Judith D. Aronson-Ramos, M.D.
Pediatric Developmental/Behavioral

Specialist

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Articles of Interest

The Developmental Pediatric Consultation: What is it? And why it may
benefit your child.

Children on Medication

Better Breakfasts

A Guide to Information on Nutritional Supplements and Dietary Interventions in Children

Quick Tips for Family Harmony

Resources for Sleeping Problems in Children

Searching for Utopia: A Classroom without Labels

The Alphabet Soup of Learning Disabilities: How We Label Children with ADHD and Autistic Spectrum Disorders

The Developmental Pediatric Consultation: What is it? And why it may
benefit your child.
by Judith Aronson-Ramos, M.D.

At the present time there has been a huge increase in the number of children with complicated learning, developmental, social-emotional or behavioral difficulties. Many children and their families seem to be struggling in school and at home with little professional support. Often families would like to be able to discuss their children's struggles with a knowledgeable professional, if they could only find one. Pediatricians typically see between 40-60 patients a day in hectic frenetically paced offices where parents are unable to receive the guidance and thorough evaluations they want and need. Under these circumstances, it is easy for a family to feel lost.

A further problem is the fragmentation of care. In the ideal situation, Pediatricians, Specialists, Teachers and caregivers would be communicating with each other. In today's fast paced world of managed care and dropping reimbursement for medical professionals this is only a dream. This type of communication is time consuming, not reimbursed, and hard to achieve. Parents need a way to deal with this problem.

Another frequent complaint is a lack of empathy amongst the medical professionals treating their child. A partial explanation may be the time constraints on physicians today. Although this may be the reason it does not solve the problem. Parents need and want a professional who will see their child in his or her own unique light. What other way is there?

Having seen a professional for a problem does not mean that problem has been addressed sufficiently. Parents can be more confused at the end of a visit with a Specialist. Families are not simply looking for labels and diagnoses for their children. On their own, such practices can be more destructive to the child and the family. Understanding and coping with a child's problems requires more than a diagnosis. In fact the diagnosing is the least of it. Parents need and want to know what next? What do they do now? What are the best interventions to help their child? What are the long term implications? Are there other diagnoses? And what does the diagnosis really mean? Does their child need other tests? Specialists? Medication? A special school? The list is long. Parents are capable of tackling the issues. Who is more motivated to act in the best interests of a child than a well-informed parent? However on this journey a well-informed professional guide is invaluable.

Sometimes parents suffer from information overload with a special needs child. Armed with notebooks full of evaluations and treatment plans they need to synthesize and interpret all the information. This type of analysis can reveal inconsistencies and sometimes lead to new conclusions. Remember children are constantly growing and changing. Their problems are developmental because of the dramatic physical and psychological changes normally occurring throughout childhood. On the bright side a problem at age 6, can be an asset at age 16. This can be a source of joy and satisfaction in working with children and their families. Change is the rule not the exception and with change can come hope and understanding.

Some families suffer from significant omissions in their child's medical file. Information that is not sufficiently analyzed or thorough can be misleading. There can be underlying emotional, behavioral, or even medical issues that are overlooked. It is important to know when further diagnostic testing is appropriate, or specific recommendations for therapies, educational interventions or other programs are needed. This is often lacking in the current medical system. A parent can become their own best expert. It may seem overwhelming or impossible at first, but with guidance this is a realistic achievable goal.

My personal contribution to my profession and community is to offer parents a place where children with a wide variety of problems including: ADHD, genetic syndromes, learning disabilities, autism and atypical children without diagnoses can receive guidance and support to determine the best course of action for the family and the child. By working closely with other professionals we can achieve the goal of the best possible care for each child and family.

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Children on Medication: The Basics Every Parent and Child Should Know
by Judith Aronson-Ramos, M.D.

Medicating children is a very different process than adults. When a child has been prescribed a medication, usually parents are cautious and concerned. Having a child on medication is the joint responsibility of parent, child, and physician. In the best circumstance it is a working partnership where there are open lines of communication. Usually it is the parent who initiates an office visit to discuss medication, but it is the child who has to take it everyday. This gives the parent the added burden of being directly responsible for their child's health and well being on medicine.

It is important for the process to be therapeutic from the start. This begins with a clear understanding about the medication, what can be expected, and what are the responsibilities of parent and child. I use the word "responsibilities" very literally, because just as a physician has the obligation to obtain informed consent and discuss risks, benefits, and side effects, the patient (if it is a minor child the parents), also has an obligation to the physician. Some of these responsibilities include: to follow up as scheduled, monitor for side effects, follow directions exactly, ask before combining the medication with other medicines or supplements, and being mindful of the supply one has and not run out precipitously.

Sometimes these issues are not discussed in detail. Other physicians provide written instructions. However, it is vital that both patients and parents have a good understanding about their prescriptions, especially when it comes to the use of psychotropic medications (for example ADHD, anti-anxiety and anti-depressant medications). Any child, capable of pronouncing the name of their medication should know what their medicine is called, and why they are taking it. I typically discuss this in an age appropriate style with any child or adolescent I have on mediation. A child incapable of this, who may be on medication, should have a means of being identified through a bracelet, id tag, etc. Parents and caregivers should know the name, spelling, and dosage of the medication. This is important to have available not only for emergencies but in cases where it may be necessary to use another medication and it needs to be determined whether or not there may be an interaction.

Parents should be sure to schedule routine follow up with their physician. Once a child is stable on a medication there is a natural tendency to get comfortable with having the prescriptions and skip regular follow up visits. However, these visits are not only important to asses a child for any side effects, benefits, or different treatment options but also to be able to communicate any changes in the medication's use or effectiveness that may have developed in the interim. In today's world medications are monitored constantly and prescribing practices change frequently. Look at the example of some of the warnings regarding suicide and antidepressants, as well as concerns with stimulants and heart problems.

The length of time a child is on medications should also be reevaluated periodically at intervals of nine months to a year. Without systematic follow up this can fall through the cracks. Also there are situations where laboratory evaluations, blood pressure, weight and other parameters should be monitored more closely.

Finally, it is important to always respect that medications can change in their effectiveness over time, causing new untoward effects or losing their effectiveness all together. Children in particular are constantly growing and developing. There are physical, metabolic, hormonal, and psychological changes happening whether a child is on medication or not. Once a child is on a medication we need to be particularly vigilant about monitoring and adjusting that medication to keep up with these changes.

Lastly, always be honest and open with the physician prescribing the medication. Sometimes dosages are changed or medication is given differently than it was prescribed putting everyone at risk. Most physicians will listen to your concerns and suggestions, but cannot help if they don't have an accurate understanding of what is actually occurring. I value partnership with my patients which benefits everyone involved. I take very seriously the responsibility of medicating a child and know that each parent does too.

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Better Breakfasts
by Judith Aronson-Ramos, M.D.

Breakfast time can be a challenge in many households. Weekday mornings for most families are hectic and rushed. Often there is little time to think about preparing and eating a nutritious breakfast. Convenience is usually the priority. However, numerous research studies have demonstrated that eating a balanced breakfast directly impacts school performance. The latest research emphasizes the importance of protein, not only in the morning, but also to sustain concentration throughout the school day.

Unfortunately, many common breakfast choices contain little or no protein, and often parents are struggling to get their children to eat anything let alone a balanced meal. Children, especially those who watch a lot of television, have been exposed to commercial messages encouraging them to choose sugary nutrition depleted products. Groups that monitor children's television viewing have noted that advertising for high sugar cereals and breakfast products out number all other products.

Here are some practical suggestions to make breakfast easier and more nutritious along with a few recipe ideas:

1. Name what you eat. Kids love to call things by their own creative names and enjoy the process of thinking them up. Design your own unique family favorites. ("Cheese Toast", "Banana Boats", "Magical Muffins" etc.)
2. Prepare in advance. Keep a supply of hardboiled eggs, cheese, nuts and whole grain waffles and breads that can be combined into healthy breakfasts. Some cooked dishes can be prepared the night before and refrigerated or frozen for later use. Sunday is nice time to prepare for the week ahead.
3. Eat with your kids. Many parents are so frazzled themselves they are skipping meals. The same principles of nutrition apply to adults as children. To be more productive and focused in the workplace a breakfast containing a healthy serving of protein is preferable.
4. Don't restrict breakfast to traditional breakfast foods. If it is healthful it can be eaten. A turkey sandwich, grilled cheese, pizza with whole grain crust, or last night's dinner can be acceptable choices. Americans tend to eat their largest protein serving at night when it would be more beneficial to have it in the morning. There are also healthy frozen food choices that are quick and easy to prepare.
5. Breakfast meats that are rich in protein, should also be healthful. Avoid sausage and bacon unless made from turkey, or minimally processed without nitrates and preservatives. Alternative products are readily available at any health food store, and many traditional grocery stores now have small organic or "natural foods" sections, which can have many alternative choices. The taste test applies here and don't be discouraged if it takes a few tries to get the brand and product your kids will enjoy. Be persistent and keep trying.

Recipes

Terrific Toasts

Step 1 - Best Bread
Any good quality bread can be combined with many different foods to make a complete breakfast. Start with the healthiest bread your children will eat. If they don't like whole-wheat try variations - honey wheat, light wheat etc - sometimes they have a milder flavor. You can also try different grains and styles: rye, pumpernickel, spelt, and others have unique flavors and offer advantages over white bread. Even sourdough has more nutritional value than plain white bread. The rule of thumb here is the more whole grains in the bread the more nutritious. There are also many "low carb" breads that have substantial amounts of protein added to them and make a good choice.

Step 2 - Top it Off
There are numerous toppings that can make something as simple as toast a nutritious choice. If your child only wants "butter" choose an enhanced spread that has no trans fat and contains added nutrients such as omega fatty acids. There are numerous products available (smart balance spread, canoleo, etc.)

If you can add more variety try any of the following toppings: peanut butter, other nut butters (almond, walnut etc), farmers cheese or cottage cheese and jam, melted cheese (place bread with cheese on top in the toaster oven and broil for 1-2 minutes), yogurt, and Neufchatel cheese (very similar to cream cheese with less saturated fat). Make your own spreads by combining textures and flavors your children like.

You can also be creative with flavorful crunchy foods sprinkled on top: soy nuts, peanuts, sunflower seeds, dry cereals, crumbled turkey bacon, Parmesan cheese etc. Children especially enjoy it when they do the sprinkling themselves. Even sweet treats like mini M&Ms, or healthy alternates can be used sparingly to make it appealing.

Exciting Eggs

Start with purchasing a good quality egg. It is now possible to buy eggs from hens that are raised "cage free" and fed healthier grains in nearly any grocery store. There are also eggs that contain omega three fatty acids in the yolk, because the chickens are fed flax seeds. These "omega enriched" eggs are an excellent source of protein with the added benefit of omega three fatty acids. Remember that brown or white eggs have the same nutritional value.

Eggs can be prepared numerous ways quickly. They have been overlooked in recent years due to concerns about cholesterol. However, they are an excellent protein source for most children. Here are some preparation suggestions:

Traditional - fried, scrambled, or omelets. Omelets can contain so many different foods: vegetables, cheese, crumbled turkey bacon or sausage, cream cheese and lox; be creative and add what your child enjoys.

Deviled Eggs - hard boil the eggs and mix the yolk with mayonnaise and add spices and stuff back into the white. The yolk can also be mixed with plain yogurt, honey mustard, humus, tahini, or any condiment you think your children will like.

Frittatas - there are numerous basic recipes, this is similar to an omelet but prepared slightly differently. The egg and whatever you choose to add are whipped together then poured into a hot pan lightly greased with oil and covered. It is not flipped during cooking like a traditional omelet and has a very light fluffy texture.

French Toast - egg can be mixed with regular milk or soy milk and lightly fried. It can be topped with a variety of appealing sweets: syrup, cinnamon sugar, powdered sugar, mini chocolates or sprinkles, and other treats.

Cereals

There are many cereals that are nutritious and when combined with milk make a good breakfast. Whole grain cereals with reduced sugar are the best choices. Some common brands that still have appeal to children include: Kix, Cheerios, Total, various types of granola, Chex. When reading the labels look for whole grains, minimal sugar, and few additives. Hot cereals (oatmeal, cream of wheat) can be excellent choices, and you can try adding a teaspoon of protein powder for added nutritional benefit. Sweeten with honey, organic sugar, raw sugar, or blackstrap molasses. Blackstrap molasses is also an excellent source of calcium and iron.

Bread Products

Waffles, muffins and bagels are standard breakfast fare. Choose them wisely. Whole grains with fewer additives are always preferable. Homemade muffins can be prepared and frozen for easy use. This way you can add healthful ingredients: whole-wheat flour, wheat germ, nuts, and no additive. In buying any prepared food the smaller the list of ingredients the better. Learn to read labels. "Natural" does not always mean healthy. Be aware that ingredients are listed in order of the amount contained in the product. You can enhance the nutritional value by adding a protein rich spread to any of these products, or drinking a protein rich drink with them (milk, protein shake or smoothie, soy beverages). Remember these bread products contain little or no protein by themselves, however, combined with a protein source as described above they suitable for breakfast.

Out of the Bread Box Choices

Trail Mix - make your own with nuts, raisins, peanut butter filled pretzels, protein bars cut in cubes, sesame stick, healthy crackers, and other choices based on your children's likes and dislikes.

Fruit Salad with yogurt or cottage cheese.

Bars - protein bars, granola bars, breakfast bars; there are many choices. Read the labels carefully and choose products with at least 5-7grams of protein and less than 20 grams of sugar. Trans fat content should be zero and saturated fat less than 5 grams. If you purchase bars in a health food store or the health food section of your grocery store you will choose a more nutritious product.

Shakes/Smoothies - protein powder can be mixed with milk, or juice and fruit or yogurt to make a very nutritious drink. Try different combinations and add the protein powder slowly as it can dramatically affect the texture and taste.

For more information:

General Information:
The Family Nutrition Book, by William Sears, M.D. Dr. Sears also has a website www.askdrsears.com

Eating Well For Optimum Health, by Andrew Weil, M.D. Dr. Weil also has a website: www.drweil.com

SuperImmunity for Kids, by Leo Galland, M.D. Dr. Galland also has a web site: www.mdheal.org

Cookbooks:
The Whole Foods Market Cookbook, by Steve Petusevsky

Cooking Rocks, by Rachel Ray. This cookbook has many kid friendly recipes some may need to be modified to increase their healthfulness.

Other helpful websites for information on nutrition and nutritional supplements: www.consumerlab.com - annual subscription can be valuable as this organization evaluates many different food and vitamin supplements for quality and purity.

www.cspinet.org - web site of Center for Science in the Public Interest. This watch dog groups publishes Nutrition Action News which evaluates different foods available in grocery stores, fast food restaurants, and other popular eating establishments. They also review different topics in health and nutrition.

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1. Know yourself and your child. Don't begin a diet or nutritional plan you or your child will not be able to successfully follow. Be realistic. Be reasonable. There are isolated examples of diets that have cured diseases (gluten free- celiac disease, the ketogenic diet - seizures, etc). However, in general, diets are very difficult to prove or disprove and scientifically sound evidence is lacking for many of the popular diets. If a family is committed to try a particular diet, and proper supplements are used to prevent nutritional imbalance, a diet can be tried for a reasonable period of time. In general 4-6 weeks of a dietary intervention should be sufficient to judge whether or not there is a beneficial effect.
2. Know exactly what you are taking. Dietary and nutritional supplements comprise an essentially unregulated industry. The Dietary Supplement Health and Education Act (DSHEA) enacted by the federal government in the late 1990's stipulates that botanicals (herbal products) and other dietary supplements are not "drugs" and are therefore not held to the same regulatory standards as drugs. This means that any product sold on the market does not need to demonstrate evidence of both safety and efficacy. Companies can make statements that do not have to be proven by scientific research. (This is why products carry the label "this statement has not been evaluated by the FDA".) Additionally, what the bottle states and what is actually in the product may vary.
   
   There are however several good independent laboratory groups that perform third party testing on products and the results are available to consumers. (Examples include Consumer Labs - www.consumerlabs.com, and The Council for Responsible Nutrition - www.crnusa.org and www.supplementwatch.com ). These organizations do not receive financial support from companies making the products they are analyzing. This is essential to prevent a conflict of interest that could bias results. Products that pass their analyses can be labeled with their seal of approval. Be sure you look into the validity of "certifying" groups. Keep the following points in mind: who pays for their research, are there financial links to specific industries or companies, and who serves on their scientific advisory boards.
   
3. Know where to get good information. The federal government created the National Center for Complementary and Alternative Medicine (NCCAM) in 1997. This is a branch of the National Institute of Health. Their website has a tremendous amount of information available to consumers and professionals (www.nccam.nih.gov). This agency provides information about products that may be harmful, as well as potentially dangerous interactions between supplements and medications.
4. Know what is affecting what. Oftentimes when children are placed on a diet or given a supplement there are many different variables changing at once. In this setting it is impossible to know what products were, or were not effective. A reasonable stepwise approach will allow you to better evaluate what is truly making a difference. Some practitioners will state certain products need to be given in combination to have an effect. Be wary if the list is long and costly.
5. Know the difference between self-interest on the part of a practitioner and good clinical practice. When the person recommending a product is also selling you that product beware of conflict of interest and ethical issues.
6. Know when to stop. There are an unlimited number of diets and product to try. Constantly jumping from one thing to another can be a time consuming pursuit.
7. Know what is based on good scientific research and what is not. All "studies" are not equal. A good valid study is well designed, published in a reputable journal, and others have duplicated the results. With the Internet families can do their own research if they know where to go. Information can be shared with the professionals involved in your child's care. If done in the spirit of mutual understanding a good professional will not be defensive. Some helpful websites include the following, of course you may find others in your own research:
   www.quackwatch.org
   www.jointcommission.org/
   www.fda.gov/medwatch/
   www.childrenshospital.org/holistic
   
8. Know what is reasonable. As the old adage goes, if it sounds too good to be true, it probably is. Do not rely solely on the advice of those individuals actually selling you products. It is imperative to do your own research or consult with practitioners involved in your care.
9. Know what are the significant side effects and precautions for anything your child takes. Potential side effects and drug interactions may not appear on product labels. It is important to do some research and be sure of the safety of any products you give your child. The following websites have extensive information on product safety and product interactions. Remember the liver metabolizes many products, and children may be particularly vulnerable to toxic metabolites at different ages. Always keep the poison control center hotline on hand, in the event of an accidental ingestion 1-800-222-1222. In the case of a serious or concerning side effect noted from taking a supplement you should immediately go to your nearest emergency room. Take the bottle of the product in question with you.
   
   http://medicine.iupui.edu/flockhart/ - Continuously updated information on liver metabolism and different drugs and supplements.
   http://dietary-supplements.info.nih.gov/ - Impartial information provided by the United States office of Dietary Supplements, a branch of the National Institute of Health.
10. Know what tastes good!! If you find something tastes terrible don't expect your children to take it. Similarly, there are times when a product does not appeal to your taste buds but may be delicious to your child. Be persistent and resourceful to find a product that will work, often there is a solution.

Quick Tips for Family Harmony
by Judith Aronson-Ramos, M.D.

Conflict Resolution Guidelines for the Family

1. Know thyself. What "sets you off", be able to anticipate the times when you know you will "lose it". Know thy kids, many parents can predict when a child will lose control before he or she does.
2. Pause to consider what the conflict is; define it in your mind. Breathing deeply can help you not to react to quickly. Take time to respond. Act don't react.
3. Limit yourself to the situation at hand, don't make the problem larger than it is or drag other issues into the current conflict. Be specific.
4. Plan what your next move will be, visualize it.
5. Watch body language, yours and your child's (pointing, grimacing, arms folded etc). Most communication is non-verbal.
6. Restate the other person's feelings, they want to be heard. Restate your feelings. Use "I feel..." instead of "You did..."
7. Have a compromise solution in mind.
8. Try to see how your role may have contributed to the conflict.
9. Role play.
10. Try family meetings: once a week at a set time, Sunday nights for example. Everyone gets a job in the meeting each week - note take, leader, etc. A sample meeting might be as follows, but adapt it for your family. Begin with a comment about something nice that happened in the family or at home that week, Each person takes a turn. Each person can then make one gripe about another family member, but restate feelings positively. Brain storm resolutions to the problem. End with a plan for each person to improve something next week. Finish with a treat!

Anger Management for the Family

1. Know what anger is - a normal healthy emotion, not an excuse to explode. Describe examples.
2. Know what makes each family member angry
3. Know your body's signals (rapid heart best, sweating etc)
4. Have a back up plan for when you can't control your anger: punching bag, hit a pillow, go to your room, breathe deeply in and out five times, go for bike ride or run etc.
5. Practice anger control:
   *Keep a tally sheet.
   * Draw pictures of angry feelings.
   * Practice changing negative thoughts to positive ones, try using "I feel" statements instead of negative ones (Instead of "You are a real pain! Why can't you just sit and finish you homework like everybody else does", becomes " I feel annoyed when you take so long to sit and do something that should be quick. Next time I would like you to try….")
   * Keep a journal (the wh's of your anger incident: Why, Where, When, What) Place sticky notes with anger alternatives around the house: on the fridge, in the bathroom, in bedrooms etc. For example: No big deal! I can handle it! I am calm. Breathe in, breathe out relax. I can ignore that. I know he doesn't mean it. So what? What's the big deal? Next time will be better. Etc.
   
6. Practice forgiving each other.

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Resources for Sleeping Problems in Children
by Judith Aronson-Ramos, M.D.

Sleep problems are pervasive among families. They are among the top five reasons families visit their Pediatrician. Here are some guidelines and in resources that may be helpful.

The following books are excellent guides for parents on the prevention and treatment of sleep problems in children.

Solving Your Children's Sleep Problems, by Richard Ferber, M.D. This book was written in the 1970's and remains the classic text Pediatrician's recommend for the behavioral approach to correcting a sleep problem.

Nighttime Parenting: How to Get Your Baby and Child to Sleep, by William Sears, M.D. Looks at the sleep issue from the perspective of the entire family and covers a wide range of sleep habits.

Healthy Sleep Habits, Happy Child, by Dr. Weissbluth. This is a step-by-step guide to solving sleep problems. It includes information about what to expect as typical behavior at different ages.

Melatonin is widely used as a sleep-promoting agent. It must be given at night within thirty minutes of bedtime. For more information about dosages and safe available preparations go to www.consumerlabs.com. For more specific information relating to its usage in children go to www.keepkidshealthy.com In general the recommended dosage for a child will range from 0.3mg to 10mg. This should be used under the care of a physician especially if your child is taking other medications. Melatonin works by enhancing the body's own natural secretion of the hormone. There are published studies in reputable journals, which have documented the positive effects of melatonin in promoting sleep.

"Sleep Hygiene" is a term, which refers to the condition right before and during sleep. It involves the use of a consistent bedtime routine with children and limiting over stimulating activities or foods right before bedtime. Many children struggle with the transition from wakefulness to sleep and need to learn ways to self-calm and let go. Parents can help in this process by giving children the tools they need: structure, routine, bedtime story or ritual, limiting noise, TV, video games, phone calls, emailing etc late at night. Most children need 8-10 hours of sleep at night. Teenagers actually need closer to ten hours of sleep at night due to hormonal fluctuations. Fatigue will always make it more difficult to perform well in school and control one's behavior the next day. Some children have added difficulty falling asleep due to the effects of their medication. In these cases the child may need extra time to wind down with calming quiet activities in his or her bedroom: reading, drawing, journaling etc. Even though a medication may make it more difficult the same principles of sleep hygiene apply. In specific circumstances a supplement or medication may be needed to regulate a true sleep disturbance.

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Searching for Utopia: A Classroom without Labels
by Judith Aronson-Ramos, M.D.

What would the world be like if all of our children were appreciated for their unique qualities? What would school be like if the teacher had to teach how the child learns best? What would happen if "behavior problems" were seen as problems to overcome, not infractions to punish?

I would like to explore the utopian vision of a world where children are not labeled with disorders, whenever they encounter problems at school or at home. I will do this by using the example of ADHD (attention deficit hyperactivity disorder) since this is one of the most common diagnoses a family is likely to encounter.

If there is a child who has trouble "paying attention" in school, the first thing that might happen is the teacher may point this out to the parent. They may describe the child as unable to focus, distractible, having a hard time starting or completing tasks in school, and possibly impulsive in his work habits and behavior. The parents may then agree with the teacher's concerns as they note the child struggles with his homework, and has a difficult time controlling him or herself during other activities at home. Come to think of it the parent may feel the child has difficulty on a sports team or in other group activities where he needs to wait his turn, and pay attention to a coach. In other words it may be noticed that the difficulty is not just occurring in school.

If the problems persist the school or teacher may suggest that the parents have their child "evaluated". An "evaluation" can mean different things to different professionals. There are guidelines, which suggest a standard of care, but each practitioner has his or her unique approach. If the parents agree their child is struggling they will seek a professional usually a child psychologist, but occasionally a neurologist to evaluate their child.

The evaluation under ideal circumstances would consist of the following: direct observation of the child at school or extensive interview with the teacher by telephone or questionnaire; the teacher will also be asked to fill out a "rating scale" for ADHD that will be used for background information; the parents will be interviewed and asked to fill out various questionnaires regarding their perceptions of their child's functioning; a psychologist or a team of professionals which may include educators, and physicians - will perform testing on the child - this testing can include a wide range of assessments; when all of the information is complete the evaluator will write a report which will give the child a diagnosis or a label, and list some recommendations.

In the case of a child with suspected ADHD remember there is no blood test, no brain scan, no specific medical examination, which can make this diagnosis. The diagnosis itself is based on teacher, parent and the evaluator's observations of the child. There is no single defining criterion upon which the label rests. Parent and Teacher rating scales are a significant part of the data used to make the diagnosis. They provide the clinician with information to describe the child's symptoms in the classroom environment. What an awesome responsibility! When a teacher or parent fills out one of a variety of different rating scales or check lists, that information is providing pivotal feedback upon which a diagnosis rests. The professional will then combine this information with the results of testing they perform on the child this will likely include and IQ test amongst other standardized instruments.

The results will then be analyzed and the professional will use a book called the DSM IV (the diagnostic and statistical manual) to see what diagnostic category the child fits into. The DSM is the gold standard for making the diagnosis of ADHD. This manual also includes the diagnostic criteria for most of the learning disabilities and psychiatric disorders seen in children.

The point I am trying to make here is whether or not a diagnosis or label fits a child a parent should understand that these determinations are not etched in stone, and are based upon other human beings interpreting their observations through the lens of their experiences and their own personal biases. This is not to say every diagnosis is subjective or inaccurate, what I am getting at is a parent needs to understand a label is just a label. It is a snapshot in time of a child's functioning. A child does not have ADHD, like it is some sort of disease you catch, but a child may have a learning and behavior profile that reflects all of the major symptoms of ADHD such as impulsivity, lack of focus, distractibility etc.

The problem lies in what does the label do to the child. Is it a liberating insight that helps him or her to learn better, or is it a negative description of stereotypes that leads others to unfairly judge a child.

So then why do we use labels? Is the outcome always so pessimistic?

For some students a label is a relief, as it defines the problems they have been having in school and gives them hope that they are not entirely defective. For some students the label helps to compartmentalize their school problems, limiting their difficulties to a specific area. Additional benefits of diagnostic labels can be:

1. In the best hands, labels provide services in the public school setting.
2. Labels give a common language to discuss a child's strengths and weaknesses.
3. Labels may lead educators and parents to information and research, which can be truly beneficial and helpful.

There is also a growing body of literature, which is focusing on the positive aspects of learning differently. In a recent article in Fortune Magazine (fn1) some of the top CEOs of Americas corporations tell about how they struggled in school all having been diagnosed with dyslexia. Others have written about Thomas Edison's life being the quintessential example of ADHD through the life span. There is speculation about Benjamin Franklin having ADHD. If we had labeled these amazing innovators who have immeasurably contributed to humankind, would the outcome have been the same? Are the labels so pejorative in their very nature that we cannot see beyond the stereotypes?

Most likely it was the unusual characteristics all these individuals possessed that enabled them to be innovative, and provide the breakthrough contributions they did in their respective fields. If their idiosyncrasies were used to diagnose them with learning disabilities or behavioral disorders would they still have achieved their greatness? How many minds have been stifled in so doing? This is a continuing saga with many contemporary examples. We universally love to celebrate the child who overcomes diversity in school to achieve later success in life. There is no better story than the underdog or outcast who achieves greatness. This story has been told and retold throughout history from Michelangelo to Winston Churchill (who by the way was kicked out of school on more than one occasion). But, are we making this a more difficult road to travel than is necessary. These are certainly questions worth pondering. Often examples of these great minds and talents that always struggled and did poorly in school, are enlightening for parents and children. It offers a more optimistic view of how a learning or behavior difference, if channeled appropriately, may be a hidden asset. Everyone needs a glimmer of hope.

In their more traditional everyday use, labels do emphasize weaknesses and deficits, often obscuring a more positive and optimistic view of a child. Some have blamed this bias on the insurance industry. To be reimbursed for diagnosing and treating a child in medicine or psychology a diagnostic code must be given. These are diagnoses predominantly based on a model of deficits. Identifying how a child differs from the norm is what determines a given diagnosis. It is what is "wrong" that is catalogued in the DSM among other diagnostic tools, which are used to determine the exact label. And remember, there is even still debate about some of the actual diagnoses, which are constantly undergoing revision in each new version of the DSM.

The point I am trying to make is that parents and educators need to protect children and from the harmful effects of labeling. Especially in today's environment of a tremendous proliferation in the number of labels we assign to children. It has become routine for me to see a patient with 5 or 6 different diagnoses which all overlap. For the parent and child this creates a huge burden of feeling that the child's very being is defined by what he or she lacks or what is wrong with him or her.

Instead we need to move toward a new model of understanding where a child is not viewed as deviant for not fitting the mold, but perhaps just different. Where when professionals evaluate children they spend as much time focusing on their strengths and what they are good at, as on their weaknesses and problems. Where children are as much a part of their learning as the teachers and parents that surround them, and we think to ask them what would make school easier, better, or a more successful place to learn.

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The Alphabet Soup of Learning Disabilities:
How We Label Children with ADHD and Autistic Spectrum Disorders
by Judith Aronson-Ramos, M.D.

Learning Disabilities are a confusing topic for many parents and teachers. The list of labels seems to be growing at an alarming rate. New diagnoses pop up and old labels get replaced sometimes at a rate that outpaces the knowledge of professionals. Parents are equally confused about all of the D's? Diagnoses such as: LD, ADHD, ODD, PDD, OCD, NVLD, ASD, CAPD and others.

What is going on here? What do all of these labels mean? What are the important features of the most common learning difficulties? Are there really that many children with learning problems now? Or do we Americans just love to label everything so we are special and unique, including our children? Are the expectations and demands of our technologic society placing unrealistic demands on our children who are incapable of measuring up to these standards? Has this proliferation of labels gone too far? Who is assigning these labels? How are diagnoses made? These are some of the questions parents ponder when their child begins to struggle in school, or is diagnosed with a developmental disorder. Ideally a diagnosis should foster understanding and facilitate the use of strategies and tools to help a child. Instead, oftentimes there is confusion and a feeling of helplessness.

What Exactly Is On The Label of our Can of Alphabet Soup?

Before I can try to answer some of these questions, think for a moment about the act of labeling children and what this means for teachers, parents, and children. For example, it is a well know fact that a student's performance in the classroom is strongly influenced by the expectations and attitudes of his or her teachers. This is also true at home and in activities outside of the classroom. This had been demonstrated by numerous experiments in clinical psychology and educational theory over the years. However, even without the research, we all instinctively know this is true from our own personal experiences. We can each recall those individuals and teachers who got our best or our worst performances in school and life.

A specific diagnostic label can be stigmatizing and encourage misleading assumptions about a child. Labeling a student may bias a teacher leading to self-fulfilling prophecies regarding a student's abilities. This may also create a difficult relationship with the parents from the start. The parent can be defensive about the child's abilities or problems, as they feel their child is being judged before even given an opportunity to perform in the classroom.

For children, having a "diagnosis" may cause them to feel they are somehow defective or disabled. This in turn can lead to problems with self-esteem and feelings of isolation. For many a label reinforces a negative self-image, and proves that they are not as smart or talented as others. Not surprisingly for many children when they hear the term "disability" or "disorder" they think of someone physically handicapped or in a wheelchair.

What is good about a label?

So why do we use labels? Is the outcome always so pessimistic? For some children a label is a relief, as it defines the problems they have been having and gives them hope that they are not entirely defective. For some children with simple learning differences, the label serves to compartmentalize their school problems, limiting their difficulties to a specific area. Additional benefits of diagnostic labels can be:

1. In the best hands, labels provide services in the public school setting.
2. Labels give a common language to discuss a child's strengths and weaknesses.
3. Labels may lead educators and parents to information and research, which can be truly beneficial and helpful.
4. Properly labeling or diagnosing a child can lead to critically important early treatment

There is a growing body of literature, which is focusing on the positive aspects of learning differently. In an article in Fortune Magazine some of the CEOs of the world's most successful corporations tell about how they struggled in school all having been diagnosed with dyslexia. This profile included: Michael Eisner, formerly CEO of Disney, Charles Schwab, the head of Virgin Atlantic Airways, and others. Some authors have written about Thomas Edison's life being the quintessential example of ADHD through the life span. Others have postulated that Albert Einstein and Bill Gates exemplify many of the traits of Aspergers Disorder. There is speculation about Benjamin Franklin having ADHD. If we had labeled these amazing innovators who have immeasurably contributed to humankind, would the outcome have been the same? Are the labels so pejorative in their very nature that we cannot see beyond the stereotypes? Most likely it was the unusual characteristics all these individuals possessed that enabled them to be innovative, and provide the breakthrough contributions they did in their respective fields. If their idiosyncrasies were used to diagnose them with learning disabilities or behavioral disorders would they still have achieved their greatness? How many minds have been stifled in so doing? This is a continuing saga with many contemporary examples.

We universally love to celebrate the child who overcomes diversity in school to achieve later success in life. There is no better story than the underdog or outcast who achieves greatness. This story has been told and retold throughout history from Michelangelo to Winston Churchill (who by the way was kicked out of school on more than one occasion). But, are we making this a more difficult road to travel than is necessary. These are certainly questions worth pondering. Often examples of these great minds and talents that always struggled and did poorly in school, are enlightening for parents and children. It offers a more optimistic view of how a learning or behavior difference, if channeled appropriately, may be a hidden asset. Everyone needs a glimmer of hope.

Where does the model of labels as deficits come from?

In their more traditional everyday use, labels emphasize weaknesses and deficits, often obscuring a more positive and optimistic view of a child. Some have blamed this bias on the insurance industry. To be reimbursed for diagnosing and treating a child in medicine or psychology a diagnostic code must be given. These are diagnoses predominantly based on a model of deficits. Identifying how a child differs from the norm is what determines a given diagnosis. What is "wrong" is catalogued in the Diagnostic and Statistical Manual (or DSM for short), among other diagnostic tools, which are used to determine the exact diagnostic label.

Public school systems utilize the same model of deficit based labels. To qualify for an IEP (Individualized Education Plan) or any special education services, students must have a diagnosis which satisfies different eligibility criteria. A child must have impairments significant enough to interfere with functioning to obtain special services. Eligibility criteria are designed to be stringent to prevent over utilization of special education funding. As such this model also does not emphasize strengths, unusual abilities, or the potentially positive aspects of a learning difference.

There still continues to be debate about some of the actual diagnoses. The question of what constitutes a learning disability continues to be debated in the special education literature. The most widely accepted definition is a child who shows a significant discrepancy between intelligence testing (I.Q.) and achievement test scores. Different school districts may vary in their precise definitions and terminology. However, it is the child who fails to learn or achieve, in spite of apparently normal intelligence that generally qualifies for a learning disability. Within the realm of learning disabilities there are numerous more specific labels such as: dyslexia, disorder of written expression, dyscalcula, dysgraphia and others. Under ADA, (the Americans With Disabilities Act) guidelines other disorders traditionally viewed as behavioral will also qualify a child for special services under the category of Other Health Impaired, this includes ADHD, ODD, Autism and other labels. There are many excellent books written about the specifics of the Federal Laws enacted to protect and serve children who learn differently, as well as the obligations of teachers and administrators to ensure the student's needs are being addressed. The important point here is that all children who receive any type of special remedial services in the public education system must qualify based upon their specific diagnostic label. No diagnosis, no services.

What is in a label?

The most pervasive "D" is ADHD or Attention-Deficit Hyperactivity Disorder. Conservatively the prevalence of this diagnosis is anywhere from 4-12% of school aged children. Some investigators have suggested the incidence may even be as high as 20% of school- aged children. The population numbers approximately 1.5 million children. These numbers are constantly being revised. The condition is still thought to be more prevalent in boys, but it is also often overlooked or misdiagnosed in girls, as they less frequently present with hyperactivity or other obvious and externalizing symptoms. The prevalence is still about 3 to 1, boys to girls.

For teachers this is the most common learning disorder they will encounter in the classroom. For parents it is often one of the first diagnoses to be entertained when a child is struggling in school. The amount of information currently published on this topic is mind- boggling. Similarly the amount of research funding for ADHD and the use of medications for the disorder is astounding. As such you are bound to find confusing and conflicting information. I will try to provide clear, concise, and understandable background information about ADHD, the most common learning disorder of childhood. I will use the questions that follow as a guide:

1. How the diagnosis is made?
2. What is the history of the disorder?
3. What are the observable phenomena?
4. Where do we go from here?

How the diagnosis is made

To understand how a child is given the diagnosis of ADHD it is helpful to understand the terminology, which has gone through many changes over the years. The current terminology for ADHD comes from the so-called "bible" of psychiatric medicine called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or DSM-IV published in 1994.This manual includes the diagnostic criteria for most of the learning disabilities and psychiatric disorders seen in children. The psychiatric disorders are classified into two broad groups: either behavioral disorders or emotional disorders. In general, the only diagnoses, which do not appear in the DSM, are clarifications and refinements of a learning disability given by learning specialists, speech and occupational therapists, educational psychologists and others. Also not included in the DSM are other medical diagnoses, which secondarily affect learning (syndromes, physical impairments etc.). The DSM, however, being "the bible", is very comprehensive. According to the generally accepted diagnostic criteria for ADHD, a child must have the following:

1. Fulfill the criteria as stipulated in the DSM (see below).
2. Information regarding the child's symptoms must be obtained from more than one setting (not just school).
3. Any coexisting condition which may be masquerading as ADHD or complicating the child's symptoms must be uncovered.

What are the exact criteria to diagnose ADHD?

A summary of the main criteria in the DSM- IV must include six or more symptoms from list 1or 2.

1. Inattention Symptoms

• Often fails to give lose attention to details
• Difficulty sustaining attention
• Often doesn't seem to listen when spoke to directly
• Often doesn't follow through
• Often has difficulty organizing
• Often avoids tasks requiring sustained attention
• Often loses things
• Is easily distracted
• Is often forgetful in daily activities

2. Hyperactivity-Impulsivity Symptoms Hyperactivity

• Fidgets
• Leaves seat
• Runs and climbs excessively
• Has difficulty with quiet leisure activities
• Is always on the go
• Talks incessantly

Impulsivity

• Blurts out answers
• Difficulty waiting for his/her turn
• Interrupts or intrudes upon others

In addition to the symptoms catalogued above, the following criteria must also be met:

1. Onset of symptoms is before the age of 7 years old
2. Problems due to these symptoms have lasted for more than 6 months.
3. Symptoms are true impairments affecting the child's ability to perform developmentally appropriate activities and not explained by another disorder (such as Autism, or another learning disability).

This last point may be worthy of further discussion. We are all familiar with the child diagnosed with multiple seemingly overlapping disorders. Some of this may be due to the professionals involved and their understanding of the child's symptoms. Especially with the diagnosis of ADHD there is a considerable amount of subjectivity involved when the diagnosis is predominantly based on descriptions of behavior. No matter how clear and precise these descriptions are they are still based on judgments about what teachers, parents and others observe. Also the symptoms of ADHD are present in all children and adults to some degree, what establishes the disorder is the persistent and severe pattern of the child's symptoms. It is possible for a child to have ADHD and another diagnosis. In fact, as we will see the majority of children with ADHD have "co morbid" conditions. This is the medical terminology for the coexistence of more than one learning or behavior problem at a time. The current professional view is that 15-20 % of children with ADHD have co morbid conditions.

What kinds of ADHD exist?

The current subtypes of ADHD are as follows:

1. ADHD, Predominantly Inattentive
2. ADHD, Predominantly Hyperactive-Impulsive
3. ADHD Combined Type
4. ADHD, NOS (not otherwise specified)

Depending on the symptoms noted above from lists one and two, the child will then be assigned a type of ADHD. Children who have symptoms of both inattention and hyperactivity or impulsivity will be given the diagnosis of ADHD Combined Type. Other than the labels listed above there are not valid uses of the diagnosis. For example, there are no such diagnoses as: atypical ADHD, mild ADHD, autistic ADHD, or other interesting combinations of terms you may have heard.

Exactly how is a diagnosis made?

The diagnosis can be made by a medical doctor, psychologist or learning specialist. However, only a medical doctor (M.D.) is qualified to treat the disorder with medication. The M.D. could be the child's Pediatrician, a Developmental Pediatrician, Neurologist, or Psychiatrist. All are trained to prescribe medication for ADHD, though different practitioners will have varying levels of expertise, qualifications, and experience treating the disorder.

Professionals will make the diagnosis of ADHD based on the presence of the symptoms listed in the DSM as reported by parents, teachers, and other care givers. The information is usually obtained by rating scales or questionnaires. Some professionals independently make their own observations of the child in natural settings but this is not always the case, and a diagnosis can be made without direct observation. Even with the use of other tools, which can aid in the diagnosis of ADHD the standard of care still utilizes questionnaires from teachers and parents. Computer based continuous performance tests where the child is presented with a target and must hit a computer key only when that target is visualized or heard, are helpful but not the mainstay of diagnosis. Similarly brain scans of various kinds are still only being used as research tools. Careful analysis of school work including error patterns can be helpful but only with the behavioral descriptions. Ultimately, the diagnosis of ADHD rests on the eyes and ears of the observers.

In the past the diagnosis of ADHD was rather sloppily applied. Children were put on medication without complete evaluations. Teacher and or parents could get medical professionals to trial stimulant medication in children without a full assessment. Some teachers and parents over labeled hard to handle or active children with the disorder. Now however, there are more professional guidelines in the fields of Pediatrics, Child Psychiatry, and Child Neurology for the diagnosis of ADHD. Hopefully, this will limit continued misdiagnosis and over diagnosis of the disorder. At least it is a start in the right direction.

Some of the most commonly used teacher rating scales are the Connors Teacher and Parent Rating Scales, and more recently the Vanderbilt Rating Scales. There are others being used as well. The point is there must be some type of structured observation of behavior by adults, to qualify for the diagnosis. It is not sufficient for a parent or teacher to make generalizations about a child's behavior. The questionnaires are designed to require an observer to give more thought and careful consideration to a particular student who is struggling. Some of the materials used in making a diagnosis are listed below. Keep in mind there is still variability in how different professionals make the diagnosis and the materials they use.

1. Teacher rating scales and questionnaires
2. Parent report and questionnaires
3. Psycho educational evaluations (may include a variety of different tests such as IQ )
4. Physician report (usually a Neurologist, Psychiatrist, or Pediatrician)
5. Computer based Continuous Performance Tests (TOVA, the Gordon. and others).
6. Samples of schoolwork.

This vital role of the teacher may explain the political fall out which occurred in October of 2000, when congressional hearings were held on the topic of teacher and school recommendations for stimulant medication. At that time various different experts testified before congress about ADHD, the use of medications, and the proper diagnosis of the disorder. Prior to these hearings the Christian Science Monitor as well as other entities had been staunchly protesting against the use of medication to treat children diagnosed with ADHD. They also unfairly implicated teachers and entire school systems. They in fact go much further and question the entire validity of the diagnosis.

The overwhelming body of scientific research not only demonstrates ADHD does exist, new imaging techniques have actually been able to demonstrate how the brain of a child with ADHD differs from a control subject. One of the earliest and most widely known research studies was published in 1990, but since that time studies at the National Institute of Health, and elsewhere, have continued to refine the neurobiological basis of the disorder. If anything, research has become more specific in refining our knowledge about ADHD. Some of the basic neurobiological problems noted in children with ADHD are: differences in blood flow to certain regions of the brain, neurotransmitter dysfunction (dopamine and norepinephrine), and possible anatomic findings (smaller basal ganglia). The important feature here is not to learn neurology, but to accept the fact that children who are properly diagnosed have basic wiring differences that are affecting their behavior. To insinuate that a student can simply control him or herself, or turn misbehavior off or on, is to have a limited understanding about what constitutes ADHD. It is extremely typical for ADHD students to suffer from "performance inconsistency". This on again, off again phenomenon can be very frustrating for teachers and parents. However, to penalize a child for doing something well once, by insisting they should always be able to perform at that level is very unfair. Children with ADHD struggle in this area and quite often are victimized by their own successes. This is also true for children with a host of different learning disabilities.

Current Political Trends

Politics continue and always will. In 1999 the state of Colorado Board of Education passed a resolution, which asked school personnel to use academic solutions to resolve problems with behavior, attention and learning, instead of recommending psychotropic drugs. Similar resolutions have been passed in Connecticut, California, Texas and Georgia among other states. Obviously this reflects the much needed goal of using greater precision and restraint in making a diagnosis of ADHD, as well as considering all available options for treatment. This zeal for prescribing medication is not apparent among all teachers or school districts. Ultimately it is the medical professionals who prescribe medications, and it is their obligation to work with children and families to use medication appropriately. Although medications have clearly been over prescribed for ADHD, there are still children who greatly benefit from medication for their ADHD. The recently published and highly regarded MTA study demonstrated the clinical benefit of medication in treating children with ADHD. This study compared children who received counseling only, medication only, or medication and counseling. The group of children who did the best was those who received medication only. This study is ongoing and will continue to produce new data to help us in understanding what works best for children with ADHD.

Difference of opinion should and will always exist. Even though, the overwhelming body of scientific research today demonstrates the value of using medication in a child with ADHD this does not mean that every child will respond to medication. In some cases side effects interfere more with a student's functioning without enough improvement to merit the use of a drug. All of these are issues a good professional will work on and discuss with the family of a child with ADHD. The question of proper diagnosis will always exist, and professional organizations as well as parents and teachers have a role to play in monitoring how children are labeled.

ADHD A Different Perception

There are other authors and researchers that have advocated an entirely different view of ADHD. One of the more prominent is Thomm Hartman who in his book, ADD A Different Perception opened the door to debate about how we view ADHD globally. Perhaps ADHD is not itself a disorder, but a description of traits found among the earlier societies in the hunters and warriors. In his view, ADHD may in fact be a collection of skills and predilections that were advantageous at a different time in human history. With the advent of an agricultural society these traits are no longer advantageous. It is a different set of skills that makes you a good hunter vs. a good farmer. The ADHD traits, which served ancient hunter-gather societies, cannot serve the same purpose in modern agrarian societies. Numerous other authors in different fields ranging from psychology to cultural anthropology have since made this and similar arguments. These authors have speculated that ADHD is not so much a disorder as a human survival trait, which although it may not carry the same benefits in today's society it still has the potential to positively impact creativity, entrepreneurship, and ingenuity. This viewpoint may not be accepted in to the body of mainstream scientific literature, but it is thought provoking nonetheless.

The Soup can under pressure

We cannot ignore the fact that as school funding declines, and demands placed on teachers to prepare their students for standardized tests increases, that there is a diminished tolerance for children with learning differences. The traits seen in a child with ADHD or other "learning disorders" become an inconvenience in the classroom and disruptive of a tight schedule necessary to prepare children for standardized achievement tests. We must be as objective as possible in making or suggesting the diagnosis of ADHD. There is the real danger of implicating a disorder when it is the child's learning style and temperament, and a teachers teaching style that are at odds. We must resist the tendency to view every child who doesn't fit in as having a "disorder" or "diagnosis". There will always be those children who walk to the beat of a different drum.

The history of the Disorder

Over the years the diagnosis of ADHD has been refined. Experts in the field of ADHD cite literary references dating back to Shakespeare which describe characters with features characteristic of ADHD (Fidgety Phil). In 1902 an English physician, George Still, made the first medical description of what we now call ADHD. Dr. Still's initial descriptions were followed years later by similar descriptions of children. In 1918 there was an Encephalitis epidemic in this country, after which the concept of the brain injured child syndrome developed. Numerous recovered children with various degrees of impairment were found to suffer from some of the now classic symptoms of ADHD. This is where the initial idea of "minimal brain" damage came from. The names continued to change over the years: minimal brain dysfunction 1950's, hyperkinetic disorder of childhood, ADD, and ultimately ADHD with different subtypes the term in use today.

What are the main symptoms of ADHD?

The hallmark symptoms are: inattention, impulsivity, and hyperactivity. Current research is beginning to suggest that the disorder has less to do with attention than it does with behavioral inhibition. This view is that ADHD is primarily a "developmental problem of self-control". Attention is not the problem per se, and may actually play a more minor role than previously thought, when the disorder was first named. We take for granted now that ADHD is not just a disorder where attention is lacking. Research has gone so far as to anatomically locate the main impairments of ADHD in the frontal lobes of the brain. This is the area where the "executive function" skills are located. The executive functions are those brain processes, which are the overall managers of all of our goal directed activities.

The Observable Phenomena

To this day controversy continues regarding the key features of ADHD. Along with refinement of the diagnosis into the different subtypes has come debate about the true nature of the disorder itself. One of the leading researchers in the field Dr. Russell A. Barkley has recently proposed that ADHD has less to do with attention and more to do with a "developmental problem of self-control". In fact deficits of attention may not even be universal in the disorder. What about that behaviorally disruptive impulsive child in the classroom, who can sit and attend when the activity has a high degree of interest for him or her (computer based learning game, hands on project etc)? Is attention really a key feature describing their disability? Parents would often wonder when their disruptive ADHD child can sit and hyper focus on a Gameboy or computer program for hours on end. According to Dr. Barkley "ADHD is a developmental disorder of behavioral inhibition that impairs the development of effective self regulation (executive functioning) and is not, as its name implies, chiefly a disorder of attention."

A paradigm shift may be underway here. In fact Dr. Barkley thinks those children who simply can't focus (ADHD Inattentive subtype) may comprise an entirely different disorder all together. Often these children have no behavioral difficulties and may be socially well integrated but "space out" for their academics and can't sustain their attention. Often they have little or nothing in common on the surface with their impulsive and hyperactive ADHD cousins. ADHD is not just a disorder of attention, and in spite of the name other features of the disorder may drive the impairments from which a child suffers.

There is a well known Developmental Pediatrician who does not subscribe to the use of the label "ADHD", Dr. Mel Levine. He writes: "Sometimes it is difficult to decide whether a particular child's brain is "disabled" or "highly specialized"…It is only during childhood that a young person is expected to be reasonably adept at everything. That expectation may discriminate against children who have uneven abilities. Furthermore, it may sometimes cause variation to be confused with deviation. So it is that some of the children who suffer from significant neurodevelopmental dysfunctions may ultimately perform very well in life when they are permitted to practice their "specialties", to pursue the areas where their abilities best serve them. In the adult world such specialization is not only encouraged by the way jobs are organized, but is also highly desirable and likely to increase the chances for success." (Educational Care)

What about the other big "D"?

The Pervasive Developmental Disorders are another large heterogeneous group of learning and behavioral disorders that are increasing in number. Here terminology has become very confusing. There are many professionals using the specific diagnostic terms differently, as well as creating new categories of disorders that do not actually exist in the medical literature. As a group the Pervasive Developmental Disorders include the following:

1. PDD- NOS: Pervasive Developmental Disorder Not Otherwise Specified
2. Autistic Disorder
3. Aspergers Disorder
4. Rett's Disorder
5. Childhood Disintegrative Disorder

The last two disorders will not be discussed here. However all of the disorders share certain common features. All of the disorders describe individuals with significant impairments in:

Social interaction
Communication
Stereotyped or repetitive behaviors

Some confusion has arisen as professionals have used the term PDD as a diagnosis when it is not. PDD's are a category which includes the five disorders listed. Professionals have used the term PDD as shorthand for PDD-NOS, but the distinctions are important when trying to understand the differences between these overlapping disorders.

All of the PDD's are present by age three and share some features. All of the individuals in this group share difficulties in relating to others. There are significant differences however in the degree and severity of impairment. The term itself describes a pervasive developmental disorder, as such this does not include individual unless their degree of impairment is both pervasive, throughout all areas of their lives and severe in how it impacts functioning and relationships. Once again as we noted in our discussion of ADHD the diagnosis is based upon descriptions of behavior (except in Retts syndrome where we have a genetic marker). For each diagnosis there is a description of qualifying criteria. We will look at each disorder, and then make some generalizations about the use of the labels.

There are a variety of standardized tests or screening tools professionals use to diagnose any of the PDD's. A complete assessment should include the following: complete medical evaluation by a Pediatrician or Neurologist, interviews with teachers and caregivers, direct observations of behavior, psychological and educational assessments, a thorough communication assessment by a speech and language pathologist, and the use of specific rating scales. The most well known behavior rating scales include: the CARS (Childhood Autism Rating Scale), GARS, and ADOS (Autism Diagnostic Observation Scales). Many of the "autistic" behaviors however, are noted through direct observation, preferably in a natural setting (home or the child's preschool). Intelligence testing, in the form of an IQ test, is not required to make the diagnosis of autism.

Autistic Disorder is also called early infantile autism or childhood autism is the classical picture of autism most of us are familiar with. The criteria for this diagnosis include the following:

1. Qualitative impairment in social interaction - This encompasses the lack of non-verbal communications; inability to develop peer relationships appropriate for one's age; a lack of spontaneous sharing with others; a lack of socio-emotional reciprocity.
2. Qualitative impairment communication - This encompasses a delay or complete lack of spoken language; difficulty sustaining a conversation; repetitive use of non-meaningful language (echolalia); limited imaginative skills.
3. Restrictied repetitive and stereotyped areas of interest and activity - preoccupations, inflexibility, obsessions with the parts of objects, and stereotypical motor mannerisms (flapping, twisting etc).

Individuals with Autism can have a range of intellectual abilities ranging from severe mental retardation to intellectually superior IQ. Because of the heterogeneity of children with autism the term autistic spectrum disorder has become common. This refers to the broad range of children with autistic like disorders ranging from PDD-NOS to Aspergers Disorder. It connotes the broad range of abilities and disabilities one can see amongst this population of individuals.

Autism is more common in boys than in girls, about four to one; however as with most developmental disabilities it is probably under diagnosed in girls. At the higher functioning end of the spectrum autism can be difficult to differentiate from Asperger's Disorder, PDD-NOS, Non-Verbal Learning Disorder or Semantic and Pragmatic Speech Delay.

PDD-NOS has become an increasingly popular diagnostic label as it describes an individual with some of the more classical features of autism, but to a milder degree, and not all of the criteria. Some professionals have used other terms, such as atypical autism or simply PDD, to describe PDD-NOS, causing some confusion. Also young children without clear features of any one disorder, or who possess a rapidly evolving profile, are often placed in this category as professionals are reluctant to label them "autistic". To add to the confusion some school districts do not recognize PDD-NOS as a diagnostic category and lump these individuals under the category of Autism.

In truth PDD-NOS does differ from autism in being less severe in its presentation. However, individuals with PDD-NOS can still be significantly impacted and have limited intellectual capacity. The lines between autism and PDD-NOS are blurry, and a diagnosis may simply reflects the bias of the professional making that diagnosis. The important fact is that the interventions are similar regardless of the diagnostic label. For all of the PDD's intensive therapeutic interventions (speech, occupational, and physical therapy), structured educational programs, and different varieties of behavioral and emotional support are all necessary parts of a comprehensive program.

Summary

I hope this introduction to the alphabet soup of some of the more common developmental problems of childhood helps you to navigate your way to create the most successful therapeutic program for your child. It provides you with a glimpse of the depth and complexity in which I view your children and their struggles.

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