Dr. Riley checking in to Early Childhood Zone

[Dr. Douglas Riley]

Greetings to the board. It has been a number of years since I have participated, and I recently posted on the General Forum. Those of you who remember me probably associate my name with my book,The Defiant Child. I am writing to let you know that my latest book, entitled What Your Explosive Child Is Trying To Tell You, may be of particular use to parents with explosive children in the three, four, and five-year old range. The book was published by Houghton Mifflin in August, 2008, and I am pleased to announce that it recently won The Mom's Choice Awards gold medal for parenting books for 2009.

The premise of the book is that there are a number of "types" of explosions. While all explosions look the same on the surface, the underlying cause of any given child's explosive behavior can vary widely. Some children explode because they are exquisitely sensitive to unexpected events or transitions or changes, and cannot tolerate anything unexpected. Others explode because of hidden food sensitivities. Still others explode because of issues related to sensory integration disorder. The book goes through eleven different underlying causes, among them anxiety, perfectionism, immaturity, undiagnosed allergies, undiagnosed sleep/airway issues, and so on, and teaches parents how to recognize and treat each of the causes behind a child's explosive behavior.

Due to the fact that the underlying causes can vary so widely, I am not of the belief that there can be a one size fits all type of treatment. For example, common sense tells us that it would never work to use the same methods to treat a child who explodes due to anxiety with the same methods you would use to treat a child whose explosions are due to oppositional defiant disorder. The book goes to great length to give specifics on the treatment of each of the underlying causes.

Chapter Two of the book is particularly relevant to the young exploders, those in the 3.5 to 5 year old range. It talks about the "Big Kid Program" at great length. The interventions in that chapter come from the idea that every young child's fantasy is to be thought of as "big," and that the proper use of verbal feedback on their behavior can make a large difference in how they act. For kids in the five and six year-old category, I also use an intervention that I refer to as "the brain game." It essentially helps children learn to control their impulse to explode by making sure that their "big kid brain" stays in charge of their behavior, and does not let their "little kid brain" become their "boss brain." Kids love to do this role play, and it is amazing how quickly they come to value using their own thinking to stay in the big kid zone. I also have a children's cartoon book, Quark Blows His Top!, about a little green alien who literally explodes and has to learn how to pull himself back together. It will soon be available on my website, drdouglasriley.com.

I will be happy to visit, and try to answer questions about the book and the techniques in it. At this point of my career - 32 years in the chair and counting - my strongest interest is in the littlest exploders. If we can help them early, it will make life so much better for them, as well as for everyone they live with and interact with during the day. It is my fondest wish that the book will be helpful to you and to your children.

Best regards, Doug Riley

 

[SRL]

Welcome to the Early Childhood Board, Dr. Riley. Thanks for taking the time to stop in. We've had a number of new parents come through the board these past few weeks and I know they'll appreciate this opportunity.

I had a chance to look through your book this weekend and appreciate the emphasis on identifying causes of challenging behaviors. In my own experience so many of the behaviors that initially I chalked up to as being defiant had a perfectly logical reason once I had a grasp on what was really going on with my little person.

One question I do have for you, based on what parents who come through here are reporting: frequently it seems as if pediatricians tend to be more apt to refer children to therapists or psychiatrists for treatment, but far more reluctant to make referrals for more in-depth, multidisciplinary evaluations. Why the reluctance? I feel like I'm standing on a permanent soapbox here in encouraging parents to get thorough evaluations on their young ones. I don't mean in any way to dismiss the importance of therapists and/or psychiatrists as part of a treatment plan (if indicated), it's just that we find a lot of parents wishing in hindsight that they'd had the bigger picture early on.

SRL

 

[Dr. Douglas Riley]

SLR: I can appreciate the importance of your question. We unfortunately seem to be living in a time in which viewpoints on childhood behavior are narrowing, rather than expanding, and the the emphasis is placed on treating the observable symptoms instead of the underlying causes. One example that I gripe about all the time is the whole ADHD conundrum. If a child is off task in the classroom, has trouble finishing his work, and is disruptive (all readily observable symptoms), he is automatically assumed to have ADHD. The fact of it is that he might be under the sway of any number of forces. Maybe his sleep is disturbed due to enlarged tonsils, maybe he is having trouble learning the material, maybe he is bored, maybe things aren't good at home, maybe he's getting bullied or shunned by his peers, and so on.

Years ago, I was free to orient my testing of these children to looking at them very broadly in an attempt to find the underlying cause. Today, insurance benefits only cover testing for something that can ultimatley be treated with medication (it is medical insurance, after all, so I do see their point as much as I disagree with it). While the school psychologists and school social workers do a fine job of testing/evaluating for underlying learning issues and home issues, they are overwhelmed and cannot possibly evaluate all of the children who need their help, thus many, many kids never get an evaluation.

The pediatrician's that I know in my area find this very disheartening, as they are a group of people who are remarkably devoted to caring for children. The truth of it is that the medical system is dominated by insurance company guidelines and regulations, which are themselves tied to the DSM-IV diagnostic manual, which itself is simply a list of symptoms. Sorry to go on so long - to summarize, the system is symptom driven, not cause driven, and I believe that children suffer due to this.

Doug Riley

 

[SRL]

Often when parents start looking for help, it's with the hope of finding something that will "fix" their little exploder's behavior. In reality, the turning point usually doesn't lie with the child changing, but with the parent adjusting their thinking from seeing their child as acting out on purpose to recognizing that their child is acting out for very real reasons. The shift in attitude from thinking the child "won't" to the child "can't at this time" is absolutely critical. Could you please address this more fully?

 

[steph3306]

Hi, Dr. Riley

My son is 4 and diagnosed with Pervasive Developmental Disorder (PDD) and behavior disorder. He is very angry ALL the time. He screams at everyone. When he gets mad he hits, bites, punches, etc... His vocabulary is way behind for a 4 year old but he is very verbal for having autism. He is currently taking risperdal 3x daily, and the neurologist just started him on trileptal. He doesn't have seizures. I haven't had a chance to read your new book yet. Do you have any ideas as to why he is so angry all the time? Do you have any suggestions on how to get him to quit screaming? He is in a preschool for children with disabilites and will be going to kindergarten next year. He is very smart for only being four. He can count to at least 80, reads sight words, can tell time, very good with the computer, knows all the letters and sounds of the alphabet. It is hard to actual know what all he does know because he will not test for the teachers. He does use a picture schedule at school. The school and us can not pin point any one thing that sets him off to make him start screaming. Thanks

 

[Dr. Douglas Riley]

To SLR regarding "won't versus can't." What an important issue. In my experience with the youngest exploders, the acting out is very rarely on purpose (with the exception of the young ODD kids, who act out as a means for pulling equal with the parent in the power structure). Their symptoms almost always have a hidden cause. There is a five year old girl that I recently saw who threw massive fits at bed time, and banged on her parents door until they let her into bed with them. They initially saw it as "won't" sleep in her own room, using your terms. I indicated to them that when young children act this way, there is almost always a powerful fear driving the behavior. In her case, she was afraid that her mother would die during the night, but had never articulated anything like that to her parents. Her mother was stunned to learn this. Examples like this show why you have to look beyond the observable behavior and find the underlying cause. I love the language of "won't" versus "can't." This child clearly could not rest easily at night due to her fears (doing much better now by the way).

To steph3306, re your son's anger: Children in the Pervasive Developmental Disorder (PDD) spectrum are often exquisitely sensitive to what I refer to as "roadmap" issues. As long as things go as they expected, they can be pretty peaceful. When faced with something they did not expect, they will explode. This is likely to get better as he ages, assuming that you do not begin to totally walk on egg shells and spend all of your time trying to make sure that his life is totally predictable - doing so only makes them more reactive to change, and never teaches them to deal with anything unexpected. That said, he may continue to be sensitive to unexpected events as part of the overall package. Do your best, though, to expose him to unexpected events to desensitize him to change as best as you can.

With the young children that I see at my office who are chronically cranky or explosive, there is often an underlying food sensitivity. Very few doctors of any sort are up to speed on this issue (I had to learn about it due to issues in my own family). Does he have sandpaper rash on his wrists, or excema, or cherry red cheeks or red ears? If so, this is quite often due to a sensitivity to milk and milk-based products. There may also be underlying environmental allergies, or chemical sensitivities that have not been diagnosed. Also, given the nature of smart, autistic kids, he might get set off by something that he can't do perfectly, words that you did not say correctly, and so on. Look for patterns.

Best regards, Doug Riley

 

[SRL]

Parents, please feel free to jump in here, but since Dr. Riley has stopped by I want to ask some general questions for the benefit of our newer members, as well as those who will read our archives in the future.

Dr. Riley, I really appreciate your input. Two label questions:
1) As you may imagine, especially here on the Early Childhood board we have a lot of parents coming in and reporting standalone diagnoses of ODD or ODD/ADHD after their initial appointments. Could you discuss the ODD label—both in terms of its usefulness and its limitations? Based on what we're seeing here, I get the feeling there is pretty widespread use of the ODD label.

2) A few years ago we started seeing a trickle of 4 and 5-year-olds who had been given Conduct Disorder labels by various diagnosticians. At first we thought it was a mistake because the criteria specified teens (well, technically, first we moms went ballistic) but then I did some digging around and found that the criteria for Conduct Disorder had been changed to include younger children in the DSM-IV Text Revision. Often in questioning these parents we found that the child had been assessed in the behavioral aspects only. What advice would you give to a parent of a very young child who has been given a Conduct Disorder label?

 

[samsdad]

I noticed that you mentioned excema as a sensitivity to milk based products. Our son and daughter drink milk at a rate of 1.5 gallons per week and both have what I call minor excema. The son (See post for Angry 4 year old) shows extreme difficulty with change, redirection, etc...


Looking in that direction (or maybe a shot in the dark) We moved to an area with only well water available (though filtered) from an area with city water and the issues began shortly afterwards. Any connections from your past that would indicate this as an issue?

 

[Dr. Douglas Riley]

To samsdad, regarding excema: This is a difficult question, isn't it? I've not heard anything about the contents of well water that could set off the really rigid and explosive behaviors, unless it contains some chemicals that are not being filtered out. In this case, there could be chemical sensitivities. I will remain suspicious of milk in your case, as some children can drink it for quite a while before it impacts their behavior. I would be curious to see what would happen if you removed milk and all milk-based products from their diets for five days (milk, ice cream, yogurt, cheese, etc.). After the fifth day, give them each a lot of milk products in the morning, then watch their behavior over the next few hours to see if anything happens. Some writers say that it takes five days for a food like this to clear your system, and when it is reintroduced the symptoms can be dramatic. If the excema begins to clear, it may be a signal that you are on to something. It may be a good idea to consult with a pediatric allergist on this issue. I would be very curious to see what he or she might say.

Doug Riley

 

[Dr. Douglas Riley]

To SRL, regarding labels: I will address my comments to kids in the 3.5 to 5 year-old range, as six and up kids are quite different in many ways.

As for the term Oppositional Defiant Disorder, I am always extremely cautious about the disorder part of the term. The term "disorder" implies a fixed state of being or behavior, and really shoould not be used with kids in this age range. I'm OK with the term "oppositional behavior." You should all know that the term "disorder" is used in order to get insurance companies to pay for the medical/psychiatric/psychological/counseling services. No label, no pay, unfortunately.

That said, still be careful about the term. About the only trait that kids are virtually guaranteed to carry forward from their early years is whether or not they were behaviorally inhibited (shy), or behaviorally disinhibited (bold). Inhibited kids tend to stay inhibited, although there is interesting brain research on the ones who change. In other words, plenty of kids who display oppositional behavior when they are young will not display it at all when they are a few years older.

If you are familiar with my work, you know that I make clear distinctions between oppositional children and explosive children, and I believe it is a major mistake to treat them as if they are one category. Oppositional kids are exquisitely sensitive to power issues, and from early on attempt to pull equal with their parents. Their blowups and battles with you are meant to show you that they will take you on. Explosive children blow up over a wide variety of issues, but when they are young it is typically due to "roadmap" issues and difficulties with unexpected events and transitions. Oppositional children aren't particularly sorry after they blow up, because they see nothing wrong with battling with you. Explosive children are usually remorseful, because they don't like the way they feel after they explode, and they feel bad about their behavior. You cannot treat them both with the same methods, given the vast differences in the underlying causes of their behavior.

So, be very careful of anyone giving your child the ODD label because your child is blowing up and taking you on. It is typically done for insurance purposes, and the best therapists will admit to you that there is a huge chance of the child's behavior being quite different later on. I use the term "painfully normal" for a lot of the behaviors of the youngsters I work with, because what they are doing is painful to be around, but normal, and will get better over time.

There are many theories of how to work with ODD children, so you should read widely. The most pragmatic viewpoint is to use what works, and to avoid thinking that there is any one, single method that will work for all children. (If the methods that worked for your friend's ODD child do not work for yours, it does not in any manner mean you are a failure or a bad parent. It just means you have yet to use the methods that your particular child will respond to.)

As for Conduct Disorder - I would personally be very suspect of anyone who would use that label on the children that we are discussing on this particular board. Children can be amazingly cruel and aggressive when they are young. I've certainly worked with four and five year-olds who seemed to get a great deal of joy out of hurting animals and other children, but I also found that the behaviors decreased markedly when the parents used the correct procedures, and of the children who I have followed for lengthy periods of time, the vast majority of them developed prosocial behaviors. If someone hangs that label on your child, it is a signal to you to, first of all, seek a second opinion by a thoroughly seasoned professional who specializes in children (I always suggest that parents avoid the p and t docs who claim to treat everyone from 3 to 90). Secondly, if someone does offer that label, it is also a signal to you to begin to develop a well thought out behavior modification program so that your child's negative behaviors will not be reinforced, and so his or her positive behaviors are reinforced. In general, again, before you listen to anyone who places such labels on children due to their behavior, make sure that you have thoroughly searched to see if there are other underlying reasons that are causing the child to act the way they act.

Doug Riley

 

[ch574]

Oppositional children aren't particularly sorry after they blow up, because they see nothing wrong with battling with you. Explosive children are usually remorseful, because they don't like the way they feel after they explode, and they feel bad about their behavior. You cannot treat them both with the same methods, given the vast differences in the underlying causes of their behavior.

Dr. Riley -

I am new to this world, as my 4.5 year old son was diagnosed as ODD/ADHD less than a month ago. I will be buying BOTH of your books tomorrow, as I have yet to be able to find anything that feels like it deals specifically with ODD as it might relate to young children... or anything that feels like it offers a hopeful outcome (anything other than the idea that I'm destined for full-blown conduct disorder down the road...).

Based on what you said above, I'm trying to decide if I think my child is oppositional or explosive, and I hoping you might explain what "remorse" looks like in a 4 year old? I logged on this evening to see if anyone had any suggestions about how to handle an explosion on a young peer. She pushed my son's button, he exploded (verbally... never physically), and she disolved into tears because he "hurt her feelings." He bolted out of the house (we were in the process of leaving), and once we were in the car, I caught his eye and said, "You really hurt S's feelings with that yelling." He just closed his eyes and turned his head to the side of his car seat and didn't say anything more on the whole ride home. I dropped it altogether because I'm at a complete loss as to the best way to handle this whole thing.

So, I'm curious... what does remorse look like in a 4 year old? Is it an immediate display of sadness that he's caused someone pain, or is it delayed until the "fog of frustration" lifts? If they're oppositional (and not remorseful), would they continue the behavior, or just try to forget about it altogether? And is it possible to see signs of both? I think my son tends to be oppositional with me and my husband, but explosive on everyone else. Does that make sense?

Also - do your books offer suggestions on how to handle peer-to-peer explosions? I'm at a complete loss as to how to best explain my son's behavior to his little friends. I can barely explain it to my friends. This morning one of his friends wanted to tell him a story, and he shut his eyes, held up his hand, and screamed, "Don't TALK to me while I have food in my mouth." She was crushed, and I was stumped. I used to feel so confident when I handled my son's misbehavior... now I feel like my aggressive "handling" of it only makes things worse. And the unexpected factor of some of these explosions doesn't always allow for me to think through the best solution.

Thanks SO much for making an appearance here and sharing your expertise!!

~CH~

 

[steph3306]

Dr. Riley

Yes my son does have red checks and ears. He has little bumps all over his face. He also drinks tons of milk. He has allergies but hasn't been tested to see what he is allergic to. He has to take a singular everynight to keep him from getting a sinus infection. Sometimes he gets so sick we have to give him albuteral. He hasn't been diagnosed with asthma. So do you think the allergy is linked to the autism or to the explosive behavior?
Thanks Steph3306

 

[tiredmommy]

Steph- I can personally attest to the fact that allergies can cause behavior problems. I can now predict when my daughter's allergies are kicking up by watching her behaviors. She has outgrown her food allergies (but is still sensitive to soy) but her inhalant allergies are still present. She tends to become very tense, loud, wound up and argumentative. Her sleep becomes affected. She picks fights and taunts me. This all usually starts a few days before physical symptoms start (eye shiners, blotchy skin, nasal congestion, itchy skin and eyes, hives).

I would feel better if you took your difficult child to a pediatric allergist and had him tested. Also, I would want him tested for asthma. My Duckie isn't normal... her allergic reactions aren't typical and her asthma is the cough-variant type and may have been missed for awhile because it didn't present normally.

 

[Dr. Douglas Riley]

Steph3306: I agree that it would be good to have your son tested by a pediatric allergist, given his symptom picture. I definitely suspect that the allergies are linked to his explosive behavior, and can only hope that treatment will have a positive impact upon his autism. We all keep hearing rumors that a low casein diet can be useful for children with autism. In that regard, it hurts nothing to hold him off of milk products for a period of time to see.

Best of luck, Doug Riley

 

[Dr. Douglas Riley]

CH547: Thanks for your interest in my books. I do not recommend that you read The Defiant Child at this point, given that your son is still so young. You will definitely find my current thoughts on children in his age range in What Your Explosive Child Is Trying To Tell You, because there are entire sections of the book written specifically for children his age.

As for remorse in a four year old: You will have to watch closely to determine if your son feels sad only when he gets caught, as opposed to feeling sad after an explosion even though there has been little to no confronting him or scolding him about his behavior. Oppositional kids don't feel a lot of regret over their actions - they just keep doing the same behaviors over and over.

In reading your post, I am paying particular attention to how your son blew up when one of his friends talked to him while he was eating. This is a very good example of what I would term a "roadmap" explosion. Most likely he was engaged in eating, did not anticipate being interrupted in any manner, and blew up when he was indeed interrupted.

Your son is at the perfect age to begin the training that I refer to in Chapter Two of the new book as "big guy" training. It will involve lots of role play and is also based on high levels of positive verbal feedback and praise for appropriate behavior, otherwise known as staying in the "big guy zone." I have nothing but an optimistic outlook for kids your son's age who are doing the same behaviors, as experience has taught me that once you adopt some very straightforward strategies and stay with them consistently, his behavior will begin to change. Please keep in mind that virtually every child I write about in the new book has a lengthy history of exploding on friends, family, teachers, everyone. They sometimes hit, kick, punch, yell, and act in every embarrassing way known to man. So, again, I am very optimistic.

Doug Riley

 

[Anaheimfan]

Welcome to the board Dr. Riley.

 

[Jena]

It is nice to see you taking the time to discuss your book and also address concerns of parents here and also answer some great questions asked.

I do feel now as someone who is now working in the mental health field and raising a child with varied diagnosis's and endless issues that there are not enough therapists as of late to treat children and not enough pyschiatrists to take the time to sit down with-parents and give feedback beyond the diagnosis.

The wait lists for most clients is absolutely absurd, and I myself with private insurance it has taken me mos to get a therapist on board for my child.

I think the mental health field has come a long way, yet there's a lot more to go and a lot more work ahead.

It is so nice though to see someone like yourself take the time to post and come into our forum.

thanks.

 

[Dr. Douglas Riley]

Jena and Anaheimfan: Thanks for the welcome. It is entirely true that wait times for therapists are too long, and that there is too little availibility. I also find it frustrating that some of the professionals out there seem to think that their work is over once they have given a diagnosis. Parents want techniques that make sense and can be readily mastered instead of a lot of theoretical mumbo jumbo. That is the beauty of discussion forums like this one. My late mentor, Dr. Robert Betz, used to use the term "multiplier effect." He was an advocate of teaching techniques to broad groups of people who would then teach to more people, and so on. I have been a fan of conductdisorders.com for years, way back to the momma bear days, and have given the link to hundreds of parents over the years.

 

[SRL]

Dr. Riley,

I have a question about ADHD and school success. A lot has changed in elementary schools since I was a kid. I know that the straight row, be silent, sit still in your desk and do your worksheet atmosphere wasn't ideal for kids with ADHD. But I'm wondering if recent educational trends aren't creating another set of problems. I'm volunteering in a class for reading and between the emphasis on individualization and full inclusion, I'm finding the atmosphere extremely distracting. I'm working with the low reading group (read aloud and discussion) in the commons area while at 2 other reading groups are working along with a small math group being taught by an aide. It's too much for me and I don't even have attention issues. You can imagine what it's like for the group I work with.

This kind of individualization is really big right now and in fact, there are ten (!) reading levels/groups in my daughter's grade. What impact can this have on a child in the classroom with ADHD and how can parents help assure that their child succeed?

Thanks,
SRL

 

[samsdad]

I will try the idea of deleting the dairy products from his diet for five days the reintroduce to check the results.

This idea makes me recall a couple of other items of interest. First my son had real issues with dairy based formula, second after our move my wife switched to milk with no hormones, steroids, etc...

Man Sometimes being an engineer really makes me look differently at the world. This is like bringing my work home with me, which I really prefer to explosions.

Thanks again and I will keep all posted on my findings.