Making developmental behavioral screening work for school-aged kids

Educational success, especially completion of high school, has economic and social advantages that benefit the individual and society. Students who attain a high school diploma or its equivalent (eg, the General Educational Development exam) are more likely to become employed, pay taxes, and take care of their families, including their health. The absence of school success is associated with high rates of high school dropout, teen parenthood, criminal activity, illiteracy, unemployment, and problematic health behaviors such as smoking, obesity, and lack of physical activity. No single variable better predicts health outcomes than one's educational level: High school graduation is associated with approximately 10 years of additional healthy life.^1,2

How can healthcare providers encourage educational success in school-aged children? Early detection and early intervention of developmental problems during infancy and preschool, as well as measures to promote school readiness in high-risk populations, increase the likelihood of subsequent academic success. For children in primary school, physicians can monitor progress, detecting and intervening when new problems emerge in later childhood and adolescence. At different ages, different disorders are more prevalent, and familiarity with the range of potential disorders and the most common ages of presentation facilitates identification. Helping educators, students, and parents with issues of in-grade retention and dropout prevention is critical, as are career and vocational advocacy.

School difficulties: Causes and consequences

There are 3 types of reading disabilities:

Deficits in sound-symbol association, also known as the dyslexic type of reading disability, meaning tremendous difficulties sounding out words. Research finds that a lack of "phonologic awareness" is a key feature in almost all children who have unexpected difficulty in learning to read.³ Deficits in phonologic awareness include difficulties imitating sounds in words, segmenting sounds within words, or creating rhyming words. These lower-order skills are essential for acquiring the phonetic skills needed to associate sounds of letters or word parts (eg, -ing, -ly, -at) with their written appearance. Some children with reading disabilities of the dyslexic type have not yet mastered the fact that written words are read from top to bottom and left to right. This is why some children are erroneously perceived to "read backward," when in fact they are simply disorganized and attempt to decode starting at the end of a word and then working toward the beginning (eg, reading "saw" instead of "was"). The dyslexic type of reading disability is sometimes associated with heritable and genetic forms of reading disability.

Deficits in acquiring a sight word vocabulary, sometimes known as the orthographic type of reading disability. Children with this disability exhibit difficulty memorizing written words and therefore lack fluency when reading. Good readers eventually recognize most words on sight and no longer need to sound out letters or word parts, an essential skill for reading at an appropriate rate. Expectations for a silent reading rate and prompt sight word recognition increase at each grade level (50-90 words per minute in second grade to about 800 words per minute in medical school).

Deficits in reading comprehension, sometimes called the hyperlexic type of reading disability. Children with this reading disability may have mastered phonetic skills at grade level and also have well-developed sight word vocabularies, but they can't answer questions about what they have just read. Some students comment that their "eyes are moving across the page but they aren't taking in information." Problematic reading comprehension usually has roots in preschool language deficits (eg, trouble understanding vocabulary or syntax). They may speak in complete and lengthy sentences, which makes this type of reading disability extremely difficult to detect without a range of measurements. Such children tend to have difficulties with content-focused subjects such as science and social studies and often have deficits in applied math (ie, word problems). The end of third grade is the time when children begin "reading to learn" and are no longer just "learning to read," so for the first time they are required to read at the typical language level of an 8- or 9-year-old. If language skills are delayed, reading comprehension begins to lag and lags further and further with time.