Review article

Archives of Disease in Childhood, 1974, 49, 249.

Emotional disorder and educationalunderachievement*

MICHAEL RUTTERFrom the Institute of Psychiatry, de Crespigny Park, Denmark Hill, London

Of all the problems seen in school-aged children,learning disorders are among the most common.These disorders are first the concern of the schoolteacher and school psychologist, but many cases getreferred to medical specialists of various kinds.Paediatric referral may be initiated because quasi-neurological syndromes such as 'developmentaldyslexia' (Critchley, 1970; Naidoo, 1972) or'dyscalculia' (Cohen, 1961; Slade and Russell, 1971)are suspected; or because the learning difficulty isassociated with cerebral palsy, epilepsy, or someother overt neurological condition (Rutter, Graham,and Yule, 1970a); or because it seems that thelearning disorder had its origin in a developmentalspeech delay (Ingram, 1969; Rutter and Martin,1972). The importance and significance of neuro-logical and developmental factors in learningdisorders have been considered elsewhere withrespect to reading (Rutter and Yule, 1973).However, children with educational under-

achievement commonly suffer from the additionalhandicap of emotional or behavioural disorders.The fact of this association has long been noted, butits meaning remains poorly understood. There hasbeen controversy over the extent to which emotionaldisturbance causes learning difficulties, the extent towhich learning disorders result in secondarymaladjustment, and the extent to which both thelearning and emotional disorders stem from somecommon causal factor. Nevertheless, it is essentialto understand the mechanisms involved in theassociation if the appropriate remedial or therapeuticaction is to be taken. This paper reviews what isknown on this topic.

Definition and measurement of educationalunderachievement

Before discussing research findings on theassociations between underachievement and

*Paper originally read at a section of paediatrics symposium on'The Underachieving Intelligent Child', at the Royal Society ofMedicine, 23 March 1973.

emotional disorder it is necessary to consider first;the definition, measurement, and classification ofeducational underachievement. Obviously, under-achievement is not something that is simply presentor absent. It is a matter of degree. Very fewchildren will perform exactly at the level expected.Most will have scholastic achievements somewhatbelow or somewhat above expectation, and it ismainly when achievements are a lot belowexpectation that there has to be concern. Thequestions then are: what should be the expectedlevel of attainment for any child?, and how do youdecide what is a lot below that ? Essentially theseare statistical questions which require statisticalsolutions once the psychological and educationalconcepts have been defined. The issues arecomplex and have been considered in detailelsewhere (Berger, Yule, and Rutter, 1974; Rutterand Yule, 1973, 1974; Yule et al., 1974), so that onlya briefsummary ofthe main points will be given here.The simplest approach to defining underachieve-

ment is to compare a child's attainment with theaverage for children of the same age. That providessome guide to a child's scholastic progress but it doesnot give a measure of what level of attainment shouldbe 'expected' because it fails to take IQ or mental ageinto account. It is appropriate to expect a child ofhigh IQ to have above-average attainments, just as achild of low IQ may be expected to have below-average attainments. That follows because thereis a substantial positive correlation betweenintelligence and educational attainment. For a longtime it has been customary to take intelligence intoaccount by comparing educational age with mentalage. Thus, if a 10-year-old child with a mental ageof 13 years had a reading age of 12 years, he might besaid to be 1-year retarded in reading. While thatsounds reasonable and while such an approach hasbeen widely followed, it is in fact based on amisconception and gives rise to serious error. Inreality, the child mentioned should not be expectedto have a reading age of 13 years. Rather, the

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expectation should be for a reading age of about 12years-exactly what he had (Rutter and Yule, 1973;Yule et al., 1974). The explanation for thisapparent paradox lies in the 'regression effect'. Ifthe correlation between reading and intelligencewere unity (i.e. +1 0), then, of course, mental ageand reading age should run exactly in parallel. Butwhere the correlation falls short of unity (and thatbetween IQ and reading is about +0 6), then thetwo will differ. A highly intelligent child will haveabove-average attainments but his attainments willgenerally not be as high as his intelligence. Con-versely, a retarded child will have below averageattainments but his attainments will generally beabove his intelligence. In short, in each case thereis a 'regression to the mean' so that the attainmentsare nearer average than is the intelligence. This hasnothing to do with the qualities of intelligence or ofreading, but is simply a consequence of the fact thatthe correlation between intelligence and scholasticattainments is less than unity (Thorndike, 1963).The conclusion that reading age and mental age

should not run exactly in parallel follows inexorablyfrom the correlation between reading and IQ (or forthat matter, between any attainment and IQ) andfrom the fact that overachievement occurs withapproximately the same frequency as under-achievement. But psychologists and teachers alikehave been astonishingly reluctant to accept this fact.Nevertheless, it is a fact in practice as well as intheory as we have now confirmed in 5 separatesurveys (Yule et al., 1974). The unavoidableconclusion is that studies based on either theachievement ratio or on discrepancies betweenachievement age and mental age are invalid andmisleading. Unfortunately, this rules out mostresearch in this area (Rutter and Yule, 1973). Theappropriate procedure-and the only one that avoidsthis problem-is the use of some kind of regressionequation in which achievement is predicted on thebasis of the observed correlations betweeneducational attainment, age, and IQ in the generalpopulation. The procedure is described in moredetail elsewhere (Yule, 1967; Rutter, Tizard, andWhitmore, 1970b).The next question is how far below expectation

must a child be before there should be concern aboutunderachievement ? Again statistical consider-ations are relevant. The same regression procedureprovides an estimate of the expected frequency ofdifferent degrees of underachievement, so allowingunderachievement to be defined in terms of a degreeof educational failure which is relatively infrequentin the normal population. In this connexion itshould be noted that the findings of our epidemio-

logical studies show that extreme degrees ofunderachievement in reading occur at above theexpected level as a result of a 'hump' at the bottomof the curve of distribution of achievement inreading (Rutter and Yule, 1973; Yule et al., 1974).However, considerations of frequency are notenough to pick the most appropriate cut-off point.Prognosis is also important. There must be mostconcern over the child who is unlikely to 'catch up'with his contemporaries. So far as reading isconcerned, follow-up studies (Yule, 1973; Rutterand Yule, 1974) show that there is a very pooroutlook for children whose reading is more than 2standard errors of prediction below expectation (thiscut-off point picks up between 3 and 10% of thegeneral population). Other educational consider-ations are also important. The degree to which achild suffers from underachievement will depend notonly on the degree of underachievement and thecourse of development, but also on educationalpractice. The underachieving child is more likelyto suffer from his disability in schools whereeducational failure results in segregation andopprobrium. Also the extent to which he is at aneducational disadvantage will depend on theattainments of other children in his class, the degreeof streaming, and the extent to which teaching isindividualized rather than group based. These andother considerations will necessarily influencedecisions on when and how to provide special helpfor the underachieving child (of good intelligence orotherwise).

Classification of underachievementHaving defined underachievement, the next issue

is how to classify the different varieties of under-achievement. Three distinctions have to be made.First, underachievement may be classified accordingto the scholastic skill involved. Most attention inpublished reports has been paid to reading andspelling, two skills which are very closely associated.However, there has also been a concern withmathematical disabilities and, to a lesser extent, withother subjects. Surprisingly little attention hasbeen paid to the similarities and differences betweenunderachievement in different scholastic subjects.The second distinction is between general

backwardness (i.e. low achievement in relation to theaverage for that age, but without taking IQ intoaccount) and specific retardation (i.e. achievementwhich is low after taking both age and IQ intoaccount). In the first case there tends to be low IQand generally low attainments, whereas in the secondthere is a specific educational disability which is notexplicable in terms of low intelligence. The

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Emotional disorder and educational underachievementdistinction has been most studied with respect toreading, and has proved to be of crucial importance.Specific reading retardation differs markedly fromgeneral reading backwardness in terms of sex

distribution, neurological correlates, developmentalabnormalities, association with other educationalproblems, and prognosis (Rutter and Yule, 1973,1974; Yule, 1973). Specific reading retardation isstrongly associated with spelling difficulties butattainment in other school subjects is less affected.Underachievement in mathematics and in otheraspects of schoolwork has been less investigated andit is not known whether the differentiation betweengeneral backwardness and specific retardationapplies in the same way.

The third distinction is that between a failure toacquire educational skills and a loss of these skills.Specific reading retardation and general readingbackwardness both apply to the former situation.The children have had difficulties in learning to readfrom the very outset. However, there is also thesituation in which a child having got well launchedin his school work and having mastered the basicskills, later runs into educational difficulties and fallsincreasingly behind in his work. Sometimes theselater difficulties involve specific school subjects andsometimes they involve school work generally, or

even all learning. Either way the disorder is of a

quite different type to the variety in which there is a

failure to acquire the initial skills.

'Dyslexia'. In discussing the classification ofunderachievement, no mention has been made of'dyslexia'. That is deliberate, as there is so far no

evidence for the existence of such a unitarysyndrome, at least as usually defined (Rutter, 1969;Reid, 1968; Rutter and Yule, 1974). Of course,

the concept of specific reading retardation has muchin common with 'dyslexia', in that both refer to a

specific educational disability and in that there isgood evidence for linking reading retardation withdevelopmental delays in speech, language,sequencing, and right-left differentiation, as

postulated for 'dyslexia'. However, the featuressaid to characterize 'dyslexia' do not cluster togetheras they should if there were a single 'dyslexic'syndrome (Rutter, 1969; Naidoo, 1972), and there isevidence that psychological, social, and educationalfactors interact with biological influences to producespecific reading retardation (Rutter and Yule, 1973,1974). There may be a unitary condition of'dyslexia', but there are no means at present ofdiagnosing it and the available evidence is con-

sistently against the concept of a single neurologicalsyndrome. It deserves further study, but at the

moment there are no good grounds for separating offa special syndrome under the heading of 'dyslexia'.

Association of specific reading retardationwith emotional or behavioural disorderWith these basic distinctions in mind, we need

now to turn to the association with emotional orbehavioural disorders. There have been numerousclinic reports on this matter but these are potentiallymisleading because of selective biases in referralpolicies to clinics. Instead, epidemiological studiesmust be considered. The Isle of Wight study(Rutter et al., 1970b) showed that both specificreading retardation and general reading backward-ness were strongly associated with antisocial orconduct problems. Of the children with specificreading retardation, 25% showed antisocialbehaviour as measured on a questionnaire completedby teachers-a rate several times that in thepopulation at large. It was striking that whereasthere was some tendency to an increased rate ofemotional disturbance in reading-retarded children,the strongest association was with antisocialbehaviour. As reading difficulties and antisocialbehaviour are both relatively common problems inchildhood, some overlap would be expected purelyon a chance basis. However, the strength of theassociation was many times that which would resultfrom chance. The association was a strong andmeaningful one. The findings from otherepidemiological studies are similar (Sturge, 1972;Berger et al., 1974; Sampson, 1966; Clark, 1970;Davie, Butler, and Goldstein, 1972).

Douglas's National Survey (Douglas, Ross, andSimpson, 1968) has analysed the association in adifferent way by looking at the average attainmentof children showing emotional or behaviouraldifficulties. The youngsters showing persistentaggression or conduct disorders were found to havelow achievement in all subjects-includingmathematics as well as reading. Emotionaldifficulties were associated with low intelligence andlow attainment and were not specifically associatedwith underachievement.

In short, though the evidence is strongest in thecase of reading difficulties, it appears that under-achievement in all subjects is associated withbehavioural disturbance. There is some associationwith emotional difficulties but the strongerassociation is with disorders of conduct. Theassociation appears early in the child's school careerand persists throughout it.Most studies have not made the distinction

between failure to acquire educational skills and thelater loss of these skills, so that it is not possible to

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Michael Rutterdetermine whether the associations differ in the twocases. So far as can be determined, the associationwith conduct disorder applies particularly to thechildren who fail to acquire educational skills. Lessis known about children who develop under-achievement only later in their schooling, butclinical experience suggests that the picture is ratherdifferent (de Hirsch, 1963).

Mechanisms. Accepting the existence of anassociation between underachievement and conductdisorders, the next issue concerns the mechanismsunderlying the association. In this connexion, thefirst question must be directed to the problem of thedirection of the association. Does underachieve-ment lead to conduct disorder, does conductdisorder lead to underachievement, or are both dueto a common aetiology ? This is a complex problemto which no simple and straightforward answer is yetavailable. Furthermore, the answer may not be thesame for different varieties of underachievement.

Let us start with specific reading retardation.Could this develop as the result of a neurosis or some

other form of emotional disturbance ? It hascertainly been claimed that retardation in readingmay be due to neurotic conflict or to an 'emotionalblock' (Blau, 1946; Pond, 1967). However, thisview is based on uncontrolled studies of clinicpopulations (e.g. Miller and Westman, 1964;Silverman, Fite, and Mosher, 1959; Sperry et al.,1958) or on highly speculative psychoanalyticinterpretations (Anthony, 1961). Satisfactoryevidence in support is lacking. Contrariwise, thereis evidence against the view that specific readingretardation is due to neurosis. In the first place, theassociation is not particularly with emotionaldisturbance; it is with disorders of conduct. Thisis not a 'displacement' of neurosis, as it is thepresence of antisocial symptoms and not the absenceof neurotic symptoms which is associated withreading retardation. Secondly, the characteristicsof reading retardation with respect to both sex ratioand prognosis are quite different to those ofneurosis.Thirdly, there is good evidence that specific readingretardation is due to other factors. A wide range ofneurodevelopmental functions tend to be Impairedin retarded readers. These do not constitute aspecific pattern, but speech and language difficultiesand problems in sequencing are those most stronglyand consistently associated with reading retardation.Right-left confusion, motor impersistence, and weakintersensory integration are also important to a lesserextent. The exact cause of this developmentalimpairment remains uncertain but almost certainlyit is multifactorial, involving both biological factors

and lack of the necessary life experiences. Theseinteract with particular temperamental attributesand adverse school influences to produce specificreading retardation (Rutter and Yule, 1973). Inshort, specific reading retardation has many factorsimportant in aetiology but, except rarely, neurosisdoes not seem to be one of them.Does this mean that emotional disorder is of no

importance in children with specific readingretardation ? It does mean that the availableevidence suggests that emotional disorder is notimportant as a primary cause of severe readingretardation.* However, as a secondary influence itis much more important. Children, particularlyintelligent children, who fail to learn to read arelikely to be continually faced with negative responsesto their failure. School reports are likely to say'doesn't try', 'could do better', or 'not working up tohis capacity', when from the child's point of view heis doing all he can but without any sign of success.School becomes a negative experience which isstrongly associated with failure and with the adversesocial responses to his failure. By the time peopleare considering whether he needs special help he islikely to have 'given up', and the remedial teacher isfaced with a discouraged, miserable child who lacksconfidence and feels he cannot succeed whatever hedoes. This is particularly likely to happen withreading difficulties because reading is the key toalmost all learning in school. Unless the child canread his textbooks or understand what the teacherwrites on the blackboard, he is to a considerableextent cut off from learning in other subjects as well(Rutter et al., 1970b). Though not the prime causeof reading retardation, emotional and motivationalfactors probably are important in the continuation ofreading difficulties. As a consequence, the remedialteacher's first task will usually be to increase thechild's confidence and motivation to learn and toestablish an appropriate learning set.These are important matters but still they do not

resolve the meaning of the association betweenreading retardation and conduct disorder. Themost fruitful approach to this issue is to studychildren with both problems, in order to determinewhether they have more in common with purelyantisocial children or with purely reading-retardedchildren. This strategy has been followed in theIsle of Wight study (Rutter et al., 1970b), the morerecent investigation in an inner London borough(Sturge, 1972), and in the Inner LondonEducation Authority's literacy survey (1973). In

*It is possible that emotional factors may be more important in thegenesis of milder reading retardation, but there is very little evidencebearing on this point.

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Emotional disorder and educational underachievementboth the Isle of Wight study and the I.L.E.A. survey

the antisocial retarded readers were much more likethe 'pure' retarded readers than the 'pure' antisocialchildren. This finding suggested that in some cases

antisocial disorder might arise as a result ofeducational failure. With status and satisfactionthrough schoolwork denied him, the readingretarded child might rebel and seek satisfaction inactivities running counter to everything for whichthe school stood. The London analysis by Sturge(1972) agreed with this finding in part, but withsome variables the antisocial retarded readersoccupied a middle position between the purelyretarded readers and the purely antisocial children.However, there was no evidence that antisocialdisorder led to reading difficulties. Taking all thefindings it seems that at least three processes are

operating. First, at least in a big city population,the family influences leading to reading retardationoverlap considerably with the family influencesleading to antisocial behaviour. This is anotherexample of the truism that a depriving environmenttends to be depriving in many respects (Rutter,1972). Secondly, there are probably some featuresin the child which tend to lead to both types ofhandicap. This applies both to temperamentalcharacteristics and to organic brain dysfunction.Thirdly, reading failure itselfmay be a potent source

of discouragement, loss of self-esteem, andantagonism which in some cases may contribute tothe development of disturbances of conduct.

In summary, it may be concluded that emotionalfactors probably play only a minor role in theprimary causation of severe degrees of specificreading retardation, though motivational influencesmay often be more influential in the continuation ofreading difficulties due to other basic causes. Onthe other hand, underachievement in reading may

sometimes lead to psychological disturbance andthere is a strong association with disorders ofconduct, an association which probably stems fromseveral different mechanisms.

Other learning diabilities and emotionaldisorder

So far, this paper has been concerned with specificreading retardation, the educational disorder aboutwhich most is known. However, as noted in thediscussion of the classification of underachievement(see above), there are several other varieties oflearning disability. First, there may be a specificretardation in other scholastic skills (such as

arithmetic), or there may be the development in laterchildhood of learning inhibitions which involve a

failure to make further school progress after aninitially successful start.Much less is known about either the causes or the

emotional correlates of these other learningdisorders. In the case of arithmetic, psycho-analysts have suggested that there may be aninhibition of ego functions resulting from castrationanxieties (Vereecken, 1965), but these remainfanciful speculations which so far lack supportingevidence. More attention has been paid todisorders of learning which involve, not just aneducational skill, but rather learning in general(Buxbaum, 1964; Rubinstein et al., 1959), especiallywhen this arises later in childhood after a successfulearly start (Pearson, 1952). Over 20 years agoPearson outlined some of the ways in which learninginhibitions may arise as a result of emotionaldisorder. However, there was a lack of evidence atthat time upon which to base any assessment of therelative importance of the various mechanisms, andthe situation today is little better. Accordingly, it isnot possible to state how these learning inhibitionsactually arise. It is only possible to discuss howthey might arise. Six possible mechanisms will beconsidered-temperamental influences, anxiety,stress at a critical period, lack of motivation,avoidance of learning, and generally impairedpsychological function.

(a) Temperamental features. The strongassociations between children's temperamentalattributes and specific reading retardation havealready been noted. Poor concentration (on tasksother than reading), fidgetiness, restlessness, andimpulsiveness are the traits most consistentlyassociated with reading retardation (Rutter andYule, 1973). Whether these traits are alsoassociated with underachievement in other areas isnot known. However, attention is an importantpart of any learning task and pupils who havedifficulty maintaining their attention because ofimpulsiveness, restlessness, distractibility, or shortattention span are likely to be impaired in manyaspects of learning. Hence, these factors areprobably important in all types of underachievementpresent from the outset. There has also been wideinterest in the relation between general personalityvariables, such as extraversion or neuroticism, andlearning. The studies on these variables haveusually involved the study of average performance invarious groups and there has been less study ofchildren with underachiev mrnent. This makes thefindings difficult to interpret, particularly as thefindings are in any case complex and contradictory.In some groups extraversion is associated with

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higher achievement and in other groups with lowerachievement. The same applies to neuroticism.These variations in findings appear to be associatedin part with differences in ability level, in age, and insex (e.g. Entwistle and Welsh, 1969; Eysenck andCookson, 1969; Entwistle and Cunningham, 1968;Kline and Gale, 1971; Leith and Davis, 1972). Itmay well be that with further study sense will bemade of these findings, but at the moment thecorrelations are too low and too variable for anyconclusions to be drawn about their possible role inunderachievement.

(b) Anxiety. The same applies to the effect ofanxiety on learning. It is usually said that a littleanxiety helps learning but too much anxietyinterferes with it. Also it has been thought thathigh anxiety is most beneficial for simple tasks butlower levels of anxiety are optimal for difficult tasks.This sounds reasonable and there may well besomething in it, but the research findings are rathercontradictory and cannot be said to give unequivocalsupport to this view of the relation between anxietyand learning (see references on neuroticism, alsoLynn, 1957; Sarason, 1963; Levy, Gooch, andKellmer-Pringle, 1969). Probably a lot depends onthe child's attitude to the task, the setting in whichthe learning takes place, and the responses he haspreviously encountered after success and failure.Certainly, there is no straightforward relationbetween anxiety and underachievement.

(c) Stress at a critical period. Quite apartfrom current anxiety, it might be suggested thatunderachievement arose because of stress or anxietyduring an earlier critical period when the basiclearning skills were being established. Thisremains a theoretical possibility, but first there is nosatisfactory evidence that any such critical period forlearning exists (Rutter, 1972) and, secondly, there isno evidence that children with underachievementexperienced stress or anxiety in early life more oftenthan do other children. However, the issue has yetto be systematically studied.

(d) Lack of motivation. Learning requiresattention and involvement in the task and thesevariables will be influenced by the child's interestand motivation. Comment has already been madeon the lack of motivation which commonly arisesafter educational failure, but also lack of motivationmay be a prime factor in leading to certain kinds ofunderachievement. Again, systematic research islacking. However, both clinical and educationalexperience suggest that motivation is often an

important variable in school learning. The studiesof Douglas (1964) and Wiseman (1964) have shownthat children's educational attainments aresignificantly associated with the attitudes of theirparents towards schooling. The exact mechanismsinvolved in this association are not known butprobably an effect on the child's interest andmotivation is one of them. Later in schooling,children may lose interest in their schoolwork forother reasons and their attainments may sufferaccordingly.The child's interest and involvement in learning

will also be increased by his identification with theperson (either teacher or parent) associated with thelearning process and by his seeking to please him byhis learning success. Conversely, a bad relation-ship may interfere with learning.More specifically, the child may work less well

because his attention is deflected onto other things(Pearson, 1952). This may occur, for example,with worries about difficulties at home, with sexualpreoccupations, with daydreams, or with obsessionalruminations.

(e) Avoidance of learning. In addition to allthese factors, children may show underachievementbecause of a positive avoidance of learning (either ingeneral or with respect to a specific subject). Mostobviously this is evident in those adolescents whosework falls off as part of a rebellion against adultvalues. Some intelligent children come to rejecteducation as something which is worth working forand as a result their educational attainments maysuffer.

In other cases, learning comes to be associated inthe child's mind with pain or unpleasant feeling.This situation may arise where a parent or teacherkeeps punishing a child for not learning properly(Pearson, 1952). Eventually the child may come,by generalization, to associate learning withpunishment and so avoid it. This may apply to oneschool subject or to learning in general. The samephenomenon may result if the child's peer cultureregards schoolwork as cissy and to be despised. Ifthe child is teased and tormented as a 'swot' by hisfriends when he does his schoolwork well, he maylearn that scholastic success is to be avoided.

Alternatively, it has been argued that schoolworkmay be avoided because learning has becomeinvolved in a neurotic conflict. In these caseslearning is inhibited because of its symbolicassociations. Thus, it has been suggested thatreading may come to have a sexual connotation sothat reading is associated with sexual 'looking'(Jarvis, 1958). The only study to test this

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Emotional disorder and educational underachievement 255hypothesis gave equivocal findings (Walters, vanLoan, and Crofts, 1961), and it remains unknownhow commonly underachievement is due to this orany other type of neurotic conflict. On a moreconscious basis, certain school subjects may come tohave a masculine or feminine identity and befavoured or avoided for this reason.

(f) Impaired function. Finally, underachieve-ment may arise because of general impairmentof a child's psychological function. This mostcommonly happens in association with depressivedisorders in adolescence, but it also occurs in a moreserious fashion with schizophrenia beginning in thisage period (Offord and Cross, 1969).

Conclusions. It must be emphasized that thesevarious mechanisms by which emotional disturbancemay lead to underachievement have, with very fewexceptions, not been subjected to systematicinvestigation and their importance remains a matterfor clinical judgment. Of all the varieties ofunderachievement, specific reading retardation hasbeen most studied. In the case of this disorder, theavailable evidence suggests that emotional disorderdoes not play an important part in aetiology thoughmotivational factors are more influential in thecontinuation of difficulties. Though readingretardation shows a strong association with conductdisorder, the mechanisms involved in the associationare complex and are not well understood. Severalfactors probably play a part in the association, but itappears that only rarely does conduct disorder leadto reading difficulties. It is likely that emotionalfactors play a greater part in the learning inhibitionswhich arise later in childhood after initial success.However, which mechanisms are most important inthis connexion is still not known.

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