July 4 Post Six

            Taylor and Marcus have decided to seek out counseling for their marriage. They have been going to counseling once a week for the past two months, and they have both seen a difference in their marriage. They are now communicating much better than before and they are both a little less stressed out. Marcus feels that he is definitely receiving more attention than he was before, and Taylor feels that it is easier to talk about things with Marcus now, and she makes sure she puts more time and effort into their relationship than before. Thomas will always be their first priority, but it is nice that they both feel that they are on the same page with him.

            Thomas is now ten years old. He has been on his medication for quite some time now and he has been doing well in his behavioral therapy sessions. Thomas’s teachers at school have said that they have definitely seen an improvement in Thomas’s work ethic. This medicine has helped to improve Thomas’s attention, focus, goal-directed behavior as well as his organizational skills. Ritalin works to stimulate certain areas of the brain so that a child can better pay attention and focus on their activities. Since taking this medication, Thomas has had less trouble finishing class work and homework, less distractive behaviors and increased self-esteem. Ritalin is a very fast working drug, so Thomas’s family and teachers were able to see a change in him very quickly.

One very positive effect this medicine has had on Thomas is that he has been able to branch out and make new friends. Not only is James still one of his best friends, but he plays with other children as well. In fact, he also gets invited to a lot of other children’s birthday parties as well as frequent play dates with them. The only negative side effect that Thomas has dealt with because of this medicine is that he has difficulty falling asleep at night. The doctor explained to Taylor and Marcus that that could happen and that the medicine tends to wear off at night so Thomas may become more active at night. For now, his parents don’t seem to find this issue very serious, so they have not decided to change anything.

            Thomas and his parents have been going to Church every Sunday since Thomas has been taking his medicine. His parents feel that it is good for their family to do together. Thomas is able to sit during the service without being so fidgety and squirming around and he seems to focus on what the priest is saying. Also, his bible study teachers say that they have seen a huge improvement in him as well. He is not only paying attention, but he seems to have more confidence and speaks up in discussions. Thomas’s parents are very pleased to hear this.

            Thomas’s piano recitals have been going extremely well. He has continued to write his own pieces as well as perform them. Recently Taylor and Marcus were contacted by a professional music center asking for Thomas to come and join their school. This school is located in Southern Jersey and Thomas would be traveling for his recitals all over the country. The school is called Conservatory of Musical Arts, and it is a very prestigious piano school. Thomas’s parents know that this could really help out Thomas’s piano career, but they are nervous about making him switch schools and move hours away when he has just started doing so well in school and with making friends. The school has had scouts come out and see Thomas play, so they know how good he is. They have been very persistent on trying to get Thomas to come down there. They have even explained to Taylor and Marcus that him being at this school can open up many doors for him. They have informed the Hooks that most everyone who comes to their school ends up getting some type of scholarship to college. The Hooks know that this is a long ways away, but it is still something very important to consider.

            The Hooks have also decided that they want to get a dog. Since Thomas is an only child, they want him to have a companion. They feel that this will not only be something fun for Thomas, but also something that could help him. They have not looked into the benefits too much yet, but they do know that dogs can be used to teach behavioral modification techniques to children. After searching for a few months, they decided to get Thomas a chocolate lab for his eleventh birthday. Thomas named the dog Milo and the two are inseparable! Taylor and Marcus are very pleased with their decision.

             With Thomas transitioning to middle school, his parents are hoping that this school year goes as well as the last one did. Typically developing eleven year old children begin to use formal operational thinking, meaning that they are able to reason with more adult-like logic without concrete examples. Thomas’s parents are hoping that with his learning disability, this will not be an issue for Thomas. For how well he has been doing in therapy and on medication, they are hoping that he will develop like the other children in his class from here on out.

Questions

1. How can pets benefit children with ADHD?

2. How do children with ADHD cope with change? (For example, changing schools.) Is there a difference compared to typically developing children?

3. How long should a child with ADHD take medication for? Should they eventually expect to be off of it? Will they build a tolerance to it and have to change their dosage?

Decision Point: Do Thomas’s parents decide to move to allow Thomas to go to this new school that could really benefit his piano interests?

http://www.wsupgdocs.org/family-medicine/WayneStateContentPage.aspx?nd=1651

http://www.psychologytoday.com/blog/pills-dont-teach-skills/201102/pets-kids-add

http://www.washingtonparent.com/articles/1203/your-eleven-year-old.php

July 1 Post Five

Thomas Hook is now seven years old, and in the second grade. His parents decided not to go with the 504 services, so he has been receiving special education and has an Individualized Educational Plan. This seems to be going well for Thomas. His teachers and parents have decided to keep him in the least restrictive environment, which in his case would be in the classroom, but taken out of the classroom to take tests in order for him to be less distracted. Thomas has plenty of goals that his teachers and parents have agreed on for his IEP. One of his goals is that he will be able to read a short, two-minute story on his own with at least fifty words correct.  Another one of his English goals is comprehension based. Thomas will be given a story to read and will be asked ten questions and be able to get at least nine of them correct.

Since Thomas was diagnosed with ADHD, his parents felt that it would be best to enroll him in behavioral therapy, though they wanted to hold off on medication to see if his ADHD symptoms will lessen with solely therapy. They have done research and have seen that medication and behavioral therapy together seem to be the most successful, but they do not want to put Thomas on a daily medication unless it is absolutely necessary. They have enrolled Thomas with a therapist by the name of Dr. David Fazzari who specializes in adolescents with ADHD.

The Hooks have also decided to enroll Thomas in piano lessons. He seems to love playing around on an old keyboard that they own, and Thomas’s music teacher has informed his parents that Thomas not only enjoys the piano during music lessons, but he seems to have a natural talent for it. Despite Thomas having ADHD, he seems to be doing really well in his piano class. His teacher, Miss Gray, says that he is a natural and that he is already much more advanced than the rest of the children in this beginner class.

Thomas is now going on ten years old. His parents have been struggling within their marriage due to lack of attention to one another. Taylor is very worried about Thomas all of the time, so she spends a lot of time trying to better him, and to find ways to better help him with his condition. She doesn’t pay Marcus as much attention as she used to. Marcus has been feeling very distant from Taylor for some time now, but wants what is best for his son. He feels that some serious adjustments need to happen in order for their marriage to work out. He knows firsthand how hard it is on parents with a child with ADHD since he himself had ADHD and his parents later divorced.

Thomas’s piano skills have become extraordinary. He is playing at a level better than most adults would. Music is a way for Thomas to convey what he feels. He creates his own pieces and has had plenty of recitals all of which he plays from memory. When Thomas is playing the piano, it’s like nothing else in the world is going on. You can tell his mood through what types of songs he plays and you also would never know that he has been diagnosed with ADHD. A musical prodigy’s parents have a huge effect on his success (Solomon 2012). They were the ones who introduced him to the instrument as well as have supported his interest and have gone to all of his recitals.

Thomas has been doing decent in his studies, but not amazing. At a parent teacher conference, it had been noted that Thomas is disruptive in class, getting up when he isn’t supposed to as well as doing things like making paper airplanes in class. He frequently stares out the window and just all around doesn’t seem like he’s always paying attention. His behavior sometimes distracts the other children from learning. His parents have decided to put him on a medication to hopefully help with his grades and his disruptive behavior. His pediatrician prescribed him with Ritalin.

Since Thomas had his cleft palate surgery, everything seems to be normal for him now. He thankfully has not had any issues post surgery. He is developing normally for his age. He doesn’t seem to have too many friends, but he does have one best friend, James, who is in his class. Children with ADHD have a hard time making and keeping friends because it requires so many skills that children with ADHD do not naturally have. Some of these skills include talking, listening, sharing, being empathetic and plenty of others. Typically, children Thomas’s age have a bunch of friends and don’t seem to have an issue making them due to skills that they naturally possess. As for now, Thomas seems to keep busy with his piano lessons/recitals, studying for school, therapy, and occasionally hanging out with James. His parents hope that he will branch out and make new friends soon.

Questions:

1.     How can a child diagnosed with ADHD affect their parent’s relationship? Is there a higher divorce rate among parents with children who have disorders?

2.     In terms of a musical prodigy, what three components can musical talent be divided into? Explain each component. HINT: Solomon Textbook.

3.     What other side effects can ADHD medications have on children?

Decision Point: Do the Hooks look into marriage counseling for themselves? What benefits could this have for them?

http://www.webmd.com/add-adhd/childhood-adhd/features/child-adhd-parental-relationship

http://therapists.psychologytoday.com/rms/prof_detail.php?profid=68589&sid=1404244538.8332_20398&city=Hoboken&county=Hudson&state=NJ&spec=6&spec=293&tr=ResultsName&trow=1&ttot=92

http://www.additudemag.com/adhd/article/3577.html

http://www.helpguide.org/mental/teaching_tips_add_adhd.htm

Far From the Tree- Andrew Solomon

June 27 Post Four

Taylor took Thomas to her pediatrician following the teacher’s suggestion. She explained that Thomas had attended a half day nursery school program for the past year and the teacher felt medication was needed to reduce Thomas’ hyperactivity. Her doctor told her that the most common drugs used for ADHD are not approved by the FDA in children under six. He also felt Thomas should be evaluated for ADHD before any medication is prescribed. He recommended behavior therapy in conjunction with a strong routine and structured school program as a preferable course of treatment for a preschool age child like Thomas. ADHD medications in preschoolers have been known to cause more side effects, such as a decrease in appetite, insomnia and anxiety. Medication has been also known to slow the rate of growth in preschoolers. He suggested behavior therapy; along with a small preschool program which employs a behavior modification program to address behavioral issues in children like Thomas.

Taylor left the pediatrician’s office feeling somewhat relieved that he was not in favor of prescribing medication for children as young as Thomas. She really had not been comfortable with the idea of medication for Thomas. Taylor told the teacher what the pediatrician had said, and added that she had enrolled Thomas in Hoboken’s Universal Pre-K program for four year olds. The program was a free, full day program and offered special services such as speech or counseling, as well as special education programs should one be needed.

            This decision reduced the Hook’s financial burden of nursery school and child care. The savings enabled them to seek help from a behavioral psychologist. The psychologist took an in depth history and spent time observing and talking to Thomas. The psychologist felt that Thomas showed signs of anxiety which he stated were not uncommon in children with ADHD. He explained that excess energy turns to anxiety when unused. Other factors include mental stress and reprimanding. Thomas’ history reflected significant factors for mental stress, given his repeated hospitalizations and surgeries. His behaviors were cause for frequent reprimands by his parents and teachers. In addition, school can be a source of mental stress for many children. These factors combined with Thomas’ issues with communication caused by his cleft palate contributed to his mental stress and resulting anxiety. The psychologist agreed to see Thomas on a weekly basis. He offered the Hook’s suggestions for working with Thomas at home, and emphasized the importance of consistency when trying to modify behavior. One suggestion that was made was to provide Thomas with plenty of opportunity to exercise in order to burn off excess energy.

Thomas’ first year at the Hoboken’s Pre-K Program was an improvement over his nursery school program. The behavior therapy along with the suggested techniques the Hook’s had used at home were helpful in reducing Thomas’ hyperactivity. The school conferred with the behavioral psychologist and was able to implement some of his suggestions, in addition to their behavior modification program which rewarded positive behaviors and ignored negative ones. Although the Hooks still received reports of behavioral issues, they were able to work together with the school in managing Thomas at school.

            Thomas turned five and started kindergarten. His speech services continued with notable success. Thomas’ ear tubes had fallen out after six months, but the ENT chose to delay reinsertion to see if Thomas’ ear infections would return. He was cautiously waiting to see if Thomas had outgrown them.

                Given the fact that Thomas had been attending a kindergarten program for the past six months and continued to display ADHD behaviors, his psychologist wanted to perform various tests to verify the suspected diagnosis of ADHD. He requested that a CPRS-R (Connors Rating Scales-Revised) be done by the school. He also performed psychological testing to evaluate Thomas’ cognitive functioning. It is not uncommon for children with ADHD to suffer from academic issues in reading and/or math. The testing would also rule out any intellectual deficits. The Hooks were very much in favor of this testing since the teachers at school had made comments alluding to the need for Thomas to be evaluated for special education services. They pointed to his hyperactivity, inability to focus, his failure to complete tasks, and inability to share or take turns. These are all behaviors that are expected from a kindergarten age child. Due to his lack of focus, it was difficult to ascertain his academic skills. He would never finish reciting the alphabet or counting to a specified number. Writing tasks were often sloppy and incomplete. He demonstrated organizational issues as well.  Thomas’ cubby had always been messy and it took him longer than average to get his belongings together at dismissal.

                Taylor preferred that her psychologist perform this testing, since she had heard and read about the tendency for children like Thomas to be referred to special education due to behavioral issues.  Many referrals often result in 504 services rather than special education programs. Parents can obtain 504 or non IEP services by requesting them in writing to their district. In order to qualify for IEP services, a child’s cognitive functioning must fall significantly below his intellectual potential. If a student does not qualify as having a disability which significantly affects his academic performance, many of the services he can receive are through 504 not an IEP. Research shows that ADHD is identified in boys sooner than girls and boys have a greater incidence of being diagnosed with a disability than do girls.

When testing was completed, it revealed that Thomas had an IQ of 110, which denotes normal intelligence. Tests involving repetition of numbers were delayed. This could reflect an inability to focus in order to remember presented information.  Ability to copy shapes was below average. This could be a result of his lack of focus and tendency to rush through the activity, or can be a graphomotor issue. It was noted that Thomas failed to complete some of the items due to his short attention span and hyperactivity. The test had to be given in blocks of time over 2 days to complete many of the items required. Thomas’ lack of focus and hyperactivity made testing more difficult.

               After all the testing was completed, and the Connors Rating Scales –R was scored, it was determined that Thomas did have ADHD. Reports were forwarded to Thomas’ pediatrician and copies of the reports were given to the Hooks, who could share the results with the school if needed. Given that ADHD medication is not FDA approved in children under six, the decision was made to delay the administration of medication until Thomas turned six. This would coincide with Thomas’ entrance into first grade where the focus on academics is much greater than in kindergarten.  Thomas’ progress would be monitored in social, behavioral, and academic areas. Any signs of academic deficits could be better   assessed with the behavioral factors addressed through medication.

1) Are alternatives to ADHD medication just as effective as the medication?
2) Are specialized diets helpful in reducing ADHD behaviors?
3) Given the attention and focusing issues In children with ADHD, how accurate is the psychological testing?


Decision point- Do the Hooks agree to a special education program or do they opt for 504 services? What are the major differences between the two options?

http://www.healthcentral.com/adhd/education-153390-5.html

 http://www.webmd.com/add-adhd/childhood-adhd/features/adhd-symptoms-in-girls-and-boys

http://www.learnnc.org/lp/pages/6817

http://www.apa.org/monitor/2013/02/easing-adhd.aspx

http://www.calmclinic.com/anxiety/adhd-children

http://www.scienceworldreport.com/articles/

http://www.additudemag.com/adhd-web/article/4974.html 

http://www.webmd.com/add-adhd/childhood-adhd/understanding-adhd-treatment

http://www.webmd.com/add-adhd/childhood-adhd/features/adhd-symptoms-age

 http://www.clapa.com/medical/article/

http://www.ncbi.nlm.nih.gov/pmc/articles/             

June 24 Post Three

             Thomas has turned 3 and has continued to demonstrate improvement in his speech therapy. One issue associated with a cleft palate is ear infections which can result with an accumulation of fluid in the ears. Over the past year, Thomas has been to the pediatrician three times for ear infections with fluid in his ears. The Hooks were referred to their ENT, for frequent infections and fluid buildup can result in a hearing loss. Thomas underwent a hearing evaluation which revealed that his hearing was normal. The ENT explained that children with a cleft palate are prone to fluid collecting in their ears which is known as “Glue Ear.” Since Thomas has had these recurrent ear infections and fluid buildup, the ENT recommended a surgical procedure to insert tiny tubes called grommets. He stated that it will help to ventilate his ears and reduce the chance for fluid to collect in his ears. It could help reduce the chances of damage to Thomas’ hearing. He added, that the tubes tend to fall out after 6 months, and could require reinsertion. He also explained that ear infections are no longer an issue as the child grows older. The Hooks agreed to the procedure which was done in the hospital as an outpatient. In addition to the recurrent ear infections, Thomas had seen the dentist twice over the past year and required fillings in 4 teeth, some of which had dual surface involvement.

            During their last visit to the pediatrician, the Hooks brought up their concerns that Thomas has demonstrated an increase in ADHD behaviors. From squirming and an inability to cuddle, his parents have noticed an inability for Thomas to maintain an interest in any toy or activity for very long. He would run around the house and fall frequently due to what appeared to be clumsiness. It is not uncommon for children with ADHD to be accident prone due to their impulsivity. They act without thinking and consequently have more accidents than the average child (Web MD).

 Thomas also displayed problems taking turns when playing with his peers in the park. He would push his way onto the ladder of a slide instead of waiting his turn. Children with ADHD act on impulse and do not delay gratification. When they want something, they want it now. At this age, many parents of boys fluff this off as “boys will be boys.” They do not see it as a sign of a disability such as ADHD.

Given Marcus’ history, his son’s behaviors sparked concern. His parents took him to their pediatrician who told them that Thomas was still young and may outgrow this. Aware of Marcus’ history, he did add that if the behaviors continued or grew worse, Thomas may need to be evaluated for ADHD. He recommended that they enroll Thomas in a nursery school program to provide the training through experiences with peers in a structured setting. He suggested seeing how that goes and if there was no sign of improvement then bring Thomas back and he would provide them with a referral for further evaluation.

ADHD is difficult to diagnose. Doctors often rely on a family history, interview with child, reports from school, etc. Doctors are often too quick to diagnose a child as having ADHD so the Hook’s pediatrician is not discounting the ADHD diagnosis but feels further information is needed and had made a recommendation that would provide insight into another setting other than home.

The Hooks left their pediatrician’s office feeling conflicted. They were happy that he hadn’t dismissed their concerns and made suggestions for follow up. His recommendation for a nursery school program posed several issues. First, there was the issue of full day vs. half day, and then the resulting financial implications. A full day program would cost more and still require child care for the gap in time from when school ended to when they returned from work.  Half day programs cost less, but involved the additional cost of child care. Another consideration was whether Thomas at 3 years of age, could handle a full day program given his issues of impulsivity, and limited attention span. The thought of all this, along with the medical, dental, and behavioral issues that have plagued the Hooks over the past 3 years, left them feeling overwhelmed. Understanding the stress the Hooks were under, a friend from their church offered to take Thomas for a weekend, so that Marcus and Taylor could get away. They returned rested and were better able to consider their options and make a decision. They worked out an arrangement with their current child care provider, which reduced her time by the amount of time in the half day nursery school. They were also successful in finding an affordable program in their Hoboken community that would meet their needs.

Stress is experienced by all new parents who have to cope with the demands of an infant and the life style changes to their marriage. This is only compounded by having to deal with a first child who has a disability. Studies show that having a child with a disability can destabilize marriages and lead to divorce. Some parents refrain from having a second child due to the stress and strain it puts on the couple physically, emotionally, and financially. There is also the fear that it could happen again. Studies suggest that “raising a child with a disability decreases subsequent fertility, both by directly decreasing the likelihood of subsequent   childbearing and indirectly increasing the likelihood of marital disruption. Decisions to have another child are based on more than a first child with a disability, but on a variety of social and demographic factors, such as a woman’s age, race, social class, educational attainment, marital status, and labor force participation.” Positive factors for the Hooks were their community support, they were college educated, had jobs, and had reached an age of maturity when they had Thomas, as opposed to being teenagers. They were also a white middle class family.  Stress is higher among poor, unmarried minorities in disadvantage areas, who are unemployed and have a limited education (NCBI).             

The Hooks experienced some relief after resolving the issues with nursery school and child care. Thomas’ first year at nursery school was fraught with frequent reports from his teachers regarding his calling out, inability to share, and his inability to sit still. There were isolated episodes of temper outbursts when he was prevented from doing something he wanted.  The teachers were patient and made every effort to work with Thomas. They agreed to keep Thomas at the school and asked that Mrs. Hook speak to her pediatrician about possible medication to help improve Thomas’ behavior in school. Although there wasn’t a definitive diagnosis of ADHD, all of the reports from the teachers, Taylor experiences with Thomas at home, and the knowledge of a possible genetic component, all seemed to indicate that Thomas suffered from ADHD. There was a part of Taylor that feared her own drinking may have caused his ADHD. The idea that she could have caused this was devastating.

              The information available on the causes of ADHD provides numerous possibilities. There is no single direct cause. Some cases are believed to be genetic; some are alcohol or drug related, some are believed to involve neurotransmitters while other cases appear random with no apparent etiology. Treatment options include medication, psychological and behavioral therapies (Web MD).

1)    What ADHD treatment alternatives are available for Thomas?

2)    What role does diet play in children with ADHD? I.e. chemicals in certain foods

3)    Is a referral to special education for Thomas inevitable? Why or why not?

Decision Point: Does Taylor get medication for Thomas or does she decide to pull Thomas out of the nursery school program?