This month's Behavior Question is shared with our Behavioral Peditrician

Question:

Dear Dru, I am working on a behavior plan for a 13-year-old male who has been diagnosed with Septo-Optic Dysplasia (SOD). In addition to his many medical issues, this young man also has a number of behavioral concerns in the area of social skills and impulse control. The problem behaviors center around bizarre comments made by the young man, verbally and physically aggressive behaviors towards specific peers, and what appears to be self-stim behaviors (head rolling, playing with hairs on arm, rolling knuckles together, also picking nose and /or scabs on arm.)

This young man has also been diagnosed as ADHD. He is currently taking Ritalin and a number of other medications (hormone replacements). How much of the behavioral issues might be due to drug interaction or improper dosage of drugs? His mother is in the process of scheduling an appointment with a psychiatrist to determine the medicine issues.

Some of the information I have found online also refers to a connection between SOD and autism. Is this something to pursue? Once again, I would appreciate any help or guidance you could provide to help me help the parents and teachers, as well as the young man

I have found some limited information on-line regarding his condition, but I would greatly appreciate any information you could provide, or resources you could point me to regarding Septo-Optic Dysplasia. I would appreciate any sources that could address behaviors and strategies for addressing these behaviors.

Thank you,
Pat Judd Behavior Intervention Case Manager

Answer:

From the Behavioral Pediatrician

Dear Pat, Septo-Optic Dysplasia is a rare disorder characterized by abnormal development of the optic disk, pituitary deficiencies (hormones) and often absence of the septum pellucidum (a central part of brain that separates the two ventricles, fluid filled spaces). Because the degree of abnormality varies the disorder can encompass a variety of neurological abnormalities and consequently a variety of symptoms. This sort of "spectrum" of abnormalities is common with any brain malformations or developmental abnormalities. One cannot predict form the diagnosis the degree of cognitive delay (if any), the amount of hormonal abnormalities, or whether there will be other developmental brain symptoms and diagnosis such as Autism or epilepsy.

These children consequently require a full assessment including in depth cognitive testing as well as endocrine assessment (hormones) and neurological assessment looking for symptoms compatible with seizures or physical problems such as cerebral palsy or abnormalities of the cranial nerves which involve facial movements, hearing and vision. Of course, many of these difficulties should have become obvious and already have been diagnosed.

One cannot form a behavioral plan with only knowledge of "Septo-Optic Dysplasia". The behavioral interventions need to be created only after detailed evaluation of the spectrum of symptoms displayed by a particular child. You are right to be concerned about medication interactions. Also, frequently psychiatrists are not trained to evaluate such a spectrum of Neurodevelopmental abnormalities and the situation can be further compromised by use of medications that can worsen neurological difficulties and therefore worsen the behavioral difficulties. Such an example might be that Ritalin can cause "picking behavior" or worsen anxiety.

In treating behavior with medications it is important to clearly define the "symptoms" that one wants to improve with the medication. This defining process should also lead one to the type of medication that one might use. Similarly, one intervention should be done at a time… i.e. medication change first and then when behavior has stabilized, behavioral intervention. If two "treatments" are begun at the same time then it is unlikely to be unclear which is responsible for any noted improvement (or worsening) in behavior.

Sometimes it is helpful in a child like this to utilize a pediatrician or psychiatrist who is skilled in working with neuro-developmentally challenged children. This individual could communicate with the treating pediatric sub specialists (in this case endocrinologists+) and the family and the school. It is helpful to have such a physician contribute to making a list of those behaviors that might be targeted by either medication or a behavioral plan. It sounds to me like, in this case, that the Ritalin might be reconsidered in face of his aggression and "picking behavior".

From the Behavior Specialist

Pat,
Thanks so much for your question. As you see, it was so complex, it took two of us! I heartily second Kay's recommendation that you attempt only one intervention at a time. So, if medication changes are occurring, hold off on making any significant changes in the environment. Also, I understand Kay to be saying that "autistic-like" behavior is not uncommon in individuals whose brain formation is different, as this student's certainly is.

That being said, what would I recommend for the presenting behaviors? Not knowing what his cognition or placement is, I'm going to assume that his cognition is normal and that he has special education services (because you are involved)

Looking at the list of behaviors:

1. Making bizarre comments
2. Verbal aggression
3. Physical aggression
4. Self-stimulatory behaviors:

· Head rolling
· Playing with hair on arms
· Rolling knuckles
· Picking nose
· Picking scabs

I'm going to prioritize. The aggressive behaviors are the ones that concern me most, and I'm going to include the "bizarre comments" in this group. The other behaviors may not increase his social status but they are not getting him BICM intervention (Note to Non Californians: Behavior Intervention Case Managers [BICMs] are mandated when students in special education exhibit significant maladaptive behavior.) Moreover, these are more likely to be related to the medication issue.

Next, I'm going to hypothesize that this student has stood out in some way for a long time. (Otherwise, he would not likely to have gotten this diagnosis.) Thus, I'm wondering about his history of peer interaction. I'm also thinking that at 13, he is dealing both with the onset of puberty and with the dramatic increase in the importance of social acceptance.

I don't have any way of guessing what the predictors are for these aggressive behaviors, though experience tells me that we often see this type of behavior when the student feels stressed, either because he finds assignments frustrating or his social interactions unsatisfying.

From these hypotheses, I'm going to take some data, both anecdotal and (a little) recorded, to get more information about the predictors but let's assume that this behavior is the boy's best attempt to interact with his peers. In other words, I am assuming that he wants to be liked but doesn't know how to go about making and keeping friends. Seeing this as a severe skill deficit, I'm going to explore ways that social skill training can be provided in this school. I may also include some self-management techniques to increase appropriate comments to peers and some problem solving strategies (see below) to teach him to consider better strategies.

I'm also going to see what in the environment is supporting his aggressive behaviors and attempt to minimize them. For example, since he is more aggressive with certain peers, can I a) involve him in a supervised social group (e.g., Lunch Bunch) with these students? b) decrease the time he is with these students? c) work with these students on increasing their tolerance of him? d) work with the whole class on community-building activities and appreciating everyone for their various strengths and weaknesses ([dis]ability awareness).

Find a reinforcement for this student and include in your plan how you will communicate progress to all team members.

I hope this is helpful. The boy you describe is the kind of student we see here at the Diagnostic Center. Please feel free to mention us at your IEP Team meeting as a resource to enlist if the plan you devise is not working and/or our pediatrician could help sort out some of the medical issues involved.

Best of luck!

Dru

Below are 4 Problem Solving techniques. Choose one (or make one up) and use the pneumonic to aid in memory. There are simpler ones if the student's cognition is impaired.