Attention, Learning, and School Problems

Introduction

School problems are a common presentation in pediatric primary care and a frequent topic on the MCCQE1. The Medical Council of Canada (MCC) expects candidates to assess a child presenting with school difficulties, considering biological, psychological, and social factors.

This topic encompasses a broad differential diagnosis, ranging from Attention-Deficit/Hyperactivity Disorder (ADHD) and Specific Learning Disorders (SLD) to sensory deficits, intellectual disabilities, and psychosocial stressors.

Canadian Epidemiology

Understanding the prevalence within the Canadian context is vital for the MCCQE1.

• ADHD: Affects approximately 5-9% of school-aged children in Canada. It is the most common neurodevelopmental disorder.
• Learning Disabilities: Affect approximately 3-10% of children.
• Gender: ADHD is diagnosed more frequently in males (3:1 ratio), though females are often underdiagnosed as they more frequently present with the inattentive subtype rather than disruptive behavior.

Etiology and Pathophysiology

The etiology is generally multifactorial, following the Biopsychosocial Model:

1. Biological: Genetic heritability (high in ADHD ~75%), prematurity, fetal alcohol spectrum disorder (FASD), lead exposure.
2. Psychological: Anxiety, depression, low self-esteem.
3. Social: Poverty, family conflict, bullying, lack of educational support.

Clinical Presentation and Differential Diagnosis

Children usually present due to concerns from parents or teachers regarding:

• Declining grades
• Disruptive behavior
• Social isolation
• School refusal

Differential Diagnosis Checklist

When approaching a “School Problem” case on the MCCQE1, consider the following broad categories:

Assessment Strategy

A structured approach is required. The CADDRA (Canadian ADHD Resource Alliance) guidelines recommend a comprehensive assessment.

Attention-Deficit/Hyperactivity Disorder (ADHD)

ADHD is a chronic condition marked by persistent inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

DSM-5 Criteria Summary

• Symptoms: $\ge$ 6 symptoms of Inattention AND/OR $\ge$ 6 symptoms of Hyperactivity/Impulsivity (for children <17 years).
• Duration: $\ge$ 6 months.
• Onset: Symptoms present prior to age 12.
• Settings: Present in $\ge$ 2 settings (Home, School, Friends).
• Impact: Clear evidence of interference with social, academic, or occupational functioning.

Management of ADHD in Canada

Management is multimodal. According to CADDRA Guidelines:

Common Side Effects of Stimulants

• Appetite suppression (monitor weight/height)
• Sleep disturbance (insomnia)
• Headache/Abdominal pain
• Mild increase in HR and BP (monitor vitals)

Specific Learning Disorders (SLD)

Defined as difficulties learning and using academic skills. The affected academic skills are substantially below those expected for the individual’s chronological age and cause significant interference.

1. With impairment in reading (Dyslexia): Most common. Issues with word reading accuracy, reading rate, or fluency.
2. With impairment in written expression (Dysgraphia): Spelling accuracy, grammar, clarity or organization.
3. With impairment in mathematics (Dyscalculia): Number sense, memorization of arithmetic facts, calculation.

Management:

• Not treated with medication.
• Requires specialized instruction and accommodations (IEP).

Canadian Guidelines & Resources

Familiarity with these organizations is high-yield for MCCQE1:

1. CADDRA (Canadian ADHD Resource Alliance): Produces the Canadian ADHD Practice Guidelines.
2. CPS (Canadian Paediatric Society): Guidelines on school problems and developmental assessment.
3. CanMEDS Framework: Emphasizes the physician’s role in coordinating care between health and education systems.

Key Points to Remember for MCCQE1

• Rule out sensory deficits: Vision and hearing tests are mandatory initial investigations for school problems.
• Two Settings: ADHD symptoms must be present in at least two settings (e.g., home and school).
• Collateral History: You cannot diagnose ADHD or school problems based solely on the patient’s report or parent’s report; you need teacher data (e.g., SNAP-IV).
• First-line ADHD Tx: Long-acting stimulants for school-aged children; Behavioural therapy for preschoolers (<6).
• Comorbidities: Screen for Anxiety, Depression, and ODD in every child with ADHD.
• Medical Mimics: Absence seizures (staring spells) and Sleep Apnea (inattention due to fatigue).

Sample Question

Clinical Scenario

A 7-year-old male is brought to his family physician by his parents due to disruptive behavior at school. The teacher reports that he constantly fidgets, leaves his seat during lessons, interrupts others, and has difficulty waiting his turn. These behaviors have been present since kindergarten. His parents note similar behaviors at home; he is “driven by a motor” and cannot play quietly. He has no significant past medical history. Physical examination, including vision and hearing screening, is unremarkable. The parents and teacher completed SNAP-IV forms, which show scores well above the cutoff for hyperactivity and impulsivity, with moderate scores for inattention.

Which one of the following is the most appropriate initial pharmacological management for this patient?

Options

• A. Clonidine immediate-release
• B. Fluoxetine
• C. Long-acting Methylphenidate
• D. Haloperidol
• E. Omega-3 fatty acid supplementation

Explanation

The correct answer is:

• C. Long-acting Methylphenidate

Explanation: This patient presents with classic symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD), predominantly hyperactive/impulsive presentation. The symptoms are present in two settings (home and school), have persisted for more than 6 months, and interfere with functioning.

• Option C is correct: According to CADDRA guidelines, long-acting psychostimulants (Methylphenidate or Amphetamines) are the first-line pharmacological treatment for ADHD in school-aged children ($\ge$ 6 years). Long-acting formulations are preferred over short-acting ones to provide symptom control throughout the school day, improve adherence, and reduce the “rebound” effect and stigma associated with taking medication at school.
• Option A is incorrect: Clonidine (an alpha-2 agonist) is a third-line agent or adjunctive treatment, often used for sleep or aggression, but not first-line for core ADHD symptoms.
• Option B is incorrect: Fluoxetine is an SSRI used for anxiety or depression. While anxiety can be comorbid, the primary presentation here is ADHD.
• Option D is incorrect: Antipsychotics like Haloperidol are not indicated for uncomplicated ADHD and carry significant side effect risks.
• Option E is incorrect: While some parents may use Omega-3s, the evidence is weak, and they are not considered first-line monotherapy for ADHD in Canadian guidelines.

References

1. Canadian ADHD Resource Alliance (CADDRA). (2020). Canadian ADHD Practice Guidelines, 4.1 Edition. Toronto, ON: CADDRA.
2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
3. Canadian Paediatric Society. (2018). Mental Health and Developmental Paediatrics.
4. Medical Council of Canada. (2023). MCCQE Part I Objectives: School Difficulties.