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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
Incidence of Disorders
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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
ADHD
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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
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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
Hyperactivity
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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
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Impulsivity
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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
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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).
The many faces of ADHD
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“I sit like this at home”
Not all types of ADHD look
alike
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Inattention – spacey, day dreamers, forgetful
Can be overly helpful
Bias against boys
Poor sense of time
Carless
Disorganized
Distractible
Examples
Hyperactive - Impulsive
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Over active
Cant wait in line
Calls out
Fidgeting
Distracted
Impulsive
Interrupts
Combined Type
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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
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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 Tips
ADHD
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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.
ADHD Resources for Teachers
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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
ADHD Medications
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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
Autism Spectrum Disorders
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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.
DSM IV Criteria
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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
•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
What we do Know
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Normal development is altered – there are differences in brain growth, neuron
shape and density, neuronal connections and signaling molecules
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Changes in the structure and function of neurons – autism brain bank.
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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
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Double Hit Hypothesis – genes and the environment.
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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.
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Theories regarding oxidative stress, neuroimmunity, and neuorglial activation.
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Latest Genetic Research – 27 gene regions involved-BSRAP1, MDGA2
Autism in the Classroom
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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
Autism
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Core problems generally relate to
communication and socialization
Managing problem behaviors
Roots of Problem Behaviors
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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.
FBA Outcome
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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)
FBA Implementation
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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
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Autism Speaks School Community Tool Kit
http://www.autismspeaks.org/docs/family_ser
vices_docs/sk/School_Community_Tool_Kit.p
df
Wrights Law www.wrightslaw.com
NEA (Nat’l Education Assoc)
http://sites.nea.org/specialed/images/autismp
uzzle.pdf
Special Considerations for
ASD
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Special Diets
Sensory Needs
Medications
Increased risk for seizures
Erratic behavior in non-verbal children when
ill or injured
Asperger’s Syndrome
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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
Learning Disabilities…the list
is growing
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Dyslexia
Dyscalcula
Dysgraphia
NVLD
Specific Learning Strategies
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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
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Anxiety –GAD, SAD, Social Phobia, Selective
Mutism
Depression –MDD, Dysthymia
Bipolar Disorder
OCD
Mood Disorders and Learning
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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
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Flexibility
Patience
Conflict Management
Self-Esteem
Avoid Confrontation
Support what can be accomplished, offer
alternative assignments when possibl
Mental Health Resources for
Teachers
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Reach Institute – Columbia University
http://www.thereachinstitute.org/schoolsupport.html
National Association of School Psychologists
www.nasponline.org specific resources for
teachers
Other Disorders
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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
Conduct Disorder
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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
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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
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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.tsausa.org and http://www.tourettesyndrome.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