AAP Voices Blog

Like most general pediatricians, I see a fair number of children in my practice who have learning and thinking differences or other school-related struggles. These concerns are incredibly common – an estimated 1 in 5 children learn and think differently. Often these school struggles manifest around 3^rd grade, when curriculums can become more academically challenging.

And now, the COVID-19 pandemic has created serious complications for school systems that affect school-aged children.

When it is difficult for a child to pay attention, turn in homework, or participate in class, the teacher may ask, “Is this ADHD?”

That question can set off a rapid sequence of brief interviews, perhaps a questionnaire to document symptoms of ADHD, a diagnosis of ADHD, and prescription of stimulants. For the family, there may be a profound sense of bewilderment, with hopes for quick solutions. But the problem is that by beginning with the diagnosis – ADHD – we’ve missed the chance to carefully evaluate and consider all the possible causes of the child’s learning problems.

Instead of asking “Is this ADHD,” we should start with the question, “Why is this child struggling in school?”

In my practice in Ohio, we have implemented a cross-disciplinary team approach to evaluate children who are having trouble in school. The goal is familiar to all pediatricians when a symptom presents: Let’s find out the main cause or causes driving the symptoms.

But pediatricians may find it challenging to root out what is really causing such school struggles. Over a number of years, my practice has found a path to success in this area, even though it is a small practice. In our office, about 75% of the office space is devoted to the usual two doctor office, but 25% of it is sub-let to an outstanding child therapist and child neuropsychologist.

“The key to helping families with children who struggle in school is to start with all symptoms.”

The result is that every child I see struggling in school can receive a comprehensive evaluation of their cognitive, emotional, relational, and physical health. And I can arrange for children to undergo this evaluation and have it completed within weeks of my first visit with the family. Over the years, at least 70% of the children who presented to me with an assumption, by family, school, or even other mental health professionals that the child had ADHD turned out to have something else.

The key to helping families with children who struggle in school is to start with all symptoms. As with fever, struggling in school is a symptom with many causes. And like fever, clues are usually available from the family to point the evaluation in the right direction. For example, an 8-year-old who is not focusing or paying attention might have dyslexia, so if the family shares that he has trouble reading, specific testing for dyslexia will reveal that. Or a young girl might be having trouble with anxiety, in which case talking to the family might reveal that  the child is intensely worried to the point of being distracted, a problem that can be confirmed with an appointment with a qualified therapist.

And, some children who struggle do so for reasons unrelated to their own abilities, but in response to traumas, including bullying or food insecurity.  Again, if your conversation with the family covers these possibilities, you can help the family end these traumas.

As pediatricians, the finding of a cause for physical illness usually ends the evaluation, case solved.  But for mental health situations or learning struggles, etiologies tend to be mutually inclusive, and so it is critical that each time we help a child, all the possible causes at least be considered. 

In October 2019, the AAP published a clinical report that establishes a standard of care and provides tremendous guidance for pediatricians.

Key to the effort is working closely with developmental-behavioral pediatricians, psychologists and/or other mental health professionals to conduct a detailed evaluation of the child’s cognitive and affective functions. Teachers, parents and/or the other adults in a caregiving role for the child will also have valuable observations and insights to contribute.

In addition to the helpful guidance AAP provides for pediatricians, Understood has partnered with AAP to provide guidance for families. This guidance for families that pediatricians can share with them is a helpful mnemonic, Take N.O.T.E.:

• Notice if there’s something going on with your child that’s out of the ordinary.
• Observe and keep track of patterns in your child’s behavior.
• Talk to your child, teachers, aides, and caregivers about what you’re observing.
• Engage with trusted professionals, like pediatricians.

Millions of children struggle in school, and they come to our pediatric offices with a wide variety of presentations.

Pediatricians, working in tandem with families and caregivers, are able to partner, Take N.O.T.E. and put supports and services in place. Resources from the AAP are available as a guide. Remember to approach each child with an open mind. You can be an amazing resource to every child who struggles in school and a great help to many families.