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This website features resources and ideas to assist children suffering from a wide array of disabilities. This would be a great resource for teachers who are looking for ways to help struggling students. Options can be found here and then taken to administration for consideration.

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contributed by Brian Neese, Alvernia University

Assistive technology tools are among the least 'celebrated' but most crucial tools in K-12 education today.

According to the National Education Association (NEA), the number of U.S. students enrolled in special education programs has risen 30 percent over the past 10 years. Additionally, the NEA reports that nearly every general education classroom in the country includes students with disabilities, as three out of every four students with disabilities spend part or all of their school day in a general education classroom.

One tool to help students with disabilities even in the face of a special education teacher shortage is assistive technology. Today, assistive technology tools can help students with certain disabilities learn more effectively. Ranging in sophistication from 'low' technologies such as a graphic organizer worksheet to 'high' technologies including cutting-edge software and smartphone apps, assistive technology is a growing and dynamic field. Several areas of assistive technology and sample products may be found in any given classroom, making a difference in how students of all abilities learn.

See also 30 Examples Of Assistive Technology In The Classroom
Background On Assistive Needs & Supporting Technology Assistive Technology Module
This isn't a tech tool but a short kind of 'course' that offers an overview of assistive technology (AT) and explores ways to expand students' access to it in the classroom

Assistive Technology Act (AT Act)

A summary of the Assistive Technology Act and its consequences for educators.
AEM Student Summary Worksheet
A resource that, for example, helps teachers "think about whether the student 1) can gain information from print-based educational materials used across the curriculum by all students, 2) needs materials in a specialized format, or 3) needs modified content or alternative materials."
Text-To-Speech Assistive Tools
As an assistive technology, text-to-speech (TTS) software is designed to help children who have difficulties reading standard print. Common print disabilities can include blindness, dyslexia or any type of visual impairment, learning disability or other physical condition that impedes the ability to read. However, other students can benefit from TTS technology, such as children that have autism, attention deficit hyperactivity disorder (ADHD) or an intellectual disability.

The technology works by scanning and then reading the words to the student in a synthesized voice, using a large number of speech sounds that make up words in any given context. With the advances in speech synthesis, TTS technology is more accurate and lifelike than ever.
Tech Matrix
Search a database of nearly 400 products using extensive criteria tailored to assistive and educational technologies.
Kurzweil 3000
The Kurzweil 3000 is a leader in TTS software for individuals that struggle with literacy. In addition to a range of TTS features, the full-featured software program integrates abilities that can help students in other areas, potentially appealing to those who may have a non-print disability or those who may not typically consider a TTS program. Some of the features include:

* Multiple TTS voices

* Support for 18 languages and dialects

* Talking spell-checker

* Picture dictionary graphics for more than 40,000 words

* Text magnification

* Tools for test taking, essay writing, note-taking, reference and more

The Kurzweil 3000 strives to provide students with a multi-sensory approach to literacy learning. It is available for Windows and Macintosh.

Graphic organizers can be effective in helping students to organize their thoughts during the writing process. As an assistive technology, graphic organizers can be a strong choice for students with dysgraphia or disorders of written expressions - particularly the conceptual aspects of writing.

Graphic organizers work by helping the student map out a course of action. Depending on the type of writing, the graphic organizer can prompt the writer to describe an object, chart out a course of events or perform some other task that can help in planning the piece. Graphic organizers vary by type and technological sophistication.
Low-Tech Handouts
Graphic organizers do not need to be technologically advanced; in fact, they can exist in simple handout form.

Sample handouts can be found at the Houghton Mifflin Harcourt Company. The sandwich chart can assist students with paragraph writing. The sequence chart can help with narrative writing and the ordering of events. The sense chart is designed for descriptive writing, where writers are prompted for terms that characterize and express an item. Dozens of other sample charts exist and can help students with virtually any type of writing.
Draft:Builder
Draft:Builder is a writing tool that integrates outlining, note taking and draft writing functions to break down the writing process into three steps. Using a graphical organizer, the program helps the student visualize the project and insert information into the appropriate place without having to conceptualize the whole process. It then automates the process of creating the paper, where the student can drag and drop what is written in each note to the rough draft.

Other features include a talking spell checker that uses TTS technology, a bibliography tool, a dictionary and the ability for teachers to add locked text into the program for further guidance. Draft:Builder is available for Windows and Macintosh.
Assistive Listening Systems
A variety of assistive listening systems, or hearing assistive technology, can help students who are deaf or hard of hearing, as well as those with other auditory and learning problems. According to the National Association for the Deaf, assistive listening systems can be used to enhance the reach and effectiveness of hearing aids and cochlear implants, or by children who do not need those tools but still need help hearing. Assistive listening systems use a microphone, a type of transmission technology and a device for capturing and bringing the sound to the ear. The specific transmission technology used in the system is typically what contrasts one type of assistive listening system from another.
FM Systems
According to the American Speech-Language-Hearing Association (ASHA), FM systems are the best choice for children with sensorineural hearing loss. The most common type of hearing loss for all ages, sensorineural hearing loss occurs when the inner ear (cochlea) or nerve pathways from the inner ear to the brain are damaged.

FM systems work using radio broadcast technology. With a transmitter microphone and a receiver, the teacher and student can maintain a consistent sound level regardless of distance and background noise. Additionally, ASHA notes that the hearing aid microphone can be turned off, so the student can concentrate on the teacher alone.
Sound-Field Systems
Sound-field systems are a strong choice for classrooms that need to assist listening for all children in the class. ASHA notes that these systems benefit not only children that have hearing loss, but those that have other auditory and learning problems, such as language delays, central auditory processing disorder, articulation disorders and development delays. Additionally, sound-field systems can be used for students who are learning English as a second language.

Sound-field systems use a microphone that projects sound through mounted speakers around the classroom. In classrooms that have good acoustics, sound is able to travel evenly throughout space, eliminating problems of distance between the speaker and each listener.
Sip-and-Puff Systems
Sip-and-puff systems are used by students who have mobility challenges, such as paralysis and fine motor skill disabilities. These systems allow for control of a computer, mobile device or some other technological application by the child moving the device with his or her mouth. Similar to a joystick, the child can move the controller in any direction and click on various navigational tools using either a sip or a puff. An on-screen keyboard allows the child to type using the same movements.

Sip-and-puff systems are a type of switch device, which refers to the technology used to replace a computer keyboard or mouse. Other switch devices include buttons or other objects that a student can touch, push, pull, kick or perform some other simple action that can then control the device.
Jouse3
The Jouse3 is a sip-and-puff system that allows children to control a device using any part of the mouth, cheek, chin or tongue. Due to its accuracy and quick response, home users can use it for drawing or computer games. It can mount to the desktop, a bedframe or any other type of structure; it does not require a headpiece or placement on the body of the user.

The product supports Windows, Macintosh, Linux and Unix based computers, in addition to Android and iOS mobile devices. It can support one or two external switches, and has two types of mouthpieces.
Sip-and-Puff Systems From Origin Instruments
Origin Instruments offers a range of sip-and-puff products that students can use to control an electronic device. Using a head mounted or gooseneck user interface, or available tubing for a custom solution, the child can control a mouse, joystick or keyboard with ease. The primary system is powered using USB technology.

The product supports Windows, Macintosh and Linux based computers. Two pressure switches connect the system to the user interface solution for use on electronic devices.
Proofreading Software
Proofreading software is a branch of assistive technology that goes above and beyond the typical proofreading features found in a word processing system, such as correcting words frequently misspelled by students with dyslexia. A number of other features offered within this category can help students work on his or her English skill set to become a more effective and accurate writer.

Although primarily geared towards individuals with dyslexia, proofreading software can be helpful to those with any type of learning disorder that makes writing and reading challenging.
Ginger
Ginger offers several features that can help students with dyslexia and other learning disorders with writing. It is also designed for speakers of languages other than English. Some of the features include:

* Grammar checker that analyzes context to determine any errors or misspellings. For instance, Ginger can recognize whether 'there,' 'their' or 'they're' should be used in a sentence, which is a common mistake in writing.

* Word prediction and sentence rephrasing tools that can be helpful for students learning how to construct sentences properly.

* TTS functionality so students can hear what they've written.

* A personal trainer that provides practice sessions based on past mistakes made by the student.

Ginger is available for Windows and Mac, as well as iOS and Android mobile devices.
Ghotit
Ghotit is specifically designed for students with dyslexia and other learning disorders who have difficulties with writing. The name is inspired by the word "Ghoti," which is a constructed term that illustrates irregularities in the English language. And since many spellings are counterintuitive - especially for those with dyslexia - Ghotit dedicates itself to assisting children and adults who struggle with writing accurately.

It features the ability to learn from the user's past mistakes, personalizing suggestions for spelling and grammatical errors. Ghotit can predict words, check passages of text contextually, read text aloud using TTS technology and recognize split and merged words. It also includes an integrated dictionary for students to quickly look up a word.
Math Tools
A range of technology and tools can help students that have trouble with math, most commonly found in a learning disability called dyscalculia. Dyscalculia makes it difficult to grasp numbers and it is characterized by a general lack of understanding in the field of math.

Assistive technology in math is not just for those with dyscalculia. It can also help students with blindness, fine motor skill disabilities or some other type of disability that makes it difficult to perform math-related work.
MathTalk
MathTalk is a speech recognition software program for math that can help students with a range of disabilities. From prealgebra to Ph.D. level mathematics, students can perform math problems by speaking into a microphone on their computer. The program works with Dragon NaturallySpeaking programs for voice-to-text functionality, making it ideal for students who have fine motor skill disabilities. Students with blindness or vision disabilities can use the integrated braille translator.

In addition to these audiences, MathTalk also appeals to students with dyscalculia. The program functions as an electronic math worksheet, allowing the child to organize, align and work through problems on the screen, making it helpful for students who have difficulties performing math problems on paper.
Math Simulations
Math simulations can help students with dyscalculia visualize math problems and concepts. As a result, students can better understand the application of a particular type of problem, since many students struggle with the conceptual aspects of math.

Examples can be found at the NASA website. From video to animated simulations, teachers and students can visually see how a math concept or problem would work. And with some math simulations, students can work through the problem and then see the result play out in the simulation.
Conclusion
Thanks to the rapid advances in assistive technology tools, students, parents, and teachers have a seemingly limitless number of tools at their disposal.

As these tools start to appear in the home and in the classroom, parents and teachers can utilize them for students' academic and personal growth. But technology alone is not enough - to successfully use these tools, it's critical to develop a plan for their use and have regular check-ins to ensure the student is gaining the most value possible and not becoming overly reliant on these tools.

But while assistive tools have become plentiful, the same cannot be said for special education instructors. As previously mentioned, the vast majority of states have reported a need for teachers in special education. And many general education classrooms instruct children with special needs.

Certification is a faster way for current teachers to qualify to teach this growing population. At Alvernia University Online, teachers can pursue a special education certification for grades PreK-8 or 7-12 to help make a difference for children with special needs. They will also improve their marketability in the process, gaining additional opportunities for their career.

Overall, more teachers are needed in this area. Although the advancement of technology in special education is promising, the same increase is needed for the number of special education instructors. Certification offers one solution to quickly meet this need. Learn more about Alvernia's program today.
15 Assistive Technology Tools & Resources For Students With Disabilities

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15 Assistive Technology Tools & Resources For Students With Disabilities

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Ranging in sophistication from tools to apps, assistive technology tools can help students with certain disabilities learn more effectively.

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Academic Testing Accommodations for ADHD

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Academic Testing Accommodations for ADHD

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Accommodations during testing for students with ADHD and the merit of such. This information is school related in nature and can be used to determine the best test taking accommodations when creating policies.

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Learn Disabil (Pittsbg). Author manuscript; available in PMC 2017 May 10.

Published in final edited form as:

Abstract

This study investigated the effectiveness of five commonly administered academic testing accommodations on reading and math performance in children with attention deficit hyperactivity disorder (ADHD). A total of 96 parents of 3 rd-8 th grade students with ADHD participated. More than half of the sample also had parent-reported learning difficulties in reading and/or math. Individually administered cognitive and achievement test scores, types of testing accommodations received, and Maryland School Assessment (MSA) reading and math scores were obtained from these students' school records. Taking into account grade level and co-occurring learning difficulties, none of the five accommodations investigated were associated with better MSA scores among students with ADHD who received the accommodations versus comparable students who did not. Additionally, individual variation in processing speed performance did not moderate the association between receipt of accommodations and reading or math performance. Common testing accommodations, as presently administered, may offer little benefit for students with ADHD, regardless of co-occurring learning difficulties.

Keywords: ADHD, learning disabilities, accommodations

Introduction

Why ADHD?

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by behavioral symptoms that include difficulties with attention, focus, impulsivity, hyperactivity, memory, and organization. Youth with ADHD often demonstrate difficulties in executive functions, which refer to a complex set of cognitive process that are involved in planning, initiating, and maintaining goal-directed behavior (i.e., "getting your act together" per Denckla, 2011). In addition to being the most commonly diagnosed psychiatric condition of childhood, with recent research estimating that more than 1 in 11 American youth aged 4 to 17 years is affected ( Pastor et al., 2015), ADHD confers considerable academic risk for students. Children with ADHD are more likely to earn lower GPAs and face greater risk of retention and school dropout relative to their typically developing peers ( Barkley, 2006; Fletcher & Wolfe, 2008). Estimates of the co-occurrence of ADHD and reading disability range from 25% to 40% ( Dykman & Ackerman, 1991; Semrud-Clikeman et al., 1992; Willcutt et al., 2010), with ADHD and any learning disability co-occurring at 30% to 45% ( DuPaul et al., 2013; Smith & Adams, 2006). Robb and colleagues (2011) estimate that the average student with ADHD costs $4,700 more to educate per year than the average student without the disorder, resulting in, at minimum, an extra $30 billion spent annually on the education of students with ADHD in the United States.

The Use of Accommodations in the Educational Management of ADHD

In addition to pharmacologic and behavioral interventions, accommodations are commonly provided in the academic setting in an effort to more effectively educate and assess students with ADHD. Accommodations represent adjustments to standardized instructional practices or assessment conditions that are designed to reduce the effects of a child's disability by allowing him/her to participate more fully in instruction and to better demonstrate their knowledge and skills ( Fuchs et al., 2000). The assumption is that an effective accommodation should minimize the functional impairment associated with a student's disability but should not affect the performance of a nondisabled student ( Tindal & Fuchs, 1999). The empirical support for academic accommodations for students with ADHD is meager, despite the frequency with which they are administered ( Schnoes, Reid, Wagner, & Marder, 2006).

Extended time, the most commonly administered accommodation for students with ADHD ( Schnoes et al., 2006), has received the most empirical attention; however, findings regarding the effectiveness of extended time for these students are mixed. Brown, Reichel, and Quinlan (2011), for instance, demonstrated that receipt of extended time was associated with better scores on a passage comprehension measure among adolescents with ADHD; however, this study provided no comparison group of typically developing peers to evaluate whether the students with ADHD received a "differential boost" in performance ( Tindal & Fuchs, 1999) from this accommodation. Several studies that have compared students with ADHD to their typically developing peers have suggested that extended time may not differentially benefit these students with disabilities. Lewandowski and colleagues (2007) evaluated the effect of extended time on middle school students' performance on a math fluency test. Results indicated that typically developing students outperformed students with ADHD under both standard administration and extended time conditions, and typically developing students benefitted more than teens with ADHD from extended time. Even more concerning, Pariseau and colleagues (2010) found that elementary school-aged children with ADHD actually completed significantly fewer reading, math, and writing problems under extended time conditions than under standard time. Further, Lovett and Leja (2015) examined the effects of extended time on performance in college students. They found that college students reporting more severe ADHD symptomatology benefitted less from extended time on a reading comprehension task than those reporting fewer ADHD symptoms.

Other academic testing accommodations for students with ADHD that have received empirical attention include paced item presentation and small group testing. Among college students with ADHD, paced item presentation offered no performance benefits on computer-based testing ( Lee, Osborne, Hayes, & Simoes, 2008). Hart and colleagues (2011) found that while small group instruction increased on-task behavior in the classroom among children with ADHD, small group testing actually reduced productivity for these children.

Still other accommodations, such as oral presentation of written information, have been examined among mixed groups of children with disabilities, including some with ADHD and learning disabilities; however, these testing accommodations have not been evaluated with respect to students with ADHD specifically. Among students with learning disabilities, several studies point to possible, though limited, effectiveness of the oral presentation of written information, or read-aloud accommodation, in improving performance. Fuchs and colleagues (2000) found that students with disabilities did not benefit from the read-aloud accommodation on measures of math application but did benefit on measures of math problem-solving. Further, Tindal and colleagues (1998) demonstrated that students with disabilities benefitted from having math assessments read aloud to them by their teacher, whereas students without disabilities did not benefit from this accommodation.

The literature regarding the effectiveness of setting accommodations, such as a reduced distraction or reduced noise environment, on performance offers mixed findings. Vaughan and colleagues (2014) found that although 5- to 12-year-olds with ADHD were more likely than typically developing peers to give invalid responses on memory and reaction time measures in a group setting, performance validity between groups was comparable when measures were administered individually. Smith and Riccomini (2013) reported that students with learning disabilities in grades 3 to 5 demonstrated greater improvement in reading comprehension relative to their typically developing peers when wearing noise-reducing headphones. In contrast, Lin and Lin (2013) found that students with learning disabilities did not benefit from a reduced noise environment when tested on number sense and numeration skills.

Similarly mixed findings are evident regarding the accommodation permitting the use of a calculator. Studies of middle schoolers have shown that students with and without disabilities benefitted equally from the opportunity to use a calculator on measures of math problem-solving ( Bouck & Bouck, 2008). In contrast, Fuchs and colleagues (2000) found that calculator use offered a differential boost to fourth and fifth graders with disabilities on measures of math problem-solving but not math concepts and applications.

Thus, even the existing literature regarding the effectiveness of academic accommodations for learning disabled youth offers mixed findings, and still less is known about the impact that these accommodations might have for students with ADHD. The goal of the present study was to investigate the association between five of the most commonly recommended academic testing accommodations and performance on standardized, group-administered reading and math tests among elementary and middle school-aged students with ADHD.

Methods

Procedure

Participants were recruited from a large outpatient psychological assessment clinic and from the local community via flyers and newspaper advertisements. Participants included children in grades 3 through 8 in Maryland public schools who had been previously diagnosed with ADHD, as well as their caregivers. Potential participants were screened by a trained research assistant using the ADHD Rating Scale-IV ( DuPaul, Power, Anastopoulos, & Reid, 1998) to assess parent report of current symptoms of ADHD. Caregivers whose children did not currently meet symptom count criteria for ADHD diagnosis via the ADHD Rating Scale-IV, but whose children had a documented diagnosis of ADHD from available educational, medical, or research records were also included in the study ( n = 11).

After informed consent was obtained from parents and assent from children, parents provided basic demographic and history-related information and completed the Colorado Learning Difficulties Questionnaire (CLDQ; Willcutt et al., 2011), as well as an educational records release. A member of the study team then requested the following items from the child's school record: (1) Maryland School Assessments (MSA) scores for reading and math for the prior academic year, (2) Individual Education Program (IEP) or 504 Plan for the prior academic year (if applicable), and (3) reports of psychological or educational testing for the child completed within the past three years (if applicable).

Participants

Participants in this study included 96 caregivers of children diagnosed with ADHD. The majority of caregivers providing ratings (85%) were mothers, 70% of whom had completed at least some college. Students in the sample were 68% male, consistent with the sex distribution in the population of American children with ADHD ( Pastor et al., 2015). Students were evenly distributed across grades 3 through 8 in schools across 14 of the 24 school districts in the state of Maryland. They were primarily Caucasian (52%) and African American (34%). Eighty-three percent of these students were prescribed medication for symptoms of ADHD at the time of the study, with 73% of those on medication taking stimulants. The distribution of ADHD subtypes in the sample was similar to that found in other samples of students with ADHD ( Merikangas et al., 2010), with the largest proportion (53%) falling in the Predominantly Inattentive subtype, followed by 34% falling in the Combined subtype. The majority of students in the sample had significant co-occurring parent-reported learning difficulties (CLDQ mean scores above clinical cut points as published in Patrick et al., 2013) in reading (52%) or math (67%). The mean MSA Reading and Math scores for the present sample were 413 (range: 344-514) and 417 (range: 337-504), respectively. At the time of the 2012 MSA tests, 63% of the sample was receiving special education services allowing for test accommodations via an IEP ( n = 30) or 504 Plan ( n = 30).

Measures

The ADHD-RS-IV is an 18-item measure of ADHD symptomatology that adheres closely to DSM-IV diagnostic criteria ( American Psychiatric Association, 2000). Nine inattentive (IA) symptoms and nine hyperactive/impulsive (HI) symptoms are rated on a 0 ("Never") to 3 ("Very Often") Likert scale. For diagnostic symptom count purposes, a rating of 2 ("Often") or 3 indicates an endorsed symptom. Consistent with DSM-IV criteria for ADHD, parents who endorsed six or more inattentive symptoms and/or six or more hyperactive/impulsive symptoms for their child were enrolled in the study.

Colorado Learning Difficulties Questionnaire (CLDQ; Willcutt et al., 2011)

The CLDQ is a brief caregiver rating of learning problems in children and adolescents and was used in the present study to screen for co-occurring learning difficulties. The measure consists of 6-item reading and 5-item math subscale, along with three other subscales that were not used in the present study. Parents are asked to rate how often their child has difficulty with a particular skill on a Likert scale from 1 ("never/not at all") to 5 ("always/a great deal"), with higher scores indicating greater learning difficulty. The CLDQ reading and math subscales have demonstrated strong convergent validity and sensitivity with respect to performance-based measures of reading and math achievement ( Patrick et al., 2013; Willcutt et al., 2011).

The MSAs are standardized measures of reading and math achievement administered annually to students in grades 3 through 8 in Maryland public schools through the 2012-2013 school year. Each child earned a standardized MSA score for reading and math ranging from a minimum of 240 to a maximum score of 650. Cut scores were developed for each grade level to offer categorical descriptors (basic, proficient, advanced) of performance as well, with achievement of the proficient level analogous to performing at grade level in a given domain.

All students on the diploma track in Maryland public schools prior to the 2014-2015 academic year were required to take the MSAs by the Maryland State Department of Education. Some students were administered a modified version of the test, based on extent of special education needs; however, these individuals were excluded from the present study.

Statewide results for the MSAs are available online on the Maryland Report Card ( http://reportcard.msde.maryland.gov/MsaOverview.aspx?PV=1:3:99:AAAA:1:N:0:13:1:1:0:1:1:1:3). For reading, across the state of Maryland, 29% of students scored within the basic range, 39% in the proficient range, and 32% in the advanced range. For math, 23% of Maryland students scored within the basic range, 48% in the proficient range, and 29% in the advanced range.

Standardized Measures of IQ and Processing Speed

Scores from standardized, performance-based measures of IQ were extracted from educational, medical, and research records. Such assessment records were available for 47% of the present sample. Measures of intellectual ability from which scores were extracted included the Wechsler Intelligence Scales for Children, Fourth Edition (WISC-IV; Wechsler, 2003), the Wechsler Abbreviated Scales of Intelligence, 2nd Edition (WASI-II; Wechsler, 2011), the Stanford Binet, 5th Edition (SB-V; Roid, 2003), and the Differential Abilities Scales, 2nd Edition (DAS-II; Elliott, 2007). The majority (n = 41) of the individuals for whom performance-based IQ measures were available completed the WISC-IV. For these individuals, the WISC-IV Processing Speed Index score was utilized in supplementary analyses.

Data Analysis Plan

Descriptive statistics were used to evaluate the frequency with which the five accommodations under review were offered, as well as basic sample characteristics. Pearson correlation and logistic regression were used to evaluate associations between ADHD symptom severity, extent of learning difficulties, and accommodations received. Equivalence of the group of students offered testing accommodations (ACCOMS+ group) and the group of students not offered testing accommodations (ACCOMS− group) was evaluated using independent groups t-tests, analyses of variance (ANOVAs) and chi-squared tests of independence. Multiple hierarchical linear regression was used to assess the relationship between receipt of individual accommodations and MSA reading and math scores, controlling for learning difficulties. Separate regressions were run for elementary (third to fifth grade) and middle (six to eighth grade) school students in order to evaluate whether accommodations impact performance differentially for students at different grade levels. Finally, the potential moderating effect of processing speed on the association between receipt of the extended time accommodation and MSA performance was considered via multiple linear regression.

Results

Frequency of Receipt of Accommodations

Per students' IEP and 504 Plan records, extended time was the most frequently offered accommodation (present on 88% of IEP/504 Plans), followed by a reduced distraction environment (present on 77%), use of a calculator (present on 47%), more frequent breaks (present on 45%), and oral presentation of written information (present on 32%). Among those students with an IEP or 504 Plan, the average number of accommodations offered was 5, with a range from 0 to 13.

Associations between the number of accommodations offered and academic performance (MSA reading and math scores), between number of accommodations offered and ADHD symptom severity (ADHD-RS-IV scores), and between ADHD symptom severity and academic performance were not statistically significant; therefore number of accommodations offered and ADHD symptom severity were not included as variables in the regression models that follow.

ACCOMS+ and ACCOMS− Group Differences

As shown in Table 1 , independent groups t-tests indicated that the group of students with ADHD who were offered one or more accommodations (ACCOMS+) and the group of students with ADHD who were not offered accommodations (ACCOMS−) were not significantly different in terms of grade of child, maternal education level, ADHD symptom severity, parent-reported math difficulties, and visually-based reasoning skills (PIQ); however, the ACCOMS+ group demonstrated significantly more parent-reported reading difficulties, as well as significantly lower language-based reasoning skills (VIQ) and Full Scale IQ (FSIQ). Distribution of sex (χ ²(1, 96) = 0.079, p = .778, φ c = .029) and ADHD subtype (χ ²(3, 96) = 0.141, p = .987, φ c = .038) also did not vary significantly across groups.

Table 1

Group

ACCOMS+ (n = 60)

ACCOMS− (n = 36)

M

SD

M

SD

df

t

p

Cohen's d

No significant group differences were observed on MSA reading or math scores (see Table 1 ), even after controlling for language-based reasoning scores. Further, the distribution of students across performance levels (basic, proficient, advanced) was equivalent in the two groups for both reading (χ ²(2, 95) = 1.050, p = .592, φ c = .105) and math scores (χ ²(2, 95) = 1.943, p = .379, φ c = .143).

Elementary school-aged participants did not differ significantly from middle school-aged participants in terms of VIQ ( t(43) = 0.101, p = .920, Cohen's d = 0.030), MSA reading scores ( t(93) = 0.532, p = .596, Cohen's d = 0.110), or MSA math scores ( t(93) = 0.542, p = .589, Cohen's d = 0.110) .

Association between Accommodations and MSA Performance

Table 2 shows the results of the multiple linear regressions of receipt of individual accommodations on MSA reading and math scores, performed separately for elementary and middle school students. The unstandardized estimate associated with the constant represents the average MSA score for the sample, controlling for all of the accommodations variables entered into the model. Thus, the average MSA Reading score in the elementary model is 421 and the average MSA Math score is 433, while the average MSA Reading score in the middle school model is 414 and the average MSA Math score in that model is 417. Among elementary school-aged students with ADHD, none of the accommodations were significantly associated with MSA reading scores and only the calculator use accommodation was associated with a statistically significant MSA math score difference. Elementary school students with ADHD who received the calculator use accommodation earned MSA math scores more than 58 points lower than those who were not allowed to use a calculator. Among middle school-aged students with ADHD only oral presentation of written information was significantly associated with MSA scores, and only on the math portion of the test. Middle school students with ADHD who received the oral presentation accommodation performed, on average, 36 points worse than their peers with ADHD who did not receive the accommodation.

Table 2

Elementary School Students

MSA Reading Scores

MSA Math Scores

(n = 43)

β

SE

t

p

η ²

β

SE

t

p

η ²

Middle School Students

MSA Reading Scores

MSA Math Scores

(n = 52)

β

SE

t

p

η ²

β

SE

t

p

η ²

Impact of Learning Difficulties on Accommodations and MSA Performance for Students with ADHD

Parent-reported learning difficulties (CLDQ) were, as expected, significantly correlated with MSA reading and math scores, with greater learning difficulties associated with worse performance in both cases (reading r = -.535, p < .001; math r = -.403, p < .001). Two hierarchical multiple regressions (one using only elementary school students, the other only middle school students) in which CLDQ scores were entered in the first block, followed by the five accommodations in the second block, indicate that parent-reported learning difficulties account for a significant proportion of the variance in MSA math scores but are only marginally associated with reading scores at both grade levels ( Table 3 ). These regressions also indicate that, controlling for parent-rated reading difficulties, neither elementary nor middle school students with ADHD benefitted significantly from any of the accommodations on the MSA reading test. In math, elementary school students with ADHD who receive the calculator use accommodation continue to perform significantly more poorly (38 points worse) than their peers who were not allowed to use a calculator, even when parent-rated math learning difficulties were controlled in the model. No such association was found among middle schoolers.

Table 3

(n = 43)

Elementary School Students

MSA Reading Scores

MSA Math Scores

(n = 52)

Middle School Students

MSA Reading Scores

MSA Math Scores

In order to further investigate the impact of learning difficulties on the relationship between receipt of accommodations and reading/math performance, we created two groups for each academic domain based on parent-reported learning difficulties. Students whose parents endorsed reading difficulties on the CLDQ reading subscale that fell above the clinical cutoff score of 2.67 identified by previous research ( Patrick et al., 2013) were assigned to the "students with reading difficulties" group, while those whose parents endorsed reading difficulties falling below the clinical cutoff were assigned to the "students without reading difficulties" group. Similarly, students whose parents endorsed math difficulties on the CLDQ math subscale falling above the clinical cutoff score of 2.60 ( Patrick et al., 2013) were assigned to the "students with math difficulties" group, while those whose parents endorsed math difficulties falling below the clinical cutoff were assigned to the "students without math difficulties" group. These two groups are not mutually exclusive; some of the students with reading difficulties also were rated as having math difficulties and vice versa. Using these groups, students with ADHD who also have learning difficulties, per their parents' ratings, were compared to students with ADHD without learning difficulties in terms of the relationship between receipt of accommodations and reading/math performance. Given the impact of grade level on our previous findings, grade was included as a continuous covariate in these regressions, which are presented in Tables 4 and ​and5. 5 . Findings of these regressions indicate that, controlling for grade, students with ADHD did not benefit from any of the accommodations, regardless of whether they had co-occurring reading or math difficulties.

Table 4

Students With Reading Difficulties

Students Without Reading Difficulties

Table 5

Students With Math Difficulties

Students Without Math Difficulties

Moderating Effect of Processing Speed on Extended Time-MSA Performance Association

To test for a possible moderating effect of processing speed on the association between receipt of the extended time accommodation and MSA performance, a processing speed-by-extended time interaction variable was regressed, along with the individual processing speed and extended time accommodation variables, on MSA scores, within the subsample ( n = 41) for whom WISC-IV Processing Speed Index scores were available. For both reading and math, the interaction term (β = −0.780, SE = 0.992, p = .437 and β = −0.465, SE = 1.117, p = .680, respectively) did not indicate a significant moderating effect of processing speed.

Discussion

The aim of the present study was to offer a preliminary evaluation of the effectiveness of five of the most commonly administered academic testing accommodations for students with ADHD. Among our sample of students with ADHD in grades 3 through 8, more than half received at least one accommodation. Similar to Schnoes and colleagues' (2006) findings, extended time was, by far, the most commonly offered accommodation in our sample. Thus, a majority of students with ADHD are being offered accommodations, five on average, and these most commonly include extended time. Those students with ADHD who were offered accommodations appeared to be similar to those who were not, in terms of both demographic variables and the severity of ADHD symptoms; however, parent-reported reading difficulties tended to be greater and language-based reasoning skills tended to be poorer among the group of students who did receive accommodations.

Our data further suggest that the severity of a student's ADHD was not associated with the number or the specific type of accommodations offered, or with the student's reading and math performance, and number of accommodations offered was also not associated with MSA scores. Our comparison of the group of students who received no accommodations to the group of students who received one or more accommodations suggests that, cumulatively, accommodation receipt is not associated with better reading or math MSA performance.

When each accommodation is evaluated with greater specificity, taking into account both grade level and co-occurring parent-rated learning difficulties, a consistent pattern emerges. When these covariates are taken into account, none of the accommodations under study here were associated with significantly better performance on reading or math testing.

This absence of significant associations point to three possibilities. The first is that students with ADHD, including those with co-occurring learning difficulties, do not benefit from accommodations such as extended time, more frequent breaks, oral presentation of information, a reduced distraction environment, or the use of a calculator, because these accommodations do not mediate the core neurocognitive deficits that these students manifest. Alternately, perhaps no significant benefit of receiving these accommodations was observed because students with ADHD have not been taught to use them effectively. This hypothesis raises the possibility that the types of accommodations investigated here may still hold value if students with ADHD are taught to use them strategically and are provided with ample time for practicing them. For example, extended time is often intended to support students who are easily distracted and frequently require extra time in order to complete classroom assignments; however, under testing conditions, students are not usually provided with the same types of scaffolded supports they typically receive within the instructional condition. In the testing conditions, students are required to regulate their own behavior, utilizing their extended time strategically, in order to benefit. Given the nature of their disability, which includes weaknesses in self-managed inhibitory control, planning, and organization, students with ADHD are especially unlikely to be able to use such an accommodation effectively, unless they receive specific training and practice in its strategic use. For instance, impulsive students may be less likely to use extended testing time to go back and check their work for errors unless they are specifically trained and prompted to do so. The final possibility is that the present study is underpowered to detect significant effects of accommodations due to its relatively small sample. It is worth noting, however, that the findings of analyses employing the full sample ( n = 96), which effectively double the sample size of analyses run separately for elementary and middle school students, thereby increasing power to detect significant effects, also indicate no significant benefit of any of the accommodations under investigation. In addition, effect size estimates presented in the tables for all nonsignificant associations between accommodations and reading/math performance were small (all η ² < .10). This further suggests that the study was adequately powered to detect meaningful effects and that the nonsignificant findings represent an actual absence of or very small association between the variables.

While prior research points to the effectiveness of some accommodations for students with learning disabilities ( Elliott & Marquart, 2004; Lewandowski, Cohen, & Lovett, 2013; Lewandowski, Lovett, & Rogers, 2008), our findings suggest that, when ADHD is also present students with parent-reported learning difficulties do not seem to benefit from the accommodations that they are offered. The characteristic symptoms of ADHD may make it especially difficult for students with learning difficulties to make appropriate use of accommodations which might otherwise be helpful to them.

It is worth noting that the calculator use accommodation remains significantly associated with poorer math scores for elementary school students with ADHD, even after parent-rated math difficulties are controlled. It may be the case that elementary school students are not yet well trained in the effective use of a calculator, given the emphasis in elementary school on mastering calculation itself, and as a result use of a calculator does not improve their test performance. Additionally, access to a calculator could increase distractibility, particularly for younger students who have less experience with such tools and who are already at risk for difficulty with sustained attention as a result of their ADHD.

The present study also allowed us to consider the extent to which a student's speed, rather than his/her attention (though the two constructs are clearly associated), may relate to the effectiveness of the extended time accommodation. It stands to reason that students who work especially slowly, but who may not necessarily be off-task, might be better able to benefit from receipt of extended testing time than their off-task or impulsive peers. Our preliminary findings among the subsample of students for whom we have processing speed data do not support this hypothesis, as processing speed does not moderate the (nonsignificant) association between receipt of extended time and reading or math performance.

Limitations

These results should be interpreted in light of several limitations of the present study. Primary among these limitations is the fact that we do not have access to data regarding the fidelity of implementation of the accommodations investigated in this study. We do not know how, or whether, the testing accommodations listed on a student's IEP were actually administered for that student during the MSAs. It is worth noting, however, that the Maryland State Department of Education completes unannounced fidelity checks during standardized testing, with a particular focus on special education. Failure to offer accommodations specified as part of an IEP or 504 Plan is in direct violation of state and federal law, thus presenting significant risk to both teachers and administrators. Even when offered, however, students may decline to use accommodations.

An additional limitation of the present study is the size of the sample. In particular, the subsample of students for whom we have individually-administered IQ testing scores is too small to allow for use of language-based reasoning scores as a covariate in our central multivariate regression analyses, despite this variable's significant association with receipt of accommodations. Thus, the possibility remains that, since the ACCOMS+ group has poorer language-based reasoning skills than the ACCOMS− group, the ACCOMS+ group would have performed more poorly on the MSAs if they had not received accommodations.

Learning difficulties in the present study were parent-reported and cannot be equated with a diagnosed learning disability. It is, however, notable, that the measure of parent-reported learning difficulties used in the present study demonstrates strong sensitivity in the prediction of learning disabilities as defined by performance-based measures.

The naturalistic nature of this study does not allow us to evaluate the issue of "differential boost" in performance for students with ADHD relative to their typically developing peers; however, given that the students with ADHD in this study who did receive accommodations do not appear to be receiving any sort of "boost" from the accommodations examined here, relative to the students with ADHD who did not receive them, this limitation seems less pertinent. Future research in this area would benefit from the use of experimental designs to more rigorously evaluate the effectiveness of individual types of academic testing accommodations for students with ADHD and learning disabilities. Such designs will also further our understanding of whether certain combinations of individual accommodations might offer benefits for students such students.

Finally, the processing speed scores that were used to evaluate the moderating effect of sluggishness on the lack of association between extended time and reading/math performance offer an imperfect measure of cognitive sluggishness or slowed response speed. These scores are likely confounded with inattention, thus reducing the chance of detecting a moderating effect of pure slowness.

Due to these limitations, the findings of this study must be considered preliminary and should be used to help guide future research in this area, rather than to recommend or deny specific accommodations for particular types of students or direct educational policy decision-making.

Conclusions

Results of the present study offer no support for the effectiveness of commonly administered academic testing accommodations for students in elementary and middle school who have ADHD. Being offered extended time, more frequent breaks, a reduced distraction environment, oral presentation of written information, and/or the opportunity to use a calculator was not associated with better performance on reading or math testing for students, regardless of grade level or co-occurring learning difficulties. Further study of academic accommodations for ADHD is warranted, particularly in terms of whether instruction and in and practice with strategic use increases their effectiveness.

Contributor Information

Alison Esposito Pritchard, Clinical child psychologist at the Kennedy Krieger Institute and assistant professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine.

Taylor Koriakin, Graduate research assistant at the University of Connecticut Neag School of Education.

Lisa Carey, Education consultant with the Center for Innovation and Leadership in Special Education at the Kennedy Krieger Institute.

Alison Bellows, Research assistant in the Neuropsychology Department at the Kennedy Krieger Institute at the time of this manuscript.

Lisa Jacobson, Faculty neuropsychologist at the Kennedy Krieger Institute and assistant professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine.

E. Mark Mahone, Director of the Department of Neuropsychology, co-director of the Center for Innovation and Leadership in Special Education, and co-director of the Intellectual and Developmental Disabilities Research Center at the Kennedy Krieger Institute, as well as professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine.

References

DuPaul GJ, Gormley MJ, Laracy SD. Comorbidity of LD and ADHD: Implications of DSM-5 for assessment and treatment. Journal of Learning Disabilities. 2013;46(1):43-51. doi: 10.1177/0022219412464351. [[PubMed] [CrossRef] Google Scholar]

Fletcher J, Wolfe B. Child mental health and human capital accumulation: The case of ADHD revisited. Journal of Health Economics. 2008;27(3):794- 800. doi: 10.1016/j.jhealeco.2007.10.010. [[PubMed] [CrossRef] Google Scholar]

Vaughan CG, Gerst EH, Sady MD, Newman JB, Gioia GA. The relation between testing environment and baseline performance in child and adolescent concussion assessment. The American Journal of Sports Medicine. 2014 doi: 10.1177/0363546514531732. [[PubMed] [CrossRef] Google Scholar]

Willcutt EG, Betjemann RS, McGrath LM, Chhabildas NA, Olson RK, DeFries JC, Pennington BF. Etiology and neuropsychology of comorbidity between RD and ADHD: The case for multiple-deficit models. Cortex: A Journal Devoted to the Study of the Nervous System and Behavior. 2010;46(10):1345-1361. [[PMC free article] [PubMed] Google Scholar]

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Academic Testing Accommodations for ADHD: Do They Help?

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This study investigated the effectiveness of five commonly administered academic testing accommodations on reading and math performance in children with attention deficit hyperactivity disorder (ADHD). A total of 96 parents of 3[rd] -8[th] grade ...

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Colorín Colorado is a national multimedia project that offers a wealth of bilingual, research-based information, activities, and advice for educators and families of English language learners (ELLs). Colorín Colorado is an educational service of WETA, the flagship public broadcasting station in the nation’s capital, and receives major funding from the American Federation of Teachers and National Education Association. © Copyright 2023 WETA Public Broadcasting.

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Abstract

Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children. The routine Paediatric clinic or Family Medicine/General Practitioner surgery presents with several desirable characteristics that make them ideal for providing effective mental health services to children and adolescents. DSM-5 and ICD-10 are the universally accepted standard criteria for the classification of mental and behaviour disorders in childhood and adults. The age and gender prevalence estimation of various childhood behavioural disorders are variable and difficult to compare worldwide. A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, EMBASE, Database of Abstracts and Reviews, and the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including "childhood", "behaviour", "disorders" or "problems". Childhood behaviour and emotional problems with their related disorders have significant negative impacts on the individual, the family and the society. They are commonly associated with poor academic, occupational, and psychosocial functioning. It is important for all healthcare professionals, especially the Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in children and adolescents.

Keywords: Childhood behavioural disorders, Disruptive behaviour disorder, Conduct disorder, Challenging behaviour, Emotional disorder, Anxiety, Depression, Autism, Pervasive developmental disorders

Core tip: Mental health problems in children and young people (CYP) include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either "internalizing" or "externalizing". The routine Paediatric or General Practitioner clinic present with several desirable characteristics that make them ideal for providing effective mental health services to CYP. Childhood mental health disorders have significant negative impacts on the individual, the family and the society. It is particularly important for all Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in CYP.

INTRODUCTION

Mental health disorders (MHD) are very common in childhood and they include emotional-obsessive-compulsive disorder (OCD), anxiety, depression, disruptive (oppositional defiance disorder (ODD), conduct disorder (CD), attention deficit hyperactive disorder (ADHD) or developmental (speech/language delay, intellectual disability) disorders or pervasive (autistic spectrum) disorders[ 1]. Emotional and behavioural problems (EBP) or disorders (EBD) can also be classified as either "internalizing" (emotional disorders such as depression and anxiety) or "externalizing" (disruptive behaviours such as ADHD and CD). The terminologies of "problems" and "disorders" are interchangeably used throughout this article.

While low-intensity naughty, defiant and impulsive behaviour from time to time, losing one's temper, destruction of property, and deceitfulness/stealing in the preschool children are regarded as normal, extremely difficult and challenging behaviours outside the norm for the age and level of development, such as unpredictable, prolonged, and/or destructive tantrums and severe outbursts of temper loss are recognized as behaviour disorders. Community studies have identified that more than 80% of pre-schoolers have mild tantrums sometimes but a smaller proportion, less than 10% will have daily tantrums, regarded as normative misbehaviours at this age[ 2, 3]. Challenging behaviours and emotional difficulties are more likely to be recognized as "problems" rather than "disorders" during the first 2 years of life[ 4].

Emotional problems, such as anxiety, depression and post-traumatic stress disorder (PTSD) tend to occur in later childhood. They are often difficult to be recognised early by the parents or other carers as many children have not developed appropriate vocabulary and comprehension to express their emotions intelligibly[ 5]. Many clinicians and carers also find it difficult to distinguish between developmentally normal emotions ( e.g., fears, crying) from the severe and prolonged emotional distresses that should be regarded as disorders[ 6]. Emotional problems including disordered eating behaviour and low self-image are often associated with chronic medical disorders such as atopic dermatitis, obesity, diabetes and asthma, which lead to poor quality of life[ 7- 9].

Identification and management of mental health problems in primary care settings such as routine Paediatric clinic or Family Medicine/General Practitioner surgery are cost-effective because of their several desirable characteristics that make it acceptable to children and young people (CYP) ( e.g., no stigma, in local setting, and familiar providers). Several models to improve the delivery of mental health services in the Paediatric/Primary care settings have been recommended and evaluated recently, including coordination with external specialists, joint consultations, improved Mental Health training and more integrated on-site intervention with specialist collaboration[ 10, 11].

A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including "childhood", "behaviour", "disorders" or "problems".

CLINICAL PRESENTATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Various definitions for a wide range of childhood behavioural disorders are being used. The DSM-5[ 12] offers the commonest universally accepted standard criteria for the classification of mental and behaviour disorders. The ICD-10 is the alternative classification standard[ 13].

Challenging behaviours

Any abnormal pattern of behaviour which is above the expected norm for age and level of development can be described as "challenging behaviour". It has been defined as: "Culturally abnormal behaviour (s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy or behaviour which is likely to seriously limit or deny access to and use of ordinary community facilities"[ 14]. They can include self-injury, physical or verbal aggression, non-compliance, disruption of the environment, inappropriate vocalizations, and various stereotypies. These behaviours can impede learning, restrict access to normal activities and social opportunities, and require a considerable amount of both manpower and financial resources to manage effectively.

Many instances of challenging behaviour can be interpreted as ineffective coping strategies for a young person, with or without learning disability (LD) or impaired social and communication skills, trying to control what is going on around them. Young people with various disabilities, including LD, Autism, and other acquired neuro-behavioural disorders such as brain damage and post-infectious phenomena, may also use challenging behaviour for specific purposes, for example, for sensory stimulation, gaining attention of carers, avoiding demands or to express their limited communication skills[ 15]. People who have a diverse range of neurodevelopmental disorders are more likely to develop challenging behaviours[ 16].

Some environmental factors have been identified which are likely to increase the risk of challenging behaviour, including places offering limited opportunities for making choices, social interaction or meaningful occupation. Other adverse environments are characterized by limited sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect and abuse, and where physical health needs and pain are not promptly identified. For example, the rates of challenging behaviour in teenagers and people in their early 20s is 30%-40% in hospital settings, compared to 5% to 15% among children attending schools for those with severe LD[ 15].

Aggression is a common, yet complex, challenging behaviour, and a frequent indication for referral to child and adolescent Psychiatrists. It commonly begins in childhood, with more than 58% of preschool children demonstrating some aggressive behaviour[ 17]. Aggression has been linked to several risk factors, including individual temperaments; the effects of disturbed family dynamics; poor parenting practices; exposure to violence and the influence of attachment disorders. No single factor is sufficient to explain the development of aggressive behaviour[ 18]. Aggression is commonly diagnosed in association with other mental health problems including ADHD, CD, ODD, depression, head injury, mental retardation, autism, bipolar disorder, PTSD, or dyslexia[ 19].

Disruptive behaviour problems

Disruptive behaviour problems (DBP) include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). They constitute the commonest EBPs among CYP. Recent evidence suggests that DBPs should be regarded as a multidimensional phenotype rather than comprising distinct subgroups[ 20].

ADHD is the commonest neuro-behavioural disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries[ 21]. ADHD is characterized by levels of hyperactivity, impulsivity and inattention that are disproportionately excessive for the child's age and development[ 12]. The ICD-10[ 13] does not use the term "ADHD" but "hyperkinetic disorder", which is equivalent to severe ADHD. DSM-5 distinguishes between three subtypes of the disorder: predominantly hyperactive/impulsive, predominantly inattentive and combined types (Table ).

Table 1

Criteria

6 of 9 inattentive symptoms

6 of 9 hyperactivity/ impulsivity symptoms

Both criteria for (1) and (2)

Details

Fails to pay close attention to details or makes careless mistakes

Squirms and fidgets

Has difficulty sustaining attention

Can't stay seated

Does not appear to listen

Runs/climbs excessively

Struggles to follow through on instructions

Can't play/work quietly

Has difficulty with organization

"On the go"/"driven by a motor"

Avoids or dislikes tasks requiring a lot of thinking

Blurts out answers

Loses things

Is unable to wait for his turn

Is easily distracted

Intrudes/interrupts others

Talks excessively

Other criteria

Onset before age of 12, lasting more than 6 mo, symptoms pervasive in 2 or more settings, causing significant impairment of daily functioning o development

CD refers to severe behaviour problems (Table ), characterized by repetitive and persistent manifestations of serious aggressive or non-aggressive behaviours against people, animals or property such as being defiant, belligerent, destructive, threatening, physically cruel, deceitful, disobedient or dishonest, excessive fighting or bullying, fire-setting, stealing, repeated lying, intentional injury, forced sexual activity and frequent school truancy[ 13, 22]. Children with CD often have trouble understanding how other people think, sometimes described as being callous-unemotional. They may falsely misinterpret the intentions of other people as being mean. They may have immature language skills, lack the appropriate social skills to establish and maintain friendships, which aggravates their feelings of sadness, frustration and anger[ 12].

Table 2

A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 mo as evidenced by at least four out of 8 symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 mo from any of the categories below, with at least one criterion present in the past 6 mo

Aggression to people and animals: (1) Often bullies, threatens, or intimidates others; (2) Often initiates physical fights; (3) Has used a weapon that can cause serious physical harm to others ( e.g., a bat, brick, broken bottle, knife, gun); (4) Has been physically cruel to people; (5) Has been physically cruel to animals; (6) Has stolen while confronting a victim ( e.g., mugging, purse snatching, extortion, armed robbery); (7) Has forced someone into sexual activity

Angry/irritable mood: (1) Often loses temper; (2) Is often touchy or easily annoyed; (3) Is often angry and resentful

Argumentative/defiant behavior: (4) Often argues with authority figures or, for children and adolescents, with adults; (5) Often actively defies or refuses to comply with requests from authority figures or with rules; (6) Often deliberately annoys others; (7) Often blames others for his or her mistakes or misbehavior

Destruction of property: (8) Has deliberately engaged in fire setting with the intention of causing serious damage; (9) Has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft: (10) Has broken into someone else's house, building, or car; (11) Often lies to obtain goods or favors or to avoid obligations ( i.e., "cons" others); (12) Has stolen items of nontrivial value without confronting a victim ( e.g., shoplifting, but without breaking and entering; forgery)

Vindictiveness: (8) Has been spiteful or vindictive at least twice within the past 6 mo

Serious violations of rules: (13) Often stays out at night despite parental prohibitions, beginning before age 13 yr; (14) Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period; (15) Is often truant from school, beginning before age 13 yr

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic and the behavior should occur at least once per week for at least 6 mo

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning

The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context ( e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning

If the individual is age 18 yr or older, criteria are not met for antisocial personality disorder

Specify whether: Childhood-onset type (prior to age 10 yr); Adolescent-onset type or Unspecified onset

Specify if: With limited prosocial emotions: Lack of remorse or guilt; Callous-lack of empathy; Unconcerned about performance or Shallow or deficient affect

Specify current severity: Mild; Moderate or Severe

The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder

ICD-10

It also requires the presence of three symptoms from the list of 15 (above), and duration of at least 6 mo. There are four divisions of conduct disorder: Socialised conduct disorder, unsocialised conduct disorder, conduct disorders confined to the family context and oppositional defiant disorder

Specify current severity: Mild; moderate or severe based on number of settings with symptoms shown

CD is the commonest reason for CYP referral for psychological and psychiatric treatment. Roughly 50% of all CYP with a MHD have a CD[ 23]. About 30%-75% of children with CD also have ADHD and 50% of them will also meet criteria for at least one other disorder including Mood, Anxiety, PTSD, Substance abuse, ADHD, learning problems, or thought disorders[ 24, 25]. Majority of boys have an onset of CD before the age of 10 years, while girls tend to present mainly between 14 and 16 years of age[ 26]. Most CYP with CD grow out of this disorder, but a minority become more dissocial or aggressive and develop antisocial personality disorder as adults.

ODD is considered to be the mildest and commonest of the DBPs, with prevalence estimates of 6%-9% for pre-schoolers and boys outnumbering girls by at least two to one[ 27]. CYP with ODD are typically openly hostile, negativistic, defiant, uncooperative, and irritable. They lose their tempers easily and are mean and spiteful towards others (Table ). They are mostly defiant towards authority figures, but they may also be hostile to their siblings or peers. This pattern of adversarial behaviour significantly negatively impact on their lives at home, school, and wider society, and seriously impairs all their relationships[ 28].

Emotional problems

Emotional problems in later childhood include panic disorder, generalized anxiety disorder (GAD), separation anxiety, social phobia, specific phobias, OCD and depression. Mild to moderate anxiety is a normal emotional response to many stressful life situations. Anxiety is regarded as a disorder when it is disproportionately excessive in severity in comparison to the gravity of the triggering circumstances, leading to abnormal disruption of daily routines. Panic disorder is characterized by panic attacks untriggered by external stimuli. GAD is characterized by generalized worry across multiple life domains. Separation anxiety disorder is characterized by fear related to actual or anticipated separation from a caregiver. Social anxiety disorder (also called social phobia), is characterized by fear of social situations where peers may negatively evaluate the person[ 12].

Common manifestations of Anxiety disorders include physical symptoms such as increased heart rate, shortness of breath, sweating, trembling, shaking, chest pain, abdominal discomfort and nausea[ 29]. Other symptoms include worries about things before they happen, constant concerns about family, school, friends, or activities, repetitive, unwanted thoughts (obsessions) or actions (compulsions), fears of embarrassment or making mistakes, low self-esteem and lack of self-confidence[ 30].

Depression often occurs in children under stress, experiencing loss, or having attentional, learning, conduct or anxiety disorders and other chronic physical ailments. It also tends to run in families[ 7- 9, 31]. Symptoms of depression are diverse and protean, often mimicking other physical and neurodevelopmental problems, including low mood, frequent sadness, tearfulness, crying, decreased interest or pleasure in almost all activities; or inability to enjoy previously favourite activities, hopelessness, persistent boredom; low energy, social isolation, poor communication, low self-esteem and guilt, feelings of worthlessness, extreme sensitivity to rejection or failure, increased irritability, agitation, anger, or hostility, difficulty with relationships, frequent complaints of physical illnesses such as headaches and stomach aches, frequent absences from school or poor performance in school, poor concentration, a major change in eating and/or sleeping patterns, weight loss or gain when not dieting, talk of or efforts to run away from home, thoughts or expressions of suicide or self-destructive behaviour[ 31].

Disruptive mood dysregulation disorder (DMDD) is a childhood disorder characterized by a pervasively irritable or angry mood recently added to DSM-5. The symptoms include frequent episodes of severe temper tantrums or aggression (more than three episodes a week) in combination with persistently negative mood between episodes, lasting for more than 12 mo in multiple settings, beginning after 6 years of age but before the child is 10 years old[ 32].

Autistic spectrum and pervasive development disorder

The definition of Autism has evolved over the years and has been broadened over time. DSM-IV-TR[ 33] and the ICD-10[ 13] defined the diagnostic category of pervasive developmental disorders (PDD) as the umbrella terminology used for a group of five disorders characterized by pervasive "qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities" affecting "the individual's functioning in all situations". These included autism, asperger syndrome, childhood disintegrative disorder (CDD), pervasive developmental disorder not otherwise specified (PDD-NOS) and Rett syndrome.

Autism and Asperger Syndrome are the most widely recognised and clinically diagnosed among this group of disorders. CDD is a term used to describe children who have had a period of normal development for the first 2-3 years before a relatively acute onset of regression and emergence of autistic symptoms. PDD-NOS was used, particularly in the United States, to describe individuals who have autistic symptoms, but do not meet the full criteria for Autism or Asperger's Syndrome, denote a milder version of Autism, or to describe atypical autism symptoms emerging after 30 mo of age, and autistic individuals with other co-morbid disorders[ 34].

The category of PDD has been removed from DSM-5[ 12] and replaced with Autism Spectrum disorders (ASD). ASD (Table ) is diagnosed primarily from clinical judgment usually by a multidisciplinary team, with minimal support from diagnostic instruments. Most individuals who received diagnosis based on the DSM-IV should still maintain their diagnosis under DSM-5, with some studies confirming that 91% to 100% of children with PDD diagnoses from the DSM-IV retained their diagnosis under the ASD category using the new DSM-5[ 35, 36], while a systematic review has found a slight decrease in the rate of ASD with DSM-5[ 37].

Table 3

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by 3 out 3 of the following, currently or by history

Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions

Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication

Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two out of 4 of the following, currently or by history

Stereotyped or repetitive motor movements, use of objects, or speech ( e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)

Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior ( e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day)

Highly restricted, fixated interests that are abnormal in intensity or focus ( e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)

Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment ( e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

With or without accompanying intellectual impairment With or without accompanying language impairment

Associated with a known medical or genetic condition or environmental factor

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior

There are many intervention approaches and strategies, used alone or in combination, for supporting individuals with ASD. These interventions need to individualized and be closely tailored to the level of social and linguistic abilities, cultural background, family resources, learning style and degree of communication skills[ 38].

Various communication enhancement strategies have been designed to manage ASD[ 39], including augmentative and alternative communication (AAC), Facilitated Communication, computer-based instruction and video-based instruction (Table ). Several behavioural and psychological interventions (Table ) have also been used successfully in managing ASD children, including applied behaviour analysis (ABA) and functional communication training (FCT)[ 40].

Table 4

Augmentative and alternative communication

Supplements/replaces natural speech and/or writing with aided [ e.g., Picture Exchange Communication System, line drawings, Blissymbols, speech generating devices, and tangible objects] and/or unaided ( e.g., manual signs, gestures, and finger spelling) symbols

Effective in decreasing maladaptive or challenging behaviour such as aggression, self-injury and tantrums, promotes cognitive development and improves social communication

Scripts are often used to promote social interaction, initiate or sustain interaction

Table 5

ABA

Uses principles of learning theory to bring about meaningful and positive change in behaviour, to help individuals build a variety of skills ( e.g., communication, social skills, self-control, and self-monitoring) and help generalize these skills to other situations

Discrete trial training

A one-to-one instructional approach based on ABA to teach skills in small, incremental steps in a systematic, controlled fashion, documenting stepwise clearly identified antecedent and consequence ( e.g., reinforcement in the form of praise or tangible rewards) for desired behaviours

Anger management

Various strategies can be used to teach children how to recognise the signs of their growing frustration and learn a range of coping skills designed to defuse their anger and aggressive behaviour, teach them alternative ways to express anger, including relaxation techniques and stress management skills

Social (pragmatic) communication disorder

Social (pragmatic) communication disorder (SCD) is a new diagnosis included under Communication Disorders in the Neurodevelopmental Disorders section of the DSM-5[ 12]. It is characterized by persistent difficulties with using verbal and nonverbal communication for social purposes, which can interfere with interpersonal relationships, academic achievement and occupational performance, in the absence of restricted and repetitive interests and behaviours (Table ). Some authors consider that CYP with SCD present with similar but less severe restricted and repetitive interests and behaviours (RRIBs) characteristic of children on the autistic spectrum[ 41]. SCD is thought to occur more frequently in family members of individuals with autism[ 42].

Table 6

Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following

Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for social context

Impairment in the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language

Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction

Difficulties understanding what is not explicitly stated ( e.g., making inferences) and nonliteral or ambiguous meaning of language ( e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation)

The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination

The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities)

The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder

The term "pragmatic" has been used previously to describe the communication skills that are needed in normal social intercourse and the rules that govern routine interpersonal interactions, including ability to pay at least some attention to the other person in a conversation, take turns, not interrupting the other speaker unless there is a very good reason, match language and volume to the situation and the listener, etc[ 43]. Social and pragmatic deficit are known to also occur in diverse clinical populations, including ADHD, William's syndrome, CD, closed head injury and spina bifida/hydrocephalus[ 44].

Treatment modalities that have been used for supporting children with SCD are similar to those that have been used for several years in children with ASD (Tables and ). The first randomized controlled trial of social communication interventions designed primarily for children with SCD was reported in 2012[ 45]. The Social Communication Intervention Project ( http://www.psych-sci.manchester.ac.uk/scip/) targets development in social understanding and interaction, verbal and non-verbal pragmatic skills and language processing among children with SCD.

Pathological demand avoidance or Newson's syndrome

Pathological demand avoidance (PDA) or Newson's Syndrome is increasingly being accepted as part of the autism spectrum. PDA was first used in 2003[ 46] for describing some CYP with autistic symptoms who showed some challenging behaviours. It is characterized by exceptional levels of demand avoidance requested by others, due to high anxiety levels when the individuals feel that they are losing control. Avoidance strategies can range from simple refusal, distraction, giving excuses, delaying, arguing, suggesting alternatives and withdrawing into fantasy, to becoming physically incapacitated (with an explanation such as "my legs don't work") or selectively mute in many situations. If they feel threatened to comply, they may become verbally or physically aggressive, best described as a "panic attack", apparently intended to shock[ 46]. They tend to resort to "socially manipulative" behaviours. The outrageous acts and lack of concern for their behaviour appears to draw parallels with conduct problems (CP) and callous-unemotional traits (CUT), but reward-based techniques, effective with CP and CUT, seem not to work in people with PDA[ 47]. PDA is currently neither part of the DSM-5[ 12] nor the ICD-10[ 13].

Though demand avoidance is a common characteristic of CYP with ASD, it becomes pathological when the levels are disproportionately excessive, and normal daily activities and relationships are negatively impaired. Unlike typically autistic children, people with PDA tend to have much better social communication and interaction skills, and are consequently able to use these abilities to their advantage. They often have highly developed social mimicry and role play, sometimes becoming different characters or personas. The people with PDA appear to retain a keen awareness of how to "push people's buttons", suggesting a level of social insight when compared to CYP with Autism. On the other hand, children with PDA exhibit higher levels of emotional symptoms compared to those with ASD or CD. They also often experience excessive mood swings and impulsivity. While the prevalence of ASD in boys is more than four times higher compared to that of girls, the risk of developing PDA appears to be the same for both boys and girls[ 47].

O'Nions et al[ 48] have recently reported on the development and preliminary validation of the "Extreme Demand Avoidance Questionnaire" (EDA-Q), designed to quantify PDA traits based on parent-reported information, with good sensitivity (0.80) and specificity (0.85). EDA-Q is available online (https:// www.pdasociety.org.uk/resources/extreme-demand-avoidance-questionnaire).

PREVALENCE OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDHOOD

Accurate estimation of various childhood EBPs is difficult due to the problems of research methodologies relying on subjective assessments and varying definitions used. According to most studies, between 10% and 20% of CYP are affected annually by MHDs, and the rates are very similar across different racial and ethnic groups after controlling for income, resident status, education, and neighbourhood support. However, poverty and low socioeconomic status are risk factors that appear to increase the rate of MHDs across populations[ 49]. A 2001 WHO report [ 50] indicated the 6-mo prevalence rate for any MHD in CYP, up to age 17 years, to be 20.9%, with disruptive behaviour disorders (DBD) at 10.3%, second only to Anxiety disorders at 13%. About 5% of CYP in the general population suffer from Depression at any given point in time, which is more prevalent among girls (54%)[ 31, 51].

A previous British Child and Adolescent Mental Health (CAMH) survey carried out by the office of National Statistics (ONS) in 1999 and 2004, comprising 7977 interviews from parents, children and teachers, found the prevalence of MHD among CYP (aged 5-16 years) to be 6% for conduct problems, 4% for emotional problems (Depression or Anxiety) and 1.5% for Hyperkinetic disorders[ 51]. A similar survey in the United States between 2005 and 2011, the National survey of children's health (NSCH) involving 78042 households, indicated that 4.6% of CYP aged 3-17 years had a history DBD, with prevalence twice as high among boys as among girls (6.2% vs 3.0%), Anxiety (4.7%), Depression (3.9%), and ASD (1.1%)[ 24]. Reported prevalence rates for DMDD range from 0.8% to 3.3% with the highest rate in preschool children[ 52].

AETIOLOGY AND RISK FACTORS FOR CHILDREN'S BEHAVIOURAL AND EMOTIONAL DISORDERS

The exact causes of various childhood EBPs are unknown. Several studies have identified various combinations of genetic predisposition and adverse environmental factors that increase the risk of developing any of these disorders. These include perinatal, maternal, family, parenting, socio-economic and personal risk factors[ 53]. Table summarizes the evidence for various risk factors associated with development of childhood EBPs.

Table 7

Adverse family life

Dysfunctional families where domestic violence, poor parenting skills or substance abuse are a problem, lead to compromised psychological parental functioning, increased parental conflict, greater harsh, physical, and inconsistent discipline, less responsiveness to children's needs, and less supportive and involved parenting

Chronic stressors in children also lead to abnormal behaviour pattern of 'reactive responding' characterized by chronic vigilance, emotional reacting and sense of powerlessness

Physically aggressive behaviour rarely starts after age 5

Chronic irritability, temperament and anxiety symptoms before the age of 3 yr are predictive of later childhood anxiety, depression, oppositional defiant disorder and functional impairment

Children with intellectual disabilities are twice as likely to have behavioural disorders as normally developing children

Rate of challenging behaviour is 5% to 15% in schools for children with severe learning disabilities but is negligible in normal schools

Child's gender

Boys are much more likely than girls to suffer from several DBD while depression tends to predominantly affect more girls than boys

Unlike the male dominance in childhood ADHD and ASD, PDA tends to affect boys and girls equally

There is ample evidence supporting the genetic inheritability of many EBDs in CYP from their parents. From a prospective study of 209 parents along with their 331 biological offsprings, moderate inheritability ( r = 0.23, P < 0.001) between parental and offspring CD was found[ 74]. Anxiety seems to be transmissible from mothers to their preschool children, through both genetic factors and also through behaviour modelling and an anxious style of parenting[ 6].

A developmental taxonomy theory has been proposed by Patterson et al[ 75] to help understand the mechanisms underlying early onset and course of CPs. They described the vicious cycle of non-contingent parental responses to both prosocial and antisocial child behaviour leading to the inadvertent reinforcement of child behaviour problems. Parents' engagement in "coercive cycles" lead to children learning the functional value of their aversive behaviours ( e.g., physical aggression) for escape and avoidance from unwanted interactions, ultimately leading to the use of heightened aversive behaviours from both the child and parents to obtain social goals. This adverse child behavioural training combined with social rejection often lead to deviant peer affiliation and delinquency in adolescence[ 76].

NEUROBIOLOGY OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Conflicting findings have been reported in the brain structural variations among CYP with EBPs using magnetic resonance imaging (MRI) studies. The most consistently reported structural abnormalities associated with the DBD include reduced grey matter volume (GMV) in the amygdala, frontal cortex, temporal lobes, and the anterior insula, which is involved in part of a network related to empathic concern for others. Reduced GMV along the superior temporal sulcus has also been found, particularly in girls[ 77]. A decreased overall mean cortical thickness, thinning of the cingulate and prefrontal cortices; and decreased grey matter density in different brain regions have been reported[ 78].

Subtle neurobiological changes in different parts of the brain of CYP with EBPs have been reported from many research studies of functional scans. Peculiar brain changes have been found in the hypothalamus, inferior and superior parietal lobes, right amygdala and anterior insula[ 79]. Functional MRI studies have demonstrated less activation in the temporal cortex in violent adult offenders[ 80] and in antisocial and psychopathic individuals[ 81] compared to non-aggressive offenders.

Reduced basal Hypothalamic-Pituitary-Adrenal (HPA) axis activity has been reported in relation to childhood DBDs and exposure to abuse and neglect[ 82]. It has been hypothesized that high levels of prenatal testosterone exposure appears to be part of the complex aetiology of EBDs, providing possible explanation for the higher prevalence in males for DBDs, by increasing susceptibility to toxic perinatal environments such as exposure to maternal nicotine and alcohol in pregnancy[ 83].

COMPLICATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

EBDs in childhood, if left untreated, may have negative short-term and long-term effects on an individual's personal, educational, family and later professional life. CD has been linked to failure to complete schooling, attaining poor school achievement, poor interpersonal relationships, particularly family breakup and divorce, and experience of long-term unemployment. DBPs in parents have been linked to the abuse of their offspring, thereby increasing their risk of developing CD[ 84, 85]. Children presenting with hyperactivity-inattention behaviours are more likely to have a more favourable educational outcome compared with those with aggression or oppositional behaviours[ 86, 87].

A high prevalence of sleep disturbances is associated with various childhood EBPs. Sleep problems in early childhood is associated with increased prevalence of later Anxiety disorders and ODD[ 88, 89].

Several studies have confirmed a strong relationship between early childhood EBPs and poor future long-term physical and mental health outcomes. Chronic irritability in preschool children, CD and ODD in older children each may be predictive of any current and lifetime Anxiety, Depression and DBDs in later childhood, Mania, Schizophrenia, OCD, major depressive disorder and panic disorder[ 84, 90- 92]. Individuals on the adolescent-onset CP path often consume more tobacco and illegal drugs and engage more often in risky sexual behaviour, self-harm, and have increased risk of PTSD, than individuals without childhood conduct problems. They also frequently experience parenting difficulties, including over-reactivity, lax and inconsistent discipline, child physical punishment and lower levels of parental warmth and sensitivity[ 74, 84, 93, 94]. Approximately 40%-50% of CYP with CD are at the risk of developing antisocial personality disorder in adulthood[ 84]. Other potential complications include adverse mental and physical health outcomes, social justice system involvement including incarceration, substance use and abuse, alcoholism, homelessness, poverty and domestic abuse[ 95, 96].

An analysis of several Scandinavian studies up to the 1980s has shown higher rates of violent death, estimated to be almost five times higher than expected among young people with previous MHD, with common associated predictive factors including behavioural problems, school problems, and co-morbid alcohol or drug abuse and criminality[ 97].

ASSESSMENT AND DIAGNOSIS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Assessment through detailed history taking as well as observation of a child's behaviour are indispensable sources of information required for clinical diagnosis of EBPs[ 1]. This should include general medical, developmental, family, social, educational and emotional history. Physical and neurological examination should include assessment of vision, hearing, dysmorphic features, neuro-cutaneous stigmata, motor skills and cognitive assessment. Condition-specific and generic observer feedback on screening rating scales and questionnaires can be used to complement direct clinical observations.

There is no single gold-standard diagnostic tool available for the diagnosis of EBDs, which largely depends on the clinical skills of an integrated collaboration of multi-professional experts. Diagnosis relies on interpretation of subjective multi-source feedback from parents or carers, teachers, peers, professional or other observers provided through a number of psychometric questionnaires or screening tools[ 98]. Significant discrepancies between various respondents are quite common and clinical diagnosis cannot rely on the psychometric tools alone. There is evidence from the literature suggesting that parents have a tendency to over-report symptoms of ODD and CD in children compared to the teachers[ 99].

There are several screening tools that are used for assessing the risk of MHD among CYP. The tools help to identify which individuals would require more in-depth clinical interventions[ 100]. Supplement material shows a list of common Mental Health screening and assessment tools, summarizing their psychometric testing properties, cultural considerations and costs. The commonest behaviour screening tools include the Behavioral and Emotional Screening System (BESS; ages 3-18 years), the Behavior Assessment System for Children-2 nd edition, Pediatric Symptom Checklist (PSC), the Ages and Stages Questionnaire-Social Emotional (ASQ-SE, Ages 0 to 5 years) and the Achenbach System of Empirically Based Assessment (ASEBA), for children aged 1.5 years through adulthood.

MANAGEMENT OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDREN

Identification of appropriate treatment strategies depend on careful assessment of the prevailing symptoms, the family and caregiver's influences, wider socio-economic environment, the child's developmental level and physical health. It requires multi-level and multi-disciplinarian approaches that include professionals such as Psychologists, Psychiatrists, Behavioural Analysts, Nurses, Social care staff, Speech and language Therapists, Educational staff, Occupational Therapists, Physiotherapists, Paediatricians and Pharmacists. Use of pharmacotherapy is usually considered only in combination with psychological and other environmental interventions[ 15].

Holistic management strategies will include various combinations of several interventions such as child- and family-focused psychological strategies including Cognitive Behavioural Therapy (CBT), behavioural modification and social communication enhancement techniques, parenting skills training and psychopharmacology. These strategies can play significant roles in the management of children with a wide range of emotional, behavioural and social communication disorders. Effective alternative educational procedures also need to be implemented for the school age children and adolescents.

In early childhood, similar parenting strategies have been found useful to manage several apparently dissimilar EBPs ( e.g., infant feeding or sleeping problems, preschool tantrums, disruptive and various emotional problems). This may suggest there is a common maintaining mechanism, which is probably related to poor self-regulation skills, involving the ability to control impulses and expressions of emotion[ 101].

Several studies have confirmed the effectiveness of various psychological and pharmacologic therapies in the management of childhood EBDs. A meta-analysis of thirty-six controlled trials, involving 3042 children (mean sample age, 4.7 years), evaluating the effect of psychosocial treatments including parenting programmes on early DBPs, demonstrated large and sustained effects (Hedges'g = 0.82), with the largest effects for general externalizing symptoms and problems of oppositionality and non-compliance, and were weakest, relatively speaking, for problems of impulsivity and hyperactivity[ 102].

The treatment of CD among CYP with callous-unemotional traits is still at early stages of research. The mainstay of management for CDs includes individual behavioural or cognitive therapy, psychotherapy, family therapy and medications[ 103].

Parental skills training

Any challenging behaviour from CYP is likely to elicit persistent negative reactions from many parents, using ineffective controlling strategies and a decrease in positive responses[ 104]. There is evidence from published research that social-learning and behaviourally based parent training is capable of producing lasting improvement in children with callous-unemotional traits or CD, reducing externalizing problems for children with DBDs, leading to significant parent satisfaction, particularly when delivered early in childhood[ 84, 105- 107]. These interventions are typically delivered in a group format, one 2-h session per week for 4-18 wk, by trained leaders, with the focus on improving parenting skills to manage child behaviour, where parents typically learn to identify, define and observe problem behaviours in new ways, as well as learn strategies to prevent and respond to oppositional behaviour[ 108, 109].

Pooled estimates from a review of 37 randomised controlled studies identified a statistically significant improvement on several rating scales among children with CD up to the age of 18 years[ 23]. A previous meta-analysis of 24 studies confirmed that Parent-Child Interaction Therapy (PCIT) demonstrated significantly larger effect sizes for reducing negative parent behaviours, negative child behaviours, and caregiver reports of child behaviour problems than did most or all forms of Positive Parenting Programme (Triple P)[ 110]. A recent Cochrane review of 13 studies confirmed the efficacy and cost-effectiveness of group-based parenting interventions for alleviating child conduct problems, enhancing parental mental health and parenting skills, at least in the short term[ 111].

Differentiated educational strategies

Research has focused on identifying alternative educational strategies that can be used to improve learning opportunities for children presenting with challenging behaviours from various causes. Supportive school strategies for children with EBDs have traditionally focused on classroom management, social skills and anger management, but many researchers have more recently argued that academically-focused interventions may be most effective[ 112]. Traditional school policies of suspending or expelling children with EBD can be harmful to them. Researchers have developed "step-by-step" guidelines for teachers to guide them in the selection and implementation of evidence-based strategies that have been identified as effective in increasing levels of engagement and achievement by children with EBD, including peer-assisted learning procedures, class-wide peer tutoring, self-management interventions and tiered intervention systems - most notably Response to Intervention (RtI) and Positive Behavioural Interventions and Supports (PBIS)[ 113, 114].

There is increasing evidence to confirm that school-based interventions to address emerging DBPs produce significant reductions in both parent-, self- and teacher-reported internalizing and externalizing symptoms[ 114, 115].

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) is an educational system designed for the management of children with Autism and related communication disorders[ 116, 117]. There is some evidence that TEACCH programmes also lead to some improvements in motor skills and cognitive measures[ 117].

Best practice management strategies for children with PDA are known to differ from those with Autism. Specific guidelines for children with PDA[ 118] have been published by the British institute for Learning Disabilities. Educational support for CYP with PDA relies on highly individualized strategies that allows them to feel in control. They would respond much better to more indirect and negotiative approaches. For example, "I wonder how we might..." is likely to be more effective than "Now let's get on with your work"[ 118].

Child-focused psychological interventions

Cognitive behavioural therapy (CBT) is one of the most widely used non-pharmacologic treatments for individuals with emotional disorders, especially depression, and with individuals with behavioural problems including ASD[ 119]. CBT integrates a combination of both cognitive and behavioural learning principles to encourage desirable behaviour patterns. Research evidence from several trials[ 120] provide strong support for the effectiveness of cognitive-behavioural interventions among CYP with Anxiety and Depression. A recent study of child-focused CBT programme introduced at schools has shown that it produces significant improvement in disruptive behaviours among children[ 121].

Self-esteem building strategies can help many children with EBDs, who often experience repeated failures at school and in their interactions with others. These children could be encouraged to identify and excel in their particular talents (such as sports) to help build their self-esteem.

Behavioural modification and social communication enhancement strategies

Behavioural interventions and techniques are designed to reduce problem behaviours and teach functional alternative strategies using the basic principles of behaviour change. Most interventions are based on the principles of Applied Behaviour Analysis (ABA) which is grounded on behavioural learning theory. Table summarizes the common behavioural modification strategies for management of childhood EBDs.

Several strategies have been designed to help children acquire important social skills, such as how to have a conversation or play cooperatively with others, using social group settings and other platforms to teach peer interaction skills and promote socially appropriate behaviours and communication. There is ongoing research in the development of social communication treatment approaches[ 45]. Table summarizes common social communication enhancement strategies.

PSYCHOPHARMACOLOGY OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Medications are often prescribed as part of a comprehensive plan for the management of childhood EBDs that includes other therapies. The greatest level of evidence for pharmacotherapy of childhood EBDs is available for their use in the management of childhood and adolescent ADHD. There is less evidence of any efficacy for medications in the management of other DBPs including ODD and CD. Table lists the common classes of medications used in the management of childhood EBD.

Table 8

Atypical antipsychotics

Aripiprazole, Clozapine, Olanzapine, Quetiapine, Risperidone, Ziprasidone

Low white blood cell count (Agranulocytosis - with Clozapine), Diabetes, Lipid abnormalities, Weight gain, Other medication-specific side effects

Selective Serotonin Reuptake Inhibitors

Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Sertraline

Headache, Nervousness, Nausea Insomnia, Weight Loss

Serotonin-norepinephrine reuptake inhibitor

Venlafaxine, Levomilnacipran, Duloxetine, Desvenlafaxine

Other antidepressants

Bupropion, Mirtazepine, Trazodone

Stimulants

Methylphenidate Immediate Release and Modified Release ( e.g., Concerta XL, Equasym XL), Dexamfetamines Immediate Release and Modified Release ( e.g., Lisdexamfetamine)

ADHD

Decreased appetite/ weight loss, Sleep problems, Jitteriness, restless, Headaches, Dry mouth, Dysphoria, feeling sad, Anxiety, Increased heart rate, Dizziness

Blood pressure and heart rate will be checked before treatment and periodically during treatment. Child's height and weight are monitored

Non-stimulants

Atomoxetine

Alpha-2 agonists

Clonidine, Guanfacine

Drowsiness, Dizziness, Sleepiness

Antihistamines

Hydroxyzine HCl, Hydroxyzine, Pamoate, Alimemazine

Sleepiness, Drowsiness, Dizziness, Dry mouth, Confusion, Blurred Vision, Balance problems, Heartburn

Psychostimulants (including different formulations of Methylphenidate and Dexamphetamines) remain the primary medication of choice for management of ADHD in CYP for more than 60 years. About 75% to 80% of children with ADHD will benefit from the use of psychostimulants. Non-stimulant therapy with Atomoxetine or alpha 2-adrenergic agonists (Clonidine and Guanfacine) are also effective second-line alternative options[ 133]. A recent analysis of 16 randomized trials and one meta-analysis, involving 2668 participants with ADHD, showed that both stimulant and non-stimulant medications led to clinically significant reductions in core symptoms with consistently high effect sizes. The psychosocial treatments alone combining behavioural, cognitive behavioural and skills training techniques demonstrated small- to medium-sized improvements for parent-rated ADHD symptoms, co-occurring emotional or behavioural symptoms and interpersonal functioning[ 134].

The use of pharmacological treatments for symptoms of ASD is common but challenging, as there are no medications that directly treat the social and language impairments present in individuals with ASD. The medications used most frequently include antipsychotics ( e.g., Risperidone) and Selective Serotonin Reuptake Inhibitors (SSRI) to treat mood and repetitive behaviour problems, and stimulants and other medications used to treat ADHD-related symptoms. The evidence base is good for using atypical antipsychotics to treat challenging and repetitive behaviours, but they also have significant side effects[ 119, 135]. Naltrexone is an opioid antagonist that has been shown from a systematic review (involving 155 children from 10 studies) to significantly improve symptoms of self-injury, irritability, restlessness and hyperactivity in autistic children, with minimal side effects and generally good tolerance, although long-term data are lacking[ 136].

Medication use in preschool children for control of ASD and ADHD symptoms is still largely controversial. Stimulant medications for treatment of ADHD are not uniformly licensed for pre-schoolers as there is limited available research evidence to confirm efficacy and safety. Moreover, the effectiveness of parenting interventions in this age group are comparable to the effects of using stimulant drugs among the older CYP[ 137, 138].

Research evidence from two systematic reviews and 20 randomized controlled trials has recently documented the efficacy of psychopharmacology in the management of childhood DBP. Psychostimulants have have been shown to have a moderate-to-large effect on oppositional behaviour, conduct problems, and aggression in youths with ADHD, with and without ODD or CD, while Atomoxetine has only a small effect. There is very-low-quality evidence that Clonidine and Guanfacine have a small-to-moderate effect on oppositional behaviour and conduct problems in youths with ADHD[ 139].

Other behavioural disorders in children could also be successfully treated by medications. Traditional and the newer atypical antipsychotics can be used for OCD, Depression, aggression and mood instability[ 140].

The commonest antidepressants in used in children are the SSRI and Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) medications as they work well and usually have fewer side effects compared to the older Tricyclic Antidepressants. Antidepressants can be used in the management of Major Depression, Anxiety, Seasonal Affective Disorder (SAD), OCD, PTSD and Social Anxiety. They may also be used to treat enuresis and pre-menstrual syndrome[ 141].

CONCLUSION

Childhood EBDs have significant negative impacts on the society, in the form of direct behavioural consequences and costs, and on the individual, in the form of poor academic, occupational and psychosocial functioning and on the family. The costs to society include the trauma, disruption and psychological problems caused to the victims of crime or aggression in homes, schools and communities, together with the financial costs of services to treat the affected individuals, including youth justice services, courts, prison services, social services, foster homes, psychiatric services, accident and emergency services, alcohol and drug misuse services, in addition to unemployment and other required state benefits[ 23].

Prevention and management of EBD is not easy and it requires an integrated multidisciplinary effort by healthcare providers at different levels to be involved in the assessment, prevention and management of affected individuals, and also to provide social, economic and psycho-emotional support to the affected families.

There is increasing evidence base for several psychosocial interventions but less so for pharmacological treatment apart from the use of stimulants for ADHD. Preventive measures that have been researched for controlling the risk of childhood emotional and behaviour problems include breastfeeding[ 142], avoiding second-hand smoke exposure in non-smoker youths [ 143] and intensive parenting interventions.

Footnotes

Conflict-of-interest statement: The author declares no conflict of interest for this article.

Manuscript source: Invited manuscript

Peer-review started: October 29, 2017

First decision: November 20, 2017

Article in press: December 5, 2017

Specialty type: Pediatrics

Country of origin: United Kingdom

Peer-review report classification

Grade A (Excellent): A, A

Grade B (Very good): 0

Grade C (Good): 0

Grade D (Fair): D

Grade E (Poor): 0

P- Reviewer: Ho RCM, Yellanthoor RB, Yucel O S- Editor: Ji FF L- Editor: A E- Editor: Li RF

References

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21. National Institute for Health and Care Excellence (NICE) Attention deficit hyperactivity disorder: diagnosis and management. [updated 2008 Sept 24] Available from: https://www.nice.org.uk/guidance/cg72.

24. Centers for Disease Control and Prevention (CDC) Perou RH, Bitsko SJ, Blumberg P, Pastor RM, Ghandour JC, Gfoerer SL. Mental Health Surveillance among Children - United States 2005-2011. Morbidity and Mortality Weekly Report (MMWR) 2013;62(Suppl 2):1-35. Available from: [ https://www.cdc.gov/mmwr/pdf/other/su6202.pdf. [ PubMed] Google Scholar]

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Behavioural and emotional disorders in childhood: A brief overview for paediatricians

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Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children.

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This website serves as a resource for families and educators offering tools for training educators, finding quality education, access to journals and publications, information on educational standards, and advocacy information and tips. It is a one stop shop when beginning your journey into exceptionalities as it can lead you in the right direction to find any information you may be searching for!

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The importance of collaborating with families to promote participation in educational decision-making has been identified as one of the key principles of the Individuals with Disabilities Act (IDEA). IDEA provides for specific rights that enable parents to participate as equal members of the IEP team and to be involved in evaluation, placement, and special education and related service decisions. Family–professional partnerships have been defined as a relationship in which families (not just parents) and professionals agree to build on each other’s expertise and resources, as appropriate, for the purpose of making and implementing decisions that will directly benefit students and indirectly benefit other family members and professionals. Teachers should respectfully and effectively communicate considering the background, socioeconomic status, language, culture, and priorities of the family, and ensure families are informed about their rights as well as about special education processes.

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This game is wonderful for practicing math and ELA skills. It has a variety of resources for teachers to explore to help with anything from organization to behavior solutions. Teachers can assign different skills for students to work on or allow the games to adapt to the student's current knowledge.

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The American Association on Intellectual and Developmental Disabilities has a variety of resources available on their website. They have an overview of the history of ID as well as informational publications, educational opportunities and more.

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Intellectual Functioning

Intellectual functioning-also called intelligence-refers to general mental capacity, such as learning, reasoning, problem solving, and so on.

One way to measure intellectual functioning is an IQ test. Generally, an IQ test score of around 70 or as high as 75 indicates a significant limitation in intellectual functioning.

Adaptive Behavior

Adaptive behavior is the collection of conceptual, social, and practical skills that are learned and performed by people in their everyday lives.

Conceptual skills-language and literacy; money, time, and number concepts; and self-direction.
Social skills-interpersonal skills, social responsibility, self-esteem, gullibility, naïveté (i.e., wariness), social problem solving, and the ability to follow rules/obey laws and to avoid being victimized.

Practical skills-activities of daily living (personal care), occupational skills, healthcare, travel/transportation, schedules/routines, safety, use of money, use of the telephone.

Standardized tests can also determine limitations in adaptive behavior.

Age of Onset

The condition originates during the developmental period, which is defined as before the age of 22. Intellectual disability is one of several conditions known collectively as developmental disabilities.

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Intellectual functioning-also called intelligence-refers to general mental capacity, such as learning, reasoning, problem solving, and so on. One way to measure intellectual functioning is an IQ test. Generally, an IQ test score of around 70 or as high as 75 indicates a significant limitation in intellectual functioning.

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Learning disabilities are common. About 15% of the population in the United States has one or more.

This website gives information on what to look for when deciding if a child may have a learning disability as well as tips in providing the resources necessary for students with LD to thrive.

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Your chances of knowing someone with learning disabilities are very good. Did you know?

Children with learning disabilities begin school expecting to learn and be successful. If your child is having difficulty in school, she may learn differently from other kids. Parents are often the first to notice that "something doesn't seem right." But sometimes knowing what to do and where to find help can be confusing.

Children grow up to be adults and unfortunately learning disabilities cannot be cured or fixed; it's a life long issue. And some individuals don't realize they have learning disabilities until they are adults. With the right support and interventions, however, children and adults with learning disabilities can succeed in school and life. Recognizing, accepting and understanding your learning disability are the first steps to success.

Defining Learning Disabilities

Learning disabilities are due to genetic and/or neurobiological factors that alter brain functioning in a manner which affects one or more cognitive processes related to learning. The majority of children K-12 who receive special education are served under the specific learning disability (SLD) category. Approximately 80% of those children have an SLD in reading.

Learning disabilities range in severity and may interfere with the acquisition and development of one or more of the following:

oral language (e.g., listening, speaking, understanding);

reading (e.g., phonetic knowledge, decoding, reading fluency, word recognition, and comprehension);

written language (e.g., spelling, writing fluency, and written expression); and

mathematics (e.g., number sense, computation, math fact fluency, and problem solving).

Learning disabilities often run in families. They should not be confused with other disabilities such as intellectual disabilities, autism, deafness, blindness, and behavioral disorders. None of these conditions are learning disabilities. Because learning disabilities cannot be seen, they often go undetected. Recognizing a learning disability is even more difficult because the severity and characteristics vary. Learn more about what a learning disability is here.

Learning Disabilities

Related Disorders

Don't Delay

If you suspect that your child's learning difficulties may require special assistance, please do not delay in finding information and support. The sooner you move forward the better your child's chances for reaching his full potential.

Maybe you have wondered if you are overreacting, or if the situation will work itself out over time. The truth is, you know your child better than anybody else. And regardless of who may tell you that it's a "phase" or "nothing to worry about," only you know how much your child dreads Monday morning. You have watched the impact of his daily struggles on his self-confidence. Deep down, you know something isn't right.

The good news is there are things you can do. In fact, the only "wrong" thing to do is to do nothing. If you wait to seek help for your child, frustration and a sense of failure will continue to erode your child's self-esteem, while the window of time for meaningful intervention narrows. If you suspect you or your child has a learning problem, don't delay in seeking help and taking action!

Parents can help children with learning disabilities achieve success by encouraging their strengths, knowing their weaknesses, understanding the educational system, working with professionals and learning about strategies for dealing with specific difficulties.

Since you are one of the best observers of your child's development, you will be able to recognize potential problems early. But, in order to spot problems early, you'll need to know the warning signs!

Seeing the Signs

There may be a number of reasons why your child is having a hard time. But what you are seeing could also indicate a learning disability. This does not mean your child is "slow" or less intelligent than your child's peers. Their brain is simply wired differently for learning and your child needs to adapt strategies that make the most of your child's abilities. The earliest possible intervention is critical to your child's success in school.

Learn to recognize the signs of a potential learning disability. If you have observed several of these signs in your child, consider the possibility of a learning disability.

It is normal for parents to observe one of these signs in their children from time to time. But if your child consistently exhibits several of these signs, it is important for you to take action to get him the help that he needs.

Pre-School
Have you noticed that your child has:

pronunciation problems

difficulty finding the right word

difficulty making rhymes

trouble learning numbers, alphabet, days of the week, colors and shapes

trouble concentrating

trouble interacting with peers

difficulty following directions or learning routines

difficulty controlling pencil, crayons, scissors

Grades K-4
Does your child:

have trouble learning the connection between letters and sounds

confuse basic words (run, eat, want)

make consistent reading and spelling errors including letter reversals (b/d, inversions (m/w), transpositions (felt/left), and substitutions (house/home)

experience difficulty learning basic math concepts

have trouble learning about time

take a long time to learn new skills

have trouble remembering facts

Grades 5-8
Is your child having difficulty:

with reading comprehension or math skills

with letter sequences (soiled for solid, left for felt)

with prefixes, suffixes, root words and other spelling strategies

organizing his/her bedroom, notebook, papers, and desk

keeping up with papers or assignments

with handwriting

with time management

understanding oral discussions and expressing thoughts aloud

High School and Adults
Is your child having difficulty:

spelling the same word differently in a single document

taking on reading or writing task

with open-ended questions on tests

with memory skills

adapting skills from one setting to another

with a slow work pace

grasping abstract concepts

focusing on details

misreading information

It is never too early to seek help for your child, but waiting too long could be harmful. If you see several of these signs over a period of time, consider the possibility of a learning disability. Knowing what a difference early help can make will help you lose your fear and take the next steps to getting help for your child!

Losing the Fear

It can be hard to acknowledge that your child is having difficulty in school let alone a potential learning disability. Perhaps you have worried that by calling attention to your child's learning problems he might be labeled "slow" or a "discipline problem," or sent to the wrong class.

What many parents and their children don't realize is that most kids with learning disabilities are just as intelligent as their peers. Their brains are simply wired differently for learning. They need to be taught in ways that are best adapted to how they process information.

And, scientists and researchers are learning more every day about learning disabilities. Their research provides hope and direction. From research we now know that:

Receiving help in the early grades greatly improves the chances for these kids to adapt learning strategies that will enable them to succeed in school. Among children who struggle with basic reading and language skills the most common learning problems 75% of those who do not receive help until the third grade will struggle with reading throughout their lives. But if those same kids receive appropriate help by the first grade, fully 90% of them will achieve normal reading ability.

By identifying what is causing your child's learning problems, you are one step closer to getting the help you both need. Your child can still have hope for a wonderful future if given the proper tools and learning strategies.

Getting Help

Though the process of getting help may seem overwhelming, finding support for your child and for yourself is easier than you might think. In most cases, talking with your child's teacher should be the first step.

Share your concerns with your child's teacher and ask about her observations of your child's performance, interactions with his peers, etc. Together you may come up with strategies to try in the classroom and at home to support your child's learning needs.

Most teachers want to help and will work with you to try and meet your child's learning needs. If you feel it may be necessary, your child's teacher can also help to arrange a full evaluation of how well your child is performing in school.

Also, be sure your child has had a thorough physical examination by a medical doctor or nurse practitioner to assure that there are no major health problems that might be interfering with learning. Be especially certain to have eyes and ears checked for correctable vision and hearing problems.

Useful tips when meeting with your child's teacher

Write down any questions you have before entering the meeting. These questions should be geared toward gaining greater understanding of your child's problems and how to address them in the school setting.

Review records of previous conferences and educational decisions before attending conferences and be prepared to share them with school personnel.

Be ready to share your observations about your child's academic progress. Listen well and participate in the meeting with an open mind, knowing that you are all there to facilitate school success for your child.

Keep careful and detailed notes at the meeting. Don't be afraid to ask for clarification if you do not understand something that was said.

Ask for information on the curriculum and how students' work is evaluated, so that you know how to gauge your child's progress.

Appreciate that teachers must juggle the unique needs of many students. Work with school personnel to come up with strategies that are practical, given the realities of the school and the classroom.

Acknowledge that the major motivation for success must come from your child. Work with teachers to keep expectations high and to nurture an enthusiasm for learning.

Agree on how you and the teacher will make follow-up contacts to review progress.

Now that you know the first step to take, there are several more steps you can take to find support and make sure your child gets the right kind of help!

Take Action

The most important thing you must determine is the source of your child's learning problem. Time is of the essence if your child does, in fact, have a learning disability, "wait and see" almost always means "wait and fail." If you act early, you will gain the peace of mind that comes with knowing what is causing your child's learning difficulties. You also will be helping to ensure that she overcomes her struggles and enjoys success in school.

In addition to working with your child's teacher, here are additional steps you should take:

Collect information on your child's performance. Keep notes, copies of your child's assignments, and any correspondence from your child's school regarding your child's performance in a folder so that you can document any patterns. At the same time, it is also important to observe your child's strengths and interests, encouraging and rewarding your child for the things he does well.

Monitor your child's progress. Watch your child's progress to be sure that your child's needs are being met. Keep your child's education folder up to date, adding new samples of schoolwork and test results. If your child is not making progress, discuss your observations with school personnel and work together to make changes. You may need to ask for a comprehensive educational evaluation to determine if your child may be eligible for special education services.

Learn as much as you can. The more you understand about the way your child learns and the help that's available, the better equipped you will be to help your child succeed. If it turns out that your child does have a learning disability, you also need to be aware of your rights and protections under the law.

Join with others who care. By joining with other parents and professionals you can increase awareness of the issue, dispel popular misconceptions, help establish educational systems that provide for the needs of children with learning disabilities, and get support for yourself. Locate the LDA Chapter near you today!

Enjoy your child and encourage an interest in learning. You can encourage your child's interests outside the classroom and create a home environment that supports the way your child learns. Rather than focusing solely on your child's deficiencies, emphasize and reward your child's strengths.
Visit our Parents area for additional information on how to help your child and help yourself! * National Center for Education Statistics
**National Adult Literacy and Learning Disabilities Center
***National Institutes of Health

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Children with learning disabilities begin school expecting to learn and be successful. If your child is having difficulty in school, she may learn differently from other kids. Parents are often the first to notice that "something doesn't seem right." But sometimes knowing what to do and where to find help can be confusing.

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The Autism Speaks organization has several different types of resources on their website as they advocate for individuals with autism on many levels. You can get information on what autism is as well as ways to help those who have it. Autism has a wide spectrum of ability levels so strategies are not always one size fits all.

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Autism Speaks does not provide medical or legal advice or services. Rather, Autism Speaks provides general information about autism as a service to the community. The information provided on our website is not a recommendation, referral or endorsement of any resource, therapeutic method, or service provider and does not replace the advice of medical, legal or educational professionals. Autism Speaks has not validated and is not responsible for any information, events, or services provided by third parties. The views and opinions expressed in blogs on our website do not necessarily reflect the views of Autism Speaks.

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The American Speech-Language-Hearing Association's mission statement is "Making effective communication, a human right, accessible and achievable for all." That sums up the purpose of this page. It serves as a hub for accessing information directly related to the speech, language, or hearing issue that best describes an individuals current situation.

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Most children develop speech and language skills within a specific age range. A child who takes longer to learn a skill may have a problem.

Learn more about what to expect from your child from birth to 5 years old.

Speech-language pathologists, or SLPs, can help your child.

To find an SLP near you, visit ProFind.

Find out more about child speech and language...

Speech Disorders

Language Disorders

Early Detection

Medical and Developmental Conditions

Communication Options

Additional Resources

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Most children develop speech and language skills within a specific age range. A child who takes longer to learn a skill may have a problem. Learn more about what to expect from your child from birth to 5 years old. Speech-language pathologists, or SLPs, can help your child.

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The American Foundation for the Blind assists those struggling with visual impairments at any age. This page has resources from research and current news to advocates and technological assistance. It is a gateway to educating yourself as well as finding help if it is needed.

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The American Foundation for the Blind (AFB) understands that information is power. We are committed to connecting parents and guardians of children who are blind or visually impaired to life-changing information, resources, local services, and a vibrant and supportive community.

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The Division for Emotional and Behavioral Health strives to ensure that all students see success. This website gives information on characteristics of emotional and behavioral disabilities as well as information on specific disorders. There is information on events held by the DEBH, an informational video series, and information on how to become a part of the advocacy group.

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Council for Children with Behavioral Disorders

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Behavior Disorders: Definitions, Characteristics & Related Information

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Teaching and Certification in Special Education

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Teaching and Certification in Special Education

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The NYS Department of Education offers a comprehensive look at what the necessary requirements are for an individual wishing to teach in special education. This page gives information for all grade levels with links for additional information.

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Special Education Teaching Assignments and Certification

The following table shows the certification required for various types of special education teaching assignments. The types of teaching assignments are described on the Continuum of Special Education Services for School-Age Students with Disabilities webpage. Certification requirements are available on the Search Certification Requirements webpage.

Effective July 1, 2021, all special education teachers who teach one or more subject areas in a special class (self-contained class) in grades 7-12, with some or no students under alternate assessment, must either:

Please note that teachers who hold any of the special education certificates listed in the following table can teach students who are under alternate assessment at any grade level.

For questions about teaching assignments that are not answered in the following table, please contact the Office of Special Education at speced@nysed.gov. For questions about certification requirements, please contact the Office of Teaching Initiatives at tcert@nysed.gov.

A printable version can be found at: Special education teaching assignment by certificate
Severe or Multiple Disabilities Annotation
Special education teachers who hold the Severe or Multiple Disabilities Annotation can teach a special class where all students are under alternate assessment and all students have severe cognitive disabilities. Students can be at any developmental level (birth-grade 12).

Last Updated: October 26, 2023

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Special Education Teaching Assignments and Certification : Educator Resources:OTI:NYSED

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Reading and Literacy Skills in Special Education

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Reading and Literacy Skills in Special Education

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Reading Rockets is a great resource to use when you are looking for ideas to assist with any educational dilemma. This page, while aimed at distance learning, offers several strategies in teaching literacy that can be used to meet students where they are at academically.

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Literacy Instruction at a Distance: Strategies for Supporting Students with Learning Disabilities

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Explicit instruction in core literacy skills (phonemic awareness, phonics, fluency, vocabulary, and comprehension) combined with multisensory supports, are key to helping children with language-based learning disabilities thrive in a virtual learning environment. Try these ideas and online learning tools with your students.