PedsCases.com: School Difficulties

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Case homepage School Difficulties

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You are a student intern completing an elective in pediatrics when you meet Mrs. O’Neil and her daughter, Katie, in clinic. Mrs. O’Neil states 7 year old Katie has poor attention, school difficulties and stomachaches which started about the same time as the receipt of this year’s fall report card. It is now spring. Your preceptor has seen Katie since she was born (after an uncomplicated term pregnancy and spontaneous vaginal delivery). Katie’s only health problems have been mild asthma, for which she uses an inhaler, and seasonal allergies. There were no developmental concerns in the preschool period.

Mrs. O’Neil explains Katie has been refusing to practice reading and shows little patience for her spelling homework, although she doesn’t mind doing her math worksheets. The fall report card indicates Katie is frequently found staring out the window, but will respond when redirected to her school work. She draws well and prints neatly but never writes much on her journal assignments. She is not meeting classroom expectations for reading, spelling or written composition, has average grades in math, and excels in music and gym. She has been increasingly quiet in reading group and may complain of needing to use the washroom or having a stomachache when it is her turn to read aloud. Katie is well-behaved in class, has many friends, and until recently said she enjoyed attending school.

Your top differential diagnosis of Katie’s school problems includes:

Responses: choose the best one answer

Asperger’s syndrome, ADHD, and language learning disability

Reading disability (dyslexia), ADHD, anxiety

Anxiety, ADHD, Intellectual Disability

Learning disability in written expression, oppositional defiant disorder, petit mal epilepsy

Reveal options

Explanation:
Katie should be assessed for a possible reading disability, a type of learning disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). According to DSM-IV, a learning disorder is academic functioning (reading, math, or writing skills) that is substantially below that expected, given age, measured intelligence (IQ), and age-appropriate education. “Substantially below” in this case means a discrepancy of greater than 2 standard deviations between academic achievement scores and the child’s IQ. Children with a reading disorder (also known as dyslexia) may omit, substitute or distort words during oral reading or may demonstrate slowness and comprehension difficulties with oral and silent reading.

Clues that Katie may have a reading disorder include her refusal to practice reading, not meeting classroom expectations for reading, spelling, or written composition, and being increasingly quiet in reading group while trying to avoid reading aloud. Some children with a reading disorder avoid reading as much as possible due to the struggles they encounter. Difficulty manipulating sounds in words, confusing letters, inability to distinguish rhyming, and speech difficulties are other possible signs to look out for.

Katie is less likely to have a more general language learning disability as she is not displaying signs of a receptive or expressive language problem in a general sense; she is only specifically reluctant to read aloud. As well, her developmental milestones in the language sector were described as normal.

An isolated writing disability is less likely, given Katie’s combined symptoms of reading and writing difficulties.

Attention Deficit Hyperactivity Disorder (ADHD) is another important possibility, given Katie’s difficulties sustaining attention, failure to complete tasks, and avoidance of certain activities. The core symptoms of ADHD, according to the DSM-IV, include inattention, hyperactivity, and impulsivity. Subtypes of ADHD are classified based on the predominant symptom present: Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type, and Combined Type. Many children with ADHD also have learning disorders.

Katie’s symptoms may also be stemming from anxiety. Although worry and fear are common emotions felt in childhood, worrying that interferes with function is not. Generalized Anxiety Disorder in children, as described in DSM-IV, denotes worrying about a number of events or activities, on more days than not, for at least 6 months. This includes at least one symptom of restlessness, fatigue, difficulty concentrating, irritability, muscle aches, muscle tension, or sleep difficulties not attributed to another medical or psychological issue. Because children have difficulty controlling this worry, they may suffer academic impairment and avoidance of normal activities.

Asperger’s disorder is an older term used to describe higher functioning children with autism spectrum disorders (ASDs). It is characterized by severe deficits and impairment in multiple sectors including social interaction and communication, as well as the presence of stereotyped interests, activities or behaviors, in children whose language development is not significantly delayed (e.g., they are using single words by age 2 years, and phrases by 3 years). Katie is not demonstrating these behavioural characteristics.

Intellectual Disability, formerly referred to as mental retardation, is unlikely as Katie does not have general impairment in intellectual/cognitive functioning or deficits in adaptive behaviors. With Intellectual Disability, one would expect a history of past and present delays in all or most developmental sectors.

Katie is not persistently or consistently disobedient and hostile toward her parents, teacher, or other adults, therefore ruling out Oppositional Defiant Disorder (ODD).

Petit mal epilepsy, or epilepsy consisting of absence seizures, is hinted at in the stem by her periods of “staring out the window”. Although possibly concomitant to her primary presentation, this diagnosis is less likely.

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