School health and educational medicine

Childhood and adolescent development

Development in childhood and adolescence is a complex process that affects both the body and the psyche. 

Any child or adolescent may encounter difficulties.

It is not always easy to distinguish between, on the one hand, behaviours that reflect the minor ups and downs of the development process and, on the other, signs of mental distress with the potential to become a disorder. 

The concept of mental distress, which is somewhat poorly defined, is often discussed without clarifying what it means.

While mental distress may be expressed through a variety of behaviours and disorders, these cannot, in themselves, be considered as reliable measures of this distress. 

Distress may be silent, and there are some pupils whose behaviour may not suggest that they are in difficulty. 

To aid prevention, and to use the terminology of the World Health Organization (WHO), it is important to strengthen the psychosocial skills of children and adolescents so that they can understand and express when something is wrong. 

WHO defines psychosocial skills as “a person’s capacity to respond effectively to the challenges and stresses of daily life. It is a person’s ability to maintain a state of mental wellbeing by adopting appropriate and positive behaviour in their relationships with others, their own culture and their environment.”

It is important not just to help them identify the little signs but also to help them express them. 

The worse a young person feels, the less likely they are to seek help.

Any decline in academic performance should be taken as a warning sign, 

but having said that, good performance is not necessarily a guarantee of mental wellbeing.

Children

From nursery school age, children gradually have the capacity to take on new interests and new academic and extra-curricular knowledge, and for intellectual, sporting and cultural activity. 

They put effort into early academic learning. They form new and different relationships, including those beyond their family circle, with opportunities for new encounters (teachers, friends, etc.).

During childhood, signs of mental distress may manifest themselves loudly (antagonistic behaviour, need for confrontation, return of impulsive behaviour in the pre-pubescent years) or more silently (withdrawal, inhibition, etc.). 

School absenteeism is, however, something that should be taken as a warning sign. 

Nonetheless, this is first and foremost a period during which it is important to take account of signs that do not cause problems for the family or the school and may arise in the child’s relationships, or in their intellectual and academic knowledge.

Adolescents

Adolescents go through a period of physical and mental transformations during which their relationship to themselves, to others and to the world is changing. 

They need to adapt to these changes. Such adaptations are part of the process of adolescence and are traditionally described using the term “adolescent crisis”.

There are, however, some adolescents for whom this period leads to distress. Distress is a subjective concept that may be expressed through a variety of behaviours and manifestations.

The warning signs are many and non-specific: the same sign can signify a hazard of development that is not serious (“adolescent crisis”), the expression of a vulnerability liable to lead to the development of a disorder, or the expression of a disorder that already exists.
 

Children and adolescents experiencing learning difficulties
 

1. Description

Academic learning sits at the crossroads of a child’s cognitive and psycho-emotional development.

Consequently, when pupils experience difficulties at school, it is important to combine these two approaches to understand the nature of their difficulties. A distinction is drawn between learning difficulties associated with a lack of mental availability due to a psychopathological condition (depression, anxiety, etc.) and specific learning difficulties associated with neurodevelopmental disorders (difficulties with language (speaking or writing), difficulties with motor skills, difficulties with mathematics and attention deficit disorder, with or without hyperactivity).

2. Gathering information

Exploratory questions need to be asked to clarify the nature of the learning difficulties:

●● Have these difficulties at school always been present or have they arisen recently?

●● Are the difficulties experienced in all areas or in specific areas (for example in learning to read or write, with arithmetic, geometry, etc.)?

●● Are the academic difficulties part of a picture that also includes other signs (difficulties concentrating, behavioural issues, difficulties in relationships with other children, strange behaviour)?

●● Have the difficulties been observed by all of the child’s teachers?

●● Are the learning difficulties evident outside the school setting?

The teaching team may be able to refine the picture:

●● What are the child’s relationships with the teacher and their peer group like?

●● How does the child behave in learning situations and outside learning situations (during break, in the school canteen, etc.)?

●● How do the parents react to the child’s difficulties?

Where a situation is developing despite the application of simple reassurance and support measures, the teacher meets the parents to inform them, tactfully and sensitively, of the school’s concerns, bearing in mind the distress of the child or adolescent and the parents in these situations. The teacher asks the parents what they think and how they view their child’s difficulties.

The teacher proposes a meeting with the school psychologist and school doctor to further assess the child’s difficulties. 

The school doctor will offer their insight into both the impact of any health problems and the cognitive and emotional aspects.

3. A case-by-case approach

A child’s psychological and intellectual functioning cannot be reduced to cognitive aspects alone: self-esteem, self-confidence and anxiety have a considerable influence on their capacity to learn. 

In addition, a cognitive and/or instrumental disorder may lead to the child suffering a major blow to their perception, increasing their difficulties.

An assessment by the school psychologist and a consultation with the school doctor are therefore very important because they offer an opportunity to explore the perceptions that the young person has of themselves, their self-confidence, their enjoyment of learning, their experience of failure, their experience of incompetence, their sense of disappointing their teacher and parents, their anxiety about assessments and their emotional reactions (tears, sadness, indifference, etc.). 

It is also useful to assess the impact of difficulties in the child’s relationships with their parents and with their peers.

It is also important to work with the pupil and teachers to draw up a list of life events, particularly in situations where there is a decline in performance:

●● External difficulties experienced by the child: family separations, changes in lifestyle, etc. 

●● Difficulties experienced at school: stigmatisation, bullying, etc.;

●● Serious incidents that amount to trauma: neglect, lack of parenting, abuse.

In cases of learning difficulties, the school doctor carries out a medical check-up. The doctor assesses the child’s difficulties and may offer a consultation or a specialist check-up to evaluate these difficulties and whether they amount to specific learning difficulties. 

The doctor can refer the child to appropriate support and ensure that they are monitored in school.

With the agreement of the parents, the school doctor can contact the family doctor to support the care plan and, where appropriate, can refer the child to a specialist local service (Medical Psychology Centre, Day Therapy Activities Centre, and others).

It is essential to consider a clear assessment of these signs and vital to change some practices. 

Thus:

●● A child can be directly referred to a speech therapist by a teacher who identifies their difficulties in the classroom, although this referral is part of a doctor’s remit since it requires a medical prescription to be issued in advance. In the majority of cases, it is general practitioners who issue the prescription and receive the report. 

The school doctor should be informed of this, which is the case for each request to put in place educational accommodations as part of an Individual Care Plan (PAI) in Monaco*.

●● Referral to medical psychology or learning difficulty referral centres. This must be reserved for complex cases and be a decision for the doctor. It is not something which is done as a first step.

●● Cooperation between all members of the educational team should ensure that something which often turns out to be a difficulty is not referred to as a “disorder”.

●● Depending on the assessment, a PAI may be proposed.

●● Preparation of a submission to the Medical Educational Committee (CMP) should only be considered in certain situations where a multidisciplinary assessment has been carried out. It should not be proposed as a first step.

* In France, the Personal Support Plan (PAP) enables educational accommodations to be put in place (see Official Bulletin No. 5, dated 29 January 2015).

By Dr Jeanne-Marie BERMON, school doctor at the Medical Inspectorate for Schools