CHAPTER 36

Children and School: A Primer for the Practitioner

Geeta Grover, MD, FAAP, and Jeanne Anne Carriere, PhD

Pediatricians are the medical practitioners most knowledgeable of typical and atypical child development. Their routine contact with young children and their families, as well as their longitudinal perspective on their patients’ lives, places pediatricians in a unique position to evaluate, diagnose, and manage not only children’s medical needs but also their developmental, social-emotional, behavioral, and educational needs. Research has highlighted the importance of early experiences to optimize development and supported early intervention for children with developmental delays. Traditionally, the 5-year-old health maintenance visit has been regarded as the “school readiness” visit. However, waiting until this visit to address concerns or provide preventive guidance for educational readiness is too late. School readiness and the academic, behavioral, and social-emotional development it entails must be promoted from infancy through early childhood.

During the school-age years, pediatricians should continue to monitor children’s educational progression by inquiring about academic, social-emotional, and behavioral development. Parents often turn to pediatricians for advice on their children’s behavioral or academic difficulties at school. Early academic, behavioral, and social-emotional difficulties place children at risk for school disengagement and school failure. It is imperative that pediatricians have an understanding of the multiple facets, evaluation, and management of children’s school readiness needs and the ways in which delays or deficits in academic, cognitive, physical, behavioral, and social-emotional development can affect a child’s school engagement and long-term success. The evaluation and management of educational difficulties requires a multidisciplinary approach; however, the pediatrician should have a principal role in monitoring the critical elements supporting school readiness and providing ongoing guidance, support, and advocacy for patients and their families.

Epidemiology

Attempting to establish a set of determinants that result in successful learning or that place a child at risk for failure is an oversimplification of the complexities of school readiness, school engagement, and school failure. School readiness, school engagement, and school failure are nonlinear cumulative processes, not solitary events, and a multidisciplinary approach to assessment and management is required.

School readiness is the term used to describe those qualities and traits that are considered prerequisites for a child to be ready for school success. When defining school readiness, parents tend to focus on the pre-academic skills their child has mastered (eg, identifying letters and sounds, counting, writing their name). Teachers’ definitions of readiness regularly incorporate social skills and behavior as well. Factors identified in the literature as affecting school readiness include physical health, motor skill development, social and emotional development, language development, adaptive skills, and cognitive abilities. In addition, significant additional factors exist that readily affect school adjustment and success other than a child’s skills and attributes, such as parent-child interactions, access to quality early childhood education, and both positive and negative life experiences (see Chapters 141 and 142).

Language deficiencies and problems with emotional maturity are cited most often as the factors that most restrict school readiness. Language development and school readiness are intertwined. Language proficiency provides a strong foundation for the cognitive and literacy skills required for school achievement. By providing a rich language environment from infancy, parents give children a head start on school success. Currently, however, more than 1 in 3 American children start kindergarten without the language skills necessary to learn to read. Similarly, with regard to emotional maturity, a recent study found that students who entered kindergarten lagging their peers in social-emotional skills were more likely to experience grade retention, receive special education services, and be suspended or expelled at least once by the fourth grade. School engagement can be broadly defined as meaningful student involvement throughout the learning environment. Research has shown that school engagement is associated with positive outcomes, including academic achievement and persistence, that is, staying in school until graduation. Within the school research literature, school engagement has 3 components: behavioral, emotional, and cognitive. Behavioral engagement is related to active participation, both in the classroom and the school community as a whole. It includes following classroom norms; demonstrating good conduct; and being involved in academic, social, and/or extracurricular activities. Emotional engagement refers to students’ emotional reactions to teachers, peers, academics, and the school as a whole. Emotional engagement creates a sense of belonging and value to the school community. Cognitive engagement is related to students’ investment in learning. It encompasses the problem-solving flexibility and coping skills students use as well as the hard work they do to understand and master the curriculum presented to them. School engagement is considered crucial to achieving positive academic outcomes and protecting students from school failure.

School failure is a multifaceted, epidemiologically complex issue. Research suggests that health and educational success are intricately connected. Compared with non-affected children, children with physical illnesses, mental health concerns, socio-emotional concerns, behavioral issues, and neurologic deficits are more likely to have difficulty learning throughout their school careers. They are at increased risk of poor attendance, poor achievement, academic decline, and failure to graduate from high school. Dropping out of school, which is commonly seen as an event, is in fact a process that often begins with early school failure.

Overall, high school completion rates in the United States have been slowing rising over the last decade, with 83% of all students graduating from high school. Graduation rates vary by state, however, and are lower for children from low-income families and for children with disabilities. The overall rate of high school completion is 76% for low-income students, with some states reporting rates as low as 63%. The high school completion rates for children with disabilities are even more concerning. In the United States, approximately 64% of students with disabilities graduate from high school, with rates as low as 29% for certain states.

Approximately 15% of children in the United States have a developmental disability. In the US public school population, 13% of children receive special education services under the Individuals with Disabilities Education Act (IDEA) of 2004. These services are provided to students with qualifying disabilities, if their disability affects their academic achievement or educational performance. Not all children with a diagnosed disability qualify for or require special education support (Box 36.1).

The number of children with diagnosed disabilities is significantly lower than the number of children who experience some level of adverse environmental, socioeconomic, or stress-inducing conditions that negatively affect their ability not only to get to school each day but be ready to learn on arrival (see Chapters 141 and 142). These children experience poor educational outcomes when they do not receive comprehensive support, intervention, and services. Youth who interface with the juvenile justice system have previously experienced increased rates of academic failure, disengagement from school, and/or school disciplinary problems. More than half of such students perform academically below grade level. This population meets eligibility for special education services at 3 to 7 times the rate of their nonincarcerated peers. Approximately 85% of incarcerated juveniles are functionally illiterate (ie, lacking the literacy skills to manage daily living and employment tasks that require reading) or low literate. High school dropouts are 3.5 times more likely than high school graduates to be arrested in their lifetime and 63% more likely to be incarcerated than their peers with 4-year college degrees.

^a To fully meet the definition and eligibility for special education and related services as a “child with a disability,” a child’s educational performance must be adversely affected as the result of 1 of the 14 categories listed here.

^b The Individuals with Disabilities Education Act of 2004 allows each state to determine whether to use this eligibility category for student age 3 through 9 years.

Research has not supported retention as an effective remediation strategy for poor school performance, and many studies have linked retention to future school failure. Grade retention rates in the United States have declined in the past decade, and currently, approximately 10% of students are retained each school year. Most retentions occur in kindergarten, with retention rates between 1st and 12th grade of 3% to 5%. However, retention rates as high as almost 9% in these grades have been reported for students of color, students of parents without a high school diploma, students whose families receive public assistance, and students living in the Southern states. Children receiving special education services experience retention at a significantly higher rate, with 32% being retained at some point in their school career.

Considering that the average child in the United States spends approximately 50% of the waking day in a school or a similar learning situation for approximately 12 or 13 years, it follows that a lack of success in these settings will lead to difficulties for much, or all, of adult life. School difficulties that go undetected, untreated, and undertreated can result in establishing a lifelong pattern of frustration and failure. For example, children with attention-deficit/hyperactivity disorder (ADHD) are 2 to 3 times more likely to drop out of high school than their peers without ADHD, and those who attend college are less likely to graduate than their peers without ADHD (see Chapter 133).

Clinical Presentation

Defining school readiness is not an easy task, because the intellectual, physical, social, and emotional development among children of kindergarten age varies tremendously. To confound the concept of readiness, kindergarten expectations and standards have changed significantly in the past 2 decades, becoming less socially play based and more academically focused. School readiness involves far more than adequate pre-academic skills (Box 36.2). Early childhood educators also emphasize the importance of sufficient physical, cognitive, language, social-emotional, and behavioral skills to children’s success in the formal schooling environment. Current research emphasizes the importance of children’s “learning to learn behaviors,” highlighting the role that abilities such as sustained attention, engaging in goal-directed tasks, impulse control, and emotional regulation have on children’s engagement in learning activities and academic achievement. Children who can control impulses, consider options, and demonstrate flexible thinking and creativity are better able to actively engage in learning opportunities than their peers who lack those skills. As conceptualized by the National Education Goals Panel, school readiness encompasses 5 dimensions: physical well-being and motor development; social and emotional development; approaches to learning; language development (including early literacy); and cognition and general knowledge.

Lack of specificity of children’s presenting signs and symptoms and of parental concerns make it challenging to determine a specific etiology for school failure. For example, parental concern about a child’s inability to focus may be suggestive of an attention disorder, a learning disability, a mood disorder, or perhaps all 3. Parental concerns can be categorized into 3 broad areas: learning (eg, learning disability; problems with higher-order cognition, including intellectual disability), attention (eg, ADHD), and emotional/behavioral (eg, anxiety, depression, serious emotional disturbance). Signs of school difficulties are presented in Box 36.3. It is important to look not only at academic skills but also at other components of the educational experience, such as social and emotional experiences. Additionally, it is important to ascertain the basis for the perception that a child is failing. It is necessary to determine whether the problem exists in the eyes of the student, parent, teachers, or everyone involved. Academic achievement across subjects must be assessed, especially in the areas of reading, mathematics, and writing. It is also important to evaluate students with good skills who fail to perform satisfactorily in the areas of writing, planning, organization, project completion, test taking, or classroom participation. Difficulty with academic performance may result in school failure despite satisfactory academic skills. In addition to academic skills and performance, the development of good social skills and peer relations is equally important. Some students have difficulties “fitting in,” which results in a disappointing educational experience despite academic excellence.

Pathophysiology

Developmentally, support exists for promoting school readiness from a young age. Research highlights the effect of nurturing relationships and positive experiences on early brain development. Strong neural connections are created and modified by positive reciprocal interactions, creating a solid foundation for learning. Conversely, adverse environments can have harmful effects on healthy brain development.

The developing brain continues to make new synaptic connections and discard underused connections from birth to approximately age 5 years, well before formal schooling begins. For example, it is known that children who grow up without being read to and with little exposure to books or printed language during their first 5 years are at increased risk for developing reading failure and subsequent school failure (see Chapter 34). School readiness must be promoted from infancy throughout early child-hood; waiting for the 4- to 5-year-old well visit to address school readiness is too late. Most children with learning disorders experience language, motor skills, and emotional or behavioral problems well before they encounter difficulties in the classroom. These deficits are noted by parents an average of 3 years before the disability is formally identified.

^a This domain focuses on children’s social and emotional development, including their interpersonal and intrapersonal skills.

^b This domain covers such factors as health status, growth, and disabilities.

^c This domain focuses on expressive and receptive language skills and literacy development.

^d This domain includes general knowledge as well as gaining knowledge by making connections with objects, events, or people for similarities, differences, and associations. It also includes knowledge about societal conventions.

^e This domain refers to the ability to use skills to actively engage in learning.

Adapted with permission from National Education Goals Panel. Ready schools. Washington, DC: U.S. Government Printing Office; 1998

Another critical period in brain development occurs during adolescence, when the brain again undergoes a process of synaptic pruning and myelination that is especially notable in the prefrontal lobe, the area responsible for the executive function skills of reasoning, impulse control, attention, and planning. These skills are higher-order cognitive tasks that enable attention, self-regulation, planning, organization, and completion of goal-oriented tasks, all of which are necessary to effectively engage in learning.

Interventions designed to improve children’s school connectedness and prevent later academic problems are most effective when they are provided during the preschool years, before a child enters formal K-12 schooling. School engagement stems from learning theories demonstrating that learning improves when students are curious, interested, or energized by their schooling and that learning worsens when students are bored, indifferent, or disengaged from their school. Levels of student engagement can be seen on a spectrum from deeply engaged to resistant. For students with fluctuating engagement or true resistance to participation in school and learning activities, a multitiered system of support (MTSS) is often needed to improve student outcomes. School engagement is adaptable and is a function of not only the child but the context, that is, the school environment. This implies that behavioral, emotional, and cognitive engagement can be responsive to prevention and intervention.

Stay updated, free articles. Join our Telegram channel

Join