Who’s Who In Learning & Behavior Evaluation & Management?

I tried to convey why it’s so important to get a proper diagnosis of learning and behavioral problems in my last blog, Labels – Why should my child be diagnosed? Today I’d like to explain what is done during the evaluation and who’s involved in testing and treatment. Primary care physicians are a great place to start with questions about how to evaluate and treat various concerns. After that where should you go?

Start with the pediatrician

learning and behavior evaluation and managementParents are sometimes surprised to learn that I treat ADHD, anxiety, and many other behavioral disorders. I see many kids every day with these issues. I enjoy watching as they learn to manage their behaviors and improve their executive functioning over the years. Even kids who really struggle in the early years can grow into confident and accomplished adults.

I often say that kids with ADHD are talented, smart and can do wonderful things. They have unique gifts.

There are some pediatricians who don’t treat these issues, but I find there’s a huge need. In many cases since I’ve followed a child for years, I know them well and can help better than a specialist who doesn’t have that history.

Despite plenty of experience, I do use specialists often.

Many learning and behavior problems have similar symptoms, so it might take several professionals to help evaluate the situation.

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, other specialists are very helpful to assess the issues.

Cautions…

There are of course many tests and treatments available that have not been proven to help. Future blogs will cover testing and treatments, but until then, just a few cautions.

There are 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 many treatments that haven’t been shown to be effective but still advertise good results for a fee.

If it sounds too good to be true, it probably is. Discuss tests you are considering with your child’s doctor, especially if there is a large price tag attached.

 


Who’s who?

The alphabet soup of credentials confuses many parents. I’ve tried to compile a list of experts in various fields who might need to be involved in your child’s assessment and care as well as explain what types of things they can do to help in the process of evaluating and treating learning and behavior issues.

Parents

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. Their feedback on how each treatment is working is helpful in fine tuning treatment plans.

Teachers & Other School Professionals

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.

Many schools will have a school counselor or psychologist evaluate and help treat students.

Teachers with advanced background in learning disabilities are used to help address specific concerns.

It’s 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. 

Therapists (not mental health)

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.

Check with your insurance to see what is covered in your plan. Ask the school if they offer any of these services.

Mental health specialists

Psychologists (clinical psychologists, cognitive psychologists, educational psychologists and neuropsychologists) and clinical social workers offer testing as well as therapy for many disorders.

Some therapists specialize in testing, others in treating. Some do both. You will have to ask what their qualifications are and what role they play in diagnosis and management.

Clinical therapists can do parent training to help parents manage behaviors at home, especially for younger children.

Therapists cannot prescribe medications, but some 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 young children and anxiety.

Therapists 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. If a person is out of network your cost might be about the same as a person who is harder to get in to see but on your plan.

Physicians

Physicians (pediatrician, family physician, developmental pediatrician, neurologist, and psychiatrist) can make a diagnosis and 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 a while to get into specialists and they can be expensive, so starting with your primary care 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. Therapy along with medication often improves outcome, so multiple specialists working together can be beneficial.

Physician-extenders

Nurse practitioners and physician assistants can work with physicians to diagnose disorders and prescribe medications to treat them. In some states they can work independently.

They do not offer psychotherapy, so it is often beneficial to work with more than one person to get the best outcome.

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. Ask about training and experience.

Working as a team

The types of professionals who work with any given child to assist in diagnosis and treatment vary depending on the issues at hand. 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. It’s important that all members of the team have access to what the others are doing.


Looking for more?

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 a volunteer board member 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. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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Sleep Deprived Teens: Health, Safety, & Mental Well Being Are At Significant Risk

Teens do not get enough sleep. Most teens need 8.5-10 hours of sleep each night. Not 6 hours. Not even 8 hours. Most don’t get even close to meeting their needs and that’s a bigger deal than many realize. Sleep is very undervalued, but we need to prioritize it.

Why don’t teens get enough sleep?

One of the most common reasons is that their biological clock (AKA circadian rhythm) makes it hard to fall asleep before 11 pm and school starts too early to allow them to sleep until 8 am, which would allow for 9 hours.

In addition to their circadian rhythm, some of their habits and activities can interfere with a healthy bedtime.

Screens are a big problem.

The light interferes with our natural melatonin rising. I regularly ask teens (and parents) to limit screen use for at least an hour before bedtime, but most teens say that’s impossible because they have to finish their homework at that time and they need their computer or tablet to do homework. If you can’t turn off the screen, at least use a program that limits the blue light that prevents the rise of melatonin. I personally use f.lux. (It’s free and works on PC, Mac, ipad, android, and Linux). I find that it really helps. (This is not a paid endorsement, just a personal statement.)

Phones.

On a similar note, phones distract kids from what they’re doing, delaying falling asleep. It takes longer to finish homework when there are distractions from the phone. Kids often are tempted to check in one more time on all their social channels, which delays sleep time. And then friends who are still up will text to see who’s up (or who they can wake up).

Activities are too late. 

I’m not talking about kids just out and about on a school night. I’m talking about regularly scheduled activities that otherwise help build a well rounded person. It’s not uncommon for activities to be scheduled to run until 9:30 or 10 on school nights for middle and high school aged kids. They get home and are hungry, need a shower, and are ramped up so not ready for sleep.

Activities start too early.

I know many kids who must be at school before school actually starts. Whether it’s band practice, church study groups, sports, or taking a missed test before school, they all interfere with sleeping in, which is what teens need.

School starts too early.

Most school districts around the country start school well before the recommended 8:30 earliest start time. School districts that have initiated later start times have shown improved test scores, fewer absences and tardies, less depression, improved athletic performance, and better graduation rates. Unfortunately, those schools are still in the minority.

Medical causes of sleep deprivation and fatigue can also occur. 

If you suspect any of these, you should schedule a visit with your doctor.

  1. Anxiety
  2. Restless leg syndrome
  3. Sleep apnea – pausing of breath, often associated with snoring
  4. Medications that affect sleep cycles
  5. Heartburn or acid reflux
  6. Hormone imbalances, such as thyroid problems
  7. Anemia, or low red blood cell counts
  8. Depression
  9. Nutrition: not eating enough, or eating foods that are not nutritious. If you eat foods that cause spikes in your blood sugar, as those sugars drop you feel fatigued.
  10. Infections
  11. Celiac disease
  12. Chronic pain conditions
  13. Chronic sleep deprivation – I know this is counter-intuitive, but being tired can make it harder to sleep.

 What happens with too little sleep?

sleep is needed
Teens who are sleep deprived suffer in many ways. Make sleep a priority!

Sleep deprivation can lead to many problems that are often not attributed to poor sleep, such as irritability, poor academic performance, accidents, obesity and more.

Moodiness.

We all associate the teen years with angst, so we can easily attribute a teen’s moodiness to just being a teen. But being chronically tired can lead to emotional dysregulation. This will look like irritability, frustration and anger.

School problems. 

It has been well established that getting proper amounts of sleep can help with focus and learning. When our teens fail to get enough sleep, they often report problems with attention, memory, decision making, reaction time, and creativity. It’s no surprise that teens report problems paying attention to a lecture or trouble completing homework in a reasonable time with full accuracy. Grades can easily fall, which leads to anxiety and depression, which in turn leads to more moodiness and trouble sleeping.

Sleep deprivation mimics ADHD. Whenever I see a teen who wants to be evaluated for ADHD because of new loss of focus, falling grades, problems with behavior, or similar issues, I always look at sleep. Most often they don’t have ADHD if this is a new problem. They need more sleep, not a stimulant medication. You can’t put a band aide on a broken bone. Fix the problem, not the symptoms! (The same goes for a teen with ADHD who thinks the medicine that’s worked for years suddenly isn’t sufficient. Unless the medicine recently changed, they need sleep.)

Injuries.

Teens with chronic sleep deprivation are more likely to be accidentally injured.

Drowsy driving is comparable to drunk driving. Teens are at the highest risk for falling asleep at the wheel. Drowsy driving is the most likely to occur in the middle of the night (2-4 am), but also in mid-afternoon (3- 4pm) as teens drive home from school.

Athletes are more likely to be injured while playing their sport, so it is in the best interest of the team to let players sleep.

Risky behaviors. 

Teens with chronic sleep deprivation have been shown to participate in more risk taking behaviors, such as driving without a seatbelt, drinking alcohol, skipping the bike helmet and tobacco use.

Pros and Cons of later school start times for our economy

There are many temporary issues with changing school start times. Parents might have to find solutions to child care of younger kids if they rely on teens babysitting after school. New bus schedules need to be started. Sports programs will need to change practice times. After school job availabilities will change.
Despite these common arguments, economic analysis from the Brookings Institution shows that a one hour delay of school start times could lead to a $17,500 earnings gain for students, compared to a cost of $1,950 during the student’s school days.
Another study that presumed all students start school at 8:30, with a year-by-year economic effect. The study did not take into account other potential benefits of later school start times, such as decreased depression and obesity rates. They found an average annual gain of about $9.3 billion due to fewer automotive accidents, improved graduation rates, and other factors.

What can teens do to get more zzzz’s?

Go to bed when tired at night.

Fighting sleep initially will make it harder to go to sleep when you finally go to bed.

Attempt to follow a regular sleep schedule.

Going to bed and getting up at about the same time every day helps. While sleeping in on weekends can help repair a sleep deficit, it can make it harder to get to sleep Sunday night and getting sufficient sleep every night is better than just getting more sleep a few days/week. Try to sleep in no more than 2 hours past your school day wake up time.

Follow the same routine each night at bedtime.

Brush teeth, read a book or color, take a bath or shower — do whatever helps you wind down and relax. Repeating this every night can help your brain get ready for bed.

Nap to help make up missed sleep.

A short 15-20 minute nap after school can help revitalize the brain to get homework done. Just don’t sleep too long or it can interfere with bedtime.

Turn off the screens an hour before bedtime.

This includes tv, computer games, computer/tablet use for homework, and smartphones for socializing. Use night mode screen lighting and apps that dim the screen (like the f.lux app I mentioned above).

Avoid caffeine in the later afternoon.

The time it takes half of the caffeine to be removed from your body is 5-6 hours. Ideally teens would sleep and never drink caffeine, but I know that isn’t reality. Any caffeine in the later afternoon can make it harder to fall to sleep. Don’t forget “hidden” sources of caffeine, such as chocolate, energy bars, and workout supplements.

One interesting concept that has scientific backing (but goes against the “no caffeine after 3 pm” rule) is the coffee nap. Basically, you drink coffee then quickly nap for 15-20 minutes. Sodas and teas don’t work as well as coffee due to too much sugar and too little caffeine. The coffee nap has been shown to be more effective than either a nap or caffeine alone. Don’t do this often — use it at times you really need it. Don’t do this too late in the day or the caffeine will inhibit your regular night’s sleep.

Skip the snooze button.

Set your alarm for the last possible moment you can, which allows your body to get those extra minutes of sleep. If you need to get out of bed by 6:45, but set your alarm for 6:15 and hit snooze several times, you aren’t sleeping those 30 minutes. Set your alarm for 6:45!

Skip the late night studying.

Studying too late is ineffective. When the brain’s tired it won’t learn as well and you will make mistakes more readily. It takes a lot longer to get anything done when you’re tired. Go to bed and get up a little earlier to get the work finished if needed. Of course you should also look at your time management if this happens too often. Are you involved in too many activities? Do you work or volunteer too many hours? Did you waste too much time on tv, games, or socializing? Do you put off big projects until the last minute? Homework needs to take priority when you’re more alert in the afternoon and evening. If you have problems with this, talk to parents and teachers about what you can do.

If you lay awake for hours or wake frequently, try these techniques to help fall asleep: 

If these fail, talk to your parents and doctor to help find a solution.

Charge your phone in another room. 

Friends who decide to text in the middle of the night keep you from sleeping. Even phones on silent have blinking lights that can spark your curiosity. It’s too tempting to look at your social media apps one more time.

Don’t use the excuse that you need your phone as an alarm. Alarm clocks are cheap. Get one and put your phone elsewhere!

Use your bed for sleep only.

Stop doing homework in bed. Stop watching YouTube and Netflix in bed. Train your brain that your bed is where you sleep.

Exercise.

Exercise helps our bodies sleep better, but it should ideally be earlier in the day. Too close to bedtime (which is common with athletes and dancers) wires us up.

Get natural sunlight in the morning. 

This helps to set your circadian rhythm.

Keep the bedroom cool and dark.

It is harder to sleep if the room is too warm or too bright. A fan can be used to circulate air.

Use blackout shades if needed.

Keep pets out of the bedroom. 

Your animals might love you and you love them, but if they keep you up, it’s just not worth having them around at night.

Nicotine and alcohol affect sleep.

These should not be used by teens in an ideal world, but I know teens will not always follow the rules. Teens should know that if they are using nicotine or alcohol, their quality of sleep will be affected.

Nicotine is a stimulant (like caffeine), which leads to more time sleeping lightly and less time in deep sleep. And yes, vaping and chewing lead to this problem too, since it’s the nicotine that causes the problem.

Alcohol reduces the time it takes to fall asleep but it increases sleep disturbances in the second half of the night, often leading to early wakening. Alcohol relaxes muscles, which can lead to sleep apnea (often noted as snoring). Sleep apnea does not allow the body to have restful sleep. Alcohol is also a diuretic, which might increase the need to wake to go to the bathroom during the night.

We all need to prioritize sleep: for our kids and for ourselves. Our bodies and minds will thank us.

Resources:

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