Posted tagged ‘school’

Let kids play

July 8, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

School has become far more intense since I was a kid. Kindergarteners are expected to read; first graders bubble in standardized tests; third graders are doing book reports, frantically re-reading The Old Man and the Sea by candlelight with a Vente Mocha. Are we working them too hard?

Researchers at the Albert Einstein College of Medicine examined data from about 12,000 children aged 8-9, collected across many different schools in  the USA in 2001. Their study correlated classroom behavior with the availability of routine recess time—time to get outside and play. No one ought to be surprised at the results: the children with no or little recess had far-worse classroom behavior than the kids who had time to run and play. In fact, more playtime equaled better behavior. If playtime were a medicine, higher doses (as expected) worked even better than low doses. The improved behavior was seen even after correcting for factors like overall classroom achievement, the income of the families, proportion of minority and disadvantaged students, and the proportion of boys in the class. Among all groups, more playtime led to better functioning in the classroom.

Is your child tough to handle, restless, jumpy, a noodge? Get him or her outside, playing. Playtime one “drug” that everyone needs. It helps kids focus and do well in school. And it’s cheaper than a trip to Starbucks!

Who has ADHD?

September 10, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kristin would like to know, “How do you actually ‘diagnose’ a nine year old boy with ADHD? Descriptions of ADHD are so vague. Most of what is described as ADHD symptoms seem like normal boy behavior to us. Can a child be a straight A student and still have ADHD?”

It’s a fair question. There is no objective test for any psychiatric or mental health disorder, including ADD (Attention Deficit Disorder; one subtype is ADHD, or Attention Deficit-Hyperactivity Disorder), depression, anxiety disorders, autism—none of these can in any way be “tested for” or diagnosed with the kind of precision expected of ordinary medical diagnoses. I’m convinced that in 100 years, doctors will look back at my generation of physicians and chuckle knowingly, saying things like “¡ssǝ1ǝn1ɔ ʍoɥ ‘suɐıɹɐqɹɐq ǝsoɥʇ”. (Apparently, in the future, people speak upside down.)

In an effort to codify and standardize the language and diagnoses of psychiatry, the American Psychiatric Association first published the “Diagnostic and Statistical Manual of Mental Disorders” in 1952. The current version, last revised in 2000, is called the DSM-4-TR. It’s been criticized as “cookbooky”, relying on lists of symptoms to establish mental health diagnoses using checklists reminiscent of ordering a family meal at a Chinese Restaurant. Choose at least one from Column A (eg “inability to sit still”) and one from column B (“starting not older than seven years”), plus some qualifiers, and you’ve either got Mongolian Beef or Major Depression, maybe even both.

Though there are legitimate criticisms of the DSM, in fairness to psychiatry there are important caveats that are often overlooked. The book states explicitly that the diagnostic labels are mainly useful as “convenient shorthand for professionals,”  and that only well-trained professionals should interpret the standards and apply diagnostic criteria. So consider the DSM as a starting point for mental health diagnoses, not a straightjacket (sorry, poor time for a straightjacket joke).

DSM-IV Criteria for ADHD

I. Either A or B

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level.


  • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  • Often has trouble keeping attention on tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
  • Often has trouble organizing activities.
  • Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  • Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  • Is often easily distracted.
  • Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level.


  • Often fidgets with hands or feet or squirms in seat.
  • Often gets up from seat when remaining in seat is expected.
  • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
  • Often has trouble playing or enjoying leisure activities quietly.
  • Is often “on the go” or often acts as if “driven by a motor.”
  • Often talks excessively.


  • Often blurts out answers before questions have been finished.
  • Often has trouble waiting one’s turn.
  • Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

In summary: children with ADD have either inattention or impulsivity & hyperactivity, have these to a greater extent than expected for the developmental age, have these starting in early childhood, and have these as a more-or-less permanent part of their behavioral makeup. The symptoms must occur in multiple settings, and must occur to such an extent that they interfere with social, school, or occupational functioning. Part V is especially helpful—it says, essentially, that it’s ADD unless it is something else. Clearly, attorneys were involved in the preparation of this document.

To help “standardize” the diagnosis and hopefully make the assessment more objective, many clinicians rely on standardized testing instruments. Parents and teachers are asked a number of questions, like “How often does he fidget,” and answer something like always, sometimes, or never. The answers are decoded in a manner similar to the quizzes in Glamour Magazine (“What kind of guy is perfect for you?”), and the total score can be compared with thousands of other children who took the test. The “outliers”—the ones with the highest scores, above some set statistical set point—are said to have ADD.

Though these tests are helpful, it’s easy to see how parent or teacher preconceptions could color their answers. There are strong feelings about ADD and medication for ADD, and I’m not sure that making adults bubble in answers recalling a child’s behavior is likely to cut through their own feelings in a way that can reliably reveal what’s going on with a child. ADD “testing” has a role—in my mind, chiefly to rule out learning disorders and other problems that often go together with or appear very much like ADD—but a more reliable diagnosis I believe requires a thorough medical history and evaluation, as well as multiple observations over time by a skilled examiner. It’s not easy, and not quick, to do it right.

In answer to the final question, “Can a straight A student have ADHD?”—according to the DSM criteria, ADD characteristics like hyperactivity and inattention must occur to a degree to cause problems in school, home, or work. If your child is getting along well at home and with friends, and is getting straight As at school, he would not meet DSM criteria for ADD and should not be diagnosed as having ADD. Nonetheless, he may  benefit from behavioral interventions to encourage better sustained attention—but that’s a subject for a future post!

Special needs misadventures

April 17, 2009

Deb posted: “I’m wondering if you can guide me here. My 8 yr old son with mild-moderate special needs was having regular behavior problems at school and was up for a 3 yr reevaluation though the school. After a thorough private neuropsychiatric evaluation we were sent to another psychiatrist to rule out some of the neuropsych’s concerns. This Dr did rule out the concerns, asserting different ones in their place. Upon seeking another opinion because the two specialists’ assessments were so different, we received yet another ‘suggested’ diagnosis. The only point these specialists agreed on was that my child needed intensive therapy (4-5 days/week) and medication, although they could not agree on which kind and what for. Amazingly enough, during the period of time that we met and were evaluated by these specialists my son ‘remembered how he was supposed to behave’ and almost all of his problems at school disappeared. So my question is, at what point should a parent stop seeking out additional opinions in hope of finding some consensus in evaluating their child’s special needs? I want to give my child every support possible to be successful but frankly it’s often hard to remember why we went through all the testing in the first place. Can you offer some guidelines for how much is enough?”

This is a fair but tough question—I don’t really have enough information to speculate on what kind of problems Deb’s child is having, or what kinds of diagnoses or treatments would be appropriate. But it does raise the question of how to approach children with special needs and learning difficulties, and Deb’s post illustrates a frustration many parents have felt when trying to get help for their kids.

Part of the problem lies with the very nature of psychiatric diagnoses. In other realms of medicine, a diagnosis is made firmly on fairly objective data: take a history, ask about the symptoms, do an exam, maybe some tests—viola, you’ve got a diagnosis, or at least a very likely stab at a diagnosis, and treatment follows logically from there. The psychiatrists have tried to codify and objectify their diagnoses, too, in a huge book called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, now in its fourth edition. To have “Attention Deficit Disorder,” for instance, you have to have 6 of 9 listed characteristics along with four required features. The DSM is an effort to make diagnoses in the realm of mental health standardized and objective, so practitioners are more clear and precise.

But in issues of mental health, especially in children, over-reliance on the DSM tends to oversimplify problems. It shoves kids into little boxes with clear labels on them: this one has ADD, that one has expressive language disorder, this other one has autism, this one has a processing disorder, etc. But in my experience many kids who need extra help in school have a combination of many features of each of these problems, and every one of these kids is unique. The labels themselves can become a distraction, forcing children into loops of expensive testing and diagnostic pigeonholing that doesn’t really help delineate exactly what kind of help would be best for the individual child.

Complicating matters further: children change and develop. A child who seems to mostly have problems with speech and language may later on have more problems with memory. And health and social circumstances can certainly have a big impact on a child’s success. If obstructive sleep apnea is preventing a good night sleep, a child might have symptoms identical to Attention Deficit Disorder; a child who’s being bullied may retaliate and be labeled with “Oppositional Defiant Disorder”; a child with a hearing deficit may seem autistic. Performance on testing to help determine a child’s diagnosis may depend on the rapport developed with the psychologist, and may be influenced by how well the child slept the night before and what was had for breakfast. A very good psychologist can work through these complications, at least most of the time. But it’s tricky.

So what’s a parent to do? Concentrate on what’s holding your child back, right now. Is it learning, or remembering? Conduct? Attention? Handwriting? Speaking? Getting along with others? All of these skills can be reinforced and tutored. As children grow, expect their strengths and weaknesses to change, and reassess how things are going and whether specific therapies are still leading to measurable, significant, and important improvements. If input from testing doesn’t make sense, don’t automatically accept suggestions. Even if you do follow a new course, reassess whether there really has been an improvement before continuing long-term. A certain amount of trial-and-error is unavoidable, but don’t feel locked into any sort of therapy that just isn’t working.

I like to think that a pediatrician can help get to know your child well, and hopefully provide guidance and a good objective viewpoint as parents try to digest these sorts of decisions. Our job is also to stay alert for medical conditions that can affect school performance and behavior.

I know some of our regulars have special needs kids—I’d love to hear from parents about their experiences with these problems, first hand.

ADD and head injuries

December 18, 2008

A recent study from the British Medical Journal concerning the causes of Attention Deficit Disorder (ADD) illustrates the power of using epidemiologic studies to determine the cause of a disease.

Epidemiology looks at factors in a population that might or might not be associated with illness. Researchers look at large groups of people with and without a certain disease, and try to tease out what wakes the two populations different. Does one group exercise more? Or eat more of a certain food? Does one group have more of a family history of that disease? Or maybe a certain environmental exposure? Studies like these can get quite complex, because human lives themselves are so complex.

As an example, we know that lung cancer used to be very rare—almost unheard of, in fact. It started becoming more common in men during the 1930s. Factors that may have correlated with the rise of lung cancer could have been increased living in cities, increased use of automobiles, or increased reading of newspapers. But careful observations of these and other factors found that it was cigarette smoking that contributed most heavily to lung cancer. Over the following years, as more women started to smoke, their rates of lung cancer rose to about the same level as men. No clinical trials have ever been done in people proving that smoking causes lung cancer—that is, no one has deliberately exposed people to cigarette smoke to see if they get cancer—but the overwhelming weight of epidemiology has been instrumental in demonstrating the risks.

ADD affects 5-8% of schoolchildren, and contributes to poor school performance, delinquency, and substance abuse. We know that genetics plays a part, but environmental influences also seem to be important. One observation that has been made is that many children with ADD have a history of some sort of head injury in early childhood—so is it possible that minor brain damage from these kinds of injuries is a cause of ADD? That’s what the BMJ study tried to figure out.

The study looked at 62,000 children in the United Kingdom, using a heath database that records diagnoses and medical problems. They found that in this group, children with ADD were about twice as likely as children without ADD to have had been seen at a medical facility for some kind of head injury in the past.

Does that mean that head injuries cause ADD? Maybe. But perhaps it’s the other way around. After all, we know kids with ADD are more impulsive and hyperactive—maybe they’re more likely to hurt themselves. Which comes first, the ADD or the head injury?

To answer that question, the authors looked at another health observation among the children: a history of any burn injury. A burn on some other part of the body wouldn’t cause injury the brain, but would be another way of showing that the kids with ADD are more injury-prone in general. Sure enough, in the database the children with ADD were also about twice as likely to have had a burn injury than kids without ADD. So it’s not just head injuries that are associated with ADD, it’s injuries of any kind—which fits the hypothesis that kids with ADD are reckless, and hurt themselves more. That’s why they more often have a history of a head injury. It’s not the head injury that caused the ADD, but rather the ADD that caused the head injury.

So: don’t worry about the inevitable minor head bonks. They’re a part of childhood that can’t always been avoided. But children who are especially reckless and get injured a lot might just be telling their parents what kind of person they are.

The adjustment to preschool

October 12, 2008

Here’s a question from Meredith: “My daughter (23 months) has just started a preschool class that meets 2 days/week for 4 hours a day. She cried the first day, which was expected, because I did too. She has now cried all 4 days she’s attended. I know it might take a while for her to adjust, but it is affecting her sleep patterns (nap and bedtime) quite a bit. She is also much more sensitive, whiny, and sometimes uncontrollable, which has not been her nature until now. Any suggestions for talking to her about school or should I wait a few months and try again? I thought for sure she’d be ready by now!”

Actually, I think a two-year old is going to be “less ready” than a one-year old would have been. Many two-year-olds are quite clingy, and have a rough time with transitions. That the preschool is only two days a week will actually make it harder for her—she’ll be less able to adjust to a new routine that’s so infrequent.

So: first, ask yourself why you’re putting her in school. Good reasons might be because she seems bored at home, or because she seems to enjoy group playdates. Another good reason might be that you need the time for yourself. Less-good reasons would be because you’re feeling pressure from other parents, or because you’ve read somewhere that two-year olds “should” be in school. There’s no convincing evidence of any lasting benefit or detrimental effect of enrolling a child of this age in a day program, so it’s more a matter of individual needs and family situations. Certainly, if a child is enjoying school, that’s a good reason to do it. But if you don’t really have good reasons for having her in school, this might be a good time to think about it again.

If you’d like to proceed with a plan to at least try to help her get used to school, here are some ideas:

  • Do “play therapy”: act out little routines and plays with her stuffed animals, going to school and having a good time. This is a great, indirect way of communicating with a toddler.
  • Have a quick, short, no-lingering drop off. “Bye, see you later!” are good last words. Don’t hang around. You must hide your own anxiety and ambivalence. Kids pick up on that stuff, believe me!
  • Have her bring something very special, like a blanket, or make a little pin she can wear with a picture of you on it.
  • Don’t go check on her, and don’t call.
  • Expect that drop off and pick up will be the worst times for both of you. But also expect that within a few more weeks that she’ll be enjoying herself, most of the time, after you’ve gone. If she isn’t, set a time-limit on how long to keep trying: something like “If there isn’t any improvement in two weeks, I’m going to withdraw her from school. But I’m going to keep trying until then.”

Anyone else have any good ideas? Post a comment!

Best of luck! Let us know how it goes, and if you come up with any other good ideas to help her!

What’s kindergarten for?

October 1, 2008

Kelly posted a question about academic expectations in kindergarten: “We have son born in July that just started Kindergarten. We made the decision to not hold him back. (Bucking that trend) Now, we are faced with reports that he needs help focusing and staying on task. What is realistic at this age? I worry that since we did not hold him back that he is being judged against kids that are 1+ years older than him (reference trend of holding boys back). Wonder if this has paved the way for more ADD diagnosis. Thoughts on what is correct expectations at this age? Also, any tips for us to use to try to get him to focus.”

First, let me thank you for “bucking that trend” and starting your son in kindergarten. I’ve written before about how routinely holding kids back is going to lead to problems for many children, both the held-back and their younger peers. Unless a child has a specific delay in intellectual or social development, it is almost always a good idea to get children started in kindergarten when they’re supposed to start. As you’ve seen, though, so many parents are holding especially boys back that the ones who are placed appropriately are often compared with children a year or so older. This is helping nobody. You’ve got an interesting idea about how this might be increasing the rates of ADD diagnoses—I have not seen any studies about how a child’s exact age compared to grade affects the rate of ADD diagnosis, but it’s a plausible thought that ought to be explored.

The silent treatment snit

August 2, 2008

“I’ve read about toddlers throwing temper tantrums, do you have any advice on how to handle a toddler who refuses to talk to you? I picked my 2 1/2 year old up from preschool today and she wouldn’t look at me or talk to me. I tried talking to her a few times but then just gave up and drove home in silence. When I tried to get her out of the car she threw a temper tantrum. Once she finally calmed down I asked her why she wouldn’t talk, if something happened at school, etc. and she said nothing happened. This is not the first time she has refused to talk (she has done the same thing to her dad and grandma before but she seemed to be doing better lately). Is this normal behavior, and is it best to not try to talk to her when she behaves like this?”

A “silent treatment” is a kind of snit—a different species, perhaps, from a temper tantrum, but certainly a close relative. As with all snits, the only thing you ought to do during a toddler-aged snit itself is ignore. How you best deal with snits otherwise has more to do with what you do before and after the snit than what you do during the snit itself.