in the Early Elementary Years

Transcription

1 Volume 17 l Number 2 l Sprig 2010 Diagosis of Attetio-Deficit/Hyperactivity Disorder i the Early Elemetary Years Mary A Roberts, PhD Cliical Professor of Pediatrics, Uiversity of Iowa Childre s Hospital Attetio-Deficit/Hyperactivity Disorder (ADHD) is a commo disorder of school-age childre, with prevalece estimates ragig from 3 to 7 percet. Boys are more likely to be diagosed with ADHD: At the Uiversity of Iowa Childre s Hospital Pediatric Psychology Cliic there is a ratio of three boys diagosed for each girl. I child psychiatry settigs the ratio may be as high as ie boys to oe girl. The three symptom dimesios of the diagosis of ADHD iclude iattetio, overactivity, ad impulsivity of greater tha six moths duratio that is outside the ormal limits for age ad developmetal level. (The six moths duratio is to exclude disruptios caused by adjustmet disorders, family disruptio, etc.) Diagosis of ADHD i the 6- to 9-year-old child ca be complicated by a high rate of comorbid learig ad behavior disorders. A appoitmet with the child s primary care physicia may be the first time a professioal outside the sphere of the child s daily life raises with parets the questio of ADHD. Classroom teachers ofte otice behavioral issues i childre ad it is helpful prior to a physicia referral to have iformatio about these observatios. I the 6- to 9-year-old age group, teachers may idetify problems with sittig still i the classroom, completig class work, ad/or impulsive behavior i the classroom or o the playgroud. The teacher discusses these observatios with parets ad additioal evaluatio may be coducted at school, icludig classroom observatios of the attetio (cotiues o page 2) EPSDT Care for Kids Newsletter Sprig

2 Diagosis of ADHD i the Early Elemetary Years (cotiued from page 1) of the child ad a compariso peer. The teacher may complete a behavior checklist ad ask the paret to do the same, ratig the child s behavior at home. If ot already available, a physicia may ask that this iformatio be collected before proceedig with a diagosis. Due to the high rate of comorbid difficulties, it also is helpful to obtai iformatio o the child s academic achievemet, ay educatioal supports beig provided (e.g., Title I readig, Readig Recovery, learig disabilities resource support), ad other behavior cocers. It also is helpful if the behavior checklists completed ca be compared to orms for the child s age or grade. Durig a office exam, ufortuately, it is the exceptio rather tha the rule that the child will exhibit ay of the behaviors described above. Childre with ADHD do best i ovel settigs; durig brief visits; with self-paced tasks; ad i situatios that provide frequet feedback. This may be the reaso these childre ofte have a very log attetio spa for videogames. It may also be the reaso that teachers ofte are the first to idetify possible ADHD symptoms: they work with childre i a settig that is more routie tha ovel, with tasks paced by the teacher. Also, i the geeral educatio classroom, childre with ADHD ofte do ot get feedback o their performace as ofte as eeded. The diagostic criteria require that the ADHD symptoms be maifest i more tha oe settig; however, parets may ot fid symptoms to be as problematic because a child ca geerally pace his or her ow activities at home. It is ofte helpful to ask parets about homework completio or how log the child ca maitai attetio to daily readig activities. For some childre, there are physical factors that may exacerbate ADHD symptoms. Childre who egage i excessive scree time or sleep poorly (due to havig a televisio o while goig to sleep, for example, or who sore due to elarged tosils) may beefit from evirometal modificatios or medical itervetio. Childre with little routie i their daily eviromet may beefit from icreased structure ad orgaizatio. Oce the physicia has made the diagosis of ADHD, treatmet may be iitiated. The child would qualify for a 504 Pla i the geeral educatio classroom (i.e., a documet agreed upo by school staff ad parets to provide accommodatios i the regular classroom), which might iclude preferetial seatig ear the teacher, a positive behavior system, redirectio to task, ad/or remiders to take home materials eeded for homework. Medicatio treatmet also may be cosidered as a optio. If ADHD symptoms remai problematic after implemetig classroom ad home modificatios ad iitiatig medicatio treatmet, it may be time to cosider a referral to a child psychologist for assessmet of possible learig difficulties. There may be psychologists i your commuity or you may cosider referral to the regioal Child Health Specialty Cliic. Physicias also may cosider referral to oe of the cliics at the Uiversity of Iowa Childre s Hospital such as the Pediatric Psychology Cliic, the Healy Cliic at the Ceter for Disabilities ad Developmet, or the Child Psychiatry Cliic. A referral to the Behavioral (cotiues o page 7) EPSDT Care for Kids Newsletter Sprig

3 Aticipatory guidace for 5-10 year olds by Stacy McCokey, MD Departmet of Pediatrics, Uiversity of Iowa Childre s Hospital Well Child visits i the middle of childhood take o a differet focus tha those for youger childre. Childre are udergoig slower physical developmet i terms of growth ad fie ad gross motor skills, with most of the developmet goig o i the cogitive ad social skills areas. Bright Futures aticipatory guidace chages its focus to differet areas as well. It may be helpful to cosider some of the developmetal tasks of this age group prior to goig through the aticipatory guidace itself. The followig is a summary of some of the developmetal tasks by age: The primary task for 5 year olds is school readiess. How easily will the child separate from his or her parets? Are they capable of followig directios, gettig alog with others, ad do they have impulse cotrol? What is their spa of attetio? These are questios that eed to be addressed durig the pre-kidergarte visit. 6 year olds would like to be more idepedet from parets ad other supervisory adults, but are ot always capable of makig good decisios about safety. They also are developig the cogitive skills that allow them to participate i healthcarerelated discussios. Durig this visit it is importat to iclude them directly i the discussio to ecourage these commuicatio skills. 7 year olds are startig to develop their cosciece, which assists i uderstadig rules ad relatioships, as well as the developmet of morals ad copig skills. They are busy comparig their family s values ad morals to those aroud them, particularly to those of their best frieds, which is a ew milestoe for them as well. 8 year olds are developig skills i multitaskig ad logic, which chages how they approach school ad socializig tasks. 9 ad 10 year olds are possibly startig to udergo pubertal developmet (10 years old for girls ad 11 years old for boys). They cotiue to desire idepedece from their parets, which ca create some difficult situatios for families. At this age it is very importat for families to support their child s self-cofidece ad self-esteem to eable a child to withstad peer pressure. EPSDT Care for Kids Newsletter Sprig

4 Bright Futures Aticipatory Guidace by Stacy McCokey, MD Departmet of Pediatrics, Uiversity of Iowa Childre s Hospital Bright Futures breaks Aticipatory Guidace ito five categories: school readiess/performace, metal health, utritio ad exercise, ad safety. Followig are questios for physicias ad suggestios for parets, appropriate for childre at each age level from 5 to 10 years old. School Readiess: 5 6 years old: If the family is recetly immigrated, are there ay laguage cocers for the child or parets? Does the family uderstad how the local school system (i.e. AEA) works? For a child with special healthcare eeds, is the family aware of how to iitiate a IEP or 504 pla? Ecourage families to atted the back-toschool ight, ad school cofereces. If school is ot goig well for a child by this age, cosider askig teachers for a evaluatio for specialized help or tutorig years old: Set aside a specific time for homework, providig a well-lit space, free of distractios. Metal Health 5 6 years old: Establish importat routies for your family, ad be cosistet. Show affectio. Liste to ad respect your child. Ecourage teachig the differece betwee right ad wrog ad the skills to maage ager without violece. Ecourage parets to be a good role model i ager maagemet, selfdisciplie, ad impulse cotrol. Promote resposibility by assigig chores that are appropriate to the child s developmetal level. Ecourage competece, idepedece, ad selfreliace by ot doig everythig for your child; rather help them do well. Show affectio ad pride i your child s special stregths ad use praise liberally. Establish reasoable cosequeces for assiged chores ot completed withi a deadlie. Aswer a child s questios about pubertal chages hoestly, simply, ad at the child s level. Review iformatio the child receives at school o the subject. (cotiues o page 5) EPSDT Care for Kids Newsletter Sprig

5 Bright Futures Aticipatory Guidace (cotiued from page 4) 9 10 years old: Provide your child with a persoal space. Aticipate early adolescet behavior: chages i commuicatio, moodiess, challeges to rules, refusal to joi family activities, ad icreased risk-takig behavior. Supervise activities of groups of childre: kow your child s frieds. Help your child lear respectful behavior toward others. Ecourage your child to ask questios about sexuality ad be prepared with a aswer idicatig what you deem acceptable. Ecourage childre to delay sexual activity. Talk about/advise agaist the use of alcohol, tobacco, ihalats, ad other drugs. Discuss your child s body image: do they feel they are too fat, too thi, or just right? Nutritio & Exercise 5 6 years old: Breakfast research shows that eatig breakfast helps kids lear ad behave better i school. Help your child choose appropriate foods: at least five servigs of fruits ad vegetables per day. Avoid foods that are high i fat, sugar, ad calories ad low i utritioal value. Childre 4 to 8 years old eed 16 ouces of low-fat milk or dairy products per day. Limit itake of whole fruit juice to 4 to 6 ouces per day. Ecourage 60 miutes of exercise per day, which ca be divided ito shorter uits of time. Fid activities that the etire family ca ejoy. Limit scree time (TV computer, games) to 2 hours per day. There should ot be a TV i your child s bedroom. Eat meals together. Tur off the TV durig meals years old: It is almost ever appropriate to lose weight while growig discuss dietig with physicia. Make physical activity a part of child s routie, ot the exceptio. Oral Health 5 6 years old: Brush teeth twice daily with a pea-sized amout of toothpaste. Floss oce per day. See a detist every six moths Use a mouth guard durig sports activities. (cotiues o page 7) EPSDT Care for Kids Newsletter Sprig

6 ! EPSDT Care for Kids Newsletter Sprig Tuberculi test Testig is recommeded for high risk groups, which iclude household members of persos with TB or others at risk for close cotact with the disease; recet immigrats or refugees from coutries where TB is commo (e.g., Asia, Africa, Lati America, Pacific islads ad former Soviet Uio); migrat workers; residets of correctioal istitutios or homeless shelters; persos with certai uderlyig medical disorders. Childre with HIV ad icarcerated adolescets should be screeed yearly. 1 For ewbors discharged withi 24 hours or less after delivery. V Medicaid recommeds ad will reimburse for aual visits for older childre ad adolescets, but does ot yet require them. 12/09 A Cervical Dysplasia Pap test at age 21 Screeig A Sexually trasmitted Scree as appropriate. People with a history of, or at risk for, STIs ifectios should be tested for chlamydia ad goorrhea. A Procedures Metabolic screeig The Iowa Newbor Screeig Program tests for hypothyroidism, galactosemia, pheylketouria, hemoglobiopathies, cogeital adreal hyperplasia, plus expaded metabolic screeig. Lead Screeig Assess ad scree childre at 12 mo. ad 2 years of age; Assess ad test high-risk childre at 18 moths, 3,4, 5 ad 6 years. A A Hemoglobiopathy Oly oce (ewbor scree) ad offered to adolescets at risk. Hemoglobi/hematocrit Perform oce betwee 9-moth ad 12-moth visits for childre at risk; also aually for adolescets if risk factors are preset A A Lipid screeig A A Aticipatory guidace Provided at every visit Immuizatio Perform a immuizatio review at each visit; admiister immuizatios at recommeded ages, or as eeded Sesory screeig Visio Hearig S O O S O S O S Developmetal ad behavioral assessmet Surveillace Developometal screeig: 9, 18, 24 or 30 mo Autism screeig: 18 & 24 mo Oral health Assessmet - Detal history; Detal referral (Oral health, 6 mo 2 yrs: Referral to detal home if available; otherwise, assess oral health) EPSDT Care for Kids Newsletter Sprig Nutritio/Obesity prevetio Assess/educate Measuremets Weight/legth: each visit through 18 mo; BMI each visit 24 mo ad older Head circumferece Blood pressure A Physical exam As part of each visit History Iitial/Iterval KEY S Subjective, by history; To be performed S each visit durig time period idicated To be performed at all visits O Objective, by stadard testig method; Scree at least oce O each visit durig time period idicated durig durig time A Assess risk; period idicated A each visit durig time period idicated A G E Ifacy Early childhood Late childhood Adolescece by days mo mo mo mo mo mo mo mo yr yr yr yr yr yr yr yr yr yr yr yr yr See below V Iowa EPSDT Care for Kids Health Maiteace Recommedatios

7 Diagosis of ADHD i the Early Elemetary Years (cotiued from page 2) Pediatrics Cliic at the Ceter for Disabilities ad Developmet also may be idicated if the child displays oppositioal behavior, ocompliace, or aggressio. Olie resources are available, as well. Childre ad Adults with Attetio Deficit Hyperactivity Disorder (chadd.org) is a excellet resource for parets. Iformatio o local CHADD groups may be available through local schools. The America Academy of Pediatrics (aap.org) provides helpful iformatio to physicias (toolkit for assessmet) ad parets (iformatio about treatmet optios). Bright Futures Aticipatory Guidace (cotiued from page 4) Safety 5 6 years old: Teach your child to safely cross streets, lookig right, left, ad right agai. A child should ot cross aloe util they are10 years old. A adult should supervise gettig o ad off buses, icludig where to stad, wait, ad whe to board. Use a belt positioig booster util a child is 4 9 tall ad pouds. The child s bottom should be i the seat crease, kees bet over edge of seat, ad seatbelt across chest ad legs. A child should stay i back seat util 13 years of age. Helmets should be used with all bikes, scooters, skateboards, ATV ridig, horseback ridig, skiig, etc. Teach your child to swim ad ever leave them aloe while swimmig. Do ot permit swimmig i fastmovig water or divig, uless the depth is checked by adult. Childre should wear life vests while ridig i boats. Wear suscree SPF 15 or higher, reapply every 2 hours. Discuss private parts (areas covered by swimmig suits) with your child: Teach them it is ever okay for aother adult to ask for help with their private parts or to see yours uless a paret is preset (such as durig a visit to the doctor.) I additio, teach them it is ever okay for aother adult to ask a child to keep a secret from his or her parets. Istall smoke detectors o all levels of your home ad frequetly check ad chage batteries. Istall CO detectors o all levels of your home with bedrooms. Have a fire escape pla ad a place to meet outside: practice it. If gus are i the home, have ammuitio locked separately. Ask parets of your child s frieds about gus i their homes. Computers should be located where they ca be moitored. Check Iteret history frequetly to see web sites visited ad cosider usig paretal safeguards or filter. Discourage olie chattig ad providig persoal iformatio. Esure that your child uderstads how ad whe to call 911 ad what to do i case of fire or other emergecy. Tell them it is okay to ask to go home if they feel ucomfortable at someoe s house. Teach your child the rules of the road for bikes. No ridig after dusk. EPSDT Care for Kids Newsletter Sprig

8 Uiversity of Iowa Childre s Hospital Ceter for Disabilities ad Developmet Uiversity Ceter for Excellece o Disabilities 100 Hawkis Drive Iowa City IA What s i this issue Diagosis of ADHD i the Early Elemetary Years...1 Aticipatory guidace for 5-10 year olds...3 Bright Futures Aticipatory Guidace...4 Iowa Recommedatios for Schedulig Care for Kids Screeigs...6 If you have questios about billig related to EPSDT Care for Kids services, please call Provider Services: If you have questios about cliical issues ad EPSDT Care for Kids services, please call Please ote: Due to budget restraits, the EPSDT Care for Kids Newsletter is set to offices ad orgaizatios, rather tha to idividuals. The ewsletter is also available o lie at /EPSDTNews. Readers are welcome to photocopy or dowload material from the ewsletter to share with others. If you wish to reproduce material from the ewsletter i aother publicatio, whether prit or electroic, please obtai permissio prior to publicatio by cotactig the editor. Please iclude the followig ackowledgmet with reprited The EPSDT Care for Kids Newsletter is published three times a year, i prit ad olie, as a joit effort of the Iowa Prevetio of Disabilities Policy Coucil, the Iowa Departmet of Huma Services, the Iowa Departmet of Public Health, ad the Ceter for Disabilities ad Developmet, which is atioally desigated as Iowa s Uiversity Ceter for Excellece o Disabilities. The goal of this ewsletter is to iform Iowa health care professioals about the EPSDT Care for Kids program, to ecourage them to make use of this importat resource, ad to provide them with iformatio about a wide rage of developmets i the field of health care. Newsletter Staff Executive Editors Elle Lik, MD Do Va Dyke, MD Productio Editor Lizee Kull McCray Graphics Editor Loretta Popp Please sed correspodece cocerig cotet to: Elle Lik, MD Family Care Ceter Pediatrics Uiversity of Iowa Childre s Hospital PFP 200 Hawkis Drive Iowa City, IA material: Reprited by permissio of EPSDT the Iowa Care for EPSDT Kids Newsletter Care for Sprig Kids Newsletter Editorial Board Kay DeGarmo Rhoda Eserro, MD Carol Hito Sally Nadolsky Steve Wolfe, MD Please sed chage of address iformatio to: Breda Nosbish Uiversity of Iowa Childre s Hospital Ceter for Disabilities ad Developmet S263 CDD 100 Hawkis Drive Iowa City, IA