Light It Up Blue on April 2!

The ninth annual World Autism Awareness Day is April 2, 2017. Every year, Keystone Behavioral Pediatrics joins other autism organizations around the world in helping to increase awareness of autism and of how we can help children achieve success through change provided by our highly educated and experienced therapists.

Celebrate autism awareness by wearing blue on April 2

In some of the latest news from, its newest study out of the Autism Speaks MSSNG project – the world’s largest autism genome sequencing program – identified an additional 18 gene variations that appear to increase the risk of autism. The new report appears this week in the journal Nature Neuroscience. It involved the analysis of 5,205 whole genomes from families affected by autism – making it the largest whole genome study of autism to date.

The omitted letters in MSSNG (pronounced “missing”) represent the missing information about autism that the research program seeks to deliver.

“It’s noteworthy that we’re still finding new autism genes, let alone 18 of them, after a decade of intense focus,” says study co-author Mathew Pletcher, Ph.D., Autism Speaks’ vice president for genomic discovery. “With each new gene discovery, we’re able to explain more cases of autism, each with its own set of behavioral effects and many with associated medical concerns.”

Identifying subtypes to advance personalized treatment

To date, research using the MSSNG genomic database has identified 61 genetic variations that affect autism risk. The research has associated several of these with additional medical conditions that often accompany autism. The goal, Dr. Pletcher says, “is to advance personalized treatments for autism by deepening our understanding of the condition’s many subtypes.”

The findings also illustrate how whole genome sequencing can guide medical care today. For example, at least two of the autism-associated gene changes described in the new paper are also associated with seizures. Another has been linked to increased risk for cardiac defects, and yet another with adult diabetes. These findings illustrate how whole genome sequencing for autism can provide additional medical guidance to individuals, families and their physicians, the investigators say.

Many genes; a few key pathways

The researchers also determined that many of the 18 newly identified autism genes affect the operation of a small subset of biological pathways in the brain. All of these pathways affect how brain cells develop and communicate with each other. “In all, 80 percent of the 61 gene variations discovered through MSSNG affect biochemical pathways that have clear potential as targets for future medicines, Dr. Pletcher adds.

Increasingly, autism researchers are predicting that more-effective, personalized treatments will come from understanding these common brain pathways – and how different gene variations alter them.

Lead study author Ryan Yuen, left, and senior author Stephen Scherer, both of The Centre for Applied Genomics at the Hospital for Sick Children (SickKids), in Toronto.

Not one autism, but many

“The unprecedented MSSNG database is enabling research into the many ‘autisms’ that make up the autism spectrum,” says the study’s senior investigator, Stephen Scherer, Ph.D.

For instance, some of the genetic alterations found in the study occurred in families with one person severely affected by autism and others on the milder end of the spectrum, Dr. Scherer notes. “This reinforces the significant neurodiversity involved in this complex condition,” he explains. “In addition, the depth of the MSSNG database allowed us to identify resilient individuals who carry autism-associated gene variations without developing autism. We believe that this, too, is an important part of the neurodiversity story.”

Dr. Scherer is the research director for the MSSNG project and directs The Centre for Applied Genomics at the Hospital for Sick Children (SickKids), in Toronto. MSSNG is a collaboration between the hospital, Autism Speaks and Verily (formerly Google Life Sciences), which hosts the MSSNG database on its cloud platform.

Beyond traditional genetics

Traditional genetic analysis looks for mutations, or “spelling changes,” in the 1 percent of our DNA that spells out our genes. By contrast, the MSSNG database allows researchers to analyze the entire 3 billion DNA base pairs that make up each person’s genome.

In their new study, the investigators went even further – looking beyond DNA “spelling” variations to find other types of genetic changes associated with autism. These included copy number variations (repeated or deleted stretches of DNA) and chromosomal abnormalities. Chromosomes are the threadlike cell structures that package and organize our genes.

The researchers found copy number variations and chromosomal abnormalities to be particularly common in the genomes of people affected by autism.

In addition, many of the copy number variations turned up in areas of the genome once considered “junk DNA.” Though this genetic “dark matter” exists outside of our genes, scientists now appreciate that it helps control when and where our genes switch on and off. The precise coordination of genetic activity appears to be particularly crucial to brain development and function.

An unprecedented resource

Through its research platform on the Google Cloud, Autism Speaks is making all of MSSNG’s fully sequenced genomes directly available to researchers free of charge, along with a toolbox of analytic tools. In the coming weeks, the MSSNG team will be uploading an additional 2,000 fully sequenced autism genomes, bringing the total to over 7,000.

Currently, more than 90 investigators at 40 academic and medical institutions are using the MSSNG database to advance autism research around the world.

Autism Speaks is also funding the creation of a community portal that will allow study participants to explore their genomic information and share experiences with others who have similar genetic profiles.

For more about the MSSNG, visit For more about Autism Speaks, visit

Annual Art Exhibition supports Mainspring Academy’s students

Mainspring Academy will hold its 2nd Annual Art Exhibition & Reception at MOCA Jacksonville on Saturday, April 1, 7 – 11 p.m., at Jacksonville’s Museum of Contemporary Art (MOCA). 

Guests will enjoy an evening reception catered by Cafe Nola and have the opportunity to purchase unique art created by Mainspring Academy’s students.  All funds raised from the event are designated for hardship scholarships, capital improvements and teacher education and advancement.

Event sponsorship opportunities are available. Please Contact Jackie Bargas at for more information.

Guests may register to attend on Mainspring Academy’s website. Cost is $75 per person and the attire is “snappy casual.”

Mainspring Academy is the area’s premier academic center for students, kindergarten through high school, who have special needs and learning challenges in Jacksonville and surrounding areas. The academy offers a variety of curricula to accommodate each student’s unique style of learning. Mainspring was founded in 2010 on the principles of special education, applied behavior analysis and psychology. The faculty believes that every student is capable of learning and growing in knowledge and understanding of educational and life concepts.

Mainspring Academy was founded in 2010 as Keystone Academy by Keystone Behavioral Pediatrics. In 2015, the academy became its own private, nonprofit school. Keystone continues to provide behavioral services to its students and encourages everyone to support the great work that Mainspring does to help its students be successful by participating in the art exhibition and donating to the academy.

If you are unable to attend but would like to make a tax deductible donation, please visit Mainspring Academy’s Donate Now page.

Keystone offers ABA services on Florida’s Emerald Coast

Keystone recently announced that ABA services are available to the Emerald Coast. The mission of Keystone Behavioral Pediatrics – Emerald Coast is to provide Okaloosa and neighboring counties with the same standard of excellence which has been established by KPB in the Jacksonville area. 

Presently, behavior therapists are offering ABA services in Emerald Coast homes, with the eventual goal of offering therapy in a variety of settings including a clinic, community settings and schools, in addition to in-home. Therapy is individualized to each child based on an initial assessment (ABLLS-R, VB-MAPP, AFLS, essentials for living, functional assessments of problem behaviors, etc.) and continually modified based on the child’s progress.

Laura Mathisen, M.S., BCBA, leads the team of ABA therapists for Keystone Behavioral Pediatrics – Emerald Coast.

Applied Behavior Analysis (ABA) therapy is a systematic teaching approach based on B.F. Skinner’s analysis of behavior and the subsequent contributions of other behavior analysts. ABA focuses on changing behavior in socially significant ways to improve the lives of the children and families who seek ABA services.

Keystone’s Emerald Coast team is led by Laura Mathisen, M.S., BCBA, who serves as senior clinical supervisor. She has experience providing behavior analytic services for children and adults with developmental disabilities, genetic disorders and traumatic brain injuries. Mathisen specializes in early intervention services, problem behavior reduction and supervision of BCBA candidates. She worked at Keystone Behavioral Pediatrics for three years and eventually served as director of behavior analysis. After her military husband was transferred to Destin in 2013, she continued to work for Keystone as a senior clinical supervisor and board certified behavior analyst (BCBA), while also working as a BCBA clinical supervisor for a private ABA clinic in the Florida Panhandle, where her caseload primarily focused on problem behavior reduction and early intervention cases.

For questions and to make an appointment with the team at Keystone Behavioral Pediatrics – Emerald Coast, complete the Appointments or Contact form at or call 904.619.6071.

Keystone Behavioral Pediatrics, based in Jacksonville, Fla., offers consultation and integrated healthcare to children who may have one or more behavioral, developmental, socio-emotional or learning issues, for example, autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), intellectual delays, aggression, self-injury, tantrums, anxiety, compliance, self-help skills, toileting, speech/language or cognitive, physical, sensory, and motor skills. Keystone’s comprehensive and highly skilled team of providers – child psychologists, board certified behavior analysts, licensed mental health counselor, occupational therapists, speech/language pathologists, feeding therapists, registered behavioral technicians and clinical assistants – work together to develop a plan of action to provide success for each child through change. Medication management is also available, if medication is recommended as part of a child’s plan.

Speech-Language Department in Top 14 Best in Jacksonville

Keystone BehaviorBest Speech Therapy for Children in Jacksonville al Pediatrics’ Speech/Language Department has been selected as one of the top 14 best in Jacksonville by Expertise. Out of the 210 speech pathologists reviewed, 131 were curated and only 14 selected as top picks for 2017. Speech/language therapy is designed to treat speech, language, cognitive-communication and swallowing disorders in individuals up to age 18 and includes early intervention.

Director Jennifer Martin, M.A., CCC-SLP, and her team of speech/language therapists uniquely function as part of an interdisciplinary team, coordinating findings and recommendations with other professionals. They also offer treatment focused on helping children and their parents learn strategies for improving functional communication and oral motor or feeding/swallowing skills. In some cases, treatment sessions will be offered jointly with other departments, if coordination would benefit the child most.

Keystone offers a range of specialized services unique in northeast Florida including:

  • PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) therapy
  • Oral-motor therapy
  • Articulation therapy – therapy
  • Language therapy
  • Fluency therapy
  • PECS (Picture Exchange Communication System)
  • Sign language
  • Development and training in augmentative & alternative communication systems
  • Early intervention

In selecting Keystone as one of the top 14 speech pathologists in 2017, Expertise created lists of the best local professionals in Jacksonville. After searching the area for every business that provides speech-language pathology, the Expertise team filtered out any businesses that fail to meet its definition of an expert. It also flagged and removed any business with a history of dissatisfied customers or with limited online information that makes them difficult to contact.

Next, Expertise used in-house software to grade each business on 25 variables across five judgment criteria:


A history of delighted customers as a signal of outstanding service


Building customer confidence with licensing, industry accreditations, and awards


Masters of their craft, based on years of practical experience and education


Consistently approachable and responsive, so customers never feel ignored


Providing customers seamless experiences both online and off

Once the businesses were ranked, the Expertise team manually reviewed the highest scoring results to ensure that they can proudly stand behind each of their selections.

Additional Resources

American Speech-Language-Hearing Association
The Stuttering Homepage

Teaching Tips Are Applicable for Every Caregiver

By Andrew Scherbarth, Ph.D., BCBA-D, Licensed Psychologist/Board Certified Behavior Analyst

All caregivers are teachers regardless of whether they are teaching academics in a classroom or raising a child at home. Parents and caregivers in a home setting teach kids all kinds of things about life – how to clean up after themselves, how to stay safe, how to treat others, how to approach the world, how to behave, etc. As such, caregivers have to rely upon their teaching style to convey the lessons they’re teaching. A lot of research has been done on ways for parents and teachers to effectively teach children and manage their behavior (Walker and Walker, 1991; Barkley, 1997; Latham, 1994).

The following teaching tips are applicable to anything from science to reading to manners to cleaning a room: 

  1. Be clear about what you want. Speak directly, preferably in a single sentence, and say what to do, rather than what NOT to do. Caregivers often make the mistake of saying “Don’t do ____.” The problem with saying “stop” or “don’t” is that caregivers are not providing direct suggestions. The biggest deficits for any child in inhibition and critical, abstract thinking. This rule applies regardless of whether the child is typically developing or the child has developmental, behavioral and/or emotional issues. Clarity counts. For example, say “Throw that away” instead of “Don’t chew on that plastic.” Say “Sit down” or “Get off the couch” instead of “Don’t jump on the couch.” 
  1. Say it, don’t ask it. In polite society, many adults ask each other to do things, and these adults often do it. However, when working with children or teens, questions make it seem that the child has a choice of whether to follow the instruction. The rule that I always tell others is, “Ask a question if the child will have a choice, but tell the child directly what to do it you want the child to do the instruction regardless.” It’s fine to ask if your child wants any peas, as long as you don’t mind if the child says “no.” On the other hand, if you’re not going to honor a “no thanks” when you ask your child to do homework or go to bed, then it is better to just tell them directly “Start on your homework” or “Time for bed – goodnight!” 
  1. Give calm instructions. Many think that giving loud or angry instructions are best, but often such instructions immediately startle or evoke a stress response in children. The stress response is also known as “fight or flight.” The last thing that anyone needs is for a child or teen to get prepared to fight or flee when given an instruction. Further, if caregivers lose their temper when they give instructions, it shows children and teens that the best way to be powerful is to lose control of their emotions. It is a dangerous lesson, because children model themselves after adults and try to be powerful themselves by doing the same thing. Caregivers don’t need to be sugary sweet and say “pretty please” when they give an instruction; just use a normal conversational tone, and don’t lose your cool. 
  1. Get their attention before instructions. Go up to your child or teen, get their eye contact, make sure they’re not distracted and then tell them what you need to have done. Caregivers – especially parents – often believe that if they’ve said an instruction, then the child has heard it and is critically thinking about it, and so will follow the instruction immediately. This leads to a lot of frustration when the child does not get started immediately and may result in the parent getting loud, angry or just giving up. However, caregivers often give instructions from across the room or while the child is occupied with a toy or other task. Giving instructions while the child is distracted makes instructions compete with the excitement level of the distraction. Although putting clothes away or doing homework are extremely important life tasks, they aren’t exciting enough to overcome the distraction of a fun cartoon or videogame, for example. 
  1. Make it pay off to do the right thing. Make sure that a child or teen gets a direct demonstration that you approve of her behavior by being affectionate verbally (“Great work; you did it!”), physically affectionate (high five, pat on the back or hugs) or with a privilege (“You finished your worksheet, so you can take a break now.”) Many caregivers ask, “Why treat them as special when they do what they’re supposed to be doing anyway?” But, would adults didn’t get paid to work, would they keep going to their job day after day? If adults wouldn’t work for free, then why would kids. They don’t have to receive cash to do the right thing; instead inspire appropriate behavior by giving approval, affection or some form of excitement for their efforts.

February Recognizes Important Role of School Counselors

This year’s national theme, “School Counseling: Helping Students Realize Their Potential,” focuses our attention on the special contribution that school counselors make within our school systems. It recognizes the important role that school counselors can have in helping students achieve school success and plan for the rest of their lives.

Keystone offers resources and training to school counselors and others in the school who support students, such as staff in exceptional student education programs, guidance counselors, advisors, coaches and admissions directors. Our child psychologists regularly provide in-service trainings to faculty in schools throughout the First Coast, as well as to educators in local cultural and tourist organizations.

For example, in January, Dr. Max Horovitz made a presentation on “Working with Kid with Special Needs” to the Jacksonville Zoo & Gardens’ education staff. His presentation focused on autism spectrum disorder (ASD), its symptoms and common difficulties that children with ASD face. He shared ways to give these children effective instructions and how educators can use reinforcements and visual supports to help children with ASD enjoy their experiences at the zoo more. Dr. Max described general problem behaviors that educators may observe and gave tips on how to prevent them so that children with ASD aren’t disruptive and don’t hurt themselves. The educators asked lots of questions and appreciated the opportunity to learn more about how to incorporate children successfully into their camps and classes.

Keystone meets with guidance counselors, admissions directors and exceptional student education (ESE) staff and provides in-service training to faculty in schools, as well as providing Lunch ’n Learn presentations to doctors, nurse practitioners and staff in pediatrician offices.

Some examples of presentation/in-service training topics are:

  • Ins and outs of classroom behavior management
  • Understanding early childhood emotional and behavioral difficulties
  • What is Autism Spectrum Disorder?
  • Early childhood developmental milestones
  • Early Identification: Red flags for learning challenges and how to recognize them
  • What is ADHD and what can you do about it?
  • Helping students manage stress more effectively
  • Anxiety and Mood: What do they look like and how can you help
  • Attention and executive functioning in childhood
  • Promoting study skills and executive skills coaching
  • Identification and management of concussions and other sport injuries
  • Recognizing signs of trauma and helping students cope
  • Signs of psychological disorders in students (e.g., ADHD, LD, anxiety, depression)
  • Cultural knowledge and sensitivity in the classroom
  • Bullying identification and prevention

Staff is happy to develop other presentations for specific situations or concerns. To recommend or arrange potential presentation/in-service training opportunities for Keystone, contact Karen Rieley,, 904.333.1151.

Educational & Learning Clinic Identifies Challenges, Reduces Stress

Dr. Max Horovitz, co-director of Keystone’s Educational & Learning Clinic along with Dr. Rea Romero, works with a student to assess his learning challenges and identify targeted interventions and strategies that will help him manage the challenges.

At Keystone, our providers are skilled in assessing and working with a wide range of student needs that include learning challenges, such as learning disabilities, dyslexia and other contributing issues, and giftedness, which can result in children struggling socially and/or emotionally

Common diagnoses include:

  • Learning Challenges: If your child is struggling academically, a learning disability (LD) may be suspected. Individually administered assessments allow us to determine the presence of an LD, as well as the nature of the underlying problem (e.g., dyslexia). Additional testing can also determine if other issues are contributing to challenges in the classroom (e.g., ADHD, anxiety, ASD). By providing an accurate picture of your child’s needs, we can recommend targeted interventions and strategies for remediation.
  • Giftedness: Gifted children often excel in creative, project-based learning or specific subject areas. They can become bored or unmotivated if they lack stimulation in their educational setting. Testing for giftedness helps ensure your child is provided with an appropriate curriculum based upon ability level. Gifted children may also be “twice-exceptional,” both gifted and having a learning disability in an area such as written expression. They might also have diagnoses of Attention-Deficit/Hyperactivity Disorder or Asperger’s Disorder, which may be accurate in some cases but misinterpreted in other cases. Keystone can provide a comprehensive evaluation with recommendations to address the exceptional strengths as well as areas of need.

Evaluation: Educational and Learning Assessment begins with an initial interview that includes a detailed history. Your child will then be scheduled for standardized testing, which will include assessments of intellectual functioning and academic achievement, as well as parent and teacher behavior rating scales as appropriate. Additional cognitive processing and/or neuropsychological assessments may also be administered to provide a comprehensive profile of learning abilities. The testing itself can range from one hour to several hours, depending upon the skills being assessed. After the tests have been scored, interpreted and written up as a customized report, a psychologist will meet with you to explain the results and make specific recommendations for your child.

Therapy: Students with learning disabilities can experience stress and frustration related to their difficulties at school. They may struggle to connect with peers or they may act out behaviorally. On the other hand, gifted children benefit from being challenged academically to develop their creativity and cognitive talents. However, gifted children can also struggle socially and/or emotionally, dealing with stress related to achievement. They can have difficulty fitting in or finding a similar peer group. They can also experience anxiety, depression or low self-esteem. The providers at Keystone understand the unique needs of children who are gifted or who are experiencing learning challenges. Keystone can provide therapeutic services to support and promote resiliency in your child, regardless of their needs. Clinicians are also available to provide school consultation to address psychological and/or behavioral health needs in the classroom.

Additional Resources:

National Center for Learning Disabilities – works to improve the lives of children with learning and attention issues by empowering parents, transforming school and advocating for equal rights and opportunities

U.S. Department of Education – promoting educational excellence for all Americans

LD online – The educators’ guide to learning disabilities and ADHD

Florida Association for the Gifted – connects and empowers educators and parents who promote and support educationally sound programs for gifted students through awareness, advocacy and action

National Association for Gifted Children – supports and develops policies and practices that encourage and respond to the diverse expressions of gifts and talents in children and youth from all cultures, racial and ethnic backgrounds, and socioeconomic groups

Supporting Emotional Needs of the Gifted – resources, community and understanding for meeting the social-emotional needs of giftedness


Success Story:

John’s parents brought him to Keystone Behavioral Pediatric when he was 10 years old, because he was having trouble focusing and concentrating at home and at school. He was struggling with grades at school, and his teacher was sending home frequent reports of behavioral difficulties.  Completing homework was a nightmare; he would only complete it if his mother sat with him throughout and continuously redirected him back to the homework. John’s ability to stay on-task was less than 50% during the afternoon. He also had a lot of problems going to sleep at night. It often took him one to two hours to fall asleep after his mother first sent him to bed, leading to sleepiness in the morning and during the day. John also had daytime toileting accidents, often multiple times per day.

We gave John a comprehensive psychoeducational assessment, which confirmed a diagnosis of Attention-Deficit/Hyperactivity Disorder, Combined Presentation. John and his mother attended weekly individual therapy sessions over the course of six months. Sessions focused on establishing homework routines and bedtime routines, teaching John self-monitoring strategies and his mother strategies for managing off-task behaviors, and developing a toileting protocol for John. The therapist also helped John get academic supports in the form of a 504 Plan at school.

As John began to improve, we set new goals of focusing on broadening improvements to additional areas and increasing John’s independence. As John began to achieve his treatment goals, we reduced the number of sessions to every other week and then once a month.

By the time he was discharged from our services, John’s grades had significantly improved, with no more reports being sent home of behavioral difficulties. Homework was no longer the nightmare it once was; John’s mother could be in the other room cooking dinner and doing other things, only checking in with John periodically. John’s ability to stay on-task was well over 80 percent. John no longer had problems falling asleep, often falling asleep within 15 minutes of being sent to bed. And, only one toileting accident had been reported over the previous three months.


Promote Children’s Social Skills and Expressions of Gratitude during the Holidays

Andrew ScherbarthBy Andrew Scherbarth, Ph.D., BCBA-D, Clinical Child Psychologist

While for many of us the holidays have religious meaning, they also have social meaning. Including everyone in activities, helping, sharing and thankfulness—all of these are useful around the holiday season regardless of whether we are just at home or surrounded by extended family.

To help kids develop social skills, include them in larger group activities and encourage them to invite others in the family to play.

How can we help kids use some of the most important social skills? One way is to include kids in larger group activities, even if there’s a difference in age or developmental level between kids in the extended family. Another way is to encourage kids to invite others in the family to play or enjoy something like a video together. It doesn’t always strike children as a useful or important thing to do, so as adults we may need to say, “Ask your cousin if he wants to play too.”

Similarly, we can suggest that kids go up to others doing activities and ask to join. If your child needs added prompting on either of these skills, then you can tell your child the exact words. For instance, you can tell your child to say, “Do you want to play,” “Let’s play,” or possibly “Can I play too?”

If you want to go a more indirect route, then you can start playing with a child, then after a couple minutes, invite a cousin or other family member to join in too. When there is a noticeable skill difference, such as when most people in the family can throw a football 20 feet but your child can only throw one foot, you can still find ways to include your child. For instance, everyone else can be throwing the ball 20 feet, but your child can be given a chance to catch and throw from just 1 foot away when it is her turn.

Encourage children to help out with holiday chores, share and clean up after themselves.

When it comes down to helping or sharing, parents can make small suggestions. For instance, “I’ll give you a piece of candy too, but first give this piece to your cousin.” Or kids can be given a chance to help out by setting the table with napkins or putting out something else that’s not breakable. It’s not 100 percent necessary that they help out, but many kids love attention and would probably want to be involved. If so, then you can use that to your advantage to help keep them busy and to offer a great way to earn a lot of praise for taking part in the holiday spirit of helping out. Children can also be prompted to go ask if they can help out a relative.

For self-care skills, children can even be prompted to simply help clean up after themselves. No, not every child needs to get a washcloth and wipe the table, and not every child can hold on to a plate to take back to the sink. However, most every child can go throw away their napkin or pick up discarded wrapping paper at the very least. Cleaning up is not only a self-care skill; it also helps out anyone else in the family who is cleaning up overall.

One of the last things we can do is to promote gratitude. There is often a lot of gift giving around the holidays, which means there are lots of opportunities to receive things and to show gratitude. Children can show gratitude in a number of ways—saying thank you to the gift giver directly after opening a gift, writing thank you cards, drawing pictures for gift givers, or even just giving a hug. Tell your child to show gratitude in whatever way you think fits best and heap praise on your child does.

The holidays are a great time for togetherness and joy. They also give us a special opportunity to promote social skills. Regardless of what you and your family do this holiday season, from the bottom of our hearts, everyone at Keystone wishes you and your family an excellent and heartwarming holiday season!

Aggression, Tantrums and Refusal—Annoying and Frustrating but Treatable

Dr. Scherbarth works with a child and his parent to help them understand and relate to each other better by building reasonable and enforceable limits.

The trifecta of terrible problem behavior in children is physical or verbal aggression, with tantrums and refusal to follow instructions. These symptoms are often consistent with the diagnosis of Oppositional Defiant Disorder (ODD). It is very annoying and frustrating for parents and peers—to say the least. Parents often try their best to manage it—including seeking out anger management for their child—but nothing they try seems to work. That said, ODD is entirely treatable by a clinician skilled in one of several Behavioral Parent Training programs.

ODD is a pattern of behavior for over six months that has three parts: a child or teen being argumentative in general or defiant when given instructions; the child being very angry and irritable most of the time; and at times the child may be vindictive and deliberately trying to make others angry. It can seem from the outside that the child is totally fine one minute and blows up the next minute. This appearance has led many people down the wrong path to think it’s bipolar disorder—especially when the tantrums last 45-90 minutes or when they are very destructive at home or school. However, bipolar disorder is a very different diagnosis.

ODD not only causes frustration in the moment for the parent and child, it also spreads throughout the family’s entire social life at all levels.

Parents of kids with ODD often do not want to go to stores or restaurants anymore for fear that something will set their child off. Parents may hear that other parents don’t want to set up play dates anymore. Schools may send these children home early because of the disruption they cause, or they may totally refuse to enroll these kids altogether. Kids with ODD often have little or no friends, and the friendships they do develop may be very conflicted. Clearly, it takes a serious toll on everyone and this toll creates resentment in the family towards the child and from the child back towards the family.

ODD typically emerges in younger childhood (before age 5). Without treatment, up to 2
5 percent of kids may lose ODD traits on their own; however it persists for many years in half of all kids, whereas the other 25 percent have behavior that starts to become downright cruel or even criminal in nature. With a total of 75 percent of kids with ODD having years of difficult or even criminal behavior ahead of them, it’s clearly to everyone’s advantage to seek treatment by a qualified therapist who goes beyond individual anger management counseling to also include some form of behavioral parent training.

There are a number of risk factors related to development of ODD (Barkley, 2013). Individual factors from the child include having ADHD, a mood/anxiety disorder or just an irritable temperament from birth. Parent factors include if they have ADHD themselves, irritable temperament, high stress due to a number of reasons and/or being young parents. Family social environmental factors include living in an area with a high crime rate, being influenced by delinquent peers, or having conflicted marriages or a conflictual extended family. How parents raise their children is one of the most important factors. Inconsistent parenting, highly negative parenting (or by contrast, low negative but also low discipline parenting), inappropriate expectations, as well as lack of monitoring of the child, and/or low positivity in parenting are all  risk factors.

At least one parent and the child engage in the Coercive Family Cycle (Patterson, 1982). A parent gives an instruction (possibly a harsh instruction or nearly impossible instruction), then the child reacts with negativity and both continue with negativity (yelling, harsh tone, possibly escalation to destruction) until one or the other gives up. It’s not healthy for the child, even if it “works” in the moment. Worst case scenario, the child gets away without having to do what they’re told and the negative behavior reinforced. In the “best case scenario,” the adult is able to force compliance BUT then the child learns the social lesson that to be respected in the family and society, that is that a child has to be big, loud, angry and bad. That’s not a very good outcome.

By contrast, Behavioral Parent Training (BPT) aims to make an impact by changing the parenting factors. It’s NOT about finding better ways to punish children more harshly. Rather, it has two aims—to improve warmth between parents and kids, as well as to build reasonable and enforceable limits. Warmth can be provided by making sure that there’s always positive interaction time and that when the child follows the instructions, good things happen—like acknowledgement and normal daily privileges. Limits include expectations that school work must be completed school work, children are expected to clean up after themselves to whatever extent that they can in relation to their age, destructiveness leads to consequences and rude or obnoxious behavior doesn’t pay off. The consequences for destruction shouldn’t be harsh, just consistent and providing for everyone’s safety.

Of course, BPT has limits. It only addresses the parenting factors. At times, the child’s individual factors (irritability, impulsivity) have to be addressed as well, possibly in conjunction with Cognitive Behavioral Therapy or anger management. However, anger management alone is insufficient. A course of treatment may take 3-6 months or even longer, depending on how longstanding the issues are and other factors. Therapy may require a lot of effort and be difficult at times, but it can’t be any more difficult than having these behaviors affecting the family for years or decades.

Behavioral Parent Training can allow the parents to enjoy their kids again, and kids to enjoy their parents. Contact Keystone Behavioral Pediatrics to learn more about how BPT can help.

Resources for Parents/Caregivers:

Centers for Disease Control

Mayo Institute

Child Development Institute

National Institute of Mental Health—DMDD

National Institute of Mental Health—Treatment of children with mental health issues in general


Keystone Provides Medication Management

Keystone medical director Dr. Tammy Tran monitors heart rate and blood pressure of one of children to determine the effectiveness and the medication he is taking.

When needed, we can prescribe and monitor the medications recommended for your child, while also making sure that they are effective and interacting with other medications safely. Tammy Tran, M.D., Keystone’s medical director, works as part of our team of providers to develop a group plan for each child to assist families and primary care physicians. The team works collaboratively in diagnosing, monitoring and treating any issues or concerns that you may have about your child, consulting with Dr. Tran to determine whether medication may be helpful for your child. If appropriate, Dr. Tran will prescribe and closely monitor the effects.

It may take some time to find the best medication, dosage, and schedule for your child. Your child may need to try different types of stimulants or other medication. Some children respond to one type of stimulant but not another. The amount of medication (dosage) that your child needs also may need to be adjusted. The dosage is not based solely on your child’s weight. Dr. Tran will vary the dosage over time to get the best results and control possible side effects. The medication schedule also may be adjusted depending on the target outcome. For example, if the goal is to get relief from symptoms mostly at school, your child may take the medication only on school days.

It is important for your child to have regular medical checkups to monitor how well the medication is working and check for possible side effects.

What Side Effects Can Stimulants Cause?

Side effects occur sometimes. These tend to happen early in treatment and are usually mild and short-lived, but in rare cases they can be prolonged or more severe. The most common side effects include:

  • Decreased appetite/weight loss
  • Sleep problems
  • Social withdrawal

Some less common side effects include:

  • Rebound effect (increased activity or a bad mood as the medication wears off)
  • Transient muscle movements or sounds called tics
  • Minor growth delay

Very rare side effects include:

  • Significant increase in blood pressure or heart rate
  • Bizarre behaviors

Most side effects can be relieved by:

  • Changing the medication dosage
  • Adjusting the schedule of medication
  • Using a different stimulant or trying a non-stimulant

Staying in close contact with Dr. Tran will ensure that Keystone therapists and you find the best medication and dose for your child. After that, periodic monitoring by Dr. Tran is important to maintain the best effects. To monitor the effects of the medication, Dr. Tran will probably have you and your child’s teacher(s) fill out behavior rating scales; observe changes in your child’s target goals; notice any side effects; and monitor your child’s height, weight, pulse, and blood pressure.

Common diagnoses that typically benefit from medication:

  • ADHD
  • Tic disorder, such as Tourette syndrome
  • Anxiety disorders

Resources for Parents/Caregivers:

NIH National Institute of Mental Health: Treatment of Children with Mental Illness

ADHD Parents Medication Guide prepared by American Academy of Child & Adolescent Psychiatry and American Psychiatric Association

ADAA Anxiety and Depression Association of America