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. 

Resources available:

• Finding More Help is a list of online resources as well as local professionals.
• CHADD is a national organization to support those with ADHD. Membership includes vast resources for learning more about ADHD.
• ADHDKC is a local chapter of CHADD and offers free parent meetings with great speakers on a variety of topics related to ADHD.
• Learning Disabilities Association of Kansas (LDAK) is a volunteer organization whose purpose is to advance the education and general well-being of children and adults with learning disabilities.
  
  

  More Quest for Health blogs on ADHD:

  • Why get diagnosed?
  • Who's Who in ADHD Treatment
  • Nutrition, Elimination Diets, and Vitamins
  • Alternative Treatments
  • Medications
  • Generic Methylphenidate HCl ER (for Concerta)
  • Red Dye #40 and Hyperactivity
  • Homework Battle Plan
  
  

Learning and Behavior Series Part 1: Labels - Why should my child be diagnosed?

This is the first in a series of posts about learning and behavior I will do over the next several months.

I see a lot of children with various behavioral and learning issues. Teachers and parents often first think of ADHD with any problem, but that isn't always the problem, or at least the primary one. It is simply one of the most common diagnoses. Since it is so common, I will focus on this topic often, but it can mimic other problems and it often co-exists with other issues.

I firmly believe that kids with learning and behavioral problems cannot just "work harder" to fix the problem. When I am sleep deprived, I cannot focus as well. I cannot read and comprehend what would typically be easily understood and retained. I lose track of things. I lose my temper more easily or get upset about the little things that usually wouldn't phase me. I must put extra effort into everything, which is even more exhausting. I liken this to how some people feel most of the time. How can we possibly expect them to just try harder without professional assessment and treatment?

One reason parents don't want to have their child diagnosed with ADHD or any other learning or behavioral problem is that they fear a label. What is a label? It is not a diagnosis, but the way we are perceived. Think about how many judgements and labels you make in a day. I try really hard to not judge because it's not my place, but those thoughts sneak into my mind all the time:

That person is rude. 

That's my shy (hyper, loud, smart, active, loving, etc) child.

That was a dumb statement. 

That group of giggling girls is too loud and out of control. 

I don't say anything with these thoughts most of the time because it's usually not my place. I often mentally rebuke myself for having them, but I still have opinions. The truth is that we all make judgements all the time. And when a child acts out a lot, he is judged and labeled. If a child never seems to be organized, she is judged and labeled. If a child falls behind academically, he is judged and labeled. It happens with or without a diagnosis. The label is there.

Wouldn't it be better to get a professional's evaluation and treatment? With proper management, your child might lose the negative labels and be able to succeed!

One of the problems with diagnosing many learning and behavioral disorders is they are difficult to test for since there is a continuum of symptoms of normal and atypical and there are so many variables (such as sleep) that can affect both learning and behavior. Even though ADHD is common, studies vary and disagree as to exactly how common it really is. Some experts think people are under diagnosed. Others claim too many are over diagnosed. The same goes for treatment: too few kids are medicated or too many kids are medicated. I think that all stems from the fact that the symptoms of ADHD are common to any neurotypical person, just to a larger degree, and symptoms often overlap with other disorders -- making a correct diagnosis difficult. There are still many people who think behaviors and focus problems are due to bad parenting. If it is a parenting issue alone, how would a medicine help? Probably in part due to this stigma, parents worry about how the diagnosis will reflect on the child and family more than any other diagnosis I know. If a child has an infectious disease or  a chronic condition such as asthma, there is much less hesitation to assess, diagnose, and treat the illness.

There are many reasons for parents to be hesitant to begin an evaluation when their kids are showing signs of a learning or behavioral problem. Some think it's just a phase. Many wonder if another few months of maturity will help the child. Some think the child is just misbehaving, and stricter rules or harsher punishments will help. Others think the child is just looking for attention and giving more praise will help. Some parents think it is because of the other children around -- you know, "Little Johnny is always messing around in class so my Angel Baby gets in trouble talking to him."

While I am all for looking for things on your own that can help a child's behavior and optimize their learning, I also think that avoiding the issue too long can lead to secondary problems: academic failures, poor self esteem, depression, drug/alcohol abuse, and more. Working with the school and seeking professional help outside of school can help your child succeed. If a parent is not wanting to start medication, there are other things that can be done that might help the child succeed once the specific issues are identified.

Why wouldn't you want to start a treatment that works? Asking a child with ADHD to just focus harder is like asking someone with nearsightedness to just focus harder. Without the help of glasses a person with nearsightedness can't see well. Without a medicine to help, some people just can't focus. If a child needs glasses to focus parents rarely say they'll just make the child try harder. They get glasses for the child. Without the glasses a child may have more injuries from not being able to see. He might have physical symptoms, such as headaches, from the eye strain. His grades might fall because he can't see the board. People see the vision issue as a medical one, yet when a brain has trouble with neurotransmitters causing focus problems, they often resist the medical treatment. Untreated ADHD also has consequences. The children suffer from poor self esteem because they constantly are reminded that their behavior is bad. They have a harder time doing tasks at school because they lose focus. They get distracted and miss important information. Children get in trouble for talking inappropriately, acting out or for invading other's personal space. They lag behind peers with social skills and often have a hard time interpreting how others react to their behaviors. Their impulsivity can get them into dangerous situations, causing more injuries. Older kids might suffer from depression and anxiety from years of "failures".

If you still worry about labeling your child with a diagnosis, think about what the root of your worry really is. Remember that the diagnosis is only a word. It doesn't define the best treatments for your child, but it opens the doors to allow investigation of treatments that might help your child. In the end most parents want healthy, happy kids who will become productive members of society. How can you best help them get there?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

• ADHD: CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am on the board of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!
• Anxiety: Many parents are surprised to learn how much anxiety can affect behavior and learning. The Kansas City Center for Anxiety Treatment has support groups for their current and former patients.  

• Autism: The Autism Society has a list of resources 
• Dyslexia: Dyslexia Support Group for youth with dyslexia

• Learning Disabilities: Learning Disabilities Association of Kansas
• Tourette's Syndromr and Tic Disorders: Tourette's Syndrome Association is a great resource for people with tic disorders. They have an active local chapter.
• General Support Group List: List of many support groups in Kansas: Support Groups in Kansas  (I found the search function to work best with the bottom option.)

I'll be writing a lot on this general topic over the next few months, so let me know if there are any specifics you'd like addressed!

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

Homework Battle Plan

Any parent with school aged children knows that homework can be a battle.  Even good students can procrastinate, prefer to play, or have practice after school leaving little time for homework.  Then there are the kids who struggle...

I think I threw my son's middle school homeroom teacher for a loop on back to school night.  She mentioned that I can always look on line to see the assignments, and I replied something to the effect of, "I don't have homework, so I'll never look.  It is his responsibility to know what is due."  I am not an absent parent.  I do ask about his day, what he's doing in class, and what his plans are with friends.  He knows I care because I show interest in him, but I don't micro-manage his day.  I do not want to be the parent responsible for the college kid who fails because Mommy can't manage his schedule.  Of course, I know my son and he's self motivated and capable of keeping track of assignments.  Another child might need more help, but at this age I would recommend covertly looking at the assignments and guiding with questions and looking for the student to offer solutions and plans to get the work done.


How can you help your kids with homework without letting it become your problem?  I am a firm believer that kids are the students, not the parents.  Kids need to take ownership of their homework and all other aspects of school.  Of course, for many kids this is easier said than done, but I hear all too often of college kids who have Mommy call the Professor to question a grade.  That is totally unacceptable.  Kids need to practice ownership from early on.  Parents need to guide always, but manage less and less as the kids grow.

Not every solution comes from a cookie cutter mold.  Kids have different personalities and abilities.  You know your kids best.  Think how they work and what makes them tick.

Many parents underestimate the problem with missing out on basics:  sleep, nutrition, and exercise.  If kids don't get the amount of sleep they need, healthy foods, and regular exercise, they will not be as successful academically.  I have blogged on this previously, and really feel that finding balance is important for everyone.


Kids have different problems with homework at different times, and they each deserve their own solutions. Not one of these "types" fits every child perfectly. Most kids have more than one of these qualities, but tend to fit into one type best.

Procrastination:  There is always something more fun to do than work.  Kids will put off overwhelming tasks or big projects because, well, there's a lot to do.

Ask not only what homework they have for tomorrow, but if there are any big projects due in the future.  See if they can estimate how much time it will take to do the project and help them plan how much to do each night to get it done on time.  

Breaking big assignments or long worksheets into small pieces with short breaks in between can help kids focus.  Use a timer for breaks or do a fun quick activity, like silly dance to one song.

Allow kids to have some "down" time after school for a healthy snack (brain food) and to run off energy.  Limit this time with a timer to 30 minutes or so.  The timer helps kids know there is an end point to the fun, and then it's time for work.  Play can resume when work is done correctly.

Poor Self Confidence: Kids who are afraid they won't understand their homework might fear even starting. They blame the teacher for not teaching it correctly. They might complain that they are stupid or everyone else is smarter. They blame the class for being too loud, causing distraction and therefore more homework.  They might complain of chronic headaches or belly aches.

Be sure to praise when kids do things right and when they give a good try.  Be honest, but try to think of something positive to tell them each day.  When they don't meet expectations, first see if they can see the mistake and find a solution themselves.   Guide without giving the solution.  Then praise the effort!

Find their strengths and allow them to follow those.  If they are poor in math but love art, keep art materials at home and display their projects with pride.  Consider an art class.  Remember to budget time.  Over scheduling can result in anxiety, contributing to the problems. 

Perfectionist:  While the desire to do everything right has it's benefits, it can cause a lot of anxiety in kids.  These kids think through things so much that they can't complete the task.  See also the "poor self confidence" section above, because these kids are at risk for feeling they are failures if they don't get a 100% on everything.  They can have melt downs if the directions don't make sense or if they have a lot of work to do.

Help your child learn organizational techniques, such as write down assignments and estimate time to do each project. Plan how much time to spend each day on big projects and limit to that time.  Help them review their progress in the middle of big projects to see if they are on track.  If not, have them establish another calendar and learn to review why they are behind.  (No self-blame.  Is it because one step took longer than projected, they were invited to a movie and skipped a day, they got sick and were not able to work...  This helps plan the next project and builds on planning skills.)

 Remember to give attention and praise for just being your kid.  These kids feel pressure to succeed, but they need to remember that they are loved unconditionally.  

If you notice they have an incorrect answer,  state "that isn't quite right. Is there another way to approach the problem?"  

Not everything is about the grade.  Praise the effort they put into all they do, not the end point.  Make positive comments on other attributes: a funny thing they said, how they helped a younger child, how they showed concern for someone who was hurt.

Encourage them to try something new that is outside their talent.  Not only are they exploring life, but they are developing new skills, and learning to be humble if they aren't the best at this activity.  Help them praise others.  Model this behavior in your own life.  

Co-dependence:  Helicopter parenting is a term often used to describe the parent hovering over the child in everything they do. This does not allow a child to learn from failing. It does not allow a child to grow into independence.  It allows the parent to "own" the problem of homework.  These kids call home when they leave the homework or lunch on the kitchen table for Mommy to bring it to school.  These kids grow up blaming everyone when things don't go their way and Mommy can't fix it. They don't learn to stand up for themselves.  They seem constantly immature with life situations.

Young children need more guidance, but gradually decrease this as they get older.  Teachers can help guide you on age appropriate needs.  Most parents must sign a planner of younger kids, but as kids get older the kids become more responsible for knowing what the homework is.  Many schools now have websites that parents can check homework assignments, but be sure the kids own the task of knowing what is due too.  

Have a place that children can work on homework without distraction (tv, kids playing, etc).

Be available to answer questions, but don't do the work for them.  If they need help, find another way to ask the question that might help them see the solution. Get a piece of scrap paper that they can try to work through the problem.  If they have problems with reading comprehension, have them read a few lines then summarize to you what they read.   They can take notes on their summary, then read the notes after the entire chapter to get a full summary.

Busy, busy, busy:  Some kids are really busy with after school activities, others just rush through homework to get it done so they can play.

Set limits on how much screen time (tv, video games, computer time) kids can have each week day and week end.  A maximum of 10 hours per week of screen time is recommended by experts.  If they know they can't watch more than 30 minutes of tv, they are less likely to rush through homework to get to the tv.  

Ask kids to double check their work and then give to you to double check if you know they make careless mistakes.  Don't correct the mistakes, but kindly point them out and ask if they can find a better answer.  Once they learn that they have to sit at the homework station until all the work is done correctly, they might not be so quick to rush. 

If kids have after school activities the time allowed for home work and down time are affected.  Avoid over scheduling, especially in elementary school.  Be sure they have time for homework, sleep, healthy meals, and free time in addition to their activities.  Are the activities really so important that they should interfere with the basic needs of the child? Is the child mature enough to handle the work load?

Kids who are in constant motion can't seem to sit still long enough to do homework.  Be sure they have the proper balance of sleep, nutrition, and exercise or all else will fail.   Praise their efforts when they are successful.  Set a timer after school to let them play hard for 30 minutes, but then make them sit. Help little ones organize what needs to be done and break homework into several smaller jobs.  Set regular 5 minute breaks every 30 minutes so they can release energy.  Set a timer to remind them to get back to work and compliment them when they get back on task.

Struggling despite help:  There are many reasons kids struggle academically.  Reasons vary, such as behavior problems, anxiety, illness, learning disabilities, bullying, and more.

If they are struggling academically, talk with the teacher to see if there are any areas that can be worked on in class or with extra help at school.  Can the teacher offer suggestions for what to work on at home?

If kids have chronic pains or school avoidance, ask what is going on.  Depression and anxiety aren't obvious and can have vague symptoms that are different than adult symptoms.  Bullying can lead to many consequences, and many kids suffer in silence.  If your child won't talk to you, consider a trained counselor.

Talk with your pediatrician if your child is struggling academically despite resource help at school or if he suffers from chronic headaches or tummy aches.  Treating the underlying illness and ruling out medical causes of pain is important.  Depression, anxiety, ADHD, and other learning disorders can be difficult to identify, but with proper diagnosis and treatment, these kids can really succeed and improve their self confidence!