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Understanding the Spectrum of Developmental Disorders in Elementary School Children


Understanding the Spectrum of Developmental Disorders in Elementary School Children Judith Aronson-Ramos, M.D. Director Developmental & Behavioral Pediatrics of South ... – PowerPoint PPT presentation

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Title: Understanding the Spectrum of Developmental Disorders in Elementary School Children

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

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

  • 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

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
  • 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
  • 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
  • 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
  • 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

The many faces of ADHD
  • I sit like this at home

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

Hyperactive - Impulsive
  • 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

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

Classroom TipsADHD
  • A highly organized teacher with a structured and
    systematic teaching style and calm,
  • respectful manner of interacting with
  • 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
  • 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.

ADHD Resources for Teachers
  • CHADD www.chadd.org
  • http//www.helpforadd.com/
  • National Resource Center for ADHD
  • Tufts University https//research.tufts-nemc.org/h

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
  • Interactions few with other medications
  • Missed doses may be symptomatic immediately
  • Red Flags for Teachers dehydration, extreme
    physical activity, illness, unusual behaviors

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
  • 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.

DSM IV Criteria
    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

  • 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
  • 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

  • Cognitive abilities range from gifted to severely
  • Autism is a Pervasive Developmental Disorder
  • PDDs include PDD-NOS, Autism, Aspergers
    Syndrome, Retts Syndrome, and Childhood
    Disintegrative Disorder

What we do Know
  • Normal development is altered there are
    differences in brain growth, neuron shape and
    density, neuronal connections and signaling
  • 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
  • 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

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
  • Tactile and Kinesthetic learning over rote

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

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

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
  • A crisis plan (if needed)

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

ASD Resources for Teachers
  • Autism Speaks School Community Tool Kit
  • Wrights Law www.wrightslaw.com
  • NEA (Natl Education Assoc) http//sites.nea.org/s

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

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
  • CARD Center as a resource http//www.coe.fau.edu/c

Learning Disabilitiesthe list is growing
  • Dyslexia
  • Dyscalcula
  • Dysgraphia
  • NVLD

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

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

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

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

Mental Health Resources for Teachers
  • Reach Institute Columbia University
  • National Association of School Psychologists
    www.nasponline.org specific resources for teachers

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

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

  • 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.

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

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

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