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Why I Don’t Diagnose Oppositional Defiant Disorder (Part 1 of 4)

Grumpy-kid

by James Wiley, MD, FAAP  – @adddoc

Okay, I have diagnosed it. On occasion, I still might diagnose a young person with it. However, every time I think ODD, I ask myself “What is making this kid so angry and defiant?”  And if I do diagnose ODD I consider it my failure to answer that question.

Almost all of the DSM 5 diagnoses, including ODD, have the same final criterion; the symptoms are not better explained by something else. I think ODD behaviors almost always arise from other diagnoses or social situations. Failure to consider this criterion leads to significant over diagnosis of ODD, which is too often cited as the most common co-occurring condition along side ADHD.

This week I’d like to further discuss some common conditions and situations that replace the diagnosis of ODD in my practice. In this four part blog series, we will delve more into these conditions and situations that may better explain those symptoms that resemble ODD.

First and foremost-untreated or under treated ADHD.  Kids with ADHD wake up and go to bed listening to a recording of negative messaging—“Don’t!”, “Quit doing that!”, “That’s annoying!”, “You forgot-AGAIN?”, “Be still.”, “Be quiet.”, “You’re too loud.”, “You’re moving too fast.”, “Hurry up-slow poke.”, “Stop!”, “You’re lazy.”, “You’re not working to potential.”, “You did this yesterday-you’re just not trying hard enough.”  As you read this are you feeling a little oppositional? While we parents fear over medication with good reason, if your child is oppositional and the above tape is playing in his/her head then ask your doctor about increasing the stimulant medication. If that doesn’t work change the class of stimulant-amphetamine to methylphenidate or vise versa and titrate to the dose that puts the ADHD symptoms in remission without significant side effects.

Once ADHD has been diagnosed and treatment has started, oppositional-type behaviors can further be masked by other co-morbid conditions. In this series, we’ll look at anxiety disorders, obsessive-compulsive disorder, Tourette’s disorder, learning disabilities, and depression.

Anxiety Disorders

One symptom that can appear to be oppositional disorder is also one of the most overlooked DSM 5 symptoms of anxiety–irritability. Very anxious kids are often very irritable. Think of it this way: anxiety is getting on their nerves, so it’s really easy to get on their last nerve.  When they hit that threshold there can be an explosion, (sometimes a nuclear one!). It can be something as simple as a request to take the trash out or a reminder about homework. Anxious kids are often non-complaint.  They won’t go outside because of bug phobia, they melt down about going to school because of social phobia or separation anxiety. “This doesn’t make sense!” parents will say, “There’s nothing for her to worry about!”  Right!  That’s why we call it a DISORDER. Healthy anxiety creates a flight or fight response in the brain. Anxiety disorders create that same reaction. We either avoid the situation (play sick to avoid school, stay inside to avoid bugs) or we fight–which in anxious kids can look like aggression, meltdowns or tantrums. They will kick teachers, push peers, and yell that they hate their parents when put in situations that exceed their ability to cope with an anxiety trigger such as crowds or bad weather.

6 Tips for a Stress-Free Holiday for Kids with ADHD

6 Tips for a Stress-Free Holiday for Kids with ADHD | Focus-MD

The most joyful time of the year can also be the most stressful time of the year for children with ADHD and behavioral issues. Engaging in unfamiliar social settings, such as at holiday parties with friends and distant relatives, can be a triggering time for children. Be aware of this potential struggle and follow these six tips to help your child have as much fun as possible during this busy season:

 

1. Practice hellos and goodbyes – Rehearsing this behavior and eye contact will help your child smoothly handle arriving and leaving a holiday party. Tell your child that he doesn’t have to say a lot. A simple, “Hi, it’s nice to meet you!” will work for an introduction and a “Thank you!” will work on his way out of the door.

2. Role-play receiving gifts – Practice with your child what to do if he gets a gift he doesn’t like, a gift he already has, and a gift he loves. Act out these scenarios and give your child tips on how to be appreciative of any gift he gets.

3. Script conversation starters – Before going off to mingle with the other parents, make sure your child is settled in with a group of children. Remind him of ways to start conversations with them. Questions such as, “Do you play sports?” and “What’s your favorite movie?” are fool-proof ways for your child to jump right into the group.

4. Plan a schedule with your child – Your child knowing exactly what events are coming up is a useful way to manage anxiety. Use a calendar to countdown days until the next big party and to help him get excited for it. Also, make sure you don’t overschedule events for your child so that he has enough rest time amidst all of the festivities.

5. Practice breathing exercises – To calm your child down in a stressful situation, give him tips to take deep breaths and clear his mind and frustration. Rehearse the “stop, relax, think” technique with im, and encourage him to use this trick when he’s frustrated in a social setting.

6. Applaud successful behavior – Encourage your child by pointing out what he did well at a party! This will only lead to more successful behavior.

 

By practicing these tips, you can help your child have a relaxing and enjoyable holiday season. And, give Santa Claus a reason to bring them more gifts for their good behavior! Contact Focus-MD if you’d like to talk to your child’s doctor about his behavior during the holidays. From all of us at Focus-MD, we wish you happy holidays and a joyful new year!

 

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Now Open: Nashville-Hendersonville Focus-MD ADHD Clinic

FocusMD-Nashville-Hendersonville-Open

Focus-MD is happy to announce the opening of a new clinic in the Nashville-Hendersonville area. At this clinic, Dr. Madeline Ellis provides diagnosis and treatment for Attention Deficit Hyperactivity Disorder (ADHD) in patients ages 4 – 21 years old. By focusing on the whole patient rather than merely writing a prescription, Focus-MD clinics provide holistic treatment for ADHD patients.

Madeline Ellis, MD, FAAP

Focus-MD welcomes Dr. Madeline Ellis to the Nashville-Hendersonville clinic. Dr. Ellis earned her MD degree from LSU School of Medicine in New Orleans and fulfilled her residency at Cardinal Glennon Children’s Hospital with St. Louis University. Dr. Ellis is a Board Certified Pediatrician, a Fellow of the American Academy of Pediatrics (AAP), and a member of the Tennessee chapter of the AAP. After five years of experience in private practice, with two of those years in the Nashville area, Dr. Ellis is excited to welcome patients to Focus-MD in Nashville-Hendersonville.

Dr. Ellis is experienced in working with children, schools, and resources to provide the best environments for children. Much of this experience comes from her own family. Dr. Ellis is married to Barry Ellis, and they have two children. In treating the whole child, not just the symptoms of ADHD, Dr. Ellis works extensively with children and their primary care doctors to determine the best way to treat a child’s ADHD.

Dr. Ellis invites new patients to make an appointment to see her and evaluate the best ADHD treatment at the Nashville-Hendersonville clinic:

711 East Main Street
Suite 107
Hendersonville, TN 37075

Phone: 615-686-2346
Fax: 877-369-7549

Follow Focus MD Nashville-Hendersonville on social media to stay updated with clinic updates and ADHD treatment news.
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Dear Teacher: Working with My Son’s Tics

Dear Teacher: Working with My Son’s Tics | Focus-MD

 

This is the last part of the letter written by the mother of 9-year-old Josh to his teacher to give her some background knowledge on his dyslexia and ADHD. Here, she discusses his tics and how to best work with him in the classroom.

 

Dear Teacher,

Since we’ve given you an overview of Josh’s dyslexia and ADHD conditions, I’d like to also give you some information on his tics and how to work with him most effectively to make it a great year for the both of you.

Josh has occasional tics that are characterized by a brief hesitation accompanied by a rolling of his eyes. He may lose thought of what he was saying or doing during a tic, but he typically picks up where he left off.

Here are a few things to note about Josh’s tics and how to best work with him:

  • Acknowledgement of tics — Josh has not yet acknowledged his tic to us, so we do not make a big deal of them or draw attention to them. Essentially, we treat them like a blink.
  • Frequency of tics — Josh’s tics happen much more frequently during moments of high emotion, such as times of excitement, nervousness, anger, and frustration. We predict that his tics will be quite prevalent during the first week of school with the many new experiences.
  • Outbursts — Josh suffers in silence until he doesn’t. We do not expect many meltdowns/outbursts this year. But, when he does have an outburst, it will most likely not be about what it appears. Josh tends to stew about something until it results in an outburst that is not violent but is a clear refusal to do what he is told. They will likely surprise you and throw you for a loop!
  • Tolerance — We have and suggest a “zero tolerance” policy for obstinate behavior and outbursts. We know this can be difficult if the event is pulling on your heartstrings. We suggest clearly stating that the behavior is not acceptable and will keep him from participating in whatever class events are going on. If that does not calm the storm, he could be sent to the resource room to “get himself together.”
  • Initial challenges — Josh will tell you that he cannot or does not know how to do things for which he does not want to push through the initial challenge or frustration. It can be hard to decode this. We ask that you please require him to try. When he gains the confidence that he can do something that he thought he was incapable of, that smile will fill the room bigger than any other and will empower him to try again!

We want to thank you for being willing to take this time to learn about our son. We are grateful for your efforts and want you to know that we are always available to chat, meet, and collaborate. Our goal is the best and most productive learning experience for Josh, in the respect of you and your efforts to teach Josh and his classmates. Thank you very much!

Sincerely,

Mother

 

Josh’s mother took care to explain to his teacher how to best understand his conditions and how to work with him. With the start of the new school year, it is important to monitor changes in your child’s behavior and bring him or her to our office to readjust medications if needed. Contact us to help you and your child make this year a successful one!

 

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Dear Teacher: My Son Has ADHD

Dear Teacher: My Son Has ADHD | Focus-MD

 

Josh is a 9-year-old boy with dyslexia and ADHD, and is one of our valued patients. Last week, we shared the first part of a letter that Josh’s mother wrote to his teacher at the beginning of the school year concerning his issues with dyslexia. This week, we are sharing the second part of her letter as she discusses Josh’s ADHD.

 

Dear Teacher,

Josh is also diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). ADHD is a condition in which the brain is unable to properly regulate attention. Therefore, it is often the conception that children with ADHD cannot pay attention. Quite the contrary, they may simply pay attention to the “wrong” things. This also means they may not do a good job of regulating how they interact with the world.

Josh’s ADHD is different from many of his peers in its severity. He was diagnosed when he was very young and had challenges in preschool that resulted in some social delays. These are improving but are still clearly present nonetheless.

Here are a few notes about Josh and his ADHD:

  • Frustration tolerance — Regulating responses to frustration (which can include pushing through new types of math problems or even a change in the lunch menu) are a particular challenge for Josh. We have been working on managing his frustration for years by encouraging open communication with phrases such as, “I am frustrated because…”
  • Front-loading — We have learned that front-loading Josh with what is and is not happening is beneficial to his behavior. However, we also warn him often that plans may change. As parents, we do understand that life is full of surprises, and we do not expect you to front-load Jake constantly, yet do want you to know this trick for when it would help you.
  • Impulse control — Impulse regulation is another challenge of ADHD and one that is monitored very effectively by Josh’s medication. However, as his medication is kicking in and wearing off, you may see an increase in impulse control as a challenge for him.
  • Josh’s medication — ADHD medication is always a moving target. It is a constant struggle between finding the right amount to boost Josh’s focus to learn and make friends but that still allows him to be a 9-year-old boy. Additionally, there is always the challenge of timing: when it kicks in and when it wears off.

While we are aware that it is not your job to gauge Josh’s medication effectiveness, your feedback can help us to make the adjustments to make both yours and Josh’s lives easier.

 

Does this parent’s letter remind you of your child? Bring him to our office to be evaluated, and we will help get him on the right track to make this school year a successful one! Check our blog again next week to see what this mother has to tell her son’s teacher about his tics and how to best work with him.

 

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Dear Teacher: My Son Has Dyslexia

Focus-MD | Dear Teacher: My Son Has Dyslexia

 

With the start of the new school year, children are excited to get back to pencils, paper, and of course, the playground. However, children with behavioral issues such as dyslexia and ADHD may be dreading the start of another challenging year.

Josh is one of our wonderful patients. He is a 9-year-old boy with both dyslexia and ADHD. Josh’s mother wrote this letter to her son’s teacher to introduce her to the learning challenges and social difficulties that Josh faces. Take a look at the first part of this letter, where she discusses his dyslexia.

 

Dear Teacher,

It was a pleasure to meet you last week. Josh is very excited about starting the school year. I put together some notes for you about Josh’s behavioral conditions and some things that we believe might benefit you to know as you teach him this year. We strongly believe that it is our responsibility to arm you with as much information as possible to facilitate both yours and Josh’s success this year.

Within the past few weeks, we have discovered that Josh has dyslexia. While we are learning more about dyslexia daily, some of these symptoms that you might see in Josh are:

  • Sequencing — Josh struggles to keep track of proper sequences of tasks or instructions. I have seen this in how he tackles a chapter book — read and flip, read and flip, in no apparent order.
  • Word replacement — Josh often replaces words or phrases with synonyms when reading.
  • Name and term recall — Remembering names of classmates is a huge challenge for Josh. He also has difficulty recalling names of items that have similar application (i.e., mustard/ketchup, bagel/waffle). This has begun to cause him frustration to the point at which he will say, “I’m not good at remembering names…” and then give up trying.
  • Difficulty with reading — Josh never made the expected comfortable transition to reading chapter books last year at school. He can typically read the words he needs to read, but the pieces do not come together comfortably when he reads longer stories.
  • Difficulty with simple math word problems — Josh loves math and is happy to sit for hours doing fact worksheets. But, common word problems that assume a level of intuition or assumption are a huge challenge and frustration to him.

 

If you think your child displays these symptoms and may be dyslexic, schedule an appointment with us to have him or her evaluated. Check back next week to read more of this parent’s letter, when she discusses Josh’s ADHD.

 

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Back To School. Back To An ADHD Routine.

Focus-MD | Back To School. Back To An ADHD Routine.

By James Wiley, MD, FAAP

 

It’s back to school time, and that means it’s time to get back into a routine. One of the most important routines to focus on is bedtime and awakening time. Summer tends to shift bedtime later, and it definitely shifts awakening time later for most kids, especially teenagers. So, in order to adjust the sleep cycle, we recommend beginning to wake a little earlier each day and going to bed a little earlier each night.

One of the things that you have to do in order to accomplish this is to restrict those electronics your child or teenager takes to bed with them. That sometimes meets resistance. Whether you have ADHD or not, a good night’s sleep is essential for attention — but it is especially important for ADHD patients. The ADHD brain is very hard to slow down and it takes time to adjust. So, begin now to shift that sleep cycle back to the school year pattern. You’ll be glad you did.

 

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5 Quick Low-Tech Tips to Help Start Your School Year Off Right

Focus-MD | 5 Quick Low-Tech Tips to Help Start Your School Year Off Right

By James Wiley, MD, FAAP

It’s back to school time, and we at Focus-MD do more than just prescribe medicine to treat ADHD — we also like to provide tips and tricks on how to manage life with ADHD. So, to help you and your child start the school year off right, here are five quick low-tech tips:

1. Have extra pencils, erasers, pens, and paper.
These are all inexpensive tools. Make sure you have plenty on-hand so that you don’t hear, “I can’t find my pencil” or “I can’t get started because I don’t have a pencil.”

2. Have these tools in multiple colors.
ADHD brains love color, and a great system to begin to teach your child now is to highlight the important points. This way, when it’s time to go back and study, they’re ready to go.

3. Use a simple index card.
Boys resist using planners, and it frustrates teachers and parents to no end. Boys really do have trouble with planners a lot of times. But, what they will use is a simple index card. Some school uniforms have a pocket, so the index card fits in there nicely. Have them go ahead and write the four or five subjects they’re going to have homework in on that card. And, yes — I know moms are going to accidentally wash some of them, but it’s still good to teach them that technique!

4. Use Post-It notes.
Have your child write themselves notes. Remember that if you write the note, you’re doing the executive function in the reminding. But if the child writes something on the Post-It note, then they can remember without you nagging.

5. And finally, gather the things they’re going to need for school onto a “launch pad.”
Have them create it. Remember, kids don’t play as often in a playhouse that dad builds by himself — they’re going to want to be involved in the creative process. So, if you want your kid to get organized, have them design their own system. One great way is to find a piece of paper or poster board and have them create a space in which they gather the things they’re going to need for that day (AKA a “launch pad”). Whether that be their phone, their shoes — whatever it may be — they begin to learn to put those things together in one place. It works for NASA, and it’ll make your school year go much better.

 

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Focusing on Her Future: Focus-MD Scholarship Winner, Jourdan Collins

Focusing on her Future: Focus-MD Scholarship Winner, Jourdan Collins

When it became clear in middle school that Jourdan’s grades weren’t a true reflection of her intelligence, her parents sought answers. It was obvious to her parents and teachers that the talkative, energetic student was very bright but struggled with staying on task and focusing in the classroom…and her grades showed it. After a diagnosis of ADHD, Jourdan found her life as a student changed dramatically. She says, “Treating my ADHD has given me full control over my academic achievement.”

This fall, Jourdan will attend the University of South Florida and is planning to major in Biomedical Science. Her long-term goal is to go to dental school and eventually become an orthodontist. Being aware of how important it is to treat her ADHD has made all the difference. Jourdan has said, “I now have the will to try harder and I have made tremendous accomplishments throughout my high school career that have helped me reach my goal of attending an academically challenging university.” Jourdan is not only working hard in the classroom, but she has also maintained a job at Publix for the last two years. We are excited for her future and know that this hard work will pay off.

With offices currently in 5 states and growing, Focus-MD strives to provide an unmatched standard of care to those with ADHD. Every day we get to experience success stories like Jourdan’s, and we are proud to award her the Focus-MD “Focus on your Future” $1,000 scholarship.

 

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5 Things Teachers Should Know About ADHD in the Classroom

Focus-Md | 5 Things Teachers Should Know About ADHD in the Classroom

By James Wiley, MD, FAAP

It’s back-to-school time, and as the father and brother of teachers, I get to hear firsthand the joys and struggles educators face in the classroom. One challenge is managing hyperactive and impulsive behavior in the 10% of students that have ADHD. Here are 5 tips that will help you keep your sanity and make your students with ADHD (and their parents) eternally grateful.

1. Let them move
Research is in! Kids with ADHD perform better and learn more if they can wiggle while they work. Help them find less disruptive ways to do just that! A fidget pal — like an eraser or a small stress ball — can be helpful, but some kids will need more. Allowing students to sit on exercise balls has been helpful for some. Consider allowing students to stand at desks in the back of the room or have a walking and listening track if you find you have a kid that has to move. Incorporate stand up and stretch breaks into instruction.

2. Encourage PE and recess
Kids who get recess do better on standardized tests than those who don’t. If you restrict these high-movement times, then be prepared to face the repercussions. The need for the ADHD brain to move is cumulative — that is, it builds over the day. PE and recess allow a pop-off valve for that energy. Restriction from these activities due to behavioral issues or unfinished work is counter-productive.

3. Preferential seating
Some kids with ADHD get distracted visually and need to be in the front. For the ones more distracted by sound, consider letting them sit in the back of the class — these are the kids that are always looking behind them when you place them in the front closer to you so that they can listen better! Separating a child from his/her peers in a chair away from the action can lead to stigmatization and give a subconscious green light for bullying that child. Any changes in seating should be done privately and never in front of the other students or out of frustration. One thought is to move everyone around — that way no one is singled out, and the wiggle worm just happens to land in the seat you want him/her in! Don’t hesitate to rearrange if it doesn’t help.

4. Catch them being good and be specific on the negative behaviors
Kids with ADHD hear a lot of negative messages. When they have success controlling their behavior or completing their work, make sure to notice, and be easy on the frowny faces! Equal is not always fair. Most of God’s children, including the grown-up kind, will work more for encouragement and praise than for correction and discipline. When there are behavioral problems that need to be addressed, BE SPECIFIC. “He was blurting out answers and out of his seat a great deal today” is much more helpful than “Terrible day!” Consider identifying three problem behaviors and giving a daily grade of 1-5, with 1-2 being problematic, 3 being average and 4-5 being great! Parents can then see how their child is doing in the classroom and reinforce or discipline as indicated.

5. Never mention medication in the classroom
Asking a child about medication in the classroom or in front of a peer is a serious violation of privacy. Most teachers reading this will certainly agree! But from what kids say, it happens all too frequently, and it is devastating for them and often leads to problems with medication non-compliance. It’s much better to say, “You seem distracted today” or “You’re active today” than to ask about medication. If there needs to be a conversation about medication, remember to do it in private. Finally, please share concerns about medication side effects or lack of effectiveness of medication with the parent (or physician with parental approval). You are with the child eight hours a day, five days a week for nine months (as you no doubt know!), and your professional opinion counts!

Watch the late Rita Pearson’s Ted Talks video Every Kid Needs a Champion. She says it best.

 

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