Preventing school failure: the physician as child advocate

Attending school heralds the end of the relative protection and nurture of home life. During the school day, a child experiences successes and failures that portend future feelings of self-worth and self-esteem. Usually children experiencing difficulty at school are identified by teachers, however, children are overlooked. When they are and subsequently experience chronic failure and frustration, long-term morbidity may ensue. Ideally, methods to identify potential learning problems should be available. Unfortunately, the state of the art does not allow accurate identification of problems before they occur. After any number of screening tests, we can accurately predict school successes, but predicting failure is elusive. Early school failure, however, like many maladies, can be diagnosed, particularly if a physician has a high index of suspicion and looks for signs and symptoms of ongoing failure and frustration. Family history, neonatal course, presence of minor congenital anomalies and soft neurological signs, attention problems and lack of age-appropriate processing skills in the preschool period should place a child at risk. Close observation should designate those children who fail to mobilize associated strengths that maintain development. Early intervention will reduce morbidity associated with academic difficulty. Longitudinally, reduction of chronic failure may be the most crucial intervention. The unfortunate cycle of developmental dysfunction leading to school failure and lowered self esteem with subsequent social pathology and delinquency is well known. To the extent that physicians are able to ensure appropriate school services for children experiencing failure, this cycle can be short circuited, adding significantly to the physician's traditional armamentarium.