A Parents Guide to Elementary School Children

1
A Parents Guide to Elementary School Children

• Judith Aronson-Ramos, M.D.
• Developmental Behavioral Pediatrics

2
What do we know?

• 1 out of 5 children will have a mental health or
  behavioral concern
• 1/110 children will have and Autism Spectrum
  Disorder
• 5-7 of school age children have ADHD
• 5 of school age children have Learning
  Disabilities

3
The Chicken or The Egg

• Learning Disorders
• Emotional/Behavioral Problems

4
Disorders and Concerns

• Specific Learning Disabilities
• ADHD
• Autism Spectrum Disorder
• Specific Disorders of Behavior and Emotion
• Neurological Conditions
• Chronic Illness
• Parenting the impact on all of the above

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Problems in Learning

• Learning Disabilities (LD) are neurologically-base
  d processing problems which can interfere with
  learning basic skills such as reading, writing,
  or math. They can also interfere with higher
  level skills such as organization, time planning,
  and abstract reasoning.
• Types of LD are identified by specific processing
  problems.
• They might relate to getting information into the
  brain (Input), making sense of this information
  (Organization), storing and later retrieving this
  information (Memory), or getting this information
  back out (Output).
• Specific types of processing problems might be in
  one or more of these four areas-
• INPUT
• OUPUT
• ORGANIZATION
• MEMORY

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What are the clues of a learning disability in
preschoolers and early elementary school children?

• Communication delays, such as slow language
  development or difficulty with speech. Problems
  understanding what is being said or problems
  communicating thoughts.
• Poor coordination and uneven motor development,
  such as delays in learning to sit, walk, color,
  and using scissors. Later watch for problems
  forming letters and numbers.
• Problems with memory and routine for example,
  not remembering specifics of daily activities and
  not understanding instructions or remembering
  multiple instructions.
• Delays in socialization including playing and
  relating interactively with other children.
• For an excellent checklist by age follow this
  link http//www.ncld.org/images/stories/Publicati
  ons/Forms-Checklists-Flyers-Handouts/ldchecklist.p
  df

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Grades 1-5

• Problems learning phonemes (individual units of
  sound) and graphemes (letters, numbers). Problems
  learning how to blend sounds and letters to sound
  out words - phonics.
• Problems remembering sight words.
• Difficulty with reading comprehension.
• Problems forming letters and numbers.
• Problems with basic spelling and grammar.
• Difficulties learning math skills and doing math
  calculations.
• Difficulty remembering facts.

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Grades 1-5

• Some types of LD are not apparent until middle or
  high school when demands increase and assignments
  are more complex, new areas of weakness may
  become apparent.
• Losing or forgetting materials, or doing work and
  forgetting to turn it into the teacher.
• An inability to plan out the steps and time lines
  for completing projects, especially long-term
  projects.
• Difficulty organizing thoughts for written
  reports or public speaking.
• Difficulty organizing materials (notebook,
  binder, papers), information, and/or concepts
• Poor or no sense of time.

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If there is suspicion of LD.

• The diagnostic process is called a
  "psycho-educational" evaluation. Under education
  law, public schools must provide this evaluation,
  but this may not happen immediately (RTI). An
  evaluation may also be done privately. There are
  three parts to this evaluation. The tests used
  may vary with each school system or by clinician
  (MA,PHD)
• An assessment of potential, usually done through
  an IQ test.
• A battery of achievement tests to assess skills
  in reading, writing, and math.
• A battery of tests to assess processing skills.
  These tests examine possible problems with input,
  integration, and output of information.

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What is the difference between a learning
disability, a developmental delay, and a
developmental disability?

• Someone is learning disabled if there is a large
  discrepancy between intellectual ability and
  achievement. The person with a learning
  disability may have low or high intelligence the
  person simply learns below intellectual
  capability because of a processing disorder.
• A developmentally delayed child is one who is
  younger than five years old and who is behind
  schedule in attaining milestones. A
  developmentally delayed child usually reaches the
  developmental milestones eventually.
• The developmentally disabled child has a severe
  and chronic physical or mental impairment that
  limits success in several major life areas.
  Examples of developmental disabilities include
  mental retardation, cerebral palsy, epilepsy,
  autism and others.

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Criteria of an LD

• All of the following are necessary symptoms of an
  official learning disability
• Average or above average intelligence (as
  measured by the IQ score)
• Significant delay in academic achievement
• Severe information processing deficits
• Uneven pattern of cognitive development
  throughout life
• A disparity between measured intellectual
  potential (IQ score) and actual academic
  achievement
• The learning disability persists despite
  instruction in standard classroom situations

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Types of LD

• Dyslexia Difficulty processing language. Problems
  reading, writing, spelling, speaking.
• Dyscalculia Difficulty with math. Problems doing
  math problems, understanding time, using money.
• Dysgraphia  Difficulty with writing. Problems
  with handwriting, spelling, organizing ideas.
• Dyspraxia (Sensory Integration Disorder)
  Difficulty with fine motor skills. Problems with
  handeye coordination, balance, manual dexterity.
• Auditory Processing Disorder Difficulty hearing
  differences between sounds. Problems with
  reading, comprehension, language.
• Visual Processing Disorder -Difficulty
  interpreting visual information. Problems with
  reading, math, maps, charts, symbols, pictures.

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LD doesnt explain everything that makes learning
hard..

• Difficulty in school doesnt always stem from a
  learning disability. Anxiety, depression,
  stressful events, emotional trauma, and other
  conditions affecting concentration make learning
  more of a challenge.
• ADHD Attention Deficit Hyperactivity Disorder
  (ADHD), while not considered a learning
  disability, can certainly disrupt learning.
  Children with ADHD often have problems with
  sitting still, staying focused, following
  instructions, staying organized, and completing
  homework.
• Autism Difficulty mastering certain academic
  skills can stem from unique sensory processing,
  difficulty understanding abstract ideas and
  emotions, or a unique learning style. Children
  with ASD may also have trouble making friends,
  reading body language, communicating, and making
  eye contact.

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ADHD

• 20 of school aged children
• Three types of ADHD Inattentive, Hyperactive
  Impulsive and Combined
• Diagnosed at age 6
• Rule out things that mimic ADHD- Anxiety,
  Depression, LD
• Performance must be impaired to be diagnosed

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DSM IV Criteria

• Inattention
• Often does not give close attention to details or
  makes careless mistakes in schoolwork, work, or
  other activities.
• Often has trouble keeping attention on tasks or
  play activities.
• Often does not seem to listen when spoken to
  directly.
• Often does not follow through on instructions and
  fails to finish schoolwork, chores, or duties in
  the workplace (not due to oppositional behavior
  or failure to understand instructions).
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn't want to do
  things that take a lot of mental effort for a
  long period of time (such as schoolwork or
  homework).
• Often loses things needed for tasks and
  activities (e.g. toys, school assignments,
  pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.  

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Hyperactivity

• Often fidgets with hands or feet or squirms
  in seat when sitting still is expected.
• Often gets up from seat when remaining in seat is
  expected.
• Often excessively runs about or climbs when and
  where it is not appropriate (adolescents or
  adults may feel very restless).
• Often has trouble playing or doing leisure
  activities quietly.
• Is often "on the go" or often acts as if "driven
  by a motor".
• Often talks excessively.
•  

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Impulsivity

• Often blurts out answers before questions have
  been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others (e.g.,
  butts into conversations or games).

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Additional Criteria

• Some symptoms that cause impairment were present
  before age 7 years.
• Some impairment from the symptoms is present in
  two or more settings (e.g. at school and home).
• There must be clear evidence of clinically
  significant impairment in social, school, or work
  functioning.
• The symptoms are not due to a Pervasive
  Developmental Disorder, or other Mental or
  Neurologic disorder.

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Not all types of ADHD look alike

• Inattention spacey, day dreamers, forgetful
• Can be overly helpful
• Bias against boys
• Poor sense of time
• Carless
• Disorganized
• Distractible

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Hyperactive - Impulsive

• Over active
• Cant wait in line
• Calls out
• Fidgeting
• Distracted
• Impulsive
• Interrupts

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Combined Type

• Consistent pattern of both inattentive and
  hyperactive impulsive symptoms
• The majority of elementary age children with ADHD
  have combined type
• Hyperactivity diminishes over time
• Inattention can worsen over time as demands
  increase

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Neurobiology of ADHD

• Neurobiological differences in children with ADHD
  leading to executive functioning deficits
  (organizing, planning, reasoning, attention)
• Anatomic Physiologic Differences in the Brain
  Pre-frontal cortex volume and perfusion
  smaller right frontal lobe connections between
  basal ganglia (movement) and other areas overall
  decreased blood flow to certain brain regions

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Neurobiology of ADHD

• Dopamine and Catecholamine Transporter Genes
• Size of different brain structures
• Research supports familial transmission

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ADHD at home

• An organized family with structure and routine
  at home, and calm, respectful manner of
  interacting with each other.
• A behavioral program with clear rules, frequent
  and immediate positive reinforcement for target
  behaviors, and immediate consequences for
  specified negative behaviors
• A consistent schedule so that children know what
  is expected of them and can plan for transitions.
• Modeling time management and self-control.

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More Tips

• Review and rehearse where things seem to always
  be a problem (morning routines, etc.)
• A minimum of noise and confusion during homework
  time or bedtime.
• Children need to bee aware that a transition is
  coming, when the current activity will end, what
  will happen next, and what they are expected to
  do to be ready.
• Provide outlets for excessive energy.

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ADHD Resources

• CHADD www.chadd.org
• http//www.helpforadd.com
• National Resource Center for ADHD
  http//www.help4adhd.org
• Tufts University https//research.tufts-nemc.org/h
  elp4kids/teachers/default.asp
• Reach Institute www.thereachinstitute.org

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Parents Role in Diagnosis and Treatment of ADHD

• You may be asked to complete a questionnaire such
  as the Connors, Vanderbilt, SNAP and others
• You may be asked to permit an observation at
  school or home
• You may be asked for samples of your childs
  school work or old report cards
• You may be asked to assess effectiveness of
  medication

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ADHD Medications

• Stimulants, Non-stimulants, Alpha Agonists
• Common Side Effects Vary depending upon the
  medication class stimulants- decreased appetite,
  difficulty falling asleep, irritability,
  headache alpha agonists somnolence,
  constipation non-stimulants nausea, abdominal
  pain, mood changes
• Duration of Action variable depending on
  preparation
• Interactions few with other medications
• Missed doses may be symptomatic immediately
• Red Flags for Parents dehydration, extreme
  physical activity, illness, unusual behaviors

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Biological ConceptsMost drugs in
psychopharmacology work by affecting the
communication between neurons in the brain.
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Is it Autism?

• Difficulties in the following areas
• Communication
• Social interaction
• Repetitive Behaviors/Restricted Interests

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• Cognitive abilities range from gifted to severely
  challenged.
• Autism is a Pervasive Developmental Disorder
• PDDs include PDD-NOS, Autism, Aspergers
  Syndrome, Retts Syndrome, and Childhood
  Disintegrative Disorder

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DSM IV Criteria

• THERE IS NO ONE TEST TO DIAGNOSE AUTISM WE BASE
  diagnosis on a combination of history,
  observation, assessment language, motor,
  cognitive skills and ruling out other disorders
  that may mimic autism.
• The diagnosis can be made by a neurologist,
  developmental pediatrician, child psychiatrist or
  school system team. Some clinicians use tools
  such as the ADOS, CARS, GARS, SRS, SCQ other base
  their diagnosis on history and observation alone.
  
• Many ways to diagnose but the diagnostic criteria
  are

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• 6 total from 1-3 at least 2 from 1 and 1 each
  from 2 and 3
• 1. Qualitative Impairment in Social Interaction
  (at least 2)
• Nonverbal skills eye contact, body posture,
  facial expressions
• Peer Relationships not developmentally
  appropriate
• No Spontaneous joint attention
• No social or emotional reciprocity
• 2.Qualitative Impairment in Communication
• Delay or lack of language
• Poor conversational skills
• Idiosyncratic language
• No make believe or imitation
• 3.Restricted and Repetitive Behaviors, Interests,
  or Activities Preoccupations, Inflexible
  routines, Motor Mannerisms, Parts not the whole

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How Do We Know?

• Red Flags No social smile and back and forth
  exchanges with caregivers by 2-3 months.
• No notice of when caregivers leave or enter a
  room by 6-9 months of age.
• Not responding to his or her name when called
  once or twice at nine months or later.
• Lacking in back and forth play with teachers,
  caregivers or other children. We call this skill
  joint attention and it is a critical component of
  engaging with others.
• No pointing or babbling at nine months or later.
• No functional words at 15 months or later.
• Repetitive and non-purposeful play dumping
  toys, lining things up, stacking at the expense
  of creative and imaginative use of objects.
• Limited or no eye contact.

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More Signs

• Repetitive body movements or posturing can be
  hand flapping, finger twisting, spinning,
  rocking, all of these are done to an excessive
  degree.
• Unable to be redirected at 15 months or later due
  to an intense fixation with an object or
  interest we sometimes call this sticky
  attention.
• Unable to sit or engage in expected activities
  for age from 12 months on.
• Prolonged difficulties with separation from
  caregivers, or extreme upset at changes in
  routine.
• Viewing or inspecting objects from unusual angles
  laying down to look at spinning wheels or
  objects, using peripheral vision, fixating on
  moving objects that are not toys such as fans,
  wheels, washing machines etc. All of these things
  are done to excess not just in an exploratory
  way.
• Not comprehending instructions, directions, or
  tasks that are clearly age appropriate.
• For more information on red flags visit
  www.firstsigns.org

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Subtle Signs of ASD

• Fixated narrow areas of interest
• No friends
• Inability to pick up on social cues
• Black and white or very rigid thinking
• Extreme upset over changes in routine
• Poor contact, indiscriminately social, not
  understanding implied rules of social conduct

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What We Dont Know
Are Autistic Traits found in the general
population and Autism Spectrum Disorders are an
imbalance of these traits? Is it genetic,
environmental, an interplay of both? We know
there are different types of autism, are there
different causes? What are the unknown metabolic
factors that may worsen or improve ASD? Where are
all the adults with ASD? The hidden hoard? Are we
investing enough resources in care for the adult
population with ASD? Can we predict which
children will progress and develop greater
skills?
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New Theories Autistic Traits are Common

• MANY CHILDREN HAVE MILD AUTISTIC "SYMPTOMS"
  WITHOUT EVER HAVING ENOUGH PROBLEMS TO ATTRACT
  SPECIALIST ATTENTION, SAY UK RESEARCHERS.
• THE INSTITUTE OF CHILD HEALTH TEAM SAYS DIAGNOSED
  CHILDREN HAVE SEVERE VERSIONS OF CHARACTER TRAITS
  PROBABLY SHARED BY MILLIONS OF OTHERS.
• THE 8,000 CHILD STUDY FOUND EVEN THESE MILD
  TRAITS COULD IMPAIR DEVELOPMENT.
• BOYS - WERE MOST LIKELY TO BE AFFECTED, THE US
  JOURNAL STUDY FOUND.
• SCIENTISTS HAVE UNDERSTOOD FOR SOME TIME THAT THE
  "AUTISTIC SPECTRUM" COVERS A WIDE RANGE OF
  CHILDREN.
• Fuzzy Boundary between normal andabnormal

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Mood

• Is he/she moody or is it more serious?
• Is it hormones?
• Is it a phase?
• How do I know if there is a more serious
  emotional or psychiatric problem?

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Mood Disorders

• Anxiety Disorders Generalized, Separation,
  Social, Selective Mutism, Shy
• Depressive Disorders MDD, Dysthymia,
• Adjustment Disorders with mood problems
• Situational Mood Problems
• OCD disorder vs. phase degree of symptoms,
  inference in functioning, duration
• Bipolar Disorder - rare

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Chronic Illness

• Asthma
• Diabetes
• Cystic Fibrosis
• Cancer
• Obesity
• Chronic Ear and Sinus Infections
• Allergies
• Genetic Syndromes

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Neurological Conditions

• Cerebral Palsy
• Tourettes Syndrome
• Genetic Disorders - Downs Syndrome, Fragile X
• Metabolic Diseases
• Epilepsy

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Disruptive Behaviors

• ODD Oppositional Defiant Disorder
• In children with Oppositional Defiant Disorder
  (ODD), there is an ongoing pattern of
  uncooperative, defiant, and hostile behavior
  toward authority figures that seriously
  interferes with the youngster's day to day
  functioning. 

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Symptoms of ODD may include

• excessive arguing with adults
• active defiance and refusal to comply with adult
  requests and rules
• deliberate attempts to annoy or upset people
• blaming others for his or her mistakes or
  misbehavior
• often being touchy or easily annoyed by others
• frequent anger and resentment
• mean and hateful talking when upset
• seeking revenge

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What causes ODD ?

• The symptoms are usually seen in multiple
  settings, but may be more noticeable at home or
  at school.  Five to fifteen percent of all
  school-age children have ODD. 
• The causes of ODD are unknown, but many parents
  report that their child with ODD was more rigid
  and demanding than the child's siblings from an
  early age. 
• Biological and environmental factors may have a
  role such as alcohol or tobacco use during
  pregnancy  

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Treatment of ODD

• Parenting
• Behavioral Therapy
• Structured Behavioral Plans at school
• Parent-Child Relationship training
• Use of medications for severe behavioral
  disturbance

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Conduct Disorder

• Children and adolescents with this disorder have
  great difficulty following rules and behaving in
  a socially acceptable way. They are often viewed
  by other children, adults and social agencies as
  "bad" or delinquent, rather than mentally ill.
  Many factors may contribute to a child developing
  conduct disorder, including brain damage, child
  abuse, genetic vulnerability, school failure, and
  traumatic life experiences.

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Conduct Disorder

• Incidence 2 of children and teens
• Aggression to people and animals
• Destruction of Property
• Deceitfulness, lying, or stealing
• Serious violations of rules
• often stays out at night despite parental
  objections
• runs away from home
• often truant from school

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Treatment of CD

• Treatment of children with conduct disorder can
  be complex and challenging. Treatment can be
  provided in a variety of different settings
  depending on the severity of the behaviors.
  Adding to the challenge of treatment are the
  child's uncooperative attitude, fear and distrust
  of adults.

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Outcome for CD

• Two types of CD childhood onset (before age 10
  yrs) and adolescent onset
• CD is highly resistant to treatment. It follows a
  clear developmental path with indicators that can
  be present as early as the preschool period.
  Treatment is more successful when initiated early
  and must include medical, mental health, and
  educational components as well as family support.
  
• CD may result in anti-social personality types,
  criminal behavior, and sociopathic behaviors as
  children they often end up in the juvenile
  justice system

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Family

• Divorce
• Chronic Conflict
• Different parenting styles
• Chaos
• Adoption

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How do we insure success?

• Working as a team
• Good communication between teachers and parents,
  parents and children and parents with each other
• Eliminating denial and defensiveness
• Demystifying difficulties
• Deviance vs. Difference
• Patience vs. Panic

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Why Are There So Many Books on Parenting?

• Google parenting and you will find 79 million
  references
• Since the 1900s there had been an exponential
  increase in parenting experts concurrent with a
  growing incidence of behavior problems,
  dysfunctional families, childhood onset
  psychiatric and developmental disorders
• What is going on here?

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Pitfalls According to the Professionals

• Limit setting where did it go?
• Overprotection - has become indiscriminate
• Nag-Lecture-Yell-Repeat Nag-Lecture-Yell
• Genuine praise is lacking
• Stifling emotions
• Punishment doesnt fit the crime
• Praising events and activities
  over the child

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Societal Cultural Changes Have Altered Family
Life

• 1.Demographic-loss of the neighborhood, suburban
  sprawl, self-enclosed homes,
• 2. Family Structure divorce, loss of family
  time, single parent households, harried schedules
• 3. Culture computers, cell phones, video games,
  electronic immersion

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Changes contd

• 4. Political and Economic Issues Geopolitical
  stress and Global Recession
• 5. Environmental and Nutritional influences
• 6. NDD Where are the electrical outlets at the
  park?

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THANK YOU!!

• www.draronsonramos.com
• Resources Recommended Reading, Links and
  Articles