When Parker was diagnosed as being autistic back in 2014, I was told it was highly likely that as his pragmatic speech and social anxiety improved, that he might exhibit classic ADHD behaviors. At that time, he was shy and hesitant, and tended to stay in one spot to play with letter puzzles or books.
With improvements in speech reception and expression, Parker has become quite the social butterfly. He has also developed problematic inattention to task, distractibility, and lack of focus. In 2015, after months of requiring maximum assistance in class, we made the very difficult decision to begin a non-stimulant medication. It took several months to begin to see progress. But then, little by little, the assistance needed in class decreased. Parker was able to attend to an activity, and engage actively in his learning. He expressed greater confidence, and was very proud of his new abilities to help his teachers with classroom “work.” I should mention, Parker was unbelievably fortunate to have had a remarkably low student:teacher ratio for his first and the beginning of his second year of developmental preschool. At times, there were 6 students with 3 teachers/assistants!
Parker started his second year of developmental preschool in 2016, and it got off to a rather rocky start. Our psychiatric nurse practitioner also left the practice to care for her own autistic son in July, so we were waiting to see the psychiatrist who would be taking over medication management. We struggled through until our visit with the new doctor, who we LOVE. He immediately engaged Parker’s teacher by having her fill out the Vanderbilt Assessment Scale. This is an objective way of documenting improvement or relapses in Parker’s functional ability in the classroom, and something that our previous provider had not employed. What a valuable piece of information that was! Parker’s new doctor increased his medication dose slightly, but we didn’t see the improvement we had hoped for on the subsequent rating scale.
Things were really starting to derail at school. Parker was requiring increasing assistance to stay on task, and kindergarten is getting closer. This is the time we need to be preparing for the transition to mainstream education. At our next visit with the doctor, Parker was shown to have gained a good amount of weight, and was up to 62nd percentile for weight. The psychiatrist and I looked at each other, and said simultaneously, “It might be time to try a stimulant.” One of the main side effects of stimulant medications for ADHD is a decrease in appetite. I’ve been working on an eating post, but to back up for just a minute, Parker has had issues with appetite and weight dating back to infancy. We knew it was very possible that this wouldn’t be effective, but it was a good time to try. We started with 1/5 the “normal” starting dose, and Parker showed improvement. But, this came at the cost of reduced appetite, dropping “safe foods,” and weight loss. The decision was made fairly quickly to drop the stimulant medication.
We had a meeting with Parker’s developmental therapist and teacher to discuss our options. It was at this meeting that Parker’s teacher said, “I think we need to transition to general education preschool. Now. This isn’t working.” His developmental therapist was delighted, while I was thinking, “Wait! Now?” We developed a plan to introduce Parker to his new teacher and institute daily visits to her classroom. It was fortunate that Parker had two friends in his developmental preschool class who would also be attending this class with him. The final transition would be Parker starting in the general education class following fall break. And boy, was he excited.
Fall break ended, and I put a very excited little boy on the bus at 8:30am for his first day of morning gen ed preschool. Previously, his school hours had been 12:45-4:05 (from time on the bus until time home). His new schedule would be 8:30-12:05. Things seemed to be going very well from the beginning. Parker came home brimming with excitement, and his developmental preschool teacher reported positive comments from his school occupational and physical therapists. The BIG change for me was not receiving a daily note documenting behavior. At the end of the first week, I emailed his new teacher, and she said things seemed to be going well.
Christmas break had arrived, and we had two weeks of time for celebrating with family and playing with new toys. Interestingly, during the second week of Christmas break, Parker developed a rather pervasive interest in Roman numerals. He requested a chart of Roman numerals, and proclaimed, “This is my favorite toy EVER!” He spent hours studying Roman numerals and writing them. He wrote them in chalk. He wrote them in marker. In pencil and pen and crayon and colored pencils. He also began asking to “learn things.” “I want to learn something.” He asked about the solar system. About computer coding. About the human body. He googled questions he had, and happened onto some “mywhyu” videos that explained chemistry and other higher level academia in child-friendly ways. He was elated.
While this was an exciting development, and undoubtedly a tremendous cognitive leap, it correlated with difficulty participating in his everyday activities. He was distracted and stopped playing with his toys. He also began exhibiting a dramatic increase in sensory needs. If you’re unfamiliar with sensory seeking behavior, it can “appear” to be negative behaviors. For Parker, he has an inability to remain still. He falls off of chairs from wiggling and moving. He bumps into things. Knocks things over from not being aware of his surroundings.
Christmas break ended, and Parker returned to school. I sent a Vanderbilt Behavior Assessment to gauge his classroom behavior, because at home, things were pretty rough. Again, with our experience with general ed preschool compared to developmental preschool, there’s strikingly little communication unless it’s parent initiated. Parker’s teacher completed the scale, and the results were disheartening. He was having significant difficulties staying on task and relating with classmates. I quickly reported these findings to his developmental therapist, developmental preschool teacher, and psychiatrist. We, thankfully, scheduled a meeting for the next week.
That meeting was today. Parker’s developmental therapist, current teacher, developmental teacher, and I were present. It became evident rather quickly, that Parker was having difficulty adjusting to the lack of time with adults at school. He was used to conversing with his teachers frequently in developmental preschool. As a segue to kindergarten, the goal is for Parker to learn to initiate or participate in conversation with peers. The plan going forward is for Parker to have tasks he can complete for his teacher, as this naturally increases his ability to talk to her, and gives him a sense of importance. He will also have an assigned table in the morning to facilitate comfort and bonding with a smaller group of friends.
Snack time. This was, his teacher reported, when things reliably unraveled. His new teacher had never before had a child with food aversion. Parker, who was used to eating a snack with 5-6 other children, was suddenly faced with eating a snack with 16 other children. And in general ed preschool, the snacks are… messier. Carrots with dip, chips and salsa, cheese and crackers. Parker was accustomed to only dry snacks, and to having his own snack sent to school. Going forward, the plan will be for Parker’s developmental therapist to provide a social story regarding snack time, and that Parker should know that he is not expected to eat anything he is uncomfortable with. He will also have a small table at which he can eat with one other friend, to avoid having to be in close proximity to foods that are distressing.
And lastly, Parker is having trouble attending due to boredom. In his previous classroom, Parker had a “workbox” filled with advanced activities and reading on special interests. He could use this workbox during times of instruction that he had previously mastered. The decision was made to institute the workbox in his new classroom. His developmental preschool teacher noted that Parker exhibits attention-seeking behaviors when he is bored and wishing to speak with an adult. This was occurring frequently in situations where Parker was sitting through instruction on previously learned material. I’m going to send in some learning activities related to Parker’s current interests, and he will have time built into his schedule to work on these things.
In dealing with people, objectivity is so difficult. But in gauging progress, it’s extremely beneficial. The Vanderbilt Behavior Assessment has proven a very valuable tool for making sure Parker has what he needs to succeed in a least restrictive environment. And as Parker’s developmental therapist said, “While I’m sad for Parker, that he’s having these difficulties, it’s better that he have them now.” We can get the supports in place to ensure as smooth a transition to kindergarten as possible.
Stay tuned for an update!