Written by Dr. John Carosso
Public outings with your child can be quite challenging and demanding, and there tends to be more outings over the summer recess. Children sometimes find the environment, whether it be a store or amusement park, to be over-stimulating, and want to carry-out the outing ‘on their terms’ rather than on yours. However, if you plan in advance, there are some strategies to improve the situation and make the outing more tolerable, if not pleasurable.
I hope these tips prove to be helpful and make your outings more fun and enjoyable. Happy Travels!!
Written by Dr. John Carosso
So, it’s not entirely uncommon that I see a kiddo and find that, prior, he had not been diagnosed with autism, but I find rather clear evidence to the contrary; or vice versa (but more often it’s the former issue). It’s understandable that those situations are very frustrating and confounding for a parent; they don’t know who to believe or where to turn. This problem usually stems around the diagnosis of autism, but sometimes also for Bipolar and ADHD.
This issue largely stems from the spectrum being very wide, and sometimes clinicians are looking for the more classic and stereotyped signs of autism that simply are not present. In that respect, a clinician might think that a child cannot have autism if they have good eye contact, or are social, have some friends, show shared enjoyment, are conversational, and don’t show much in the way of self-stimulatory behavior. However, it may be overlooked that the child is social but is socially awkward and, while he has friends, they recognize he is ‘different’. The child may be conversational and not prone toward ‘stims’, but is obsessive, has a mildly unusual speech cadence, sensory issues, and be highly routine-dependent among other things.
You may be thinking, isn’t there straight-forward diagnostic criteria and, either the criteria is met, or it ain’t. In a way that’s true, and there are also specific tests for autism such the ADOS and GARS. However, here’s the problem; even the criteria and tests are open to clinical judgement and a child may, for example, struggle with emotions or social skills, but for lots of different reasons. Most importantly, a child may present well in an office, but struggle in a social setting in the school or community, which is why parent-report is so vital to the diagnostic process. Of course, this is especially true for milder cases (it’s always easy to diagnosis something in a severe form).
You bet it does. The big question, in milder cases of just about any disorder, is whether the signs and symptoms are severe enough to ‘cross the line’ and be diagnosable. The milder the symptoms, the more clinical judgement comes into play. The more clinical judgement that comes into play, the more of a chance that you’ll get two different opinions. This is also truer for younger children; you’re much more likely to get a false-negative (no diagnosis when criteria are actually met) for a 2.5 year-old than a 7 year-old. Diagnoses that can be confounding in this respect would also include ADHD, Bipolar, and Reactive Attachment Disorder. However, again, the issue of getting countering opinions can be a problem with any given diagnosis.
First, take a deep breath and realize that this discrepancy can occur in any medical or behavioral health condition and, if it’s any consolation, note that it most likely reflects that your child’s symptoms are quite mild; if the symptoms were moderate to severe, there would be no differing of opinions. In that respect, I’ve found that, for some children, the symptoms are evident but very mild and it’s simply a matter of being a ‘borderline’ diagnosis. In those situations, it would be expected that one clinician may believe that the symptoms barely ‘cross the line’ but is diagnosable, while another does not; either way it’s very mild and clearly open to opinion and I clearly explain that issue during the evaluation.
To resolve, take note of five factors: 1.) the rationale of the practitioner who believes your child does not have the disorder, 2.) the rationale of the clinician who believes your child does have the disorder, 3.) the opinions and comments of other practitioners or professionals who have worked with your child such as speech pathologists or teachers, 4.) what concerns and symptoms that brought you to the clinician in the first place, and 5.) your own belief based on direct and daily observation. As you weigh these factors, take note of which explanation seems to make the most sense, which is most logical and reasonable, and which ‘fits’ best with what you observe and your experience with your child now and over the course of time. Of course, you can always get a third opinion.
In these situations, I am usually able to get the parent onboard because I clearly and explicitly explain how I’m coming-up with the diagnosis, and do so in a manner that is very parent-friendly and understandable. However, where there are remaining questions (those “borderline” cases), I begin the child in therapy, either in-office or in-the-home, and I use the eyes of the therapists to help guide the subsequent diagnostic process. In that respect, I maintain regular contact with the therapists to obtain information about what they observe during each session and whether it fits with my diagnosis. Ultimately, we are able to ‘figure it out’ one way or the other. My primary goal, in the meantime (while we ascertain the diagnosis) is to ensure that the child receives the proper level of treatment. I do not let diagnostic uncertainty, on anyone’s part, interfere with the kiddo being connected with therapists and practitioners who can work toward and promote progress. Moreover, I may use a “provisional” diagnosis that reflects evidence of signs and symptoms, but that more evidence needs to be garnered.
Yes, it matters. Practitioners who are specifically trained to make such a diagnosis would include a Licensed Child Psychologist, and/or a Board Certified Child Psychiatrist. These two types of professionals are specifically trained, more than other types, to diagnosis behavioral health conditions.
Getting two different opinions can be quite frustrating and exacerbating. If you encounter such a difficulty, I hope this posts helps in guiding you through the process to a definitive resolution. Please feel free to comment or question at jcarosso@cpcwecare.com, especially if you’ve experienced something similar.
God bless.
Written by Dr. John Carosso
A syndicated child psychologist recently wrote an article claiming that ADHD is not a real disorder and kids are ‘just being kids’ and not demonstrating signs of a disorder by being active or distracted. I formerly enjoyed reading that psychologist’s work, but have become increasingly disillusioned over time. In addition to writing that ADHD is not a genuine disorder, he also comes across as exceptionally harsh in his punishment, and seems to expect kids to be like little automotons and, if they dare disobey, he suggests sequestering the little criminal to their his room for weeks, sometimes even months, no joke.
Okay, back to the topic at-hand; is ADHD a real disorder? First, it has been clinically documented for over 100 years that some children are far more active and inattentive than others, and sometimes their activity level, and the extent of their distractibility, can get in the way of their daily functioning. This concept is nothing new; and the concept was not originated by pharmaceutical companies.
How do we come to classifying something as a disorder? There are any number of factors, including that there needs to be a consistent set of predictable signs, symptoms and characteristics, occurring together, preferably from some identifiable cause (not always the case, and may stem from multiple causes) that are significantly interfering with daily functioning, and not better explained by some other disorder or identifiable cause. Does that fit with the ADHD? I think so.
Context is very important. You see, the extent to which something is considered to be a disorder, and it’s prevalence, depends on where you are, and when you’re living in history. Consider dyslexia, for example, if you were growing-up 150 years ago in a rural community, the disorder of “dyslexia” probably would not exist, and definitely wouldn’t be anywhere near as prevalent as today. However, as many people as today would have problems with reading, but no one would know about it, or care, because the ability to read was not a big priority. That same fact would hold true in some areas of the world today where rates of illiteracy are very high. In those places, there is little opportunity to learn to read in the first place. What about ADHD? The same holds true; growing up 150 years ago on a farm would be conducive to a high activity level. There might still be problems with distractibility and not thoroughly completing chores, but such would likely be far less of an issue when compared to today when kids have to sit, all day, in a classroom. So, yes, in that respect, the diagnosis of ADHD is subject to context.
It’s not necessarily a matter of any given modern-day disorder not being a genuine disorder, instead it’s a matter of context that often makes the disorder more relevant and problematic. Given that reality, (that context plays a role) we need to seriously consider changing the context of our current educational programming and, even at home, regarding how we carrying-out activities. In that respect, would kids with ADHD and dyslexia have such a rough time, and would their condition be as problematic, if the kiddo’s had the opportunity to work on tasks while moving, run before each lengthy seated assignment, read with their ears rather than their eyes, complete assignments in shorter stints (I could go on and on) then maybe the condition(s) would be far less impactful.
It’s vital that children with genuine disorders get the help they need. Denying the issue exists will only worsen the problem, make people question the need for help, and blame the child for their behavior. We need common-sense solutions that not only help to remedy the symptoms of the disorder, but also make the symptoms less problematic in the first place. We need to think outside the box. Let’s start doing that today. God bless.
Written by Dr. John Carosso
Parents often talk of “bribing” their child and, when they use the term, there is a sense of ‘doing the wrong thing’, making the situation worse, and even a sense of guilt. However, in actuality, when using the term, parents are often simply conveying the idea of giving their child something extra to promote obedience. I would suggest, by that definition, we all “bribe” our kids on a daily basis.
Well, yes, we would be if, in fact, we were offering bribes. You see, giving a “bribe” is illegal. So, if you bribe anyone for anything, then off to jail you go.
Because we’re not bribing our kids. A bribe is an incentive, often in monetary form, to promote something corrupt or illegal.
Nope, we’re not. Instead, we are simply giving our kiddo’s some incentive to behave. That’s not illegal. In fact, it’s very legal, and quite wise.
We all need an incentive to accomplish goals. We hope that the incentive is internalized (i.e. our kids do the chore because they want to and realize that it’s just ‘the right thing to do’) but for many kids that’s just not the case. Also, in all fairness, sometimes it’s just harder for some kids, with ADHD for example, to pay attention and stay focused; they are using far more energy than other kids to accomplish tasks and they tend to tucker-out quicker. Consequently, we need to provide some external motivation (a reward or prize) for them to exert that extra energy and then fade the reward over time as the child matures, learns better coping skills, and internalizes the motivation. . It’s not much different from you getting a paycheck for doing your work, though hopefully your paycheck does not fade over time. In any case, we all need motivation of some sort.
It’s a brief explanation, but I hope that helps to clear-up the difference between a “bribe” and simply offering an incentive for your child to complete their chores. Now go give those bribes, oops, I mean rewards.
Written by Dr. John Carosso
The general conceptual idea is that kiddos with autism have difficulty filtering and processing stimuli in the environment; it’s just too much stimuli coming from all the different senses and that overload causes them to self-regulate with stims. Consequently, children may find the SSB to be very comforting. In fact, they find the behavior to be calming and an important part of their day, especially when they feel stressed.
Yes, the sensory aspects are often spread over different senses, such as visual, auditory, factory, tactile, and kinesthetic. In that respect, a child may be seen putting objects in front of their eyes, or to the sides, which is called ‘peripheral gazing’. The sensory aspect can also be auditory; the child may want to hear something over and over, a particular sound or a song, or may want to hear the fast-forwarding and rewinding of videos (which also has a visual aspect). Tactile is also common where kiddos want to touch people’s hair, feel certain items and textures, but may also be tactilely defensive where they can’t wear certain clothing given it’s just too irritating, which makes getting dressed in the morning a challenge. Olfactory may not quite as common as the tactile or visual, but these kiddo’s may want to smell everything, or experience everyday smells as especially noxious. Then there is taste and texture issues can be a real problem during mealtime. We then move into kinesthetic, proprioceptive, and vestibular that all sort of go together; the jumping, hopping, spinning, bouncing that is so common.
A common replacement behavior for the kinesthetic-based SSB is a trampoline, as opposed to hopping in the classroom. Children may be provided a particular time and place where they can jump on a trampoline. However, it’s important to be careful because there are behavioral and avoidance tendencies to consider. In that respect, if a kiddo has learned that jumping out of their seat during an unfavored math assignment will result in being permitted to jump on a trampoline then, while there may in fact be a valid sensory issue, the kiddo may also just not want to do the math assignment. Attention seeking too can be an issue; if three people attend to the child when they stim; well, that’s cool, so they’re going to keep stimming in the classroom. Consequently, we must be careful not to secondarily reinforce attention-seeking.
In the next post, I’m going to discuss the extent to which SSB are ‘defense mechanisms” and the subsequent implications. Stay tuned.
Written by Dr. John Carosso
As you do your own research about “self-stimulatory behaviors” or SSB’s, you’ll find a tremendous amount of information that can be quite helpful. However, it also can be very confusing. You’re going to hear many things about this aspect of autism that often-times is contradictory. In fact, even what “stims” are called can be rather confusing and you may wonder if they’re all talking about the same thing? In that respect, you will see SSB referred to as self-stimulatory behaviors, self-stims, stims, stereotypical behaviors, stereotypies, stereoautomies, tics, preservative behaviors, self-reinforcing behaviors, compulsive behaviors, OCD. In fact, it’s not entirely uncommon to see a kiddo diagnosed with obsessive compulsive disorder, when in actuality it’s a stim. You’ll see the aforementioned acronym “SSB”, which is “self-stimulatory behavior”, not to be confused with “SIB”, or “self-injurious behavior”; however, SSB can be self-injurious. Again, it gets really confusing with so many different names and aspects for the same thing.
SSB can include lots of behaviors such as hand-flapping, toe-walking, spinning, pacing, obsessing, lining-up objects, being very particular, and other compulsive tendencies. In that respect, sometimes OCD is confused with stims, but there are clear differences and I’ll delineate in another post.
Not so much. In fact, the contributing factors of SSB are quite confusing because they are so multifaceted. In that respect, you’ll most often see, in your research, that self-stimulatory behaviors are caused by sensory issues; either the child is sensory-seeking or sensory-avoidant, or overwhelmed by sensory information. You also read of avoidance tendencies, i.e. the child will stim to avoid an unfavored task. There is also ‘attention seeking’ as a cause of SSB. So again, it can be rather confusing and challenging given any specific rationale will greatly impact treatment considerations.
Sure, of course, but the treatment too can be difficult because there are many opinions including that SSB should be interrupted; punished, or in some way shaped into something else. However, others suggest that we should not interrupt these behaviors because they are defense mechanisms and the kiddo needs the self-stimulatory behaviors to cope. Some suggest that, subsequently, if you prohibit them, the behaviors only worsen.
Interestingly, children with autism will often say that carrying-out SSB is very important to them; that it’s self-soothing. Again, that aspect impacts the treatment processes in that we may subsequently indulge such behavior at specific times and in some places.
The neuro-diversity model suggests that society needs to adapt, not the individuals with autism. In that respect, some may suggest that autism is not a disorder and that society needs to be more tolerant. Ultimately, there tends to be a middle-ground in that, if the SSB is interfering with the child’s ability to function, then we’ll need to modify the SSB to some extent. However, if the SSB is an occasional hand-flap then, in fact, society may need to ‘just deal with it’ given we all have our quirks.
Here’s the challenging part about this: none of these aspects or terms is necessarily wrong. All these nuances, including the labels, and whether SSB is caused by sensory issues, or avoidance tendencies, or attention-seeking needs is not necessarily wrong. In that respect, SSB is extraordinarily child specific; so, for one kiddo we may very well transition the SSB into something more adaptive. However, for another kiddo we may indulge the behavior. Yes, it’s multifaceted and, in my experience, of all the aspects of autism, SSB’s are the most challenging because they are so complex and multifaceted.
I’m going to break this down a bit more for you in upcoming posts where we take a look these factors and treatment aspects. Stay tuned for more.
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