Behavioral Problems in Children

A 9-month-old girl doesn't sleep through the night. I advised the parents to let the baby cry and then go to his room at intervals of five, 10, and 15 minutes to check on him and talk to her. The baby still cried for two hours and 45 minutes …

1. Clarify and normalize what is going on.

What are “sleep –onset associations”?

The baby doesn’t agree with the plan.

Temperament (intense and persistent?)

What’s the developmental stage (stranger anxiety?)

2. Explore the parents' feelings and goals.

How important it is to them to achieve independent sleep?

To what lengths they are willing to go ?

3. Present the parents with strategic options.

•the "gradual" method (which they have been trying)

•the "cold turkey" method (which works but is unacceptable to many parents)

•the postponement of sleep training until a more propitious time.

4. Ensure timely follow-up.

A 2-year-old girl in my practice calls her mother "bitch." The mother, who is going through a divorce, is embarrassed when her daughter does this in public—at the mall, for example. Mom believes that the girl's father and his parents have taught the child this name. The nurses at the hospital where I admitted the child for pneumonia reported that the girl interacts well with her mother

• Ask Mom to ignore the girl's behavior so as not to reinforce it.

• Try time-out (no success)

• Consult her husband on this matter (he is uncooperative )

•The mother may have given up too quickly on ignoring the behavior.

•Being inconsistent in ignoring the behavior intermittent reinforcement is an extremely effective way to ensure that the behavior does not go away.

•Mom may not have an alternate plan for dealing with this behavior in public, when it is extremely difficult to ignore. For example, in going to the mall, I suggest keeping trips short

Reassuring and complimenting Mom on her parenting skills may go a long way toward helping her adjust to her new situation.

A 3-year-old brother bites his 18 month old brother, usually when the boys are in bed at night (they share a room, with both in toddler beds). The biting happens only occasionally in the parents’presence.

When it does, she alternates between using time-outs and talking to the 3-year-old. You encourage them to be more consistent with time-outs when aggression is witnessed

How do you advise the parents about what happens after "lights out”?

• Is the 3-year-old is getting a sufficient amount of praise and positive attention from his parents during the day? There has to be “time in” for “time out to work.

• Is the 3-year-old is getting a sufficient amount of praise and positive attention from his parents during the day? There has to be “time in” for “time out to work.

•The easiest way to address the night-time behavior is to separate the children or put the 18-month-old back in a crib so that the 3-year-old does not have access to bite him.

• Is the 3-year-old is getting a sufficient amount of praise and positive attention from his parents during the day? There has to be “time in” for “time out to work.

•The easiest way to address the night-time behavior is to separate the children or put the 18-month-old back in a crib so that the 3-year-old does not have access to bite him.

• Is there a calming bedtime routine? Is the 3-year-old going to bed easily or is he resisting? Is there a consistent bedtime? Are there disruptive behaviors that the mother is ignoring that occur before the biting occurs?

A 2-year-old boy eats stage 2 baby food. He also will eat Cheerios, crackers, and hash-browned potatoes, but not bread. He gags on any other food with texture and has a tantrum if he is offered table food. His teeth are late erupting--he's had eight teeth since he was 15 months old--and he didn't begin walking until 15 months. The parents believe that his eating habits have resulted from his lack of teeth.

• Physical and neurological status. Can the child chew and swallow normally? If in doubt, consider tests of swallowing function. What sort of textures does the boy find troublesome? The late teething is unimportant; he's not likely to refuse bread because he lacks canines and molars.

• Nutritional intake. Is the child's diet satisfactory, or is he being allowed to fill up on foods that he wants, such as milk or fruit juice? If so, parents should limit these liquids.

•General developmental level. Walking at 15 months is late, but still in the normal range. Fine motor and speech development would be of much greater interest.

•Temperament. Does the child tend to be slow about accepting anything different, withdrawing at first and then slowly adapting? Is he highly sensitive to subtle differences in taste and other sensations?

•Oppositional behavior. Has the boy discovered that having tantrums gets him his own way? Oppositional behavior also could arise from being forced by his parents to eat rather than being allowed to assume an amount of self-regulation that is appropriate for his age.

As long as the boy has no significant problems in any of these areas, offer him table food, but to be relaxed about it and give the problem time to sort itself out.

If the child has an inflexible or sensitive temperament, the situation calls for unusual amounts of parental tact and patience.

a 7-year-old girl told me that she is concerned about her daughter's excessive masturbation. Mom reports that ever since the child "discovered herself" at the age of 4, she masturbates often.

The child's teacher called Mom to report that she notices the child rubbing against chair legs or rubbing herself with her hands. There have been no new stressors at home or at school, but Mom reports that the child is an "overachiever"; if she is asked to do five problems for school, she will do 20, for example.

Many girls begin to masturbate about the age of 4, although some start earlier. This kind of touching feels good, and they are unaware of the effect their masturbation has on other people.

It would be helpful for the parents to tell their daughter that she should touch herself this way only when she is alone

Sexual abuse causes isolated masturbation only rarely, but it would be worthwhile to rule it out by quietly talking to the child to make sure that no one has touched her genitalia.

The parents of a 5-year-old boy are concerned about his sleepwalking. The child has been found in the car at midnight. He does most of his sleepwalking between 10 p.m. and midnight. Waking him up at 10 p.m. to break the cycle and giving him Benadryl at bedtime has not worked. Any suggestions?

He may open doors, traverse hallways, go down stairs and—rarely—go outside. Through it all, his eyes are open and his expression is dazed. Some sleepwalkers appear upset or agitated rather than calm. The child remembers nothing about his nocturnal activity in the morning.

• Sleepwalking is not harmful unless the child falls down stairs, etc. Physical harm is unusual.

• Avoid late bedtimes and stresses that may be associated with sleepwalking.

• Waking the child at a scheduled time before he usually begins sleepwalking is effective in some but not all children.

• Clonazepam (0.25 to 0.5 mg) before bedtime suppresses sleepwalking

The mother of a 3-year-old girl is concerned that her daughter steals the toys of other children. According to her mother, the child has plenty of her own toys at home. She does not have any siblings. The girl is healthy and her development is normal for her age.

"Stealing" implies that the perpetrator takes what belongs to another even though she understands personal property rights, knows her behavior will cause someone else loss or distress, and has enough self-regulatory controls not to go after everything she desires. The thief also understands that society prohibits following natural egocentric inclinations.

The 3-year-old meets none of these developmental criteria,

Approximately age 4 children begins to appreciate the beauty of rules.

Parents can, however, teach her that taking other children's things is not acceptable behavior.

Toddlers are very pragmatic creatures and can quickly learn that a behavior is not in their best interest, even if it's not clear why it's bad.

•Catch her being good ("It's so nice the way you're sharing the toys"),

•Give her time out for egregious stealing episodes (particularly when they occur right after she has been warned not to take things),

•Let her see the natural consequences of her act (return the pilfered item to its owner and ensure that the victim, not the thief, receives a lot of attention)

•Don't misinterpret the child's behavior, opening the door to unwarranted disparagement of their perfectly normal daughter.

A 4-year-old patient has been toilet trained for a year except that she refuses to use the toilet anywhere but home. She has gone as long as 15 hours without voiding; she complains of stomach pains when she holds urine for a long time but still waits until she gets home to void!

• The chief complaint is consistent with a phobia but a mild one, as the child's avoidance of the toilet interferes in only a small way with her daily activities.

• Unlike a fear, a phobia does not respond to reassurance or distraction, so the most important thing for the mother to do is respect the child's avoidance of toilets outside the house.

Often, parents never think to model using the toilet at friends' homes and in public places. Encourage the parents to use public toilets almost every time they are away from home, including at grocery stores, shopping malls, and pizza places. Modeling is often the most powerful tool that we have. No need for the parents to lecture—just use the toilet!

For the past few months, a 2-year-old has been smearing stool on herself and her crib almost every time she has a bowel movement. The child will sometimes even unbutton her clothes and remove her diaper to get at the stool. Mom usually ends up having to give her a bath, which is an enjoyable experience for the girl. This child has never demonstrated any unusual behavior before. She has mild speech delay (she uses only a handful of words) but has very good nonverbal communication

Having fewer than 25 words at 2 years of age is a major red flag for developmental disability. Studies show that, even in cases in which early language delays have improved, 42% of children are later found to have reading or cognitive deficits.

• Is this child is impaired cognitively. I recommend that arrangements be made to perform diagnostic developmental assessments.

• In the meantime, it may be helpful to reward the girl when she does not smear her stool.

• She might be interested in playing with modeling clay or doing finger painting as a substitute for whatever tactile pleasure she gets from smearing stool.

I recently saw a 10-year-old girl at an initial consultation for trichotillomania. Her habit apparently started six months ago. She was seen by a psychologist shortly after it began and was treated with behavioral modification therapy, but showed little improvement.

Trichotillomania is an underreported condition, and it is a difficult problem to treat.

•Is this child troubled by her hair loss?

•What is the secondary gain for her? Increased attention?

•And how motivated is she to master this habit?

Basic therapies include:

• Cognitive behavioral habit reversal therapy,

• Medication (clomipramine), and

• Hypnosis.

•Several small studies have compared cognitive therapy with medication. One study showed that behavioral interventions and hypnosis were more acceptable to patients than medication.