CASE ILLUSTRATION 1
Parents of a 12-week-old girl complain that their daughter rarely sleeps more than a total of 4–5 hours between 8 p.m. and 6 a.m. She may fall asleep at 8 p.m., only to awaken an hour later. She seems to fall asleep during or after short feeds and then remains awake for hours later on. Each night is a struggle of long awakened periods between short spells of sleep. Her parents note that she cries when left alone. She seems content at night when parents walk around with her.
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.
CASE ILLUSTRATION 1 (CONTD.)
On further questioning in this case, the parents reported that their baby falls asleep immediately after daytime feeds and sleeps for 3–5 consecutive hours thereafter. This baby did not adapt to an acceptable or optimal day/night schedule so their doctor recommended waking the baby up after no more than 2–3 hours of daytime sleep. Parents were to try to occupy their infant’s daytime hours by walking around, talking, playing music, and offering other playful activities. It was recommended that nighttime feeds be made minimally stimulating: soften the lights, produce minimal noise, and avoid “fun” interactions at night. Although sleeping and feeding “on demand” need not always be discouraged, in this case the infant’s pattern needlessly disrupted parents’ well-being and this justified modification. After 5–6 days of compliance with this schedule, it became easier for parents to keep their daughter awake during the day and the parents settled for a nighttime feed at 11 p.m. before they retired and another feed at 4 a.m.
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.
CASE ILLUSTRATION 2
The parent of a 3-year-old boy reports that her son throws himself on the floor, throws objects, and screams … usually when he does not get his own way. This seems to happen daily. At his child care center, he has begun to bite other children when he is angry, and other parents have begun to complain about him.
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.
CASE ILLUSTRATION 2 (CONTD.)
In this case, the child’s degree of aggression was within reason for a child at his developmental stage. His tantrums began as a result of typical frustrations experienced by children his age. Over a period of months as his parent became busier with other family needs, however, he discovered that expressing anger was an excellent way to get adult attention, and the frequency of these behaviors increased. As part of the management plan, his parent was instructed to ignore his anger and put him in his room for a few minutes when he became physically violent with others. Concomitantly, she was to increase time spent doing happier things with him, like playing games, going on walks, and having him help around the house. At day care, he was given increased individual attention during times he was behaving well. Child care providers were asked to ignore him when he was aggressive toward other children and to shower a “noticeable” amount of attention on the other child. Within a couple of weeks he stopped biting and seemed happier. Although he still had a terrible temper, these strategies gave his mother the feeling that she had some control over the situation.
Toddler: Oppositional Behavior
CASE ILLUSTRATION 3
A 3-year-old boy refuses to go to bed on time. He prolongs bedtime rituals by making numerous requests (e.g., for water, use of bathroom, adjusting the door, etc.). He repeatedly leaves his bed. On many nights he finally falls asleep in the living room or his parents’ bedroom while spending time with his parents.
CASE ILLUSTRATION 4
A father solicits your opinion on vitamin supplements to counterbalance his 28-month-old daughter’s picky eating habits. She drinks apple juice and eats hot dogs and Honey-Nut Cheerios, and little else. When these foods are not offered, she protests violently and eats nothing.
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.
CASE ILLUSTRATION 4 (CONTD.)
In the second case, the same principles were applied to other behaviors. The child was offered three wholesome meals and one snack at preset times of the day. After telling their daughter once, parents were not to engage in any discussion with their child about the volume eaten. No other foods in the house were made available to her during this behavioral management period. Between meals this girl was allowed an unlimited quantity of water, but nothing else. After a difficult period of 11/2 days (thrown silverware, persistent crying, etc.), she began to nibble at new foods and to enjoy the positive attention for doing so. Although the child still enjoyed only a limited range of foods, parents were able to expand her repertoire to include broccoli, milk, and pasta.
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.
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
CASE ILLUSTRATION 5
A 3-year-old girl has been touching the genitals of the family’s dogs and has commented on her father’s genitals. One week prior to their visit to your office, the little girl was repetitively using her finger and food in a way that resembled intercourse to her astonished parents. Not knowing how to react they have been begging their daughter to stop. Surprised by their odd reaction, the child has increased such activities.
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.
CASE ILLUSTRATION 6
During a routine health supervision visit of a 12-year-old girl, your customary questioning of social development reveals that this seventh grade student has been having problems with peers at school. She dislikes school and many of her classmates. Problems began about 3 months ago when another girl knocked an apple out of her hand and onto the cafeteria floor. Your patient tried to swat at the (but missed) and was reprimanded by the lunch monitor. Your patient broke into tears at that time and has since been the butt of sneaky jokes among a group of girls. False rumors about her have been spread verbally at school and through the occasional e-mail that children write to one another from home in the evenings.
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.
CASE ILLUSTRATION 6 (CONTD.)
The primary care physician made a verbal agreement with the young girl and her parents that they would work together on the problem until there was no bullying at all. The girl would heretofore share her experiences with her parents, despite embarrassment, and parents would take these seriously and keep her from facing these issues alone. Parents would speak with their child’s school administration and suggest a plan. Further history-taking, in this case, uncovered that this girl is an excellent artist. The parents were encouraged to consciously shower verbal praise for her artistic accomplishments as well as other successes. They were to encourage school staff to do the same. They were also to seek new opportunities for their daughter to exhibit these strengths to herself and to others.
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.