For some children a health problem could be to blame for acting up in class or even a drop in grades. Doctors at Baylor College of Medicine say what might look like a behavioral issue could actually be a sign of hearing loss, sleep apnea, or a voice problem.

All of these physical ailments will hinder the student’s attention, says James H. Bray, PhD, associate professor of family and community medicine and a psychologist at Baylor.

Hearing Loss

“Children may not be cognitively mature enough to make the connection that they have a hearing problem, or they may even feel embarrassed to say they have a problem and a natural reaction is to withdraw,” he says in a release.

Bray says that sometimes children may not even realize there is an issue. They may think they can hear what the teacher is saying but actually are getting the information wrong.

Sleep Apnea

People sometimes think that only adults can have sleep apnea, but it can affect individuals of all ages—even children, says Dr. Julina Ongkasuwan, MD, FAAP, FACS, assistant professor of otolaryngology–head and neck surgery in the Institute for Voice and Swallowing at Baylor.

“Behavioral issues may be related to sleep apnea in children because they are not getting good rest at night,” she says. “Daytime sleepiness, hyperactivity and attention problems can all be signs of sleep apnea.”

Voice Problems

Symptoms of voice issues include hoarseness, frequent voice loss, difficulty being heard, or understood and pain when talking.

“Studies have shown that students with voice issues are more negatively perceived by teachers,” says Ongkasuwan, also a physician at Texas Children’s Hospital. “Some voice issues may cause the children to not participate because they become self-conscious or cannot be heard.”

What to Do

Bray and Ongkasuwan agree that if you suspect your child has a health ailment or is showing signs of a learning disability, to make an appointment with a pediatrician for an initial assessment.

In some cases, there may be simple solutions such as making sure a child sits in the front of the class or incorporating hearing tests into yearly checkups.

Children who suffer from sleep apnea or a voice problem may benefit from a sleep study or voice evaluation, Ongkasuwan says.