Neelkamal Soares, MD

My 3-year-old son slaps and bites other children at preschool. His teacher says he is too hyperactive and needs medicine to calm him down. I think he's just a typical active boy. How do I know if he has a hyperactivity problem, and what can I do about his misbehavior so he isn't expelled from preschool?

Disruptive behaviors are some of the most frequent concerns raised by parents. The key is to provide families and childcare providers with the necessary strategies to assess and intervene in disruptive behaviors. Here, both a developmental-behavioral pediatrician (NS) and school psychologist (LP) provide answers from their respective viewpoints.

. When deciding whether a child has an underlying disorder, it is important to determine the duration of symptoms and how they affect the child and the preschool.

: Disruptive behaviors emerge in early childhood and can persist into later years; they often impair developmental functioning

 and are associated with later academic and social difficulties.

 Yet diagnosing behavior disorders in young children is controversial because of the difficulty in identifying behaviors as symptoms during a developmental period marked by variability and instability.

 Researchers are determining that aggression occurs naturally in young children as a part of development.

 However, just because it is normal for a preschool child to be extremely active and sometimes display impulsive hitting or biting does not mean it is acceptable. If the boy in this vignette is disrupting his own learning or that of other children, then the problem behaviors must be addressed as soon as possible.

Whether or not a behavior can be labeled as part of a disorder such as attention-deficit/hyperactivity disorder (ADHD), it always serves a function. Disruptive behaviors generally occur for a handful of reasons.

 One is to get attention-from adults, peers, or both. Another is to avoid something the person does not like, such as a difficult or boring task. A third is to access something tangible he or she wants, such as a toy. Finally, some behaviors serve a self-stimulatory or self-regulation purpose (rocking, thumb sucking). Depending on the context, the same behavior can occur for  different reasons. So in the above vignette, it is important to obtain information on when the child exhibits the disruptive behavior, and how other people respond, to determine its function.

 Generally, oppositional defiant disorder (ODD) is a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, and conduct disorder (CD) is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, for at least 12 months. If criteria for ODD or CD are not met, “disruptive behavior disorder, not otherwise specified” is considered.

ADHD must be diagnosed in at least 2 environments and affect functioning before age 7 years. Because a “lower age limit” is not defined in the 

Diagnostic & Statistical Manual, 4th edition

 (DSM-IV), ADHD is now being diagnosed in more preschoolers. The Preschool ADHD Treatment Study (PATS)

 determined that younger children do meet criteria for ADHD. Typically, the symptoms are more severe and there is a higher prevalence of comorbid conditions in younger children than in older children with ADHD. However, community clinicians may not have access to diagnostic instruments or may not feel confident separating typical developmental progression from ADHD behaviors. I suggest that these practitioners avoid diagnosing ADHD in preschoolers unless they are comfortable with the diagnostic and treatment protocols. Instead, they can refer to child psychiatrists, clinical child psychologists, or developmental-behavioral pediatricians, although in most communities access to these specialists is both time- and distance-limited.

. Once function is determined, one can generate strategies to help the young child learn an alternative acceptable behavior that serves the same function as the original behavior.

 A child hitting during play to get to the toys he wants can be taught how to request toys from other children and how to handle himself if they refuse. This is “social skills training.” A child who hits to get what she wants because she is not able to communicate as a result of language delay, sees others react immediately to aggressive behavior. For her, hitting becomes a means of communication. Here, it is important to teach her functional communication. In addition to teaching and reinforcing appropriate behavior, adults and even peers should stop giving the child what he wants when he hits or bites. This process, called “extinction,” helps the child understand that disruptive behaviors are no longer effective and that requesting appropriately is more effective.

Successful implementation of self-control and problem-solving skills has been linked to greater success in the child's interaction with peers.

 A community behavior therapist or psychologist can guide a parent or teacher on how to teach a child these skills (

). It is also important that all adults working with a child communicate with each other on the strategies being taught. This helps reinforce the strategies and reduce any confusion or contradiction.

 Studies have shown that stimulant medications are effective in preschoolers but cause more adverse effects in younger children than in older children.

 The a2-agonists clonidine and guanfacine

 are increasingly being used off-label for impulsivity, hyperactivity, and aggression. The clinician should use caution when prescribing these medications because of the risk of cardiac adverse effects, particularly rebound hypertension that occurs with erratic dosing. Sedation may also worsen behaviors, because a young child tries to fight somnolence and becomes more irritable. Atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole) are increasingly used to treat disruptive behaviors.

 However, their use in preschoolers has not been studied. The adverse effects of these agents range from irreversible tardive dyskinesia and potentially lethal neuroleptic malignant syndrome to the more common weight gain, sedation, and elevation of cholesterol and blood sugar levels that requires frequent metabolic monitoring. I caution primary practitioners against using atypical antipsychotics in preschoolers and suggest referral to a specialist for guidance.

 It is important to first determine whether the child is in a public or private preschool setting.

 The Individuals With Disabilities Education Act (IDEA) requires public schools to provide children and youths from age 3 to 21 years with free and appropriate education. If a child demonstrates interfering behaviors in the preschool classroom, school personnel must devise interventions to address these behaviors. If the boy in this vignette is in a public preschool program, the mother should ask what strategies have been implemented. If the teacher or mother suspects that the behavior may require more specialized management, then he or she can request an evaluation from the preschool director, district special education director, or early childhood special education coordinator. This will likely be a functional behavior assessment whose data will be used to develop a behavior intervention plan, which highlights the target behaviors and specific strategies individualized to the particular child's behavior.

 IDEA does not directly apply to day-care centers and private preschools. However, the parent can engage the school district of residence to evaluate the child or can ask the state's preschool grant coordinator for information on how to access services. A list of coordinators for each state is found at 

. While a private setting certainly has the right to expel a child for a reasonable concern, it is hoped that they would prefer to work with the family toward a more suitable alternative, keeping the child in preschool, with appropriate interventions. Also, recent IDEA Reauthorization forbids school personnel from making school attendance, evaluations, or services dependent on a child taking psychotropic medication. So a reasonable response from the parent to the teacher in this case is to decline the option of medication and instead request an evaluation.

Community mental health agencies, community and educational psychologists, and clinical social workers who understand the specific needs of families in the context of available resources can also help. A list of suggested readings on disruptive behavior for parents and educators is provided in 

, Michael C. Cassano, MD, and colleagues discussed 

effective family and educational interventions for children with disruptive behavior

1. Wakschlage LS, Briggs-Gowan MJ, Carter AS, et al. A developmental framework for distinguishing disruptive behavior from normative misbehavior in preschool children. 

2. Agostin TM, Bain SK. Predicting early school success with developmental and social skills screeners. 

Behavior Problems in Preschool Children: Clinical and Developmental Issues

. 2nd ed. New York: Guilford Press; 2002.

4. Alink LR, Mesman J, van Zeijl J, et al. The early childhood aggression curve: development of physical aggression in 10- to 50-month-old children. 

5. Iwata BA, Vollmer TR, Zarcone JR. The experimental (functional) analysis of behavior disorders: Methodology, applications and limitations. In: Repp AC, Singh NN, eds. 

Perspectives on the Use of Nonaversive and Aversive Interventions for Persons With Developmental Disabilities

. Sycamore, IL: Sycamore Publishing Co; 1990:301-330.

6. Posner K, Melvin GA, Murray DW, et al. Clinical presentation of attention-deficit/hyperactivity disorder in preschool children: the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS). 

7. Mayeux L, Cillessen AH. Development of social problem solving in early childhood: stability, change, and associations with social competence. 

8. Wigal T, Greenhill L, Chuang S, et al. Safety and tolerability of methylphenidate in preschool children with ADHD. 

10. Haas M, Karcher K, Pandina GJ. Treating disruptive behavior disorders with risperidone: a 1-year, open-label safety study in children and adolescents. 

Articles

My 3-year-old son slaps and bites other children at preschool. His teacher says he is too hyperactive and needs medicine to calm him down.

Child Near Expulsion From Preschool: Is Medication the Answer?

ABSTRACT: Pediatricians can help guide the families of children with an autism spectrum disorder through the maze of interventions, toward the goal of optimizing these children's potential for a productive, independent, brighter future. This requires an awareness of local resources, smart use of published information, partnership with educational and therapeutic agencies as well as families, and the willingness to be an advocate and provide a medical home. Keeping track of their child's progress in school and knowing when to engage health insurance and Medicaid can also benefit these families. Connecting families to regional institutions' training programs may help reduce the cost of researchbased interventions.

With the prevalence of autism spectrum disorders (ASDs) in the United States now estimated to be about 1 in 110 children,

 pediatricians may have an influx of children with an ASD in their practice. The guidelines from the American Academy of Pediatrics (AAP) emphasize the need for early identification and prompt referral of children in whom an ASD is suspected.

 Even after diagnosis, the families of children with an ASD often return to the medical home for routine care-and for advice.

These families face many hurdles when seeking care for their child. A common obstacle is the paucity of subspecialists (developmental-behavioral pediatricians, child psychiatrists, and child neurologists) in many communities. This makes obtaining necessary services, such as screening for comorbid medical and psychiatric conditions, difficult. Although the AAP and other autism advocacy organizations provide many resources on ASDs for families, access to evidence-based therapies may be limited because of a lack of trained providers on a local level or because of larger legislative and reimbursement issues. In addition, given the difficulties in accessing evidencebased therapies, some families may choose to seek complementary and alternative medicine (CAM) that may be unsupported by scientific research. Consequently, pediatricians are likely to feel helpless in advocating for the families of their patients with ASDs.

In this article, we present 9 strategies pediatricians can use to help the families of children with an ASD navigate the maze of therapeutic options.

Debrief the family after diagnosis to reinforce the management plan

Before meeting with the parents of a child with a newly diagnosed ASD, you must first understand your role in the management plan. Ideally, this should be clear after reviewing the medical and therapeutic recommendations for the child in the report from the subspecialist who made the diagnosis. However, do not assume that the subspecialist has initiated the various processes specified in the report's recommendations. If you cannot glean from the report what your role is, a call to the subspecialist's office can help clarify which processes were initiated and what is expected of you. This prevents duplication of referrals and resources and ensures that the child begins appropriate therapy.

The parents of a child with a newly diagnosed ASD often experience grief and sometimes relief that their long-held suspicions were valid. When you meet with them, it is important to discuss their interpretation of the subspecialist's diagnosis and to determine what they believe the next steps are and what steps they may have already taken. It is not surprising that some families are so overwhelmed by the diagnosis of autism that they do not completely recall what is expected of them in the management plan. The meeting helps reinforce the plan, provides an empathic sounding board, and helps determine the family's priorities going forward.

Sort through the resources on ASDs and create handouts for parents

The AAP's Children's Health Topics Web site provides a wide array of resources-both academycreated and external-to help answer questions from the families of children with an ASD.

 In addition to the must-have policy statements, the Web site has links to family and community resources and professional resources, such as webinars from experts in the field. The AAP's 

Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians

 (available for sale through its bookstore) provides a wealth of family handouts and professional fact sheets on many topics, including therapeutic interventions across the life span.

It is helpful to sort all your ASD-related resources into 2 types: print copies you can give to families and electronic files you can use for future reference or for ongoing professional development. 

 is a good example of a starter resource handout for parents. This handout lists resources from several organizations; most notably the Family Services 

 from Autism Speaks (which can be downloaded for free). 

 provides online resources for well-known research-based interventions. In addition to comprehensive intervention programs, many children with an ASD require assistance from related services to help improve speech, language, and social skills as well as sensorimotor functioning. 

As thorough as the resources in the tables are, they are even better when modified to highlight what is available in your particular community. The AAP Toolkit has templates that can be edited to list local professional, therapeutic, and family support resources. Information on these services can be obtained from your local AAP chapter or subspecialist or from the Web sites of Autism Speaks (under Community, Family Services) and the Autism Society of America (under Autism Community, Autism Society Local Chapters).

With input from families and other providers, periodically review your customized resource list to make sure it is up to date. This list typically includes subspecialist physicians, community mental health agencies and psychologists, early intervention and school special education programs, therapeutic providers (occupational therapy, physical therapy, speech, behavior analysts), family resource and advocacy centers, and family support groups, to name a few.

Know your "alphabet soup" of research-based interventions and CAM therapies

Many interventions for children with ASDs have been developed over the years; these have evolved from different philosophies. It is important to understand the conceptual differences behind the various approaches.

Table 2 – Research-based interventions for children with ASDs 	


 	A video describing ABA is available at
 	

http://www.youtube.com/watch?v=iyCx-OLzgJw



 	To find board-certified behavior analysts in your area, visit the Behavior Analyst Certification Board Web site:
 	


 	For information and resources on DTT, visit
 	

http://autismpdc.fpg.unc.edu/content/discrete-trial-training-0

http://www.autisminternetmodules.org/mod_intro.php?mod_id=41



 	Please note: you will need to create a username and password to access the training materials 	


 	For an introduction to and more resources for VB, visit
 	

http://www.autismspeaks.org/treatment/verbal_therapy.php

Developmental Individual Difference Relationship (DIR)/Floortime Model


 	For information and a video demonstration of this model, visit
 	

http://www.icdl.com/dirFloortime/overview/index.shtml


 	Information on this model is available at
 	

http://www.autismspeaks.org/docs/d_200911_ESDM.pdf

Social Communication, Emotional Regulation, and Transactional Supports (SCERTS)


 	For a video describing this model, visit
 	

Training and Education of Autistic and Related Communication Handicapped Children (TEACCH)

Families of children with an autism spectrum disorder face many hurdles when seeking care for their child. Creating resource handouts for parents and partnering with educational institutions and research facilities are just a few ways pediatricians can help guide these families through the maze of therapeutic options.

Neelkamal Soares, MD

Articles

Child Near Expulsion From Preschool: Is Medication the Answer?

Navigating the Autism Therapy Maze: 9 Ways to Help Families Find What Works