Understanding the Spectrum of Developmental Disorders in Elementary School Children

1. Understanding the Spectrum of Developmental Disorders in Elementary School Children Judith Aronson-Ramos, M.D. Director Developmental & Behavioral Pediatrics of South Florida www.draronsonramos.com

2. Incidence of Disorders • 1 in 6 children have a developmental disorder • ADHD the most common disorder of early childhood 5-20 % • Other common disorders: Learning Disabilities (Dyslexia, Dysgraphia, Dyscalcula, NVLD), Autism, Aspergers, Anxiety, OCD, Depression, Mood Disorders, Syndromes, Neurological Abnormalities

3. 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

4. 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.  

5. Hyperactivity • 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.

6. Impulsivity • 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).

7. 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 disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).  

8. The many faces of ADHD • “I sit like this at home”

9. 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 • Examples

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

11. 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

12. Neurobiology of ADHD • Neurobiological differences in children with ADHD leading to executive functioning deficits (organizing, planning, reasoning, attention) • Anatomic Differences: Pre-frontal cortex, smaller right frontal lobe, connections between basal ganglia (movement) and other areas; overall decreased blood flow to certain brain regions • Dopamine Transporter Genes • Size of different brain structures • Research supports familial transmission

13. Classroom TipsADHD • A highly organized teacher with a structured and systematic teaching style and calm, respectful manner of interacting with students • A behavioral program with clear rules, frequent and immediate positive reinforcement for target behaviors, and immediate consequences for specified negative behaviors • A consistent daily schedule so that areas of academic instruction, recess, and routines (e.g., passing out daily work, assigning homework) are done in the same manner and order daily; • A morning review of each day's schedule (with the student given a copy of her schedule for that day • A minimum of classroom noise and confusion (visual and auditory); • A system in which students are 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 • An emphasis on interactive and participatory instructional activities in which students have little or no wait time.

14. ADHD Resources for Teachers • 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

15. 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 Teachers – dehydration, extreme physical activity, illness, unusual behaviors

16. Autism Spectrum Disorders • Autism is the fastest-growing developmental disability in the U.S. • Over 1.5 million individuals in the United States have been diagnosed with autism spectrum disorder. • The diagnosis rate for autism is rising 10-17% each year. • Males are 4 times more likely than females to be diagnosed with autism. • The symptoms and characteristics of autism can present themselves in a wide variety of combinations, from mild to severe. • Autism is a spectrum disorder - meaning the symptoms can occur in any combination and with varying degrees of severity.

17. 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:

18. 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

19. 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

20. What we do Know • Normal development is altered – there are differences in brain growth, neuron shape and density, neuronal connections and signaling molecules • Changes in the structure and function of neurons – autism brain bank. • Genetic abnormalities – twin studies 75% twin concordance if identical, 3% non-identical; 3-8% affected sibling; association with genetic diseases-Fragile X, Tuberous Sclerosis, PKU etc • Double Hit Hypothesis – genes and the environment. • Abnormalities in signaling molecules such as Neurotrophin, Reelin, PTEN and Hepatocyte growth factor, neurotransmitters such as serotonin and glutamate, and synaptic proteins such as Neurexin, SHANK and Neuroligin. • Theories regarding oxidative stress, neuroimmunity, and neuorglial activation. • Latest Genetic Research – 27 gene regions involved-BSRAP1, MDGA2

21. Autism in the Classroom • Variable in abilities and deficits • Low functioning and non-verbal to gifted in a mainstream or advanced classroom • Sensory Sensitivities to sound, light, touch, smell can be a problem • Learning style may be unique (appearing inattentive yet hearing every word) • Visual Perceptual skills more developed than Verbal • Tactile and Kinesthetic learning over rote

22. Autism • Core problems generally relate to communication and socialization • Managing problem behaviors

23. Roots of Problem Behaviors • Behaviors exhibited by students with autism may include loud vocalizations, leaving the instructional area, self-injury, aggression or other inappropriate behaviors. • The important thing to note is that this behavior is exhibited because of the communication and social deficits. • With a quality, systematically implemented positive behavior support plan students with autism—even those with the most challenging behavior—can achieve a reduction in inappropriate behavior and success in the educational environment.

24. FBA Outcome • Upon the completion of a functional behavior assessment, a positive behavior support plan can be developed and should include: • Modifications in the environment that reduce the likelihood of the problem behavior • Teaching plans for developing replacement skills and building competencies of the student, • Natural and minimally intrusive consequences to promote positive behavior and deter problem behaviors • A crisis plan (if needed)

25. FBA Implementation • A functional behavior assessment can be completed to assist with determining why a behavior is occurring and should include: • A clear description of the problem behavior(s) • Activities, times and situations that predict when behaviors will and will not occur (i.e., setting events) • Consequences that maintain the problem behaviors (i.e., functions) • Summary statements or hypotheses • Direct observation data to support the hypotheses

26. ASD Resources for Teachers • Autism Speaks School Community Tool Kit http://www.autismspeaks.org/docs/family_services_docs/sk/School_Community_Tool_Kit.pdf • Wrights Law www.wrightslaw.com • NEA (Nat’l Education Assoc) http://sites.nea.org/specialed/images/autismpuzzle.pdf

27. Special Considerations for ASD • Special Diets • Sensory Needs • Medications • Increased risk for seizures • Erratic behavior in non-verbal children when ill or injured

28. Asperger’s Syndrome • Cognitive Skills may be very high – gifted in certain areas • Despite intellectual advancement gaps in learning • Behaviors include: rigidity, black and white thinking, perseverating, anxiety, preference for sameness, poor social skills • Difficulty working in groups • Eccentric and quirky • Eye Contact may be atypical • Problems with transitions • http://www.udel.edu/bkirby/asperger/teachers_guide.html • CARD Center as a resource http://www.coe.fau.edu/card/contact.htm

29. Learning Disabilities…the list is growing • Dyslexia • Dyscalcula • Dysgraphia • NVLD

30. Specific Learning Strategies • Multi-sensory and kinesthetic tools • Breaking tasks down into component steps finding where your student struggles • Repetition and reinforcement • Visual and auditory aids • Use your ESE team as a resource • Online resources are proliferating – www.ldonline, www.greatschools.org, www.draronsonramos.com for links

31. Mood Disorders • Anxiety –GAD, SAD, Social Phobia, Selective Mutism • Depression –MDD, Dysthymia • Bipolar Disorder • OCD

32. Mood Disorders and Learning • Mood Disorders interfere with learning for obvious reasons • Unique characteristics of mood disorders can result in specific behavior patterns – i.e. anxious-fearful of mistakes, depressed – assumes-the worst, ocd – constant erasing • Support of teacher can be critical • Stress of social interaction • Fear of change

33. Handling Mood Disorders in the Classroom • Flexibility • Patience • Conflict Management • Self-Esteem • Avoid Confrontation • Support what can be accomplished, offer alternative assignments when possibl

34. Mental Health Resources for Teachers • Reach Institute – Columbia University http://www.thereachinstitute.org/school-support.html • National Association of School Psychologists www.nasponline.org specific resources for teachers

35. Other Disorders • Conduct Disorders • ODD • Tourettes Syndrome • Sensory Integration Dysfunction, aka Developmental Coordination Disorder • Sensory Impairments: Visual, Auditory • Fine Motor Skills and Visual Perceptual Weaknesses • Trichotillomania – related to anxiety and ocd

36. Conduct Disorder • Rare in the elementary school population • Signs may be evident • Extreme behaviors leading to injury, damage, no regard to consequences or feelings of others • Precursor to sociopathic and criminal behavior • Therapeutic school placement may be necessary

37. ODD • ODD vs. CD behavior does not involve serious violations of others' rights. I • Impairment in the child's family, academic and social functioning. • Children with ODD show extreme levels of argumentativeness, disobedience, stubbornness, negativity, and provocation of others. • While such behavior can be true of most children at some point of their lives, this diagnosis is warranted only for the few children (3-4%) whose symptoms persist over months or years, occur across many situations, and result in pronounced impairment in their functioning in home, school, and peer settings. • These children's anger is usually directed at authority figures. These children are more willing to lose a privilege than to lose a battle, so discipline by withholding privileges often has no effect on their behavior. • It is the oppositional struggle which becomes the reality in this child's mind, and this struggle, unlike the typical lower level defiance seen in many children, basically takes over the child's life and relationships with others. • For example, while "temper tantrums" are common among children, frequent and very prolonged temper tantrums (3-4 hours) often characterize children with ODD.

38. Tourettes Syndrome • Combination of vocal and motor tics for at least 6 months • Common in elementary school children • Peak incidence around 8-10 years • Self-awareness of tics is variable • Teasing and social isolation can be a problem • ADHD, Anxiety, and OCD can coexist • Treatment is supportive – counseling, medication, and family support • Tic exacerbation with stress • National Tourettes Syndrome Association - http://www.tsa-usa.org and http://www.tourettesyndrome.net

39. DCD/SID – variety of difficulties with fine motor skills, coordintation, visual-perceptual tasks, attention, and personal space • Sensory Impairment – specific to the impaired area • Fine Motor Delays – extreme difficulties with handwriting, coloring, neatness • Trichotillomania – exacerbated by stress and tension