Educational difficulties: GP referrals

When a child's school progress is poorer than the expected family norms, anxious parents will sometimes visit their GP as a first port of call end this may lead to a referral to the Consultant Community Paediatrician. These referrals may or may not be appropriate. Sometimes they have to be re-routed back into Education.

Sometimes parents will approach the General Practitioner or Paediatrician with a diagnostic label which they have read about or seen on TV. Levels of concern about these various labels can fluctuate according to what is fashionable in the media at the time and they can include ADHD, dyspraxia and dyslexia. Sometimes parental perceptions are accurate and at other times they are not.

The following paragraphs describe the types of educational difficulties that sometimes lead to referral and what Community Paediatricians have to offer.

Deteriorating School Performance

This must be clearly documented by parents and school and should not be confused either with simple fluctuations or the widening gap which children sometimes experience when they have learning difficulties and the demands are becoming increasingly excessive.

Deteriorating school performance may be a reflection of many things - bullying, family adversity, abuse or depressive illness. There may be an undetected medical condition such as new onset epilepsy or (rarely) a progressive degenerative neurological condition which may be associated with other regressions.

The General Practitioner has a number of options in this situation.

He/she may wish to refer to the local School Nurse who can liaise appropriately with the school.
There may be a need for a psychiatric or Social Service referral Some form of statutory meeting between school, Social Services and Health. This can be facilitated by the School Health Service.
If organic factors or psychiatric illness is suspected, referral routes may either be to the Consultant Community Paediatrician, Paediatric Neurologist or Child Psychiatrist.

Dyslexia

This term is applied to children who have specific learning difficulties and this may affect a number of areas (not just reading). The assessment of such children is the remit of the Educational Psychologists. Community paediatricians do not have this type of expertise.

Dyspraxia

We are increasingly detecting children with impairments of executive and organisational motor functioning. Sometimes it is accompanied by other difficulties such as attention deficit, tick syndromes or mild autistic spectrum. Consultant Paediatricians are happy to see such children and would carry out a full neurological examination and exclude other disorders. However, if we confirm the diagnosis, we would want further more detailed assessment and therapeutic advice by the Occupational Therapy/Physiotherapy Team. Schools can themselves refer directly into this service, but waiting lists are lengthy. In the past, such children were described as "clumsy".

Attention deficit hyperactivity disorder

This is a controversial topic. Many children with learning difficulties also have concentration difficulties. Before making this diagnosis it is essential to ensure that them am no factors within the child e.g. anxiety/depression/adverse family situations which might be affecting activity and concentration levels. Poor parenting skills are relevant in a high proportion of such cases. However, it must be borne in mind that difficult overactive children can place enormous stress on parental functioning.

Consultant Paediatricians sometimes assess these children, sometimes prescribe stimulant medication (Methylphenidate) and monitor aver a period of time, whilst also liaising with the school. However, Child Psychiatry may be a more appropriate referral route and some joint working can be done between Child Psychiatrists and Community paediatricians. Sometimes parents want to use the ADHD label as a panacea for other problems which they cannot easily accept,

Children with learning difficulties

Children with severe learning difficulties and perhaps other handicaps are normally detected at the pre-school stage. Children with moderate or minor learning difficulties may not emerge until after they start school. Resources for such children are decided through the Educational Code of Practice, which is a staged process involving consultation between teachers, parents and Educational psychologists. If the case has reached Stage 3, a decision maybe made to formally assess the child's educational needs. Medical advice is required at this stage and this is provided by Consultant Paediatricians, School Doctors and, in some parts of Northumberland, General Practitioners.

Sometimes such children are referred to the Consultant Community Paediatrician or the School Doctor directly by the schools or the Educational Psychologists. This usually occurs if there is a concern about health or psychiatric factors.
In children with mild or moderate learning difficulties, a specific cause is not often found and this can be disappointing to parents who are having to come to terms with the fact that their child has learning difficulties.
On occasion a diagnosis can be made: a syndrome diagnosis (if there are dysmorphic features) or a neurological or psychiatric diagnosis e.g. autistic spectrum disorder. Children with mild autism may not be recognised until after they start school or even into adolescence.
Finally parents sometimes request a paediatric referral because they are in direct dispute with either the school or the Education Department. Community paediatricians have to exercise caution before becoming involved in such disputes unless they genuinely feel that the child's needs are not being met and can act as advocates.

In conclusion, the paediatrician has an important role in assessing some children with educational and learning difficulties. However them are limitations as to what we can offer and sometimes the problem is best dealt with by consulting the child's school (with parents permission) or facilitating more constructive dialogue between parents and school.