Psych eval results-ADHD, ODD

[lemonberry]

DS-5yo ADS-GDD

We've been waiting for this psychiatrist eval for DS to get his ADHD diagnosis for a long time. I wasn't feeling well and DH went alone. Well he came back with the diagnosis of autism (already dx), ADHD with a prescription for Adderall, and Oppositional Defiance Disorder. I flipped out when he told me ODD. My kid is a complete rule follower and the teacher's pet and I'm pretty sure it was dx based off of some assessment that DH did. I tend to underplay DS's issues on assessments while DH tends to go overboard.

I don't know if I learned about that dx on previous boards, my local SN community, psych classes, or somewhere else, but this is a diagnosis that I don't want to tell the school system about, right?

I'm pretty sure the dx caused some sort of trouble for a local mom when her son kept getting suspended from school and I know my sister (special ed teacher) has talked about kids from her class that got expelled with ODD. I keep thinking that if we do tell his new teachers that it'll give them reason for similar things to happen to him. His Pre-K teacher knows and was the one that said he's more of a teacher's pet.

[funchicken]

I know how you feel. We had a private psych eval last summer, and I was not impressed with her findings. We already had an ADHD and SPD diagnosis. When I submitted my request for the eval, I said that we were concerned about ASD and anxiety. I felt like the inventories we completed were inadequate to capture DD's social deficits, the eval left a ton of unanswered questions, and I was really reluctant to share the private psych's new diagnosis (disruptive mood dysregulation disorder) with the school.

When I requested the Child Study Meeting, I withheld most of the report. Our school psychologist has a PhD in clinical psychology, and she works in private practice in addition to working for the school. When we sat down in the CST meeting the first thing she said was that she suspected that DD was on the spectrum. I told her that we had been concerned about that since she was 3 years old and had been unable to get a diagnosis despite seeing many professionals and requesting an MFE when DD was in kindergarten. I ended up giving her the full report from the private psych, and telling her that I disagreed with a lot of it. She seemed to disagree as well, so she did a full eval of her own, and her conclusion was that the DMDD diagnosis was incorrect. We now have that on the record that the school psych and I both disagree with the private eval.

Do you need to share the new report with the school? Does he already have an IEP in place? I'm assuming you went to see the psychiatrist so you could trial meds, is that correct?

[auntie]

Apr 23, 2018 1:44:48 GMT -5 lemonberry said:

DS-5yo ADS-GDD

We've been waiting for this psychiatrist eval for DS to get his ADHD diagnosis for a long time. I wasn't feeling well and DH went alone.


I'm sorry. Is GDD "global developmental delay"? Is there some reason this label is kept with or added to ASD? Normally ASD would subsume delays as it does sensory issues. 


It sounds like you were looking for meds to help. IME, psychiatrists sometimes do less robust evals given that they're basically there to provide appropriate medications. An eval by a psychologist or neuropsychologist tends to be more extensive- these tend to be broken up over a couple of days. Often the scale used are sent ahead of time for the parents/caregivers to complete together rather than all at once. Since he's 5, I might hold off until he's 6 and can participate in BSAC. 


Well he came back with the diagnosis of autism (already dx), ADHD with a prescription for Adderall, and Oppositional Defiance Disorder. I flipped out when he told me ODD. My kid is a complete rule follower and the teacher's pet and I'm pretty sure it was dx based off of some assessment that DH did. I tend to underplay DS's issues on assessments while DH tends to go overboard.


It's hard to say. Maybe your DH experiences behavior from your DS that neither you nor this particular teacher see. His reporting could be valid. DS was very different in my care than he was for teachers, as an example. They would report all manner of shenanigans I never saw. Playing devil's advocate, you may be wearing rose-tinted mommy-goggles. or are so accommodating that he's not challenged by situations that are not easy for him. 


But yeah, I would not only be upset to get an ODD dx, I would be highly suspicious. As co-occurring conditions this is ridiculously unusual. In almost 20 years knocking around autism world, I can think of a handful of people I know who have been labeled thusly and most have lost the ODD piece when evaluated by someone who really understands autism. 


It's kind of hard to have both. ODD presumes a degree of empathy (not sympathy, per se, but the ability to anticipate an emotional response to action- Theory of Mind) that is not possible in a very young kid on spectrum. At 5, most kids with ASD haven't fully differentiated themselves from their primary care-person and don't realize that other people have different feelings and thoughts than they do. 


I would absolutely get a second neuropsych eval done by someone very familiar with kids on spectrum. 

I don't know if I learned about that dx on previous boards, my local SN community, psych classes, or somewhere else, but this is a diagnosis that I don't want to tell the school system about, right?


I would not at this point. My concern wouldn't necessarily be suspension; a well written IEP can include a BIP and language to avoid OSS which can act as a reward to some kids. My concern would be that behavior associated with "ODD" rather than in the context of ASD could lead to placement in a self contained classroom for kids with emotional/behavioral disturbances. This is pretty much putting the lamb in class with the wolves.

I'm pretty sure the dx caused some sort of trouble for a local mom when her son kept getting suspended from school and I know my sister (special ed teacher) has talked about kids from her class that got expelled with ODD. I keep thinking that if we do tell his new teachers that it'll give them reason for similar things to happen to him. His Pre-K teacher knows and was the one that said he's more of a teacher's pet.


It's not the dx that causes trouble; it's the behavior. However, if he's melting down and that is seen as oppositional rather than sensory overload or anxiety it won't be addressed properly. 


All that said, ODD is like many other behavior conditions in that it is treatable and often less of an issue as the child becomes older and has better emotional regulation. I have worked with a number of scouts with ODD; they can be a tough crowd, but they aren't doomed to grow up as sociopathic criminals. 

[lemonberry]

Apr 23, 2018 5:01:56 GMT -5 funchicken said:

I know how you feel. We had a private psych eval last summer, and I was not impressed with her findings. We already had an ADHD and SPD diagnosis. When I submitted my request for the eval, I said that we were concerned about ASD and anxiety. I felt like the inventories we completed were inadequate to capture DD's social deficits, the eval left a ton of unanswered questions, and I was really reluctant to share the private psych's new diagnosis (disruptive mood dysregulation disorder) with the school.

When I requested the Child Study Meeting, I withheld most of the report. Our school psychologist has a PhD in clinical psychology, and she works in private practice in addition to working for the school. When we sat down in the CST meeting the first thing she said was that she suspected that DD was on the spectrum. I told her that we had been concerned about that since she was 3 years old and had been unable to get a diagnosis despite seeing many professionals and requesting an MFE when DD was in kindergarten. I ended up giving her the full report from the private psych, and telling her that I disagreed with a lot of it. She seemed to disagree as well, so she did a full eval of her own, and her conclusion was that the DMDD diagnosis was incorrect. We now have that on the record that the school psych and I both disagree with the private eval.

Do you need to share the new report with the school? Does he already have an IEP in place? I'm assuming you went to see the psychiatrist so you could trial meds, is that correct?

I don't think we're required to share it with anyone, but I think they send papers home every year with a request for medical records. We have been sharing all of his evaluations with Pre-K for the last couple of years during our IEP sessions, but he'll be with new teachers that we don't know for K in the fall.



The psychiatrist visit was partially to trial meds (which seems to be a disaster so far), but mainly because DS was offered a possible spot for a non-means tested medicaid waiver and it was recommended when we were put on the wait list to get it done for the ADHD dx.

[lemonberry]

Apr 23, 2018 7:06:43 GMT -5 auntie said:

Apr 23, 2018 1:44:48 GMT -5 lemonberry said:

DS-5yo ADS-GDD

We've been waiting for this psychiatrist eval for DS to get his ADHD diagnosis for a long time. I wasn't feeling well and DH went alone.


I'm sorry. Is GDD "global developmental delay"? Is there some reason this label is kept with or added to ASD? Normally ASD would subsume delays as it does sensory issues. 

Another mom told me it's basically to differentiate functioning levels since Aspergers was added to the dx and he had delays with expressive & receptive speech.

It sounds like you were looking for meds to help. IME, psychiatrists sometimes do less robust evals given that they're basically there to provide appropriate medications. An eval by a psychologist or neuropsychologist tends to be more extensive- these tend to be broken up over a couple of days. Often the scale used are sent ahead of time for the parents/caregivers to complete together rather than all at once. Since he's 5, I might hold off until he's 6 and can participate in BSAC. 

The psychiatrist visit was partially to trial meds (which seems to be a disaster so far), but mainly because DS was offered a possible spot for a non-means tested medicaid waiver and it was recommended when we were put on the wait list to get it done for the ADHD dx. He originally got his autism diagnosis from a psychologist and it was like that with the paper assessments coming a month before.

Well he came back with the diagnosis of autism (already dx), ADHD with a prescription for Adderall, and Oppositional Defiance Disorder. I flipped out when he told me ODD. My kid is a complete rule follower and the teacher's pet and I'm pretty sure it was dx based off of some assessment that DH did. I tend to underplay DS's issues on assessments while DH tends to go overboard.


It's hard to say. Maybe your DH experiences behavior from your DS that neither you nor this particular teacher see. His reporting could be valid. DS was very different in my care than he was for teachers, as an example. They would report all manner of shenanigans I never saw. Playing devil's advocate, you may be wearing rose-tinted mommy-goggles. or are so accommodating that he's not challenged by situations that are not easy for him. 

This could definitely be the case. I do tend to have mommy-goggles in all things related to DS.

But yeah, I would not only be upset to get an ODD dx, I would be highly suspicious. As co-occurring conditions this is ridiculously unusual. In almost 20 years knocking around autism world, I can think of a handful of people I know who have been labeled thusly and most have lost the ODD piece when evaluated by someone who really understands autism. 


It's kind of hard to have both. ODD presumes a degree of empathy (not sympathy, per se, but the ability to anticipate an emotional response to action- Theory of Mind) that is not possible in a very young kid on spectrum. At 5, most kids with ASD haven't fully differentiated themselves from their primary care-person and don't realize that other people have different feelings and thoughts than they do. 


I would absolutely get a second neuropsych eval done by someone very familiar with kids on spectrum. 

I'm looking into what neuropsychs are around here and hopefully can get him on a waitlist soon.

I don't know if I learned about that dx on previous boards, my local SN community, psych classes, or somewhere else, but this is a diagnosis that I don't want to tell the school system about, right?


I would not at this point. My concern wouldn't necessarily be suspension; a well written IEP can include a BIP and language to avoid OSS which can act as a reward to some kids. My concern would be that behavior associated with "ODD" rather than in the context of ASD could lead to placement in a self contained classroom for kids with emotional/behavioral disturbances. This is pretty much putting the lamb in class with the wolves.

I'm pretty sure the dx caused some sort of trouble for a local mom when her son kept getting suspended from school and I know my sister (special ed teacher) has talked about kids from her class that got expelled with ODD. I keep thinking that if we do tell his new teachers that it'll give them reason for similar things to happen to him. His Pre-K teacher knows and was the one that said he's more of a teacher's pet.


It's not the dx that causes trouble; it's the behavior. However, if he's melting down and that is seen as oppositional rather than sensory overload or anxiety it won't be addressed properly. 

The weird thing is that he doesn't really have big meltdowns anymore especially since we switched ABA centers. Every once in a while he'll spiral when he starts getting overloaded but he seems to have gotten self-regulation way more in control. And at school, he mostly imitates the other kids so they never really have a problem there. But I definitely don't want him in a self-contained class.

All that said, ODD is like many other behavior conditions in that it is treatable and often less of an issue as the child becomes older and has better emotional regulation. I have worked with a number of scouts with ODD; they can be a tough crowd, but they aren't doomed to grow up as sociopathic criminals.

Thanks, auntie. If he does come away with the dx the second time around, that's comforting to know especially that it can be outgrown.

[auntie]

The conversation so far, with lemonberry,



DS-5yo ADS-GDD



We've been waiting for this psychiatrist eval for DS to get his ADHD diagnosis for a long time. I wasn't feeling well and DH went alone.





I'm sorry. Is GDD "global developmental delay"? Is there some reason this label is kept with or added to ASD? Normally ASD would subsume delays as it does sensory issues.



Another mom told me it's basically to differentiate functioning levels since Aspergers was added to the dx and he had delays with expressive & receptive speech.



So this kind of doesn't make sense on a couple of levels. 

Where did the Aspergers come from and based on what? Aspergers does not exist as a dx in the DSM-5; all individuals who met the criteria for Aspergers have been assigned ASD as their new dx. Paperwork for DS comes in ASD(Aspergers) for continuity because it's the dx he got in 2000 but the codes from his psychologist and his psychiatrist use the code 299.0 for billing; previously he will billed under 299.8. DS was always classified under Autism relative to IDEA. 

The other piece is that Aspergers (AS) was reserved for individuals with no delays in speech or adaptive skills by age 3. These are kids who had pretty typical or advance speech and were on schedule for skills like dressing, toileting, self feeding. These are kids who were not identified by EI or their pedis because they look pretty typical aside from more subtle ToM, social and emotional maturity until the gap widens between them and their peers in school.

FWIW, back in the day, individuals who didn't meet the criteria for Aspergers because they had delayed speech or fine motor issues that precluded dressing or even those late to PT were given HFA as a dx instead. IQs would be similar and over time it could be hard to parse out which dx a kid had. By the secondary grades, I would say the only difference remaining is that those with an Aspergers dx tended to be a little more socially engaged.

It's a weird thing, but sometimes clinicians would give an "upgrade" to Aspergers for a kid with ASD or PDD-Nos who caught up with language. Both DS's dev pedi and psychologist disagreed with this practice because they felt there was a difference between HFA and Aspergers around the degree of sociability and also the size of the delay between the child and peers with HFA being closer to 1/2 and Aspergers being closer to 1/3. I have a small mom-group of friends with sons who have either HFA or Aspergers- they're all adults now. The ones labeled AS were more likely to graduate from high school at the usual time, college, too. They tended to get their drivers licenses by age 20; the kids with HFA either didn't or were closer to 24. All but 2 went to college and did well.


It sounds like you were looking for meds to help. IME, psychiatrists sometimes do less robust evals given that they're basically there to provide appropriate medications. An eval by a psychologist or neuropsychologist tends to be more extensive- these tend to be broken up over a couple of days. Often the scale used are sent ahead of time for the parents/caregivers to complete together rather than all at once. Since he's 5, I might hold off until he's 6 and can participate in BSAC.



The psychiatrist visit was partially to trial meds (which seems to be a disaster so far), but mainly because DS was offered a possible spot for a non-means tested medicaid waiver and it was recommended when we were put on the wait list to get it done for the ADHD dx. He originally got his autism diagnosis from a psychologist and it was like that with the paper assessments coming a month before.



Well he came back with the diagnosis of autism (already dx), ADHD with a prescription for Adderall, and Oppositional Defiance Disorder. I flipped out when he told me ODD. My kid is a complete rule follower and the teacher's pet and I'm pretty sure it was dx based off of some assessment that DH did. I tend to underplay DS's issues on assessments while DH tends to go overboard.





It's hard to say. Maybe your DH experiences behavior from your DS that neither you nor this particular teacher see. His reporting could be valid. DS was very different in my care than he was for teachers, as an example. They would report all manner of shenanigans I never saw. Playing devil's advocate, you may be wearing rose-tinted mommy-goggles. or are so accommodating that he's not challenged by situations that are not easy for him.



This could definitely be the case. I do tend to have mommy-goggles in all things related to DS.


Mommy-goggles can interfere with seeing your DS as others do. Be careful around this. If you can see clearly where he needs help and where his behaviors are off-putting to others, you can put plans in place for meaningful interventions. But if you can't/won't see it, this won't happen. 


But yeah, I would not only be upset to get an ODD dx, I would be highly suspicious. As co-occurring conditions this is ridiculously unusual. In almost 20 years knocking around autism world, I can think of a handful of people I know who have been labeled thusly and most have lost the ODD piece when evaluated by someone who really understands autism.





It's kind of hard to have both. ODD presumes a degree of empathy (not sympathy, per se, but the ability to anticipate an emotional response to action- Theory of Mind) that is not possible in a very young kid on spectrum. At 5, most kids with ASD haven't fully differentiated themselves from their primary care-person and don't realize that other people have different feelings and thoughts than they do.





I would absolutely get a second neuropsych eval done by someone very familiar with kids on spectrum.



I'm looking into what neuropsychs are around here and hopefully can get him on a waitlist soon.


Has he seen a dev pedi? Are you in with a really good one? Sometimes a dev pedi works in a clinic setting with their own in-house neuropsychs available. If you can wait until 6, you can get BASC with student reporting. I would also ask for Vineland (full version) to get a sense of his emotional and social maturity. I personally found Vineland the single best scale for understanding where DS was emotionally and how hard was appropriate for pushing him out of his comfort zone. 


I don't know if I learned about that dx on previous boards, my local SN community, psych classes, or somewhere else, but this is a diagnosis that I don't want to tell the school system about, right?





I would not at this point. My concern wouldn't necessarily be suspension; a well written IEP can include a BIP and language to avoid OSS which can act as a reward to some kids. My concern would be that behavior associated with "ODD" rather than in the context of ASD could lead to placement in a self contained classroom for kids with emotional/behavioral disturbances. This is pretty much putting the lamb in class with the wolves.



I'm pretty sure the dx caused some sort of trouble for a local mom when her son kept getting suspended from school and I know my sister (special ed teacher) has talked about kids from her class that got expelled with ODD. I keep thinking that if we do tell his new teachers that it'll give them reason for similar things to happen to him. His Pre-K teacher knows and was the one that said he's more of a teacher's pet.





It's not the dx that causes trouble; it's the behavior. However, if he's melting down and that is seen as oppositional rather than sensory overload or anxiety it won't be addressed properly.



The weird thing is that he doesn't really have big meltdowns anymore especially since we switched ABA centers. Every once in a while he'll spiral when he starts getting overloaded but he seems to have gotten self-regulation way more in control. And at school, he mostly imitates the other kids so they never really have a problem there. But I definitely don't want him in a self-contained class.


DS never had meltdowns; he's weird that way. It's more like a female presentation which is one of the reasons he wasn't flagged earlier. If he's doing ABA, a hybrid setting of an ABA structured class with him bridging to mainstream could be a good fit. My niece's little brother was mainstreamed K-3rd but wasn't really thriving. He's in an ABA classroom part time now and kicking ass. He does science and social studies with the gen ed class as well as specials. I don't know how long this will be the more appropriate setting but for now he's doing so much better than he had been and he's happier. 


All that said, ODD is like many other behavior conditions in that it is treatable and often less of an issue as the child becomes older and has better emotional regulation. I have worked with a number of scouts with ODD; they can be a tough crowd, but they aren't doomed to grow up as sociopathic criminals.

[funchicken]

I'm sorry the meds haven't been working out, lemonberry. We tried a stimulant last October and it didn't go well. DD has been doing well on Zoloft, and the psychiatrist and I talked about trialing another ADHD med after school gets out, but I'm not sure if we should. The school psychologist said that she didn't have enough information to confirm or rule out DD's ADHD diagnosis. She said it's possible that DD's attention issues stem from ASD. Her distractions seem more internal, and even though she looks like she's not paying attention, she completes all of her schoolwork.

It's hard when you're dealing with conflicting information. I hope you're able to find a good neuropsych who can help you.

[akafred]

Until DSM-5, an autism dx subsumed ADHD, meaning you couldn't technically have both. And this is because many of the ADHD behaviors overlap with ASD symptoms. The same may be true of ODD; not officially but in reality.

The problem I personally have with ODD as a diagnosis is that it only addresses the symptoms or behaviors, without addressing the causes at all. As auntie implied, sometimes oppositional behaviors are driven by a sensory component. In many kids including my DD, these behaviors are driven by anxiety. When she has a low level of anxiety, she is the sweetest, most cooperative, thoughtful, and helpful child around. When her anxiety is extreme, she is vindictive and cruel. And every level in between.

[auntie]

funchicken,

Attention can be difficult to parse.

For DS, he does have ADHD- combined type- it wasn't until the intermediate grades that the executive function deficits associated with ADHD began to become more evident. Even now he's better about tracking time, expectations and materials in a global sense than either my mother or niece.

He was clearly distracted from within- he has a tendency to live in his head which is a far more interesting place than, say, math class. Add in the anxiety component of ASD and the "what if..." thinking that comes with that and it's a wonder he was ever able to engage and pay attention. Plus, sometimes the body language associated with "paying attention" in our culture- sitting upright, making eye contact with a speaker, being still- was just beyond him at times. He can behave in a more expected manner now, but as a little kid sometimes he learned best when it looked like he wasn't focused at all.

[auntie]

Apr 24, 2018 8:00:49 GMT -5 akafred said:

Until DSM-5, an autism dx subsumed ADHD, meaning you couldn't technically have both. And this is because many of the ADHD behaviors overlap with ASD symptoms. The same may be true of ODD; not officially but in reality.


This was controversial at the time. Many clinicians did diagnose ADHD in persons with what were called pervasive developmental disorders under the DSM IV. Both DS's dev pedi and psychologist, who agreed on nothing else, felt that ADHD and ASD could best be described as co-occurring in some individuals like DS.  There is certainly some overlap in symptoms, especially around executive functioning, but behaviors like hyperactivity, impulsiveness, inattention are not really a part of ASD. 

The problem I personally have with ODD as a diagnosis is that it only addresses the symptoms or behaviors, without addressing the causes at all. As auntie implied, sometimes oppositional behaviors are driven by a sensory component. In many kids including my DD, these behaviors are driven by anxiety. When she has a low level of anxiety, she is the sweetest, most cooperative, thoughtful, and helpful child around. When her anxiety is extreme, she is vindictive and cruel. And every level in between.

The problem I have with ODD and ASD given together is that ODD requires a level of social and emotional thinking that are beyond the skill set of a younger child with ASD. Kids with ODD will behave in ways they know are irksome/challenging to an adult in charge just to get a reaction- a child with ASD, who is younger and hasn't had years of social thinking training- would not have the bandwidth to select a behavior that would be specifically annoying, would not be able to identify- much less appreciate/enjoy- the reaction as negative and probably wouldn't understand that the other person even has an opinion of the exchange that is different than theirs. 

[funchicken]

Apr 24, 2018 8:06:21 GMT -5 auntie said:

funchicken ,

Attention can be difficult to parse.

For DS, he does have ADHD- combined type- it wasn't until the intermediate grades that the executive function deficits associated with ADHD began to become more evident. Even now he's better about tracking time, expectations and materials in a global sense than either my mother or niece.

He was clearly distracted from within- he has a tendency to live in his head which is a far more interesting place than, say, math class. Add in the anxiety component of ASD and the "what if..." thinking that comes with that and it's a wonder he was ever able to engage and pay attention. Plus, sometimes the body language associated with "paying attention" in our culture- sitting upright, making eye contact with a speaker, being still- was just beyond him at times. He can behave in a more expected manner now, but as a little kid sometimes he learned best when it looked like he wasn't focused at all.

auntie, that makes sense. Since, up until this point, DD has never had consistent accommodations or an IEP, I'm anxious to see how she does with support in place that takes the ASD into account. I feel like that's the next step before we think about adding a new med to the mix. The psychologist's report stated that DD only appeared to be ""on task" 59% of the time (she does a lot of doodling), but she completes 100% of her work. I have a lot more questions about the psychologist's observation report.