OwnADaycare: Must autistic children go to schools for children with special needs or can they attend a “traditional” daycare or preschool?

Van Driesen: Typical preschools are rarely prepared to offer a child with autism the support and therapy he/she needs to progress. For very young children on the autism spectrum, social settings may be extremely challenging. Children with autism may not learn through imitation (one of the basic difficulties inherent in autism), so just being around typical peers usually is not enough to learn social skills. In addition, the noise, physical interaction and high level of expectation in a typical preschool may be overwhelming.

Even with a one-on-one support at school, a child with autism may have a difficult time with behavioral and/or sensory challenges, such as circle time, sharing, and so forth. Teachers without specific training may not know how to help your child manage his or her behaviors. Also, typical preschool programs are not set up to provide the kind of intensive therapeutic programs so often recommended by professionals.   When preparing to send your child to preschool I highly recommend that you discuss preschool options with the professionals that evaluate and provide services to your child and family.  When making decisions about preschools for your child, there is “one size fits all”; each child will have individual needs and preschool programming should reflect these individual needs.

OwnADaycare: What should parents of autistic children  look for in a daycare or preschool?

Van Driesen: Although it is critical that children with autism receive specialized programming, many families have the need for their children to attend daycare.  Daycare facilities that specialize in the instruction and care of children with autism are extremely rare and families must rely on local and traditional day care facilities.  Optimally, , it is essential to choose a daycare provider that understands the social and communication issues common to autism and is well equipped to provide the support needed to acquire these skills successfully. Be sure to investigate details such as the teacher to student ratio and class size. Smaller classes are often the best environment for children with social interaction issues, providing opportunities to learn social skills without the pressure of large, overwhelming numbers of peers on which to practice them.  It may be appropriate for support services such as early intervention to be provided within the daycare setting to assist and train staff.

OwnADaycare: What tips can you offer preschool teachers and daycare providers who care for autistic children?

Van Driesen:

• Think and teach visually. Many children with autism are visual learners and using pictures and other visual aids during teaching is helpful.
• Use an area of interest or a special talent to connect with the child.  Using reinforcing materials may improve attention and focus during activities.
• Be aware of environmental distractions, such as bright lights and loud sounds, which may interfere with learning or comfort. Some children learn better when moving or using their hands, while other children may require silence in order to concentrate. Explore a variety of sensory environments with the child to determine which one is most conducive to learning.
• Utilize technology, such as television, CDs, and computers. Encourage use of the computer and keyboard to improve communication.
• Make your expectations simple and clear. Use concrete language when presenting directions, and reinforce those ideas with pictures or modeling. Avoid lengthy verbal instructions, and break tasks and instructions into clearly defined steps. Wait for the child to complete the first step before moving on to the next one.
• Stick to a routine. Some children with autism need routine to feel secure. Even the slightest disruption in schedule can cause tantrums. Prepare the child in advance for schedule changes or trips away from home.
• Be patient with yourself and the child.  Seek out support and training from experienced professionals.

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Part 3 of our interview with child neurologist Dr. Sara J. Dorison provides tips for child care center educators dealing with ADHD behaviors.

OwnADaycare: Could you give a few tips to help preschool teachers or daycare providers help manage ADHD behaviors?

Dr. Dorison: It is often difficult for a preschool teacher to know how to manage an ADHD child.  This is especially true of the teacher has a large class, an assistant who is not highly trained or if there are several ADHD children together in one class.

1.  Set expectations that the child can meet.  For example, insisting that a child sit for extended periods of time is likely to be unattainable and for this reason a teacher would be wise to allow ADHD children a bit more leeway in terms of physical activity.  If the child is not able to meet expectations, then the expectations need to be changed or accommodations can be made such as allowing a child to run class errands or hand out snacks (instead of trying to wait quietly).

2.  Identify one or two “problem behaviors” to target.  For example, if an ADHD child is physically aggressive, then the teacher and child can sit down and talk about “angry hands don’t touch.”  If all behaviors are targeted at once, the child will be confused and unable to meet the demands.  This will result in frustration and poor cooperation.  Other behaviors such as not cleaning, fidgeting, etc. should be dealt with after the aggression has resolved.

3.  Set up a positive reward system that might be done at first every hour (depending on how bad the problem is).  So, a child might receive a sticker every hour if she did not push/hit another child.  Then, the system would be changed to a sticker for before lunch behavior and after lunch behavior.  The important thing is that the child feels that the teacher feels warmly towards her and that the teacher be encouraging with comments such as, “Well, this morning did not go well since you pushed Jacob, but let’s try this afternoon to have no angry touching.  I know you can do it!”

4.  It is essential that the teacher comment positively at unexpected on times regarding good behavior.  “Catching” an ADHD child being good and complementing her will help tremendously in terms of increasing the positive behavior and the child’s interest in complying.   It will keep the child motivated to succeed.

5.  Keep close communication with parents without a negative overtone.  So many times parents come to pick up their children and the teacher starts to run down a full list of negative behaviors the ADHD child had during the day.  A simple, “She had a tough day today, but tomorrow will be better!”   Negative comments should be written in a note or discussed over the phone and not in the presence of the ADHD child who will feel confused and sad to hear his teacher convey negative comments.  Frequent negative remarks from a preschool teacher often result in school anxiety and worsening of ADHD symptoms.

6. A preschool teacher might ask for a professional behavioral consultant to come and help make a behavioral plan for an ADHD child.   This might be a psychologist that works in the school or the community.

7. The teacher should keep the class feeling positively towards an ADHD child.  Often the other children in the class feel negatively towards a child that hits and gets reprimanded by the teacher. When an ADHD child has a good day, the teacher can say to the class, “Let’s all cheer for Jane since she had a great day with no angry hands touching!”

8. Give intermittent and unexpected rewards.  If an ADHD child has a good morning, for example, perhaps she can be the line leader to recess or pass out the snacks.  Compliments and positive reinforcement are the best ways to increase good behaviors.

9. Make the ADHD child feel special.  Often days are full of frustrations for ADHD children since they can elicit so many negative interactions from other children and teachers (as well as parents).   Parents frequently report that 90% of their verbal interactions with their ADHD child is negative.  A preschool teacher should be sure to give the ADHD child a special hug in the mornings and special compliments when the child does something well.  The teacher should make an effort to recognize something in which the child excels such as art, athletics, helping, etc.  Increasing an ADHD child’s confidence will decrease anxiety, frustration and improve her behavior.

10.  Avoid telling parents that you feel the child has ADHD and definitely do not mention the possibility of medications. Most parents feel upset when a teacher suggests a medical diagnosis and even more upset when a teacher suggests that the parents begin medication.  Even though the experienced preschool teacher will likely recognize ADHD, most parents appreciate a discussion of the symptoms with a suggestion to discuss it with a pediatrician.

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Part 2 of our interview with child neurologist Dr. Sara J. Dorison details the important aspects of managing ADHD in the preschool setting.

OwnADaycare: What are the symptoms of ADHD in preschool children?

Dr. Dorison: Preschool children with ADHD often have difficulty sitting still during story reading (“happy circle”), finishing little projects and waiting their turns.  Often they have low frustration tolerance which can lead to impulsive aggression.  For example, an ADHD child is more likely to push another child when that child grabs for a toy.   Due to impulsivity, many children with ADHD have a hard time following the rules.   Often it is hard for the ADHD child to “keep his hands to himself” since impulsivity is such a prominent feature.   Transitions such as going from the playground to the classroom can be difficult for them and they have a great deal of difficulty waiting quietly.   They might have difficulty learning their letters since paying attention in class is hard for them.   Low frustration tolerance can lead to tantrums.

OwnADaycare: What can parents or early childhood educators do if they suspect children are exhibiting ADHD behaviors?

Dr. Dorison: Parents must educate themselves and seek professional advice.  Reading about ADHD is very helpful so that parents can see whether their child indeed meets the typical profile of an ADHD child.  Pediatricians are generally able to guide parents in the right direction which is often towards a psychologist, child neurologist or child psychiatrist.  In general, a preschool child with ADHD does not need medication.  They can be helped significantly with behavioral management techniques that stress consistency, positive reinforcement and encouragement.  They must be given adequate exercise and reasonable expectations should be set.  An ADHD child might not be able to sit quietly so teachers and parents must tolerate a degree of fidgetiness. A preschool child that suffers severe ADHD where the impulsivity is dangerous (running in parking lots, running across the street, climbing onto the cooktop, jumping from high places) or where aggression is a prominent feature (hitting other children),might need medication.

Parents must be careful when consulting professionals to seek those who know about ADHD.  Many young children with ADHD are incorrectly diagnosed with Oppositional Defiant Disorder (ODD) and Bipolar Disorder.  Incorrect diagnosis can lead to damaging labeling of children and inappropriate use of medication.

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Our interview with child neurologist Dr. Sara J. Dorison details the important aspects of ADHD in the preschool setting.

OwnADaycare: What is ADHD?

Dr. Dorison: Attention Deficit Hyperactivity Disorder is a syndrome characterized by the presence of clinically significant levels of hyperactivity, impulsivity, disorganization, difficulty staying on task, short attention span, and difficulty waiting on line, interrupting, and low frustration tolerance. The diagnosis is based on the DSM-IV criteria which outline the criteria necessary to make the diagnosis.  It is felt to be present in about 5% of children.

OwnADaycare: How is ADHD diagnosed?

Dr. Dorison: ADHD is a clinical diagnosis and is made by taking an appropriate history and physical examination of the child and their behavior.  Unfortunately, there is no blood test, genetic testing, brain wave test or brain imaging test that can currently make the diagnosis.  The diagnosis is often made with the assistance of psychoeducational testing, or with a clinical interview, generally with a child psychiatrist or child neurologist.  The clinical features must be present in at least two settings and over a period of time.   Often doctors or psychologists use the Connor Rating Scales which ask parents and teachers to fill out forms regarding behaviors.   It is important to rule out other disorders that can present similarly in a young child.  These include Asperger Syndrome, Developmental Delay, Pervasive Developmental Disorder, Autism, deafness, lead poisoning and severe anxiety.

OwnADaycare: Many times, diagnosis of ADHD comes sometime after the age of 6. Can you please explain why? In other words, why is early diagnosis difficult and when is the earliest that a child can be diagnosed with ADHD?

Dr. Dorison: Toddlers and very young children normally exhibit many of the features of ADHD.   Two year olds, for example, are impulsive and disorganized.  They can’t sit for an hour listening to a lesson.  So, it is difficult to discern whether a young child has a “normal” amount of impulsivity or disorganization or a clinically significant amount of these features.   Over time, however, children without ADHD mature and gain more control in these areas and the ADHD children are left behind in terms of their difficulty with their symptoms.   As their peers mature, children with ADHD generally become more obvious to both the teachers and the parents.   Also, as the academic demands of school increase, children with ADHD often begin to lag behind their peers and not perform to their potential.

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While this study doesn’t apply to preschool aged children, as a daycare provider it is still important to know the hazards of using food as a reward and how using non-food rewards.

Hazards of food rewards

When you reward or bribe a child with food, these same children may continue to reward themselves with food later in life. When children are rewarded with treats, they unfortunately associate these treats with happiness or being good. Studies show that associating food with with good behavior or bad behavior has long-lasting effects on children’s food preferences and their eating styles. It also may contribute to overweight and obesity.

“Rewarding children with unhealthy foods in school undermines our efforts to teach them about good nutrition. It’s like teaching children a lesson on the importance of not smoking, and then handing out ashtrays and lighters to the kids who did the best job listening.” Marlene Schwartz, PhD, Co-Director, Rudd Center for Food Policy and Obesity, Yale University

There are many significant advantages of giving children Non food rewards.  Non food rewards set a foundation for healthy attitudes toward food. Non food rewards do not impede a child’s development of natural hunger cues. Recognizing kids with respect and verbal appreciation are superior motivators than rewards of food.  Non-food rewards (like praise and privileges) can also be less expensive than food rewards. In addition studies show that children actually prefer non-food treats! Just ask.

Enforcing policies

Did you know that in some states (Alabama and the District of Columbia) where food rewards for children are prohibited?  There are also many states that discourage rewarding good behavior or performance with food. If you firmly believe in prohibiting food rewards in your daycare or childcare business, be sure to communicate this with staff and parents. Make sure your policies are clear and well documented in your child contract and reiterate your stance when clients sign the contract.

Types of nonfood rewards

Privileges as Rewards: Choosing an activity, going first, sitting next to friends, selecting a book or record, helping the teacher, free time, extra time with a toy or in dramatic play

Group rewards: Extra time outside (recess), field trips, playing special games or watching a special movie, free choice of activity at the end of the day, special theme days

Social Rewards: Acknowledgment for a job well done like words of thanks, praise, and special attention or ceremonies

Gifts: Stamps, stickers, bookmarks, books, balls,  playing cards, magnets, shoelaces, bubbles, modeling clay, bracelets, rings, necklaces, coloring pencils, markers, stencils, erasers, pencil cases, coloring books

Recognition: Trophies, rewards, plaques, ribbons, special letters home.

It is also wise to use a points system in order to provide larger rewards like gift certificates, games, toys, and larger outings like sporting events. Points can be accumulated individually or as a group and may later be redeemed for prizes. Ask children in your child care center about the types of non-food rewards they prefer. Also remember that positive reinforcement goes a long way in reinforcing good behavior.

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Suzy Martyn, Parenting Consultant, Speaker, and author of Enjoy the Ride: Tools, Tips, and Inspiration for the Most Common Parenting Challenges provides the following suggestions:

1. Model the desired behavior. If a toddler sees the behavior naturally in a parent or teacher, they are much more apt to do it when directed so.
2. Encourage and affirm. It takes 7 positive statements to make up for a negative one so our children need to hear much more praise in order to accept any direction.
3. Intervene and guide earlier rather than later. Sometimes children can work out conflict or direct their own behavior in a positive manner but most of the time, they can benefit from an adult noticing early on when he/she needs some guidance, direction, and reminder in order to get them back on track before he/she gets too far off.
4. Read books, watch movies, and talk often about examples of good behavior.
5. Notice when someone is behaving well and comment about it. Make it something desirable to attain.
6. Start fresh after each conflict is resolved. Don’t bring up old mistakes or make children feel hopeless, criticized, or defeated.
7. Talk about your own experiences and how your good behavior brought about good things.

Zohra Sarwari, professional speaker, author, and home schooling mother of three, provides the following tips:

1. Sit with your child away from the fight, and ask questions.  Let your child answer the questions for you.  For example: When you toddler grabs a toy from someone else, ask him or her how they would feel if this happened to them?”  Give them a toy that belongs to you and ask them how would you like to give that back to me?  Should I grab it or ask you for it?
2. Make a chart for good deeds.  Every time they do a good deed check it on the chart.  Or put a sticker on the chart.
3. Explain to them how feelings work, and what makes us sad, and what makes us happy.  Ask them which feeling do they like most and which one do they not like?
4. Make sure that your toddler isn’t hungry or tired, and that is why they are acting out.  I always carry extra snacks, and make sure they take their nap, at nap time.
5. Always have many different activities available for your toddler.  An active mind is a happy mind.  I always make sure that I have books, puzzles, numbers, pencil and paper.
6. Ask them what is wrong?  Listen to them explain it to you, and then address the problem.  Many times as parents we jump to conclusions, and deal with a problem without knowing what the root problem is.  Take a few minutes, and find out what is really bothering your child.

Remember that no child is perfect and part and good behavior is a skill set that must developed. In the meantime, your best bet for dealing with behavior issues with toddlers in child care centers is to set clear boundaries, to be firm, calm when issues arise and always follow through. Consistency is the key. Then remember to emphasize and reinforce appropriate behaviors in order to encourage children on an appropriate behavioral path.

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