A Parents Guide to
Elementary School
Children
Judith Aronson-Ramos, M.D.
Developmental & Behavioral Pediatrics
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
The Chicken or The Egg
Learning Disorders
Emotional/Behavioral Problems
Disorders and Concerns
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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
Problems in Learning
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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 areasINPUT
OUPUT
ORGANIZATION
MEMORY
What are the clues of a learning
disability in preschoolers and early
elementary school children?
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Communication delays, such as slow language development or difficulty with
speech. Problems understanding what is being said or problems
communicating thoughts.
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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.
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Problems with memory and routine; for example, not remembering specifics
of daily activities and not understanding instructions or remembering
multiple instructions.
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Delays in socialization including playing and relating interactively with other
children.
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For an excellent checklist by age follow this link:
http://www.ncld.org/images/stories/Publications/Forms-Checklists-FlyersHandouts/ldchecklist.pdf
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.
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.
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.
What is the difference between a
learning disability, a developmental
delay, and a developmental disability?
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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.
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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.
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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.
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
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.
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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.
ADHD
• 20 % of school aged children
• Three types of ADHD: Inattentive,
Hyperactive Impulsive and Combined
• Diagnosed at age 6
• Rule out things that mimic ADHDAnxiety, Depression, LD
• Performance must be impaired to be
diagnosed
DSM IV Criteria
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Inattention
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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.
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.
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).
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.
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
Hyperactive - Impulsive
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Over active
Cant wait in line
Calls out
Fidgeting
Distracted
Impulsive
Interrupts
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
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
Neurobiology of ADHD
• Dopamine and Catecholamine
Transporter Genes
• Size of different brain structures
• Research supports familial
transmission
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.
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.
ADHD Resources
• CHADD www.chadd.org
• http://www.helpforadd.com
• National Resource Center for ADHD
http://www.help4adhd.org
• Tufts University https://research.tuftsnemc.org/help4kids/teachers/default.asp
• Reach Institute www.thereachinstitute.org
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
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; nonstimulants – 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
Biological Concepts
Most drugs in
psychopharmacology work by
affecting the communication
between neurons in the brain.
Is it Autism?
Difficulties in the following areas
• Communication
• Social interaction
• Repetitive Behaviors/Restricted
Interests
•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
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:
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
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.
More Signs
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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
Subtle Signs of ASD
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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
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?
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”
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?
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
Chronic Illness
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Asthma
Diabetes
Cystic Fibrosis
Cancer
Obesity
Chronic Ear and Sinus Infections
Allergies
Genetic Syndromes
Neurological Conditions
• Cerebral Palsy
• Tourette’s Syndrome
• Genetic Disorders - Downs
Syndrome, Fragile X
• Metabolic Diseases
• Epilepsy
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.
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
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
Treatment of ODD
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Parenting
Behavioral Therapy
Structured Behavioral Plans at school
Parent-Child Relationship training
Use of medications for severe
behavioral disturbance
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.
Conduct Disorder
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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
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.
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
Family
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Divorce
Chronic Conflict
Different parenting styles
Chaos
Adoption
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
Why Are There So Many
Books on Parenting?
• Google parenting and you will find 79 million
references
• Since the 1900’s 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 –NagLecture-Yell
Genuine praise is lacking
Stifling emotions
Punishment doesn’t fit the crime
Praising events and activities
over the child
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
Changes cont’d
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?”
THANK YOU!!
www.draronsonramos.com
Resources – Recommended Reading,
Links and Articles