Understanding Early Childhood Diagnosis: What Preschool Teachers Need to Know

Editor’s note: This text-based course is an edited transcript of the webinar Understanding Early Childhood Diagnosis: What Preschool Teachers Need to Know, presented by Karalynn Royster, PsyD, IMH-E®.

Learning Outcomes

After this course, participants will be able to:

• Articulate common early childhood diagnoses.
• Summarize two aspects of talking to parents about essential concerns.
• Distinguish two ways to support the next steps for their preschool children.

Introduction

Our course today aims to delve into the importance of understanding diagnoses and how that can support preschool teachers in their roles. While it's essential to clarify that preschool teachers are not tasked with diagnosing mental health conditions, they frequently encounter and work with children exhibiting various behaviors. As frontline educators, you play a pivotal role in identifying these needs and connecting children with the necessary support systems.

Moreover, you often collaborate with professionals in the early childhood sector who provide services to these children. Drawing from my personal experience of teaching preschool for many years during my undergraduate studies, I deeply appreciate and respect the challenges you face. Having been in the trenches myself, I hope to convey a genuine understanding of your experiences.

Now, transitioning to my current role working with children with diverse needs and supporting mental health initiatives, I bring a unique perspective to our discussion.

Agenda

By the end of this course, my aim is for you to be able to articulate common early childhood diagnoses. Some of these fall under the category of neurodevelopmental disorders, indicating that children are born with specific brain structures or genetic codes that lead to persistent diagnoses throughout their lifespan. However, our primary focus remains on the early childhood period.

I will concentrate on discussing not all but some of the most prevalent diagnoses. These are the ones where we need teachers' insights and support to better understand and aid children effectively. Our discussion will center specifically on early childhood diagnoses.

Following that, we'll summarize two crucial methods for communicating with parents. We'll delve into how to approach these conversations, outlining the necessary steps to take, whether with your team, directors, co-teachers, or parents. Understandably, some teachers may feel apprehensive about broaching these topics with parents, so I'll provide practical skills to navigate these discussions.

Lastly, we'll spend some time exploring ways to support children with various mental health needs, both within and beyond the classroom. We'll discuss making referrals, assessing the validity of referrals, completing necessary forms, and supporting parents at home. 

Case Study

I'd like you to consider a particular child, a five-year-old who identifies as male. As psychologists, we call it a case and refer to the person the case centers around as a patient or client. Teachers often refer to such cases as "my little buddy in pre-K" or "this little guy in my three-four class." Now, let's explore some behaviors exhibited by this child and reflect on what thoughts arise for you as a teacher.

Firstly, he threw a chair at a peer last week. Additionally, he experiences significant distress most mornings, often having tearful goodbyes with his primary caregiver. Furthermore, he struggles notably when there's a substitute teacher, demonstrating resistance or discomfort with unfamiliar faces in the classroom setting.

He tends to stand apart during circle time or group activities and is unwilling to join the group. He may refuse to sit and appear disengaged from communal activities, expressing a preference to remain on the periphery. This aversion to social interaction extends to physical contact, as he recoils from peers or classmates touching him, even in casual encounters.

Notably, he seems to have a strong attachment to you as the teacher, displaying resistance or discomfort when interacting with other adults in the classroom. This resistance comes from obvious behaviors like being pushed and other things, such as another child bumping him or accidentally touching him when reaching for something. Despite efforts from other individuals, he maintains a preference for one specific person, exhibiting difficulty when tasks typically performed by that person are undertaken by others.

Regarding dietary habits, he prefers consistency, prefers familiar meals, and is showing reluctance to try new foods or textures. This aversion to culinary variety may pose challenges during meal times if unfamiliar dishes are introduced.

As we examine these behaviors, it's important to remember that our goal in considering diagnoses is to better understand and support the child. By delving into the underlying reasons for these behaviors, we can effectively provide targeted interventions to address his needs.

Reflect

Take a moment to reflect on your initial thoughts regarding this case. Consider what strategies you might employ to support this child, any questions or uncertainties that arise, and what stands out to you the most. Jot down your thoughts.

While it's natural to speculate about a potential diagnosis, such as autism spectrum disorder, it's important to remain open to various possibilities. We'll revisit this case later in the course to explore different perspectives and considerations. 

The Basics

What is mental health?

Before delving into specific diagnoses and behaviors, let's establish a foundational understanding of mental health. What exactly is mental health, especially concerning children? At its core, mental health pertains to wellness, encompassing emotional well-being, behavioral adjustment, and a relative absence of disabling symptoms.

Technically, mental health is defined as a state of mind characterized by emotional well-being, behavioral adjustment, and relative freedom from disabling symptoms. It's the ability of children, in particular, to adapt to the challenges inherent in childhood and young life without experiencing significant impairments that hinder functioning. It's crucial to recognize that children, particularly those in their formative years, may not navigate challenges in the same manner as adults. Expecting them to do so would be unrealistic.

Parents sometimes hold unrealistic expectations regarding their young children's ability to cope with adversity. As educators, you understand the developmental stages and limitations of young children. As a psychologist, I focus on assessing whether a child's difficulties impede their functioning and whether their coping mechanisms align with what is typical for their age and environment. This distinction is vital in gauging the need for intervention and support.

Can Young Children Really Have Concerns?

Frequently, I encounter questions from parents questioning the validity of mental health concerns in young children. They may express doubts about whether a three-year-old can experience anxiety or depression, or they might dismiss traumatic experiences from early childhood as inconsequential. However, the truth is that children's social and emotional experiences during their early years profoundly shape their future development.

As early childhood educators, you understand this fundamental truth intuitively. The work you do is grounded in the knowledge that the period from birth to age five is critical for laying the foundation for children's cognitive, emotional, and social development. Teachers play a pivotal role in nurturing children's capacity to engage, learn, regulate emotions, and navigate the world in a healthy manner.

It's essential to recognize that young children can indeed experience mental health concerns, which may manifest within the context of their environment or primary caregiving relationships. However, these concerns are not always solely attributable to external factors. Throughout today's course, we'll explore the nuances of childhood mental health and how various factors contribute to children's well-being.

What Is My Role?

As a teacher, your role is pivotal in building strong relationships with the children in your care. You are often the first to observe and assess their developmental progress, noting any deviations from typical milestones or behaviors. Your keen observations enable you to identify concerns and communicate them to parents in a supportive manner. Whether it's expressing worry about a child's development or offering reassurance when separation anxiety arises, you serve as a trusted source of guidance and support for both children and parents.

Your interactions with parents provide a valuable opportunity for collaboration and dialogue. Parents may confide in you about their concerns regarding their child's well-being, seeking your insight and expertise. In these conversations, you have the chance to share your observations, offer developmental guidance, and provide practical tools and strategies.

Furthermore, if ongoing concerns persist, you can facilitate access to additional resources and support services. This may involve making referrals to early childhood consultants, discussing the situation with your director, or devising a plan of action to address the child's needs proactively. Your proactive approach and commitment to the well-being of the children in your care are instrumental in fostering a nurturing and supportive learning environment.

As a former preschool teacher myself, I have a deep appreciation for the insights and perspectives of early childhood educators. In my current role as a psychologist specializing in diagnosing and treating developmental concerns, I find that preschool teachers are invaluable sources of information and collaboration.

What Should I Do?

Preschool teachers possess a unique vantage point, overseeing diverse groups of children with varying developmental trajectories. This firsthand experience equips them with a nuanced understanding of typical and atypical developmental patterns. When discussing concerns with preschool teachers, I often receive invaluable feedback and observations that help inform my diagnostic process.

I greatly value the input of preschool teachers who confidently assert, "This is not typical," or "This is different from what I've seen before." Their expertise and intuition play a crucial role in recognizing when a child's behavior or development warrants further attention.

Moving forward, I'll provide guidance on what actions to take and why they're necessary. Collaborating with preschool teachers ensures that children receive the support and interventions they need to thrive.

What is Early Intervention?

Some of you may be well-versed in the world of early intervention, while others may not be as familiar. Therefore, I'll provide a brief overview to ensure everyone is on the same page.

Early intervention stems directly from a bill passed in 2004, specifically the Individuals with Disabilities Education Improvement Act of 2004. The Infants and Toddlers with Disabilities Program (Part C) of the Individuals with Disabilities Education Act (IDEA) was created in 1986 to enhance the development of infants and toddlers with disabilities, minimize potential developmental delay, and reduce educational costs to our society by minimizing the need for special education services as children with disabilities reach school age.

Early intervention is particularly effective due to its timing. Research demonstrates that interventions provided during early childhood are significantly more beneficial than those administered later in life. This effectiveness is largely attributed to the brain's malleability during early developmental stages. During this period, neural development is rapid, allowing interventions to shape and support neural networks and neurotransmitter systems.

Moreover, early intervention has proven effective in mitigating environmental and biological risks. It has shown positive outcomes for children with identified concerns, such as autism spectrum disorder, as well as for conditions with clearer diagnostic criteria, such as Down syndrome. While diagnosis for conditions like autism may not be as straightforward as a blood test, early intervention has been shown to be highly effective in supporting children with diverse needs.

It's important to recognize the substantial funding and support available for young children and families, particularly within programs tailored to the zero to three and three to five age ranges. Access to these services can be transformative for families, offering invaluable support during crucial developmental stages.

Without the vigilant observations of teachers and early interventionists, some children who could benefit from these services may slip through the cracks. Therefore, the role of educators in identifying and advocating for children's needs is paramount.

Highlighting the significance of high-quality early intervention services, it's crucial to acknowledge their profound impact on a child's developmental trajectory and overall outcomes. Such services benefit the individual child and their family and extend their positive effects throughout the broader community, including school, religious, and social spheres.

Your keen observations and insights as educators hold the potential to significantly influence a child's access to essential services and support. Your advocacy and attention to detail can determine whether a child receives the interventions needed to thrive.

Bottom Line

My ultimate message to you is this: please don't hesitate. If you have concerns about a child's development, raise them early and openly. Initiating discussions and addressing issues promptly can significantly improve outcomes later in life.

Pay close attention to developmental milestones and any signs of a child struggling. Discuss your observations with your team, collaborate on strategies, and then communicate with the child's family. By working together, we can ensure that children receive the support they need to thrive.

Diagnostic Manuals

• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 TR) 
  • American Psychiatric Association, 2013, 2023
• Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-5)
  • Zero to Three, 2016

I believe it's important to discuss the manuals commonly used in the field of mental and behavioral health, as they play a crucial role in making diagnoses. The primary manual utilized for this purpose is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), often abbreviated as the DSM.

Originally trained using the DSM-IV, I've witnessed the evolution of this diagnostic tool through various revisions. The DSM serves as the definitive resource for the American Psychiatric Association in providing standardized diagnoses. These diagnoses inform treatment plans and determine eligibility for services and insurance billing.

Within the DSM are sets of criteria that must be met for a particular diagnosis. For instance, specific symptoms or behaviors must be present for a condition to be classified as anxiety or attention-deficit/hyperactivity disorder (ADHD). However, it's essential to acknowledge the criticisms directed at diagnostic systems, as they can oversimplify complex human behaviors and fail to consider cultural differences adequately.

While diagnoses serve as a shared language among professionals, avoiding reducing individuals to their diagnoses is crucial. Instead, we should view diagnoses as tools for understanding and conceptualizing a person's experiences. For example, when someone is identified as having depression, we collectively understand certain aspects of their condition. While we must approach diagnoses with caution and sensitivity, they can provide a framework for further exploration and understanding.

There's a growing recognition within the field of early childhood development for a more nuanced understanding of diagnoses in young children, championed notably by organizations like Zero to Three. Zero to Three is a prominent nonprofit organization dedicated to the well-being of infants, toddlers, and their families. Their extensive advocacy, education, and policy work profoundly impact the early childhood landscape with initiatives such as Strolling Thunder and advocacy efforts at the Capitol.

Zero to Three initially focused on the zero to three age group but expanded its scope to include children up to age five in 2016. While this expansion may not directly affect our discussion today, it underscores the evolving understanding of mental health and development in young children. This broader perspective acknowledges that conditions like anxiety may manifest differently in toddlers compared to adults, highlighting the importance of tailored approaches to diagnosis and intervention.

While the DSM-5 remains a primary reference for diagnosing mental health conditions, it's essential to recognize that diagnostic criteria may not always fully capture the nuances of young children's experiences. Despite some modifications for younger age groups in the DSM, there's a growing recognition of the need for specialized approaches to understanding and addressing mental health concerns in early childhood.

Throughout this presentation, I'll reference both the DSM-5 and Zero to Three's resources to provide a comprehensive understanding of mental health considerations in young children. This dual perspective reflects the field's evolving understanding and approach to early childhood mental health.

Guiding Questions

When we delve into a child's behavior and begin discussing potential diagnoses, our primary goal is to understand the underlying reasons behind their actions. As a behavioral health clinician, I approach this process with a focus on uncovering the "why" behind the behavior, just as you, as teachers, do within your roles. Together, we form a collaborative team, seeking to decipher the motives and drivers behind a child's actions.

Consider the case of the five-year-old child we discussed earlier. Is their difficulty with the new teacher rooted in anxiety, making change challenging and uncertainty unsettling? Or perhaps it stems from a tendency towards oppositional behavior, particularly in response to shifts in authority figures? Alternatively, could it be indicative of autism spectrum disorder, where disruptions to routines pose significant challenges?

It's evident that merely knowing the surface-level facts of a child's behavior is insufficient. To provide effective support, we must uncover the underlying motivations and triggers. This is precisely why we're dedicating this course to exploring various diagnoses—to gain insight into the "why" behind behaviors. While diagnoses are not always definitive, they serve as tools to guide our understanding and inform our approaches to support.

Rather than simplifying behaviors with labels like "ADHD," our collaborative approach encourages a deeper exploration of the complexities underlying a child's actions. By adopting this mindset, you, as educators, play a vital role in understanding and supporting the diverse needs of the children in your care.

We're now going to delve into specific diagnoses commonly encountered in early childhood. My aim is to provide you with a clear understanding of each diagnosis grounded in scientific evidence and factual information. By the end of this discussion, you'll have a comprehensive grasp of what each diagnosis entails and what it does not.

Firstly, I'll outline the diagnostic criteria for each condition, ensuring you have a solid foundation of knowledge. Then, we'll explore how these criteria manifest in practical terms within your classroom environment. This will include common observations you may encounter from both parents and fellow educators.

Moreover, for each diagnosis, I'll offer some general strategies and supports. While these recommendations may be broad in nature, they aim to provide you with practical ideas for assisting children with these diagnoses in your classroom. While our discussion today may only scratch the surface, I encourage you to explore further resources and courses for a deeper understanding of specific diagnoses.

My goal is for you to leave this session equipped with valuable insights and actionable strategies to support the diverse needs of the children under your care.

Autism Spectrum Disorder (ASD)

Let's begin by discussing autism spectrum disorder (ASD), a topic that often garners significant attention and inquiries. One reason for prioritizing this diagnosis is its complexity and the challenges associated with accurate diagnosis. Unlike some childhood disorders that may be readily observable, ASD requires specific tests and a methodical approach to assessment.

Furthermore, the frequency of ASD diagnoses appears to be on the rise, sparking discussions about potential reasons behind this trend. While some attribute the increase to improved diagnostic capabilities and heightened awareness, others speculate about underlying factors contributing to the apparent surge in diagnoses. Current estimates suggest that approximately one in 36 children may have ASD, though prevalence rates vary considerably.

Given the significance and prevalence of ASD, it's essential to understand its manifestations and characteristics. Let's delve into what ASD actually entails and how it may manifest in the early childhood setting. 

Autism spectrum disorder (ASD) is defined by a specific set of diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). While the criteria may seem daunting, I've provided the exact language from the DSM to ensure clarity and accuracy in our discussion. Let's explore these criteria in detail to gain a comprehensive understanding of ASD.

Diagnostic Criteria (American Psychiatric Association, 2013)

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. 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.
2. Deficits in nonverbal communicative behaviors 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.
3. 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.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. 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 interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest 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).

C. 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).

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

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

To initiate our discussion on autism spectrum disorder (ASD), it's crucial to understand the deficits that must be present across three primary domains: social-emotional reciprocity, nonverbal communicative behaviors, and difficulty in maintaining and understanding relationships. These must be seen in history, currently, and below what peers are doing. 

In the domain of social communication, individuals with ASD may struggle with back-and-forth conversations, exhibit limited affect or facial expressions, and demonstrate difficulty initiating or responding to social interactions in a typical manner. It's important to recognize that ASD encompasses a broad spectrum of abilities, and these challenges may vary widely among individuals.

Nonverbal communication poses another area of difficulty for individuals with ASD. This includes struggles with gestures, body language, and eye contact, although it's essential to note that the absence or presence of eye contact alone does not determine an ASD diagnosis. ASD affects various aspects of nonverbal communication beyond just eye contact, highlighting the complexity of the condition. By thoroughly examining the diagnostic criteria for ASD, we aim to dispel misconceptions and provide a nuanced understanding of the diverse manifestations of this disorder. 

Another significant aspect of autism spectrum disorder (ASD) involves patterns of verbal communication, which often exhibit unique or abnormal characteristics. We'll delve into these specific patterns further as we proceed. However, one of the hallmark symptoms of ASD is the difficulty in establishing and understanding relationships.

Individuals with ASD may struggle to discern appropriate social behaviors, such as knowing when and with whom certain actions are acceptable. For example, young children with ASD may engage in behaviors like kissing their teacher without permission, highlighting challenges in understanding social boundaries and norms.

This difficulty in navigating social interactions extends to play activities, where imaginative play poses a particular challenge. While typical children may easily engage in imaginative scenarios, such as pretending a banana is a telephone, individuals with ASD may struggle to grasp the abstract nature of such play. Their preference for concrete thinking may lead them to interpret the banana solely as a piece of fruit rather than as a prop for imaginative play. It's fascinating to note that despite technological advancements, children still engage in the banana phone gesture across generations. This enduring behavior underscores the universality of certain play patterns. By exploring these specific behaviors and communication patterns associated with ASD, we aim to deepen our understanding of the disorder and its impact on social functioning. 

Moving on to the more individualized aspects of autism spectrum disorder (ASD) criteria (part B of the diagnostic criteria), we encounter a broad pattern of restricted or repetitive behaviors, interests, or activities. These behaviors manifest in two of the following four areas alongside the criteria outlined previously in part A of the diagnostic criteria. First, stereotyped or repetitive movements may include doing things repeatedly, lining up toys, repeating phrases (known as echolalia), or using idiosyncratic phrases out of context, such as something you said to another teacher like, "Let's go get the milk for lunch."

Next, insistence on sameness becomes apparent, with individuals developing rigid routines or rituals and displaying discomfort or distress when these routines are disrupted. This preference for routinized activities reflects a need for predictability and order in their environment. It may appear as setting up their cot in a specific order or having a specific morning routine when they enter the classroom.

Moreover, individuals with ASD may exhibit highly restricted and fixated interests that extend beyond typical childhood fascinations. These interests often dominate their thoughts and conversations to an intense degree, such as an exhaustive knowledge of train models or an exclusive focus on specific topics such as flags, rocks, bugs, or air conditioners. On its own, it's not concerning, but when combined with other criteria, it may indicate ASD. They are often more intense and focused than other children, especially on these interests.

Furthermore, some individuals may demonstrate heightened or diminished sensitivity to sensory input, experiencing sensory overload or seeking sensory stimulation in unusual ways. While not all children with ASD exhibit sensory sensitivities, there is an overlap between ASD and sensory processing disorder.  

The symptoms of autism must be evident during the early years of a child's life (part C of the diagnostic criteria), highlighting the crucial role of early childhood educators like yourselves. While some individuals may not seek diagnosis or recognize concerns until later in life, it's essential to trace the presence of symptoms back to the early developmental period, from zero to five years old.

Moreover, these symptoms must be causing significant challenges or impairments in specific areas of functioning to warrant a diagnosis (part D of the diagnostic criteria). Without a notable impact on daily life or functioning, a diagnosis of autism may not be appropriate. Additionally, clinicians consider alternative explanations for observed behaviors, such as intellectual disability, which may better account for the cluster of symptoms present in some cases (part E of the diagnostic criteria).

Understanding these criteria ensures accurate diagnosis and appropriate support for individuals with autism spectrum disorder, emphasizing the importance of early identification and intervention. Your insights and observations as early childhood educators play a vital role in this process, helping to identify potential concerns and facilitate timely access to support services for children and families.   

Diagnosis

When you encounter a diagnosis of autism spectrum disorder (ASD), you may notice additional qualifiers, such as "level one," "level two," or "level three." These levels indicate the level of support the child is expected to require, ranging from some support for level one to very substantial support for level three. It's important to understand that these levels are not intended to signify mild, moderate, or severe severity, although they are often interpreted that way.

Furthermore, the diagnosis may specify whether the child has language impairment or intellectual impairment. Language impairment refers to difficulties with speech and communication, while intellectual impairment relates to cognitive delays. Understanding these aspects can provide valuable insights into the child's needs and abilities, informing your approach as an educator.

Additionally, the diagnosis may include information about any known medical or genetic conditions that could impact the child's development and behavior. While rare, the diagnosis may also mention catatonia, characterized by extreme immobility and unresponsiveness. Although catatonia is uncommon in the context of ASD, it's included for comprehensive assessment purposes.

Overall, these details within the diagnosis help paint a clearer picture of the child's unique profile and support requirements, enabling educators like yourself to provide tailored support and interventions to promote their development and well-being.

Characteristics and Behaviors

• Deficits in social reciprocity
  • Back and forth conversations/play
  • Struggles to respond to bids
• Deficits in non-verbal communication
  • Struggling to use gestures/pair gestures
  • Eye contact
  • Standing too close
• Deficits in developing, maintaining/understanding peer relationships
  • Plays outside the group
  • Prefers solo play
  • Doesn’t respond or attempt to engage with peers
• Stereotyped motor movements or speech
  • Echolalia
  • Flapping
  • Spinning
• Insistence on sameness/inflexible with change in routine
  • Strongly prefers sameness
  • Adaptation to changes is hard
• Restricted interests
  • Unusual interests
  • High level of facts, etc. 
• Sensory 

In the classroom, there are certain behaviors that may warrant your attention and prompt you to keep a watchful eye. One such indicator is deficits in social reciprocity, which essentially refers to the ability to engage in back-and-forth conversations or play interactions. Think of it as a tennis match, where one person volleys something over, and the other's job is to hit the ball back. Children on the spectrum may struggle with this interactive dance, resulting in limited engagement or responses during social interactions. For example, when asked about their day, they may provide a brief response without reciprocating the inquiry. Another scenario to observe is when a child is engaged in play, such as playing with trucks, and you offer a verbal interaction like, "I like that truck. That's a really cool truck," but the child doesn't respond. This lack of reciprocal response is referred to as a bid. In typical social interactions, individuals often acknowledge and respond to such bids with a comment or acknowledgment. However, children on the spectrum may struggle to reciprocate these social cues, which can impact their ability to engage in meaningful social exchanges.

Another area to observe is deficits in nonverbal communication. Pay attention to whether children pair gestures with verbal communication, such as waving while saying "bye-bye" or performing finger movements while singing songs like "Itsy Bitsy Spider." Challenges with eye contact and understanding personal space may also be evident. Young children often display quirky and awkward behaviors, but when these patterns persist, it could indicate difficulties in interpreting nonverbal cues. For instance, a child may inadvertently stand too close or face away from peers during play, demonstrating a lack of awareness of social norms. Not only do they struggle to pick up on these social cues, but they also may not interpret nonverbal signals in the same way. For instance, you might make a facial expression signaling not to go down the slide backward, but they might not perceive it as intended. It's just difficult for them to read these cues.

Let's move on to deficits in developing, maintaining, and understanding peer relationships. One common observation is that children like Sarah prefer solitary play, while Johnny tends to engage in activities independently. They may not actively participate in group play or interact with peers in typical ways. For example, they might play adjacent to a group or engage in parallel play rather than fully integrating into peer activities. In group settings, they might take on roles like the "rule enforcer" or "classroom helper," paying close attention to adherence to rules and norms. They may even inform adults about perceived rule violations by other children, demonstrating a keen focus on monitoring social interactions and maintaining order within the group.

Stereotyped motor movements or speech refer to repetitive actions or vocalizations that may seem puzzling or unusual. This includes repeating phrases or words (echolalia), hand flapping, rocking, spinning, or other repetitive behaviors. These actions are often referred to as "stimming" and can include spinning in circles, repeatedly flipping light switches, watching the wheels on the car spin over and over, or disassembling objects out of curiosity rather than mischief.

Individuals on the spectrum may struggle with changes in routine, finding comfort in predictability and structure. They may insist on sameness because adaptation to changes is hard. Additionally, they may exhibit an intense focus on specific topics, accumulating detailed knowledge on subjects of interest, earning them nicknames like "little professors" or "Jeopardy contestants." They may have restricted interests that seem unusual or include a high level of facts. It's important to note that not all individuals with autism display these behaviors, but they are common observations. Lastly, sensory sensitivities, which we'll explore further later on, are also characteristic of autism spectrum disorder.

Classroom Strategies

Collaboration is key when supporting children on the autism spectrum. It often involves a multidisciplinary team of specialists, including occupational therapists, speech therapists, physical therapists, and mental health professionals. Each brings a unique perspective and expertise to the table, contributing to a holistic approach to care.

Visual schedules are an invaluable tool in the classroom for children with autism. While many classrooms may already use written schedules, adding visual cues, such as pictures representing different activities, can greatly benefit these students. For instance, instead of just listing "circle time" on the schedule, include a picture of the carpet where circle time takes place. This visual support helps children anticipate transitions and understand what comes next, providing a sense of predictability and structure.

Children on the spectrum often thrive in environments with consistent routines and clear expectations. They may struggle with unexpected changes, so preparing them in advance for any deviations from the routine and providing support through the change is essential. This might involve discussing upcoming events or changes in the schedule days or even weeks beforehand, allowing the child time to process and adjust to the upcoming change.

Occupational therapy (OT) can provide valuable support for children with autism, addressing sensory processing issues and motor skills development. OT interventions may include using sensory tools like headphones or weighted vests to help children regulate their sensory input and maintain focus in the classroom.

Teachers can also leverage the child's interests as a way to engage them in learning. Educators can tap into their intrinsic motivation by incorporating topics or activities that align with the child's passions and make learning more meaningful. For example, if a child is fascinated by trains, the teacher might incorporate train-themed activities into math, science, or literacy lessons.

Play-based interventions are another effective way to support children with autism. Play provides a natural context for practicing social skills, communication, and problem-solving. During playtime, teachers can scaffold interactions, model appropriate behaviors, and provide gentle guidance to help children navigate social situations. For example, have a conversation with the child and say, "I noticed that your friend over there is waving you over. I think that means they want you to play with them." 

By integrating these strategies and working collaboratively with a multidisciplinary team, educators can create a supportive and inclusive environment where children on the autism spectrum can thrive academically, socially, and emotionally.

Attention-Deficit/Hyperactivity Disorder (ADHD)

     ADHD, or attention deficit hyperactivity disorder, is a commonly discussed condition in both clinical and educational settings. While many still use the term ADD (attention deficit disorder), it's important to note that with the transition from the DSM-IV to the DSM-5, the distinction between ADD and ADHD was eliminated. Now, all presentations fall under the umbrella term ADHD.

There are three main types of ADHD recognized by the DSM-5: inattentive type, hyperactive-impulsive type, and combined type. The inattentive type primarily involves symptoms related to difficulty sustaining attention, organizing tasks, and following through on instructions. On the other hand, the hyperactive-impulsive type is characterized by symptoms such as fidgeting, difficulty staying seated, and interrupting or intruding on others. The combined type, as the name suggests, encompasses symptoms of both inattention and hyperactivity-impulsivity.

These distinctions are crucial for understanding the varied presentations of ADHD and tailoring interventions to meet the specific needs of each individual. It's not uncommon for children to exhibit symptoms from both categories, making the combined type the most prevalent subtype of ADHD.  

Diagnostic Criteria (American Psychiatric Association 2013)

Inattentive Type 

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
• Often has trouble holding attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
• Often has trouble organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
• Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
• Is often easily distracted.
• Is often forgetful in daily activities.

The criteria for ADHD, inattentive type, provide clear behavioral indicators for educators and clinicians to recognize. Children with this type of ADHD often struggle to hold attention on tasks or play, are forgetful in daily activities, and have difficulty paying close attention to details or following through on instructions. They may avoid tasks that require sustained mental effort, lose necessary items, get easily distracted by external stimuli, and be frequently forgetful in daily activities. For a diagnosis of ADHD, inattentive type, in children under the age of 16, at least six of these criteria need to be present. These criteria offer a practical framework for understanding and identifying inattentive behaviors in the classroom setting. 

Hyperactive Type  

• Often fidgets with or taps hands or feet or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go,” acting as if “driven by a motor.”
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting their turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games).

The criteria for ADHD, hyperactive type, are often more familiar to many people, as they describe behaviors commonly associated with hyperactivity. These children are frequently described as constantly moving, resembling an "energizer bunny" type. They struggle to sit still, are easily distracted by novelty, and find it challenging to inhibit their impulses.

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more settings (such as at home, school, or work, with friends or relatives, or in other activities).
• There is clear evidence that the symptoms interfere with or reduce the quality of social, school, or work functioning.
• The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

These symptoms typically manifest at a young age and may be observed across multiple settings, not just in one specific environment. While these behaviors may indicate ADHD, it's also essential to consider other factors, such as anxiety or autism spectrum disorder. While it is not your role to figure that out, it is your role to think about it. Is the child like this because they are nervous or want to pay attention but can't?

Characteristics and Behaviors  

• Frequently moving
• Impulsive
• Easily distracted
• Not hearing or remembering directions
• Handsy/aggressive 
• Off-task
• In other people’s space
• Fidgety
• Into everything

In the classroom, children with ADHD, the hyperactive type, are often observed as frequently moving around, displaying impulsive behavior, and struggling to follow directions. For example, a child may start getting ready to go outside but quickly become distracted by playing with their shoelaces or exploring someone else's cubby instead. They may appear easily distracted and have difficulty focusing on tasks or activities.

Children with ADHD, especially the hyperactive type, often struggle with remembering and following through on directions, which can lead to challenges in the classroom. This difficulty in retaining instructions may result in behaviors that draw attention, such as being handsy or aggressive. These children may exhibit behaviors like biting, hitting, kicking, throwing objects, or disrupting activities. It's common for such behaviors to catch the attention of teachers and caregivers, potentially leading these children to receive support or intervention.

In contrast to the inattentive type, who may appear quieter and more dreamy, children with hyperactive symptoms are often more visibly active and may engage in disruptive behaviors. While their actions may be disruptive or challenging, it's essential to understand that these behaviors often stem from underlying difficulties with attention and impulse control rather than intentional harm.

Children with ADHD, particularly those with the hyperactive, impulsive type, often struggle with impulsivity and may have difficulty restraining themselves from acting out. These behaviors can attract significant attention from teachers, parents, and eventually behavioral health clinicians. They may frequently appear off-task, engaging in activities unrelated to the current task or lesson. It's common to find them in other people's spaces or fidgety and restless, seemingly interested in everything around them.

It's worth noting that boys are often diagnosed more frequently with the hyperactive, impulsive type, while girls tend to receive diagnoses of the inattentive type more often. However, this gender difference in diagnosis doesn't necessarily reflect the actual prevalence of ADHD in boys versus girls. It's believed to be influenced by societal factors and gender norms related to behavior and attention. As a teacher, it's essential to consider how gender stereotypes may impact your perceptions of students' behavior and to be mindful of any biases in your observations. This awareness can help ensure that all children receive appropriate support and attention, regardless of gender.

Classroom Strategies

• Reduce commands to 1-2 steps at most
• Use of visual schedules
• Use of behavior monitoring systems (e.g., positive reinforcement) 
• Use of play to help support inhibition
• Meta-cognition strategies
• Lots of physical movement
• Outside time

Classroom strategies for children with ADHD can significantly impact their ability to stay engaged and succeed in the learning environment. One crucial strategy is the reduction of commands, where directions are broken down into one or two steps at most. For neurotypical children, instructions are typically broken down into manageable steps. However, for children with ADHD, it's essential to break down instructions even further. For example, instead of saying, "Get ready to go outside," it's more effective to say, "Put your boots on," followed by, "Now, put on your jacket." This approach helps children with attentional differences manage instructions more effectively as they are not receiving the ambiguous direction of "Get ready to go outside."

Visual schedules are also highly effective for children with ADHD, providing a clear visual representation of tasks and routines. Additionally, implementing a behavior system, such as positive reinforcement, can help reinforce desired behaviors and set clear boundaries. While whole-class behavior chart systems may not be ideal and can be shaming for children, targeted behavioral supports tailored to individual needs can be highly beneficial.

The research strongly supports the use of behavioral interventions for children with attention difficulties. Quick, clear positive reinforcement and establishing definite boundaries are key. For instance, implementing a system where specific actions have clear consequences, such as transitioning from red to yellow after hitting, reinforces desired behaviors. Play-based approaches are also beneficial for fostering self-regulation. Incorporating games like "Don't Break the Ice" or classics like "Simon Says," "Red Rover," or "Red Light, Green Light" helps children practice impulse control in a fun way.

Additionally, employing metacognitive strategies can aid in self-awareness and planning. By vocalizing your thought process, like prioritizing tasks aloud, children observe and learn organizational skills naturally. For example, say things like, "I am about to go on my lunch break. I need to fill up my water bottle, then tell Miss Jocelyn, my co-teacher, that I'm doing X, Y, and Z." Modeling this out loud helps children see how you prioritize things.

Physical movement is vital for many children with ADHD, as gross motor play helps regulate their behavior. Outdoor time, especially recess, is crucial for their well-being, as fresh air and exercise support regulation. The removal of recess is like torture for these children and is not supported in the literature as a strategy. Sleep is another critical factor. Poor sleep exacerbates inattention and hyperactivity, and there's a strong correlation between ADHD and sleep issues. You can provide a calm, relaxing space for naptime in the classroom. Encourage a healthy bedtime and a good nighttime routine with the family, and assist children in establishing healthy sleep habits.

Anxiety Disorders

Let's discuss anxiety disorders briefly. I'll provide a general overview because distinguishing between specific phobias or generalized anxiety disorders might not be particularly helpful for our discussion.

Diagnostic Criteria (American Psychiatric Association, 2013)

Imagine children experiencing excessive worry about specific situations, events, or topics, surpassing what we typically expect for their age. For instance, picture a group of four-year-olds hearing a plane overhead and wondering if it signifies a bombing. Or consider children who genuinely fear their mother's death or worry excessively about falling ill and going to the hospital. These concerns may seem disproportionately intense for their age.

Now, it's essential to recognize that worry is a common experience for both children and adults. It serves a functional purpose, alerting us to potential dangers. For instance, encountering a bear at a campsite naturally triggers a physiological response and prompts us to seek safety, which is adaptive. However, in anxiety disorders, worry extends beyond what the situation warrants and it becomes challenging to manage.

Many children have quirky worries, like fearing a tornado on a sunny day. Typically, we reassure them, and they move on. However, anxiety disorders differ in that the worry seems to linger no matter how much reassurance they receive. It feels as if the worry becomes stuck, spinning endlessly despite efforts to alleviate it. This difficulty in managing anxiety can be challenging for both the child and the parent. Furthermore, I prefer the term "manage" over "control" when discussing anxiety. It conveys the idea that the worry may be too overwhelming for the child to handle entirely.

Sometimes, we observe physiological symptoms in children that are primarily body-based. They might cry uncontrollably, take deep breaths, or speak with a shaky voice. Additionally, they may struggle with saying goodbye, appearing on edge, or exhibiting irritability. Another aspect of anxiety involves somatic symptoms, where children experience physical discomfort without a clear bodily cause. Common complaints among children include stomach aches and headaches, particularly in situations like preparing for school or outdoor activities. These complaints often prompt us to question the underlying cause, considering the possibility of anxiety.

Separation anxiety is a prevalent category of anxiety disorders in early childhood, characterized by difficulties separating from caregivers. Many of us have encountered this scenario in preschool settings, where some children find it challenging to adjust to being apart from their parents. While it's normal for some children to need time to adapt, the adjustment period seems prolonged for others. These children may struggle to settle even after their parents leave, exhibiting persistent anxiety.

What distinguishes typical separation worries from more concerning cases is their duration and underlying fears. While it's natural for children to experience separation anxiety during certain developmental stages or transitions, persistent anxiety that lingers beyond what's expected raises concerns. Often, children express fears related to their caregivers, such as worrying that they won't return or fearing something might happen to them or their parents. These fears, particularly the fear of a caregiver's death, elevate the anxiety to a more severe level.

In discussing anxiety, we've covered typical levels of worry and anxiety that children experience. However, there's another level beyond this—the heightened anxiety characterized by irrational fears, such as fearing a parent's death while they're away, despite no evidence to suggest such a possibility.

Characteristics and Behaviors

• Long, tearful goodbyes that are difficult to re-regulate
• Frequent talking, drawing, or playing about a specific topic
• Reassurance seeking
• Panic attacks
• Tearfulness
• Sadness and fears
• Fearful of new events/teachers/situations

We've already started delving into this, but what you might observe in the classroom are prolonged and challenging goodbyes, making it difficult for children to return to a baseline state. While it's not uncommon for kids to experience tearful moments, it's concerning if it takes them hours to calm down, with anything exceeding 30 minutes raising red flags. Additionally, you may notice frequent instances of children talking, drawing, or playing about very specific topics, ranging from fears of natural disasters to specific foods. While this behavior may indicate an attempt to gain mastery over their fears, it's worth paying attention to if it occurs more frequently than expected.

Another behavior to watch for is reassurance seeking, where children repeatedly ask about the return of their caregivers despite receiving reassurance. This behavior persists because the reassurance doesn't seem to alleviate their anxiety, leading them to seek it repeatedly throughout the day. While full-blown panic attacks are rare in children under five, they can occur, characterized by hyperventilation, vomiting, profuse tears, and a rapid heartbeat. The primary goal during panic attacks is to regulate the child's emotions and physiological responses to restore a sense of safety and calm.

Furthermore, you may encounter tearful children who exhibit signs of sadness or fear, particularly in response to new events, teachers, or situations. It's understandable that such changes would be overwhelming for them, as they struggle when things don't follow a familiar pattern. Recognizing and addressing these emotional challenges is essential for supporting children's well-being and promoting their healthy development.

Classroom Strategies

• Clear and consistent routines
• Loving and attuned responses
• Mindfulness and breathing strategies
• Collaboration with caregivers
• Balance reassurance with healthy responses
• A worry corner or stuffy 
• Books about worry and feelings

Classroom strategies are crucial in supporting children with anxiety. Establishing clear and consistent routines can be incredibly helpful, especially during the initial stages of an anxious response at drop-off. Consistent actions, such as hugs from mom and a comforting routine like being held and then reading a book, provide a sense of security for the child. Teachers' warm, loving, and attuned responses play a vital role in reassuring anxious children. It's important for children to feel supported and understood, knowing that their teachers are there to help them navigate their worries.

Mindfulness and breathing exercises are highly effective strategies for managing anxiety at any age. Even very young children can learn to take deep breaths to help calm themselves down. Collaboration with parents is essential in understanding what strategies may work best for each child and reinforcing consistent approaches between home and school. Balancing reassurance with encouraging healthy responses empowers children to manage their worries more effectively. For example, acknowledging a parent's return while also reminding the child that parents always come back can help instill confidence in the child's mind.

Many classrooms now incorporate designated spaces like worry corners, cozy corners, or calm-down corners, providing children with a soothing environment where they can go to relax. Transitional objects, such as a piece of mom's scarf, a picture, a keychain, or a favorite stuffed animal from home, can offer comfort and familiarity throughout the day. Integrating books about feelings and coping strategies into classroom activities normalizes discussions about emotions and provides valuable opportunities for children to express themselves and learn from one another. By implementing these strategies consistently and compassionately, educators can create supportive environments where anxious children feel safe and empowered to manage their worries.

Selective Mutism

A specific type of anxiety disorder that often lacks awareness in both the mental health and teaching communities is selective mutism. This condition primarily affects children in early childhood, making it particularly relevant to our discussion. Selective mutism is characterized by an individual's consistent failure to speak in specific social situations despite being able to speak in other settings. This can include environments such as school or social gatherings where the child remains silent or minimally communicative, even though they may be fully capable of verbal expression in other contexts. The condition is often misunderstood or overlooked, leading to challenges in diagnosis and support for affected individuals. 

Diagnostic Criteria (Selective Mutism Association, 2024) 

• Speaks freely at home and with family but is nonverbal due to anxiety in public settings or around strangers
• Is paralyzed with fear or shuts down completely when unable to communicate
• Struggles to make eye contact when uncomfortable
• Presents as behaviorally inhibited 
• Relies on pointing, nodding, writing, and other forms of nonverbal communication to answer questions 
• Speaks through a trusted individual—e.g., whispering an answer to a question to a parent or friend at school 

The true hallmark of selective mutism is often described by parents as a stark contrast between their child's behavior at home and in other settings. At home, these children are often chatterboxes, constantly vocalizing, playing loudly, and engaging with their siblings in a boisterous manner. However, when observed in the classroom, they become predominantly nonverbal. Their demeanor may appear fearful rather than defiant, with blank facial expressions and apparent struggles to articulate words. Maintaining eye contact can be challenging for them, often opting to look downwards. As a teacher, you may find it difficult to elicit verbal communication from them. Occasionally, they may resort to pointing, nodding, or even writing, but direct verbal responses to questions are rare.

This stark contrast between home and school behavior is a key characteristic of selective mutism. In some cases, these children may rely on a trusted individual, such as a parent, friend, or sibling present in the classroom, to communicate on their behalf. For instance, when prompted about their day or weekend, they may gesture towards their parent, who then relays their response to you.

Characteristics and Behaviors

In the classroom, the manifestation of selective mutism often aligns closely with the description provided earlier. In some instances, you may encounter children who speak only in whispers or brief utterances, making their speech barely audible or comprehensible. They may offer only one or two words throughout the day, typically limited to responses like "yes" or "no." Recognizing that these children are not exhibiting this behavior due to a lack of knowledge or a deliberate refusal to engage is crucial. Rather, it stems from underlying anxiety. Their body's response to stress leads to a state of shutdown, hindering their ability to express themselves adequately. Understanding this distinction is paramount—they are not intentionally being disobedient or evasive in their responses. For example, I've witnessed situations where a child is expected to participate in circle time sharing activities but remains silent for an extended period, causing discomfort among their peers and uncertainty among teachers. Merely waiting them out in such scenarios can exacerbate the issue. Hence, seeking guidance and support on how best to assist these children in the classroom is imperative.

Classroom Strategies (Selective Mutism Association, 2024)

• Limit direct questions; instead, use statements/reflections and praise
• Wait 5 seconds 
• Prepare greetings for how to greet the child each day
• Empathize and encourage
• Praise for any communication
• Build the relationship!

Collaborating with parents is paramount in addressing these challenges. The Selective Mutism Association offers extensive resources and training for educators dealing with such issues. If you suspect a child in your class is struggling, I urge you to explore these materials in greater depth. From my experience, nurturing a strong teacher-student bond can profoundly impact a child's progress. Understanding and valuing each child's unique needs can truly make all the difference. It's remarkable how, with the right support, children can overcome obstacles and flourish academically and socially.

Here are some quick tips to aid you in this endeavor: Firstly, allow a brief pause of 5 seconds before intervening or answering questions on behalf of the child. Secondly, minimize direct inquiries and instead utilize statements, reflections, and praise to encourage participation. For example, rather than asking, "What's the weather doing today?" try acknowledging, "You're showing me on our chart what the weather's like today." Thirdly, tailor your greetings to suit each child's comfort level, such as offering a handshake, high five, or expressing enthusiasm without verbal interaction. Finally, emphasize praise and positive reinforcement for any form of communication initiated by the child. Ultimately, nurturing a positive relationship with the child is paramount to fostering their development and creating a supportive learning environment.

Sensory Processing Disorders

Diagnostic Criteria

• Not technically a diagnosis in the DSM
• Occupational therapists provided
• Being hyper- or hypo- aroused by sensory stimuli 
• Repetitive behaviors 

We'll delve into sensory processing disorders (SPD) now. It's essential to grasp that SPD isn't formally recognized as a diagnosis in the DSM. While it appears in the DC 0-5, it's categorized differently in the DSM as "other neurodevelopmental," which lacks specificity. There was considerable debate over its inclusion in the DSM, but ultimately, it was omitted. Nonetheless, many professionals in early childhood education and clinical fields have observed its potential relevance to certain children's experiences, prompting a need to understand it. SPD involves being hyper or hypo-aroused by sensory stimulation. This can manifest in repetitive behaviors rather than isolated incidents of sensory seeking.

The Eight Sensory Systems (Star Institute, 2024)

• Visual
• Olfactory
• Auditory
• Tactile
• Taste
• Vestibular
• Proprioception
• Interoception

The first crucial aspect to understand about sensory processing is that there are actually eight sensory systems. Alongside the familiar five senses we learn in school—visual, olfactory (smell), auditory (hearing), tactile (touch), and taste—we also have vestibular, which governs our head and body position in space, including inner ear movement sensations. Additionally, there's proprioception, which involves receptors in muscles and joints and is related to activities like heavy work such as jumping, swinging, pushing, pulling, and climbing. Lastly, interoception provides clues about internal bodily sensations like temperature, hunger, and the need to use the restroom.

From my experience, when a child struggles with sensory information, it often involves these last three systems. While touch sensitivity or aversion to loud noises are more commonly recognized, challenges with proprioception and interoception may be less apparent. For instance, a child might have difficulty sensing when they need to use the bathroom, leading to frequent accidents, or they may struggle with spatial awareness and frequently bump into objects.

Characteristics and Behaviors

• Bumping into things, clumsy behavior
• Risky behaviors: jumping off high spaces, climbing, etc. 
• Fidgeting
• Extreme dislike of textures (slimy, sand, play-doh, etc.) 
• Wild behavior 
• Spinning, flapping
• Watching objects move with intensity 
• Drooling, messy eaters 
• Eyes that dart/take in everything
• Recoil to touch/love hugs or tight squeezes

Some of the manifestations I observe in the classroom include instances of bumping into objects or displaying pronounced clumsiness. For example, a student might trip over a step that has been consistently present throughout the year, prompting curiosity about the recurrent mishap. Additionally, there are occasions when a child unmistakably foresees a collision from afar but still collides with the object, highlighting a lack of coordination.

Risky behaviors also emerge, where children are drawn to heights or engage in activities perceived as dangerous. Despite warnings, they may be compelled to jump from elevated surfaces, not out of defiance but rather from a desire to experience the sensations associated with movement and impact. Furthermore, some children exhibit climbing behaviors beyond conventional play structures, seeking sensory input through physical exertion.

Others may demonstrate heightened fidgetiness or aversion to certain textures, such as sand or playdough, impacting their comfort during sensory activities. In and of itself, these are not problematic, but if coupled with other areas that are concerning or getting in the way of the child being their best self, there could be more concern.

Intense or disruptive behaviors, like excessive giggling, screaming, hand flapping, or spinning, often signal underlying dysregulation, while fixating on specific objects or constantly scanning their surroundings reflects a heightened sensory awareness. Issues with oral motor skills might manifest as messy eating habits or drooling, which, when excessive, may indicate oral motor concerns affecting their interaction with food and objects. Lastly, depending on their sensory preferences, children may display varying degrees of comfort with physical touch, either seeking or avoiding hugs and squeezes.

Classroom Strategies

• Less visual stimuli in the room
• Noise-canceling headphones
• Calming zones with a variety of textures
• Lowering lights/sounds
• Hugs, tight squeezes 
• Sunglasses
• Crash opportunities 

When addressing potential sensory challenges in the classroom, consider modifying the environment to accommodate the child's needs. For instance, reducing visual clutter can be beneficial if a child is visually overstimulated. While removing all visual stimuli is unnecessary, selectively reducing the number of items on display can help alleviate sensory overload. In preschool classrooms, it's common to have a variety of visual stimuli, including pictures, artwork, posters, art centers, and toys. While this richness of visual information is typical and beneficial for most children, it's essential to consider individual needs. If you notice a child who may be overwhelmed by the visual environment, removing everything is unnecessary. Instead, consider selectively reducing visual clutter to support the child's sensory needs.

Similarly, providing noise-canceling headphones can help mitigate distractions for children sensitive to auditory stimuli. Adjusting the volume of background noise or limiting simultaneous audio sources can also create a more conducive learning environment.

Creating designated calming areas within the classroom can offer students a retreat where they can regulate their sensory experiences. These areas can incorporate a variety of tactile textures and subdued lighting to promote relaxation. Depending on your center's policy, hugs, and tight squeezes can help children regulate their senses and calm down as well.

In addition, offering sensory tools such as sunglasses or crash pads allows children to engage with their environment in a way that feels safe and comfortable. Implementing strategies like these can enhance the overall sensory experience for all students in the classroom.

Trauma and Behavioral Disorders

Diagnostic Criteria (American Psychiatric Association 2013) 

• Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
  • Directly experiencing the traumatic event(s).
  • Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.
  • Learning that the traumatic event(s) occurred to a parent or caregiving figure.
• Presence of one or more of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  • Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
  • Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma reenactment may occur in play.
  • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  • Marked psychological reactions to reminders of the traumatic event(s).
• One or more of the following are associated with the traumatic event(s) or negative alterations in cognition and mood.
  • Persistent avoidance of stimuli
  • Avoidance of or efforts to avoid places or physical reminders that arouse recollections of the traumatic event(s).
  • Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).
• Negative alterations in cognitions
  • Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
  • Markedly diminished interest or participation in significant activities, including constriction play.
  • Socially withdrawn behavior.
  • Persistent reduction in expression of positive emotions.
• Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
  • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)
  • Irritable behavior and angry outbursts (with little or no provocation) are typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums)
  • Problems with concentration
  • Hyper-vigilance
  • Exaggerated startle response

Post-traumatic stress disorder (PTSD) occurs when a child has been exposed to an actual or threatened death or when such an event has occurred to someone they love or care about, including a caregiving figure. This exposure could involve witnessing such events, experiencing them directly, or having them happen to someone close to them.

These traumatic experiences trigger a range of symptoms, including intrusive thoughts such as flashbacks, nightmares, or persistent preoccupation with the event. Some children may also experience dissociation, feeling disconnected from their bodies or surroundings, though it can be challenging for them to articulate. Additionally, they may exhibit distress or heightened emotional reactions when reminded of the traumatic event.

Another common symptom is avoidance, where children actively avoid anything that reminds them of the trauma, including objects, conversations, or specific places associated with the event. Finally, there may be negative changes in mood, characterized by increased sadness, anger, or withdrawal, and a diminished capacity for experiencing joy. These mood alterations, such as being excessively sad, are often observable in children with PTSD.

The symptoms of PTSD must persist for more than a month to be clinically significant. For instance, many children may exhibit signs resembling PTSD shortly after experiencing a traumatic event, such as a car accident or a natural disaster. During the initial weeks following such events, it's common for both children and adults to experience symptoms like intrusive thoughts, nightmares, and heightened arousal. However, it's the duration of these symptoms beyond the initial phase that distinguishes PTSD. If these symptoms persist beyond the initial weeks and begin to significantly affect the child's daily functioning and relationships, it may indicate PTSD.

Characteristics and Behaviors

• Startle easily
• Violent/aggressive play or play themes
• Fearful of caregivers
• Inappropriate conversations/topics/knowledge
• Easily dysregulated
• Shut down/hard to reach 
• Nightmares/distress around routine activities
• Fight or flight responses

In a classroom setting, signs of PTSD in children may include heightened startle responses. For instance, if someone drops something or slams a door, a child with PTSD may react by jumping visibly, indicating a heightened sensitivity to loud or sudden noises. Additionally, their play behavior may exhibit aggression or violence, which can be concerning. While fearfulness of caregivers or adults doesn't necessarily indicate abuse, it's important to monitor such behaviors closely. Inappropriate conversations, knowledge, or topics beyond a child's developmental stage may also raise red flags. For example, if a young child discusses adult concepts or experiences, it may suggest exposure to inappropriate content or traumatic events.

Children with PTSD may also struggle with emotional regulation. They might easily become dysregulated or shut down in response to triggering situations, such as going to the bathroom or experiencing nightmares during nap time. Furthermore, they may exhibit fight, flight, or freeze responses, indicating a heightened state of distress or perceived threat. This physiological response occurs when the body perceives danger and prepares to react accordingly. Therefore, it's crucial to recognize these signs and provide appropriate support and intervention for children experiencing PTSD symptoms in the classroom.

Classroom Strategies

• Express concern and/or report as needed
• Discuss your own concerns and get support
• Set boundaries
• Provision of safety
  • Emotional, social, physical, and regulation

Navigating such situations as a teacher can indeed be challenging. It's crucial to foster open communication with parents or caregivers to gain insights into a child's experiences outside the classroom. If you suspect a child is experiencing trauma or distress, discussing your observations and concerns with the parents is essential. Together, you can explore strategies to support the child effectively. For example, if the child and their family were in a tornado, they could experience effects from that trauma.

In some cases, you may need to consider reporting concerns of child abuse or neglect. However, consulting with your colleagues, such as your co-teacher and director, is advisable before making such a report. Collaboration ensures that the decision is well-informed and addresses the child's best interests.

Setting clear boundaries with the child and their family is also important. Establishing acceptable behavior and providing a safe environment, physically, emotionally, and socially, is paramount. For instance, if a child exhibits fear during storms, the class can collectively create supportive measures to help the child feel safe, such as designated comforting spaces or supportive actions from peers and teachers. By prioritizing safety and communication, teachers can effectively support children experiencing trauma or distress in the classroom.

Having Tough Conversations with Parents

• Private, dedicated conversations
• Lead with warmth and compassion, as well as humility 
• Bring data and concrete observations
• Bring referrals 
• Be ready to share what accommodations are being provided at school 
• Be ready to discuss continued ideas/support

Discussing concerns about a child's development or behavior with parents can be challenging, but it's necessary to ensure the child receives appropriate support. Once you've identified potential areas of concern through discussions with colleagues and observations, initiating a conversation with the parents is essential. Typically, these discussions occur as parents are picking up their child from school, but it's preferable to schedule a dedicated and private time for the conversation to ensure privacy and focus.

When approaching the conversation, it's important to lead with warmth and compassion, acknowledging the sensitivity of the topic. Expressing empathy and understanding can help alleviate some of the potential anxiety or stress parents may feel. Additionally, be clear about the purpose of the conversation and what you hope to discuss, such as observations or concerns regarding the child's behavior or development.

Ensure that both parents or any relevant caregivers are present, if possible, and set a respectful and supportive tone for the discussion. While it's important to be honest about your observations and concerns, approach the conversation with humility, recognizing that you're not making definitive diagnoses but rather sharing observations and suggesting further evaluation if needed.

When delivering difficult news to parents, leading with empathy and humility can help create a supportive environment. Acknowledging the conversation's potential difficulty and understanding the emotions involved can help parents feel more at ease. It's important to convey that while you may not have all the answers, you believe it's worth exploring further. For example, stating that you're not a speech therapist or an occupational therapist but suggesting that meeting with one could be beneficial demonstrates humility and a commitment to the child's well-being.

Parents often appreciate concrete observations and data to support discussions about their child's behavior or development. Therefore, it's helpful for teachers to document and organize observations before the conversation. Providing specific examples, rather than vague descriptions, allows parents to better understand the concerns being raised. For instance, instead of saying a child doesn't play well with others, providing examples of interactions with peers can offer clarity.

In preparing for the conversation, focusing on two or three key points you want the parents to take away can be beneficial. This helps ensure that essential information isn't overlooked or lost during the discussion. Drawing from my experiences as a psychologist, where distilling information into key points was emphasized, can guide teachers in structuring the conversation effectively. 

When making referrals, providing actionable steps rather than vague suggestions is essential. Instead of simply expressing that support is needed, offer specific recommendations and resources. For example, you might suggest meeting with the Early Intervention (EI) team and providing their contact information, offering to facilitate an introduction if needed. Similarly, if you know of a therapist or service provider in the community, share their details with the parent and offer assistance in connecting with them. Providing a list of recommended places for occupational therapy can also guide parents in taking the next steps.

Additionally, it's valuable to share what measures are already being taken at school to support the child. By discussing observations and strategies implemented in the classroom, you can help parents understand how their child's needs are being addressed. For instance, explaining how these observations inform classroom practices can be enlightening for parents if you've noticed certain behaviors or patterns, such as difficulty with indoor recess compared to outdoor recess. This information demonstrates proactive efforts and encourages parents to consider similar strategies at home or in other settings.

Lastly, engaging in open discussion with parents about their thoughts and preferences regarding potential interventions is crucial. Encourage parents to share their perspectives and preferences and be receptive to their input. Collaborating with parents in developing a plan moving forward fosters a sense of partnership and ensures that interventions align with the child's needs and family dynamics.

Next Steps for Teachers

Your next steps involve making referrals, collaborating with outside providers, and completing necessary documentation for your center. This includes documenting actions required on your end and any forms requested by external providers. When referring a child to a community service, it's essential to communicate effectively with the provider. Given your intimate knowledge of the child, they will likely reach out to you again for insights. Your observations and experiences are invaluable for informing their approach.

Formal surveys or tools may be provided for you to complete to streamline this process. Considering your busy schedule, your prompt and thorough completion of these documents is greatly appreciated. Your input is crucial for the comprehensive assessment and support of the child's needs. By sharing your observations of what has been effective or ineffective in the past, you contribute to the development of a tailored intervention plan that maximizes the child's progress and well-being.

Common Forms

You may encounter various forms as part of the assessment process, and it's helpful to familiarize yourself with their names and purposes. One such form is the BASc-3, which stands for Behavior Assessment System for Children, Third Edition. This assessment evaluates a broad range of behaviors observed in a classroom setting. It compares your responses to those of other teachers who work with children of the same age, providing valuable data on what is considered typical and what may be outside the norm.

Another form you might encounter is the Connors assessment, which focuses specifically on Attention-Deficit/Hyperactivity Disorder (ADHD). This assessment helps in identifying symptoms related to ADHD and assessing their severity.

Additionally, you may come across the Vineland Adaptive Behavior Scales (VABS) or the Adaptive Behavior Assessment System (ABAS). These assessments measure adaptive functioning, which refers to how well an individual manages daily activities and responsibilities. It assesses abilities related to self-care, social interactions, communication, and other essential skills needed to function effectively in various environments, including the classroom and home.

Teachers play a crucial role in this process by being honest, thorough, and timely in their observations and documentation. It's essential to understand the parameters of the assessments, such as the timeframe being referenced, to provide accurate information. It's best to communicate with the provider for clarification if there are any uncertainties or unanswered questions.

Although there may be numerous demands on your time, engaging in discussions with the provider can offer a more nuanced understanding of the situation. Providers value your input and insights as they contribute to a comprehensive understanding of the child's needs. Collaboration between behavioral health professionals and educators is essential, as both share the common goal of promoting the child's success and well-being.

Case Presentation

Let's briefly revisit our case study. I encourage you to review your notes and consider how you might perceive the behaviors differently now. You don't need to share your thoughts but take a moment to reflect on where your mind is going. What changes might you consider making in your classroom? What thoughts or questions arise about the underlying reasons for these behaviors? Feel free to jot down your reflections.

• 5 y/o male
• Threw a chair at a peer last week
• Comes in very upset most mornings, tearful and difficult goodbyes
• Struggles when there is a substitute teacher
• Stands outside circle time, often refusing to sit
• Prefers to not be touched by peers/classmates
• Has one staff he really prefers 
• Eats similar/same meals most days

As you reflect, notice that I intentionally framed and analyzed this child's behavior within the context of various diagnoses. It's conceivable that this child could fit into several of the categories discussed today, and that's acceptable. Despite the potential diagnoses, many of the behaviors we've discussed remain concerning, regardless of their origin.

Considering this, seeking a referral for further evaluation is likely prudent. Consultation with other members of your team can help determine the best course of action for supporting this child as their teacher. Think of this child as a puzzle—understanding what's happening is key to providing effective support. For instance, if the concern revolves around anxiety, the symptoms might also align with a diagnosis of autism. How would you adjust your support in that case? Remember, while diagnosing isn't your role, communicating with parents and fostering an inclusive classroom environment are crucial aspects of your job. Understanding the diagnosis enables you to tailor your support to effectively meet the child's needs.

Common Questions/Concerns

Teachers sometimes inquire about how to handle situations where parents seem resistant to hearing their concerns. This can occur for various reasons, perhaps stemming from the difficulty of acknowledging potential issues with one's child. As a teacher, your role is to express your concerns respectfully and empathetically, understanding that it's ultimately the parents' prerogative to process and respond to them.

If faced with parental reluctance, consider involving your director or shelving the discussion for a later time. You might also gather more information to bolster your case. Offering validation and reassurance can also help ease the conversation, emphasizing that your intention is to support the child's well-being rather than criticize the parents' parenting skills. Maintaining a humble approach can be beneficial, acknowledging uncertainty and expressing hope that your concerns are unfounded. It's worth noting that your observations and insights can have a lasting impact, even if the parents do not immediately acknowledge them.

Another common concern is realizing that your facility may not fit a particular child's needs best. The child might need a higher level of care than your facility may be able to offer. In such cases, it's essential to communicate openly with your director or admissions coordinator. Before broaching the topic with parents, ensure that logistical arrangements are in place to effectively address the child's needs.

Directness is crucial, but it's essential to approach the conversation with careful consideration and preparation, particularly if significant financial implications are involved. Ultimately, the goal is to ensure that the child receives the support and care they require in the most suitable environment possible.

Helpful Resources for Teachers

I'd like to draw your attention to some of the resources I've provided for you. Firstly, there's the milestone tracker from the Centers for Disease Control (CDC). The CDC Early Milestone Tracker can be invaluable if you assess developmental milestones and consider whether a referral for early intervention is necessary. This tool allows for comprehensive tracking, which can be particularly useful if your childcare facility isn't already utilizing a similar system.

I've also included a direct link to the Selective Mutism Toolkit we discussed earlier. This resource offers practical guidance and strategies for addressing selective mutism in educational settings.

Autism Speaks is another excellent resource. As a well-known national organization, they provide extensive support for educators and parents of children on the autism spectrum. Their website contains a wealth of information and resources that can be accessed easily.

Lastly, I highly recommend exploring the Harvard Center for the Developing Child. This resource is one of my personal favorites, offering a plethora of information on various topics related to child development. It's a valuable resource for deepening your understanding and enhancing your practice.

If you have any questions or comments or need support after this presentation, please don't hesitate to reach out to me. I'm always eager to hear your thoughts and provide assistance wherever possible.

CDC Developmental Milestone Tracker: https://www.cdc.gov/ncbddd/actearly/milestones/digital-online-checklist.html

Selective Mutism Toolkit for Teachers:  https://www.selectivemutism.org/educators/

Autism Speaks: https://www.autismspeaks.org/

Harvard Center on the Developing Child, Early Childhood: https://developingchild.harvard.edu/science/deep-dives/mental-health/

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bödeker, K., Watrin-Avino, L. M., Martin, A., Schlensog-Schuster, F., Janssen, M., Friese, L., Licata-Dandel, M., Mall, V., Teich-Bělohradský, J., Izat, Y., Correll, C. U., Möhler, E., & Paulus, F. W. (2023). Assessment and diagnostic classification using DC:0-5 in early childhood mental health clinics: The protocol for the Developmental Psychiatry Diagnostic Challenges Study (DePsy). Children, 10(11), 1770. https://doi.org/10.3390/children10111770

Brown, K. A., Parikh, S., & Patel, D. R. (2020). Understanding basic concepts of developmental diagnosis in children. Translational Pediatrics, 9(Suppl 1), S9–S22. https://doi.org/10.21037/tp.2019.11.04

CDC. (2022, April 11). Learn the Signs. Act Early. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/actearly/whyActEarly.html#:~:text=Early intervention:&text=Can have a significant impact

Center on the Developing Child. (2013). In Brief: Early Childhood Mental Health. Center on the Developing Child at Harvard University. https://developingchild.harvard.edu/resources/inbrief-early-childhood-mental-health/

Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. § 1400 et seq. (2004).

Selective Mutism Association. (2024). What is Selective Mutism? Retrieved from: www.selectivemutism.org

Star Institute for Sensory Processing. (2024). Your 8 Senses. Retrieved from: https://sensoryhealth.org/basic/your-8-senses

Substance Abuse and Mental Health Services Administration. (2016). DSM-5 Changes: Implications for Child Serious Emotional Disturbance. Rockville, MD: Substance Abuse and Mental Health Services Administration (US). Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t4/

Zero to Three. (2016). DC: 0-5: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Washington, DC, USA: Zero to Three/National Center for Infants, Toddlers, and Families.