Discuss conditions that may contribute to a child’s failure in school

Learning Objectives

Upon completion of the case, the student should be able to:

Discuss conditions that may contribute to a child’s failure in school. Summarize the signs, symptoms, and management of ADHD. Demonstrate ability to measure and assess growth including height/length, weight, and body mass index using standard growth charts. Discuss the epidemiology, risk factors, management, and complications of childhood obesity. Discuss diagnosis, causes, and management of hypertension in children. Discuss the risk factors for and diagnosis of type 2 diabetes mellitus Review the recommendations, formulations, and potential side effects for the influenza vaccine

Knowledge

Calculation of Body Mass Index (BMI)

BMI = weight (in kg) divided by height (in meters) squared. The BMI better reflects the amount of body fat (compared to weight from muscle or bone) than weight-for-height measurements.

Growth Curve Terms

Weight age = Age at which the patient’s weight would plot at the 50th percentile. Height age = Age at which the patient’s height would plot at the 50th percentile. Weight age and height age are particularly useful terms in communicating with parents, who often want to have some frame of reference for just how large or small their child is.

Attention Deficit Hyperactivity Disorder (ADHD)

Symptoms

The core symptoms of ADHD are: Inattention Hyperactivity Impulsivity

Prevalence

The estimated prevalence in the U.S. is about 8 to 10%, making ADHD the most common neurobehavioral disorder of childhood and among the most common chronic health conditions in school-aged children. Diagnosis

There is no laboratory test for the diagnosis of ADHD. Rather, the diagnosis is based on a set of characteristic clinical findings.

Diagnosing ADHD

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), criteria for diagnosis of ADHD include the presence of at least six of the symptoms listed below (or at least five for individuals 17 years of age and older): Symptoms of Inattention

Does not pay attention to detail or makes careless mistakes in school or at work Has trouble holding attention Does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or work duties Has difficulty with the organization of tasks Is reluctant to do tasks that require sustained mental effort (e.g., homework) Often loses things necessary for tasks and activities (e.g., school materials, keys, glasses)

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Is often easily distracted by extraneous stimuli Is often forgetful in daily activities

Symptoms of Hyperactivity and Impulsivity

Is fidgety, or squirms in seat Has difficulty remaining seated when this is expected (e.g., in classroom) Often runs about or climbs in inappropriate situations Has difficulty playing quietly Is often “on the go,” or acts as if “driven by a motor” Talks excessively Often blurts out an answer before a question has been completed Has trouble waiting for a turn Often interrupts others who are playing or speaking

In addition, the following conditions must be met:

Several inattentive or hyperactive-impulsive symptoms were present for at least six months and are inappropriate for the person’s developmental age Several symptoms must be present before age 12 Symptoms are evident in two or more settings, (e.g., at home, school, or work; with friends or relatives; in other activities). Symptoms interfere with the individual’s functioning socially or at school or work Symptoms are not better explained by another mental disorder

A patient can be diagnosed with one of three different types of ADHD based on which features they exhibit: ADHD, Combined Type ADHD, Predominantly Inattentive Type ADHD, Predominantly Hyperactive-Impulsive Type

Click here to see the 2019 AAP Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention- Deficit/Hyperactivity Disorder in Children and Adolescents

Important Causes of School Failure

Sensory impairment

Hearing and vision impairment in particular, may mimic inattention.

Newborns are universally screened for hearing prior to their discharge home after birth.

Vision and hearing should be screened subjectively (i.e., by history) in infants and toddlers.

Objective vision screening should be part of health maintenance visits beginning at 3 years old.

Objective hearing screening should be performed on all newborns and should be resumed at the 4-year-old health maintenance visit.

View the AAP Recommendations for Preventive Pediatric Health Care

Sleep disorder

Inadequate sleep may adversely affect school performance.

This may be due to a formal sleep disorder (e.g., obstructive sleep apnea, narcolepsy) or simply poor bedtime routines in the home (poor “sleep hygiene”).

Patients with ADHD often have poor sleep hygiene, but typically do not seem overtired.

Mood disorder

Prevalence of mood disorders increases with age.

Depression affects an estimated 3.2% of children aged 3 to 17 years.

Childhood depression is marked by a high rate of conversion to bipolar disorders.

Children with ADHD also have a higher rate of mood disorders than control populations.

Mood disorders may mimic OR accompany ADHD.

Learning disability

A learning disability (LD) is a disorder of cognition which manifests itself as a problem involving academic skills.

Most states require documentation of a discrepancy between IQ (in the normal range) and academic achievement for the diagnosis of a learning disability.

Learning disabilities clearly impair academic performance, but may also lead to behavioral and attention problems, particularly at school.

Comorbidity between LD and ADHD is common; many experts feel that one diagnosis should not be made without evaluating for the other.

© 2021 Aquifer, Inc. – Elizabeth Hernandez (elizabethhdz33@stu.southuniversity.edu) – 2021-08-21 00:04 EDT 2/10https://pediatrics.aappublications.org/content/144/4/e20192528http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf

Conduct disorder

Oppositional defiant disorder (ODD) is characterized by a pattern of negativistic, hostile and defiant behavior.

Conduct disorder (CD) is a more severe disorder of habitual rule-breaking, characterized by a pattern of aggression, destruction, lying, stealing and/or truancy.

ODD/CD is the psychiatric condition with the highest comorbidity rates with ADHD.

Anxiety disorder

Like depression, anxiety is a mental health problem that can mimic some ADHD symptoms or be a comorbidity. According to an analysis of the 2016 National Survey of Children’s Health, 7.1% of children had anxiety.

“Red Flags” for Risk of Learning Disability

The following are “red flags” that might raise a clinician’s concern for learning disabilities: History of maternal illness or substance abuse during pregnancy Complications at the time of delivery History of meningitis or other serious illness History of serious head trauma Parental history of learning disabilities or difficulty at school

Response to ADHD Medication