Sunday, June 22, 2014

Learning and Behavior Series Part 2: Who's who in learning and behavior testing

This is part 2 in a series of posts on Learning and Behavior issues.

Parents are sometimes surprised to learn that I treat ADHD, anxiety, and some other behavioral disorders. There are some pediatricians who don't, but I find there is a huge need, and I feel that in many cases since I've followed a child for years, I know them well and can help better than a specialist who will only see them a few times. That being said, I do use specialists often. Of course the professionals at school are imperative to being part of the team. And there are times when the diagnosis isn't clear, or a child doesn't respond to the treatment well and other healthcare specialists are very helpful to assess the issues.

Many different professionals typically work together to help assess learning and behavioral concerns, each using his area of expertise to contribute to the whole picture. There are no specific laboratory or imaging tests available to determine a diagnosis on a routine basis. This can make it a little tricky if the symptoms are not clear cut. Many learning and behavior problems have similar symptoms, so it might take several professionals to help evaluate the situation. We often base our diagnosis on the symptoms parents and teachers (and older children) report and by ruling out other disorders. There are standardized questionnaires or tests for various conditions that have been validated. Each condition has specific treatments that have been shown to benefit the condition. There are also tests available, such as EEG for ADHD, that are not shown to be beneficial and can increase cost without adding to the diagnostic evaluation. There are of course many tests and treatments available that have not been proven to help. If it sounds too good to be true, it probably is. Discuss tests you are considering with your child's doctor first, especially if there is a large price tag attached.

The evaluation includes several types of assessments because there are many things that can cause learning or behavioral issues. Contributing issues include but are not limited to: ADHD, anemia, anxiety, bullying or abuse, chronic illness, depression, hearing or vision problems, learning disabilities, malnutrition, oppositional defiant disorder, sensory integration disorder, and sleep deprivation.

A big part of the diagnosis lays in the symptoms noted at home and school, so there are a lot of questions about how your child fares at each. Both parents and teachers and any other significant adults should fill out standardized questionnaires as recommended by the clinician doing the evaluation for many behavioral issues. It is important to answer each question as honestly as possible to avoid misrepresentation of symptoms, which can lead to an improper diagnosis. It is also important to review the family history, since many of these issues run in families. A physical exam should be done to help identify any physical symptoms that can contribute to learning or behavioral problems. This should include hearing and vision assessments by appropriate professionals. Some clinicians may go to your child's classroom to observe behaviors. Psychological and IQ testing might be performed, depending on the symptoms.

So where does everyone fit into the diagnosis and treatment of kids with behavioral or learning issues?

  • Parents (or primary caregivers) are critical to giving insight into how children learn and behave. They should be interviewed and fill out standardized questionnaires to help with the diagnosis and then their feedback on how each treatment is working is helpful in fine tuning treatment plans.
  • Teachers are imperative in helping assess the issues and concerns since they can compare any one child to a room of their peers and they know how your child handles various situations and what their typical behaviors are. Teachers with advanced background in learning disabilities are used to help address specific concerns. It is recommended that each teacher fill out standardized questionnaires to help with the initial evaluation of focus and behavior disorders and again to assess responses to treatments. Schools may put students on IEP or 504 Plans to help with their education. For more on these see IEP & 504 Plan. 
  • Physical Therapists, Occupational Therapists, Audiologists, and Speech Therapists can be school based or private, but they are helpful in addressing specific motor skills, sensory issues, hearing issues, or speech/language concerns. They do not prescribe medication, but work within their area to improve certain skills that affect learning and behavior.
  • Psychologists (clinical psychologists, cognitive psychologists, educational psychologists and neuropsychologists) and clinical social workers offer testing as well as therapy for many disorders. They can do parent training to help parents manage behaviors at home. They cannot prescribe medications, but many people find that the therapy provides enough benefit that medication is not needed or that the therapy in addition to medicine helps better than either treatment alone. Cognitive behavioral therapy is the preferred first line treatment for certain disorders, such as ADHD in a young child or anxiety. These therapists also often provide social skills training, which is needed for many children with behavioral and learning issues who don't learn social skills as easily as their peers. You should check your insurance list of providers to see who is covered. It also might be worth pricing some who do not take your insurance but will give you a bill to submit yourself. It may be that even if a person is out of network your cost is about the same as a person who is harder to get in to see but on your plan.
  • Physicians (pediatrician, family physician, developmental pediatrician, neurologist, and psychiatrist) can prescribe medications for treatment of certain diagnoses, such as ADHD or anxiety. Not all have experience with each of these issues so you must ask what their experience is. It can take quite awhile to get into specialists and they can be expensive, so starting with your primary physician often is easier and very helpful to rule out medical issues and to do the evaluation and treatment if they are comfortable. Many psychiatrists do not accept insurance and they are typically difficult to get in to see. Physicians (including psychiatrists) generally do not do therapy. They focus on the medication benefits and side effects.
  • Nurse practitioners and physician assistants can work with physicians (and independently in some states) to diagnose disorders and prescribe medications to treat them. They do not offer psychotherapy. Benefits include that they are generally easier to get in to see and they are relatively inexpensive compared to physicians. Not all are comfortable with treating these issues.
The types of professionals who work with any given child to assist in diagnosis and treatment vary depending on the issues at hand, but the most important thing is that they work as a team and communicate with one another. This communication is often done through parents and written reports, but it is important that all members of the team have access to what the others are doing. 

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