When local media want to report on news stories about behavioral health issues that children and young adults face and how they affect families and others in our community, they often turn to Keystone Behavioral Pediatrics’ highly educated and experienced therapists for their observations about these issues.
Here are some recent media interviews with Keystone clinical child psychologist, Max Horovitz, Ph.D.:
Child misconduct – Dr. Max was interviewed by First Coast News reporter Ken Amaro about a disturbing allegation of misconduct by one child to another child in a local daycare center and why a child might act in such a manner. http://fcnews.tv/2tu15Xn
Child abuse – A Nassau County deputy was put on administrative leave while the Florida Department of Children and Families looked into child abuse claims, after a video surfaced of the deputy spanking and yelling expletives at a young girl. Keystone’s Max Horovitz, Ph.D., was interviewed about whether his discipline was appropriate. While spanking is legal if done according to the law, Horovitz said it can do more harm than good, leading to social and legal problems in adulthood. – http://bit.ly/2su3Wvk
Teen suicide – When a popular Netflix series, “13 Reasons Why,” began sparking a serious conversation among teens centering on the sensitive topic of suicide, Max Horovitz was interviewed about how parents should handle the topic with their teens. He said suicide is a topic parents should discuss with their kids. http://bit.ly/2qCm4SW
Children killing children – Two boys were put behind bars at just 12 years old, accused of killing. When interviewed about the killings, Dr. Max said that there’s no way to predict which children will kill. He noted, however, that children who have been neglected can develop differently and begin to act out and that some killer kids may have turned out differently if reared in a loving environment. http://bit.ly/2spIV9X
Dr. Max is director of Keystone’s ADHD Clinic and co-director of its Educational & Learning Assessment Clinic. Thanks, Dr. Max, for helping Keystone get the word out into the community about how we can help children, their families and the community in which they live!
Children with trauma are often misdiagnosed with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), mood disorder or a combination of these disorders, because diagnosis can be difficult without knowing about any abuse history. This is what Rea Romero, Ph.D., neuropsychologist, and Brian Ludden, Ed.D., M.S., LMHC, NCC, CCMHC, also noted in their work with Jacob, an 8-year-old boy, who was permanently removed from his mother’s care due to abuse and neglect, possibly including sexual abuse.
They submitted a case study about Jacob that was accepted in late 2016 for a poster presentation at the 2017 American Psychological Association (APA) Convention. Dr. Romero will present the poster of their work on Aug. 5, 2017 in Washington, D.C.
Jacob has a history of erratic mood swings, anger outburst, impulse control, fire-setting, stealing, lying and aggression. Before coming to Keystone Behavioral Pediatrics to work with Dr. Brian and Dr. Rea, Jacob had been given Adderall for two years, with minimal benefit. Prior to receiving a neuropsychological assessment at Keystone, Jacob’s treatment had focused on ADHD and disruptive behaviors.
Jacob’s assessment revealed average to superior cognitive functioning, and academic achievement, visual-spatial skills and language skills also ranged from average to superior. Likewise, other neuropsychological assessments results were at the expected level or well above the expected level.
The assessments did reveal that Jacob has problems with adaptive, emotional and behavioral functioning. Research shows that abuse and neglect can affect neurobehavioral development that is necessary for efficient behavioral/emotional control and regulation. This led Dr. Rea and Dr. Brian to believe that Jacob’s difficulties in emotional and behavioral regulation are related to his history of significant traumas associated with abuse and neglect.
Patients will receive a better treatment plan and interventions if complete biopsychosocial history is taken into account
While Jacob denied suffering from increased startled response, flashbacks and psychological symptoms, which are usually an indication of posttraumatic stress disorder (PTSD), his emotional and behavioral problems and patterns are indicative of trauma. Jacob also struggles with handling interpersonal relations and maintaining meaningful relationships, also symptoms of trauma.
Currently, Jacob is receiving a combination of individual mental health sessions and family mental health sessions. Dr. Brian and Dr. Rea have focused on helping Jacob improve his communication with his family and on reducing behavioral concerns, anxiety and the impact of persistent thoughts related to traumatic childhood experiences. He has been taught the use of mindfulness meditation, guided visualizations, compartmentalization, diaphragmatic breathing and other adaptive coping skills for managing and reducing his emotional and behavioral issues.
Over the course of six months of treatment, Jacob’s behavior has improved considerably. As a result of ongoing family mental health sessions, Jacob has come to develop a relationship with his biological mother. Jacob should continue to progress through treatment and master the various mindfulness and self-regulating skills that he has learned in treatment.
As a result of this case study, Dr. Rea and Dr. Brian are presenting to conference attendees that patients will receive a better treatment plan and interventions if complete biopsychosocial history is taken into account. Keystone supports Dr. Brian and Dr. Rea’s research efforts and encourages all therapists to engage in research that continues to improve clinical results for the kids we serve.
By Jessica Hamblen, PhD and Erin Barnett, PhD, for PTSD: National Center for PTSD
Children and Adolescents Experience PTSD, Too
What events cause PTSD in children?
Any life threatening event or event that threatens physical harm can cause PTSD. These events may include:
Sexual abuse or violence (does not require threat of harm)
Natural or manmade disasters, such as fires, hurricanes, or floods
Violent crimes such as kidnapping or school shootings
Motor vehicle accidents such as automobile and plane crashes
PTSD can also occur after witnessing violence. These events may include exposure to:
Finally, in some cases learning about these events happening to someone close to you can cause PTSD.
What are the risk factors for PTSD?
Both the type of event and the intensity of exposure impact the degree to which an event results in PTSD. For example, in one study of a fatal sniper attack that occurred at an elementary school proximity to the shooting was directly related to the percentage of children who developed PTSD. Of those children who directly witnessed the shooting on the playground, 77% had moderate to severe PTSD symptoms, whereas 67% of those in the school building at the time and only 26% of the children who had gone home for the day had moderate or severe symptoms (6).
In addition to exposure variables, other risk factors include:
Previous trauma exposure
Preexisting psychiatric disorders
Low social support
Parents have been shown to have protective factors (practice parameters). Both parental support and lower levels of parental PTSD have been found to predict lower levels of PTSD in children.
There is less clarity in the findings connecting PTSD with ethnicity and age. While some studies find that minorities report higher levels of PTSD symptoms, researchers have shown that this is due to other factors such as differences in levels of exposure. It is not clear how a child’s age at the time of exposure to a traumatic event affects the occurrence or severity of PTSD. While some studies find a relationship, others do not. Differences that do occur may be due to differences in the way PTSD is expressed in children and adolescents of different ages or developmental levels.
As in adults, PTSD in children and adolescence requires the presence of re-experiencing, avoidance and numbing, and arousal symptoms. However, researchers and clinicians are beginning to recognize that PTSD may not present itself in children the same way it does in adults.
What does PTSD look like in children?
Criteria for PTSD include age-specific features for some symptoms.
Elementary school-aged children
Clinical reports suggest that elementary school-aged children may not experience visual flashbacks or amnesia for aspects of the trauma. However, they do experience “time skew” and “omen formation,” which are not typically seen in adults.
Time skew refers to a child mis-sequencing trauma-related events when recalling the memory. Omen formation is a belief that there is a belief that there were warning signs that predicted the trauma. As a result, children often believe that if they are alert enough, they will recognize warning signs and avoid future traumas.
School-aged children also reportedly exhibit post-traumatic play or reenactment of the trauma in play, drawings, or verbalizations. Post-traumatic play is different from reenactment in that post-traumatic play is a literal representation of the trauma, involves compulsively repeating some aspect of the trauma, and does not tend to relieve anxiety.
An example of post-traumatic play is an increase in shooting games after exposure to a school shooting. Post-traumatic reenactment, on the other hand, is more flexible and involves behaviorally recreating aspects of the trauma (e.g., carrying a weapon after exposure to violence).
Adolescents and Teens
PTSD in adolescents may begin to more closely resemble PTSD in adults. However, there are a few features that have been shown to differ. As discussed above, children may engage in traumatic play following a trauma. Adolescents are more likely to engage in traumatic reenactment, in which they incorporate aspects of the trauma into their daily lives. In addition, adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors.
Besides PTSD, what are the other effects of trauma on children?
Besides PTSD, children and adolescents who have experienced traumatic events often exhibit other types of problems. Perhaps the best information available on the effects of traumas on children comes from a review of the literature on the effects of child sexual abuse.
In this review, it was shown that sexually abused children often have problems with fear, anxiety, depression, anger and hostility, aggression, sexually inappropriate behavior, self-destructive behavior, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, substance abuse, and sexual maladjustment.
These problems are often seen in children and adolescents who have experienced other types of traumas as well. Children who have experienced traumas also often have relationship problems with peers and family members, problems with acting out, and problems with school performance.
Along with associated symptoms, there are a number of psychiatric disorders that are commonly found in children and adolescents who have been traumatized. One commonly co-occurring disorder is major depression. Other disorders include substance abuse; anxiety disorders such as separation anxiety, panic disorder, and generalized anxiety disorder; and externalizing disorders such as attention-deficit/hyperactivitiy disorder, oppositional defiant disorder, and conduct disorder.
How is PTSD treated in children and adolescents?
Although some children show a natural remission in PTSD symptoms over a period of a few months, a significant number of children continue to exhibit symptoms for years if untreated. Trauma Focused psychotherapies have the most empirical support for children and adolescents.
Cognitive-Behavioral Therapy (CBT)
Research studies show that CBT is the most effective approach for treating children. The treatment with the best empirical evidence is Trauma-Focused CBT (TF-CBT). TF-CBT generally includes the child directly discussing the traumatic event (exposure), anxiety management techniques such as relaxation and assertiveness training, and correction of inaccurate or distorted trauma related thoughts.
Although there is some controversy regarding exposing children to the events that scare them, exposure-based treatments seem to be most relevant when memories or reminders of the trauma distress the child. Children can be exposed gradually and taught relaxation so that they can learn to relax while recalling their experiences. Through this procedure, they learn that they do not have to be afraid of their memories.
CBT also involves challenging children’s false beliefs such as, “the world is totally unsafe.” The majority of studies have found that it is safe and effective to use CBT for children with PTSD.
CBT is often accompanied by psycho-education and parental involvement. Psycho-education is education about PTSD symptoms and their effects. It is as important for parents and caregivers to understand the effects of PTSD as it is for children. Research shows that the better parents cope with the trauma, and the more they support their children, the better their children will function. Therefore, it is important for parents to seek treatment for themselves in order to develop the necessary coping skills that will help their children.
As the largest provider of integrated, collaborative healthcare in northeast Florida for children who have behavioral, developmental, mental, emotional and learning issues, Keystone Behavioral Pediatrics recognizes May as National Mental Health Month.
One of Keystone’s child psychologists, Max Horovitz, Ph.D., was interviewed by Action News CBS 47 Fox 30, about the connection between mental health issues and suicide by teenagers. Specifically, the news station was reporting on increasing concern by educators, schools and parents about the Netflix show, “13 Reasons Why,” which tells the story of the main character, Hannah Baker, who took her own life, leaving behind 13 tapes for the 13 people she said were responsible. Schools are beginning to send letters home to parents warning them about the show’s potentially dangerous message.
During the interview, Dr. Horovitz noted that some children are more easily influenced than others and parents might consider talking with their child about the show’s message. “We want kids to know there are a lot of ways they can be helped that don’t have to be suicide,” Horovitz said.
Several other occasions spotlight mental health issues throughout the month:
May 4 – Children’s Mental Health Awareness Day
May 7-13 – National Anxiety and Depression Awareness Week
May 13-17 – Children’s Mental Health Awareness Week
Keystone advocates every day for the importance of integrating behavioral health and primary care for children, youth and young adults is mental and/or substance use disorders by working with children in its Southside clinic, in their homes, at their schools and in the community. This year’s national theme, “Partnering for Help and Hope.” is especially meaningful, in light of the number of news stories recently that report instances of police having negative interactions with children and young adults who have special needs.
Keystone would welcome the opportunity to help local media discuss children’s mental health issues in a variety of subject areas to bring attention to National Mental Health Month. Its team of child psychologists and therapists can make themselves available for interviews as needed.
Keystone’s team also provides in-service training to educators in schools and other community organizations, police officers and emergency medical service providers. Keystone can share information and techniques to help them understand why children with special needs may act and/or react the ways that they do in stressful situations and what methods can be used to deescalate a potentially unpleasant or potentially dangerous situation.
To schedule an interview or an in-service training, contact Karen Rieley, director of marketing and communications, 904.333.1151, firstname.lastname@example.org.
Since its opening in 2013, Keystone Child Development Center has grown rapidly. The school was founded based on the inclusion model that provides opportunities for students with disabilities to learn alongside their non-disabled peers. The center’s leaders have spent the past four years developing and perfecting an educational approach that is thoughtful and balanced. They have successfully prepared hundreds of preschool children for success in primary school and beyond.
“Our goal was to produce an educational program that is developmentally appropriate for all young children and based on the best practices in the education field,” Katie Falwell, CEO and founder, said. “We are inspired by a variety of philosophies and approaches, which we have blended together into a program that reflects our commitment to helping children lay the best possible social, emotional, physical and cognitive foundations.”
As a result of rapid growth and what has been learned from the success of Keystone Child Development Center, Dr. Falwell is retiring KCDC and launching two new schools. Collage Day School and Mosaic Day School will open with the 2017-18 school year.
Collage Day School
Collage Day School, an academically challenging, independent day school that will open in Palm Valley this coming August, is currently accepting applications for students from 3 months old through 5th grade. The school focuses on providing a rich, integrative curriculum that encourages creative thinking and that is personalized for each student.
Students will start classes on Thursday, Aug. 10, and the school will follow the St. Johns County Public School Calendar. Collage Day School is located at 171 Canal Boulevard, Ponte Vedra Beach, FL 32082. The 8-acre campus is nestled between the Intracoastal Waterway and Atlantic Ocean in the heart of the Ponte Vedra Beach area of St. Johns County, which offers students hands-on experiences with nature and outdoor learning and additional layers of education, history and ecology.
The faculty of the School is made up of a combination of certified lead teachers and assistant teachers. Each teacher is tasked with bringing subject matter to each student in a way that is engaging and appropriate for the developmental stage of the student, rather than following a scripted lesson plan developed by someone else.
Our approach is thoughtful and balanced. It is also developmentally appropriate and based on the best practices in the education field. We are inspired by a variety of philosophies and approaches, which we blend together into a program that reflects our commitment to helping children lay the best possible social, emotional, physical and cognitive foundations.
Collage staff is challenged with uncovering the unique learning profile of each individual student and matching that knowledge with instruction to help their students develop the tools to be problem solvers, innovators, creators and change makers.
The grounds around Collage Day School will be put to good use as a “living classroom” where children can develop cognitive, social and emotional skills. The school is dedicated to promoting students’ health. Students do not spend their day sitting in front of computers under artificial lights, but have the opportunities to move and use their bodies in healthy ways and to spend time outdoors with a myriad of natural features such as woods and pathways, garden, play equipment and an inner courtyard that provides a common area for the Collage family to gather and socialize.
Collage is completing the process for full membership and accreditation by the Florida Council of Independent Schools (FCIS), Florida Kindergarten Council (FKC) and the National Association for the Education of Young Children (NAEYC). The school’s VPK program is endorsed by the Florida Department of Children & Families.
How important is preschool?
As reported in Parents.com, “There’s increasing evidence that children gain a lot from going to preschool,” says Parents advisor Kathleen McCartney, PhD, dean of Harvard Graduate School of Education, in Cambridge, Massachusetts. “At preschool, they become exposed to numbers, letters, and shapes. And, more important, they learn how to socialize — get along with other children, share, contribute to circle time.”
Mosaic Day School
Mosaic Day School offers education for children with special needs, ages 1-7. Mosaic has classes designated for early intervention for students who are not appropriate for Collage Day School. Students attending Mosaic will receive services from Keystone Behavioral Pediatrics, as needed, and attend either a half-day program (morning or afternoon) or a school day program (8:30 a.m. – 2:30 p.m.). Before- and after-care will also be available. Mosaic also offers a day treatment program for older students that are not able to successfully participate in a classroom setting.
The school primarily serves children with behavioral/developmental issues who have experienced failure in the continuum of available public or private special education environments and require a high degree of individualized attention and intervention. The program includes intensive one-to-one sessions and small group sessions, when appropriate, which teach students to relate to their peers and participate cooperatively in group activities. The goal is for each student to reintegrate or matriculate to a less restrictive academic setting with traditional classrooms.
Mosaic Day School is located at 6867 Southpoint Rd. N, Jacksonville, FL 32216.
To learn more about Collage Day School, visit @Collage Day School on Facebook and contact Rebecca Bowersox, director of admissions, email@example.com, 904.900.1439.
Beginning April 4, psychiatrist Chadd K. Eaglin, M.D., joins Keystone Behavioral Pediatrics as our new medical director in charge of medication management. He will work with our team of providers to develop a comprehensive plan for your child to assist your family and primary care physicians.
Depending on the specific concerns and/or diagnoses that a child may have, such as ADHD, autism, anxiety, depression or other behavioral issues, a course of medication in combination with other therapy techniques may be helpful. Keystone’s team works collaboratively in diagnosing, monitoring and treating any issues or concerns that parents may have about their child, consulting to determine whether medication may be helpful. If medication is determined to be helpful, Dr. Eaglin will prescribe and closely monitor the effects.
It is important for a child to have regular medical checkups to monitor how well the medication is working and check for possible side effects. Most side effects can be relieved by changing the medication dosage, adjusting the schedule of medication or using a different stimulant or trying a non-stimulant.
Staying in close contact with Dr. Eaglin will ensure that Keystone therapists and parents find the best medication and dose for their children. After that, periodic monitoring by Dr. Eaglin is important to maintain the best effects.
Dr. Eaglin comes to Keystone with 11 years of education and experience in medicine and psychiatry. He received an M.D. from the University of Missouri at Kansas City School of Medicine and completed his psychiatry residency training program at the University of Hawaii. He is certified by the American Board of Psychiatry and Neurology with specialty training in NeuroStar Transcranial Magnetic Stimulation (TMS) therapy. He focuses on diagnosis, treatment and management of patients from school-aged children to geriatrics who have mood disorders, anxiety disorders, impulse control orders, autism and complex behavioral challenges.
For now, Dr. Eaglin will be available by appointment each Tuesday morning, 9 a.m. – 12 p.m. The goal is to build his caseload to a full time practice with Keystone. To set an appointment, call 904.619.6071 or fill out the online Appointments form.
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.
In some of the latest news from AutismSpeaks.org, 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.
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.
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 www.keystonebehavioral.com 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.
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.
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
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
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: