Judith Aronson-Ramos, MD, FAAP Developmental & Behavioral Pediatrics of So FL CHADD November 2012

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 Class size, lack of staff and resources  Curriculum and standardized testing demands  Lack of training in disabilities  Effect of individual accommodations on the class as a whole  Disruptions to the schedule  Parent demands  Time constraints

 Unique needs of child  Performance at home vs. school  Emotional aftermath of the school day  Lines of communication with the teacher  Negative peer influence  Goodness of fit with the teacher  Homework nightmares

JPG

 Child’ s behavior in the office  Teacher’s expectations and observations  Clinical judgment and experience  Reasonable expectations of medication and psycho- social interventions  Parent and Teacher education  Complications of peer influence  Medical history and active medical problems  Impaired teachers and parents

Elementary School 8 yr old Joey, third grade, always active, very bright, learns best through doing, has trouble sitting, frequently distracted by peers, interrupts the teacher, cannot seem to remember classroom rules, needs frequent prompts and reminders, if his teacher is not watching will be out of his seat bothering other students. Parents report at home he is full of energy, cannot sit for dinner, has trouble sitting down to do his homework, tantrums if he does not get his way, often comes home from school saying “I’m just stupid”

 Joey’s need for movement and difficulty sitting  Low tolerance for sedentary activities  Distracted by peers and the environment  Limited ability to stay on task or inhibit impulses  Bright and curious  Loves learning through doing  Homework is a battle

 Reward system between two environments  Movement breaks – extra points when not used  Visual reminders – cards, checklist, drawings  Positive peer role models  Break work time and assignments into chunks  Remember the teacher may need support too  Find something positive to praise  Behavioral report card  Conference at every reasonable opportunity

 Many physicians will specify a way to provide feedback use it!  Bring work samples, teacher comments in agendas and notes, and a list of concerns to you office visit  See if your physician will provide you with rating scales to obtain data from you and the teacher  The Vanderbilt Teacher and Parent rating scales are useful and available on my website Also available are ratings for side effects, and other issues

Clinical Attention Problem Scale AM/PM 0 = Not true 1 = Somewhat or Sometimes True 2= Very or Often True Morning 1. Fails to finish things he/she starts Can’t concentrate, can’t pay attention for long Can’t sit still, restless, or hyperactive Fidgets Daydreams or gets lost in his/her thoughts Impulsive, or acts without thinking Difficulty following directions Talks out of turn Messy Inattentive, easily distracted Talks too much Fails to carry out assigned tasks

Afternoon 1. Fails to finish things he/she starts Can’t concentrate, can’t pay attention for long Can’t sit still, restless, or hyperactive Fidgets Daydreams or gets lost in his/her thoughts Impulsive, or acts without thinking Difficulty following directions Talks out of turn Messy Inattentive, easily distracted Talks too much Fails to carry out assigned tasks Additional Comments

Vanderbilt Teacher Informant - Inattention 1.Fails to give attention to details or makes careless mistakes in schoolwork Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork not due to lack of comprehension Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities

Hyperactivity/Impulsivity 10. Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining0123 seated is expected 12. Runs about or climbs excessively in situations in which remaining0123 seated is expected 13. Has difficulty playing or engaging in leisure activities quietly Is “on the go” or often acts as if “driven by a motor” Talks excessively Blurts out answers before questions have been completed Has difficulty waiting in line Interrupts or intrudes on others Loses temper From the Vanderbilt Rating Scale Teacher Informant FORMS

SELF RATINGS 1.How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. 5.How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6.How often do you feel overly active and compelled to do things, like you were driven by a motor? 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8.How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9.How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10.How often do you misplace or have difficulty finding things at home or at work? 11.How often are you distracted by activity or noise around you?

Part B 12.How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13.How often do you feel restless or fidgety? 14.How often do you have difficulty unwinding and relaxing when you have time to yourself? 15.How often do you find yourself talking too much when you are in social situations? 16.When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17.How often do you have difficulty waiting your turn in situations when turn taking is required? 18.How often do you interrupt others when they are busy?

 For your follow up or assessment visit the physician will use clinical impression, history, previous assessments, rating scales, and direct observation and testing  For ongoing management the more data a physician has the more capable she is to make the best recommendations for your child and family  Make the most of your office visit, use your time with the doctor wisely

 Everyone is busy  Help coordinate communication  and cell phone is often best  Share notes between the two

 No an uncommon scenario  You cannot be an effective advocate for your child, if you are not in control of your own symptoms  You cannot be an effective teacher if your classroom is in chaos  You have the gift of empathy  Use what you have learned to do the best for your child/students

 forget to record the homework assignment  forget to bring the materials that they need to complete homework  put off starting homework at home  tend not to persist or stay focused on the homework assignment  may complete the homework in a careless manner  forget to hand in assignments that are completed

 STUDENTS often need direct instruction in some basics BEFORE they can even attempt to complete home work independently. The following apply to all students and can be modified to be age appropriate-  Instruction in how to accurately record an assignment in an agenda, planner etc.  TIME - plan how much time would be needed to complete an assignment, use timers with young children  Organize materials daily –design a specific work space for homework  Start and check work with your child as age appropriate  Keep track of assignments with your child

 If you can obtain modifications and accommodations with homework before assigned this is best  Get perspective remember it is only homework, speak softly provide encouragement  Don’t over support and older child, let them fail, natural consequences are invaluable  Know the difference between supporting and over doing for your child  Make homework relevant where and when you can…real world connections, life parallels, daily life applications

 Can’t work independently – Get child started, check in periodically  Can’t sit – sit for 10 minutes at a time  Doesn’t write down homework – will write the assignment 3/5 days a week  Leaves papers and books at school – will check with teacher before packing up  Interrupts in class – earn sticker for every time hand is raised

 Antecedent – what preceded the problem behavior  Behavior – exactly what occurred  Consequence – what happened after, events that followed the behavior

 Teacher was working in small groups with students  Jonny threw his pencil at fellow student  Teacher put Jonny in time out  ANALYSIS: Teacher was working on math skills, Jonny’s worst subject, he was unable to complete his worksheet, he wanted his teacher’s attention, he went to time out and did not have to complete the work sheet

 Prepare for your appointments  Be as specific as possible about your concerns  Keep track of troubling medication side effects  Be patient  Share as much specific information as possible – not what you think caused a problem behavior but describe the problem behavior  Consider using an ABC chart  Let your older child or teen speak for themselves

 Mindfulness  Objectivity  Understanding the roots of your stress  Consider your child or teen