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Tips on Managing Oppositional/Defiant Behaviors in Your Child: PART 3

Defiant stance
"I don't WANT to!!"

Here’s the 3rd post in this weekly series about managing oppositional/defiant behavior.

Rule 3: Make your request into a game.

To utilize this technique, you have to be creative.   Creative, not brilliant!  If you can’t come up with games easily, brainstorm with your partner, a teacher, or a fellow mother to come up with some ideas.   The game does not have to be ingenious as long as you provide the enthusiasm. You can also present a scenario to me here via the comments form, and I’ll try to come up with a game for your specific struggle.

When it comes to oppositional behavior, the child digs in their heels to gain a sense of control over their environment (which includes you).   It may be because of other areas of their life that feels out of control, or it may be because they truly get overwhelmed at the prospect of any task in which they have to execute something.   When someone asks you to do something, you must a)understand what they are requesting of you, b) organize a plan of how to execute that task, then c) gather yourself together, which entails mental and physical organization, and execute that task.   If a child is tired or hungry, even little tasks can seem overwhelming.   However, most children enjoy playing games even if they are silly and there is no real reward at the end, and a sense of competition or trying to beat a previous record may provide an organizing force which they can wrap themselves around.  This provides a focus for an otherwise mundane task, plus serves as a means to master the situation (increased control.)

In our clinic, we’d see patients back to back for 45-60 minutes at a time.  This was enough time for the child to get out toys and start really playing while I was speaking with mom.  If the child started stalling upon cleanup time, it created a pressure situation that threatened to throw off a packed schedule.   It’s tempting to just clean up the toys yourself, but we wanted to model responsibility and structure.

The solution?  Everything’s a game! If I saw the child start to manipulate and try to get out of cleanup, I’d say, “Hey Colin, let’s see how fast you can put the toys into the basket and I’m going to time you.  I bet you can’t do it in less than a minute!  Ready, set, …go!!!”  Then I’d make a big show of looking at my watch and counting “10….15….okay now 30 seconds…you only have 30 seconds left!”  As they neared the end of the time, I’d continue to exclaim: “ohmygosh you’re going to finish WAY ahead of time-I can’t believe it!!  This has never been done before!”  etc etc.   By the next time, the child would know the ritual and clean up the toys like their life would depended on it, and of course each time they’d “break their own record”.

If you’re animated enough, for a younger child this is often enough.  You can see how this is a lot nicer way to end the session than me or his mother “counting to 10 or else!” (which can be effective too, but is negative rather than positive).    Not every child will respond to a game challenge, but creating a race, beating a previous record, and cheering them on is entertaining for most kids.

Important points to remember during the “game”:

  • Notice the language in the task request: “how fast you can put your toys in the bucket” uses slightly different wording than “put your toys away” or “time to clean up”.   It’s not a command, and doesn’t have connotations of ending play-rather, it’s a challenge.
  • The more details in the game, the more interesting it becomes.  Start out simple, and add on new rules if they child’s interest starts to wane. Example: with the above scenario, you could add some kind of sensory aspect, like “for however many seconds you finish before 1 minute, you can roll that many marbles into the basket.”
  • If you find yourself saying, “I don’t have the energy to be a circus clown every day…”- think again of the return on investment.  Would you rather spend 5 minutes being animated and fun, or 20 minutes growing increasingly irritated?
  • Signify the end of the task with a high five, a “strong work!” or other such acknowledgment, or a “hooray!” and jump in the air.
    parent child high five
    "You did it!"

    Kids think it’s hilarious when adults do this.  If you feel ridiculous, who cares?  Pat yourself on the back for giving your child what they need.   “Marking” the end of the task with acknowledgment shows them you’ve noticed they finished, and helps to transition to the next activity of the day.

Do you have a specific situation where you feel it’s impossible to come up with an appropriate game?  Do you have a special game you play with your child to accomplish task completion?  Share your dilemma or idea below!

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Questions and dilemmas regarding treatment plans

Can taking stimulants stunt my child’s growth?

Questions and dilemmas regarding treatment plans
Not sure what to do? Read on..

This is one of the most frequently asked questions when it comes to medication treatment options.

Here’s the general consensus:

Although there does seem to be (on average) a temporary growth suppression during the first 1-3 years of treatment, the adult height of ADHD children treated with stimulants is equal to the adult height of children who are stimulant-free.   The studies finding growth suppression during the initial 1-3 years are focused on pre-pubertal growth rates, and average about 1 cm/year difference.

When reviewing this topic, I came across some non-physician-writers spinning data on studies as if to say, “See? stimulants DO stunt your growth,” when in fact these studies are in line with what we already know- that there may be temporary growth suppression.   (see “ADHD Central” article) Pay close attention when you’re reading reviews: if the author is merely reporting the data, and points out flaws or limitations of studies, then it’s likely good information.  If, however, an author gives a summary of previous long-term findings, and then points out one study is seemingly out of alignment and uses this to make a point, take it with a grain of salt.   People have all sorts of agendas when it comes to psychiatry and psychotropic medication.

Possible caveats

There is some evidence that ADHD children may be larger than non-ADHD children, and some speculate that even though the adult height of ADHD children is equal to peers, perhaps they would be taller if they had not been on stimulants.    However this is just speculation, and even if it were true, is it relevant?  From my experience, children with ADHD often have horrible diets and crave carbohydrates, so it’s also possible that the “larger” ADHD adults may be larger than average due to dietary influences, such as large quantities of cow’s milk and red meat, which are laden with hormones.

On the other hand, there is other evidence suggesting that children’s brains with ADHD are developmentally immature, and this may correlate to hormonal development as well.   Many children in my practice, whether they are on stimulants or not, are not only developmentally immature, but physically as well.  This may be due to the brain itself, or simply due to stress.  Children under a great deal of stress seem to grow more slowly, even if they have adequate food intake, as if the stress takes such a toll that the body uses it’s reserves just for daily functioning.  When the stress calms down, growth resumes.

Things to consider

When I get this question with a child already on a stimulant medication, I ask the parent if the child has “fallen off the growth curve”.  For example,  if your child was in the 50th percentile for height and weight, is he now in the 10th?  If he was previously in the 90th, is he now in the 70th?  Etc .  Sometimes weight falls but height does not, which is not a cause for worry.  Your child’s pediatrician typically tracks height, weight, and BMI (body mass index)  in the yearly exam, and you can ask for a copy and track it yourself.  You can also download growth charts here and track this at home (this is a good idea, to reassure yourself!)

A typical weight loss when starting a stimulant is 5-10 lbs in the first few months to a year, and then it seems to taper off.   Sometimes children will skip their lunch, so it is imperative that they have a good, solid breakfast with lean protein and healthy fats. (eggs are a “perfect food!”)   A protein shake is better than a meal high in refined carbs (like pop-tarts, most breakfast cereals, bagels, and muffins.)  Pack your child some snacks like zip lock baggies of nuts, trail mix, or nutrition bars that they can snack on throughout the day.  (These snacks are also good because they won’t go bad sitting in a backpack!)

Keep in mind stimulants have been used safely for over 60 years, so we do have good long-term data on them.    Drug holidays over the summer can help with weight gain, but discuss this with your doctor first.  Sometimes the benefit of maintainence treatment outweighs any benefit of putting on a few pounds.  For example, if your child is so impulsive he or she frequently puts themselves in harm’s way,  then it’s likely that they are better being treated, even during the summer.  A  lot kids have summer school or tutoring, so take this into consideration as well.

Some children have so much stress due to their attention problems that even if they don’t need the medication to learn, they function much better and are calmer, less anxious, and happier with the medication.  Get feedback from your child, too- some kids are unaware  of medication’s effects, while others can clearly announce, “it helps me stay calm, ” or “I can think better, ” or, conversely, “it makes my stomach hurt.”

The bottom line

Look at the big picture.  Consider side effects, and then benefits noticed by yourself, your spouse, your child, teachers, coaches, clinicians- including how medication affects their peer relations, since this this relates to quality of life and social development.   Discuss a risk/benefit analysis with your doctor.  No solution will be perfect, but take heart in the fact that the overwhelming evidence shows that there is mild, if any growth suppression during the first couple of years, and that final adult height is normal.  This appears to be the case whether they continue to take medication throughout adolescence or not.

The Nutrition Factor

Finally, consider that many ADHD kids have poor appetites and poor diet anyway.  Throw a stimulant in the mix, and then may not be getting much nutrition at all!   I always recommend a high-quality, complete and preservative-free children’s multi-vitamin.   There is mounting evidence that we’re all overfed and undernourished, and mental illness or neurological syndromes compound this issue in 2 ways, aside from dietary factors.  1) Stressed brains work harder and therefore burn through nutrients faster than non-stressed brains, and 2) many psychological and neurological syndromes, including ADHD, show evidence of reduced efficiency when both using nutrients and recycling them.  Therefore, these kids need even more supplementation than the average child.    To read more about the brand I recommend in my practice, click here, or email me for some articles.

The products run about $12/month for the children’s version and $18/month for the teen version.  If you cannot afford this, any multivitamin is better than nothing! Try an OTC brand such as GNC.     I also sometimes use the Juice Plus children’s chewies, which run about $23/month.  (juice plus flash-freezes and condenses whole fruits and vegetables into chewies or capsules. Email me to order or to obtain more info. )

Sidebar: The side effects that would make me consider discontinuation with stimulants are the following: persistent, significant insomnia; stomach pain or discomfort that does not resolve; increased anxiety/agitation/jitteriness; depressed mood; heart palpitations or heart “racing”; and frequent headaches/migraines.

For more review on this growth and stimulant medication, see these links:

http://pedsinreview.aappublications.org/cgi/content/extract/23/2/67

http://pediatrics.aappublications.org/cgi/content/abstract/63/6/847

http://www.sciencedirect.com/science

Children’s Multivitamin Product Info:

Usanimals for ages 3-12

Bodyrox for ages 13-18.

(To place an order, visit www.drdunckley.usana.com or call me at (714) 926-4796.  I encourage people to call or email me to ensure they get not only wholesale prices but the preferred customer discount. )

Victoria L Dunckley, M.D.

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