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Natural Gas Appliances

Many companies make tankless water heaters. In deciding who makes the best tankless water heater, it really depends on what the customer is looking for. Below are some tankless water heater reviews.


The copper heat exchanger in their tankless water heater is commercial grade and includes a 12-year limited warranty. Their concentric venting system is different, thereby making it stand alone as an innovative technology. Rinnai has won many awards for their energy efficient tankless water heaters such as the “Super Nova Star Award.” Also, they were chosen as the “Best Tankless Whole-House Water Heater” by With over 30 million sold in the world and over four decades of experience, Rinnai makes some of the best tankless water heaters on the market. They strive to keep the purchase and the vent cost as low as possible. Rinnai is pretty proud of the fact that they are the only water tank manufacturer to offer two installation options in one unit—saving you the hassle of buying extra parts. This Rinnai tankless water heater offers two options for natural gas venting—both concentric and PVC pipe options are found on the top of the unit for convenient access during installation. This concentric vent design is very unique with its important safety benefits. The concentric vent means that it holds both intake and outtake pipes, so the vent is cool to the touch as the warm air is insulated inside. If a intake or outtake pipe develops a leak, the air stays in the concentric vent and does not enter the home. The dangers of a gas leak are immeasurable; from fire and combustion to carbon monoxide poisoning.

Rheem ( (Rheem Price List

Their features are made to be very user friendly. With their digital display, the water temperature can easily be set or changed, and monitored. They also have a self diagnostic system that displays different codes if there are maintenance issues. Their designs are a successful attempt to make the use of their tankless water heaters more convenient and less expensive for their customers. Some models can even be installed under the sink, in the bathroom or in the kitchen. Rheem’ tankless water heaters were featured as one of the top 100 green products in the “Building Products Top 100.” Condensate Neutralizer – Saves time and install costs compared to other manufacturers’ models, which require a standalone component to be purchased and installed. Maintenance Notice Setting Automatically alerts homeowners after 500 hours of water heater use (about a year or a year and a half), flashing a warning code to call for service check. Accessory available: Recirculation Pump Kit—Provides instantaneous hot water at the tap and the water heater controls a set timer so it runs every so often (for example, every 30 minutes) to keep hot water flowing through the pipes and ready when homeowners need it; The tankless unit is responsible for heating the water, and the pump pushes the water through the home’s pipes. 

Rheem Performance

  • Industry First! 0.26 GPM minimum flow rate, 0.40 GPM minimum activation flow rate
  • RTGH-95 for 3 bathroom homes*– 9.5 gal./min. at 35°F rise max., 8.4 gal./min. at 45°F rise SCAQMD rule 1146.2 compliant
  • RTGH-84 for 2-3 bathroom homes*– 8.4 gal./min. at 35°F rise max., 6.6 gal./min. at 45°F rise SCAQMD rule 1146.2 compliant


One of their innovative safety designs is known as the air-fuel safety rod. Also, they can install direct vent model conversions. Takagi can run a vent up to 50 feet, instead of the usual 35 feet while using five elbows instead of three. Some of their tankless water heaters are made in compact sizes and are small enough to even fit between wall studs. Takagi works hard making them as energy efficient as possible. They want to help in the aid of reducing factors that contribute to global warming.

How To Choose Your Tankless Water Heater:

Gallons Per Minute / Flow Rate

Measures steady flow of hot water usage

Fixture / Appliance

Typical Flow Rates

Bathroom Faucet

0.5 – 1.5 GPM

Low Flow Kitchen Faucet

1.0 – 2.5 GPM


1.0 – 2.0 GPM


1.0 – 2.5 GPM

Clothes Washer

1.5 – 3.0 GPM

If you typically run a bathroom faucet with a flow rate of 1.0 GPM and shower head with a flow rate of 1.5 GPM simultaneously, the flow rate through the water heater would need to be at minimum 2.5 GPM. *We want a water heater with a minimum 11.5 GPM = bathroom faucet + 1 Shower + Dishwasher + Clothes Washer + kitchen Faucet ALL at the same time 

Gallons per minute (GPM) measures the steady flow of hot water that a water heater will produce.

To determine the GPM that you need, you will add up GPM for the major fixtures / appliances that you expect to use at the same time.

How cold is your incoming water?

Required temperature rise is the difference between your incoming ground water temperature and your desired output temperature.

You know your required flow rate is 2.5 and you live in Atlanta where groundwater temperature is 55°. You would need a water heater that produces a minimum temperature rise of 45°.

The map provides average ground water temperatures. You should use the expected coldest ground water temperature for your area. After determining your ground water temperature, 55° in Atlanta for example, you will subtract this from your desired output temperature. For most uses, you’ll want your water heated to around 100–115°. *64 is Florida’s lowest ground water temperature – 115-64 = 51 or 100-64= 35 – we would need a water heater that produces a minimum temperature rise of 35 to 51 – So we want FLOW rate @ 35 degrees or FLOW rate @ 51 degrees (gallons per minute) to meet or exceed 11.5GPM


Rheem tankless water heaters


Rheem tankless water heaters are designed for the homeowners who prefer small, space saving and compact units that provide on demand water heating with the continuous supply of hot water. Rheem is the well-known US brand in the industry that has many awards and certifications that meet local and international standards. This review covers the models for residential applications and it includes the gas- and electric-powered models.

Model and type selection

There are two types of gas-powered tankless water heaters for residential use and whole house water heating; Professional and Performance line, divided into ultra-efficient condensing and non-condensing models. The Professional series can be found in both US and Canada, while the Performance line only in US (these are also known as EcoSense series).

Prestige condensing

Rheem tankless water heaters from Prestigeseries are ideal for the busy homes, and families with the high demand for hot water. If you have to use hot water for showers, dishes and laundry at the same time, or big tubs, this group of heaters is the perfect selection, mainly due to the high water flow and gas input.

Prestige series is the most efficient line of all tankless water heaters from Rheem as the condensing technology increases its efficiency to high 94%.

Both Rheem H84 and H95 are built as the indoor and outdoor units, one uses the horizontal or vertical venting system while the outdoor model is ventless.

Model Venting Gas input
Flow rate (GPM)
@35F rise
EF # of Bathrooms
RTGH-95DVLN Indoor
Direct Vent
0.94 3
RTGH-95XLN Outdoor 11,000
0.94 3
RTGH-84DVLN Indoor
Direct Vent
0.92 2-3
RTGH-84XLN Outdoor 11,000
0.92 2-3

Mid-Efficiency models

Model Venting Gas input
Flow rate (GPM)
@35F rise
EF # of Bathrooms
RTG-95DVLN Indoor 11,000
0.82 3
RTG-95XLN Outdoor 11,000
0.82 3
RTG-84DVLN Indoor 11,000
0.82 2-3
RTG-84XLN Outdoor 11,000
0.82 2-3

Rheem Performance line

The Performance line is for US customers only, and it consists of the gas and electric-powered water heaters that are also named as EcoSense. The gas water heaters are designed with and without the condensing technology (mid-efficiency) and basically, have the same features as the above tankless models from the Professional line.

Rheem tankless water heaters are ideal solution for homes and high demanding families, as this technology provides continuous supply of hot water, efficiently and only when it is needed. The great things about tankless is the sophisticate technology, the advanced features and professional grade quality.

Takagi Tankless Water Heaters

T-M50-N (Indoor, Outdoor)

The T-M50 Series, specifically designed for heavy-duty applications, is the largest Takagi tankless heater yet, and the most powerful (14.5 GPM max) in the tankless industry! The T-M50 Series is suitable for commercial applications (hotels, restaurants, government, convalescent homes, etc.) that require high demand and the most durable of heaters. Along with commerical grade copper alloy, the T-M50 Series is the only commercial unit in the industry that offers a “dual-combustion system,” providing redundancy for added reliability


Tankless Water Heater 

Indoor or Outdoor Tankless Water Heater

  • An indoor tankless water heater is installed inside your home. An outdoor unit is installed outside the home and is designed to withstand the elements.
  • If mounted outside, the unit vents from free air flow. 
  • Mounting inside of the home, you must use some type of ventilation piping, whether it is vertical or horizontal venting.Tank less water heaters require specialized venting. Indoor tank less water heaters must be installed so water created by condensation can be drained away from the heater. This requires the venting to be attached to a drain.
  • Tank less water heaters do require a great amount of oxygen…which in turn, requires additional venting to install an indoor unit. 
  • One key advantage to having a tank less water heater installed indoors is that it will not be exposed to severe weather, including freezing temperatures-which can cause significant damage to the unit.


How does the Tankless Water Heater work?

A conventional tank-style water heater stores hot water, and heats the water 24/7, whether you use it or not. Tankless Water Heaters only heats water on demand (whenever water is requested at a faucet). When the faucet is opened, the water flows through the Tankless Water Heater, which heats it to the temperature you have the unit set to. When the faucet is closed, the Tankless Water Heater senses the command as well, then shuts down when water is no longer being requested.


What does thermal efficiency mean in regards to a Tankless Water Heater?

This is the amount of generated BTUs which enter the water and the percentage of the total BTU passing out            through the vent pipe. BTU or British Thermal Unit is the heat required to raise 1 pound of water one degree F.


How long does a tankless water heater last?

This depends on the quality of the water and how well the water heater is maintained over time. Typically, you can expect to get between 15-20 years from a tankless water heater if the unit is maintained, back flushed at least 1-2 times per year, and is properly installed. 


 Is there a standing pilot?

No, the direct ignition sends a spark to the main burner when hot water flow is detected. This feature improves the energy efficiency of the Tankless Water Heater overall.


 How much more do they cost to purchase?

Usually, a Tankless Water Heater will cost about 2 times as much as a standard water heater to purchase and install. However, please note that in addition to lower operating costs, usable square footage is gained by going with a Tankless Water Heater.

How long does it take for the Tankless Water Heater to reach a faucet or appliance to provide hot water?

It depends on the existing piping size and distance from the Tankless Water Heater. This is the reason we call them tankless.  Labeling the units as instantaneous or on-demand can create the illusion that the hot water is immediately delivered. A professional plumber can help assess your Tankless Water Heater’s location, and/or re-locate the water heater to a better location if needed.

Surprisingly, the location of your tankless heater in your home plays the biggest role in how much water you use.

Tankless systems heat water on demand. Good for your heating bill, bad for the water bill. Since there isn’t warm water waiting for you, there’s a lag time between the moment you turn the shower on and when you start to feel warm water. That whole time, you’re letting perfectly good (but very cold) water wash down the drain.

 “‘Distance plays a very large role in how fast hot water gets to the outlet,’ says Joe Wiehagen, a senior research engineer at the National Association of Home Builders’ Research Center. The farther away your system is from your faucet (in my case on the other side of the house and on another floor) the more piping filled with cold water needs to empty before new, heated water can make its way to you.” So if you want to make sure your new tankless water heater is as thrifty with water as it is with heat power, make sure you have it installed nearest to where you’ll be using it most.

Portable Tankless Water Heaters

Any Portable Tankless Water Heaters are not designed to be plumbed into any fixtures or faucets, and are not meant for a permanent type of installation. Portable Tankless Water Heaters, such as our L5, L7, and L10, are meant for outdoor recreational use only, with the use of standard garden hoses and should be used only outdoors, and disconnected and stored in a warm, dry location when not in use. Installing a Portable Water Heater as a permanent installation can void any warranty on the unit, due to being deemed as an improper install.

Condensing Versus Non-Condensing Tankless Water Heaters


Non-condensing (mid-efficiencies) units have efficiencies around 80%, meaning around 20% of the heat is wasted and exhausted.

Condensing Tankless Water Heaters (High Efficiency) extract the additional heat from the exhaust gases through various means and therefore exhaust cooler gases, usually around 100 degree F. As mentioned before cooling the exhaust gases produces condensation, in this case inside the unit. Since the exhaust gases are now much cooler a less expensive venting material can be used, mostly standard PVC schedule 40 is used as it can easily withstand the heat and the corrosively of the gases. Since we have captured the residual exhaust heat to heat the water we have achieved higher efficiency in the high 90% (up to 98%).

As a note, a Condensing unit does not always condensate, surrounding air temperature and air humidity are important factors. The manufacture claimed efficiencies are achieved mostly in labs under controlled conditions and real life values maybe lower.

Since the exhaust gases have been cooled inside the unit the condensation water is collected now inside the unit. The heat exchanger is the heart of the tankless water heater. It has now to be of higher quality and non-corrosive material to withstand the corrosiveness, usually made of special stainless steel alloy.

The collected condensation water has to be neutralized before it can be drained to the outside. This can be done through special filtration or dilution.

Conclusively Condensing Tankless Water Heaters are very efficient (up to 98%), real energy savers and use inexpensive venting material. They are slightly more expensive to manufacture but are over all on par with non-condensing tankless water heaters that need to use expensive stainless steel venting materials and are less efficient (about 80%).

Routine Maintenance On Your Tankless Water Heater

In order to get the most out of your tankless water heater, it is very important to perform routine maintenance on your unit from time to time. Examine the area around the heater for any combustible materials such as paper, or chemicals. Be sure to clear away any such materials you find. Regularly check the exhaust vent and air inlet for any dust, soot or other debris that may have accumulated, restricting the air flow that the device requires. Check the pipes for leaks. Examine the water heater for  anything that seems out of the ordinary; any unusual sounds, smell of gas, etc.

We  recommend using a clean, lint-free cloth to wipe down the heater’s exterior. You may also clean the heater’s remote control in a similar fashion. Avoid applying water directly to the heater or its remote control.

Periodically check the water heater’s water drain valve and water filter screen in order to avoid any debris from building up. Otherwise, your hot water may not flow properly or will flow at a lower temperature than desired. To do this, turn off the device and allow it to cool.

One of the ongoing maintenance requirements is to make sure that heat exchanger elements are free from any limescale or scale as it is commonly know. Flushing tankless water heaters whose heat exchangers are blocked by the lime scale is very important and must be done before something happens. If you don’t flush the water heater, the heat exchanger can be damaged as not enough water will pass through and cool it down.

Visit the link below for addition information regarding routine maintenance on your tankless water heater.…

What are the pros and cons of continuous flow hot water systems?

Advantages Disadvantages
Higher efficiencies than non-condensing technologies Requirement for condensate draw off
Condensing continuous flow water heaters amongst the most energy efficient systems available in the European market Direct storage systems do not take full advantage of condensing technology due to hot water store proving wasteful with energy consumption
Condensing continuous flow water heaters operate in condensing mode constantly due to low incoming temperature Higher initial investment cost
Building regulations compliant  
Subsidiaries and incentive available  
Reduce CO2 emissions
Posted in Anger Management, Behavior, Emotions, For Nurses, Health, Pediatric Nursing, Positive Parenting, Relationships, School, Social Skills, Therapy

ODD has two components: Emotional and Social

Oppositional Defiant Disorder 

The Types of Behaviors that would qualify as ODD:

  1. Pattern of behaviors that consists not just of defiance, stubbornness, arguing, refusal to obey – These are certainly symptoms of ODD – BUT ALSO 
  2. A Pattern of Anger – Quickness to become upset – Easily Frustrated – Irritable – A child who appears to have difficulties controlling their MOODS (but particularly CONTROLLING their ANGER & FRUSTRATION) 
  • So if you PUT the two together – you have a child who has problems with HOSTILITY & ANGER and coupled with that is SOCIAL CONFLICT piece and that is the defiance and arguing with other people 
  • *** Families may see this type of behavior from time to time in NORMAL children – especially very young children (preschoolers and also in the adolescent years) BUT ODD is a cut above that kind of NORMAL behavior 
  • What differentiates ODD from NORMAL behavior??? How do we tell the difference between the child that is Temperamentally Stubborn and Strong Willed “Pig Headed” and the child that would go over clinically to the distinction of being ODD??? 
  • Answer: Oppositional behavior falls along a CONTINUUM – a DIMENSION with NORMAL behavior – so what separates the clinical disorder from the every day run of the mill??? There are several factors that we look for to make that distinction: 
  1. The first is the FREQUENCY with which these events are happening – it is one thing to have it happen on OCCASION (a few times a week or LESS) But if you are seeing this behavior pattern NEARLY EVERY DAY around various ACTIVITIES that your child has to accomplish, RULES they have to follow, DIRECTIONS or INSTRUCTIONS you give them – then this is ONE discriminating feature – FREQUENCY (Is this happening a lot more than we see in other children???) 
  2. SEVERITY – so that when the bouts themselves take place – when the DEFIANCE occurs or when the ANGER occurs – it is to a GREATER DEGREE than what we would ORDINARILY see even in normal children. So there is EXCESSIVE BEHAVIOR during these episodes 
  3. The Last distinction – which is the MOST IMPORTANT: This level of behavioral disturbance begins to INTERFERE with the child’s ability to succeed – to functional effectively in various major life activities. Those would be things like: Family Functioning, The ability to develop Independence & Self Reliance, Social Relationships with other People (particularly with other children), School Functioning and so on – These are the areas that we look at to see if the behaviors are beginning to affect the child’s ability to function effectively in Life – 
  • Does the Family find that they are spending LESS and LESS time with this child because of all the fighting 
  • Are the parents experiencing marital difficulties – this is another sign that something is happening that is beyond the pale… 
  • Have other families refused your child to visit because of the frequency with which they are ANGRY, AGGRESSIVE or HOSTILE to others
  • Are we hearing complaints from Teachers about this behavior pattern (preschool or elementary) 
  • If you are starting to get feedback “If the environment is kicking back” – then you are getting information that your child is not doing well in these areas and that is when you have crossed the line into a clinical disorder – it is no longer just normal behavior 
  • Basically it is  matter of DEGREE
  • ODD and Conduct disorder – how are they related?? The two are certainly connected to each other. Simplistically Conduct disorder is just a more advanced stage of ODD. 
  • ODD CAN occur by itself – the younger the child the more likely it occurs on its own (especially in the early preschool years ‘terrible 2’s and 3’s’) But as the child gets older if the ODD persists beyond the preschool years – it is the MAJORITY of the TIME – associated with another disorder – ADHD, Conduct Disorder, Depression or Bi-polar disorder (these are the more common ones that link up with ODD)
  • If we looked at a group of preschoolers 50% of them would have a second disorder BUT By the time a child is 8 years of age – 80% of them DO have a second disorder. 
  • ODD alone there is RECOVERY from that disorder – especially when PARENTS CHANGE their tactics, LEARN how to manage the child better, Quell some of the temper tantrums. If it is ONLY ODD then it has a VERY HIGH chance of GOING away within the next 2-4 years BUT if it is linked to another disorder – it is probably going to be VERY PERSISTENT – and one of the disorders it is linked to is conduct disorder. BRIEFLY, Conduct Disorder is a pattern of more severe aggressive behavior, fighting, lying, stealing, running away from home, engaging in antisocial activities (like delinquent activities as we often think of them – adolescents carrying and using weapons, breaking & entering, picking fights with other people) it is a much more severe pattern of social behavior than is just oppositionality or defiance. EVERY PARENTS NIGHTMARE 
  • ADHD connection to ODD – Do the two often occur together and does the treatment for ADHD will that take care of a great deal of the ODD??
  • Answer: The two disorders do go together VERY VERY often. For instance if a child has ODD  – the most common disorder that will be seen with it is ADHD and that is about 40-50% of preschool children with 1 disorder but by the time they get to be 8 years of age 60-80% of them have second disorder – most commonly ADHD and we know that at least 2/3 of ADHD children will go on to develop ODD within 2 years of their onset of ADHD. So the two go together and they increase their risk for each other. One of the reasons for that is that we know that ADHD is a CAUSE of ODD. 

Causes of ODD

  • ADHD is a cause of ODD 
  • Think of ODD as involving TWO SETS of behaviors – TWO DIMENSIONS of behavior that are LINKED to each other 
  1. First dimension that we see in ODD is a problem in REGULATING EMOTION (particularily ANGER, FRUSTRATION, IMPATIENCE, & HOSTILITY) Part of ODD is a MOOD disorder and the mood rather than being Anxiety and Depression which everybody associates that term with (MOOD DISORDER) in this case is ANGER, FRUSTRATION & HOSTILITY – This dimension of ODD belongs to the child – which means that it arises from INTRINSIC factors in that child – it could be due to a second disorder depression, bi-polar disorder or ADHD – it could just be simply a reflection of that child’s personality & temperament – Some children are more difficult, we would refer to them as having an ‘irritable’ or ‘difficult’ temperament – they are quick to anger, to get upset by things, they don’t have good frustration tolerance. ** So there is this EMOTIONAL element of ODD and that BELONGS to the child and ARISES from the child from temperament, personality OR another disorder 
  2. The second dimension of ODD is: SOCIAL CONFLICT – that is the defiance, the refusal, the  arguing, the stubbornness  – that involves TWO people NOT one like the EMOTIONAL DIMENSION does. the SOCIAL piece comes out of PARENTING. It comes out of FAMILY INTERACTION PATTERNS that are inadvertently training the child to use these MOODS and EMOTIONS as a SOCIAL TOOL – as a DEVICE in order to MANIPULATE people. ** Now neither party (the child or the parent) is doing that intentionally but that doesn’t mean the training isn’t occurring and the learning isn’t taking place because it is! Children are learning how to use these NEGATIVE moods that they POSSES in order to AFFECT another person and coerce them into doing as they would like them to do. That is a LEARNED piece and that LEARNING comes out of PARENTING. 

** So we have a social piece and an emotional piece to ODD and they arise from DIFFERENT factors – the EMOTIONAL piece arises IN THE CHILD – the SOCIAL piece comes out of PARENTING. 

** So TWO causes of ODD are the child has a NEGATIVE disposition for some reason that predisposes them to irritability and frustration and there is a LEARNING component to ODD and that arises with in the FAMILY through the way Parents are trying to COPE with their overly emotional child. If you Put the TWO together you are going to GET ODD. 

** ADHD is a contributor to the EMOTIONAL DIMENSION – ADHD children have a SELF CONTROL disorder and part of their difficulty with SELF REGULATION is they can’t control their EMOTIONS very well  – so that when ordinary emotions arise across the course of the day (as they will) the ADHD child can’t manage them as well as another child – they are often VERY impulsive, Quick to show their Emotions – Not moderate their emotions – So you can see the Link between ADHD and ODD – is ADHD is causing it – it is causing the EMOTIONAL aspect of ODD – but it doesn’t take long for those emotions, once they start to occur, to begin to interfere with interactions with parents and then training piece starts to kick in and now you are on your way to clinical ODD 

  • The same is true with the other disorders – whether it is Depression or Manic Depression – those ALSO predispose to the EMOTIONAL component of ODD – BUT once that is operative then the training has a chance to kick in 


We know from studies of adoptive children that 3-5x more likely to develop ODD, ADHD or both of them. Children who have been taken out of the adoption pool carry a much higher risk for psychological problems. WHY would this BE???? it is not the active adoption – that alone does not create these disorders – it has to do with where the child ORIGINATES. If the child is adopted here in the United States or in a Western Developed Country – what is likely is that the child’s ADHD is of the GENETIC type and that means that their biological parents were highly likely to be ADHD and ADHD parents are likely to have their children in their teenage years when they start bearing children. So ADHD is a major risk factor for teenage pregnancy – 40% of ADHD children as they grow up will have a baby before they are 19 years old and more than half of those babies will be put up for adoption because the parents aren’t yet ready to have or raise a child due to their own young age and also the immaturity that ADHD brings with it. So there is a genetic connection here. The child is MORE likely to have ADHD because the parents were likely to have it and the parents were more likely not to be capable of raising their own children – hence they wound up in the adoption pool. 

The Second contributing factor to this high risk for ODD and ADHD in adopted children (again coming back to ORIGIN) – some adopted children originate in undeveloped or lesser developed countries (Eastern Europe, Romania, China or the Koreas or South America like Columbia) these are going to be children that are coming out of situations where there was a high likelihood that there were pregnancy and birth complications- these may be children who were exposed to malnutrition during their pregnancy or parents who smoked and drank more and who had less prenatal care and were more likely to get infections – so these children would have been exposed to INSULTS to their nervous system that might have occurred during their pregnancy and arouse as a result of these various medical risk factors. In addition in certain countries such as Ukraine or Romania – these children may then have been put into orphanages that were understaffed – there would have been continuing malnutrition, lack of caregiver attention (so there was under stimulation)  – So now we have a child who because of the ENVIRONMENT is now at risk of developing ODD and ADHD. ** There is a genetic contribution but also a biological environment contribution that has to do with these EARLY hazards that have to do with pregnancy and/or early childhood. These two can often coexist with each other – that is the Genetics and the parents along with the hazards in the environment. But all of that explains WHY adopted children are more likely to have these disorders. 

DO kids Outgrow these disorders?

If Kids have ODD by itself – especially in EARLY childhood – between 2-4years – and it is the ONLY problem there – then YES about 50% of all children recover every 2 years which means that by the time we get to be about 8-10years of age the vast majority of ODD has dissipated – and the reason is because PARENTS have RE-ADJUSTED their parenting strategies in order to improve the child behavior. And more likely the ODD was of the SOCIAL CONFLICT variety – it didn’t involve the EMOTIONAL component. So if it is the RESULT of parenting then often resolving the parenting resolves the ODD. Nevertheless when the child gets to SCHOOL AGE – the situation is improved markedly. 

IF ODD is developing in the context of ANOTHER disorder (which it often is) then that Emotional  component of ODD is going to be there and adjusting your parenting ALONE isn’t going to necessarily going to be enough to address that second disorder. ADHD is one of the co-existing disorders that goes with ODD and if it is there – then you are going to have to TREAT that ADHD  in order to see REDUCTIONS in the oppositional behavior. ADHD treatments can be quite effective at doing so BUT the longer you let the ADHD go without treatment – the greater is the likelihood that ODD will develop and that treating the ADHD wont be enough to reduce the oppositional behavior and that is because the LEARNING has had a number of years to take place. You can get rid of the ADHD with medications but the LEARNING component of ODD will remain even though the EMOTIONAL component might be resolving with the treatment of the ADHD.

 ** The fact is that these other disorders DO contribute to ODD and they will need treatment in their own right. 

What Kinds of Parenting Strategies Seem to Lead to this inadvertently Training 

  • It is hard to not have negative feelings towards a child after they have drug you through the coals. It is hard to not develop a NEGATIVE attitude towards a child and also start avoiding interaction with a child that you know is going to fight you every step of the way. So it certainly understandable how parents slip into this. 
  • What can Parents do on their own or in conjunction with seeking therapy
  • Great Book To buy “Your Defiant Child” 8 steps to better behavior 
  • VERY IMPORTANT POINT: If you suspect your child has ANY of these disorders: ODD, ADHD, Depression, Bi-polar disorder… the Parent needs to ACT very QUCKLY and that is because RISK FACTORS are starting to occur if you leave these disorders untreated and the LONGER you let them go the more likely other risks start to occur – and some of those are IRREPARABLE risks – like risks of accidental injury – risk of Losing friends within the neighborhood & community and being labeled as a “PROBLEM CHILD” and so on – ** It is HARD to DUMP that label! 
  • The American Academy of Pediatrics – last November 2011 – issued a recommendation to ALL PEDIATRICIANS with regard to EARLY diagnosis & treatment of ADHD & ODD – but particularly ADHD because of its risk factors – they are now asking that pediatricians identify and treat these children from as young as 3-4 years of age rather than waiting until the child is 7, 8 or 9 years of age and has entered school and has 3-4 years of failure under their belt which is VERY difficult to reverse if you LET IT GO – FOCUS needs to be on EARLY identification & treatment in ALL of these cases. This is VERY different from what they used to say: “Give them some time, maybe it is immaturity…” – “We certainly don’t want to start them on drugs.” THAT HAS ALL CHANGED NOW as of November 2011 – The RISK FACTORS – the amount of RESEARCH on ADHD that has been done showing that it is an EARLY onset disorder and the EARLIER you treat it – the more likely you are to eliminate these ongoing RISKS – including the risk for ODD – So EARLY INTERVENTION is something that the American Pediatric Academy is pushing – Rather than the OLD CONSERVATIVE approach of: “Just Leave them alone – lets see if they outgrow it and if they don’t then we’ll intervene.” BUT that is TOO LITTLE TOO LATE 

SOCIAL COMPONENT of ODD – which is LEARNED through FAMILY INTERACTIONS with other people in the family – particularly with parents – WHAT IS GOING ON THERE????

  • What is going on there is that we see a pattern that we call – DISRUPTED PARENTING – ABNORMAL PARENTING – it is characterized by the following features: 
  1. HIGHLY inconsistent reactions to the child – some days the child acts up and defies and you are ALL OVER THEM – You React EQUALLY as NEGATIVELY HARSHLY: Yelling, Screaming, Threats and so on. OTHER DAYS your child defies and you LET IT GO – you are tiered of dealing with them – you don’t want to confront them anymore so you let that episode SLIP by. So what is seen is a VERY INCONSISTENT PATTERN of Vacillating between CONFRONTING the child IGNORING or NOT CONFRONTING the child’s defiance. 

*** Defiant Behavior is very much like GAMBLING behavior  – it doesn’t have to be rewarded every time in order for the gambler or addict to keep playing the slot machine – in fact it only needs to succeed about 1 in 10 times and the child will try to DEFIANT behavior every time – even if it doesn’t work and that is because they are on what is called a GAMBLERS REWARD SCHEDULE – Their behavior succeeds periodically and that is all it has to do to maintain it CONTINUOUSLY – just like the person playing the SLOT machine only need to succeed 1 out of every 5 or 6 handle pulls in order to keep putting their money in the slot machine every time – So this INCONSISTENT PATTERN contributes to this PERIODIC success of the child at b being OPPOSITIONAL 

2. The second thing that we see is that the parents are also VERY emotional themselves – we see a high rate of EXPRESSED emotions: ANGER, YELLING, SCREAMING, ARGUING  – The parent sometimes looks to be almost as oppositional as the child is in their Emotionality 

3. The third thing that is seen is that the parents often drift towards EXTREME forms of discipline with the child – and that’s because they are FED UP – they are TIERED – they are BURNED OUT and they OVER REACT from time to time and then there are other times when they completely IGNORE the child because they are FATIGUED or in a state of what is called LEARNED HELPLESSNESS = nothing seems to be working so they just don’t even bother dealing with the child (they usually just try to avoid the child) and you will see them spending LESS SOCIAL time, recreational and leisure time with the child and that gives the child a lot more opportunities for their DEFIANCE and RULE BREAKING to succeed 

*** So this pattern of disrupted parenting is  VERY important for people to understand because what is leads to from the child’s perspective is that the child can be periodically successful at getting the parent to BACK OFF – to NOT enforce their RULES & INSTRUCTIONS & COMMANDS and so on AND the child LEARNS that the quicker they get ANGRY and the HIGHER the ESCALATION (that is the more they escalate to more extreme forms of anger which may include even violence or self injury in some children) The child is learning that QUICK ANGER – ESCALATING ANGER usually gets the other person to BACK DOWN and LEAVE the interaction and then the child can go off and do whatever it is that they were doing before (watching TV, playing wth friends, doing whatever they wanted to do) 

  • So – it is often during these times – RULES, DEMANDS, CHORES that the child becomes DEFIANT and if that defiance succeeds at getting the parent to withdraw – even if it is only ONE out of TEN times – it is going to be used every time with the parent. 
  • The truth is that these kids are SO HARD to parent – so without putting any judgement on the parents  – it is CERTAINLY HELPFUL for parents to LOOK at themselves  — Really in ANY relationship, anytime you have a problem in ANY relationship – the FIRST place you ought to LOOK is at YOURSELF and not in a blaming sort of way but also because the only one you have a whole lot of control over is YOUR OWN REACTION in that relationship. It is not a moral failure and there are many reasons WHY the parent may be engaging in these behavior patterns BUT the first thing is to RECOGNIZE what they are. Just acknowledging: “What a minute – I have a role to play in this and the role I am currently playing is not working it is contributing to the problem – not helping.” 
  • WHY is the PARENTING DISRUPTED? Where is that coming from?? ONE Source: is that the child is VERY difficult  – you have a negative, difficult, strong willed – maybe even a child with ADHD or mood disorder – so that is posing difficulty  – these are VERY HARD CHILDREN TO RAISE even for NORMAL parents but what has also been discovered is that some of the disruptive parenting is coming from the fact that the parent has a psychological disorder as well – For EXAMPLE: ADHD runs in families – If a child has it – there is a 30-50% chance that one of those parents is ADHD as well. NOW one can see where the disrupted parenting is coming from because the PARENT is ALSO IMPULSIVE, INATTENTIVE, DISTRACTED, EMOTIONAL and in general has more DIFFICULTIES with SELF CONTROL themselves and now you have TWO people with the same disorder trying to interact with each other and it is making things WORSE. 
  • OR another disorder that is often seen linked to disruptive parenting is DEPRESSION (particularly in the mother) and where there is depression – a parent is going to be more IRRITABLE, more HOSTILE, less TOLERANT, less PATIENT – they are going to be OVERLY sensitive to even normal child gambits of child defiance and that is going to start in with this parental training of the child in this oppositional behavior 
  • OR if it is not depression – another link is that the father has a drug abuse problem or also is depressed, has ADHD or may is even ANTI SOCIAL and the FATHERS behavior can start to engender the same kind of interaction problem – the same kind of disruptive parenting – 
  • So before we start blaming the parenting for the child’s ODD – we need to first step back and ask WHY is the Parenting Disrupted?? And often – not always but often – the parent may have a psychological disorder as well 

Disrupted Parenting is CONTRIBUTING to the PROBLEM 

  1. Get your child diagnosed – see if there are any co-morbid disorders like ADHD or Depression which can be treated – The Emotional Component Can be treated 
  2. We know there is a PARENTAL component most of the time in this disorder  – caused by disrupted parenting 

What should a Parent DO????? Parent may be thinking “I am just worn out and I just want to avoid the child acting out and that is what I do…” Understandable – HOWEVER it is NOT working! So what should a Parent DO??? 

  • If the parent thinks they have a psychological disorder such as adult ADHD or Depression or Drug Use problems or the Parent happens to be a Single Parent that has been abandoned by their partner  or in a Divorce situation  – the parent needs to get professional HELP for themselves and for these issues or these stressors BEFORE they are going to be successful at dealing with their child  – So it is like a “HEAL THY SELF” recommendation – BOTH child and parent need to be evaluated and make sure that the parent is getting help for any issue that be contributing to the disruptive parenting 
  • Parents need to TAKE A STEP BACK and REDUCE the number of commands they are giving  the child because it is NOT working – the child is defying them. The more commands you give the more that the child defies you – the more TRAINING that is going to take place. 
  • So one thing that parents are told to do is to PULL BACK for 1 or 2 weeks  from the number of commands and instructions they are giving a child and begin to look at WHAT is ESSENTIAL and what ISN’T – in other words “Don’t Fight Battles You Don’t Have to Fight.” 
  • A lot of the instructions we give to children are NOT necessarily important for their DEVELOPMENT – they are the usual routine things like – picking up toys or putting away clothes or emptying dishwashers or feeding pets – those kinds of things – SOME of those such as – “cleaning up your bedroom” can be SET ASIDE for a week or two – it is NOT going to be a DISASTER if we let those go AND that is because you want to FOCUS on REDUCING some of the things that produce CONFLICT  – now coupled with that Parents are Encouraged to Develop a more POSITIVE relationship with the child and that comes through using your ATTENTION, APPROVAL, PRAISE, RECOGNITION with that child – Whenever the child does something appropriate  – even if it is NOT following a command – even if it is just playing quietly or getting along with another child in the family  – Parents need to go LOOKING for these ‘momentary’ periods of GOOD behavior  – where the child is behaving WELL and Parents need to COME IN with as much ATTENTION, APPROVAL, even AFFECTION around those times – NOTICE that this is ASKING parents to do something COUNTER INTUITIVE  – RATHER than doing what the PARENT WANTS – which is “How can I get this child to listen when they defy me”  – Parents are asked to STEP back for now and IGNORE that for now  – Lets even CUT BACK  on the rules and instructions and Lets START TO FOCUS on the POSITIVE episodes of behavior. 
  • All children have some positive behavior  – it may not seem that way BUT kids are not oppositional ALL DAY LONG and so YOU want to INCREASE the ATTENTION that is being PAID to this kind of QUEIT behavior, Getting along behavior (with other children or with parents) and even the times when the child follows an instruction or a command  – the Parent needs to make sure that they come in with A LOT more APPROVAL, PRAISE and even AFFECTION  – The point is to try to STRENGTHEN that good behavior FIRST. 
  • Make a GAME for a day – See How many times you can catch your kid being GOOD – often you will find that you FOCUS on the bad because it is what is driving you NUTS – but if you START looking for the good – all of the sudden you start noticing more often that your child isn’t ALWAYS defiant. 
  • Also what is often found is that parents are NOT noticing the good behavior because when the good behavior is happening parents are using that time to get other work done! If the child is quiet the parent is not using that time to go and reward the child – the parent is using that child to go and load the dishwasher, or attend to a younger sibling, or run a load of clothing, or get some extra work done, or answer their email, or reply to phone calls – but notice that the parent is kinda letting SLEEPING DOGS LIE – ‘ I got a chance here to get some other things done!!’  ——-> What that SHOWS the child is that the ONLY attention they are going to GET is when they are DISRUPTED because when they are well behaved – they are pretty much IGNORED. It is understandable WHY parents are doing it – but Parents are their own WORST enemies in this case. And parents really need to REVERSE the situation – And whenever they catch their child playing well, playing quietly, getting along with another child/someone, and ESPECIALLY if the child is following some type of instruction  – They need to come down on that child with as much APPROVAL and ATTENTION and AFFECTION as they can  – Parents will find that, that INCREASES that behavior – It is hard to believe BUT it does! 

*** We do need to understand – Some ODD children – particularly those with ADHD or mood disorders – Praise alone is just not enough to turn the tide back to a POSITIVE relationship – BUT parents should START with that – BECAUSE if that is NOT there (positive relationship) then the REST is NOT going to work. 

*** Some children are just not as responsive or sensitive to PRAISE – it just doesn’t seem to sustain their good behavior as well. —-> 

Systematic Rewards System or a Token Reward System – Parents Call it the ‘Chip Program’ 

  • The parent organizes the child’s rewards & privileges on a chart and then also a chart of the child’s Rules that they have to follow, instructions, chores and just good behavior is created. 
  • Parents create this poker chip program  – where the parents give chips or points to the child for doing what they are supposed to do: Chores, instructions and so on and the child is allowed to spend those for their privileges, other rewards and even for saving up some of those chips longer term (more expensive privileges – like being able to get a new video game, or being able to go to a friends house or going to a movie or doing these other things kids like to do) BUT they are also going to need these points or chips for getting their EVERY DAY privileges such as: using the internet or watching television and staying up a little bit later past bedtime and so on. 
  • In The book “The Defiant Child” It explains just how to set up one of these Chip Programs so that it works well. – It is kind of technical! 
  • It has been found that by linking the child’s GOOD behavior to their privileges and rewards through this kind of accounting system  – this provides that additional reinforcement beyond just the PRAISE alone and Token Systems work VERY very well with Oppositional Children IF they are set up CORRECTLY. 
  • 2. The second component to treatment besides INCREASING PARENTAL ATTENTION is beginning to LINK up good behaviors with REWARDS and privileges with appropriate behavior. And then of course teaching parents how to REMOVE those chips when the child misbehaves – this introduces sort of a FINING element – it is like getting a ‘speeding ticket’ -the child is going to be ‘fined’ within the token system for NOT following rules, NOT doing chores, or for inappropriate behavior. 
  • The CHIP program becomes kinda of a TWO sided COIN – it becomes a means of increasing rewards and privileges for when the child is doing well BUT it also becomes a means of LOW LEVEL discipline or mild punishment to the child when they misbehave – they will be fined within the token system. 
  • Taking a CHIP away from the child gives the parent a method of discipline when they are frustrated. And Parents of children with ODD tend to go towards the EXTREME levels of punishment so introducing this Chip System allows parents a REASONABLE method of punishing so that the parent feels like they are DOING something BUT they do NOT have to go to the extreme. 
  • IMPORTANT POINT: TIMING IS EVERYTHING WHEN DEALING WITH A CHILD’S MISBEHAVIOR – that is if you delay, stall, natter, nag, remind, threaten, yell, scream and then 30 minutes AFTER the misbehavior has started is when you FINALLY decide to do something  (such as put your child in time out) IT IS TOO LATE. 30 MINUTES is FAR TOO LONG. Research shows that if you WANT to control a CHILD’s behavior Your reaction MUST occur within 5 to 10 SECONDS and if you are DELAYING that reaction – if the consequences are being POST-PONED then that is where your problem is coming in. 
  • YELLING is NOT a consequence – THREATENING is NOT a consequence – it is HOT AIR 
  • Parents NEED to understand that yelling and screaming and arguing are NOT consequences for children – Parents have to STEP in and either remove these points or privileges OR institute time out – BUT it HAS to be done within 5 to 10 SECONDS – THE LONGER YOU DELAY THE LESS CONTROL YOU HAVE 
  • Parents delay because they want to be REASONABLE, they want to give THIRD & FOurtH CHANCES, they don’t necessarily want to discipline their child  – there are MANY REASONS for STALLING – BUT the STALLING is HURTING YOU (Parents) – it is your own worse enemy 
  • Just Remember – Timing is EVERYTHING – and the quicker you react – With a Consequence  – the better the CONTROL you are going to have over the child’s behavior 
  • Often times Parents are BURNT out but that is because they have LET IT GO ON for TOO LONG and then they have LOST CONTROL OF THE INTERACTION
  • With the Chip System – it gives parents something SPECIFIC to do – “You did not take the dishes to the sink – that is part of the rule – I have one of your tokens.” This way parents don’t have to go into the screaming and yelling  – Parents have been able “to do something” 

There are TWO other Consequences that need to be mentioned. Although the TOKEN system works VERY well for most children – it is NOT enough to REDUCE ALL THIS BEHAVIOR  —> Some misbehavior is WELL ENTRENCHED and that is when you get into TARGETED TIME OUT and the reason it is called TARGETED is because it is ONLY going to be used for ONE or TWO rule violations during the FIRST week it is introduced – Parents DON’t get to use time out for everything that they may have been doing previously  – Parents ONLY identify ONE or TWO problems and USE time out ONLY for those things  – THIS IS IMPORTANT – because if parents use time out excessively they RUIN it! 

The second thing that has be emphasized with TIME OUTS is that it is QUICK  – “SWIFT JUSTICE” – If you are going to TIME a child out – it is going to have to be done in 5 to 10 seconds of the FIRST infraction  – DON’T let it go on and on and on  – because THAT is why a time out may NOT be working  – some parents say “oh I tried time out and it doesn’t work for me” — it is because that parent waited 15 minutes before they finally timed their child out and of course now it is not going to work. 

What makes punishment work – like time out – ARE TWO things to keep in mind:

  1. THE SPEED WITH WHICH YOU DO IT “SWIFT JUSTICE” works – It is NOT how painful the punishment is  – it’s how quickly you do it AND here is the second piece —>
  2. HOW MUCH reinforcement or reward is available in that family for doing the right thing  – In families where the rewards have been PUSHED up – The approval, the praise, the affection, the token system, the points, the privileges –  When there is a sufficient level of those around  – to reward a child for doing WELL and doing the right thing – THEN PUNISHMENT works – BUT if there is VERY LITTLE reinforcement in the family for what the child is doing well – then you could punish this child FOREVER and it is NOT going to change their behavior 

*** So the Trick to punishment is make sure there is an adequate amount of reward, attention and affection when good things are done and then when you have to time out do it VERY QUICKLY – DO NOT LET IT ESCALATE and then it will work 

*** But often times TIME OUT becomes another area for DEFIANCE – the child will say “Nope not going to the time out chair” and they won’t do it – what do parents do then?? 

Answer: Well often times the child may have to be physically escorted to the time out location – whether its taking them by the shoulder or grabbing hold of their shirt collar or their belt loops in the back (not talking about grabbing an ear or pulling hair!!!) – you may have to physically escort the child to the time out area and if that is what you have to do then that is what you have to do. 

*** Sometimes the child may go to time out but there is a lot of yelling and screaming and whining  – Parents need to IGNORE that as long as the child STAYS in time out  – all the rest is just window dressing – forget about it – DON’T take the BAIT  – don’t ENGAGE the child – as long as the child is staying there in time out – that is okay 

What do Parents do if the child LEAVES the time out location? Before the child has served their penalty? This is when parents should Back Out time out with ISOLATION to the bedroom  – in other words go to the child’s bedroom – make sure there is VERY little toys in there – SANITIZE the bedroom of privileges before you do this and then if the child has trouble staying in time out then they are going to have to go into their bedroom and if necessary the parents will close and HOLD the door shut in order to ENFORCE the time out ** This is the BACK UP when all else fails and the child will NOT remain in TIME OUT – then we use this ISOLATION to the bedroom  – it is called BARRIER RESTRAINT  – that is you are using the DOOR as a barrier to restrain the child from leaving time out  – DON’T try to hold the child in time out, in a time out chair – DON’T try to physically restrain them  – most parents are VERY POOR at doing so  – instead use the bedroom and the closed door as the barrier and then that imposes the restraint on the child  – Often times you do not need to go to this level BUT with more SEVERELY oppositional children YOU DO (more details about this in the book “The Defiant Child”)

Posted in Behavior, For Nurses, Health, Pediatric Nursing, Self Care, Therapy

Hunger Index – to teach kids


Review with your child. Ask your child before and after a meal to tell you where they are at. 

Before Eating


– 1 = A little bit hungry: I’d like to eat, but I’d be comfortable waiting a while before eating.

-2 = Quite Hungry: I want to eat something now.. a snack or a light meal.

-3 = Very Hungry: I want to eat something “hearty” now.

-4 = Extremely Hungry: I feel ravenous, like I absolutely have to eat something right now. I am starting to get shaky, possibly sweaty, possibly nervous, and beginning to lose concentration. 

After Eating

+4 = Over-Satisfied: I have eaten more than my body wants and I feel uncomfortable!

+3 = Completely Satisfied: My body is relaxed and comfortable. If I ate any more, I would be too full. 

+2 = Just Satisfied: My body is relaxed and comfortable. I don’t need any more food, but if I had a small amount more, I’d still feel comfortable. 

+1 = Un-Satisfied: I ate some food, but it wasn’t wait enough and I’m still a bit hungry. I would like to eat something else now. 

Posted in Emotions, For Nurses, Health, Pediatric Nursing, Therapy

Bed Wetting Treatment

Information from Dr. Bettina Shapiro, North Carolina University


How does a bedwetting alarm work?

A bedwetting (enuresis) alarm is a device that emits an auditory and/or tactile sensation in response to moisture. The alarm is attached to a child’s underwear or pajamas in the area where the first drop of urine would be expelled. When the child wets, the alarm goes off and alerts those in range that wetting is occurring. The child hears or feels the alarm and learns to get out of bed and empty urine into the toilet. Gradually, the child learns to respond to the feeling of a full bladder by waking and going to the bathroom before the alarm goes off. Alarm training is a type of behavioral conditioning.

The average length of treatment is 2-6 months. If the child has VERY deep sleep, it can take LONGER. Requires the purchase of an alarm/sensor system. 

Get an alarm/sensor that goes into the child’s underwear. It is wireless (meaning no cords!). The sensor goes into a pad, then the pad goes inside the underpants. Cost is between $45-$100 online. Some alarms have sounds AND lights. Some only have alarms (the noise).

Treatment must be done EVERY night. This is an ALL or NOTHING treatment. 

Do NOT start treatment until the family is MOTIVATED and READY to start and do it EVERY night. This is a PARENT FOCUSED program. 

Do NOT reward the child for staying dry. Do NOT punish the child for wetting. What you are REWARDING is treatment COMPLIANCE. This means: they are wearing the sensor to bed and they are getting up (with or without parents help) to use the bathroom AS SOON AS the alarm makes noise. Non-compliance would be: “I don’t want to get up.” or “I don’t want to put the sensor back on.”  ***Reward child at the end of the week for COMPLIANCE

Put the alarm by the child’s head.

If the child is in deep sleep, they may not wake up even with the alarm. The parent may need to sleep nearby and immediately take the child to the bathroom when they hear the alarm. Parent must jump up immediately and run the child to the bathroom. 

In the beginning the alarm often rings 3-5 times a night. After a while, the frequency will decrease. 

Keep a record of all this on a chart.

Even with the alarm, continue having the child wear pull-ups so that sheets do not need to be changed. Or, use a rubber bed pad. 

The child must be fully awake when they are taken to the bathroom. If the child is still asleep, it actually continues the bed wetting problem. 

Each night that the child complies with the plan, he gets a sticker. At the end of the week, if he has enough stickers, he gets a reward. 


Things NOT to do:

  • Fluid restriction. Do not do this. You want the bladder reasonably full, so process will work. Do not stop liquids early in the evening.
  • Do not take the child to the bathroom while the child is still asleep.
  • Do not punish the child for wetting.
  • Do not reward the child for staying dry.

What is considered Treatment Success?

“Success” is 14 consecutive nights of dryness.

Then you can discontinue treatment. 

If there is a relapse, it’s no big deal (this is fairly normal). If child starts to wet the bed again, go back to the treatment process. After 14 days of dryness, keep monitoring for 16 weeks (have the child wear the sensor for 16 weeks). 

List of Products Available

When deciding on a bedwetting alarm, look at how the alarm is placed. Does it fasten to any pair of underwear, or does it come with its own specialized underwear? Some children like using their own briefs while others prefer those with a built-in sensor, where placement is never a problem. A pad type alarm is an option for those who prefer to lie on the sensor rather than to wear it.

Methods of stopping the alarm after triggering can vary. Some alarms require a two-step turn-off in which the sensor is removed from wetness before the reset button is pressed.Wireless alarms require wearers to get out of bed to turn the alarm unit off, which works well for heavy sleepers. Sound comes from a unit clipped to the shoulder in wearable alarms. In wireless and bedside alarms, it comes from a separate unit set away from the sleeper. Most users prefer to have the sound close to the ear, but some like the option of hearing the sound from a distance.

  1. Rodger Wireless Bed Wetting Alarm new-alarm-red-double $129.95 (Dual receiver available – parents can keep one of the receivers in their bedroom)

2. Malem Wireless Bed Wetting Alarm new-malem-wireless_1$139 (Easy Clip on sensor – Dual receiver is an option – Receiver can be placed up to 50 feet from sensor) 

3. Malem Ultimate Bed Wetting Alarm J-M04CN-BI-01.jpg $99.95 (The alarm sounds continuously until the sensor is removed. No mini-pads to buy and attach each night! does NOT offer dual receiver.)

Link to a Chart That Compares Different bedwetting alarm system products: Here

Bed Wetting-P&C Valor Cypress.jpg

Source: Cottage Counseling, Lakewood Ranch FL & NeuroPsych Associates, Sarasota FL

Posted in Emotions, For Nurses, Parent-Child Bonding, Pediatric Nursing, Positive Parenting, Relationships, School, Social Skills, Therapy

Behavior Management Strategies

Behavior Management Strategies – Attending to Desirable Behaviors 

Developing an alliance 

One of the most POWERFUL tools that parents have is our ATTENTION – it is the most meaningful and least expensive tool that we have! A child will work VERY hard to get attention for an adult (that includes both POSITIVE and NEGATIVE attention). 

*** If ANY type of attention follows a behavior, THAT behavior is more likely to occur again, so Parents – use your attention WISELY! **

Special Time heals the upsets and disconnections of daily modern life. We live in a stressful culture that disconnects us from each other, from our feelings, and from our own inner wisdom. Special Time is the antidote for parents and children, because it:

  • Reconnects us with our child after the separations and struggles of everyday life, so she’s happier and more cooperative.
  • Gives the child the essential–but unfortunately so often elusive–experience of the parent’s full, attentive, loving presence.
  • Gives the child a safe place to play out the everyday issues that all kids need to work through, such as feeling powerless, by reversing the roles and letting the child lead.
  • GIves the child a regular opportunity to express scary feelings and ideas to a compassionate, trusted adult who will listen and help her work them through using her own natural language: Play.
  • Deepens our empathy for our child so we can stay more compassionate and see things from his point of view, which strengthens the connection and our parenting.
  • Builds a foundation of trust and partnership between parent and child which is a precondition for him to trust us with his big feelings when he’s upset (as opposed to him lashing out.)
  • Convinces the child on a primal level that she is central to the parent, that she really matters, that she is important. (You know she is, but often she doesn’t.)

Every child benefits from Special Time to reconnect with each parent on a regular basis. How often? At the risk of sounding like your dentist telling you to floss, every day would be fantastic — but once a week is substantially better than never!

Think of Special Time as preventive maintenance to keep things on track in your family. And if you’re having issues with your child, it’s the first thing to change.  Often, it’s the only thing you need to change.

How do you do it? Ten tips.

1. Announce that you want to have special time with each child for ten minutes a day, as often as you can.  Call it by the most special name there is — your child’s name. So in your house it might be Talia time and Michael time.

2. Choose a time when any other children are being looked after by someone else (unless they are old enough to stay occupied with something.) If you have more than one child, you’ll want to set up a schedule so all siblings know their special time is coming soon. One good strategy for siblings as you do time with one child is books-on-audio, which absorbs their attention enough to keep them from noticing you laughing with their sibling. (Headphones are essential, and if they need something to do with their hands, give them drawing materials to illustrate as they listen. Great for brain development!)

3. Set a timer for ten minutes. Turn off all phones so you can’t hear incoming calls. Is ten minutes long enough? I suggest starting with ten minutes because it will seem like an eternity if you aren’t used to being fully present in the moment with another person. Don’t worry, it gets easier, and you do start to enjoy it!

4. Decide if you will also have other time most days to roughhouse with your child to get her laughing. If so, then Special Time is all your child’s to use as she sees fit. If not — let’s say you work outside the home and have limited time with your child — then you do need to reserve some time for roughhousing. In that case, I recommend that you alternate days. The first day, your child decides how to use the time. The next day, you decide, and you always choose roughhousing/laughter.

5. Say “I am all yours for the next ten minutes. The only things we can’t do are read or use screens. This time is just to play. What would you like to do?” or, if you are including roughhousing in special time, add “Today you get to decide what we will do with our ‘Jonah time.’  Tomorrow, I get to decide.  We’ll alternate.”

6. Give your child 110% of your attention with no agenda and no distractions.  Just connect to your child with all your heart.  Really notice your child, and follow his lead. If he wants to play with his blocks, don’t rush in to tell him how to build the tower.  Instead, watch with every bit of your attention. Occasionally, say what you see without interfering:  “You are making that tower even taller….you are standing on your tiptoes to get that block up there…”

If she wants you to pull her in a circle on her skates until she falls down, over and over, resist “teaching” her to skate, consider it your workout for the day, and make it fun: “For special time, my daughter took us out into the cul-de-sac to roller skate. I pulled her in a circle round and round so hard and she laughed and laughed until she fell on the ground. She kept coming back for more. After all this laughing, we had a great night!” – Christine

Resist the urge to judge or evaluate your child. Don’t take control or suggest your own ideas unless he asks.  Refrain from checking your phone.  Just show up and give your child the tremendous gift of being seen and acknowledged. (If you’ve ever really been seen and appreciated, you know just how great a gift this is.) Your child may not be able to articulate it, but he will know when you’re really being present with him. Kids sense our presence and they “follow” it like a magnet.

7. If she wants to do something that she isn’t usually allowed to do, consider whether there’s a way to do it safely since you are there to help her.  Maybe you always tell her that it’s too dangerous to jump off the dresser onto the bed, but for special time you can push the bed next to the dresser and stay with her as she jumps to be sure she’s safe.  Maybe he has always wanted to play with his dad’s shaving cream but you weren’t about to let him waste a can of it, or to clean it up.  For special time, you might decide to gift him with his own can of cheap shaving cream and let him play with it in the tub, and then the two of you can clean it up together.  If you can’t grant her desire (go to Hawaii), find a way to approximate it (make grass skirts and play hula dancing together.)

Why bother?  Your child learns that you really do care about his desires, even if you can’t always give him what he wants (so he’s less likely to feel like he never gets his way, and more likely to cooperate in general.)  And since these desires will no longer be forbidden fruit after your child has a chance to indulge her curiosity and experience them, she’s less likely to try them behind your back.

8. When it’s your day to decide what to do, initiate games for laughter, emotional intelligence and bonding.That usually means roughhousing in a way that gets your child giggling.  I know, it sounds like too much energy. But it’s only for ten minutes, and it will energize you, too.  I promise.  Favorite themes include:

  • Power (“You can’t get away from me!  Hey, where’d you go?  You’re too fast for me!”)
  • Rebellion, control and breaking the rules (“Whatever you do, don’t get off the couch! Oh, no, now I have to give you 20 kisses! Where do you want them?”)
  • Mock aggression (Pillow fights)
  • Separation and reunion (Peekaboo, Hide ‘n Seek, The Bye Bye Game, “No, don’t leave me!”)
  • Fear (“I’m the scary monster coming to get you…Oh, I tripped… Now, where did you go?  EEK! You scared ME!”)  Be just scary enough to get your child giggling, not scary enough to scare him.

You might also tackle a specific issue that your child is struggling to master, by, for instance, playing school. Let him be the teacher and assign you tons of homework and embarrass you when you don’t know the answer.  Or play basketball and let her dominate the court.

In all these games, the parent bumbles ineffectually, blusters and hams it up, but just can’t catch the strong, fast, smart child who always beats us. The goal is giggling, which releases the same anxieties that are offloaded with tears, so whatever gets your child giggling, do more of that! A great source of ideas for games is Dr. Lawrence Cohen’s book Playful Parenting, which has inspired many of the games I suggest. Here are some links with more ideas:

Games for Bonding and Emotional Intelligence

Let’s Get Physical — Games to Connect with Your Child

More Games to Transform Tears to Laughter

9. Don’t structure Special Time. I used to call this “quality time,” but that often confused parents. After all, reading to kids, or baking cookies with them — aren’t those activities quality time? Yes, indeed, and they’re wonderful things to do with your child. But they aren’t Special Time. So no screens, no books, no structured activities. Instead, show up and connect!

10. End Special Time when the timer buzzes.  If your child has a meltdown, handle it with the same compassionate empathy with which you would greet any other meltdown (“It’s so hard to stop…you can cry as much as you want, Sweetie…I am right here“) and give him your full attention in his meltdown.  But don’t think of that as extending special time, just as you would not give your child anything else he has a tantrum about, like an extra cookie. Special time needs boundaries around it to signal that the rules aren’t the same as in regular life.

11. Be aware that often your child’s emotions will bubble up during special time, especially at the end.  That doesn’t mean she’s a bottomless pit.  It means she feels safer with you after this time together, so all those feelings she’s been lugging around are now coming up to be processed.  Or it means that letting go of you brings up all those feelings of how hard it is to share you. Often kids use this time to express their upsets, so it’s good to schedule a little cushion at the end in case your child has a meltdown, especially when you’re just starting out, or when your child has been having a hard time.  When the meltdown begins, just empathize, and give yourself a pat on the back for being the kind of parent your child trusts enough to express all these big feelings.  Once she cries, those feelings will dissipate, and she’ll feel so much better–and so much more connected to you.

What’s so special about special time?  It transforms our relationship with our child.  And since that relationship is 90% of our parenting, you can’t get more special than that!

Click here to watch Dr. Laura’s video “Making ‘Special-Time’ Effective.”

Special Time:

To increase your child’s GOOD and OKAY behavior, it is important to pay attention to that behavior when it is happening. This takes PRACTICE, which we call Special Time. Special time involves setting aside approximately 15 minutes (though any amount of time is good) a day with the child and letting the child DECIDE what they want to do with this time (play a game with you, play alone with toys, etc – it is DISCOURAGED to spend this time watching TV and playing video games). Your job is to FOCUS on the child and their activity. Show the child you are ATTENDING by being on their eye level (sit on the floor), watching INTENTLY, and COMMENTING aloud about their actions. Try to be an ENTHUSIASTIC commentator! Pretend you are describing the child’s actions to someone who can’t see what is happening (“WOW, you’re building with Blocks. Now you are making the cars move. I like watching you play!”) During Special Time, DO NOT: 1) Ask Questions, 2) Give Instructions, or 3) Guide the Child’s behavior. 

Throughout the day, watch the child and comment about what the child is doing well. Catch the child being good. Find things that are good or okay about what they are doing and comment on those things. 


ATTENDING not only increases good behavior, it also shows the child that you are interested in what they do and it builds a better relationship between you. You want to be on the same “TEAM” working together. 

Rules of Thumb: 

  • PAY ATTENTION to your child when they are behaving APPROPRIATELY. This increases the chances of GOOD behavior in the future.
  • Catch the child being GOOD – don’t save attention for PERFECT behavior.
  • Follow the child’s LEAD during Special Time. Be an ATTENTIVE and APPRECIATIVE audience. 
  • Use descriptive comments during special time rather than asking questions or giving instructions. 
  • If you pay attention to “bad” behaviors such as whining or screaming, they will occur more often in the future. 


Descriptive commenting is talking about what the child is doing as they’re doing it.(This technique is a way to communicate with children to show you care, to share in your enjoyment of the child’s activity, to increase/extend play, and to reinforce the child’s positive actions.) 

 It conveys in descriptive language what the child is seeing, touching, feeling, hearing, smelling, or tasting.

When you narrate during a child’s play, you are putting the child’s actions into words and describing the actions in a running commentary. It’s like a play by play coverage of an event. It gives the child the appropriate language for her actions and teaches concepts without being intrusive about it. 

Descriptive commenting, which play and speech therapists use, may feel artificial and uncomfortable at first. It’s not the kind of communication you would use with another adult. You are facilitating the child’s language development. The child will imitate you, and with the pressure off to answer questions, children often come forward and talk more. It’s teaching in a non-threatening way. Children often give you lots more information with this technique. They surprise you with how much they know. Then you can reinforce them. It’s a different way of helping children learn. It goes something like this: “You’re putting a blue block on top of a yellow block. Now a green block is going on top of the blue one. You’ve got three blocks on top of each other. There goes a red one on top of the green one. This is getting tall!”

You are giving the child your undivided attention and the descriptive vocabulary for what he/she is doing at the exact moment he’s/she’s doing it. It tells the child that what she/he is doing is of value and is important to you. This makes a tremendous difference in a child’s self-esteem and self-confidence. It also increases their attention span and creativity.


Some Guidelines on Descriptive Commenting:

  • Watch your pace. If you talk too much or too fast, a child may react by saying, “Why are you  talking like that?” (If that happens, you can answer, “Because I’m interested in what you’re doing.”) Be sure to comment only on the positive. When you attend and comment on the appropriate behavior, it will increase. When you attend and comment on the negative, it will increase. (So avoid describing negative behaviors like, “Now you’re throwing the cars.”)
  • When you first begin descriptive commenting, it’s easy to mix it with praise, such as, “I like   the way your cars are all lined up.” Or, “What a nice tower!” Instead, just describe what you see. “Your cars are all lined up in a row.” “You have built a tall tower!”
  •  Don’t interpret your child’s play with comments like, “I like the butterfly you made.” This can  get you into hot water with the child. It may not be a butterfly! First, the child may say, “That’s not a butterfly!” Or, the child, feeling that you must know everything, withdraws thinking, “It must be a butterfly!”
  • When you are making descriptive comments stay focused on the child’s play and try to stay  away from irrelevant comments. For example, “You’re putting the cow in the barn. Here comes the farmer. Here comes the duck. Hmmm, I wonder where I put my scissors.”
  • Avoid needless corrections and rules such as, “Remember that trains need to ride on the   tracks,” or “Doll beds belong in the bedroom.” Save your rules for things that really matter. In the creative world of a child, doll beds can become boats in the water or trains can become airplanes and fly. Needless rules and excessive corrections will eventually make the child wary of exploring and experimenting.


Giving Effective Directions

When you as your child to do something, your direction needs to be CLEAR. 

Advice for giving GOOD directions:

  1. Ensure you have your child’s attention and eye contact BEFORE giving the direction.
  2. Use a FIRM (not LOUD) voice.
  3. Use a direction that is specific and simple to understand.
  4. Use physical gestures such as pointing along with your verbal directions. 
  5. Use positive directions (“do this”) rather than negative directions (“don’t do this”). For example say “Stay by my side” father than “Don’t run down the aisle. “Positive directions give a child a good understanding of what he/she is supposed to do and give you an opportunity to reward the child for following your directions. 
  6. Pay attention to and reward your child if they follow your direction.
  7. Only give directions that you are prepared to enforce. 

Directions you should AVOID:

  1. Chain directions – giving several directions at one time (“get dressed, brush your teeth, comb your hair, and go to the car”) A child’s brain cannot process that much information. It is better to break directions down into small, individual steps and then to praise for completion of each one. 
  2. Vague Directions – directions tat are not clear or specific. (“be good” may mean different things to you and the child.) It is much better to be clear about what you want (“keep your hands in your lap.”)
  3. Question Directions – directions given in the form of a question (“are you ready to clean your room?”) Asking question directions opens the door for the child to say “no.” If you are not offering a true choice, don’t ask a question.
  4. Directions followed by a reason – giving a direction and following it with an explanation (“wash your hands because it is time for dinner and you have been playing in the dirt.”) This type o direction offers too much information for a child to process and the child may not remember the actual instruction. If you choose to give an explanation give it before the direction (“It’s time for dinner and your hands are dirty, so go wash your hands.”) The direction should be the last thing you say. 

Rules of Thumb:

  • Use simple and clear positive directions.
  • Praise the child when he/she follows a direction.
  • Only give directions you are prepared to enforce. 


Rewards, like ATTENTION, will increase behavior. Any behavior (good or bad) that is followed by a reward is more likely to occur again.

Types of Rewards:

Social Rewards:

  • Physical Rewards – hugs, kisses, pat on the back, high five, etc.
  • Verbal Rewards – praise (“I like it when you…” or “Thank you for…”)
  • Activity Rewards: things you do with your child that the CHILD likes (playing a game, reading a story, making something together etc.)

Nonsocial Rewards: include things such as money, toys, food, stickers, etc. These must be things that the CHILD likes. ALWAYS combine nonsocial rewards with social rewards such as praise. 



Rules of Thumb:

  • Rewards that occur immediately after a behavior are most effective.
  • Always tell the child what he/she did that you liked (“I like it when you pick up your toys the first time I ask you to.”)
  • Use eye contact, smiles, and enthusiasm when you give praise.
  • Social rewards can be used anytime. Nonsocial rewards are helpful when you want to CHANGE a behavior and then can be faded out. 



Ignoring is the opposite of paying attention. It is actually the removal of all of your attention from the child. Ignoring is best used for MILD behavior problems such as winning, crying, begging, demanding attention, and tantrums.

When you are ignoring, DO NOT

  1. Make physical contact with the child (subtly put some distance between you).
  2. Talk or comment to the child.
  3. Make eye contact with the child.

Remember, paying attention to “bad” behavior will only make it worse. Once you begin ignoring a certain behavior, you MUST keep ignoring until the behavior stops. When it stops, lavish attention on the child for appropriate behavior. It is VERY important not to give in after you have begun ignoring because that teaches the child that he/she just needs to outlast you.

It is important to know that when you begin ignoring negative behavior, you may initially see an increase in this behavior as the child tries to figure out how much it will take from him/her to get a reaction from you. If you hold on and continue to consistently ignore, the behavior will eventually disappear. 

Rules of Thumb:

  • Ignoring the behavior will help it go away, but you must be consistent and must “outlast” the child.
  • When you first begin ignoring a behavior, it may initially increase in frequency and intensity. If you continue to ignore it, the behavior should go away.
  • It can be helpful to give the child a “heads up” before you start an ignoring program (“I will not listen to you when you are having a tantrum.”)


Time-out means time-out from ANYTHING reinforcing (attention, rewards, favored activities, etc). It is used for behaviors that cannot be ignored such as aggression, destruction of property, dangerous behavior, and non-compliance (not following a direction after one warning). 

There are many approaches to time-out. The one described here is one that has been researched for many years. Before you implement any time-out program, it is important that you and your child both understand: 1) what specific behavior time-outs are used for, 2) where time-out will occur, 3) what the rules and steps are for time-out, and 4) that time-out will occur every time the behavior occurs.


Choosing a time-out place

  1. Choose a place away from toys, people, windows, TV, radio, and all that the child likes.
  2. Your child’s bedroom is typically not optimal. If it is the only option, all toys should be removed.
  3. Do NOT use a dark or scary room (closet). Time-outs should be boring, not scary.
  4. The end of a hallway is often a good option.
  5. It may be helpful to put a small chair in the time-out place.

Steps for an effective time-out:

  1. Tell the child, “Because you did ______, you have a time out.” Say this only once in a calm, firm voice. (do not lecture, scold or argue, accept any excuses, or talk to the child while walking him/her to the chair.” 
  2. If the child refuses to go, lad him/her by the hand.
  3. Tell the child to stay in the chair until you say he/she can get up. It can be very helpful to set a timer that can be kept within the chid’s view. You do not have to start the timer until the child is sitting relatively calmly in the chair.
  4. Do not let anyone talk to him/her while in the chair and do not let the child play with anything while in the chair. Ignore whining, etc. while in the chair. Do not let the child leave the chair (to use the bathroom, get a tissue etc.) during time-out.
  5. After time has elapsed (one minute for every year of age up to five minutes) tell the child he/she can get up. People have different standards for completion of time-out. One food rule of thumb is that the child cannot be screaming or aggressive for at least the last 30 seconds of time-out before being let out. Alternately, you can start the timer over when the child becomes disruptive in time-out. 
  6. If the child was sent to time-out for not following direction, re-give the initial direction following the time-out. The child MUST follow the direction with no more than one warning or should go back to time-out. If the child follows the direction, praise for following direction (in a relatively neutral voice) and praise the next positive thing the child does. 

Rules of Thumb:

  • Use time-out for dangerous behaviors and not following directions after one warning.
  • Let the child know what types of behaviors result in time-out.
  • Use time-out immediately after the behavior.
  • Do to give any attention to the child while he/she is in time out.
  • Only “threaten” time-out if you are willing to follow through with it and use it. 

Other Effective Punishments 

Natural Consequences: occur when you allow the child to experience the consequences that normally/naturally follows their actions. Examples of this include: Handling the car roughly and the car scratching the child; Not bringing toys inside, having them ruined by the rain and not replaced; Teasing other children and being avoided by them; Refusing to wear a coat and being cold. Obviously, there are times when it is not safe to allow the natural consequence to occur; for example, you cannot allow you child to suffer the natural consequences of riding a bike into a busy street. 


Logical Consequences: occur when you make a child’s punishment logically/sensibly follow from the nature of the bad behavior. Examples of this include: Riding bike into street and not being allowed to ride bike for a week because he/she could not ride it responsibly; Refusing repeatedly to care for a pet and having the pet placed in another home; Carelessly spilling a drink on the sofa and having to drink only in the dinning room or kitchen. 


Response Cost: is also known as Behavior Penalty. This is where there is  a penalty for doing a particular bad behavior. The penalty is not logically related to the behavior but is rather adding or taking away something that will effect the child. Chose a penalty that will be a punishment for that particular child. Penalties might include losing privileges (TV time, play-time, special events, any other activity enjoyed), adding extra chores, or fining the child monetarily. Examples of this include: swearing and being fined 25 cents; Fighting with sibling and loosing bike for two days; Lying to parents and having to clean the bathrooms. 

Rules of Thumb:

  • Look for the mildest punishment that stops the behavior.
  • Allow the natural consequences to occur if it is not dangerous and there is one available. 
  • If it is not possible to allow a natural consequence or the consequence does not stop the behavior, try a logical consequence. Make sure that there is a clear logical connection between the behavior and the consequence. Highlight the logic to the child. 
  • If neither natural nor logical consequences are feasible, try a response cost. Make sure that you have assigned a specific penalty ahead of time for a specific behavior. Tell the child about it. 

Positive Self Talk is VERY important 




Source: MedPsych in Lakewood Ranch FL

Posted in Behavior, For Nurses, Health, Pediatric Nursing, Therapy

ADHD or “Quick Brain” and Trauma in Kids

Thoughts From A Pediatric Psychiatrist 

Some Health Professionals believe that Attention Deficit Disorder (ADHD) is misleading in itself – they believe a better name for ADHD would be — QUICK BRAIN.

  • ODD (oppositional defiant disorder) typically goes along with ADHD
  • Low Frustration is also a typical symptom of those diagnosed with ADHD 
    • Child becomes Easily frustrated when you TAKE away the video game
    • Child becomes Easily frustrated when it is TIME for bed
  • Another common finding in kids with ADHD — they are ANGRY but also HEARTBROKEN
  • Quick Reactions to Emotions is another common trait in those with ADHD

“ADHD is an Explanation NOT an Excuse.” 


  • LACK of CONTROL of Attention
  • Under Attend to things OTHERS want you to focus on and Over Attend to things YOU want to do.
    • If a child likes Legos – they will be very focused while building legos. 
    • Same Child shows no focus during math class. 
  • AVOIDANCE– like behaviors or OVER Attending like behaviors?? 
    • A child is brought by a parent to psychiatrist intake – the child is in the waiting room reading a book of interest. When it is time to walk into the psychiatrists office the child has a hard time breaking focus from their book. *This could either be an avoidant behaviors (reading the book in waiting area not wanting to visit psychiatrist) or a over attending behavior of being super focused into a book of interest. 
  • THINKING about the WRONG thing. 
    • During Science class the child is thinking about baseball. 
  • All Brains are UNIQUE
  • No Brains are good at Everything!
  • ADHD Brain is Good At: 
    • Creativity
    • Innovation
    • Athletic
  • ADHD Brain Not very Good At:
    • Organizing
    • Planning
    • Categorizing Stuff
    • Memorizing (ADHD child may be the last one to learn the names of all the states)
    • SLOW things
  • QUICK BRAINS: If their brains get BORED they start looking for things that are EXCITING —> child starts to MOVE around, CHAT with others etc. This happens because they Can’t be excited when doing something boring! 
    • Sometimes an ADHD child does better if allowed to MOVE around, Doodle etc. (sitting on a yoga ball, given fidgets etc.)
  • QUICK BRAINS have a TOUGH time doing SLOW STEADY work every day. 
  • QUICK BRAINS have trouble regulating EXCITABILITY (too much sound or sight) – This is part of the EMOTIONAL problem. REGULATING EMOTION is hard. 

Kids with ADHD & Trauma

Kids Who have experienced trauma are set up for diagnosis of – But it does not mean they automatically should have a diagnosis of Depression and/or anxiety. Your psychiatrist should not be QUICK to diagnose and label your child with such diagnosis on the first visit. Try starting ADHD medication – See what happens with the medication – see what moves forward and what lags behind – whatever is found to lag behind would be a secondary diagnosis. 

  • Depression
  • Anxiety 

Kids who have ADHD diagnosis and have experienced trauma sometimes STRUGGLE with WILLFULNESS. It happens that when these kids are given EXCESSIVE SUPPORT  it can EMPOWER these kid – kids will actually feel empowered. The result is that the average demand is not being met when in reality these kids are 10% smarter than the average. We need to assume that these kids are capable and bright. OVERDOSE OF EMPATHY .

Starting Medication for ADHD

Use the Sequential checklist – Emotional/Behavior NICHQ Vanderbilt Assessment Scale for both Parent and Teacher **If you are going to ask a teacher to fill this out make sure that you TRSUT this individual. 

The NICHQ Vanderbilt Assessment Scales were developed through the Attention Deficit Hyperactivity Disorder (ADHD) Learning Collaborative project. This resource is used by healthcare professionals to help diagnose ADHD in children between the ages of 6 and 12. 

  • Total number of items scored 2 or 3 in items 1-9: _____  (ADHD, predominantly inattentive type—6 or more symptoms)
  • Total number of items scored 2 or 3 in items 10-18:_____  (ADHD, predominantly hyperactive-impulsive type—6 or more symptoms                                                                               
  • Total number of items scored 2 or 3 for items 1-18:_____  (ADHD, combined type—6 or more symptoms of both types)
  • Total number of items scored 2 or 3 in items 19-26:_____  (oppositional defiant disorder screen—4 or more symptoms)
  • Total number of items scored 2 or 3 in items 27-40:_____  (conduct disorder screen—3 or more symptoms)
  • Total number of items scored 2 or 3 in items 41-47:_____  (anxiety/depression screen—3 or more symptoms)

Older Child:

  • 1-9 = 8 — (ADHD predominantly inattentive type—6 or more symptoms)
  • 10-18 = 4(ADHD, predominantly hyperactive-impulsive type—6 or more symptoms)               
  • 1-18 = 12 — 10 (ADHD, combined type—6 or more symptoms of both types)
  • 19-26= 2 or 3 —(oppositional defiant disorder screen—4 or more symptoms)
  • 27-40 = 1 (contains forced sexual question) — 1 (conduct disorder screen—3 or more symptoms)
  • 41-47 = 4 — 4 (anxiety/depression screen—3 or more symptoms)
  • Diagnosis: ADHD, combined type – anxiety/depression OR  ADHD, combined type – oppositional defiant disorder – anxiety/depression

Younger Child:

  • 1-9 =  3 — (ADHD predominantly inattentive type—6 or more symptoms)
  • 10-18 = 8 — (ADHD, predominantly hyperactive-impulsive type—6 or more symptoms)  
  • 1-18 = 11 — 12 (ADHD, combined type—6 or more symptoms of both types)
  • 19-26= 8 — (oppositional defiant disorder screen—4 or more symptoms)
  • 27-40 = 3 (sexual force & property destruction on purpose) —(conduct disorder screen—3 or more symptoms)
  • 41-47 = 6 — (anxiety/depression screen—3 or more symptoms)
  • Diagnosis: anxiety/depression – conduct disorder –  ADHD, combined type – oppositional defiant disorder – OR anxiety/depression – oppositional defiant disorder – ADHD, combined type

The Difference Between ODD and Conduct Disorder: Article by Empowering Parents

ODD is characterized by a child or teenager who fights against authority figures, such as parents and teachers. Kids with ODD often lose their tempers, argue, resist rules and discipline, refuse to comply with directions and in general have a low frustration tolerance. The defining characteristic is a fight against being controlled. 

Conduct Disorder is used to describe an older child or adolescent who has moved into a pattern of violating the rights of others: intimidation or aggression toward people or animals, stealing or the deliberate destruction of property. The DSM-5, a diagnostic handbook used by mental health professionals, describes these individuals as having “a callous and unemotional interpersonal style.” It means a lack of empathy—not understanding or caring about how their behavior may physically or emotionally hurt others.

A key difference between ODD and conduct disorder lies in the role of control. Kids who are oppositional or defiant will fight against being controlled. Kids who have begun to move—or have already moved—into conduct disorder will fight not only against being controlled, but will attempt to control others as well. This may be reflected by “conning” or manipulating others to do what they want, taking things that don’t belong to them simply because “I want it,” or using aggression or physical intimidation to control a situation. 

Scoring Instructions for the Vanderbilt Assessment Scale—Parent Informant: The Vanderbilt Assessment Scale has two components: symptom assessment and impairment of performance. 

For the ADHD screen, the symptoms assessment component screens for symptoms that meet the criteria for both inattentive (items 1-9) and hyperactive-impulsive ADHD (items 10-18). To meet DSM-IV criteria for the diagnosis of ADHD, one must have at least 6 responses of “Often” or “Very Often” (scored 2 or 3) to either the 9 inattentive or 9 hyperactive-impulsive items, or both and a score of 4 or 5 on any of the Performance items (48-55). There is a place to record the number of symptoms that meet this criteria in each subgroup.

The Vanderbilt Assessment Scale also contains items that screen for 3 other co-morbidities: oppositional defiant disorder, conduct disorder, and anxiety/depression. 

For the oppositional defiant disorder screen there must be a score of 2 or 3 on 4 of the 8 items (19-26) on the subscale and a score of 4 or 5 on any of the Performance items (48-55). 

For the conduct disorder screen there must be a score of 2 or 3 on 3 out of the 14 items (27-40) on this subscale and a score of 4 or 5 on any of the Performance items (48-55). 

For the anxiety/depression screen there must be a score of 2 or 3 on 3 of the 7 items (41-47) and a score of 4 or 5 on any of the Performance items 48-55).

More on Scoring Instructions: Here

 Diagnosing ADHD

Deciding if a child has ADHD is a several step process – there is NO single test to diagnose ADHD, ANXIETY, DEPRESSION and certain types of learning disabilities can have SIMILAR symptoms. 

The American Psychiatrist Association;s Diagnostic and Statistical Manual, Fifth edition (DSM-5) is used by mental health professionals to help diagnose ADHD. It was released in May 2013 and replaced the previous version, the text revision of the Fourth Edition (DSM-IV-TR). This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD. Using the same standard across communities will help determine how many children have ADHD, and how public health is impacted by this condition. 

There were several changes in the DSM-5 for the diagnosis of ADHD: symptoms can now occur by age 12 rather than by age 6; several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting; new descriptions were added to show what symptoms might look like at older ages; and for adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children. 

Source: Behavioral Health Center, Sarasota FL

Posted in Behavior, School, Therapy

IEP Accommodations

Alphasmart for all extended writing tasks in the classroom and on standardized tests

Parent Idea: “I drafted my requests based on our state education department’s testing accommodations manual and proposed them at my son’s IEP review. They are: double time on tests longer than 20 minutes, with a 5 minute break per 20 minutes of testing; use of a visual timer set for 20-minute intervals; separate location for standardized tests; answers recorded in test booklets instead of answer sheets; use of on-task focusing prompts; use of word processors for extended writing tasks on tests; test directions and questions read aloud…and there are a few more. Best of all, he feels comfortable when he takes these tests, and he is doing very well, meeting grade level standards! His accommodations help him succeed in an inclusion class and we’re hoping he will be able to mainstream to a general ed. class in the next few weeks — with accommodations!”

Extended testing time with the option to take tests outside the normal classroom setting, and some tests are read to him.

 Adding the option for him to learn typing, since his motor delays make writing difficult.

Homework is a stressful time for our family. My fourth grade son takes medication during the school day. We are working with his doctor to add an afternoon dose to help during homework time, when my son is tired and distracted. He often knows the answers, but can’t focus to write them down. I write his answers down for him. I had this added to his IEP. After all, we’re trying to see if he knows the material, not if he knows how to write.

In his IEP, they have provided him with special assistance. If they are having a math test, they will cut the paper in half and allow him to do only half and get them correct, rather than being overwhelmed at the whole page and just writing down any number and getting them all wrong. They are also reading his tests and papers to him so he will be able to keep up with learning to read.

My 8th grader has a set of books at home. He writes his assignments in his assignment book, which his teacher initials each day as being correct. I am contacted after two missing assignments and he receives a lunch detention to make up missed work. Gum is allowed during tests. He sits near the teacher, and receives physical and verbal prompts for refocusing. He uses one folder for all homework assignments. And he writes on graph paper to assist with poor handwriting.

All long-term projects have to be broken into manageable tasks with weekly deadlines, rather than being a two-month project that overwhelms them. They get extra time for all tests if they need it.

My 11th grade daughter has done a great job of weaning herself from many accommodations to a few. Her favorite, and the teachers’ too, is that of taking tests in the classroom. She starts the test with the other kids and if she is struggling or does not feel she has enough time, she writes her guided study hall teacher’s name at the top of the test. Then, she turns the test in, just like all the other kids. When she gets to guided study hall, the test is waiting for her to finish or to ask for clarification from her IEP teacher. None of the kids in the class are aware of this accommodation, and that is important when you are a teen. It also encourages my daughter to try taking tests in classrooms with distractions, and she has less anxiety, knowing she has this option if needed

My 10th grader, who has an IEP for the first time, after years of only a 504 plan, now gets daily help at school for keeping himself organized.

My 14 year old son has brain damage from a brain tumor, along with ADHD, a math disorder, ODD, depression, and cognitive disabilities. He has an extra set of books at home, limited math assignments, a goal of completing 75 percent of his homework, and a calm down spot when he needs it. Most tests are read to him, and he gets to do errands for teachers. He also has a separate behavior plan. I have asked for OT to be done this year and the school is going to work that in. He is medicated with Lamictal, Prozac and Ritalin LA. My 11 year old has ADHD and is controlled with the Daytrana patch and does not need an IEP.

“I am a teacher and I suggest auditory cuing to sustain attention by asking, ‘How will you remember this?’ This is used during class or one-on-one discussions of important concepts. For example, when teaching geometry shapes, ask ‘How will you remember this is is called a pentagon?’ This question requires student attention (thus can be repeated), allows processing time for memory, allows creativity of mnemonics, and gives arousal to the executive function. It can be written into the IEP as: ‘Student will be asked twice during class how he will remember facts or rules.'”

Accommodations for Florida’s Statewide Student Assessments:

Text-to-speech and masking are computer-based accommodations for eligible students with disabilities that must be assigned by the test administrator in the system prior to the test administration. Text-to-speech provides an audio presentation of the items (questions) and answer choices for all tests. However, text-to-speech is not enabled on the passages included in FSA ELA Reading Component and FSA ELA Writing Component assessments. Masking allows the student to cover any area of the test page to temporarily hide information that might be distracting.

Paper-based versions of the computer-based tests are available in regular print, large print, one-item-per-page, and contracted and uncontracted braille as an accommodation if the student with a disability is unable to take the test on a computer. However, a student cannot use a paper-based version of the test when taking the assessment on the computer, because the computer-based tests have interactive components that cannot be demonstrated on the paper- based tests, and therefore the test items are not identical.

Any student may request to use a hand-held calculator instead of the online calculator. (if calculator is allowed)


Classroom: The student needs assistance to be able to understand and follow oral directions. Statewide Assessment: – Copy of directions from the test administration script to follow as directions are read aloud. – Test directions repeated, summarized or clarified.- Opportunity to paraphrase or repeat directions to demonstrate understanding. – Sign language interpreter to interpret oral directions.

Classroom: The student requires assistance to maintain attention and effort in written assignments. Statewide Assessments: – Verbal encouragement (“keep working,” “make sure to answer every question”). – Note: Verbal encouragement may NOT be used to cue a student regarding correct or incorrect responses.

Classroom: The student dictates responses for written assignments and assessments.Statewide Assessments: – Dictation of responses to a test administrator or proctor. Dictation of responses to an audio recorder. – Note: The test administrator or proctor will record or transcribe responses into the student’s answer document. The student must indicate punctuation and spell unfamiliar words. For FSA ELA Writing Component, the student may review the response and direct the test administrator or proctor to make specific changes.

Classroom: The student is only able to work for short periods of time when completing assignments and assessments. Statewide Assessments: – Testing time separated into short periods for a single session of the test.- Note: Between sessions and during breaks, the student must be closely monitored to ensure they do not share responses or change responses to items previously completed. The student must not be allowed to preview upcoming sections of the test.- If the student requires more than one day to complete a single test session, he or she must use a paper-based version of the test. The student’s need for flexible scheduling that requires multiple days for one session using a paper-based accommodation should be documented and sent to the district testing office for submission to the Bureau of K-12 Assessment.

Classroom: The student must have extra time to complete classroom assignments and assessments, even when working continuously. Statewide Assessments: – Extended time. – Extended time must be offered in accordance with the student’s IEP or Section 504 plan. Extended time is not unlimited time. Extended time should align with the accommodation used regularly in the student’s classroom instruction and assessment activities. Extended time must be documented so that the amount of additional time is clear, such as double time, 50% more time, etc.- Note: The student is not required to use all of the extended time that is allowed and may end the testing session prior to the expiration of the extended time period.

Classroom: The student’s performance predictably deteriorates at certain times. Statewide Assessments:  -Test taken at a preferred time of day that differs from the regularly scheduled time.

Flexible Setting

The setting in which the test is administered is an IEP or 504 team decision and is implemented at the district or school level. The test should be administered in a room with comfortable seating, good lighting and sufficient workspace. For example, some students may need additional space around their test booklets or computer for assistive technology (Thompson, Thurlow, Quenemoen, & Lehr, 2002). Some students may require a detachable glare reduction filter or a shade or hood over the monitor to control glare. Students may need special task lighting on the work area or additional illumination. The computer monitor should be positioned to the student’s preferred distance and height. Students with low vision may need to view the screen from a closer distance (Allan, Bulla, & Goodman, 2003, February). If a separate setting or specialized furniture or equipment is required for a student, arrangements must be made in advance to assure the availability of the location and proper staff.

Classroom: The student must be in a small group or individual setting when completing assignments and assessments. Statewide Assessments: – Individual or small group setting. – Note: The small group is of a size comparable to the normal instruction group indicated in the student’s IEP or Section 504 plan.


Classroom: The student must have a distraction- free environment or close monitoring when completing assignments and assessments. Statewide Assessments: -Individual or small group setting. – Study carrel or partitioned area. – Close monitoring while working.- White noise (sound machine) or approved calming music through headphones or earbuds to reduce auditory distractions. – Reduced stimuli (limit items on the desk, study carrel).- Increased or decreased opportunity for movement.- Note: The student may be tested in a separate setting if the accommodation(s) may disturb other students.