memory’? A neuropsychological study.’ Journal of Verbal Learning and Verbal Behaviour. 22. 341-357.

22. Van Zomeren, A. H., Brouwer, W. H., Deelman, B. G. (1984) ‘Attentional deficits: the riddles of selectivity, speed and alertness.’ I n Brooks, N. (Ed.) Closed Head Injury: Psychological. Social and Family Consequences. Oxford: Oxford University Press.

23. Kleinpeter, U. (1975) ‘Social integration after brain t rauma during childhood.’ Acta Paedo- psychiatrica. 32, 68-75.

24. Heiskanen, O., Kaste, M. (1974) ‘Late,prognosis of severe brain injury in children. Develop- mental Medicine and Child Neurology, 16. 11-14.

25. Craft , A. W., Shaw, D. A,, Cartlidge, N. E. (1972) ‘Head injuries in children.’ Brirish Medical Journal, 3, 200-203.

26. Rutter, M. (1981) ‘Psychological sequelae of brain damage in children.’ American Journal of Psychiatry. 138, 1533-1544.

Chronic Illness and School Ac h i evern en t CHRONICALLY ill or handicapped children are vulnerable to a variety of psychosocial problems, including school failure. While prevalence estimates vary, evidence from several surveys places the incidence of school-related problems at about 30 to 40 per cent among children with chronic i~~nessesl-~.

Although most school problems occur among children with cerebrocortical impairment, those with other chronic and systemic illnesses also show a high frequency of learning disorders. RUTTER et a/.’ reported a prevalence rate of 14 per cent for severe reading problems among Isle of Wight children with chronic illness not directly involving the central nervous system, in contrast with a rate of 4 . 5 per cent among healthy controls. SEIDAL et aL4, surveying an urban population, arrived at an almost identical rate of 15 per cent. Clearly, chronically ill children are at risk for academic failure even in the absence of known cerebrocortical in- volvement. The following review describes studies relating to children with diabetes, haemophilia and renal failure, and cites investigations of several other chronic

27. Brown, G.,Chadwick, O.,Shaffer.D.,Rutter,M., Traub, M. (1981) ‘A prospective s tudy of children with head injuries: 111. Psychiatric sequelae.’ Psychological Medicine, 1 I , 63-78.

28. Arbus, L., Moron, P., Lazorthes, Y., Luxey, C. (1969) ‘SCquelles neuro-psychiques des traumatismes craniens de I’enfant.’ Neuro- chirurgie. 15, 27-34.

29. Flach. J. , Malmros, R. (1972) ‘A long-term follow-up study of children with severe head injury.’ Scandinavian Journal of Rehabilitation Medicine. 4, 9- 15.

30. Black, P., Blumer, D., Wellner, A. M., Shepard, R. H., Walker, A. E. (1981) ‘Head t rauma in children: neurological, behavioral and in- tellectual sequelae.’ I n Black, P. (Ed.) Brain Dysfunction in Children: Etiology, Diagnosis and Management. New York: Raven Press.

31. Rutter, M. (1982) ‘Developmental neuro- psychiatry: concepts, issues and prospects.’ Journal of Clinical Neurops.vcho1og.v. 4, 9 I - I 15.

disorders, to illustrate the extent of current knowledge and to highlight the range of questions that remain.

Early studies of diabetic children reported average or above-average in- telligence and school achievement5-’. WEIL and A C K 9 carried out intelligence, reading and arithmetic tests on 39 patients and 26 healthy siblings. While the diabetic children did not differ from their siblings on any of these measures, both groups had a high rate of academic difficulties. WEIL and ACK’S suggestion that family factors may induce academic problems both in patients and in their siblings has received indirect support but no clear confirmation from other sibling studies of diabetics’’, ’ I .

GATH et al. I * obtained teachers’ question- naire data for 70 diabetic children and matched classroom controls, and found that significantly more diabetics were ‘backward’ in reading. The groups were not matched for intelligence. Reading problems were not related to hypo- glycaemic attacks, but were related to clinical assessment of poor control. H o L M E s el a/.’3 found that attention, fine- motor performance and computational speed were impaired in diabetic under- graduates with abnormal glucose levels. In a current review, DELAMATER et a/.14 conclude that diabetic children’s cognitive and academic performance may be adversely affected and urge further investigation. 7.5

76

Haemophilia Investigators agree that the cognitive ability of haemophilic children is average” or above averagel6. 17, but that school achievement is often well below average. This picture of unfulfilled potential has prompted frequent comment’” l 9 but few empirical studies. DEITRICH’~ reported that for a group of haemophilic junior high school patients, mean achievement- test scores were two years below national norms. These children were especially low in arithmetic and spelling; reading levels were average. This achievement pattern is consistent with the self-reports of adult patients interviewed by GOLDY and KATZ” who recalled reading extensively as children but finding little t o interest or satisfy them in academic subjects. They remembered the elementary years as the hardest period in their school lives and emphasized the social problems caused by their avoidance of physical activities. OLCH” carried out cognitive and academic tests with 45 patients aged between two and 21. There were no controls. The children were in the high average range of intelligence and showed variability on specific cognitive tasks. School achieve- ment was below grade level by the late elementary years. The older children showed strength in reading but were low in arithmetic. Within the patient group there was no relationship between days ofschool missed and achievement scores, although the patients missed on average twice as much time as their classmates. ALLAIN” describes a boarding-school for haemo- philic children which provided medical attention, health-care instruction and a structured educational and social ex- perience. The children showed academic lags of between one and four years on admission, but made rapid gains and surpassed the national average in their school-leaving exams. Currently, school success may be facilitated by recent advances in home treatment which lead to reduced school absences and a less restrictive 1ifestye2’.

Renal failure Renal failure and its treatment with dialysis or transplantation put prolonged stress on patients and their families22 and can be expected to have pervasive effects

on the child’s mastery of development tasks. KAHN er evaluated 14 patients aged six to 17. Patients and their siblings both showed low achievement although intelli ence was average or above. KORSCH era/.’ followed 35 patients aged 18 months to 20 years who had had kidney transplants one to five years previously. Most of these patients were in age-appropriate school or work settings and were showing adequate behavioural as well as physical recovery. Achievement levels were not tested. BOURAS et al.” studied 24 children aged between five and 19 years who were on dialysis or who had received transplants. On average these children were two to three years below grade level. The authors suggest that lowered school performance is one facet of a general stress reaction that causes the children to pour all their available energy into coping with anxiety and pain. This interpretation is endorsed by TRAVISz6 who cites clinical reports of sudden increases in cognitive test scores following a successful transplant.

F

Other diseases Diabetes, haemophilia and renal failure are only a few of the medical conditions which have been associated with school problems. Juvenile rheumatoid arthritis2’ asthma2.*’ and congenital heart disease2’ may involve cognitive or achievement problems. Residual effects of disease and of treatment are being studied in long- surviving leukemic ~ h i l d r e n ~ ’ - ~ ~ and in children with controlled metabolic dis- orders such as g a l a c t o ~ a e m i a ~ ~ ’ ~ ~ , phenylke t~nur ia~’ and maple syrup urine disease36* ”.

Children with chromosomal anomalies may show problems in cognitive develop- ment and school achievement. While i t generally is assumed that the observed learning problems reflect CNS abnorm- alities, the structures involved remain obscure and the problems themselves require extensive study on the behavioural level. The same may be said of a variety of endocrine dysfunctions3’* 39. Examples of work in these areas are investigations of sex-chromosome anomalies4’* 4’ , Turner’s ~ y n d r o m e ~ * * ~ ~ , Noonan’s Prader-Willi ~ y n d r o m e ~ ~ . ~ ~ , hypopituitar-

hyper- and h y p o t h y r o i d i ~ r n ~ * - ~ ~ and adrenocortical insufficiencys2.

Research considerations Achievement problems have been in- dicated for several patient groups but not firmly established for any. Clearer information will depend on close attention to research design and especially to the use of appropriate controls and reliable, relevant measures. Control selection, recently discussed by BRESLAUS3 and WATSON and KENDALL54 may involve siblings, healthy non-siblings, other patient groups or national norms: each of these groups only partially illuminates the ill child’s functioning. Measures such as grade promotions, classroom marks, informal ratings and interview impressions are open to bias and are less reliable than norm-based tests or standardised question- n a i r e ~ ’ ~ . Other relevant techniques such as classroom observations6 have been neglected.

Factors mediating school problems have received very little attention. Days of school missed are greater for chronically il l children’ and are related to grades in normal children57 but have not been shown to relate to achievement within patient g r~ups ’~ . ’ ’ . The r d e played by type and amount of compensatory education during school absences is not known. Attitudes to handica ped children have been widely studied” 6o and the ill child’s acceptance by peers and teachers seems related to achievement6’ but observations of actual classroom behaviour are lacking. General stress responses may have pervasive effects” including withdrawal of energy from achievement demands63, a passive, non-achieving ~ e l f - c o n c e p t ~ ~ and a height- ening of minor specific learning disabilities. These possible mediators may best be explored through case study and self- report techniques. There have been no in- depth comparisons between children who achieve well in spite of their illness and those who fall behind, although this approach has been used effectively to study family f ~ n c t i o n i n g ~ ~ . Finally, as achieve- ment is a process rather than a single event, its concomitants should be revealed most clearly by longitudinal studiess4.

Clinical considerations Paediatric and educational psychologists have recently focused attention on the clinical importance of health factors in

a ~ h i e v e m e n t ~ ~ - ~ ~ . The relative merits of various interventions have not been determined, but guidelines of good clinical practice can be followed70. An ideal assessment probably should include a family interview, classroom observation and appraisal of mood and self-concept as well as psycho-educational testing. Inter- ventions might consist of individual programming, out-of-school tutoring, remedial help, classroom ‘survival skills’ training or therapy.

Much remains to be learned about the school problems of chronically ill children and about the services that will best prevent or remedy these problems. This important area of paediatric care deserves continued and increasingly sophisticated attention.

ANNE SCHLIEPER Department of Child Psychology. Children’s Hospital of Eastern Ontario, 410 Smyth, Ottawa, Ontario KIH 8LI.

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