Lecture 4: 4yo WCC, School Readiness, Learning Differences, and autism

Question 1

4 yo WCC

Answer 1

• Review of Health
• Healthy habits:
  
  • Nutrition
  • Dental
  • Elimination
  • Sleep
  • Activity
• Developmental Milestones
• Hearing and Vision Screening
• Tuberculosis Screening (risk factor based)
• Vaccines

Question 2

4 year milestones

Answer 2

• Gross Motor- Balances on one foot 4-8 seconds, hops on one foot, gallops, throws ball overhand ~10 feet
• Fine Motor- Copies square, writes first part of name, ties a knot
• Language- Uses 300 – 1,000 words, 100% understandable speech, strings full sentences together to tell stories
• Social- Has a preferred friend, group play, can take turns in a game, magical thinking
• Problem Solving- Follows 3 step commands, goes to toilet alone, brushes teeth alone, uses fork well, can use clothing with buttons

Question 3

vaccines

Answer 3

• MMR #2
• VZV #2
• IPV #4
• DTaP #5
• Combinations Available:
  
  • MMRV – Pro Quad (think: Quad means 4 = 4 yo and 4 shots in 1)
  • Kinrix: IPV and DTaP (think: skipping off to KINdergarten next year)

Question 4

hearing and vision

Answer 4

• Old enough to follow directions, recognize shapes
• Vision is evaluated using Snellen Chart for children.
  
  • Refer for further evaluation if cannot read 20/32.
  • New technology is now available where smart phone attachments can detect the refractive error on children at much younger ages.
• Hearing is evaluated using audiometer.

Question 5

school readiness

Answer 5

• Physician should perform:
  
  • Vision Screening
  • Hearing Screening
  • Hemoglobin Screening – building blocks of learning
  • Lead Screening – if not done or if learning difficulties
  • Sleep Hygiene/Obstructive Sleep Apnea Screening
  • Elimination – toilet trained, expect elimination problems once entering school
  • Literacy Promotion
  • Any chronic medical issue can have an effect on learning
• ​
• Skills to assess:
  
  • Ability to take turns
  • Ability to play with peers
  • Ability to play separated from adult
  • Ability to sustain activities
  • Ability to follow a story
• Physician should watch for:
  
  • Understandable speech, full sentences
  • Knowledge of colors
  • Copy Shapes
  • Stand on one foot
  • Dress and Undress
  • Knows age, name, gender

Question 6

conditions that affect learning

Answer 6

• Intellectual Disability
• Learning Disabilities
  
  • Ex: Dyslexia
• Emotional/Behavior Disorders
  
  • Ex: ADHD
• Autism spectrum Disorder
• Hearing/Vision impairments

Question 7

specific learning disability

Answer 7

• Performance in one (or more) academic area(s) below expected for overall cognitive ability
• “A disorder in one or more basic psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, speak, read, write, spell, or do mathematical calculations. (…) Such terms do not include children who have learning disabilities which are primarily the result of visual, hearing, or motor handicaps, of mental retardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage.” –US Office of Education
• Specific learning disability is where your performance is below the expected for cognitive ability

Question 8

learning disabilities

Answer 8

• Children with learning disabilities can have intelligence in the normal range.
• Examples of specific learning disabilities:
  
  • Dyslexia- Difficulty with reading
  • Dyscalculia- Difficulty with math
  • Dysgraphia- Difficulty with writing
• Per the American Academy of Child and Adolescent Psychiatry, 1 in 10 children have a learning disorder (LD).
• Most common LD is dyslexia. Accounts for 80% of LD.

Question 9

pathogenesis of learning disabilities

Answer 9

• Some genetic predisposition
  
  • Higher rates in siblings and twins
  • Increased likelihood if a parent had a learning disability
• Linked to some genetic disorders.
  
  • Neurofibromatosis 1- Rates as high as 50%
• Premature birth, in utero substance exposure, perinatal issues can increase risk for learning disabilities
• Lead poisoning, malnutrition, head injury

Question 10

signs of LD

Answer 10

• Increased Learning Effort:
  
  • Students find school boring
  • Anxiety with school
  • Class clown
  • Longer time to complete work
• School Distress:
  
  • Frequent failing grades
  • Frequent absences
  • Social disengagement
  • Suspensions
  • Aggressive, bullying behaviors
• School Failure
  
  • Retention (having to repeat a grade)
  • Expulsion
  • Dropping out

Question 11

identification and diagnosis

Answer 11

• Screen for school progress
  
  • What’s your favorite class?
  • Is any class particularly hard? Why?
  • What kind of support is the child receiving?
• Formal diagnosis involves intensive testing that should be provided by the school system.
• Once a learning disorder has been diagnosed, the school system is required to provide the proper accommodations to help the child.

Question 12

dyslexia

Answer 12

• International Dyslexia Association
• “Dyslexia is a specific learning disability that is neurological in origin.
• It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities.
• These difficulties typically result from a deficit in the phonologic component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction.
• Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede the growth of vocabulary and background knowledge.”

Question 13

what do people with dyslexia see

Answer 13

• Wrong orientation of letters
• Upside-down letters
• Moving letters

Question 14

signs of dyslexia

Answer 14

• Some signs in history:
  
  • Late-speaking
  • Did not learn letters in kindergarten
  • End of first grade cannot read and has difficulty spelling.
• Children may have compensated well while expectation was “learning to read,” but can have more difficulty when their objective is “reading to learn”.
• “High functioning” children may learn to memorize certain words to compensate for their disability.

Question 15

dyslexia management and prognosis

Answer 15

• Management is dependent on when dyslexia is suspected.
  
  • For the youngest children who are learning to read early literacy programs focus on literacy promotion.
  • For children who are learning to read and are behind classmates, re-learning phonologic processing.
  • For older children (adolescents) accommodation is the focus.
• Affected individuals can continue to have difficulty with their learning disorder into adulthood.

Question 16

behavior disorders

Answer 16

• Children with learning disorders can present with symptoms that are concerning for a behavior disorder.
• Prior to diagnosis of a behavior disorder it is important to investigate organic and social causes of the child’s inappropriate behavior.
  
  • Pain
  • Hunger
  • Trauma
  • Anxiety

Question 17

attention deficit hyperactivity disorders (ADHD)

Answer 17

• Behavior disorder that is comprised of inattention, hyperactivity and impulsivity.
• Types of ADHD:
  
  • Predominantly Inattentive
  • Predominantly hyperactive/impulsive
  • Combined
• Epidemiology:
  
  • Rate: 5-10% in US
  • Male: Female: 2-6:1
  • Males more likely to have hyperactivity/impulsivity
  • Females more likely to have inattentive type

Question 18

diagnosing ADHD

Answer 18

• Most common screening tool is the Vanderbilt Assessment
• Can be used in children ≥ 4 years old.
• Parent and teacher* are asked to fill out a questionnaire
• The questionnaire can be used to screen for:
  
  • ADHD
  • Oppositional-Defiant Disorder
  • Conduct Disorder
  • Anxiety/Depression
• If possible, refer for more thorough testing
• *The teacher should have constant contact for 4-6 months prior to filling out Vanderbilt

Question 19

diagnostic criteria ADHD per DSM V

Answer 19

• Children need to demonstrate ≥ 6 symptoms for at least 6 months to a degree that is inconsistent with developmental level, and that negatively impacts school, academic and occupational activities.
• There need to be several inattentive of hyperactive/impulsive symptoms in two or more settings.
• There should be several symptoms present before 12 yo.
• Interferes with social, academic or occupational function.
• Symptoms cannot be present only during exacerbations of other psychiatric disorders (ex. depressive episode or manic episode)

Question 20

Inattentive symptoms

Answer 20

• Often fails to pay close attention to detail, or makes mistakes.
• Often has difficulty sustaining attention on tasks or activities.
• Often does not seem to be listening.
• Often does not follow through on instructions or fails to finish tasks.
• Often has difficulty organizing tasks and activities.
• Often is reluctant, avoids or dislike engaging in tasks that require sustained mental effort.
• Often looses things necessary for tasks or activities.
• Is easily distracted by extraneous stimuli.
• Is often forgetful in daily activities.

Question 21

hyperactive and impulsive symptoms

Answer 21

• Often fidgets (tapping, squirming)
• Often leaves seat when expected to be seated.
• Often runs and climbs in situations where inappropriate. (In adolescents or adults may be a feeling or restlessness.)
• Often unable to participate in leisure activities quietly.
• Often “on the go” or “driven by a motor”.
• Often talks excessively.
• Often blurts out answer before question completed.
• Often has difficulty awaiting turn.
• Often interrupts others.

Question 22

diagnosing subtypes of ADHD

Answer 22

• Combined:
  
  • of hyperactivity/impulsivity
  • of inattention
• Predominantly Inattentive Presentation
  
  • of inattention
  • < of hyperactivity/impulsivity
• Predominantly Hyperactive/Impulsive Presentation
  
  • of hyperactivity/impulsivity
  • of inattention

Question 23

ADHD severity

Answer 23

• Refers to level of impairment
  
  • Social Functioning
  • Occupational/Academic functioning
• Mild, Moderate, Severe

Question 24

treatment of ADHD

Answer 24

• Non-Pharmacologic Interventions:
  
  • Behavior modification
  • School based intervention
• Medications:
  
  • 1^st line for children yo who meet diagnostic criteria.
  • Can be used in younger children (4-5 yo) if they are not responding to behavior therapy.
  • Most common medications are stimulants in short acting or long acting forms.
  • Side effects include weight loss, sleep problems, and can affect mood.
  • Response to stimulant medication cannot be used to confirm ADHD diagnosis because all children can show improved behavior regardless of diagnosis.

Question 25

Factors to consider with ADHD

Answer 25

• Factors that can lead to misdiagnosis of ADHD:
  
  • Trauma
  • Anxiety
  • Hunger
  • Child who is young for grade level
  • Giftedness
  • Learning disability
  • Language or communication disorder
  • ASD
  • Other medical diagnosis that can affect cognition or behavior.

Question 26

Autism

Answer 26

• What is Autism?
  
  • A neurodevelopmental disorder characterized by deficits in 2 domains:
    
    • Communication and social interaction
    • Restrictive and repetitive patterns of behavior, interests and activities
• The cause of Autism is unknown, but it is thought to be associated with a genetic predisposition with a possible environmental “trigger”.
  
  • 4:1 male to female distribution (1:54 males, 1:252 females)
  • High concordance with siblings and twins
  • 75% of children with ASD have no identifiable genetic cause.
• Physiologic Evidence of Autism:
  
  • Brain growth rates
  • Abnormalities of grey and white matter
  • PET scan abnormalities in serotonin function
  • Decreased Purkinje cells in the cerebellum

Question 27

autism and vaccines

Answer 27

• Bottom line: vaccines do not cause autism
• 1998: Andrew Wakefield, a pediatric gastroenterologist in England, along with 11 other researchers published a paper connecting MMR with developmental regression in 12 patients.
• Since then 10 of the 12 researchers published retractions citing no causal link between MMR and autism.
• Wakefield was funded by lawyers who were representing patients with lawsuits against vaccine companies.
• The British Medical Journal published a series of articles discussing how Wakefield and colleagues chose facts that suited their hypothesis and falsified facts.
• Further studies have disproven this theory repeatedly

Question 28

autism and vaccine theories and ingredients

Answer 28

• Antigen Theory:
  
  • Exposure to many antigens (ie. Multiple vaccines) causes autism.
  • CDC study from 2013 looked at antigen load of children in the first 2 years of life and there were no differences between children with ASD and those without the diagnosis.
• Vaccine Ingredients
  
  • Thimerosal-Mercury derived additive that was used as a preservative for multi-dose vials of vaccine.
  • Since 2003 there have been 9 CDC-funded studies that found no connection between thimerosal and ASD.
  • 1999-2001- Thimerosal was reduced to trace amounts in all childhood vaccines.

Question 29

diagnosing autism

Answer 29

• DSM V, published 2013
  
  • Diagnostic and Statistical Manual of Mental Disorders
  • Main changes to Autism diagnosis:
    
    • Did away with subcategories such as Asperger’s.
    • Symptoms can be current or historical.
    • Each person should be evaluated in terms of other medical issues (genetic diagnosis, seizures, language delay, ect…)
    • Social Communication Disorder- Describes disability in social interaction without repetitive behaviors
• Most Popular: Modified Checklist for Autism in Toddlers (M-CHAT)
  
  • New edition is M-CHAT R/F
  • Designed to be administered to children between 16-30 months
  • Not meant for diagnosis
• For other ages:
  
  • Communication and Symbolic Behavior Scales and Development Profile (children less than 18 months)
  • Childhood Autism Screening Test (School-aged children)

Question 30

MCHAT scoring

Answer 30

• Low Risk: 0-2, Re-screen after 24mo.
• Medium Risk: 3-7, Perform MCHAT R/F (flowsheet that elaborates on abnormal answers regarding communication, social interaction and repetitive movements). Positive screen triggers a referral.
• High Risk: 8-20, Referral to behavior specialist.

Question 31

diagnostic criteria for autism

Answer 31

• Criteria 1: Persistent deficits in social communication and interaction in multiple settings. Three of the following:
  
  • Social-emotional reciprocity (adjusting emotions in a back-and-forth setting)
  • Non-verbal communication (ex. Poor eye contact, inappropriate body language)
  • Developing, maintaining, and understanding relationships (ex. Adjusting behavior to social setting, making friends, lack of interest in peers)
• Stereotypical movements, use of objects, or speech (ex. echolalia, ordering toys) https://www.youtube.com/watch?v=w5xL4SMQ6g8
• Insistence on sameness, unwavering adherence to routines, ritualized behavior (ex. Ritualized greetings, needing to take the same route everyday).
• Highly restricted, fixated interests that are abnormal in strength or focus (preoccupation with certain objects, perseverative interests)
• Increased or decreased response to sensory input or unusual interest in sensory aspects of the environment. (ex. Adverse responses to sound, indifference to temperature, excessive touching or smelling of objects).
• Criteria 3: Must impair function
• Criteria 4: Must be present in early development. May be more apparent later on with new stressors (ex. starting day care). Symptoms may be masked by learned adaptations.
• Criteria 5: Symptoms cannot be better explained by intellectual disability and global developmental delay. (Intellectual disability can co-occur with ASD)
• Important specifications:
  
  • With or without intellectual impairment
  • With or without language impairment
  • Associated with medical, genetic or environmental factor
  • Associated with another neurodevelopmental, mental or behavior disorder
  • With catatonia
• Referral to behavior specialist for neuropsych evaluation
  
  • ADOS-2
• Testing for genetic causes:
  
  • Fragile X
  • Rett syndrome
  • Angelman Syndrome
  • Neurofibromatosis
  • Tuberous Sclerosis
• Ancillary testing:
  
  • Hearing and vision testing
  • Speech and language assessment
  • Sensorimotor and occupational testing
• Imaging and Lab:
  
  • Not routinely indicated for diagnosis

Question 32

management for autism

Answer 32

• Co-Occuring Disorders
  
  • 45-75% of ASD cases have intellectual disability
  • 11-39% have a seizure disorder
  • 10-25% have an associated genetic disease
  • 50% have Anxiety and Phobias
  • 50% with Obsessive Compulsive Disorder
  • 2/3 with ADHD
  • Depression–more common in older children as they become more aware of their differences from peers.
  • Disruptive behavior- May require treatment with antipsychotics.
  • Bipolar Disorder

Question 33

treatment for autism

Answer 33

• Applied Behavior Analysis (ABA):
  
  • Behavior therapy to nurture socially appropriate behaviors and help decrease and manage challenging behaviors.
  • Once children have the diagnosis of Autism they should be eligible to receive this treatment
• Medications may be needed to manage behavior and other psychiatric diagnosis.
• Alternative Medicine- Supplements such as melatonin may be helpful. However, special diets, chelation therapy, immunomodulation, and manipulative body therapies are not proven to be helpful and may be harmful.

Question 34

Individualized education program (IEP)

Answer 34

• Legal document for children with special learning need that addresses what a child’s needs are, how services will be provided an how progress will be monitored.
• Required by law through the Individuals with Disabilities Act (IDEA).
• Every child is covered by Special Education from 3-22yo.
• Child should have a need for special education as a result of disability in order to qualify.

Question 35

components of IEP

Answer 35

• The document should contain:
  
  • Present level of performance
  • Annual education goals
  • What support and services a school will provide.
  • Modifications and accommodations that the school will provide to allow for equal access to resources.
  • Accommodation for standardized tests.
  • How and when a school will measure progress.
  • Transition planning for after high school graduation.

Question 36

diagnoses that qualify for IEP

Answer 36

• Autism
• Deaf-blind
• Deaf/Hearing Impairment
• Emotional Disturbance
• Traumatic Brain Injury
• Visual Impairment, blind
• Intellectual disability
• Multiple disabilities
• Orthopedic impairment
• Other health impairment (ex. ADHD)
• Specific Learning Disability (ex. Dyslexia)
• Speech and language impairment

Question 37

504 plan

Answer 37

• Required by Law through Section 504 of the Rehabilitation Act.
• Document that provides how a child with disabilities will access education/resources.
• Definition of disability per Section 504 is broader than IDEA and therefore children who don’t qualify for IEP may qualify for 504 plan.
• Less structured than IEP.