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
  
  

Chores for kids become chores for parents?

As a parent I see the great value of chores for kids.

• Anyone can learn the satisfication of completing a task, improving self confidence.  
• Young children can improve self care competence such as with bathing and dental hygiene. 
• Older kids can learn money appreciation and management if they are paid and expected to save some and share some of their well-earned money.  Learning to save for a large ticket-item and not spend frivolously is a great life lesson many adults missed.
• Older kids can establish a great attitude about work and learn real-world skills such as laundry, cooking, and cleaning.  
• Kids might even gain self esteem by the positive intrinsic reward of a job well done.  
• They learn responsibility.

The downside?

Chores for the kids often make work on the parents harder.  (Who said parenting is easy?)

Parents must decide what tasks are able to be done by children at various stages of maturity.  There are on-line resources available to help guide parents.  This is one place I disagree with the WebMD list because they say a 10 year old can mow the lawn--not recommended by the AAP until 12 years!

Some good lists: Workingmom.com, Focus on the Family, Chores-Help-Kids

Parents must make sure the chores are completed or set a means of monitoring what is done. Ideally chores would be accomplished without fighting and whining, but how?  Verbal praise and acknowledgment is always a winner.  If parents choose to reward chores with stickers, gifts, or money, there must be a way to track when a task is complete.

Consistency is key in any form of discipline, and this includes the tracking of chores.  The biggest reason chores fail in my house is we (the parents) forget to check the lists to be sure the kids did them.  Having a consequence for not doing the expected chores versus getting a reward for doing the list... behavior experts disagree on these points.

Many behavior experts recommend to not remind kids to do chores.  They feel that the negative consequences of not doing the chores will teach the lesson better than the constant nagging to do the chores.  I have found that without reminders the chores are simply not done, but this does not mean I must always directly remind.  Praising the initiation ("I'm glad you are getting your homework done early tonight!"  "I see you remembered to sort your laundry, that's the hardest part!") is often an effective way to get kids to complete the task.  There is a fine line between nagging the kids to do the expected things and letting the chores slip by without being completed.

Over the years we have had many means of keeping track of chores in my family.

• When the kids were young, we first tried a dry erase board, but that got erased too easily.
• We then found a simple paper chart each week that had lists that could earn stickers. I liked the format because it separated tasks into the general categories below, but we often forgot to mark things off at the end of a busy day, so there was little reinforcement for the kids to do the chores.  The categories of chores:

• Self: included things such as brush teeth, bathe, get dressed 
• Home: included things such as pick up toys in living room
• Room: included things such as pick up room, make bed
• School: included things such as help a friend, homework, pack backpack

• One of my favorites was a system called 10-20-30Go! that friends developed.  It was wonderful because it is based on the kids taking full responsibility for marking down what they did. It is simple and includes a strong family and faith base.  It was one of the longest running systems that worked for us, but as all systems, it also faded in follow through.   A big reason was that we often had activities that interfered with the family meeting night, no matter what night of the week we tried to do it.  (Family meeting nights are still a great thing, but difficult in a busy house!)  We also found that the kids didn't look forward to their allowance, so it was little reinforcement to do the tasks.  They might have been too young at the time.
• Another favorite system of mine due to ease of use, cost (free), and kid -centered responsibility is MyJobChart.  It works well for kids who can use the internet fairly independently.  My kids can log in to their account and mark the chores as they do them, or once a day.  They earn points, which they can choose to share (with pre-determined charities), spend (on items I help pick), or save (for the future!)  I like many features of this system, but it still has periods that my kids forget about it for weeks, then periods that we all remember again.  They still do their chores (or they have no clean clothes the following week... or whatever natural consequence follows the forgotten chore) but they don't always mark them down for credit.

What do you find helps to keep your kids up to date on their chore list?