Learning and behavior problems in school age children

Many of the referrals that our office receives are for school age children and issues related to challenges that they are facing at school. Due to the significant number of referrals for this clinic, it is difficult to see these children in a timely manner. The wait time is often six to twelve months. It is also important to note that with many of these referrals, unless the child has a contributing medical or developmental disorder, there may not be a great deal that we can help with. In such cases most of our assistance is with giving the family information and supporting them to find the help their child most needs.

For this reason we prepared the following document. Please have a look at the information below, and hopefully you will find information that helps you in the meantime.

Why have you been referred to a pediatrician? This is an important question and often neither the family nor the teachers have a clear answer. Sometimes it may be useful in order to exclude medical conditions, or to verify a diagnosis. If your teachers have requested an assessment, make sure they are specific and you know what you expect to accomplish with an appointment here. It is very unfortunate when families come in with unrealistic expectations, and have inappropriately delayed accessing other important resources.

Could your child have a learning disability? This is often a question unanswered, and as physicians we are not able to properly test for most learning disabilities. Proper assessment usually requires testing by an educational psychologist, or a teacher with special training. We cannot properly test children for learning disabilities as this is outside of our scope of practice.

There are different ways schools can test children. Report cards give us a sense of how the child is working compared to the expectations of their grade. Schools often do testing called “Woodcock-Johnson”, or psychometric testing, which also determines where your child is functioning in comparison to their grade. This is a test of achievement rather than true potential. These tests do not tell us why they are struggling; it only helps us to determine the degree.

The most important and useful testing for a child having problems is called psychoeducational testing. In this case, the testing is done by a trained psychologist. This testing can be done at any age, and is most useful when the child is in grade 2-3. The results are often very helpful,allowing us to determine the differences between a child’s performance and their potential, and offering direction for how to manage their areas of weakness. In many cases it tells you how your child will best learn, whichis useful information for the teachers and parents.

In most cases where a child is struggling at school, it is important to have some form of educational testing done. Parents may need to petition their school for testing.It is often helpful to be specific asking for the type of testing most appropriate (as discussed above).

In some cases you may want to have testing done privately. Here in Nanaimo, there are a number of registered psychologists that do formal psychoeducational testing. This testing can be expensive, in the range of $1500-$3000, depending on what actual testing is done. Many extended health benefit plans will cover this.

Are there other problems affecting his/her learning?It is important that your child’s hearing and vision have been recently tested, ideally within the past year. These are very treatable problems that need to be addressed. You can have your hearing tested properly through public health unit (25-755-3342), and there are many optometrists in town that do screening tests with children (Vision Arts). There are subsidies for these examinations as well, and they do not require a referral.

Children with normal hearing can still have an auditory processing disorder. Much like attention deficit, this is a condition where the individual has difficulty “capturing” information that he or she is told, even though their hearing is normal. It is often worse in noisy environments or where they struggle with competing voices and other sounds. Such children seem inattentive, have difficulty following instructions and are easily distracted. It can be important to consider this as it often presents like ADHD, but helping the children involves a very different approach. Testing for this condition is quite specialized, and can be done by some private psychologists. It is also offered by McNeil audiology in Victoria. You can ask your family physician for more information, but they do not require a referral.

Many children today have problems with lack of sleep and poor sleep hygiene. Lack of proper sleep causes daytime symptoms including poor attention and focus, distractible behavior, and difficulties with learning. Consider doing a diary of your child’s sleep pattern, and look at whether your child has specific symptoms that could relate to poor sleep. On our website we have a useful screening questionnaire you can read. A good sleep routine is important for a child’s ability to learn effectively, and instituting a good schedule is often the first step. This might include: avoiding late night on weekends, ensure your child is up at a regular hour every day, and ensuring that your child has regular physical activity each day.

Although less common, children can also develop brief blanking events which are actually small seizures (“Petit mal”), and these can seem like frequent daydreaming. Often these children are in trouble for not paying attention, and seem to not be listening. They can struggle with school as a result. Testing for this requires an EEG study, booked through the hospital. If you feel your child may be at risk for seizures speak to your family physician about further testing.

Does your child have significant emotional problems? If so, it is important to have your child seen by a mental health worker or counselor. Most schools have support workers that can see your child. The Child and Youth Mental Health team (there is one in Nanaimo, and another in Parksville) is also accessible for families, and you can contact them directly. The “intake workers” can also direct you to appropriate services for your needs. Here in Nanaimo there are manycommunity resources available, many of which are listed in the following appendix.

Sometimes issues with violent behavior, aggression and conflict at home can become the major issue. In these cases, waiting for a developmental pediatric assessment which might be six months or more may be inappropriate. It might be necessary to decompress such conflicts through finding help elsewhere: with family, friends, and other support groups to which you might belong. We also have a crisis response team that can be contacted anytime if you feel unable to manage.

Are all of these challenges creating significant parenting difficulties? In many cases, children with special challenges of their own can make parenting very difficult. How we respond to different behaviors can contribute to whether situations get worse or get better. In these cases it can be too much to rely on our normal parenting instincts.

There are many resources to help parents deal with these challenges. One of the most popular programs is the “triple P.” parenting program. This is offered through many of the community resources listed above. You can also find their website at:

Everyone thinks your child has ADHD, but you are not convinced. What else could be causing your child’s difficulties? Many of the topics above review these other associated areas of concern. Keep in mind that children can have ADHD as well as other developmental challenges, so they are not exclusive of one another. Specific ideas a parent might want to consider while awaiting a pediatric consultation might include:

  1. Any visual or hearing impairment.
  2. Problems with auditory processing
  3. Learning disabilities ( as discussed above)
  4. A disorder of sleep
  5. Emotional/ mooddisorders
  6. Anxiety disorder

The first step for testing for ADHD is to score the child’s symptoms with a specially designed questionnaire. We use the SNAP rating scale. You can print this from our web site (found on the page entitled forms). It is usually necessary to have both a parent and a teacher complete the form, to show that the symptoms are not specific to one place. These questions help us to define a child who is struggling.

Does every child with ADHD diagnosis need medications? No! ADHD is treated by behavioral management and medications. Everyone benefits from the behavioral management (even parents). Website like ours, CADDRA, and Kelty (listed above) all have good information for this.

Even if your child has significant ADHD symptoms, he or she may not need medications. This is where we look at two main questions:

  1. Is the child showing behavior problems directly a result of his/her ADHD?
  2. Potential vs achievement: If there is no real difference between what your child is capable of doing (potential) and what they doing (achievement), there is likely nothing to treat. The greater the difference, the more important it is to be treating. How do we determine if there is a difference? Ideally by psychoeducational testing reports, but if thisis not available then we have to use the history, reports cards, etc.

Any decision to use medications is made with the family input. If you do take medications, it is usually started as a trial, and with lower doses. You can learn about different medications through the various websites as described above.

We hope that this worksheet is useful, and it might help you to prepare for your pediatric assessment. It may even eliminate the need for this assessment. There are often many different issues that affect a child’s success at school. Our goal is to work together with your family and the school to optimize your child’s learning and developmental potentials.

Community Resources:

Child and Youth Mental Health, on Albert Street, for families with children dealing with significant emotional distress. This department has qualified counselors and psychologists available, and can be self referred. The intake workers can also direct families to other community resources when appropriate.

Child Development Center, on Nelson Street, has many programs for preschool children with developmental challenges. It also has family support workers and an excellent library with resources for families. In addition, they organize parenting courses regularly.

Nanaimo Family Life Association, on Townsite Road, offers many excellent programs including counseling services and workshops for families. They have many volunteer counselors as well, for youth and families facing challenges. 250-754-3331

NARSF, on Wallace Street, is a multiservice agency established by the health authority and Ministry of Child and Family Development. Some of the programs include managing with teens, dealing with eating disorders, and family therapy. Their website is also quite helpful at

Rainbows Nanaimo, is a support group for children and families who have suffered loss, whether by death or divorce or other reasons. They have helpful programs for kids ages six and up. 250-751-7888

There are also many good resources available on the Internet:

Kelty Mental Health: this organization operates through the children’s hospital. It publishes a very helpful website for children with mental health challenges (also for ADHD), which has many articles and resources for both parents and teachers. This can be found at:

CADDRA: There is a Canadian organization for research and treatment of ADHD. Their website offers many helpful pages on management including different medications:

BCCH Family Support & Resource Centre: This is a consumer health library/bookstore set up for families throughout BC. It has a great web site that allows you to find books, DVD’s, etc and order them free to borrow, with free mailing service as well.