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

5. Problems in Learning • Learning Disabilities (LD) are neurologically-based 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

6. 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/Publications/Forms-Checklists-Flyers-Handouts/ldchecklist.pdf

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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 hand–eye 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.

13. LD doesn’t explain everything that makes learning hard….. • Difficulty in school doesn’t 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.

14. 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

15. 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.  

16. 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.

17. 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).

18. 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.

19. 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

20. Hyperactive - Impulsive • Over active • Cant wait in line • Calls out • Fidgeting • Distracted • Impulsive • Interrupts

21. 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

22. 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

23. Neurobiology of ADHD • Dopamine and Catecholamine Transporter Genes • Size of different brain structures • Research supports familial transmission

24. 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.

25. 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.

26. 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/help4kids/teachers/default.asp • Reach Institute www.thereachinstitute.org

27. 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 child’s school work or old report cards • You may be asked to assess effectiveness of medication

28. 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

29. Biological ConceptsMost drugs in psychopharmacology work by affecting the communication between neurons in the brain.

30. Is it Autism? Difficulties in the following areas • Communication • Social interaction • Repetitive Behaviors/Restricted Interests

31. 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

32. 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:

33. 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

34. 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.

35. 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

36. 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

37. What We Don’t 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?

38. 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” and”abnormal”

39. 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?

40. 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

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

42. Neurological Conditions • Cerebral Palsy • Tourette’s Syndrome • Genetic Disorders - Downs Syndrome, Fragile X • Metabolic Diseases • Epilepsy

43. 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. 

44. 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

45. 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  

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

47. 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.

48. 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

49. 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.

50. 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