Understanding the Spectrum of Developmental Disorders in Elementary School Children

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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

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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

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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

•  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

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

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The many faces of ADHD

• I sit like this at home

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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
• Examples

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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 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

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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.

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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/h
  elp4kids/teachers/default.asp

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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 Teachers dehydration, extreme
  physical activity, illness, unusual behaviors

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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.

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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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• 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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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

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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

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Autism

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

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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
  autismeven those with the most challenging
  behaviorcan achieve a reduction in inappropriate
  behavior and success in the educational
  environment.

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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)

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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

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ASD Resources for Teachers

• Autism Speaks School Community Tool Kit
  http//www.autismspeaks.org/docs/family_services_d
  ocs/sk/School_Community_Tool_Kit.pdf
• Wrights Law www.wrightslaw.com
• NEA (Natl Education Assoc) http//sites.nea.org/s
  pecialed/images/autismpuzzle.pdf

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Special Considerations for ASD

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

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Aspergers 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/c
  ard/contact.htm

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Learning Disabilitiesthe list is growing

• Dyslexia
• Dyscalcula
• Dysgraphia
• NVLD

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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

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Mood Disorders

• Anxiety GAD, SAD, Social Phobia, Selective
  Mutism
• Depression MDD, Dysthymia
• Bipolar Disorder
• OCD

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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

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Handling Mood Disorders in the Classroom

• Flexibility
• Patience
• Conflict Management
• Self-Esteem
• Avoid Confrontation
• Support what can be accomplished, offer
  alternative assignments when possibl

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Mental Health Resources for Teachers

• Reach Institute Columbia University
  http//www.thereachinstitute.org/school-support.ht
  ml
• National Association of School Psychologists
  www.nasponline.org specific resources for teachers

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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

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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

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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.

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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.tourettesyn
  drome.net

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• 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

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