How a Pediatrician Can Help With School Problems By Mark B. Levin, M.D. & Timothy J. Patrick-Miller, M.D. The Pediatric Group, P.A., Princeton

Society places a premium on education. Educational achievement is rewarded with increased income, desirable lifestyle and longevity. School performance determines how far up the educational ladder a child can climb. The educational set up in our society, with rare exceptions, is meant to deliver education efficiently to as many children as possible utilizing often limited physical and human resources. That is, many children in a class (often 20-30) with few teachers (usually one) to teach them. This system precludes individualized instruction. Hence, if the teaching (processing) style of the teacher differs from the learning (processing) style of any of the students, the classroom experience for those children will be less than optimal.

When an intelligent child does not learn despite recognizing that he or she is expected to learn, frustration and anxiety are inevitable. We all have built-in personality defense mechanisms, which activate in the face of unavoidable stressful situations. The child who tunes out and the child who acts out are often employing these mechanisms. Those children who lack such mechanisms, or who are denied their use, can be overwhelmed when confronted with their poor performance. They often develop poor self-esteem, behavioral problems or psychosomatic symptoms. We, as parents, teachers and physicians, must intervene to teach these children how to deal with educational information and with their frustrations.

Sometimes a child is referred to the pediatrician by a parent or teacher because of a school problem. All too often, a child presents complaining of headaches, fatigue or abdominal pains. And sometimes, while not spontaneously communicating any concern to an adult, a child will acknowledge a problem during the annual health supervision examination (yearly check up). The rapport and communication developed with a child over time allows a pediatrician to discover clues to the underlying causes from the history (the timing, frequency and onset of symptoms, aggravating and ameliorating factors, and associated problems), the physical examination and, sometimes, from laboratory tests. The pediatrician must evaluate confounding causes as diverse as physical (related to growth, disease, sensory malfunction, etc.), metabolic (related to glucose metabolism, lead intoxication, thyroid dysfunction, iron deficiency, allergy, etc.), pharmacologic (whether prescribed or illicit) and psycho-social problems. Moreover, this evaluation must be performed thoroughly and logically so as not to miss any contributing factor.

Even though the symptoms a child suffers are real, many times the cause is intangible. The absence of physical findings by no means indicated that there is "nothing wrong". It does suggest, however, that the child's symptoms may be unrelated to internal abnormal physiologic or anatomic phenomena. In these situations a doctor's knowledge of a child's educational setting and school performance is as important as physical diagnostic skills and laboratory tests. Knowing the child and family over years gives the pediatrician an advantage over educators and casual observers regarding interpretation of a child's underlying personality and information-handling abilities. It is often these very traits that influence how a child functions in his or her world and that lead to the stresses that cause the presenting symptoms.

Any needed intervention on behalf of a troubled child is easier to implement because of the familiarity a pediatrician, who lives and practices in the region where the child attends school, has with a particular school system. Moreover, an established doctor has often developed a network of consultants that can assist in the diagnosis and management of school-related problems. A pediatrician's awareness of approaches to psycho-educational testing that can more precisely define a child's learning style and of laws and regulations enable him or her to assist the child's family in advocating for their child in the school system.

The pediatrician is in an ideal position to serve the child and the family as a central coordinator for community services and as a sounding board for the parents' ideas and concerns. He or she can offer advice to teachers regarding the child's style and the physical and physiologic bases of a particular child's functioning. He or she can also advise the child's parents regarding the child's behavior and ways to deal with it.

Psychological and educational consultants sometimes suggest a need for medication as an adjunct to their efforts. It is important for the family and the child to understand the place of pharmacologic intervention in the educational process. Prescription medication should not be among the first things tried in an effort to ameliorate a child's educational performance. What to expect from different medications, what is known about the mechanism of action of these medications, potential side effects, dosage patterns and administrative issues are all appropriate topics for discussion with a child and his or her parents. Management advice from medical consultants (e.g., a neurologist) is often valuable, but consultants are usually unavailable on short notice for the practical implementation of medication prescriptions and dosage changes or for monitoring potential medication side effects. Any needed pharmacologic intervention can be effectively managed by the child's pediatrician.

Our goals as parents, doctors, educators and psychologists are to have a child be a happy, productive member of society, to allow him or her to achieve the fullest expression of his or her intellectual potential and to ensure that he or she is able to function independently in a manner that avoids long term undesirable social, educational and emotional consequences. If you are concerned that your child's educational performance is below expectations, contact your pediatrician for a frank discussion.

All Rights Reserved 4/98 The Pediatric Group, P.A.

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.