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A Parents Guide to Elementary School Children

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Title: 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-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

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/Publicati
    ons/Forms-Checklists-Flyers-Handouts/ldchecklist.p
    df

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
    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.

13
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.

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/h
    elp4kids/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 childs
    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 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?
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 andabnormal

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
  • Tourettes 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

51
Family
  • Divorce
  • Chronic Conflict
  • Different parenting styles
  • Chaos
  • Adoption

52
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

53
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?

54
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

55
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

56
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?

57
THANK YOU!!
  • www.draronsonramos.com
  • Resources Recommended Reading, Links and
    Articles
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