Vocabulary Archives

The Most Common Misdiagnoses in Children

July 6, 2015 Brad Hoffman Leave a Comment

When symptoms have multiple causes, mistakes are made.

By Linda Spiro
Original Source: Child Mind Institute
Originally posted April 9, 2013

When you have a headache, you know there are many possible causes, ranging from the mild to the very serious. When you see your doctor, she will likely ask you detailed questions about how long the headaches have been taking place, what type of pain you are feeling, when they occur, and what other symptoms you’re experiencing. Without a thorough assessment and examination, it would be absurd for your doctor to diagnose you with a brain tumor or the flu, both of which can give you a headache. And, of course, the treatment for a brain tumor versus a virus would look very different.

The same thing is true of mental illness: many common symptoms occur for a variety of reasons, and can reflect several different diagnoses. That’s why a good mental health professional will give your child a thorough evaluation based on a broad range of information before coming up with a diagnosis. It’s crucial to understand what’s really behind a given behavior because, just as in medicine, the diagnosis your child receives can drastically change the appropriate treatment. ADHD medications, for example, won’t work if a child’s inattention or disruptive behavior is caused by anxiety, not ADHD. And, just like a medical doctor, when a treatment doesn’t work, whether it’s therapeutic or pharmaceutical, one of the things a good clinician will do is reexamine the diagnosis.Here we take a look at some of the common psychiatric symptoms that are easily misinterpreted in children and teenagers, leading to misdiagnosis. For each symptom, we explain the diagnosis it is commonly linked to, and what some of the alternate causes for what that behavior might be.

(This list is only meant to be used as a guide, and it is important to always consult with a trained diagnostician before beginning treatment or assigning a label to your child.)

1. Inattention

The common diagnosis: ADHD

The symptom of inattention is often first observed by teachers, who may notice a student who is unusually easily distracted, is prone to daydreaming, and has difficulty completing homework assignments and following directions. While all children, especially those who are very young, tend to have shorter attention spans than adults, some children have much more trouble focusing than others.Inattention that is outside the typical range is one of the three key symptoms of ADHD, along with impulsivity, and hyperactivity. So when a child seems unusually distracted ADHD tends to be the first thing parents and clinicians suspect. However, there are many other possibilities that can be contributing to inattention.”The kid who is inattentive could be inattentive because he has ADHD,” notes Dr. Steven Kurtz, the senior director of the ADHD and Disruptive Behavior Disorders Center at the Child Mind Institute. “Or he could be inattentive because he is worried about his grandmother who’s sick in the hospital, or because he’s being bullied on the playground and the next period is recess.”

Other Possibilities:

Obsessive-Compulsive Disorder:

Many children with OCD are distracted by their obsessions and compulsions, and when the OCD is severe enough, they can spend the majority of their day obsessing. This can interfere with their lives in many ways, including paying attention in school. And since children with OCD are often ashamed of their symptoms, they may go to great lengths to hide their compulsions. It is not uncommon to see children keep their rituals under control while they are at school, only to be overwhelmed by them when they get home. Therefore, a teacher may notice a student having difficulty focusing and assume he has an attention problem, since his OCD is not apparent to her.”A kid may be sitting in class having an obsession about needing to fix something, to avoid something terrible happening. Then the teacher calls on him,” says Dr. Jerry Bubrick, the senior director of the Anxiety and Mood Disorder Center at the Child Mind Institute. “When he doesn’t know the answer to the question, it looks like he wasn’t paying attention, but it’s really because he was obsessing.”

Post-Traumatic Stress Disorder:

Children can also appear to be suffering from inattention when they have been impacted by a trauma. “Many of the symptoms of PTSD look like ADHD,” explains Dr. Jamie Howard, the director of the Trauma Response and Education Service at the Child Mind Institute. “Symptoms common in PTSD, such as difficulty concentrating, exaggerated startle response, and hypervigilance can make it seem like a child is jumpy and spacy.”

Learning Disorder:

When a child seems to be looking everywhere but at the pages of the book she is supposed to be reading, another possible cause is that she has a learning disorder. Undiagnosed dyslexia can not only make a youngster fidget with frustration, she may be ashamed that she doesn’t seem to be able to do what the other kids can do, and intent on covering that fact up. Feeling like a failure is a big impediment to concentration, and anything that might relieve the feeling a welcome distraction.

“Fifty percent of kids who have learning disabilities have inattention,” notes Dr. Nancy Rappaport, a Harvard Medical School professor who specializes in mental health care in school settings. “For these kids, we need to intervene to support their learning deficits, otherwise treating them with stimulants will be a bust.”

The trickiest cases, Dr. Rapport adds, are really smart kids who have successfully compensated for their learning disabilities for years, by working extra hard. “They’ve been able to hide their weakness until they get older and there’s just too much heavy lifting. They’re often diagnosed with ADHD or depression, unless someone catches the learning problem.

2. Repetitive distressing thoughts

The common diagnosis: PTSD

Intrusive thoughts and memories that a child can’t control are one of the key symptoms of PTSD. Clinicians think of PTSD as a damaged “fight or flight” response in a child who has had a disturbing experience, whether it was an upsetting event or a pattern of domestic violence or abuse. The experience is in the past, but the child keeps reliving the anxiety.

This can take place in the form of flashbacks, thinking about the event over and over, or experiencing frightening thoughts that get “stuck.”

Other possibilities:

OCD:

“In both OCD and PTSD, you can experience thoughts that intrude, thoughts that you don’t want to be thinking about,” said Dr. Howard. “These thoughts come into your head, without your volition and without your control. In both cases, they cause you distress, and you have to work to manage them.” But there is a major difference between the repetitive thoughts in OCD and PTSD, Dr. Howard notes: “With OCD it will be a concept the causes you distress, but with PSTD it’s an actual memory of something that happened.”

3. Restricted speech

The common diagnosis: Autism

Autism is a developmental disorder that causes a child to have impairments in communication. Children with autism may have a delay in (or complete lack of) the development of spoken language. The most obvious signs of autism are usually noticed between 2 and 3 years of age. Although many children on the spectrum do speak, they may use language in unusual ways, avoid eye contact, and prefer to be alone. Autism may first be noticed by school professionals, who become aware that the child is not interacting socially with his peers in an appropriate way.

Other Possibilities:

Selective Mutism:

Selective mutism is an anxiety disorder in which children do not speak in particular social situations. Many children with selective mutism are talkative at home, but there may be a complete lack of speech in other settings, such as in school. They may not communicate with peers or teachers at all, which can lead to school professionals being concerned about their social development. These social difficulties may lead some school personnel to jump to the conclusion that they are on the autism spectrum.

“You can have difficulty with communication for a lot of reasons,” notes Dr. Kurtz. “The thing to look for is the consistency across situations. Kids with SM will be quite social and quite fabulous chatterboxes in some settings, otherwise they probably don’t have SM.”

When it comes to making a diagnosis, it is important to make the distinction between a skills deficit and a performance deficit. Children with selective mutism have a performance deficit because they have the ability to speak but cannot demonstrate it in every setting, while children on the spectrum have skills deficits, so can’t demonstrate certain skills regardless of the setting.

Children with selective mutism may also display other symptoms that may lead to alarm bells being sounded for autism. Some kids with SM appear very “shut down” in their affect. “Because the kid’s trying, whether he knows it or not, to convince people to back off, he’s also going to have poor eye contact like a kid on the spectrum, flat affect like a kid on the spectrum,” said Dr. Kurtz. “He’s not going to look like a kid whose only issue is that he is stuck in terms of being able to talk.”

4. Sadness, fatigue, and difficulties thinking clearly

The common diagnosis: Depression

It is easy for most people to recognize the symptoms of depression: feelings of sadness, decreased interest in usual pleasurable activities, fatigue, weight changes, and difficulty concentrating. While it is normal for everyone to feel “down in the dumps” sometimes, children experiencing sadness or irritability that lasts for more than two weeks and impairs their ability to function may be thought of as experiencing a depressive episode.
Other Possibilities:

Hypothyroidism:

Hypothyroidism happens when your thyroid (a gland in your neck) is not secreting enough of certain important hormones. The symptoms of hypothyroidism look very similar to those of depression, and include fatigue, weight gain, feelings of sadness, and difficulty thinking clearly. However, the treatment for hypothyroidism is very different: children with hypothyroidism are treated using a thyroid replacement hormone.

Anxiety Disorder:

Certain anxiety disorders, such as OCD, can be extremely impairing and scary to the person experiencing them. Children with OCD can have obsessions about invoking harm to their loved ones, as well as other violent or sexual images. While these obsessions are not true to what the child actually wants to happen, he has difficulty getting them out of his head. There are times when depressed mood is what is noticed first, but it may be secondary to another condition such as OCD. Due to the shameful thoughts that many children with OCD have, they may not feel comfortable sharing many of them, and may get misdiagnosed with depression.

“There are many cases where children who have fears or worrisome thoughts become depressed because they are scared and feel like things won’t get better,” explains Dr. Rachel Busman, a clinical psychologist in the Anxiety and Mood Disorders Center at the Child Mind Institute. “That’s why it’s so important to accurately assess the symptoms and obtain a history that explains when they started. There are excellent treatments for anxiety disorders and depression-once a diagnosis is made, treatment can target these symptoms.”

5. Disruptive behavior

The common diagnosis: ODD

Most children have occasional temper tantrums or outbursts, but when kids repeatedly lash out, are defiant, or can’t control their tempers, it can seriously impair their functioning in school and cause significant family turmoil. Often, these children are thought to have oppositional defiant disorder (ODD), which is characterized by a pattern of negative, hostile, or defiant behavior. Symptoms of ODD include a child losing his temper, arguing with adults, becoming easily annoyed, or actively disobeying requests or rules. In order to be diagnosed with ODD, the child’s disruptive behavior must be occurring for at least six months and be negatively affecting his life at school or at home.

Other possibilities:

Anxiety Disorders:

Children with anxiety disorders have significant difficulty coping with situations that cause them distress. When a child with an untreated anxiety disorder is put into an anxiety-inducing situation, he may become oppositional in an effort to escape that situation or avoid the source of his acute fear. For example, a child with acute social anxiety may lash out at another child if he finds himself in a difficult situation. A child with OCD may become extremely upset and scream at his parents when they do not provide him with the constant repetitive reassurance that he uses to manage his obsessive fears. “It probably occurs more than we think, either anxiety that looks disruptive or anxiety coexisting with disruptive behaviors,” said Dr. Busman. “And this goes right back to why we have to have a comprehensive and good diagnostic assessment.”

ADHD:

Many children with ADHD, especially those who experience impulsivity and hyperactivity, may exhibit many symptoms that make them appear oppositional. These children may have difficulty sitting still, they may touch and play with anything they can get their hands on, blurt out inappropriate remarks, have difficulty waiting their turn, interrupt others, and act without thinking through the consequences. These symptoms are more a result of their impaired executive functioning skills—their ability to think ahead and assess the impact of their behavior—than purposeful oppositional behavior.

Learning Disorder

When a child acts out repeatedly in school, it’s possible that the behavior stems from an undiagnosed learning disorder. Say he has extreme difficulty mastering math skills, and laboring unsuccessfully over a set of problems makes him very frustrated and irritible. Or he knows next period is math class.

“Kids with learning problems can be masters at being deceptive—they don’t want to expose their vulnerability. They want to distract you from recognizing their struggle,” explains Dr. Rappaport. “If a child has problems with writing or math or reading, rather than ask for help or admit that he’s stuck, he may rip up an assignment, or start something with another child to create a diversion.”

Paying attention to when the problematic behavior happens can lead to exposing a learning issue, she adds. “When parents and teachers are looking for the causes of dys-regulation, it helps to note when it happens—to flag weaknesses and get kids support.”

Teaching Critical Thinking Through Science

June 15, 2015 Brad Hoffman Leave a Comment

The goal of science education is much more than teaching students specific science content, it’s teaching students how to think with an emphasis on hypothesizing, planning, testing, reasoning from data, and drawing conclusions. Many of us are familiar with the scientific method, but science teaching, particularly at the elementary level, should focus on process skills. Process skills are the behaviors we want students to develop as young scientists. Regardless of the particular content or science kits used in schools (i.e. SCIS, Foss, STC), all students should have hands-on experience with scientific investigations that provide myriad opportunities to develop these process skills. Students who have regular access to real science work and investigations sharpen their critical thinking and develop both creative and analytical problem solving skills. Kids also LOVE “doing” science, and this subject matter becomes a major motivator for student engagement.

The National Association for Research in Science Teaching (NARST) highlights basic science process skills as well as integrated science process skills.

Basic science process skills include:

Observing – using the senses to gather information about an object or event. Example: Describing a pencil as yellow.
Inferring – making an “educated guess” about an object or event based on previously gathered data or information. Example: Saying that the person who used a pencil made a lot of mistakes because the eraser was well worn.
Measuring – using both standard and nonstandard measures or estimates to describe the dimensions of an object or event. Example: Using a meter stick to measure the length of a table in centimeters.
Communicating – using words or graphic symbols to describe an action, object or event. Example: Describing the change in height of a plant over time in writing or through a graph.
Classifying – grouping or ordering objects or events into categories based on properties or criteria. Example: Placing all rocks having certain grain size or hardness into one group.
Predicting – stating the outcome of a future event based on a pattern of evidence. Example: Predicting the height of a plant in two weeks time based on a graph of its growth during the previous four weeks.

Integrated Science Process Skills include:

Controlling variables – being able to identify variables that can affect an experimental outcome, keeping most constant while manipulating only the independent variable. Example: Realizing through past experiences that amount of light and water need to be controlled when testing to see how the addition of organic matter affects the growth of beans.
Defining operationally – stating how to measure a variable in an experiment. Example: Stating that bean growth will be measured in centimeters per week.
Formulating hypotheses – stating the expected outcome of an experiment. Example: The greater the amount of organic matter added to the soil, the greater the bean growth.
Interpreting data – organizing data and drawing conclusions from it. Example: Recording data from the experiment on bean growth in a data table and forming a conclusion which relates trends in the data to variables.
Experimenting – being able to conduct an experiment, including asking an appropriate question, stating a hypothesis, identifying and controlling variables, operationally defining those variables, designing a “fair” experiment, conducting the experiment, and interpreting the results of the experiment. Example: The entire process of conducting the experiment on the affect of organic matter on the growth of bean plants.
Formulating models – creating a mental or physical model of a process or event. Examples: The model of how the processes of evaporation and condensation interrelate in the water cycle.

By Brad Hoffman, M.S.Ed.
Board Certified Educational Planner and Learning Specialist
My Learning Springboard, Inc.

5 Ways to Motivate Young Writers and Readers

June 5, 2015 Brad Hoffman Leave a Comment

Research supports what successful parents and teachers do.
By J. Richard Gentry, PhD, and Steve Peha
Original Source: Psychology Today

Story-Time Writing

Most parents read stories to their kids. But how many parents write them? It’s not hard. Invite your child to write with you. Grab some paper and something to write with. And then make up a little story, writing it down, page by page as you go. Keep the stories simple. Make a sketch to illustrate each page or have your child do the illustration. Try to make stories that look like the ones you read with your child in easy books. Kids love Mom-or-Dad-When-They-Were-Kids stories or When-You-Were-A-Baby stories.

Another way to engage your child is in shared story creation where both of you contribute simultaneously. As you create the story together you serve as a model of how exactly to go about it. Over time in this gradual release learning model—I do it; we do it; you do it—your child will be writing stories on his or her own.

Listomania

Our lives are full of lists: “to do” lists, shopping lists, lists of people, list of favorite things, etc. Many of these lists are things we write down. List writing is pretty easy. So it’s often one of the first forms of writing kids can be involved in.

The next time you make a grocery list, ask your child to help you with it. Even if you do all the writing, they’ll feel included in the process. Gradually, they’ll want to do it, too. Don’t be surprised when one day they present you with their own list of things they’d like you pick up at the store.

Revive a Long Lost Tradition

Kids love to get gifts. But the tradition of “Thank You” notes seems to have fallen by the wayside. Whether you are a parent, a grandparent, an uncle or an aunt, a child’s thank you note—dictated or written in their own hand—is a treasure.

Three reasons for using this technique as a motivator for writing and reading are that it teaches kids cultural values, social interaction, and it’s a wonderful way for kids to write to a real audience. From a teaching and cognitive perspective there’s the added value of repetition: many of the notes use the same words (like “thank you” or “I like the _______ you sent me,” and so on).

Map It Out

Draw—Label—Captionwriting is a simple form that can be used by preschoolers. In the following variation taken from a case study in Raising Confident Readers: How to Teach Your Child to Read and Write: From Baby to Age 7, Danielle, (four years, eight months of age) drew a map of the aisles in the Publix grocery store and put in labels to show where here favorite foods could be found.

Repetition, Repetition, Repetition

Repetition is not a single activity, but a reminder that you should write and read with your child every day. Your child is often motivated to mimic and repeat what you do even without any prompting. Repetition is its own built-in motivator. When you do fun and engaging side-by-side writing and reading activities over time your beginner reorganizes and integrates new information such as higher-order print concepts and piles on new knowledge about sounds, letters, and literacy. Reading aloud is crucial. But don’t forget that among 3- to 6-year-olds, pencil and paper kids are often the first readers.

Posted October 10, 2013

Framework for Literacy Instruction: 3 Perspectives

June 3, 2015 Brad Hoffman Leave a Comment

Amy Shapiro and I took a graduate course for professional development on teaching beginning readers. During the course, we studied The Framework for Literacy Instruction which presents three perspectives for effective teaching—the interactive perspective, the critical perspective, and the response perspective. Across each perspective, the teacher must be cognizant of planning for the learners, the texts, and the instructional practices. It is critically important to address all three perspectives in literacy planning. If our goal is to develop critical thinkers, then focusing their attention on the content, the craft, and the big ideas is imperative. Through exposure to both fiction and non-fiction genres, students can develop a repertoire of comprehension strategies that can be applied appropriately depending on the reading task.

Learners: Affective and cognitive aspects of literacy learning.

Texts: Text structures, types, genres, and difficulty levels matched to literacy learners and literacy goals and objectives.

Instructional Practices: Developmentally appropriate research-based practices used with appropriate texts to facilitate affective and cognitive aspects of literacy development in all learners.

1. Interactive Perspective

Reading and writing accurately, fluently, and with comprehension.
Being strategic and metacognitive readers and writers.
Use a variety of informal and formal assessments to determine areas of strength and need in literacy development.
Determine texts of the appropriate types and levels of difficulty to meet literacy goals and objectives for students.
Use instructional methods that address the cognitive and affective needs of students and the demands of the particular text.
Promote students’ independent use of reading strategies and skills.

2. Critical Perspective

Judging, evaluating, and thinking critically about text.
Find out about ideas, issues, and problems that matter to students.
Understand the learner as a unique individual.
Select texts that provide opportunities for students to judge, evaluate, and think critically.
Foster a critical stance by teaching students how to judge, evaluate, and think critically about texts.

3. Response Perspective

Reading, reacting, and responding to text in a variety of meaningful ways.Find out about students’ interests and identities.
Understand what matters to students and who they are as individuals.
Select texts that connect to students’ identities and/or interests and that have the potential to evoke an emotional or personal response.

By Brad Hoffman, M.S.Ed.
Board Certified Educational Planner and Learning Specialist
My Learning Springboard, Inc.

How Do I Know If My Child Has Executive Function Issues?

May 21, 2015 Brad Hoffman Leave a Comment

A guide to tests that identify problems with organization.

Original Source: Child Mind InstituteOriginally posted April 22, 2014

Executive Function. When we are concerned about kids being disorganized—so disorganized that they have trouble keeping track of their stuff and keeping up schoolwork—the first thing we want to do is try to understand what’s going on with them.

There are tests that highlight different kinds of organizational skills your child could be weak in. But the first thing to do is to get good picture of when and how he’s disorganized.

That’s where your child’s teacher can be very helpful. Ask her to give you a rundown of the things your child is struggling with. It also might be possible to have the school psychologist observe him in the classroom, to describe the things he seems to be having trouble with. Is he failing to bring her homework into class? Does he have trouble shifting from one activity to another? Writing down assignments? Putting materials where they belong? What seem to be his issues? They can help you decide whether testing would be a good idea.

And before you focus on organizational skills, you want to rule out other things that could be causing him to seem disorganized. For instance:

If a child always seems to be forgetting to turn in his homework or losing his books, it could be because she has a learning disability and feels bad about doing, or showing his teacher her work. “Rather than organizational issues, he might need help with math,” notes Dr. Michael Rosenthal, a pediatric neuropsychologist at the Child Mind Institute.
He could also be losing things and forgetting things because he’s distracted by anxiety. And it could be an anxiety that he keeps to himself, perhaps because he’s embarrassed by it, so his teachers and parents don’t know about it.
A child could seem disorganized because she’s depressed, which causes her to feel disconnected and indifferent about things she normally would care about. “The issue could be her motivation and mood,” Dr. Rosenthal notes.
A child who’s had a traumatic experience could be disorganized because she’s constantly feeling stressed out.

But if you’ve ruled out these emotional problems that could be contributing to the behavior, it’s likely that your child is disorganized because she has a weakness in what are called executive functions.

Helping Kids Who Struggle With Executive Functions

Executive functions are mental skills that we all use every day to get things done. We use them to set goals, plan how we’re going to do something, prioritize, remember things, manage our time and possessions, finish what we start.

Some children have weaknesses in executive functions, and, regardless of how bright they are, they struggle to do schoolwork and stay on top of things they’re responsible for.

Some of these functions are more obvious than others, because they involve a child’s behavior in the world—losing her jacket, forgetting her homework, not following directions, and other executive function issues. Others are less obvious but just as important, especially for learning: retaining facts, solving problems that take several steps, figuring out what’s important in things she’s reading, putting things in a reasonable order when she’s writing.

There are several different kinds of tests that can be used to see what kinds of executive functions your child might be having a problem with.

Neuropsychological evaluation

The most comprehensive way to assess a child’s organizational issues and determine their cause is a neuropsychological evaluation. This is made up of a set of tests, questionnaires, interviews, and observations that clinicians use to get a good picture of what each kid’s strengths and weaknesses are with their executive function. The test shows how kids complete tasks and process information.

“Most parents who come in and say my kid is disorganized usually have some other problems, too,” says Dr. Rosenthal. “Organization is often one piece of the picture. But it’s important to be comprehensive in a neuropsych evaluation to evaluate all the other pieces, to isolate whether this is specifically an executive function problem or if there’s a larger issue at play.”

As a result, neuropsychological evaluations involve several sessions and require time and work on the part of the child as well as his teachers, parents and clinicians.

The evaluation includes:

Testing that measures how a child approaches a task that doesn’t have a lot of structure to it. For example, when he is presented with something he has never seen before, and he don’t know what the expectation is, how does he devise a strategy for solving this problem? Does he come up with a good, organized strategy or a haphazard, impulsive, ineffective strategy?
Parent and teacher questionnaires that parents and teachers complete to share their impression of what the child’s organizational and executive function issues are. Are they pervasive, meaning they’re present in all aspects of the kid’s life—at school, at home, even recreationally? For example, parents can say if a child is also losing his equipment when he’s playing sports, and things he cares about at home.
Clinical questionnaires are used to compare your child’s responses to thousands of other kids to see what’s normal and what’s a problem.

Dr. Rosenthal says he spends 8-9 hours face-to-face with the child doing testing, about an hour-and-a-half interviewing parents, and additional time on the phone talking with teachers. Only after all of that is completed does he collect, score and interpret the information.

Other testing that focus on executive functioning issues

There are two kinds of tests that measure executive functioning issues without doing a thorough neuro-psych evaluation (in fact both kinds are included in a neuro-psych evaluation).

The first kind is questionnaires that ask parents, teachers, and perhaps the school psychologist to observe closely the behaviors they see in a child and fill out a rating scale. The Behavior Rating Inventory for Executive Function (BRIEF) is an example of that kind of test.
The other kind of test is one in which a child is assessed by a psychologist who watches her perform a series of tasks and observes how she goes about each one. The Cognitive Assessment System (CAS) is that kind of test.

Dr. Rosenthal reports that he’s found the first group of tests, including the BRIEF, to be particularly good at identifying what is happening with a child. That’s because kids can often function better in a controlled setting like a doctor’s office, while functioning in the real world, where there are so many distractions and interruptions, is more challenging.

How to help

Once you have a good idea what your child’s specific issues are, her teacher and a school psychologist will usually work together to find ways to support her in the classroom, focusing on her strengths and helping where she’s weak.

You may want to have her work with a learning specialist, who is trained to help her with the executive function skills that she needs to perform in school, such as memorizing facts, digesting important information, organizing thoughts in writing, and solving multi-step problems.

The older a child gets, the more these executive functions affect her ability to learn as well as keep track of assignments and sports equipment. Helping her get more organized will not only make things easier for her (and for you) but will allow her to be as accomplished and successful as she can be.