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Part II: Toddlers, PreK, and School age Seminar

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Marla Throssel

on 30 November 2014

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Transcript of Part II: Toddlers, PreK, and School age Seminar

Health Promotion Seminar TWU:5003 Nov 5, 2014
Julie Abraham Nitha Jose
Chloe Cervin-Taylor Ashley Ladson
Jessica Crenshaw Amaechi Okori
Andrea D'Gama August Opara-Aku
Jonathan Garcellano Shayna Pagay
Monica Guerra Amanda Stemmans
Rachel Horner Swapna Thomas
Taisia Jignea Marla Throssel

Ages 1-3

Ages 4-5

School Age Children:
Ages 6-12

ADHD and Autism
Offer different foods from day to day. Encourage your child to choose from a variety of foods.
Serve foods in small portions at scheduled meals and snacks.
Choose healthy snacks for your preschooler.
Beverages count, too. Make smart beverage choices.
Limit the amount of empty calories (solid fats & added sugars) you feed your preschooler.
To keep sodium low, choose and prepare foods with little or no salt.
Use the Super Tracker to find the amount of sodium and empty calories in your meals.  
Put the Plan Into Action
Should receive 1200-1600 calories per day depending on their activity level and gender.

Parents can create a healthy eating plan for their preschooler using the Super Tracker's My Plan

Food plans are based on average needs by age and activity level. It varies by age and daily caloric intake.
Daily Food Plan for Preschoolers
Encourage children to eat vegetables and fruits by making if fun.
Provide healthy ingredients and let kids help with preparation.

Kids may try foods they avoided in the past if they helped make them.
Healthy Foods Are

Daily Food Plan for
and Preschool Children:
On June 2, 2011, First Lady Michelle Obama and USDA Secretary Tom Vilsack released the federal government’s new food icon, MyPlate, to serve as a reminder to help consumers make healthier food choices.

The new MyPlate icon emphasizes the fruit, vegetable, grains, protein foods, and dairy groups.
My Plate
Toddlers are always busy exploring the environment around them
Learning to walk, run, climb, throw, kick, dress, undress, etc.
Most toddlers are interested in other children although not ready to share, resulting in Parallel Play.
Parents should provide environment/toys that would challenge the child to learn something new and develop new skills.
Limiting TV/screen/game time to no more than 1-2 hours daily of high-quality screen with parent watching and interacting too. Parent interaction will promote cognitive development and prevent speech delay.
Physical Activity Toddlers:
Let’s Move!

aims to increase opportunities for kids to be physically active, both in and out of school and to create new opportunities for families to move together.
Focuses on: Active Families, Active Schools, and Active Communities
Physical activity is an essential component of a healthy lifestyle.
In combination with healthy eating, it can help prevent a range of chronic diseases, including heart disease, cancer, and stroke, which are the three leading causes of death.
Physical activity helps control weight, builds lean muscle, reduces fat, promotes strong bone, muscle and joint development, and decreases the risk of obesity.
Children need 60 minutes of play with moderate to vigorous activity every day to grow up to a healthy weight
Health Benefits:
Physical Activity:
Access to food
Influence of mass media
Busy lifestyle
Cultures (high obesity in Hispanic, Black, and Native American children)
Role modeling and positive reinforcement
Nutrition Education
Factors Influencing Food Intake:
My Plate Requirements for 9-17

years-old based on 2000 calories diet
My Plate Requirements for 6-8 years-

old based on 1600 calories diet
Bone growth in 1-8 year-old require a calcium intake of 700-1000mg
Iron-deficiency anemia – more prevalent in vulnerable populations
Salt and sugar intake should be moderate
Nutrition and dentition impact health at all ages
Older preschoolers frequently refuse to try new foods
Risk factor for cardiovascular diseases are prevalent by 3 years of age. The most common are hypercholesterolemia and obesity.
Preschooler related issues:
Schedule meals and sleep periods such that the child is awake and alert during mealtime.
Serve small portions and let your toddler ask for more.
Avoid foods that may cause choking:
Candy, mini-marshmallows, popcorn, pretzels, chips, spoonful of peanut butter, nuts, seeds, large chunks of meat, hot dogs, raw carrots, dried fruits, and whole grapes.
Drinking more than 24 oz of milk per day can reduce your child’s appetite for other healthy foods. For kids 1-2 years of age use whole milk! (they need extra at for their developing nervous systems).
Nursing Interventions to
Promote Healthy Eating in Toddlers: (
Offer simple, single foods; mixtures of foods are often rejected
Serve favorite foods along with new ones. Might take several attempts before your toddler accepts it. Show an example, eat it too!
Encourage use of utensils. Accept the need to still use their fingers.
Routines are important. Serve scheduled meals and snacks. Parents are responsible for WHAT, WHEN, and WHERE toddler eats. Toddler decides whether to eat and how much.
Turn of TV. Mealtime should be relaxed free of destructions.
DO NOT use food to bribe, reward, or punish.
Nursing Interventions to
Promote Healthy Eating in Toddlers
Toddlers often use mealtime as an occasion to assert individuality and control as well as exploration.(May even refuse a meal altogether.)
Adequate iron intake must be ensured as the toddler changes from breast milk/formula to whole cow’s milk (which is low in iron and interferes with iron absorption from other food sources).
Overconsumption of fruit juices (which have no nutrition advantage over whole fruit). Should be limited to 4-6 ounces a day.
Both whole milk and fruit juices in the bottle are associated with “baby bottle tooth decay” and should be discouraged.
A decrease in the growth rate results in decrease in appetite. Daily record over 3-5 day period presents a better picture of child’s intake.
By Taya Jignea
Nutrition and Physical Activity
The prevalence of food allergy in children in the United States cont-
inues to increase, affecting up to 8%
of children

About 1 million of preschoolers are affected and about one third of these children have the potential for a severe reaction

Most allergies develop before age of 2

Most common foods to cause an allergic reaction: milk, eggs, and peanuts

A food allergy action plan including written emergency plan should be developed for parents to use to promote better communication regarding child’s allergies
Food Insecurity
Eliminate very low food security among children
Reduce household food insecurity and in doing so reduce hunger
Food and Nutrient Consumption
Increase the variety and contribution of fruits and vegetables to the diets of the population aged 2 years and older
Increase the contribution of whole grains to the diets of the population aged 2 years and older
Reduce consumption of calories from solid fats and added sugars in the population aged 2 years and older
Reduce consumption of sodium in the population aged 2 years and older
Increase consumption of calcium in the population aged 2 years and older
Iron Deficiency
Reduce iron deficiency among young children
Nutrition Related Concerns
and Objectives: cont.
: Promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights.

Objectives emphasize
: Efforts to change diet and weight should address individual behaviors, as well as the policies and environments that support these behaviors in settings such as schools, worksites, health care organizations, and communities.

The goal of promoting healthful diets and healthy weight encompasses increasing household food security and eliminating hunger.
Nutrition and Weight Status :
As an alternative, you can count your daily activity steps using a pedometer:
girls’ goal: 11,000 steps
boys’ goal: 13,000 steps
You need to be active:
60 minutes a day
at least 5 days a week
for 6 out of 8 weeks.
Physical activity goals for kids and teens (ages 6-17) Let’s Move! Recommendations:
Healthier Food Access
Increase the number of States with nutrition standards for foods and beverages provided to preschool-aged children in child care
Increase the proportion of schools that offer nutritious foods and beverages outside of school meals
Health Care and Worksite Settings
Increase the proportion of primary care physicians who regularly assess body mass index (BMI) for age and sex in their child or adolescent patients
Increase the proportion of physician office visits that include counseling or education related to nutrition or weight
Weight Status
Reduce the proportion of children and adolescents who are considered obese
Nutrition Related Concerns and Objectives:
Engage in more interactive play, particularly dramatic play that involves fantasy

TV/electronic games are still an issue.

The Fitness Pyramid has recommendations for physical activity
Play continues to be the primary activity

More coordinated and confident

Many activities involve other children and modeling behavior

Should be monitored for safe activities that enhance gross and fine motor skills
Physical Activity Preschoolers:
Physical Activity
School-Age Children:
Exercise typically occurs through group activities and organized sports
Play activities promote social, personal, and cognitive development
Prefer interacting with peers rather than with family
A skill in motor tasks wins the respect of other children and provides a feeling of self-accomplishment
Concern exists that young children have experienced too much physical and psychological pressure to perform in sports
Physical activity and participation in sports tend to decrease with age, particularly among girls
Active Family
Give children toys that encourage physical activity like balls, kites, and jump ropes.
Encourage children to join a sports team or try a new physical activity.
Limit TV time and keep the TV out of a child’s bedroom.
Facilitate a safe walk to and from school a few times a week.
Take the stairs instead of the elevator.
Walk around the block after a meal.
Make a new house rule: no sitting still during television commercials.
Find time to spend together doing a
fun activity: family park day,
swim day or bike day.
Issue a family challenge to see who can be the first to achieve a Presidential Active Lifestyle Award by committing to physical activity five days a week, for six weeks. Adults and children can both receive the award!

Talk to your children’s principal or write a letter to your district superintendent to incorporate more physical education in schools.

Encourage schools to hold recess prior to lunch to increase physical activity before mealtime.
Active Family Recommendations
Active Family
Volunteer to help with afterschool physical activity programs or sports teams.
Be sure that children get the sleep they need. Most children under age five need to sleep for 11 hours or more per day, children age five to 10 need 10 hours of sleep or more per day, and children over age 10 need at least nine hours per day.
Learn how engaging in outside activities can be fun and affordable for families through Let’s Move Outside, which promotes a range of healthy outdoor activities for children and families across the country.
Edelman, C. (2014). Toddler, Preschool Child, School -Age Child. Health promotion throughout the life span (Eighth ed., pp. 428-488). St. Louis: Elsevier.

Let's Move. (2014). Get Active. Retrieved October 18, 2014, from http://www.letsmove.gov/get-active

Nutrition and Weight Status. (2014). Healthy People 2020. Retrieved October 18, 2014, from http://www.healthypeople.gov/2020/topics-objectives/topic/nutrition-and-weight-status

Super Tracker and Other Tools. (2014). Super Tracker and Other Tools. Retrieved October 22, 2014, from http://www.choosemyplate.gov/supertracker-tools.html
Video of childhood obesity
Retrieved from: http://www.bethwarrennutrition.com/wp-content/uploads/2014/03/childhood-obesity.jpg

Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250598/

Differences Among Race, Gender and Ethnicity
Images top to bottom retrieved from: http://i2.cdn.turner.com/cnn/dam/assets/120614124614-girl-stick-tongue-boy-story-top.jpg and http://i4.mirror.co.uk/incoming/article3129498.ece/alternates/s2197/Depressed-little-girl.jpg



Low self-esteem

Emotional overeating
Emotional Comorbidities
Soft Drink Tax
"Controlled experiments have shown that manipulations of price can yield changes in consumption". One example of this is the increase of taxes on cigarettes. "The number of jurisdictions with soda taxes has declined in recent years due to lobbying efforts by the beverage industry, but taxes have reduced consumption and increased revenue for other health-related programs" (Kersh, 2011).
Media & Marketing
"Food ads on television make up 50 percent of all the ad time on children’s shows. These ads are almost completely dominated by unhealthy food products (34 percent for candy and snacks, 28 percent for cereal, 10 percent for fast food, 4 percent for dairy products, 1 percent for fruit juices, and 0 percent for fruits or vegetables). Children are rarely exposed to public service announcements or advertising for healthier foods" (American Psychological Association, 2014).
School Interventions
"US school districts often contract with private food and beverage companies to sell less nutritious "competitive foods" in cafeterias and vending machines. The ethical responsibility of schools to limit soft drink sales and provide healthy meals and opportunities for physical activity and to combat the other adverse consequences of childhood obesity affecting education must be considered" (Kersh, 2011).
Menu calorie labeling
"In 2008 no place in the US required restaurants to post calorie labels... now dozens of jurisdictions and the United States itself have enacted menu-labeling laws" (Kersh, 2011). It is important to note, however, that people may still choose to order unhealthy foods regardless of calorie counts.
Ethics in Childhood Obesity:
Government & Media
Image retrieved from: http://www.parentsandchildrentogether.info/images/parents_and_children.jpg
Parents as Decision Makers
"Parents act as decision makers for their children because children do not yet possess the maturity and capacity needed to make health-related choices". One aspect of parent involvement is the participation in family-based interventions which are "community-based public health programs that empower the entire family to reduce sedentary behaviors and increase good nutrition choices, as well as practice problem solving to restructure thinking related to learned unhealthy behavior patterns, like stress eating" (Perryman, 2011).
Parents' Rights and Responsibilities
"Because parents have the right to raise their children according to their own value system, the choices that parents make for themselves concerning diet and physical activity are likely to be the same choices that they make for their children" (Perryman, 2011).

Child Abuse and Neglect
"Legally, child abuse is often defined as behavior or lack of action that results in damage to a child or puts a child at risk of injury. Many state courts have expanded their definition of medical neglect to include morbid obesity" (Perryman, 2011).

Ethics in Childhood Obesity:
Childhood Obesity
Almost 30% of US children don't exercise
3 or more times a week.

An estimated 61% of obese young people already have at least one additional health risk factor such as hypertension or hyperlipidemia.

Childhood obesity health expences are estimated at $14 billion annually (NCSL, 2014).
Approximately 17% of children and adolescents in the United States are obese. That's over 12 million kids!

During the past 40 years, obesity rates for children ages 6-11 have nearly tripled, from 5% to 14%.

Obesity in preschoolers (ages 2-4) is directly proportional to income status. Lower household income = greater rates of obesity.

Obese adolescents have an 80% chance of
becoming obese adults.
Screening and Assessment
The most widely used tool used to determine overweight/obesity in children and adolescents (ages 2-18) is the
BMI scale
, or body mass index.
A child's weight status is determined using an age- and sex-specific percentile for BMI rather than the BMI categories used for adults because children's body composition varies as they age and varies between boys and girls (CDC, 2012).
BMI and age (in years) are mapped out on a chart and the child's percentile rank is found.
--A child is considered
if they fall between the 85th and 94th percentile.
--A child is considered
if they fall at or above the 95th percentile.
It is important to note that occasionally BMI charts can be imprecise for children younger than 4, and charts that assess weight vs height may be more accurate (August, 2008)
Retrieved from: http://images1.friendseat.com/2011/04/bmiformula.png
Calculating BMI
Retrieved from: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html
Retrieved from: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html
According to the CDC, "there are significant racial and age disparities in obesity prevalence. In 2011-2012, prevalence was higher among Hispanics (22.4%) and non-Hispanic black youth (20.2%) than non-Hispanic white youth (14.1%). The prevalence of obesity was lowest in non-Hispanic Asian youth (8.6%)" (CDC, 2014).
Differences Among Race,

Gender and Ethnicity
Image retrieved from: http://cdn2-b.examiner.com/sites/default/files/styles/image_content_width/hash/d5/74/Children_(multi-ethnic).jpg?itok=5tFEIqJX
Retrieved from: http://www.childobesity180.org/sites/all/themes/childobesity/resources/images/img-infographic-causes.png
What causes

childhood obesity?
Clockwise from top, retrieved from: http://images.dailytech.com/nimage/17885_Fat_Kids.png, http://snatchbot.net/wp-content/uploads/2009/01/fat_gamer_kid.jpg, and http://www.nhs.uk/Conditions/stress-anxiety-depression/PublishingImages/E%20to%20I/expert-tips-on-child-anger_364x200_107668795.jpg
: unhealthy lunch options and regular consumption of high-calorie foods , like fast food, cookies, chips, soda and candy contribute to weight gain. Snacking is another culprit.

Lack of physical activit
y: computers, TV and video games keep kids inside and sedentary. By preschool age, many kids
are already lacking enough activity, which often
translates into poor exercise habits later in life.

: if a child opens up the fridge or cabinet
and finds bags of chips, candy and pizza, then that's
likely what they will eat. Similarly, if you keep your
fridge stocked instead with cut up produce, granola
bars and yogurt then they will go for that.

Psychological factors
: some kids may turn to food as a coping mechanism for dealing with problems or negative emotions like stress, anxiety, or boredom. For example, children struggling to cope
with a divorce or death in the family may eat more as a result"
(Childhood Obesity: Causes, 2014).
What causes childhood obesity?
Clockwise from top, retrieved from: http://anotherxyz.com/wordpress/wp-content/uploads/2014/04/poor.gif, http://www.pardaphash.com/uploads/images/660/377779-obesityReuters-1336803514-118-640x4801-101618.jpg, and http://2.bp.blogspot.com/-NgpSQ671Zb0/UasmjDFsdcI/AAAAAAAAALA/S-TiE-Rz_Lc/s640/images+(5).jpg
: "If your child was born into a family of overweight people, he/she may be genetically predisposed to the condition, especially if high-calorie food is readily available and physical activity is not encouraged.
Medical conditions
: Though not common, there are certain genetic diseases and hormonal disorders that can predispose a child to obesity, such as hypothyroidism, Prader-Willi syndrome and Cushing's syndrome" (Childhood Obesity: Causes, 2014).
: In a review of studies in the journal Archives of Disease in Childhood, researchers found that kids who sleep less than the recommended amount of about 13 hours a day at age 2 are more likely to be obese at age 7. Fatigue alters the levels of appetite-regulating hormones which can cause children to eat more.
Socioeconomic factors
: Children from low-income backgrounds are at increased risk for childhood obesity since low-income parents may lack the time and resources necessary to purchase and prepare healthy foods (versus fast food, which is cheaper and more readily available in low-income communities). Safety may also be an issue, as kids may not feel safe playing outside.
Healthy People 2020!
Leading health indicators
applicable to childhood obesity are:

Obesity among children and adolescents

Total vegetable intake for persons aged 2 and older
Where are we now?
In regards to childhood obesity rates, the following results have been noted:
Between 2005–2008 and 2009–2012, the obesity rate among children and adolescents aged 2 to 19 increased about 5 percent, from 16.1 percent to 16.9 percent, moving away from the Healthy People 2020 target of 14.5 percent; however, this change is not statistically significant.

And in regards to vegetable intake?
Between 2001–2004 and 2007–2010, the mean daily intake by persons aged 2 and older was unchanged at 0.8 cup equivalents of total vegetables per 1,000 calories (age adjusted). The Healthy People 2020 target is 1.1 cup equivalents per 1,000 calories (US Dept of Health & Human Services, 2014).
Determinants of Health: Social
Availability of resources to meet daily needs
- This includes availability of healthy snacks/meals.
Access to educational and economic opportunities
- preventative education regarding obesity and comorbidities for children and their parents
Access to health care services
- health screening for obesity, HTN, DM, nutrition status, etc.
Availability of community-based resources in support of opportunities for recreational and leisure-time activities
- this can include access to parks, community centers and playgrounds as a replacement for time spent in front of the television.
Public safety
- safe neighborhoods are conducive for walking and bike riding instead of traveling solely by public transportation.
Socioeconomic conditions
- there is a great link between lower-income and overweight and obesity.
- important for kids and parents when it comes to reading labels on food.
Access to mass media and technology
- this can be both a benefit and a detriment. Contstant bombardment of ads for unhealthy eating habits and video games/ movies can have a negative impact on families (US Dept of Health & Human Services, 2014).
Natural environment
- including climate and green space (trees, grass, etc.)
Built environment
- access to sidewalks, bike lanes, etc can contribute to physical activity of families.
Schools and recreational settings
- access to these even during non-work hours can help kids stay active.
Housing and community design
- remember, safety is key!
Exposure to toxic substances and other physical hazards-
think Pasadena or Texas City. Are children able to play safely outside there?
Physical barriers, especially for people with disabilities.
Aesthetic elements
- like trees, benches, good lighting (US Dept of Health & Human Services, 2014).
Determinants of Health: Physical
Each of these can impact the ability of families to maintain adequate nutrition and physical activity. Many of these determinants are lacking, especially in lower-income neighborhoods, which explains the higher incidence of obesity in low-income households.
Images top to bottom retrieved from: http://blogs.mydevstaging.com/blogs/parents-news-now/files/2012/06/shutterstock_55527616-337x225.jpg and http://kidshealth.org/parent/medical/heart/headers_93975/P_cholestorol1.jpg
Common Comorbidities
Type 2 Diabetes
Sleep apnea
Polycystic Ovary Syndrome (PCOS)

Joint Pain
Left ventricular hypertrophy
Screening for Comorbidities
Blood pressure >90th percentile (standardized according to sex, age, and height percentile)
1) Impaired fasting plasma glucose:
Fasting plasma glucose (>100 mg/dL) (Verify fasting status)
2) Impaired glucose tolerance:
2 hr glucose >140 but <200 (if OGTT is used)
Diabetes mellitus
Fasting plasma glucose >126 mg/dL, or random value >200 mg/dL (if OGTT used, 2 hr glucose >200)
asymptomatic, must have repeat abnormal
values on another occasion.*
Co-morbidity Case Detection Tests: Abnormal values (August, 2008).
Fasting (12-14 hours) lipids—
Triglycerides >110 mg/dL (75th percentile); >160 mg/dL (90th percentile)
LDL cholesterol >110 mg/dL (75th percentile); >130 mg/dL (90th percentile)
Total cholesterol >180 mg/dL (75th percentile); >200 mg/dL (90th percentile)
HDL cholesterol <35 mg/dL (10th percentile); <40 mg/dL (25th percentile)
Sleep apnea
Sleep study, electocardiogram or echocardiogram can help diagnose sleep apnea.
Polycystic ovary syndrome
Serum testosterone, third generation LH and FSH and presence of hirsutism, acne and onset/frequency of menses may indicate PCOS.
Morbidity & M
Childhood and, especially, adolescent obesity is predictive of adult obesity, which is associated with an increased incidence of diabetes, hypertension, gallstones, and hypercholesterolemia. Pulmonary consequences observed in children and adolescents include an increased frequency of reactive airways, poor exercise tolerance, increased work of breathing, and increased oxygen consumption. The few people who develop obesity-hypoventilation syndrome experience right-sided heart failure with right ventricular hypertrophy (Schwarz, 2011).
• Overweight and obesity are associated with a 52% and 60% increased risk, respectively, for new diagnoses of asthma among children and adolescents.

• Obese children are at a higher risk for psychosocial problems, fatty liver, orthopedic-related problems and sleep apnea.

• Although traditionally viewed as an “adult” illness, the rise in childhood overweight and obesity has corresponded to an increasing proportion of youths with type 2 diabetes, particularly among adolescent minority

• Obese children and teens have been found to have risk factors for cardiovascular disease (CVD), including high cholesterol levels, high blood pressure and abnormal glucose tolerance. In a population-based sample of 5- to 17-year-olds, 7% of obese children had at least one CVD risk factor while 39% had two or more CVD risk factors (NCCOR, 2009).
Practice Guideline for Clinicians:
Family history (of obesity and comorbidities (CVD, HTN, DM).
Readiness to change.
Physical assessment (includes BMI, waist circumference and use of calipers for measurement of adipose tissue).
Clinical and laboratory assessment of overweight/obese children (See previous slide for commonly tested labs with abnormal values listed).
Screen for possible eating disorders as well as depression and other psychiatric disorders.

Maintain non-judgmental atmosphere when discussing weight management with family.
Collaborate with other specialties (nutrition, physical therapy, psychiatry, etc) as appropriate.
Comprehensive lifestyle intervention, involving entire family. This includes diet modification, increasing physical activity, and decreasing sedentary activity.
Provide plenty of education and followup with parents and children.
Treat comorbidities as needed.
Note: Surgery is rarely indicated for children and adolescents. Lifestyle modification is the most widely used treatment (Lau, 2007).

prevention is key
! Always take the time to really educate families about ways to prevent obesity.*
Developmental learning disorders, conduct disorder, bipolar disorder, tourette syndrome, MR
Mortality related to unnatural causes

death 3-10 times higher than general population
epilepsy, gastrointestinal issues, respiratory problems
death related to comorbid conditions, intellectual disability, and unnatural causes
Morbidity and Mortality
3 levels of severity

Level 1: requires support

Level 2: requires substantial support

Level 3: requires very substantial support
Parents’ Evaluation of Developmental Status (PEDS)
Addresses parents concerns

Detects developmental and behavioral problems

Can be used from birth to 8 years old
9 mo, 18 mo, 2 yr, 3 yr, 4 yr
Screening Cont

Identifies children who would benefit from further evaluation

Can be done at a well-child check-up

Used to screen for developmental delays and autism
g Continued
Developmental milestones should be assessed from birth to at least 36 months
Listen to parents’ concerns (they know their child better than you!)
American Academy of Pediatrics (AAP) recommends autism screening at 18 and 24 months with M-CHAT-R
Texas Health Steps Medical Checkup Periodicity Schedule
DSM-V also used as a guide for diagnosis
Complex disorder of brain development

Difficulty with social situations, communication skills, and repetitive behaviors

Symptoms become apparent at 2-3 years old

More common in boys

Caused by gene mutations and environmental factors that influence brain development

No cure
Autism Spectrum Disorder (ASD)
1) Children between 4 and 18 years of age should be further evaluated when they present with symptoms consistent with DSM-V criteria.

2) A diagnosis of ADHD can me made only if DSM-V criteria is met. Other possible causes should be ruled out. PCP receives reports from adults participating in the child's care.

3) PCP evaluation includes an assessment of other conditions that may occur along with ADHD.

4) ADHD should be recognized as a chronic condition and requires special health care needs.
Children should be assigned a medical home.

5) Treatment varies with age:
a. Preschool age:
-PCP prescribes behavior therapy as first line of treatment
-Medication may be prescribed if there is no improvement with behavior modification
b. School age:
- ADHD medication should be prescribed along with behavior therapy

6) Medication should be titrated for maximum effect and minimal side effects
Clinical Practice Guidelines
Symptoms present for at least six months and are inconsistent with developmental age
Show symptoms prior to 12 years of age
Symptoms present in at least 2 settings
Symptoms interfere with daily functioning
Symptoms do not occur during a psychotic disorder and are not a part of another mental disorder
Diagnostic Criteria Cont.

Children often exhibit these behaviors:

Do not pay close attention to details, make careless mistakes
Difficulty sustaining attention
Do not seem to listen when spoken to directly
Do not follow through on instructions and fail to finish tasks
Difficulty with organization
Do not enjoy activities that require prolonged mental effort
Lose things
Easily distracted by thing going on around them

Child should show at least 6 of these symptoms for at least 6 months in order to be diagnosed with the Predominantly Inattentive Presentation
Symptoms of Inattention
Diagnostic Criteria
A proper diagnosis requires a comprehensive evaluation
Only properly trained health care professionals should diagnose this disorder
One of the most over diagnosed disorders
DSM-V used to guide diagnosis
Affects 3-5% of school age children
Average age of onset is 7 years old
Unknown cause—possibly genetics, a chemical imbalance in neurotransmitters
Affects more boys than girls
There is no cure, only treatment to control the symptoms
Primary features are inattention, hyperactivity, and impulsivity
A neurodevelopmental disorder
Three categories
Predominantly Hyperactive-Impulsive Presentation
Predominantly Inattentive Presentation
Combined Type
Improve mental health through prevention and by ensuring access to appropriate, quality mental health services.
increase from 68.9 percent in 2008 to 75.8 percent in 2020
Objective MHMD-6
Increase the proportion of children with mental health problems who receive treatment.
Healthy People 2020

Parental consent for testing/treatment
Following proper guidelines for diagnosis
Take child’s opinion about treatment into consideration as they get older


Treatment options
Research and findings
Ethical Issues...
Ages and Stages Questionnaire (ASQ)

Developmental and social-emotional screening

Completed by parent

Screens children from 1 month to 5 ½ years of age

9 mo, 18 mo, 2 yr, 3 yr, 4 yr
Screening Cont.
Children often exhibit these behaviors:

Difficulty staying still
Leave seat when they should not
Runs, climbs in inappropriate situations
Cannot play quietly
Constantly in motion
Excessive talking
Answers before question is finished
Difficulty waiting their turn
Interrupts others often

Must show at least 6 of these symptoms for at least 6 months to be diagnosed with the Predominantly Hyperactive-Impulsive Presentation
Symptoms of
Used by health and mental health professionals to classify mental disorders
Fifth edition is the most current (DSM-V)
Three components:
diagnostic classification
- list of mental disorders
diagnostic criteria sets
- symptoms that must and must not be present for each disorder
descriptive text
- description of each disorder
Diagnostic and Statistical Manual of Mental Disorders
Image by Google
Parents’ Evaluation of Developmental Status. (2013). Retrieved from

Rabiner, D. (n.d.). New Diagnostic Criteria for ADHD. Retrieved from

Soreff, S., Dunayevich, E. (2014). Attention Deficit Hyperactivity Disorder Follow-up: Prognosis. Retrieved from http://emedicine.medscape.com/article/289350-followup#a2650

Texas Department of State Health Services. (2014). Texas Health Steps Provider Information: Periodicity Schedule. Retrieved from

Treating Autism. Autism Treatment Trust. (2013). Medical Comorbidities in AutismSpectrum Disorder. Retrieved from http://nationalautismassociation.org/pdf/MedicalComorbiditiesinASD2013.pdf

What is ASQ? (2014). Retrieved from http://agesandstages.com/what-is-asq/
Autism Spectrum Explained: Autism Controversies. (2013). Retrieved from

Child Trends. (2014). ADHD. Retrieved from http://www.childtrends.org/?indicators=adhd

Healthy People 2020. (2014). Mental Health and Mental Disorders. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders

Foreman, D.M. (2006). Attention deficit hyperactivity disorder: legal and ethical aspects. Archives of Disease in Childhood, 91(2). Retrieved from

National Institute of Mental Health. (n.d.). What is Attention Deficit Hyperactivity Disorder (ADHD, ADD)? Retrieved from http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
American Academy of Pediatrics. (2011). ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. doi: 10.1542/peds.2011-2654

American Psychiatric Association. (n.d.). DSM. Retrieved from

Autism Speaks. (n.d.). What is Autism? Retrieved from http://www.autismspeaks.org/what- autism

Autism Speaks. (n.d.). Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R).
Retrieved from http://www.autismspeaks.org/what-autism/diagnosis/screen-your-child

Autism Speaks. (n.d.). DSM-5 Diagnostic criteria. Retrieved from
Healthy People 2020 cont.
Children’s Health Insurance Program: CHIP
Children’s Health Insurance Program: CHIP
Children’s Health Insurance Program: CHIP
Children’s Health Insurance Program: CHIP
Children’s Health Insurance Program: CHIP
Children’s Health Insurance Program: CHIP
Children’s Health Insurance Program:
Healthy People 2020’s Interest
Children’s Health Insurance Program: CHIP
Health Policy
Center of Medicaid and CHIP Services (2014). Children’s Health Insurance Proram (CHIP). Retrieved on October 25, 2014 from: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/childrens-health-insurance-program-chip/childrens-health-insurance-program-chip.html

Maternal, Infant and Child health retrieved 10/28/14 from http://www.healthy people.gov/2020/topics-objectives/maternal-infants-and-child-health

Texas Health and Human Services Commission (2014) CHIP/Children’s Medicaid. Retrieved on October 25, 2014 from: http://chipmedicaid.org/en/About
These differences are likely the result of many factors which include social determinants of infants and child health. Child health status varies by both race and ethnicity family income and educational levels of household members.

In order to bridge some of these disparities, programs like Women Infants and Children (WIC) food and nutrition services, the Children’s Health Insurance Program (CHIP) are in place. These policies are likely place to make sure that children have the required access to health care and to also achieve the ongoing goal of improving the health and well being of children and their families as well as expanding access to health care (healthy people.gov).
Health people 2020 has interest in the maternal, infant, and child health with one of the goals identified as

: Improve the health and well being of women, infants, children and families.

Improving the well being of young children has been an important public health goal for the United States because their well-being determines the health of the next generation and can also help predicts the health of families, communities and health care system as a whole. (Healthy people. gov)

Children’s health is influenced by socio-demographic factors such as family income. There remain ethnic disparities in mortality and morbidity for mothers and children, particularly for African American (Healthy people.gov).
CHIP, formerly SCHIP-State Childern's Health Insurance Program[3], provides health coverage to nearly 8 million children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage. Signed into law in 1997, CHIP provides federal matching funds to states to provide this coverage.

The Affordable Care Act extends CHIP through most of 2015 and beginning October 1, 2015 the already enhanced CHIP federal matching rate will increase by 23 percentage points, bringing the average federal matching rate for CHIP to 93%. The enhanced federal matching rate continues until September 30, 2019.

States can operate CHIP as a program separate from Medicaid, as an expansion of the Medicaid program, or a combination of both program types.

Texas considered CHIP as a separate program from Medicaid.
Children in Texas without health insurance may be able to get low cost health coverage from the CHIP (Children’s Health Insurance Program). This program covers office visits, prescription drugs, dental care, eye exams, glasses and much more.

Children with CHIP pay no more than $50 a year for health care coverage. Some families with CHIP also may need to pay co-pays for some services.
What’s Covered:

CHIP offers many benefits:
Dentist visits, cleanings, and fillings
Eye Exams and glasses
Choice of doctors, regular checkups, and office visits
Prescription drugs and vaccines
Access to medical specialist and mental health care
Hospital care and services
Medical supplies, X-rays, and lab tests
Treatment of special health needs
Treatment of pre-existing conditions
To qualify, a child must be:

Age 18 or younger*
*Children up to age 20 can qualify for Medicaid in some cases.
A Texas resident
A U.S. Citizen or legal permanent resident. TX Health and Human Services Commission do not ask about the citizenship or immigration status of the parent. Only the child must be a U.S. Citizen or legal permanent resident in Texas.

Who can apply?

Any adult who lives more than half the time with an uninsured child may apply. This includes parents, stepparents, grandparents, other relatives, legal guardians, or adult brothers or sisters.
Anyone age 19 or younger who lives on their own can apply.
A pregnant person of any age can apply for CHIP perinatal services for her unborn child for Medicaid.
Costs for CHIP:

If HHSC find your child can get CHIP, your enrollment fee and co-pays will be based on your family’s income.

Enrollment fees are $50 or less per family, per year.

Co-pays for doctor visits and prescriptions range from $3 to $5 for lower-income families and $20 to $35 for higher income families
This health policy covers not only toddler, pre-school and school age group but infancy to 18 years old.
Low income families will be for this health policy especially those qualified for the program.
People against this policy will be the low income families who are illegal immigrants who cannot get coverage at all. Also, the rich and the middle class who are tax payers are also against this policy since this policy is no use for them.
Income Guideline Chart:

CHIP Yearly Enrollment Fees:


Social welfare extends more to low income families not qualified for Medicaid
This health policy will help poor children get treatment in hospitals , provide them necessary vaccinations and be seen by dentists for their regular dental examinations
State program gives greater visibility/PR to state, govenor, and other key decision makers.

An added expenditure by the state and national governments
Need to create a separate administrative structure to contract with providers, enroll participants, make payments, etc...
Implementation would be slower and more difficult than Medicaid Expansion
Need to develop ways to cooridinate with Medicaid
By: Jonathan
Toddler related issues:
Toddlers, Pre-K, School Age Children
How to apply?

By Phone: Call 2-1-1. It’s toll-free

By Online: Upload documents to: YourTexasBenefits.com.

By Mail or Fax: You can print application form on the website:


Fax: 1-877-447-2839

Mail: HHSC
PO Box 14600
Midland, Texas 79711-4600
Picture retrieved from: http://meaningfulmama.com/2012/05/day-134-hand-print-flower-bouquet-for.html
Picture retrieved from http://www.gopixpic.com/300/handprint-flowers/http:%7C%7Cimages*mylot*com%7CuserImages%7Cimages%7Cpostphotos%7C2183058*jpg/
Picture retrieved from https://scooby.ctg.queensu.ca/spring/index.php
Picture retrieved from http://www.restoresight.org/upcoming-events/leadership-advocacy-conference/grassroots-advocacy/
Ashley Ladson

and Shayna Pagay
Monica Guerra
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