School Failure

After completing this article, readers should be able to: Failure in school can have lifelong consequences. The causes of school failure are myriad and often multiple within individual students who are struggling academically. Social, behavioral, and emotional problems frequently lead to academic difficulties. Health conditions also can impair academic performance. One in five children who repeat a grade in school has some identifiable disability.Irrespective of its cause, school failure is associated with adverse health outcomes. Children who fail in school are more likely to engage in subsequent health-impairing behaviors as adolescents. Failing students also are more likely to drop out of school. Adults who have no high school education often face limited economic opportunities, but they also are more likely to engage in health-impairing behaviors, to experience poor health, and to die at younger ages. Comprehensive approaches to evaluation and intervention may improve outcomes, and health care practitioners should play a vital role in these assessments. Moreover, clinicians can make a significant difference in outcomes by helping families identify the causes of failure and advocate for the resources to alter a child’s downward academic trajectory, preventing further compromise of a child’s health. Pediatric clinicians also should assess and intervene in risk behaviors of failing students. School readiness promotion and school failure prevention should be incorporated into routine health supervision visits.About 10% to 15% of school-age children repeat or fail a grade in school. Grade failure is more likely among males, minorities, children living in poverty, and those in single-parent homes. Children who have disabilities are nearly three times as likely to repeat at least one grade as are children who have no disabilities. The estimated prevalence of disabilities in federally funded school programs in 2001 shows: 6.0% of enrolled students had a specific learning disability, 2.3% had speech or language impairments, 1.3% were mentally retarded, and 1.0% were emotionally disturbed. Although only about 10% to 13% of enrolled children are served in programs for the disabled, these children account for more than 20% of children who fail school. Similarly, children who were small for gestational age (SGA) are nearly twice as likely to experience school failure (25% versus 14% in one report of about 100 SGA 10-year-olds and age-matched controls).Conversely, school failure is associated with adverse health outcomes. Although some of these associations are confounded by factors that confer disadvantage, such as poverty and low maternal education, longitudinal intervention studies of preschool children demonstrate that improving school performance can improve adult outcomes. The Perry Preschool Project demonstrated that a preschool intervention alone can improve school readiness and subsequently decrease school failure, school dropout, teen pregnancy, and substance use. Other studies show that adults who fail to complete high school are more likely to experience poorer health outcomes. Smoking rates are higher among adults who finished less than a high school education (in 1999, 32% compared with 23% of all persons). Low educational attainment is associated with higher age-adjusted death rates (in 1998, 562 deaths/100,000 who had less than a high school education, 466/100,000 for high school graduates, and 224/100,000 for those who had more than a high school education). Mothers who have completed less than a high school education are less likely to breastfeed (in 1993 to 1994, 43% versus 58.1%), and among breastfeeding mothers, they are less likely to continue to breastfeed for 3 or more months (in 1993 to 1994, 44% versus 56%).Grade failure is linked strongly to subsequently dropping out of school. Approximately 10% of nonretained students drop out compared with 22% of students who repeat one grade. Failing two grades increases the likelihood of dropping out to 39%. Dropping out is more common among children who fail later grades: 30% of youth retained in grades 9 to 12 drop out of school compared with 20% of those retained in kindergarten through third grade.Grade failure causes children to be older than their same-grade peers, which, even without dropping out, is associated with increased rates of health-impairing behaviors. Old-for-grade high school students are more likely to report smoking regularly; chewing tobacco; drinking alcoholic beverages; driving in a car with someone who had been drinking; having used alcohol or drugs prior to his or her last sexual intercourse; using cocaine in the past month; and ever using crack, intravenous drugs, or other illicit drugs. Old-for-grade students are more likely to report suicidal ideations (intent, plans, and attempts), violent behaviors, and risky sexual behaviors. Furthermore, grade failure is associated with increased rates of extreme scores on a parent-reported behavior problem index.Grade retention affects self-esteem negatively and alters peer group formation. Grade failure has a negative impact on measures of social adjustment, behavior, self-competence, and attitudes toward school and is very stressful for children. When children are made to repeat a grade, they perceive retention as punishment or as failure. Failing children move out of their class with same-age peers and join classes with younger children. Despite efforts by adults to protect children during this process, children tend to know the school history of each of their classmates.Valid arguments against the practice of grade retention are many because of all the negative effects and the limited and often short-lived academic benefits. Some proponents of grade retention argue that social promotion fails students. In 1983, the report on substandard student performance, “A Nation at Risk,” resulted in stricter promotion standards and higher retention rates. Two decades of experience with retention demonstrated that retention by itself does not benefit at-risk students academically to an extent that justifies the loss of self-esteem, the undermining of children’s attitudes toward school, and the increased risk of school dropout. Current educational reform that involves test-based promotion standards is likely to increase grade retention rates without increasing achievement. Conversely, promotion of failing students without any other intervention does not address their academic problems.An alternative to both grade retention and social promotion is teaching to the needs of individual students, but this approach requires testing to determine the students’ learning styles, strengths, and weaknesses. Although this approach is legislatively mandated by the Individuals with Disabilities Education Act (IDEA), schools often are limited by scarce resources and multiple demands. The PL 101–476 legislation has four key components: 1) identifying children who have learning-related problems; 2) evaluating the health and developmental status of the child who has special needs, determining current and future intervention requirements, and developing a plan to match services to needs; 3) providing services that include educational and related services; and 4) guaranteeing due process. Advocacy by parents, teachers, physicians, and others on behalf of failing children can lead to earlier identification of learning-related problems and facilitate the development of Individual Education Plans (IEPs) that meet the individual needs of children and improve their school outcomes.The differential diagnosis for school failure includes the entire range of conditions and factors that impair optimal physical, behavioral, emotional, and social development. For purposes of organization, it is helpful to separate the potential causes into exogenous and endogenous factors, but it is important to remember that school failure is the result of multiple factors, and the evaluation should not stop with identification of only one contributing factor. Table 1 lists many common contributing factors and should serve as a model for the types of conditions that act to cause school failure. A comprehensive discussion of each of these factors is beyond the scope of this work, but some warrant further discussion.Attention deficit often is considered when children are experiencing school problems. One in 10 visits to pediatricians is for behavior, and 50% of these are for attention problems. At times, children who have school problems are sent by schools to be “tested” for ADHD, often before any educational testing is done. Many conditions mimic ADHD, and the differential diagnosis for ADHD is virtually the same as for school failure. Children who have cognitive delays may appear to have problems with attention when placed in an educational setting that is too advanced for their cognitive abilities. Likewise, children in homes that have conflict may have difficulty attending to schoolwork. Some features that help to differentiate ADHD from other conditions are: 1) Chronicity–symptoms must persist at least 6 months, and some symptoms must have been present before age 7 years; and 2) Context–symptoms must be present in at least two settings (eg, school, home, work). Often, there is a family history of ADHD or school failure and dropping out. The diagnosis of ADHD does not preclude comorbidity with learning disabilities (LDs), cognitive deficits, or other conditions.The federal definition of LD is: “Specific learning disability means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations. The term includes such conditions as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. The term does not include children who have problems that are primarily the result of visual, hearing, or motor disabilities, or mental retardation, emotional disturbance, or of environmental, cultural, or economic disadvantage.” The concept of LD focuses on a discrepancy between a child’s academic achievement and his or her apparent capacity to learn. Often it is determined by discrepancies between intelligence quotient (IQ) and achievement scores or discrepancies among achievement scores (low reading with normal math is most common). Frequently, LDs are comorbid with other conditions that impair school performance. Some children appear to “develop” LDs when areas of weakness are uncovered by increasingly complex academic tasks. LDs may present early or go unrecognized until later. LDs usually are not outgrown, but children may develop strategies that accommodate or ameliorate the effects of their disability. Children whose intelligence is above average can have LDs and experience school failure. Diagnosing a LD requires psychological testing. Delay in recognizing LDs may result in repeated failure, from which children never may recover their motivation to succeed academically, even if their LD eventually is recognized and accommodated.Any acute or chronic medical condition may increase school absences. About 75% of all school absences are attributed to health problems. Most excessively absent students do not have chronic physical conditions. A number of factors may affect a family’s response to frequent minor illness, including vulnerable child syndrome, commitment to the educational process, family stress, and access to medical care. School absences may be more likely to affect school performance when the absence is prolonged (≥6 d) or cumulatively excessive (≥10 d per quarter, ≥30 d/y).Some common conditions are associated with cognitive issues (eg, iron deficiency anemia associated with a small, yet nonreversible decrement in IQ), with increases in school absences and school problems (eg, asthma), and with early school failure (eg, frequent ear infections). Some common medications may affect a student’s school performance, such as antihistamines and decongestants. Medications used for seizures and asthma also may affect classroom performance. Some conditions, such as lupus or thyroid disease, may present as school difficulties or behavioral problems before other symptoms become more apparent.In utero exposures can affect a child’s educational potential. Alcohol can affect cognitive potential adversely. Maternal drug use also might produce behavioral and cognitive problems. Maternal smoking during pregnancy is common and is associated with a decrease in IQ and an increase in behavior problems and early school failure. Untreated maternal hypothyroidism and phenylketonuria are associated with poorer developmental outcomes. Prematurity and low birthweight are associated with developmental problems; such conditions require periodic developmental assessments to decrease the likelihood of academic difficulties through early identification and intervention. Prevention is the best approach to most pregnancy-related conditions.Mood disorders may mimic ADHD and result in school problems. Mood disorders often present with greater intensity and pervasiveness than ADHD. Oppositional defiant disorder may present in school-age children as negative, hostile, and defiant behaviors and cause significant school problems.Children need a stable emotional base to attend to learning. conflict may a student’s attention from school. substandard living conditions, or may conditions that make school a negative toward their also may a child’s on Maternal during preschool can have a on a child’s cognitive and emotional development. and often affect school performance adversely. Children in care experience high rates of school failure and drop factors can to school failure. A between a student and a may be recognized when a child’s current school problems are out of with his or her prior school performance. Some schools that high standards may not be for an average class of children who have behavior substandard and may affect some children more than may appear during the 3 of school, children to third grade, children to learn. Many reading problems become apparent third grade. The to school Some children experience problems when the from the of having a in school to having multiple each with a in complete of school failure requires and When a is for school should be Often, school problems are not to the attention of a but for school problems should be of health supervision needs to be more than is in because is the likely of a child is in school. For a more complete of a child’s school performance, a are such does and or and does of school the most Most times, a is to for more to an for school difficulties. can in determining (eg, report of school work, report from the school testing be helpful for the subsequent Table an of the of an evaluation for school with a of the problems as a family or a child a complete evaluation includes from the school. When the problem from the the acute in school performance has than do problems. testing as of the may help identify cognitive and learning disabilities. with the child’s school is vital to a complete account of the child’s academic and and the of the on the it may be helpful to a child’s current and School and school also can into a child’s school of and is of or such as the or this When a child is for a out of this prior to the make more use of the are less of school than are language or language difficulties may be the or most apparent about a child who has cognitive difficulties also are a of testing may be to determine a child’s speech delays are or more absence of language difficulties does not out a learning disability. Some children may have but other such as or reading that are to succeed at school. into a child’s and and the of the of any developmental difficulties may help the factors health and even greater low education, violent and frequent have a negative on developmental outcomes. factors also may be associated with developmental such as to lead from substandard and anemia from poor family history of medical conditions, conditions, academic mental retardation, and substance may to school failure and adverse negative attitudes toward school may affect the school experience for children of may be The of of of is associated with school performance. The same can be for such as or and on the such as and also may for a child’s and Conversely, may the to school performance by of nearly any can impair school performance, it is important for a failing student’s self-esteem to have some of areas of also may serve as to on the student’s areas of For students who are in reading might it to reading about Similarly, students might math by understanding and medical conditions school failure are but they should be considered as of the of to failing students to a of medical on the of might the need for an evaluation for some of the medical causes of school failure. and hypothyroidism might to school failure and be associated with in and or A history of or might A history of or in might or The of symptoms also might the of the evaluation to conditions. For or might be associated with Table 1 for a more complete differential diagnosis of conditions to during the of physical usually to the evaluation of school failure, in the absence of on a some of the physical may more in the of school failure. of might with conditions such as alcohol and or with conditions such as absence of the of other might that the toward conditions that impair school performance and affect (eg, chronic disease, thyroid disease, or might lead to diagnosis of a that to academic difficulties. is of or no to the of school failure. and should be for studies are not of a routine evaluation for school failure, younger children may benefit from a complete and lead Other may be by on the history or physical such as thyroid testing is in the of academic failure. more such testing to the development of an that is by of a child’s academic and weaknesses. Although the legislation for all children who have disabilities, including a evaluation for learning-related conditions, the with which a student testing from a school by the school and the In most families can on testing as of any educational plan that involves their child a grade in school. can advocate for their child’s by of the educational and to testing for learning disabilities. who know to families through their school can be in this usually is best to a with the school for children’s may the need to on testing when it is not about to school often the process. can the psychological testing from the school by in that they are that their child might have a learning disability and requires evaluation often includes of measures of academic and behavioral may be if the conditions scores from these often are used to determine for can be in many including and often the least to for from 1 to 9 to a the normal a of the or the Low scores of or the the and the evaluation should a comprehensive of a child’s and not determine a child is mentally or learning should be considered in with the of the should be to the of the factors usually to school failure, multiple intervention failure is and routine to or the capacity of these Pediatric care practitioners should be and with school school issues and on to help out for may be the most important role of a care The of a child’s in the to result in more attention to the educational needs of a failing must with multiple and limited the role all the more important in improving educational outcomes for failing students. At times, schools at the of health educational but the of the health effects of school failure and an approach of about the child’s best can any potential other than retention should be The should not be as it often to grade retention versus social Often, children need for academic between these two Some conditions require special education such as speech or reading Other approaches also should be classes an to repeat some some an to and a child as failing an entire grade. school, and to a child’s learning may than having a failing child repeat a grade. class alternative educational and may be helpful In some promotion to the grade on achievement testing. Delay of such testing in with other may alone is the to academic failure. Grade retention without other the for learning on the than the issues that to the need for School should be to such issues are of should be in these A grade increases the likelihood of dropping out of school and risk behaviors. the education plan 1 or of failure may be too to optimal educational outcomes, and such delays may any motivation for families whose children fail academically need help and to become more involved in their child’s may need specific help in their child’s to be more to education, including or on a Similarly, families need to their children a to do that is from Children also may benefit from from school such as a or special education that strategies of multiple may be areas of may a key to their areas of areas of also may some of self-esteem in a failing a child’s are not recognized by the and the between and child when a child in some such as or even this is not an academic care practitioners can play a role in preventing school failure. the recognized of in school are: 1) low scores and poor grades at early 2) 3) low in child’s education, 4) number of times that a child low and high and behavior of school readiness should be of early health supervision can between and promotion through programs such as and can children’s early children to reading have an academic from that have Preschool such as children’s school readiness not only by children to and but by children with the social of school, including from for in group and in group Preschool developmental do not help readiness and should not be on to determine a child’s into school should be health and can serve measures include assessments and to anemia and testing to for identification of developmental delays and behavioral or emotional problems can lead to earlier intervention and outcomes. of younger of failing children may be an to further failure within Often, failure in but attention may be only on the child who has the most For preschool attention to developmental delays and promotion of school readiness may help failure in the In school-age of educational risk may for intervention before that child also failure can impair a child’s health. health can to school failure, but behavioral, and emotional problems often more to academic difficulties. Failure usually does not result from a but from a of multiple risk Pediatric care clinicians can to improve educational and health outcomes through with and schools in the of and intervention for failing alone is the to academic failure. Pediatric care practitioners can help by for failing both in and intervention. also can help families for learning. of a failing child’s may to on in developing an educational of younger may repeated failure within a assessments and school readiness promotion help to school failure.