Chapter 110 My little boy isn’t doing as well as he should at school

Alison Salt

Many children present to the eye clinic because of school difficulties. Parents and teachers quite reasonably ask if a problem with vision could be the explanation for poor school progress. This chapter outlines the problems that may present with school failure and suggests appropriate referral routes.

It is usually children with less severe problems who you are likely to be asked to see. Those with severe learning difficulty are usually identified before they start school, although visual difficulties affecting learning should be detected by routine vision assessment as part of their care. The increased demands of a school curriculum will often bring to light less severe problems.

Schools may take several routes in seeking advice when a child is not reaching expected targets; an educational psychologist may be asked to undertake an assessment of a child’s abilities, a pediatrician may be asked to exclude a medical diagnosis, and the child may be referred to an eye clinic or an audiologist to exclude a visual or hearing impairment.

Possible reasons for poor school progress

Global learning difficulty

Learning difficulties affecting all areas of development occur in between 3% and 10% of children. The most common causes are chromosomal anomalies; Down’s syndrome and fragile X syndrome are the most common, although they are most likely to present before school age. Mild or moderate learning difficulties may not present until the child starts school; in a majority no cause can be identified. Nevertheless, referral to a pediatrician to consider the possible etiology and appropriate intervention is appropriate.

Specific learning difficulty

Some children whose general cognitive abilities are average have specific problems with learning. However, these specific problems may also present in combination, i.e. more than one difficulty may coexist.

Dyslexia or specific difficulties with reading are described in detail in Chapter 61. These problems frequently lead to referral to the eye clinic so that vision problems can be excluded. The diagnosis will be confirmed by a detailed assessment by an educational psychologist or neuropsychologist and specific educational support will be required.

Developmental coordination disorder (DCD) (or dyspraxia) is a specific problem of motor coordination affecting the coordination of large and fine movements and may lead to difficulty with physical activities, writing, and speech clarity. These children may have difficulty with visual and spatial perception, general organization, and self-help skills, e.g. dressing. They may experience additional emotional and social difficulties. A physiotherapist or an occupational therapist (OT) can provide assessment, advice, and treatment. A psychologist can help in assessing any associated specific cognitive difficulty which may coexist.

Speech and language disorders usually present prior to starting school, but more subtle difficulties of comprehension may not be recognized without detailed assessment. Assessment and support from a speech and language therapist will be necessary and may include a language program delivered as part of the school curriculum. Specific difficulties with literacy are associated with particular speech and language disorders.

Other developmental disorders

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