Lecture # 116:
Other Health Impairments, Continued

Objectives:
1. The student will be able to identify the symptoms and types of Attention Deficit/Hyperactivity Disorder.
2. The student will know what types of support are needed for the family of a child who is dying.
3. The student will know about practical examples of collaboration between health professionals and others for the benefit of a child.

Attention Deficit/Hyperactivity Disorder
Adam's teacher referred him for an evaluation after her attempts to help him improve his classroom behavior did not succeed. The evaluation team identified Adam's problems as Attention Deficit/Hyperactivity Disorder. His doctor prescribed the stimulant medication Ritalin.

Although this medication does not help Adam's ability to learn new information, it seems to help him to concentrate better on information that is presented in the classroom and to demonstrate what he knows. Additionally, Adam meets with a group of other students who have the same symptoms, they work on social skills and relaxation techniques to cope in the classroom. In the classroom, his teacher has a structured behavior program for Adam so that he remembers what he is to do and the consequences if he does not do it. Adam says he is making friends for the first time in his school.

Meditate Word By Word On These Verses:
1 Cor. 15:50-55 and 58.

Students with AD/HD differ significantly from peers in their ability to concentrate and control their impulses. Not all children with AD/HD are hyperactive, some are hypoactive: they respond and move slowly.

There are three categories of AD/HD. The first is predominantly inattentive type, meaning children have trouble with attention in class and are forgetful and easily distracted. The second, predominately hyperactive-impulsive type, includes students who cannot sit still, often talk excessively, and find playing quietly difficult. The third is a combined type where there is inattention, hyperactivity, and impulsivity. To have the diagnosis of AD/HD, the child must be under the age of seven and have symptoms for at least six months.

The criteria for AD/HD are as follows:
A. Either 1 or 2
(1) Inattention: At least six of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level of people the same age:

(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
(b) Often has difficulty giving attention to tasks or play activities.
(c) Often does not seem to listen to what is being said to him or her.
(d) Often does not follow through with instructions and fails to finish schoolwork, chores, or duties in the workplace.
(e) Often has difficulties organizing his schoolwork and other activities.
(f) Often avoids tasks (schoolwork) that require sustained mental effort.
(g) Often loses things required to do a task - school assignments, pencils, books, tools, or toys
(h) Is often distracted by other stimuli around him.
(i) Often forgets his daily activities and schedule.

(2) Hyperactivity-Impulsivity: At least six of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental levels:

Hyperactivity:

(a) Often fidgets with his hands or feet or squirms in his chair.
(b) Leaves his seat in the classroom or in other situations in which remaining seated is expected.
(c) Often runs about or climbs excessively in situations where it is inappropriate (in adolescents and adults, may be limited to subjective feelings of restlessness).
(d) Often has difficulty playing or participating in leisure activities quietly.
(e) Often talks excessively.
(f) Often acts as if he cannot sit still.

Impulsivity:

(g) Blurts out answers to questions before they have been completed.
(h) Often has difficulty waiting in lines or waiting for his turn in games or group situations.
(i) Often interrupts or intrudes on others.

B. Onset no later than seven years old.
C. Symptoms must be present in two or more situations - school, work, home.
D. The disturbance causes distress and impairment in social, academic, or occupational functioning.
E. Does not occur exclusively during the course of the following disorders:
Pervasive Developmental Disorder, Schizophrenia, Mood Disorder, Personality Disorder, or Dissociative Disorder.

Did you notice that almost all the psychological characteristics seem to relate to school activities? Many children with AD/HD can concentrate when playing video games, sports, or watching TV. Their difficulties are more evident when restrictions are put on their behavior (having to sit quietly at a desk in school) or the task to do is complex. In these instances, the child is required to use planning, executive regulation of behavior and organization. Thus the child has more symptoms in school when he has behavioral restrictions and task complexity is greater.

Additionally, children with AD/HD seem not to associate consequences with behavior and do not develop an internal set of rules for governing behavior as his peers have done. Thus AD/HD students seem immature in their responses to the classroom atmosphere and people around them. Further, others frequently reject them because they are disruptive, intrusive, and easily frustrated. Approximately 33% of children with learning disabilities also have AD/HD.

Rejection by peers is a serious outcome of AD/HD because children who are rejected early in life tend to be high risk for many adult adjustment problems, including job terminations, bad-conduct discharges from the military, negative contact with police, and psychiatric hospitalization.

Question:
1. The two main difficulties for children with AD/HD are:
(One or more of the following answers may be correct.)
a) digestion of milk products.
b) concentration.
c) consequences of behavior.
d) control of impulses.

Treatment of AD/HD
Intervention for children with AD/HD is based on four pillars. The first is medical management. Medication can improve over-activity, inattention, and impulsivity, allowing the student to increase accuracy and the amount of schoolwork as well as improve social interactions. It does not improve learning or achievement and no long-term improvement is noted. Also, there are sometimes side effects that interfere with sleeping, eating, or appearance.

Psychological counseling is the second pillar. Usually, counseling does not improve the child's behavior in the classroom. However, it does help him personally, because he begins to better understand his behavior and thus improve his feelings about himself.

Educational planning is the third pillar. There are several ways to help a student in the classroom:

Give him experiences where he does activities with his hands.
Try to find a quiet corner of the room where he can sit away from distractions to do schoolwork.
Help the student to organize his desk - pencils in a bag, notebooks for different classes, etc.
Teach him to review his assignments and check for errors.
Students should be taught the sequence of "stop" before acting, "think" about what they are going to do, "say" aloud what they are going to do, "do" what they have said.
Teach students to talk themselves through rote tasks such as math problems or practice writing letters.
Reinforce the times the student is attentive by giving him praise.
Help the student to get his assignments done by making a chart and noting when they are done.
Identify his behaviors that are not appropriate.
Clearly communicate expectations of desirable and undesirable behaviors.

Students seem to get the most benefit from the fourth pillar: behavioral management. When it is combined with cognitive training, the child is able to monitor his own behavior and know if he is being successful or not. Such a program needs to be coordinated between home and school because the student needs consistency for it to be effective.

Causes of Health Impairments
The causes of other health impairments are three: infections, genetic factors, and environmental influences.

Numerous diseases are caused by infections. They do not cause particular health impairments to the average child, but some infections produce long-lasting consequences and can lead to death. A common infection such as streptococcus throat infection can result in rheumatic fever and heart problems. Infections cause HIV, cancers, and tuberculosis. Seizure disorder can result from brain infections such as meningitis and encephalitis.

There are genetic predispositions that are part of the reason for development of diabetes, asthma, attention deficit disorder, and specific cancers. In addition, environmental factors or infections can work in conjunction with genetic factors to cause a condition. Diabetes is a disease of genetic susceptibility. That means the child can be born with a genetic that makes him prone to diabetes. Therefore, what he eats, his weight, and stress levels may also combine to give him childhood diabetes.

Teratogens are environmental influences that prohibit normal growth of the fetus. They include exposure of the mother to infections, radiation, drugs, tobacco, or alcohol. Prenatal substance exposure increases a child's risk for developing other conditions such as AD/HD, seizure disorder, and HIV. There are also such environmental problems as lead paint and lead pipes that increase lead levels in the blood of children. This causes abnormal brain function. Cigarette smoking by a parent can cause asthma or other lung diseases for the child who lives in the same home. Diet is also a factor. Allergies can cause an asthmatic attack. We also know that eating a diet low in sugar and decreased food additives helps the child with AD/HD to control his behavior. Specifically, certain types of red food coloring are known to cause health problems.

Evaluation Procedures

Determining the Presences of Other Health Impairments
The first part of the process is to take a medical history. If you are working with a child, any information about symptoms that you have noticed should be documented in writing and given to the parents. They need to share this information with the doctor. After a diagnosis and plan of treatment is made, the child may have the ability to return to school, but with some modifications in his classroom. If the child is homebound, then he needs teaching services at home. For students with cognitive and behavior changes, a full evaluation including intelligence testing, achievement testing, and behavior rating scales are need to decide if the student will need special education.

Match these terms with the definitions below:
A. Genetic, - B. Environmental, - C. Infection.

2-1. Red food coloring.
A, B, C.

2-2. Meningitis.
A, B, C.

2-3. Hemophilia.
A, B, C.

Determining Special Education
Once the student is assessed and has an educational plan, most teachers and educational professionals carefully watch these children for physical and mental changes. Most will do well, but if their physical condition deteriorates or if they are hospitalized, modifications to learning and teaching will need to be made. Treatment for various conditions often adversely affects lerning, even though there maybe teachers within the hospital setting.

How Can Professionals Teach?
Many of these students will have the same curriculum as their peers, but for students who have frequent absences, those who work with them need to decide what is most important for a student at home or in a hospital to learn. For teachers who have students with various health impairments, they need to answer the following questions:

What are the most important academic objectives that this student needs to achieve this year?
How can I make sure the student attains the objectives?
How can the student be motivated to attain the objectives?

From the first question, teachers and social workers in schools, may find that learning dates of Civil War battles is not most important. Instead, it is more important that the student learn why it happened, when it took place, who were some of the major leaders and soldiers, what were some of the decisive battles, and how the war ended.

For the second question, you need to decide how to make sure the student masters the information. Can some lectures be videotaped for him to watch at home? Would another student be willing to work with the homebound student after school? Can you cut the supplemental reading that does not relate to the most important objectives for the student?

The third question regarding motivation of the student means trying to make it more interesting for him. Perhaps there are some movies about the topic that he can watch which are entertaining, but have factual information. Instead of written assignments, you may have him do an art project that demonstrates a certain part of the Civil War. If doctors predict that the student's condition will end in death, you can help him do a project that will leave a legacy to his family. One teacher describes how she use the concept of journaling with one of her students who had leukemia:

"I told Bill that I would give him credit in English language skills if he kept a daily journal in a notebook I brought for him. I would visit him in the hospital and we talked about what he had written. Some days, he wrote about riding his motorbike or hunting with his father. On other days, he wrote about his cancer treatments and hospital experiences. The journal gave him opportunities to escape the hospital through fantasy and to deal honesty with his health condition. He was also creating a treasure for his family: a gift of himself."

Grief Work in the Death of a Child
Care for Yourself
When you face death of anyone, a client, relative, friend, or parent, you need to give yourself permission to grieve. Sometimes another friend who is simply a good listener will let you talk about all the anger, loss of dreams, and personal loss you feel. There are theological questions to ask, feelings of irritability and discomfort, depression. Family members and pastors can also be good listeners. As a professional working with sick people, you will experience the death of someone who is your client.

Supporting the Child who is Dying
Children and adolescents who are dying often fear they will be abandoned as they approach death. Many times they feel guilty because they are causing their family so much unhappiness and pain. Silence from those close to them only increases their isolation. Children are perceptive enough to know when they are dying, and adults who think they are helping and keep the truth from the child are not helping the child. Jason and Jill are an example. Jason met Jill in the hospital when they were both being treated for leukemia. When Jason's mother told him that Jill had died, his reaction was:

"Where did she die?" he asked breathlessly.
"What do you mean, Jason?"
"Where - was it in the hospital or at home?"
"Well, she died at home."
"Oh good," Jason said, appearing relieved.
"Good?"
"Because," Jason explained, "the last time I saw her, she told me, 'I sure hope I can die at home and not have to be in the hospital.'"
"I thought back to that day," said his mother. "Jason had kept his friend, Jill, company while she had a chemotherapy treatment. Her mother and I went out of the room to talk."
"She just is not responding to the medications," Jill's mother said.
"Does Jill know?"
"Oh, no! We don't know how to tell her or what to say!"

But the little Jill knew what was happening - of course, she knew!

Question:
3. When the death of a student or client occurs, it is best to:
(One or more of the following answers may be correct.)
a) forget about it.
b) talk about it openly with his relatives and friends.
c) remember his life and honor him.

In the classroom, it is also necessary to help classmates of the child who is dying. You can suggest they write letters or draw pictures to send home to their classmate. Some parents allow pictures of the sick child to be placed in the classroom. A social worker from the hospital can visit the classroom and explain what is happening to the classmate who is in the hospital. Children have a lot of questions about illness and death. One class even sent its math computer home to the child with a terminal disease.

Social workers can also support the parents of the child who is dying. Life will never be the same for them and each day brings challenges. By contacting them frequently, listening, and phoning them after the student has died will be of invaluable support. You might feel inadequate to know what to say at such a difficult time, but sharing your feelings of inadequacy probably helps them through their own inability to make life right for their child. Do not give advice unless it is asked for.

Siblings of the dying child also need attention. Perhaps they have needs that their parents cannot meet - going to school events, getting a hair cut, help with homework. The dying child is the first priority and other children may feel guilt and grief, but relief that their sibling has died and relieved the tension in the family. One adult remembers how a teacher just put her hand on his shoulder one day after his brother died. He said that she did not try to use words to make it better. A simple touch gave him strength to go on.

Collaboration
To help a health-impaired child, it is important to remember that he is first of all, a child. Collaboration and communication between teachers, parents, medical personnel, social workers, and other students is essential because of the chronic nature of the child's medical problems.

Parents and school personnel need a high level of trust and understanding to meet the educational needs of these children. Sometimes teachers and others in the school are asked to provide documentation for changes in the student's behavior or academic performance. Sometimes the school nurse will have to give medication.

It is also helpful for classmates to understand how to help the child with health impairment. However, information is given out only with the child's permission. Sometimes classmates can be helpful in finding ways to make the student adjust better to the classroom.

Question:
4. What word is the best to describe how parents, teachers, and other students can help a child with a health impairment?

What are Program Options?
The personal, social, and medical needs of people with health impairments change as they progress through various life-span changes. Those with chronic conditions will need more support as they mature and the disease progresses. Others who have life-threatening diseases such as childhood leukemia will be able to leave the illness behind them and live full and productive lives. Needs change, and here are some examples of programs that seem to meet the needs of people with health impairments during their life spans.

Early Intervention - Angela's Story
Angela was born five weeks prematurely and weighed only four and a half pounds when she was born. She had good Apgar scores, but her doctor wanted to investigate her heart. After 24 hours, Angela's parents were informed of the prospects for survival and the surgery needed to correct her heart condition. She would need three operations to correct her problems.

Angela stayed in the intensive care unit and ten days after birth had her first surgery. At the same time, the doctors inserted a tube into her stomach so that she could be fed and not use the energy she needed to suck a bottle, but to heal her heart. By the time she was ten weeks old, the medical team began thinking of Angela's discharge from the hospital. The team and Angela's parents made a Family Service Plan to help them do what was necessary for Angela's care. Her pediatrician in her hometown was given all of her records and plan of treatment. Then the parents had to find someone to care for Angela. This was not an easy decision. They decided on a woman who cared for children in her home, Mrs. Foster. She came to the hospital and talked with the nurses about the care Angela needed. She also planned how to care for Angela and the other two children at home.

Mrs. Foster held Angela like a normal infant when she fed her even though the feeding came through tubing to Angela's stomach. She rocked her and sang to her. She suspended a balloon above Angela's feet so that Angela could kick it easily and thus get exercise. With this careful planning and love, Angela grew and her parents began to see her as the busy toddler she became after the third surgery.

This rehabilitation was possible because of Mrs. Foster's commitment to care for Angela, the medical team, and Angela's parents. While in Mrs. Foster's care, the early childhood specialist from the local school began an assessment of Angela so that if any disabilities were found, they could begin rehabilitation.

Question:
5. What was the key factor in caring for Angela?
(Only one of the following answers is correct.)
a) Mrs. Foster.
b) The team.
c) The Family Service Plan.

Elementary Years
Children with health impairments may feel different from others and alone. During elementary school, children become more concerned with relationships to peers. School gives children an opportunity to see themselves through the eyes of others besides their families. Peers play an important role in helping the child understand and accept himself. Nurse Beth works in a children's cancer ward helps children with their re-entry into school. Here is an example:

The good news for Cindy was that her cancer treatments had ended and she was declared free of leukemia. The bad news was that the treatment had changed her face - it was puffy and swollen from the effects of drugs and she had lost her hair - what if her wig fell off in physical education class? She knew she was blessed to be going home, but felt guilty about these worries.

Beth, the nurse, stepped in to help Cindy. Beth visited Cindy's school and talked with the administrator and Cindy's teachers. She bought along some brochures that explained Cindy's illness and possible after effects of treatment. Cindy was discharged from the hospital and stayed home for three weeks to increase her strength. Then she had a big day - visiting the school with Beth. She visited her classmates and explained what happened to Cindy. Then Cindy visited her brother's classroom and he helped Cindy to talk with his classmates. Then it was time for Cindy to go home.

Later in the day, Beth met again with Cindy's teachers and explained Cindy's needs. She also explained that Cindy is weak and might tire easily. The teachers were concerned about Cindy's cognitive functioning and wanted to know if the cancer treatment had affected her thinking skills. After she spent a few weeks in class to better understand her educational needs, they also made a plan to evaluate her. They agreed to phone Cindy's parents if there were educational or medical problems that needed to be solved.

In this example, teachers, administrators, the nurse, family, and classmates together helped Cindy. They shared information that helped ease Cindy back into school life. Each one knew whom to call for information.

Question:
6. Cindy was afraid to go to school because she had a ________ appearance.

Middle and Secondary School Years
The adolescent years are difficult for most students with or without disabilities. At this time teenagers need a sense of belonging. Students with chronic disability can become sensitive about the way their disability makes them different from their peers, and think that if the disability were eliminated, their social relationships would be fine.

A program called Meeting the Challenge has been developed for students to help them with interpersonal skills as they grow. There are five categories of skills: self awareness, social imitation and conversational skills, direct communication, empathy or active listening, and conflict resolution and problem solving. The program helps students identify maladaptive and adaptive solutions to specific situations.

For example, students are given a simulation experience of not being invited to a party. The group facilitator asks students to think about what the common reaction might be to such an experience. Maladaptive reactions can be: (1) "I look terrible so I was not invited," (2) "If I could just walk normally, I would be invited", (3) "I am so angry that I was not invited, so I will not speak to the Susan ever again (Susan had the party)", (4) "I am going to stay home from school on the day of the party!"

The students then think about adaptive reactions. They can tell themselves: (1) "Mike and John were not invited and they don't have any physical problems," (2) "Maybe I can be a little more friendly to others around me," (3) "Maybe there are some things I need to change in my appearance," or (4) "Maybe there are others of us who could have our own party on the same night." From these simulations, students gain insight about how their thoughts and feelings affect their behavior. By learning strategies for coping with life's problems, students with health impairments develop a sense of control of their lives and health condition.

Question:
7. Through interpersonal skills students learn:
(Select the best answer.)
a) solutions to specific situations.
b) how to accept themselves in different situations.
c) to cope with various social situations that are positive and negative.

Postsecondary Years
The needs of persons with health impairments after their educational years include:

finding employment,
using leisure time wisely,
knowing their legal rights and how they can protect those rights,
managing their condition as independently as possible.

This discussion will focus on AD/HD. Up to 70% of adults who were diagnosed with AD/HD as children continue to have symptoms of inattention, impulsivity, or hyperactivity as adults. Persons with inattentive AD/HD experience lethargy, daydreaming, and withdrawal. They are mentally hyperactive, but the activity they have is in their heads.

Persons with AD/HD tend to be less successful in life and may be more inclined to alcoholism, personality disorders, and stress. Yet, many are also successful in their chosen occupations, but even if successful, they talk about being "driven" and being "puppets of some inner force". Here is an example:

Gary never lacked ability. He is a 38-year-old security guard with a respectable IQ and boundless energy. Until recently, he has never been able to finish a simple task, like taking out the garbage, without getting sidetracked. As a child, he was in constant trouble with his parents and teachers. Gary attended college for 13 years and did not finish his degree. He has had 128 different jobs. He says, "I had asked for help for years because I did not feel good about myself. I accepted the fact that my life was a mess." His doctors thought he had manic depression, but the medications they gave him only made he feel worse.
Then he visited a psychologist at a university hospital. The diagnosis was AD/HD, a condition he was diagnosed with in grade school, but was told he had grown out of. He was treated with Ritalin in hopes that he would respond favorably. Usually, adults do not respond well to this drug, but Gary was fortunate. With his new life, he has again changed jobs, now he is a radio supervisor on a worldwide radio net. Instead of talking incessantly, he mostly listens!

Question:
8. What made the change in Gary's life?

A Vision for the Future
You remember the twins we talked about in the beginning of this lecture. David, whose T4 cell count was 0, died within 18 months after we met him. His mother, sister, and especially his brother grieve losing him. Thus far, there is no cure for AIDS, although researchers are working toward a vaccine. We have the example how researchers recently found the treatment for SARS in China. People are avoiding exposure to environmental agents that cause disease - too much sunlight, smoke, etc. Researchers are now changing the order of genes in the laboratory in an effort to stop carriers of genetic illnesses. There is hope for the future. For those of us in the helping professions, we can use our knowledge and love from God the Father to help those around us who have health impairments to live a more abundant life now.

Lecture # 116: Other Health Impairments, Continued

Lecture # 116:
Other Health Impairments, Continued