42 - 31.17b Academic Problem

31.17b Academic Problem

placebo in patients prodromally symptomatic for psychosis. Am J Psychiatry. 2006;163:790–799. McGorry PD, Nelson B, Amminger GP, Bechdolf A, Francey SM, et al. Intervention in individuals at ultra-high risk for psychosis: A review and future directions. J Clin Psychiatry. 2009;70:1206–1212. McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first episode psychosis in a clinical sample with subthreshold symptoms. Arch Gen Psychiatry. 2002;59:921–928. Morrison A, French P, Walford L, Lewis SW, Kilcommons A, et al. Cognitive therapy for the prevention of psychosis in people at ultra-high risk: Randomised controlled trial. Br J Psychiatry. 2004;185:291–297. Phillips LJ, Nelson B, Yuen HP, Francey SM, Simmons M. Randomized controlled trial of interventions for young people at ultra-high risk of psychosis; study design and baseline characteristics. Aust N Z J Psychiatry. 2009;43:818–829. Preti A. Cella M. Randomized-controlled trails in people at ultra high risk of psychosis: A review of treatment effectiveness. Schizophr Res. 2010;123:30–36. Shrivastava A, McGorry P, Tsuang M, Woods SW, Cornblatt BA, et al. “Attenuated psychotic symptoms syndrome” as a risk syndrome of psychosis, diagnosis in DSM-V: The debate. Indian J Psychiatry. 2011;53:57–65. Yung AR, Woods SW, Ruhrmann S, Addington J, Schultze-Lutter F. Wither the attenuated psychosis syndrome? Schizophr Bull. 2012;38:1130–1134. Yung AR, Phillips JL, Nelson B, Francey S, Panyuen H, et al. Randomized controlled trial of interventions for young people at ultra-high risk for psychosis: 6-month analysis. J Clin Psychiatry. 2011;72:430–440. 31.17b Academic Problem Academic underachievement or failure is a major public health concern in youth, affecting between 10 percent and 20 percent of youth, with long-ranging associations with high-risk behaviors and poorer adjustment in early adulthood. The DSM-5 includes the category Academic or Educational Problem in the section “other conditions that may be a focus of clinical attention,” since school failure requires clinical intervention and influences a child’s level of overall functioning. An investigation of the effects of students’ perception of support from parents, teachers, and peers showed a correlation with adolescent academic achievement. That is, adolescents’ perception of support from their teachers and parents was directly related to their academic achievement, whereas perceived peer support was indirectly related to actual academic achievement, it contributed to an adolescent’s overall perception of support, which was correlated to achievement. Academic difficulties and externalizing behavior problems have been found to coexist at higher rates than would be expected by chance. This association has been found in both clinical and epidemiological samples. A longitudinal study of academic underachievement and behavior problems in school-aged children from 1st grade to 6th grade found that the combination of academic and behavior problems in the 1st grade predicted continued academic difficulties and behavioral problems 5 years later. This combination was more frequently seen in boys than in girls, beginning with the 1st grade. This is also true for children with reading difficulties, attentional problems, and behavioral problems.

Behavioral choices and life events can exacerbate academic problems in the absence of learning disorder and can interfere with lessening academic failures. For example, once a student perceives that he or she is falling behind academically, a greater temptation is to replace academic pursuits with other activities, such as drug use. A recent study assessed the level of, and deterioration in, academic achievement in relation to initiation of marijuana use among young teens. In a sample of rural teens, 36 percent of boys and 23 percent of girls initiated use of marijuana by the end of the 9th grade and that deteriorating academic performance was a significant predictor of initiating marijuana use. The hypothesis remaining to be tested is whether timely intervention to improve academic standing would lower the risk of beginning drug use. The DSM-5 Academic and Educational problem category is used when a child or adolescent is having significant academic difficulties that are not caused by a specific learning disorder or communication disorder or directly related to a psychiatric disorder. Nevertheless, intervention is necessary because the child’s achievement in school is significantly impaired, and this has an impact on the well-being of the child and may negatively influence concurrent psychiatric disorders. ETIOLOGY Many risk factors may play a role in academic underachievement or failure, including genetic factors, and developmental factors such as premature birth, as well as environmental factors such as level of maternal education. Very preterm children exhibit difficulties in working memory, which is a crucial ability and skill in learning new information and developing academic skills. Children and adolescents troubled by social isolation, identity issues, or extreme shyness may withdraw from full participation in academic activities. Academic problems may be the result of a confluence of multiple contributing factors and may occur in adolescents who were previously high academic achievers. School is the main social and educational venue for children and adolescents. Success and acceptance in the school setting depend on children’s physical, cognitive, social, and emotional adjustment. Children and adolescents’ competency in general coping with developmental tasks are reflected in their academic and social success in school. Anxiety can play a major role in interfering with children’s academic performance. Anxiety can hamper their ability to perform well on tests, to speak in public, and to ask questions when they do not understand something. Depressed youth also may withdraw from academic pursuits; they require specific interventions to improve their academic performance and to treat their depression. Youth consumed by family problems, such as financial troubles, marital discord in their parents, and mental illness in family members, may be distracted and unable to attend to academic tasks. Cultural and economic background can play a role in how well accepted a child feels in school and can affect the child’s academic achievement. Familial socioeconomic level, parental education, race, religion, and family functioning can influence a child’s sense of fitting in and can affect preparation to meet school demands.

Schools, teachers, and clinicians can share insights about how to foster productive and cooperative environments for all students in a classroom. Teachers’ expectations about their students’ performance influence these performances. Teachers serve as agents whose varying expectations can shape the differential development of students’ skills and abilities. Such conditioning early in school, especially when negative, can disturb academic performance. A teacher’s affective response to a child, therefore, can prompt the appearance of an academic problem. Most important is a teacher’s humane approach to students at all levels of education, including medical school. DIAGNOSIS The DSM-5 contains the following statement about academic or educational problem: This category can be used when an academic or educational problem is the focus of clinical attention or has an impact on the individual’s diagnosis, treatment, or prognosis. Problems to be considered include illiteracy or low-level literacy; lack of access to schooling owing to unavailability or unattainability; problems with academic performance (e.g., failing school examinations, receiving failing marks, or grades) or underachievement (below what would be expected given the individual’s intellectual capacity); discord with teachers, school staff, or other students; and any other problems related to education and/or literacy. A 15-year-old 10th grade boy, Greg, with a history of prematurity and ADHD, was called to a meeting with his parents and school counselor due to his 12-week report card reflecting failure in two classes, and Cs and Ds in the rest. Until the end of 9th grade, Greg was a B and C student, and he had been stabilized for many years on his treatment for ADHD. In the 10th grade, however, since the beginning of the semester, Greg had not been able to keep up. His counselor had also noticed insidiously increasing isolative behavior for the past 2 months; previous evaluation of ADHD had included a full intellectual evaluation, which showed his full-scale intelligence quotient (IQ) to be 100 and revealed no specific areas of academic weakness. Discussion with his parents and school counselor revealed that Greg had become upset when his parents had announced that they would be separating. Greg had not been doing his homework, and felt that school was no longer relevant for his social life or future. After getting behind in his classes in the first 6 weeks of the semester, Greg stopped trying, feeling overwhelmed and demoralized. It was decided that Greg would given accommodations from his teachers so that he could pass his classes without having to hand in every assignment that had long passed. Greg would receive daily tutoring, and was referred for a psychiatric evaluation to determine the severity of his mood disorder. TREATMENT

The initial step in determining a useful intervention for an academic problem is an evaluation of educational problems and psychosocial issues. Identifying and addressing family-, school-, and peer-related stressors are critical. An individualized evaluation may be indicated so that specific educational accommodations can be applied. In children with poor working memory, that is, a poor ability to store and retrieve information, learning and academic achievement is often impeded. Children with attention-deficit/hyperactivity disorder, as well as children born prematurely, often exhibit difficulties in working memory. In an effort to improve working memory in very preterm children, a computerized working memory training program (Cogmed) is being evaluated, consisting of 25 sessions of 35 minutes each, to be administered at home. Participants will undergo a baseline cognitive assessment, and then be randomized to either an adaptive or placebo version of Cogmed. Psychosocial intervention may be applied successfully for scholastic difficulties related to poor motivation, poor self-concept, and underachievement. In some cases, on the other hand, excessive hours spent in extracurricular activities, such as mandatory practices for multiple high school sports can result in compromised academic achievement. Early efforts to relieve academic problems are critical: Sustained problems in learning and school performance frequently are compounded and precipitate severe difficulties. Feelings of anger, frustration, shame, loss of self-respect, and helplessness— emotions that most often accompany school failures—damage self-esteem emotionally and cognitively, disabling future performance and clouding expectations for success. Generally, children with academic problems require either school-based intervention or individual attention. Tutoring on an individual and frequent basis is an effective technique for increasing academic production and is typically included in a comprehensive educational program. Tutoring has proved of value in preparing for standardized multiple choice examinations, such as the Scholastic Aptitude Test (SAT), as well as for increasing academic achievement in daily school subjects. Taking examinations, either school-based or standardized exams repetitively and using relaxation skills are techniques of great value in diminishing interference of test anxiety. REFERENCES Chen JJ. Relation of academic support from parents, teachers and peers to Hong Kong adolescents’ academic achievement: The mediating role of academic engagement. Genet Soc Gen Psychol Monogr. 2005;131:77. Henry KL, Smith EA, Caldwell LL. Deterioration of academic achievement and marijuana use onset among rural adolescents. Health Educ Res. 2007;22:372–384. Ingesson SG. Stability of IQ measures in teenagers and young adults with developmental dyslexia. Dyslexia. 2006;12:81. Ivanovic DM, Leiva BP, Perez HT, Olivares MG, Diaz NS, Urrutia MS, Almagia AF, Toro TD, Miller PT, Bosch EO, Larrain CG. Head size and intelligence, learning, nutritional status and brain development. Head, IQ, learning, nutrition and brain. Neuropsychologica. 2004;42:1118. Kempe C, Gustafson S, Samuelsson S. A longitudinal study of early reading difficulties and subsequent problem behaviors. Scand J Psychol. 2011;52:242–250. Knifsend CA, Graham S. Too much of a good thing? How breadth of extracurricular participation relates to school-related