A 7-year-old girl is brought to the office due to 6 months of increased school refusal since starting first grade. The patient has been prolonging her morning routine and argues when it is time to leave for school. The mother says, "She refuses to get out of the car when we arrive and starts crying about how the other kids laugh at her. I know she misses kindergarten because she keeps asking to go back." Her teacher reports that the patient gets frustrated easily, has difficulty following directions, and either makes up words rather than trying to sound them out or angrily refuses to read at all. The patient participates in dance class after school and plays with other kids in the neighborhood on the weekends. Growth curves, vital signs, and physical examination are normal. Which of the following is the most likely explanation for this patient's behavior?
This patient's behavioral difficulties at school coincident with starting first grade are most likely due to a specific learning disorder. A learning disorder is characterized by difficulty in acquiring and using core academic skills (eg, reading, writing, and/or mathematics), which typically manifests at school age but can worsen as academic expectations increase (eg, moving from kindergarten to first grade).
Reading disorders manifest with difficulty in fluency, comprehension, and/or accuracy. A common learning disorder is dyslexia, which involves a pattern of difficulty with word recognition, decoding (ie, producing sound associated with letters or words), or spelling, affecting both reading and writing. This can affect the ability to follow directions and be associated with behavioral problems and reluctance to engage in learning due to negative self-concept (eg, this patient's worry that her classmates will laugh at her). Manifestations may not be apparent in other, nonacademic social settings (eg, after-school dance classes, playing with children in the neighborhood).
Learning disorders are more common in children with social adversities and chronic medical, neurologic, or chromosomal conditions (eg, epilepsy, diabetes mellitus, fragile X syndrome). These disorders are commonly comorbid with other psychiatric disorders including attention deficit hyperactivity disorder (ADHD), depression, and disruptive behavior disorders. Standardized testing can confirm the diagnosis and lead to early intervention, which is essential for improving outcomes.
(Choice A) This patient's difficulty should not be dismissed as age-appropriate. Without further intervention, learning disorders can contribute to poor self-esteem, anxiety, depression, disruptive behavior, and academic difficulty.
(Choice B) ADHD is characterized by a pattern of inattention and/or hyperactivity-impulsivity across at least 2 settings. There is no indication that this child struggles in the home setting.
(Choice C) Intellectual disability includes deficits in intellectual as well as adaptive functioning (eg, dressing or feeding self, communicating, socializing), both of which this patient's mother does not describe.
(Choices D and E) School refusal can be seen in oppositional defiant disorder, which is characterized by a pervasive pattern of angry/irritable mood, defiance, and vindictiveness. Fear of being scrutinized by others can be seen in social anxiety disorder. However, this patient's defiance is limited to going to and participating at school; she has no other behavioral difficulties at home, is not vindictive, has no difficulty playing with neighborhood kids, and readily participates in dance class. Her argumentative behavior and school refusal are likely related to her struggle with reading and subsequent teasing.
Educational objective:
Learning disorders present in school-aged children as difficulties with academic skills (eg, reading, writing, and/or mathematics) and may result in anxiety, behavioral difficulties, and school refusal. Early detection and intervention are essential for improving outcomes.