnostic work-up

for ADHD provides documentation of symptoms of

ADHD while also considering symptoms of

alterna-tive and comorbid diagnoses A number of

standard-ized questionnaires are available for parent, teacher,

and child or adolescent report of symptoms of

hyper-activity, impulsivity, and inattention One example is a

series of checklists for parents and teachers created by

the National Initiative for Children’s Healthcare

Qual-ity The set may be obtained from the American

Acad-emy of Pediatrics These checklists allow providers to

review parents’ and teachers’ subjective reports of a

child’s behaviors (on a 4-point scale, rated never to very

often) for consistency with a DSM-IV–based diagnosis

of ADHD and to understand a child’s current social

and academic functioning Follow-up questionnaires can be used to ascertain whether a child has improved with respect to behavioral ratings and academic or social functioning Another more extensive set of ques-tionnaires by Levine (ANSER System; see Chapter 55) looks more closely at specific areas of attention plus many functional academic areas that could contribute to attentional problems

No specific tests can be used to confirm the sis of ADHD In the past, continuous performance tests were touted as objective methods to corroborate clinical evaluations Continuous performance tests are gener-ally long, boring tasks during which numbers, letters,

diagno-or symbols are rapidly presented to a subject, usually by computer screen The child is asked to press a response button when a specified target appears, such as when the letter A is followed by the letter X In experimental situations, failure to press for the target, or omission er-ror, was thought to reflect “inattention”; hitting for the wrong stimulus, or commission error, to reflect “impul-sivity”; and the total number correct, to reflect “sustained attention.” Unfortunately, from a clinical perspective, continuous performance tests are not sufficiently sensi-tive or specific to distinguish children with and without inattention, and they cannot determine whether poor performance is due to inattention or other causes (such

as learning disabilities or emotional concerns)

SUPPORTING AND MANAGING CHILDREN’S ATTENTION SKILLS

Supporting a child in regulation of attention skills focuses

on minimizing symptoms having an impact on a child’s functioning or safety in the classroom, at home, and with transition to independent adulthood Regardless of the treatment modality, measurable outcomes should be monitored at baseline and periodically during treatment

of each child to assess efficacy of therapeutic changes Guidelines of the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry,

Table 54-5.  Comprehensive History Components

for Children with Possible Attention-Deficit/

Hyperactivity Disorder

Prenatal and Birth History

Prenatal exposure to

substances associated

with symptoms of ADHD

(tobacco, cocaine, alcohol)

Fears, worries, routines

Social history (friends?

Difficulty with completion

of school, inconsistent job performance, substance abuse (suggestive of possible undiagnosed difficulties)

Psychosocial History to Evaluate Possible Stressors That May Affect a Child’s Learning and Behaviors

Frequent moves Changes in living or custody situation

Exposure to domestic violence

History of abuse, neglect Life stressors (moves of home, school)

Table 54-4.  Differential Diagnosis of Attention-Deficit/Hyperactivity Disorder and Possible Symptom Overlap ADHD Symptom Potentially

Caused by or Overlapping with

Another Concern

Alternative “Diagnosis”

to Consider

Red Flags Not Characteristic

of ADHD and Suggestive of

a non-ADHD Diagnosis Other Clinical Considerations

Visual impairment Seizure disorder Sleep disorders: sleep apnea and narcolepsy Anxiety disorders *

Excessive worries Fearfulness Cognitive level (child not understanding? or child

is bored?)

Talks excessively Anxiety disorders *

Bipolar disorder Excessive worriesFearfulness

Grandiosity School failure or

underachievement Learning disordersAdjustment disorder

Psychosocial stressors

ADHD symptoms only in setting requiring academics (school; homework)

Consider behaviors during summer versus school year

Tic disorder Stereotypical movement

Repetitive vocal or motor movements High level of activity but not affecting performance

* Anxiety disorders including generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder.

the European Society for Child and Adolescent

Psychia-try, and the Scottish Intercollegiate Guidelines Network

describe a range of “desirable outcomes” for children

being treated for ADHD (Table 54-6)

A wide range of therapies have been advocated to

address attentional problems in children and adults,

including demystification (see Chapter 86), behavioral

interventions (see Chapter 87), and psychoactive

mecations (see Chapter 90) Recent studies suggest that

di-etary changes, including reduction in food additives and

improvements in nutrition, might benefit children with

ADHD Mind-body therapies (including but not

lim-ited to meditation and biofeedback) have been shown

in some studies to offer benefit to children with ADHD

Complementary and alternative medicines have not been

shown to improve symptoms or outcomes

The first step, demystification, teaches the child,

ado-lescent, or adult and the family about attentional issues

by use of a nonpathologic approach (see Chapters 86

and 89) Levine has developed a series of tools helpful in

this process, but the general approach is to discuss the

patient’s areas of relative strength and weakness and to

make attentional problems a characteristic to improve

rather than a source of shame (see Chapter 44)

Behavioral Approaches

At present, behavioral approaches are a starting place for

addressing global attentional issues, especially in preschool

but also in school-age children Behavioral approaches

have been shown to be better than placebo in multiple trials

Examples of behavioral strategies suggested for working

with children with ADHD and their families include

con-tingency management (e.g., point/token reward systems;

time-out; response costs) and psychoeducation in home

and school settings Although it is efficacious for some

comorbid symptoms (e.g., anxiety symptoms), cognitive-

behavioral therapy including self-monitoring and verbal

self-instruction has not been found to be effective for treatment of core symptoms of ADHD

Several large randomized controlled trials compared behavioral therapy alone and psychopharmacologic ther-apy alone and considered the combination of behavioral and psychopharmacologic interventions for treatment of ADHD symptoms Despite the intensity of these behav-ioral interventions (the MTA study “behavioral interven-tions” included 35 individual and group sessions, which tapered off during 14 months (Carey, 2000); the Abikoff study had weekly sessions for 1 year and then monthly

in year 2) geared to psychoeducation, behavior ment techniques, classroom consultation and support, and direct skill development, behavioral support alone was not as effective as medication for the core symptoms (activity and inattentiveness) of ADHD (Abikoff et al, 2004; Jensen et al, 2001) The combination of behav-ioral support with medication management of ADHD symptoms was comparable to medication only in terms

manage-of reduction manage-of core symptoms in the MTA study The combination was superior to medication alone for sub-classes of children, including those with anxiety and read-ing problems The combination was also better in cases

of poor parent-child relationships The combination was associated with greater family and teacher satisfaction Unfortunately, behavioral support in community set-tings for children with ADHD and their families is gen-erally far less intense than the behavioral strategies used

in these studies A 36-month follow-up of the original sample, however, showed no improvement from baseline

in core symptoms of ADHD but no intervention group differences (Jenson et al, 2007) It remains unclear what accounted for the differences in short-term versus long-term findings, even after post hoc analyses of various theories, suggesting another reason for close monitoring for children receiving stimulant medication over time.Psychological strategies and therapy are indicated for children with significant comorbid diagnoses (and their families), such as significant oppositional behaviors

or anxiety disorders Behavioral strategies should also

be strongly considered in cases in which (1) a child or family prefers not to use a medication, (2) a child par-tially responds or does not respond at all to medication, (3) the therapeutic benefits of a medication for the child have worn off at the end of the day, or (4) the child cannot tolerate medication management (see Chapter 7 for more on the management of aversive temperament).Although providers outside of the educational system cannot specifically “prescribe” interventions in a child’s school setting, they can support parents advocating for their children to receive supportive services and reason-able accommodations According to U.S federal law (Individuals with Disabilities Education Act, 2004; see Chapter 93), children with health problems significant enough to have an impact on a child’s educational per-formance qualify to receive services through their school program under the category of “other health impaired” to support their ability to make effective progress in an edu-cational setting Children may also receive special educa-tion if they meet one of the other eligibility criteria, such

as learning disability or intellectual disability However, ADHD does not itself qualify for special education

Table 54-6.  Possible Treatment Outcomes for

Patients with Attention-Deficit/Hyperactivity

Improved quality of work

Improved work completion

(in class; homework

returned)

Obtain by standardized report

Communication book Review of report cards Review of standardized assessments

Standardized reports Parent report during clinical interview

Quality of life questionnaires Standardized reports Self-report during clinical interview

Many children who are not eligible for special education

can receive accommodations through Section 504 of the

Rehabilitation Act Accommodations include

modifica-tions of the environment, output expectamodifica-tions, or teaching

methods The ADHD kit from the American Academy of

Pediatrics has sample letters for requesting both the

mul-tidisciplinary evaluation required to determine eligibility

for special education and a so-called 504 Plan

Pharmacologic Interventions

Numerous studies have suggested that medications,

par-ticularly psychostimulants, have an important role as

part of a treatment plan for children, adolescents, and

adults who have been carefully diagnosed with ADHD

All medications should be initiated in trial mode while

baseline data are collected from as many sources as

pos-sible, at least home and one teacher Careful attention to

the nature and severity of adverse side effects is crucial for

ultimate decisions about the use of medication A

reason-able approach to decisions about medication is to choose

measurable target outcomes before the medication trial

and to evaluate progress toward those outcomes with

treatment Several doses and formulations of medications

may be required Positive change should be demonstrated

for medication to be continued However, a favorable

re-sponse to a stimulant is nonspecific and does not prove

the diagnosis (Carey, 2000) Long-acting medications

seem preferable to short-acting preparations to

maxi-mize blood levels of medication, to minimaxi-mize decreased

attention as medication wears off, and to eliminate the

embarrassment of going to the school nurse for midday

medication Children should be seen regularly twice to

four times per year to monitor vital signs, growth side

effects, and comorbid conditions The visit is an

oppor-tunity to make sure that academic and social successes

are tracking with attentional improvement A trial off of

medication to determine whether the child or adolescent

is still benefiting is desirable to some families If children

are not making progress toward target outcomes or if

their academic or social experiences remain unfavorable,

other interventions must be put in place on a timely basis

Approaches to the use of medication and treatment

op-tions are comprehensively reviewed in Chapter 90

Complementary and Alternative Therapies

For many decades, numerous interventions beyond

med-ications and behavioral support have been advocated

for children with ADHD, including dietary replacement,

exclusion, or supplementation; various vitamin, mineral,

or herbal regimens; and biofeedback Although some

re-search has suggested possible benefits of some therapies

(including yoga, massage, fatty acid supplementation),

most studies have shown no effect, and more rigorously

designed intervention studies are needed to consider the

possible role of these therapies (see Chapter 95)

PREVENTING FUNCTIONAL PROBLEMS

AND COMORBIDITY

Children with attentional problems often face academic

and social difficulties In comparison to children without

attentional problems, children with ADHD earn poorer

grades, fail more classes and grades, have higher rates of detention and expulsion, drop out of high school, and fail to go to college Compared with children without attentional problems, children with ADHD have more difficulty with family relationships and fewer good friendships The management of attentional problems requires choosing target symptoms for the intervention The approaches will vary if the issues are narrowly re-stricted to attention or if they are pervasive, affecting academic and social life

Increasing evidence suggests that early intervention

to address attentional problems may prevent an ual’s level of inattention or impulsivity from contribut-ing to secondary concerns for children and adults, such

individ-as school failure, substance abuse, and motor vehicle accidents (Okie, 2006) Children with ADHD may ex-perience long-term adverse effects on their self-esteem, academic performance, vocational success, and social-emotional development Adolescents with a diagnosis of ADHD are more likely to report a negative outlook for the future, to have lower self-esteem, and to have an in-creased risk for motor vehicle accidents As adults with ADHD, job performance, frequent job changes, and re-lationship difficulties are reported to be more common (Faraone et al, 2006)

Individuals with ADHD who receive treatment have reduced risk of substance use disorders and cigarette use compared with individuals with ADHD who are not treated Adolescents and adults with ADHD are described as having increased rates of traffic accidents compared with non-ADHD peers However, while stim-ulant medications are being taken, driving performance (both during driving simulation tests and observed on a driving course) is significantly improved (Barkley et al, 2002; Cox et al, 2004; Wilens et al, 2006)

Because school is a child’s first job and attentional problems often negatively affect a child’s success in that first job, it is essential to find areas of success for a child who has significant attentional issues Constant recogni-tion of even partial success on the part of family mem-bers is the first step in shaping behaviors and supporting self-esteem An essential second step is finding areas in which the child feels pride Success in sports is often a lifesaver in children with attentional issues, but for many others, nonathletic pursuits must be substituted because

of developmental coordination difficulties or lack of terest The area of success is not nearly as important as the fact that the child or adolescent finds success in some arena that is important to him or her

in-SUMMARY

Evidence from neuroscience, neuropsychology, and genetics is refining our clinical understanding of the neurologic bases of attention and disorders of atten-tion Both genetic and environmental factors have an impact on attention abilities Clinicians assessing chil-dren with attentional problems should gather key his-torical information in more than one setting (including home and school settings) and use explicit diagnostic criteria to make an accurate diagnosis In addition, they should carefully consider alternative reasons for a child’s

presenting with challenges with attention regulation as

well as possible confounding factors and potential

co-morbid diagnoses that may be important in treatment

planning Individuals diagnosed with ADHD can be

treated with behavioral interventions and medication

The treatments play an important role in improving core

symptoms of activity and inattentiveness and in decreas-of activity and inattentiveness and in

decreas-ing secondary comorbidities in childhood, adolescence,

and adulthood

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Melvin D levine

DIFFERENCES IN LEARNING AND NEURODEVELOPMENTAL FUNCTION IN SCHOOL-AGE CHILDREN

A school child’s “balance sheet” of neurodevelopmental

strengths and weaknesses is a prophetic marker of her

or his readiness to succeed in school as well as in other

areas of life That profile of strengths and weaknesses

will influence profoundly a wide range of academic,

be-havioral, emotional, and career outcomes

A neurodevelopmental profile is composed of a child’s

abilities across eight interrelated constructs: attention,

memory, language, temporal-sequential ordering, spatial

ordering, neuromotor function, higher cognition, and

social cognition (Levine, 2002) Weaknesses in one or

more of these areas may be associated with academic

underachievement, behavioral difficulties, or problems

with social adjustment It has been estimated that at least

15% of school-age children harbor one or more

low-severity impairments of neurodevelopmental function

The actual prevalence may be even higher when one

takes into consideration discrete dysfunctions that lead

to a transient self-limited problem within a particular

subject area or those weaknesses that are not readily

captured on a diagnostic test (such as problems with

organization, communication, or output)

Neurodevelopmental variations are associated with

a wide range of preferred learning patterns, individual

strengths, and impediments (Table 55-1) A variation

that represents a developmental weakness (such as slow

or imprecise word retrieval) is considered a dysfunction

If that dysfunction interferes with the acquisition of a

particular skill (such as writing), it becomes a disability If

the skill impaired by the disability is particularly germane

to productivity and the attainment of reasonable success

in school and in our society in general, the disability

constitutes a handicap Neurodevelopmental variations

also include areas of unusual strength or talent In

de-scribing a child’s neurodevelopmental profile, therefore,

it is important to take into consideration his or her assets

(such as notable creativity, strong spatial perception, or

excellent nonverbal conceptual abilities) In capturing

the individuality of a child, it is also critical to take into

account his or her content affinities and areas of

consis-tent interest (such as a fascination with cars, aviation,

animals, or fashion design) Such areas should be helped

to develop into passions and domains of expertise!Most children enduring academic difficulties harbor more than one neurodevelopmental dysfunction The ad-ditive effect of multiple dysfunctions may be sufficient to constrain the innate resiliency of a child, thereby gener-ating academic underachievement It is likely that most children are able to circumvent a single neurodevelop-mental dysfunction to attain at least passable academic achievement

Neurodevelopmental dysfunctions commonly result

in the delayed or laborious acquisition of academic skills and in a notably reduced level of productivity or output in school and at home When neurodevelopmen-tal dysfunctions are overtly disruptive of learning, these problems are often referred to as learning disabilities However, there is little or no agreement on the defini-tion of this term (Bradley et al, 2002) Other labels, such

as attention deficit disorder, dyslexia, and nonverbal learning disability, have also been applied to children with “low-severity” dysfunctions These diagnostic la-bels may be required for obtaining services in school or for reimbursement purposes outside of school They also may enable students to receive accommodations, such as extended time on tests However, the diagnostic criteria for such labels are highly controversial and constantly changing Most recently, children’s eligibility for service has been based on their response to intervention (“RTI”)

In this model, services are provided when children have failed to respond to interventions in school that have been “scientifically proven” (Fletcher et al, 2005).Countless students with disheartening academic problems fail to meet their school’s criteria and therefore tend to “fall through the cracks,” as their learning needs

go unrecognized and unfulfilled Not only that, there are serious dangers inherent in applying fixed labels to children These hazards include self-fulfilling prophesies, pessimism, a tendency to ignore multifactorial causes and manifestations of a child’s problems (i.e., reductionism), and a widespread practice of neglecting children who are struggling but who fail to meet a school’s criteria for

55

535

service eligibility Under the Individuals with Disabilities

Education Act legislation, some children may be able to

receive services if a developmental delay can be

demon-strated, that is, without the requirement of a label

Labels fail to take into consideration the most

impor-tant feature of any child, namely, his or her strengths!

Consequently, this chapter shuns labeling and offers a

phenomenologic approach to the neurodevelopmental

dysfunctions that generate disabilities and significant

handicaps

CLINICAL MANIFESTATIONS OF DYSFUNCTION

Children with neurodevelopmental dysfunctions vary

widely with regard to their clinical symptoms Their

specific patterns of academic performance and behavior

represent final common pathways, the convergence of

multiple genetic, health-related, environmental, and

family-influenced factors In addition, the manifestations

of a particular dysfunction vary, depending on a child’s

strengths or weaknesses across other neurodevelopmental

constructs Thus, the manifestations of a memory

dys-function in a child with strong language skills will be

different from those in a child whose memory problems

are confounded by significant weaknesses of receptive

language as well Consequently, our broad

interpreta-tion of a child with neurodevelopmental dysfuncinterpreta-tions

must include consideration of strengths and weaknesses

in the components of all the eight neurodevelopmental

constructs summarized in Figure 55-1 In the

follow-ing section, the basic manifestations of deficits and

strengths in each of the key neurodevelopmental areas

are described

Attention

Dysfunctions of attention are, in all likelihood, the most

common neurodevelopmental problems affecting

chil-dren Weaknesses of attention are especially

incapaci-tating and are likely to have broad although often subtle

and insidious impacts on day-to-day performance

Neu-rodevelopmental dysfunctions of attention are covered

in Chapter 54

Memory

As children proceed through school, there is a growing

and potentially incapacitating strain on one or more

of the numerous and varied components of memory

(Levine, 2002) Students are expected to be

increas-ingly selective, systematic, and strategic in contending

with the imposed memory load They must become deft when it comes to the organized storage of rules, facts, concepts, and procedures By secondary school, rapid and accurate recall is an indispensable requisite for ac-ceptable academic performance Not surprisingly, some students experience tremendous frustration when their memory dysfunctions prevent them from meeting these ever-intensifying academic demands (Levine, 2003).There are students who experience difficulty with the initial registration of information or skill in short-term memory (Table 55-2), as a result of which they fail to keep pace with the torrential information flow

in a classroom In some cases, children with attention deficits are insufficiently selective, alert, and reflective to register the most salient information in memory They are likely to have generalized deficiencies of this initial registration process Other students have more specific registration weaknesses (Vallar and Papagno, 1995) Some may have trouble registering only visual-spatial data in memory, whereas others may be ineffective at the entry of sequences of data or with their hold on verbal material Some children ultimately can register

Table 55-1 A Hierarchy of Neurodevelopmental

Status

Variation An unusual pattern of neurodevelopmental

function (e.g., a higher divergent mind) Dysfunction A distinct weakness within a neurodevelopmental

function (e.g., weak retrieval memory) Disability A performance deficiency caused (at least in part)

by a neurodevelopmental dysfunction (e.g., trouble throwing a ball)

Handicap A disability occurring in a much-needed or

critical performance area (e.g., a significant reading problem)

THE NEURODEVELOPMENTAL

CONSTRUCTS

The attention controls

sequential ordering

Temporal-Spatial ordering

Neuromotor function

Social cognition

Memory capacity

Higher order cognition

Language Neurodevelopmental An Individual’s

Profile

Figure 55-1 This diagram depicts the eight neurodevelopmental

constructs, strengths and weaknesses of which contribute to a child’s neurodevelopmental profile.

Table 55-2 Four Levels of Memory and Signs

of Dysfunction

Level Signs of Dysfunction

Short-term memory Trouble following directions; need for

repetition, difficulty studying for tests Active working

memory Problems with mathematical computation; trouble remembering while reading;

problems with writing Consolidation in

long-term memory Overreliance on rote memory; inconsistent long-term recall; disorganization Retrieval from

long-term memory Slow recall; problems in writing and mathematics