Parenting K-6 Kids/challenging behaviour

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Question
We have four children, two diagnosed with autism, but also have many concerns about our 5 year old daughter. She has been recently assessed by a paediatrician and we have been told she does not meet the criteria for asd at the moment but to expect a diagnosis in the future as social expectation increases.
She is exceptionally bright with no learning difficulties. As a baby she was very aloof and didn't show any emotional expression, it was very hard to make a connection with her as we just didn't get anything back from her. She was a very easy undemanding baby who seemed delayed in most areas although at around 18 months seem to suddenly catch up and even excel in many areas although we also saw dramatic changes in her behaviour.
The main difficulties were in her severe meltdowns which would occur regularly and also her aggressive, explosive behaviour where she would kick, punch us repetitively. She didn't show emotional expression, for example if given a present she didn't smile and if she didn't like it would tell the person, when on a children's ride would just sit with a blank expression, She didn't cope with changes and needed to be in control at all times.
These difficulties have remained but she has also become very manipulative, controlling  and oppositional. She also demands constant attention which makes it impossible to hold a conversation with anyone, constantly interrupting and if we say wait a minute she will rage, Whatever we ask her to do she will refuse or argue, she will also constantly antagonise or torment particularly her brother who will become very distressed and lash out. This occurs completely unprevoked. She seems to go out of her way to upset/ alienate  people.
We have tried time outs, removing privilages, positive reinforcement, star charts, praise for good behaviour, we have spoken to her but nothing seems to make any difference. She will repeat the behaviours. When I ask her why she torments she will say why but there is no feeling behind it, no guilt or remorse, for example she teased her brother because he cannot write. When I asked why she said because he just scribbles. I asked how she thinks he would feel and she says sad but will then repeat the same behavours.She will say such hurtful things to people and be so rude. We have also noticed other worrying things like pulling her knickers down in public including at church and also being unkind to animals, for example we looked after my aunts dog and she hit it over the head with a dvd box, when I asked why she said I hate dogs.
She can be affectionate wanting to be cuddled but even then it kind of feels cold and manipulative. It is so hard to emotionally connect with her.
We do not understand her behaviour and do not feel possible asd would explain all her behaviours, we spend time with her so it's not that she is attention deprived and she hasn't suffered any trauma. School have noticed that she is very controlling. She gets friends and looses them very quickly, we be all over them one minute and then aloof and unfriendly the next. She seems to be quite obsessive over particular people/peers but will reject others and if they try to engage her will look right through them or be rude to them, even people she knows well.
She spends much of her time writing, reading  and drawing, rarely playing. She said last week you may as well sell all my toys because |I don't play with them which I found surprising for a child of 5 but she is right she doesn't really play.
We are finding in increasingly difficult to manage her challenging behaviour which is effecting everyone in our home and also relationships with her. I am really concerned as to what is going on with her or what to do? can you please advise?

Answer
Sharon;

My apologies for not responding sooner...having local weather issues in FL.

Children with complex behavioral symptoms like those you describe may have several underlying disturbances at play, each of which may require a separate approach. The initial question to answer is whether any of the behaviors are innate; that is, not under the child's voluntary control. Mood disorders like Intermittant Explosive Disorder and Bipolar Disorder are examples, but other entities purely "medical" conditions must also be considered and ruled out, such as lead poisoning, thyroid overactivity and the like. Parents best begin with a complete physical examination, then appropriate chemical, metabolic, endocrine and electroencephalogram (EEG) tests. Pediatricians can do these, but sometimes refer to specialists like Endocrinologists and Neurologists.

Once medical disorders have been ruled out, psychiatric conditions, including mood disorders are next considered. Psychiatrists and Behavioral-Developmental Pediatricians can identify these conditions. Although psychotherapy is often a part of the treatment strategy, medications are usually also required.

Finally, "volitional" disorders, like Oppositional-Defiant Disorder (ODD) are considered. These behaviors are rooted in bad decision-making and respond to discipline.

Without proceeding through these steps, parents are likely to overlook the cause(s) of these behaviors.

If both innate and volitional disorders coexist, innate behaviors must be managed before a child can make appropriate volitional decisions. This means the order of approach is very important.

From your description, it sounds like both innate and volitional behaviors are at play, so several treatment strategies will likely be required to resolve the issues.

Hope this is helpful

Al Davick

Parenting K-6 Kids

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Alan M. Davick, M.D.

Expertise

As a Johns Hopkins trained Developmental-Behavioral Pediatrician with 40 years experience, I have focused on distinguishing underlying willful, poor choice-making (like Oppositional-Defiant Disorder)from innate "conditions" masquerading as willful misbehavior (like ADHD, Autistic Spectrum Disorders, Bipolar Disorders, Cerebral Palsy, Developmental Delay, Epilepsy and "Behavioral" Seizures). Though I cannot act as a formal medical or psychiatric consultant, I will answer queries with generic information and suggestions for discussion readers may direct to their own professional advisers, including physicians, psychologists and educators.

Experience

I trained at the Johns Hopkins Medical Institutions in Pediatrics, Child Psychiatry and Behavioral-Developmental Pediatrics. Thereafter, I've continuously practiced Behavioral-Developmental Pediatrics and have taught the principles mentioned above to parents, colleagues and professional groups.

Organizations
American Academy of Pediatrics SW Florida Sportsman's Association Florida Writers Association

Publications
First Travel Meds - 1987; Managing Misbehavior in Kids: The Mis/Kidding Process; Bullying: Rarely Travels Alone; Discipline Your Child (without going to jail); AD(H)D: What Every Parent Needs to Know

Education/Credentials
Undergraduate - NY University WSC Arts & Science, NYC 1959-63 - B.A. Medical Degree- State University of NY, Upstate Med Ctr, Syracuse 1963-67 - M.D. Internship/Residency - Johns Hopkins Hosp/University - Baltimore, MD 1967-70 Major, US Army Medical Corps, Chief Pediatric Section, Savannah, GA - 1970-72 Sp. Fellow, Dept Child Psychiatry - Johns Hopkins Hospital/University - 1972-73 Practicing Behavioral-Developmental Pediatrician, lecturer, author - to date Currently practicing Child Psychiatry - SalusCareFlorida, Fort Myers, FL.

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