12: Children

This chapter reviews common childhood behavioral problems and suggests some management guidelines. Pediatric behavioral medicine cannot be easily disassociated from child development because many problematic childhood behaviors have developmental roots. Clinicians who work with children need to identify parents’ behavioral concerns, even if these are not brought up as problems by parents. Clinicians also need to develop strategies they are comfortable with to address childhood behavioral issues with parents, so that they can lead to resolution.

A child’s ability to understand and interact with the environment is constantly evolving. To learn more about the world, a child experiments with ways of interacting with it. Most often, children test the reactions of the people to whom they are closest, their parents. Colloquial phrases such as “the terrible twos,” “she’s going through a stage,” and “boys will be boys” indicate that undesirable childhood behaviors are commonly accepted as “normal.” But when an undesirable behavior is manifesting in your child, the normalcy can be difficult to accept. And even when the cause is well understood, many parents still need the knowledge and skills to respond to the problem behavior.

Extraordinary Stress

Behavioral problems associated with normal childhood development must be distinguished from problems with more complex causes. Aberrant childhood behaviors are often secondary to extraordinary life stresses. This applies to children who witness violence, are members of communities that have experienced a natural disaster or catastrophic event, are exposed to continuous marital discord, have a frequently absent parent (such as military deployment), have a chronic illness or a chronically ill sibling, or who do not feel wanted. Children living under any condition that seriously threatens healthy and successful transition through a developmental stage are likely to pose serious behavioral problems.

Children, like adults, may appear to be the dysfunctional member of an otherwise healthy family unit even though the problem actually stems from family issues. This is particularly the case with childhood behaviors, because children are dependent on adults in almost every way. Take, for instance, the child who refuses to attend school. Classically, this behavior occurs when one or both parents send subliminal messages to the child to remain home. Although the primary problem is parental anxiety about separation, it is the child who exhibits the apparent symptoms.

Stresses causing unwanted childhood behavior may be relatively more subtle than those described above. For example, children of immigrants often successfully acculturate to the prevalent culture. But when these children’s attitudes and behaviors are not culturally acceptable or understood by their parents, children can be perceived to be behavioral problems. Or, they may manifest true aberrant behaviors as a result of the stresses of this culture clash.

Inherent Disorders

In addition to childhood behavioral problems stemming from normal development and extraordinary life stresses, a third general category involves problems caused by disorders inherent to the child. Attention deficit disorders are the most common and well known, but conduct disorders, depression, autistic spectrum disorders, and other psychiatric diagnoses manifest during childhood. A complete history, observation, and response to treatment help the primary care clinician distinguish these from other causes of behavioral problems. The latest version of the Diagnostic and Statistical Manual of Mental Disorders is an excellent resource for primary care physicians trying to gauge a child’s behavior in relation to a psychiatric diagnosis.

Pediatric primary care providers must screen families for difficulties with undesirable childhood behaviors, sort out probable causes for the behaviors, recognize when a mental health referral is appropriate, and manage those problems that are likely to respond to simple environmental changes or to elementary behavioral management techniques.

Practitioner concern versus time constraints. Many parents do not know where to seek help for behavioral problems such as their baby’s night awakenings, their toddler’s tantrums, or their fourth grader’s class clown behavior. They do not realize that their child’s clinician can assist them. To overcome these barriers, health care providers should take every opportunity to talk about behavioral issues, although time constraints may limit the practitioner’s ability to listen to extensive histories. Therefore, clinicians need to screen for behavioral information in ways that are expedient and that leave time to reflect on issues that can be discussed more fully at another time.

Trigger questions and questionnaires. One way to elicit information from parents is to ask a preset list of key questions, specific to each age group. Use of a screening questionnaire that is mailed home in advance or that parents can answer electronically is a reliable way to elicit history. Numerous such questionnaires have been available since the 1990s. Despite their availability, they are rarely used by primary care clinicians. Some feel these questionnaires merely confirm what a clinician would suspect anyhow once the patient and family are in the office for a clinical evaluation. In addition, these screens have not yet been shown to be cost-effective. Nevertheless, brief screening tools, such as the 17-item Pediatric Symptom Checklist should be considered by clinicians prior to the child’s visit or even while the family is waiting to be led to a clinical interview or examination room. These tools help clinicians gather history and distinguish between disorders and problem behaviors.

To effectively screen for childhood behavioral problems, practitioners need to develop their skills of observation and to learn to apply their natural intuitions. Parent–child interaction in the office can be an excellent indicator of problems occurring at home. When reported childhood behavior problems are combined with a clinician’s suspicion that there is aberrant pattern of attachment between parent and child, this is a warning sign. Incidents in the office that induce parents to discipline their child are opportunities for clinicians to better understand the parent–child relationship and to bring behavioral management issues into discussion. Experienced clinicians have learned to become aware of subtle signs in the office that are indicative of a family’s dynamics, such as how a mother holds her baby. A mother who seems uncomfortable feeding her baby, a pattern of noncompliance, or suspicion about the levels of interest mother or father show are all indicative of issues that should register concern with the clinician. Involvement of grandparents and other extended family, references parents make about their own upbringing, and other family characteristics are also worth noting. Positive impressions that clinicians form about families also provide clinically useful information.

Television, movies, video games, texting, smartphones, and computer networks have assumed central roles in our children’s daily lives. It is still unclear what effect this has on children’s general mood and associated behavior. There are probably both negative and positive consequences to this growing phenomenon. Excessive screen time should be a concern if it appears to be associated with the emergence of behavior problems. It is certainly worthwhile to take a history of how “wired” a child is when confronted with a history of problem behaviors.

Interviewing young children. Primary care providers can find themselves in a quandary when they try to elicit information directly from the child. Most children by age 2½ to 3 years are capable of communicating certain thoughts and feelings to an inquiring health provider. But children do not typically divulge such information to clinicians when questioned directly. Children freely offer their honest opinions on just about any topic, sensitive or banal, but they often do so when it is unsolicited. Parents themselves are often surprised when their children first reveal their feelings about a delicate personal issue to an adult with whom they are not ostensibly very close (a preschool teacher, a friend’s mother in their car pool, and so on).

Primary care providers should, therefore, use tools that help children more freely and predictably disclose what’s on their minds. One way is to ask children old enough to understand and comply to draw a picture, for example, to draw “anything they want,” “something scary,” “their family,” or “the worst day at school.” The position of the characters in the drawings, facial expressions, and choice of colors can yield important information about what they are thinking and may be indicative of how they are feeling and can be used as a starting point for discussion. Children often find it easier to speak about themselves when the conversation is in the third person, such as “Why would that little girl in the picture want to hit her mommy?”

To avoid alienating parents, you may go through a few such questions when both parent and child are in the room. But many children, and most of those older than age 4 years, respond differently when their parents are in the room. Explain to parents that you would like to interview the child in the same way without them. The general nature of children’s responses can be discussed later with parents. Parents should be notified that this will occur, but the interviewer need not feel compelled to reveal children’s specific responses to each interview item, particularly if information may be hurtful and not of therapeutic value at that time. Parents and children should know that too.

Other oblique ways of eliciting information from children are to ask open-ended questions using questions that children like to respond to: “Pretend a magical genie in a bottle wanted to grant you three wishes, what would they be?” And “If you could magically turn into any animal you wanted, what would it be?” To their response to the last question, then ask, “Well that’s wonderful! And why would you be happy as that animal?”

Sentence completion games are also useful. The clinician begins the first few words of a sentence and asks the child to complete the sentence by making something up. Examples of some are given in Table 12-1. These (and clinicians can improvise on others like them) can be typed onto colorful cards so that children can choose one at a time and perceive it as a game, not a real interview. Allow the child to be imaginative with responses, and indicate that their responses can be the truth but do not have to be.

Toddlers and school-age children are often aware of the clinician’s actual intent when these interviewing techniques are used. Despite this, children seem to enjoy going along with this format of questioning and appreciate having an easy way to express themselves. Children respond best when they are comfortable with the clinician. Arranging a number of office visits can help to establish that relationship.

When using drawings, questions in the third person, or questions evoking the child’s imagination, it is important not to read too deeply into children’s responses. Children have active imaginations: they play around with frightening ideas and with wishful thinking. Sometimes they are merely obsessed with speaking about what they have recently seen on television. To be taken seriously, responses of young children should fit into a general pattern of what the clinician suspects from parent interview and symptoms. One or two worrisome responses should not stand on their own as proof for the etiology to a problem.

Beyond the physician–child–parent triad. Many toddlers are placed in the care of a day care provider, babysitter, or relative. Virtually all children older than age 5 years of age spend a large portion of their waking hours in school. Yet despite this, clinicians traditionally rely almost exclusively on parents (and the children themselves) to gather a behavioral history. Some clinicians send questionnaires to school staff to elicit information, or they ask parents about their children’s progress at school or day care. It is rare, however, for clinicians to routinely engage in direct telephone contact with child care providers and teachers. Yet these people occupy many, and occasionally most, of children’s waking hours. The value of attaining parental permission to speak directly with educational professionals in a child’s life cannot be overstated. Teachers and child care providers can provide valuable insight. Many have numerous years of experience with all types of children, and their observations rarely include the emotional biases that sometimes confound a parent’s interpretation and recollection of details. Once a behavior plan has been recommended, a relationship with daytime caretakers may extend the plan’s implementation to that setting and render it more effective.

Knowledge about stages of normal childhood development can assist a clinician with understanding the etiology of a maladaptive behavior. It can allow the clinician, and in turn the parent, to attribute an undesirable behavior to a developmental stage of childhood. An understanding of child development can guide parents to respond to a child problem behavior using a strategy that is consistent with that child’s stage of development. For example, it is often appropriate to just give a firm “no” to a child’s behavior without any supportive reason when they are very young, but that response would be insufficient for an older child who has developed skills of reasoning.

Sigmund Freud’s psychoanalytic theories emphasized unconscious and conscious mental processes that children go through. Each stage, which is several years long, is a decisive turning point where a child can become vulnerable or strong for a certain characteristic. For example, according to this theory, in the anal stage at 1½ to 3 years of age, children are personally focused on elimination and interpersonally focused on “rebellion versus compliance” with parental demands. At this stage, they may fear loss of parental love. Erik Erickson’s stages are an expanded version of psychoanalytic theory, and his teachings can help clinicians and parents understand children’s psychosocial development. Infants develop trust or mistrust through their experiences up to about age 18 months. In the next stage (ending around age 3 years), children develop autonomy versus doubt in themselves. And in preschool (up to age 6 years), children learn to either take initiative, or feel inhibited to do so. Through school age, children can acquire the psychological skills to feel competent in work, versus repeated frustration and feelings of inferiority. No one stage is ever really resolved completely forever, but the experience of those critical years are present in some way as the person moves throughout life.

Jean Piaget described stages of cognitive development. Though his theories have since been proven to underestimate children’s abilities, they are still very useful guides. For example, until around age 7 years, children are what Piaget termed as “preoperational.” They engage in make believe, and parents should not misconstrue this as lying. Complex concepts, such as cause and effect, are not yet developed. Parents must not get frustrated by trying to rationalize with them by using logic. Once well into elementary school, they are at the “concrete operational” stage, meaning they are less egocentric and understand how events outside of their own actions can lead to concrete changes. Hence, parental explanations for behavior are important for children at this age. Adolescence is marked by the increasing ability to work with abstract concepts. They test out these new skills by how they interact with their peers. They can begin to moralize about their own and others’ behaviors.

Primary care providers can and should evaluate and manage common child behavior problems in their own offices. Mental health referrals are usually unnecessary since so many undesirable child behaviors are maladaptations or manifestations of normal child development. There are occasions when the need for psychiatric assessment, psychotherapy, or play therapy is apparent from the start. But for most problems that present to primary care practitioners, children respond well to brief, solution-focused strategies. Although no single behavioral management technique works well for all children with similar problems and similar etiologies to their problems, clinicians can quickly learn to tailor their management plans to suit the individual needs of each family. These plans should be based on families’ cultural characteristics, size, work schedules, and other factors. A management failure should always first be considered a problem with the behavioral management technique prescribed, not with the child or family.

It is useful for primary care clinicians to have some understanding of the underlying theoretical basis of several psychotherapeutic interventions. Expertise and even competency in any one of these therapies takes years of specialized training—which is not feasible in the primary care setting. Providing psychotherapy in the clinical setting takes numerous sessions, and for some, many years. However, just knowing the premise behind these psychotherapeutic techniques may guide a clinician on how best to frame a conversation with a child and family when they face relatively minor behavioral problems with their children.

Family therapy is based on the premise that every family is a system (see Chapter 11). When a child has a problem behavior, it can be analyzed in terms of its being one outcome of the relationships between all members of the family. By first understanding and then intervening with the nature and dynamics of the family as a system, family therapy can help parents understand the complex etiology of their child’s aberrant behavior. In the primary care setting, this concept can help underpin the etiology and management of relatively minor behavior problems. For example, a clinician can rationalize inviting the entire family to the office when addressing a child who refuses to eat meals, when the problem hinges on a doting live-in grandmother who slips cookies to her granddaughter between meals. The grandmother’s need to have affirmation of love by her grandchild does not necessarily need to be addressed in the clinical setting, if just raising the actions and their consequences helps to stop the behavior.

Cognitive behavioral therapy comprises a series of techniques based on the notion that it is a person’s thoughts, not factors in the external environment, that primarily drive his or her feelings and behavior. When used by mental health professionals, it involves structured and directive relationship building and can take several visits before a person is able to unlearn his or her unhelpful emotional reactions to the environment. This concept can be useful for a primary care provider who is trying to coax parents to recognize that their child’s obstinate “no” to every directive need not raise their parental ire. Teach parents to recognize their reaction to their child’s misbehavior and how that emotional reaction to their own thinking may actually promote further such behaviors from the child.

Motivational interviewing was designed as a technique to improve treatment outcomes for people with substance abuse disorders (see Chapter 19). However, many clinicians have recognized that the philosophy and techniques of motivational interviewing can be helpful when trying to change other patient behaviors. Many people come to a health professional stating that they would like to stop smoking or lose weight, but they may be less than ready to do so. Motivational interviewing recognizes the stage of readiness the client is in. Behavioral experts in this technique learn not only to echo the client’s perspective but to help the client push him or herself to the next stage. Helping someone recognize the discrepancy between their stated desire and their current predicament is an important stage in the process. This concept can be helpful to clinicians, for example, those faced with parents who state they dislike their child sleeping in the parental bed each night, but then do not seem to follow the clinician’s advice. Rather than showing frustration, the clinician can show some sympathy for the parent and point out how it is not atypical to be ambivalent about changing the status quo. Encourage the parents to weigh their reluctance to change the child’s nighttime behavior against the benefits they are experiencing. Allow parents to explore aloud what it will take to become more ready to accept the difficulty that comes with reversing the situation.

Emotional intelligence is defined as the ability to identify one’s own feelings, to identify the feelings of others, and to solve problems that involve emotional issues. The extent to which this “intelligence” is innate versus learned is unknown. Emotional intelligence has been found to be related to, for example, having a lower risk for smoking during one’s youth. Parents who provide their child with “tools” to handle emotional challenges may be able to increase the emotional ability of their child. By learning a vocabulary of words that describes emotions, such as “frustrated,” “anxious,” and “envious,” children may become more likely to use them in lieu of acting out these behaviors. Clinicians can also encourage parents to foster an environment in which children will want to describe their feelings. Naturally, this is more easily accepted in theory by parents in your office than at home. Clinicians can ask about specific and recent situations at home that demonstrate the child’s personality and stage of emotional maturation. By understanding these details, a clinician can offer step-by-step suggestions that are pertinent to that family’s issues and that child’s emotional level.

Resilience There are significant individual differences in biological sensitivity to negative and positive experiences. A child’s ability to withstand or recover from a significant challenge is probably based on neurobiological and epigenetic processes. This resilience is not the only protective factor, as the resilience of that child’s family or community are also factors that predict outcome. Therefore, when assessing a child, elicit a history that is larger than that of the individual child’s own history.

There is growing evidence that one can promote childhood resilience through intervention during critical stages of development. Positive relationships with caring adults and effective parenting promote attachment. Learning problem-solving skills, self-regulation skills, and one’s self-efficacy for success are associated with resilience. Societal factors, such as positive friends, faith (i.e., hope, spirituality, and belief that life has meaning) and effective teachers and schools appear to be correlated with resilience. A good school or child care setting, and other programs or environments where children can experience success are considered to be critical.

Advocacy Clinicians have the power to help modify environments in which all the community’s children spend time, not only those children who are patients in their practices. Such environments include schools, playgrounds, parks and recreational centers, and child care centers. Clinicians can influence even the media to which these children have easy access. Advocacy can be preventive or responsive to a pattern that the clinicians have experienced in several patients of their own. Programs for which clinicians can advocate with regards to childhood behavior may be school classroom interventions, where children are taught that anger is an emotion that can be recognized before it is acted upon irrationally. Educational programs like this have helped students discuss and even act out situations that evoke their own anger and those of others. They also learn how to temper these emotions and how to de-escalate a situation.

Infancy: Night Waking

Child development in early infancy is characterized by large fluctuations in temperament and schedules. In the first few weeks of life, infants often sleep as much during the day as at night. In the first 2 months of life, two night awakenings are common, but by 3 months of life most infants are sleeping for 5–6 hours uninterrupted. In this case, the child did not naturally “learn” the difference between night and day, and parents did not train her to do so. However, if clinicians ask parents to let their young infants cry themselves to sleep, they set parents up for feelings of inadequacy or guilt. This, in turn, strains the relationship of attachment that parents are forming with their children.

It is important to note that the likely causes for night awakenings change with developmental stages. This same sleep history told by parents of a 9-month-old child would be more likely related to the child’s cognitive ability to recognize that parents still “exist” after they leave the room. At that age, if there were no other likely cause, other recommendations would be in order. A nightlight or a transitional object (favorite blanket or teddy bear) could prove to be helpful. The clinician, in this case, should devise a careful behavioral intervention schedule that includes parental reassurance for the child but may also include an allowance for the child to “cry it out” for a couple of nights.

Toddler: Aggression

Assessment of this behavior begins with elucidating, through history gathering, the extent of the child’s aggression, and its likely etiology. Angry outbursts are common at 3 years of age, when children often begin to direct their anger at others. Parental response to a given level of aggression differs widely from family to family. Parental expectations of children’s behavior, not solely the magnitude of the child’s behavior, help define whether a behavior is a problem. Large discrepancies between childhood behaviors and parental thresholds may predict that a child will continue to be problematic in the future. A child who explores the environment very actively may be described as “curious” in one family but as “always climbing the walls” in another. A “difficult and stubborn” child in one family is “persistent—just like his successful grandpa” in another. Perhaps the more positive perspective creates a better self-image for a child and leads to fewer problems later on.

Certain questions may help clinicians assess the etiology of aggressive behavior: Is the child a cruel or unhappy child? Is the child exposed to frequent violent (physical or verbal) outbursts from others at home? Are the incidents that induce these behaviors unpredictable? Is the child cognitively not acting consistently with his or her age? Positive responses to these questions make a normal developmental etiology less likely.

When development is still the most likely cause, there are a number of possibilities to consider. First, children with well-developed cognitive abilities, but with comparatively delayed language abilities, often become frustrated with limited ways of expressing themselves. Second, children at this stage often strive for adult attention and have found aggressive behaviors to be a certain way of getting it. Third, children at this stage need to express their independence, yet some adults have not found enough acceptable ways to allow the child to do this. To ascertain the likely cause(s), clinicians should explore events surrounding these incidents of aggression. Detailed examples of what instigated the last one or two aggressive behaviors are more revealing than letting the parent say, “Oh it happens for just about anything.” Always ask parents how they feel when their child acts out. Feeling like “I just don’t have time for this” may be a good indication that the child is trying to get attention. If their first reaction is to feel that this is a power struggle, then the child’s strivings for independence may be his or her primary incentive. Also ask what parents have done in response to misbehavior and whether this reaction worked.

Toddler: Oppositional Behavior

The behaviors described in these cases are typical for this age group. Toddlers commonly oppose parents for many sorts of issues, including the eating and bedtime cases illustrated here (e.g., getting dressed, putting toys away, wearing seat belt, and so on). A tendency to challenge parents’ instructions subsides naturally as children grow older. But they need to be dealt with properly for those months or years they are present. When parents mistake a child’s behavior as a personal offense, they react to the behavior in a way that creates additional conflict and heightens oppositional behavior. Therefore, it is important for clinicians to emphasize the developmental component. Children in both illustrative cases have learned to exploit their parents’ uncertainty with what exactly is in their child’s best interest. In both cases, the clinician should rule out deeper problems by interviewing the parent and, to whatever extent possible, the child. Look for unusual fears, nightmares, and other symptoms that may indicate an unusual etiology to the oppositional behavior. None was found in these two cases. Parental persistence must be designed to outlast the child’s. In Case 3, it is almost always effective within 2 weeks, and often within two nights. If this child shared a room with a sibling, it would have been suggested that the sibling sleep in the parents’ room until the index child’s behavior became less disruptive.

Parents often worry about harming their child by restricting access to food after a missed meal, so they need to be reassured that this is not harmful and will ultimately improve nutrition. It is all too common for a well-meaning grandparent who resides in the home to “save” the child by sneaking her a cookie between meals (Case Illustration 4) or lying down with the child after a designated bedtime (Case Illustration 3). Such kindly motivated behaviors unwittingly prolong the child’s maladaptive behavior, extending the period of inadequate nutrition and sleep. It is imperative that clinicians invite all adult household members to their offices when prescribing a management plan to ensure that all involved endorse both the intent and methods. It is useful to write behavioral management “rules” down on a prescription pad to be taped to the refrigerator door. This helps prevent conflict among adult household members that may arise later. Clinicians should also routinely recommend follow-up visits to their offices once the management plan has been implemented to monitor progress.

Toddler: Toilet Training

Children must be developmentally ready before toilet training is initiated by parents. First, physiologic sphincter control is necessary. This usually develops between ages 1 and 2 years, and parents often know when their child is beginning to sense a bowel movement because of a characteristic grimace or stance. The ability to follow sequential instructions, the motivation to imitate parents, and the patience to sit on a potty should also be present. It is reasonable to try toilet training at age 2 years if these milestones have been achieved. But disinterest or undue difficulty should alert parents to terminate their attempt and wait 2–3 months before trying again. Some children may not be ready until age 3. Others are ready at 18 months.

Although a number of effective toilet training methods exist, only one method is described here. Place the potty in the bathroom the child typically uses and explain what it is for by drawing parallels with the toilet that parents use. The child should be encouraged with praise to sit on the potty for a couple of minutes a day, initially with diaper and pants on and after a few days, without them. The child should accompany the parent to empty soiled diapers into the potty. Parents should avoid commenting on the foul odor of the stool, as some children identify what they have produced as extensions of themselves. Gradually, the child should be asked to sit on the potty more frequently during the day, particularly if there is a time when bowel movements are likely to occur. Encourage the child to let the potty “catch” the stool. Parents should never scold a child for an inability to do this or for any “accidents.” Night training, standing at urination, and using a larger toilet are secondary skills that should be introduced only after the child has mastered the basics or if the child expresses interest.

Preschooler: Sexual Behaviors

The clinician was initially and appropriately quite concerned herself by these actions. But after taking a physical examination and taking a careful history of the relationships in the families, she found no suspicions of sexual abuse, physical abuse or neglect, or recent emotional trauma within or outside the home. The clinician then instructed the parents to simply ignore the behaviors. On follow up, the clinician learned that these behaviors that started with normal childhood exploration, self-resolved within a week when they were no longer propagated with parental attention.

School Age: Primary Nocturnal Enuresis

One workable definition for enuresis is at least one bed-wetting incident weekly for a boy older than 6 years of age or a girl older than 5 years of age. It is considered secondary enuresis if a child had been dry previously for a period greater than 6 months. This is one of the most commonly asked questions of pediatric health care providers. Other urinary tract problems (infection, neurogenic bladder, and so on) can be ruled out with a basic medical examination and history. It is important to recognize that the only problems with primary nocturnal enuresis are the reactions of the child and the parent. Otherwise, it is a self-limiting condition that resolves spontaneously. If a child and his or her parents are not bothered by it, then no treatment is necessary. This is worthwhile to point out to families whenever the option for intervention is offered.

To treat this condition, it is necessary that children themselves, not only their parents, are motivated. Verify that a child is truly motivated and determine the source of motivation by interviewing the child separately. When a child is not genuinely motivated to try something new in order to be dry, clinical efforts should be directed toward other family members. Gauge parental actions and anxieties and if necessary influence them so that their actions and anxieties are not causes of unnecessary stress for their child. Children should never be punished for their enuretic disorder. Even if parents insist that their child help to change wet bed sheets, this task should be carried out with the same attitude as other household responsibilities the child has been expected to take on.

Not drinking to excess during the evening meal and afterward makes some logical sense and is easily followed. This should not be regarded as a fluid restriction for children who play sports or who live in very dry ambient air conditions. Going to the bathroom before bedtime to void is also advisable. Commercially available alarm devices assist clinicians and parents in instituting “conditioning therapy.” This method is of clinically proven use. With this device, an alarm awakens the child with the first few drops of urine. Eventually, this teaches the child to awaken with the sensation of a full bladder. The child is still responsible to get to the bathroom. The alarm is usually effective when used nightly for a couple of months. Setbacks occur after removing the alarm, but these are often corrected more permanently by one further trial period with the device.

Desmopressin (DDAVP) tablets, an analog of antidiuretic hormone, is a pharmacologic therapy of choice. If children respond to this medication, they usually do so within 2 weeks. Relapses after withdrawal are not uncommon, however, and this therapy is best offered when the alarm device has failed and for temporary relief (e.g., summer camp). Imipramine has also been shown to be useful in certain circumstances. Sphincter control exercises, fluid restrictions in the evening hours, and urine retention training may be tried, but these methods have shown only limited success.

School Age: Bullying

Victims of bullying are likely to internalize bad situations, and it is likely that this child did not reveal much of her distress to her parents at the onset of her problems. Indications that one’s child is being bullied may include an increasingly apparent dread of going to school, depressive signs, symptoms of anxiety (e.g., headaches, stomach aches), or changes in academic success. Many children who internalize threats and fears of bullying may believe they are somehow to blame for the behavior of others. Some parents and school staff members view bullying among school-age children as a normal part of growing up. Parents with this attitude need to be educated. Many parents who did not text, use Internet-based social media, or have classmates with digital cameras in school when they were growing up, can fail to recognize the plethora of new potential threats their child faces. Lack of recognition and resolution for bullying experiences and situations can result in anxiety disorders, depression, and social withdrawal.

Although some victims of bullying respond with aggression, many more are passive. Sometimes, certain personality characteristics or maladaptive behaviors have made children prone to becoming a victim of bullying. Problems such as having poor social skills, difficulty making friends, or even just being quiet, withdrawn, or shy can be sufficient. Victims are often those who easily become upset or have difficulty standing up for or defending themselves in public. Many feel more comfortable socializing with adults than with age-appropriate peers.

Primary care providers need to assess the level of entrenchment and severity for characteristics that predispose a child to being a victim of bullying behavior. Are there signs that this occurs in more than one environment, including the home? Are improvements recalcitrant to basic interventions? Are there too few positive social interactions with one’s own age group? For some, victimization is a sign that the child requires assessment and intervention of a mental health specialist.

The youngster’s parents kept a record of bullying episodes and communicated these with the school principal. Eventually, enrollment in an after-school art class helped this girl develop a couple of new friendships, which lent her a sense of confidence in herself and made her less vulnerable to being bullied.

Primary care physicians must realize that the interventions tendered in this case illustration are often inadequate to turn a situation around and that schools need to play a larger role. An experience with a bullied patient presents an excellent opportunity for a primary care provider to advocate in a local school or district so that bullying is taken seriously and that promising bullying prevention programs are adopted. To be successful, a bullying prevention program requires more than one interested school counselor with a plan or policy. Interventions designed by Olweus have been relatively well researched and demonstrate encouraging results. School interventions should occur at several levels: school-wide interventions (i.e., staff training and development of school-wide rules against bullying); classroom-level interventions (i.e., regular classroom meetings and class parent meetings); and individual-level interventions (interacting on a one-to-one level with bullies and victims). School administrators and all school staff must be committed, and each site needs a coordinator responsible for assuring that the plan is carried out.

It is no less essential for primary care providers to identify patients who are bullies, as well as those who are bullied. It is also important to help parents take note of signs that their children may be bullies. Bullies and victims often share problems with friendships, but they manifest these problems in different ways. Parents and clinicians need to be alert to children who are often in trouble at school (but are great at talking themselves out of blame) and who seem to need to control their friends and peers. All too often schools’ and parents’ only intervention for these bullies has been to punish them. This is typically ineffective because that response alone cannot get to the core of these children’s underlying problems. Strict rules, close supervision, and communication with the school are important interventions for parents to adopt. When underlying psychological problems have led to poor conduct, poor peer relationships, and emotional upheaval, and when these are not addressed during their youth, it has been found that bullies have a significantly higher chance of engaging in criminal activity later in life. Professional mental health assessment and management may be appropriate for persistent bullying behavior.

With the elicitation of a good history and an understanding of child development, primary care clinicians can develop reasonable hypotheses about childhood behavioral problems. Clinicians who manage childhood behavioral problems become very comfortable with a set of behavioral management protocols that can be applied to many of these common problems. Behavioral problems that require psychiatric or psychological intervention usually become apparent early in the process. Assisting families with behavioral issues that arise with their children in the primary care office improves the relationship that families develop with their primary care clinicians.