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PA-IMH Breakfast February 6, 2015
The PA-IMH breakfast seminar on Feb. 6, 2015 featured a presentation by Dr. Daniel Hart of the Institute for Effective Education. Rutgers-Camden, on “Quality Early Childhood Education: Why Does It Matter? What Does It Look Like?”. Dr. Hart’s presentation returned several times to the theme sounded by President Obama not long ago: “Tonight, I propose working with states to make high quality preschool available to every child in America. Every dollar we invest in high quality early education can save more than seven dollars later on.” But is this claim correct? Are we even in a position to define high quality early education and to identify factors in preschool that cause improved academic and behavioral performance later on? Research on some programs shows great overall benefit from high quality preschool education. For example, results of the Perry Preschool program included a reduction in the number of children needing special education, an increased number graduating from high school, increased earnings and increased home ownership. A study of the outcome of a weekly stimulating play group in Jamaica showed increased earnings 20 years later. However, while some research on Head Start shows short-term gains for the children, by the end of third grade these were no longer apparent. Is it a problem that research on preschool education may sometimes be poorly designed, in addition to having a focus on factors that are actually not very important? Research on the Abecedarian Project in the 1979s was described as using a randomized controlled design, but in fact did not entirely conform to the rules about designs of this kind. What about the factors that need to be studied? Dr. Hart discussed the adoption of Quality Rating and Improvement Systems (QRISs) by states. Started by the U.S. Department of Health and Human Services in the 1990s, QRISs are a method for encouraging the use of high quality preschool practices. But, according to an article cited by Dr. Hart and written by T.J. Sabol et al (“Can rating pre-K programs predict children’s learning? Science, 341, 23 August 2013, 845-846), QRISs on the whole have not looked at child outcomes in ways that can tell us whether programs we call “high quality” are actually facilitating learning and fostering children’s good development. Most QRISs have been based on local professionals’ judgments about the selection of practices that indicate high quality, their decisions about how to determine levels of quality, and suggested methods for creating composite ratings for programs. Rather than looking at what teachers actually do, QRISs have tended to look at easily-determined information like the teachers’ academic qualifications. Acccording to Sabol and colleagues, when child outcomes are measured, high quality programs do not give better results on most outcomes than programs that are rated lower in quality. In their research, a measure of the quality of child-teacher interaction—not usually included in QRISs-- was the best predictor of good learning outcomes. There are many reasons to encourage early childhood education and to fund it adequately, but there continue to be many unanswered questions about how we assess high quality programs and assure the public that funds are well-spent. PA-IMH Breakfast 1-7-15 Powerpoint Slides Provided click here
The PA-IMH breakfast seminar audience on Jan. 7, 2015, heard a presentation by Nathan Blum, M.D., Professor of Pediatrics at CHOP, on aspects of Attention Deficit/Hyperactivity Disorder (ADHD) in preschool children. Dr. Blum addressed questions of both theoretical and practical importance: 1) at what age is it possible to diagnose ADHD?, 2) when preschool children are diagnosed with ADHD, is the diagnosis associated with impairment?, 3) how do the symptoms and diagnosis change with age?, and 4) when ADHD has been diagnosed in young children, how should we treat the disorder? As Dr. Blum noted, the answers to these questions are not necessarily the same for preschoolers as they are for school-age children. The nature of the answers is also complicated by differences between the criteria for diagnosis given by DSM-IV and DSM-5, and by the fact of subtypes of ADHD. DSM-IV offered mixed messages about early diagnosis of ADHD, sometimes suggesting that age 4 or 5 years was the youngest period at which an ADHD diagnosis could be made, but at other times referring to the attentional capacities of toddlers. DSM-5 commented that although parents may observe excessive motor activity in toddlers, there is so much normal variability in attention and impulsiveness that other symptoms may not be able to be distinguished until age 4. In line with this observation, the American Academy of Pediatrics now recommends that children with symptoms of ADHD be evaluated from age 4 onward. At age 3, 3% of boys and less than 1% of girls have already been diagnosed with ADHD. Do these symptomatic children show other impairments? What happens to them as they get older? Younger children diagnosed with ADHD were also seen to have problems of slowed language development, and as they moved into the school years they had lower reading scores than others, but their math scores were not different from those of non-ADHD children. By age 11, about 50% in one study no longer met criteria for attention disorders of for other mental health problems. Which were the children who, after being diagnosed with ADHD at age 3, later did not show symptoms of the disorder? Dr. Blum pointed out that although it is possible to describe differences between groups who were more or less likely to continue to show symptoms, there is no way to identify an individual who will “grow out” of ADHD symptoms. The period between 3 and 4 years is the time when “growing out” is likely to occur if it is going to do so, with about 50% of symptomatic 3-year-olds improving by age 4. For preschool children who persisted with symptoms of ADHD, a number of factors were associated with the persistence, but no single factor or pattern predicted what would happen to an individual. Children with persisting ADHD were more likely to have had sleep problems at 24 and 36 months and to have lower language ability. They had more negative behaviors even in infancy, and more negative parenting behaviors were likely to be present. There were more externalizing, disruptive behaviors, and also more internalizing behaviors such as anxiety and negative moods. Family incomes and parental educational levels were lower among children with persistent ADHD. Those children also were more likely to be exposed to parental psychopathology, and 25% of parents of ADHD children have ADHD themselves. Dr. Blum also discussed some issues about treatment of ADHD in preschool children. He pointed out that of the available treatments, behavior therapy and methylphenidate (Ritalin), neither treatment is specific to ADHD, but is instead directed at symptoms that cause problems. The American Academy of Pediatrics has recommended that the first choice of treatment is evidence-based behavioral therapy. If this is not sufficient, or if behavioral therapy is not available where the family lives, or acceptable to the family, methylphenidate may be used after weighing the risks of starting the medicine at an early age versus delaying treatment. The side effects of methylphenidate in preschoolers with ADHD are more worrisome than they are in school-age children. In one study, 11% stopped the medication because of side effects, more than half of these being irritability and emotionality, and others being decreased appetite, tics, insomnia, and occasionally other problems. In the same study, preschool children grew an average of 1.38 centimeters a year less than expected; in another study, the growth lag in school-age children was only 0.86 cm. In addition to these problems, it was notable that while 22% of children on methylphenidate met the criteria for a significant improvement, 13% of those on a placebo also met the criteria, leaving a relatively small difference to be attributed to the medication. Parent training has also resulted in some improvements in preschool ADHD symptoms, but these do not occur in all children or by all measures. For example, in a study of the New Forest Parenting Program, parent ratings of children’s behavior improved, but observational measures did not change. This program’s positive effects occurred when training was provided by home visitors with a mental health background, but not when it was done by medically-trained visitors who had been trained in the parenting program. In conclusion, Dr. Blum offered the following summary statements: Preschoolers with ADHD have significant functional impairments; behavioral treatments and medication can both cause improvement, but less than half the children are excellent responders; and methylphenidate side effects may be more significant in preschoolers than in school-age children. The PA-IMH breakfast seminar presentation for November, 2014 was given by Judith Silver, Ph.D., of CHOP, and focused on the special needs of children between birth and three years who are involved with the child welfare system. Because Pennsylvania state laws will soon change to lower the bar for investigation of abuse and neglect cases, it will become increasingly important to be able to make an accurate assessment of the needs of vulnerable young children. Infants and toddlers are especially vulnerable to neglect, they are the largest cohort of victims of substantiated abuse and neglect, they make up half of all substantiated medical neglect cases, they account for 70% of all child deaths, and they are often without contact with mandated reporters of abuse and neglect. Unfortunately, few states treat the needs of infants and toddlers as different from the needs of older children, and few have put to work some of the promising approaches for meeting young children’s developmental needs. The Family Advocacy & Support Tool (FAST 0-5 module) offers a way to help caseworkers plan effective interventions and provides a rating system that identifies specific problems as “actionable”. The FAST approach includes items that have to do with risk for death and injury and medical neglect or developmental disabilities. Failure to thrive is one focus, and includes concerns about babies receiving insufficient calories because of inappropriate formula preparation, failed breast feeding, or food insecurity, all possibly associated with parents’ intellectual disability or with medical causes such as lead exposure or HIV. Another serious concern has to do with the development of early vision and hearing problems, which must be resolved in the first year or less in order to prevent long-term effects on language development or blindness.
For most breakfast seminar attendees, an important aspect of FAST was the setting of standards to use in assessing behavioral and emotional concerns such as sleep practices, self-regulation issues like crying and tantrums, and the progress of eye contact and social engagement. Most of the FAST items of this kind are not only focused on birth to age three, but provide information on developmental sub-periods, as sleep practices or concerns with crying are very different for young infants than they are for toddlers. For example, with respect to sleep issues, one item is specifically designed for babies from birth to four months of age, the period when death from SIDS is by far the most likely. During this age period, babies’ sleep situations may be evaluated as having 0 or 1 concerns, in which no changes are needed, or they may be ranked as having moderate or significant concerns, and therefore needing to have this issue included in the individual family plan. Concerns about crying in young babies and tantrums in toddlers are carefully defined in the FAST approach. If infants aged 1 to 5 months are moderately easily soothed, this concern is a minor one, but there is much more concern if a baby cries for extended periods and does not soothe, especially if the caregiver gets no breaks from responsibility. The concern with tantrums focuses on children from about 12 months to 5 years of age. No problem is indicated if these are brief outbursts that are resolved in 10 minutes or so, and if they are triggered by age-appropriate issues like power struggles or crankiness. There is slight concern if tantrums occur more than 5 times a day and if they resolve in 10 to 15 minutes. Moderately concerning tantrum behavior involves tantrums more than five times a day, lasting more than 20 minutes, or involving aggression or head-banging on soft surfaces. Significant reason for concern exists if tantrums are intense and the child hysterical and inconsolable for long periods, and where there is abrupt head-banging on hard surfaces. In the last case, planning should include investigation of developmental disorders like language delays, or reminders of past trauma as reasons for significant tantrums. The FAST birth-to-five module presents an extremely useful definition/checklist approach that should be of great value to professionals doing individual family plans. On Sept. 5, 2014, Judith Miller,Ph.D. of the Center for Autism Research at Children’s Hospitalof Philadelphia, presented on “DSM-5: Changes to Autism Spectrum Disorder and Intellectual Disabilities” This topic drew a large and interested audience because of ongoing changes in the use of the new criteria for these diagnoses, and their implications for services children may receive.
Dr.Miller noted the history of changes in DSM descriptions and criteria for autism and similar disorders. From 1980 on, there have been alterations in DSM views of autistic disorders and pervasive developmental disorders, with the addition of Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder in 2000. DSM-5 omits some of these categories and places individuals on an autism spectrum disorder continuum, with narrative descriptions of specific criterion skills and behaviors, and assessment of the severity of each problem in terms of services needed. Comparing the DSM-IV-Tr criteria for autism to the DSM-5 criteria for ASD, Dr. Miller pointed out that the delayed language criterion, at one time such a focus for assessment of autism, has now been removed from the DSM-5 list. The reason for this was that this problem is not unique to autism, and in fact with increased access to speech interventions is less likely than it once was. Language problems are still of interest in the DSM-5 approach, but are considered as aspects of social-emotional reciprocity and of stereotyping. Like DSM-IV-Tr, DSM-5 looks at a category of nonverbal communication. There is a concern with difficulties with relationships in general, not just with the peer relationships of concern to DSM-IV-Tr; the old criterion of delayed pretend play is also included in the relationship category. The old categories of lack of emotional reciprocity and impaired conversations are included as aspects of social-emotional reciprocity. Circumscribed interests continue to be a criterion, as do routines and resistance to change. Stereotyped movements, speech, and object use now takes the place of stereotyped language and stereotyped movements. The earlier “preoccupation with parts” criterion is now expanded to unusual sensory reactivity or interest, although Dr.Miller pointed out that not all ASD children have these and that the evidence for Sensory Integration Disorder is weak. Finally, the old criterion of onset before 30 months is now broadened to onset in early developmental period. Each of these criteria is considered in terms of its severity and the level of support the child needs. The narrative description required by DSM-5, which no longer uses the “axis” approach, is intended to focus on a child’s individual pattern of strengths and weaknesses and to avoid the “diagnostic overshadowing” that suggests that all children with a diagnosis are alike. Children who have deficits in social communication but do not meet other criteria for ASD should be evaluated for social communication disorder. Dr. Miller also stressed the fact that autism is simultaneously heterogeneous and often coupled with co-occurring diagnoses. Problems that have known medical or genetic foundations, like Rett’s disorder or Fragile X, are no longer included in this diagnostic category. However, children who were previously diagnosed as autistic under DSM-IV-Tr will be “grandfathered” into the new diagnostic category with respect to the availability of services. Audience questions included a number of inquiries about how these changes affect the services children get. Dr. Miller noted that the States interpret Federal criteria in different ways, but that school districts also develop their own cultures that help to determine how services are provided. One audience member referred to her experience that parents are quick to accept the idea that a child is autistic without waiting for a full assessment. This question led to a discussion of which professionals can diagnose ASD, with the conclusion that although people should be working within the scope of their expertise, state laws differ with respect to the role of social workers in ASD diagnosis. The interest of the audience in ASD limited the time that Dr. Miller was able to give to the new DSM-5 diagnosis of Intellectual Disability Disorder, now replacing the term “mental retardation”. However, she noted the DSM-5 emphasis on adaptive impairments in various areas, and pointed out that IQ scores are more problematic at the low end of the range. |
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