BEHAVIOR: Ask the experts

BEHAVIOR: Ask the experts

GIRL WHO HOARDS

Q A 10-year-old girl hoards everything, and her parents are worried.She doesn't want to throw out used pencil stubs or give away her outgrowntoys and clothes to another child who could use them. She tells her parentsthat others will not care for her things as she does. She doesn't mind buyingnew things to give away but doesn't want to part with her possessions. Whatdo you think?

Kim F. Burlingham, MD, Winnsboro, TX

A This story raises red flags. It is not the kind of situationin which you should simply reassure the family--"don't worry, she'lloutgrow it"--or advise watchful waiting. Rather, these behaviors maysignal that this little girl is in trouble.

What kind of trouble? Clearly, we don't have enough information to know,but here are some questions I'd want answered:

• What is the meaning of the hoarding for her? Perhaps holding on to the past signals significant anxiety about moving on in her life and is an attempt to stay immature by retaining the objects of her youth--to use Piagetian terms, a "concrete operations" solution to anxiety-provoking developmental challenges.
• The pencil stubs and such sound almost like the transitional objects used by toddlers. Is her hoarding some sort of self-comforting measure?
• Does the child have an incipient (or not so incipient) psychiatric disorder? Obsessive-compulsive disorder would be high on my list, especially if there is a positive family history. More worrisome would be if she viewed the retained objects as a part of herself, as some toddlers do their bowel movements.Ifherhoarding represents a failure to differentiate herself from inanimate objects, this is infantile and troubling.
• Has the child experienced the death of a loved one or other major change, such as moving to a new neighborhood? Is she attempting to control the little things in her life because she can't control the big ones?
• Are these behaviors new or longstanding? A history of retentive behaviors throughout her life suggests a different cause than hoarding that starts suddenly. Chronic hoarding might represent a temperamental characteristic, such as extreme difficulty coping with transitions and unpredictable changes, or reflect chronic stress of some kind. If the symptoms are new, look for recent precipitants.

Talk to the parents and talkto the child, preferably alone, and try toevaluate which hypotheses seem to make sense. Then I'd refer her to a mentalhealth professional--sooner rather than later--to help understand thebehaviors and to provide needed therapy.

Steven Parker, MD, Boston, MA

DR. PARKER is Director, Division of Developmental and Behavioral Pediatrics,Boston City Hospital, and Associate Professor, Department of Pediatrics,BostonUniversity School of Medicine.

STUTTERING

Q I'd like some advice on stuttering. When should a parent beconcerned, and when should the child be evaluated?

L. Stewart Barbera, MD, Huntingdon Valley, PA

A Many children do not speak fluently, but only about 1% trulystutter. Stuttering is a type of speech dysfluency that is accompanied bysecondary manifestations, such as blocking, mannerisms, and avoidance oftroublesome sounds and words. Between the ages of 1 and 4 years, in particular,about 30% of children have dysfluent speech.

If someone in the extended family stutters, your patient is more likelyto continue stuttering than if there were no such family history. Boys aremuch more likely to stutter than girls. Evaluation of stuttering is bestleft until the child is 2¹Ž₂to 3 years old andhas been stuttering for more than three months. The stuttering is of lessconcern if it consists just of repeated sounds than if the child's speechis blocked, sounds are prolonged, or the head is turned during the stuttering.

Advise parents to follow three simple rules in dealing with the childwho stutters: Do not correct stuttering because that only makes the childmore self-conscious; do praise fluency; and allow the child time to talk,avoiding the temptation to try to hurry him along or to complete sentencesor phrases for him.

Edward R. Christophersen, PhD, Kansas City, MO

DR. CHRISTOPHERSEN is Professor of Pediatrics at The Children's MercyHospital.

CRITICAL PARENTS

Q Some parents of children in my practice complain to me abouttheir child's behavior right in front of the youngster. They often soundvery negative or hopeless, or may threaten the child with physical punishment."He's always bad" is a typical comment. How do I deal with thissituation and my own initial negative feeling toward the parent?

Barbara Hipp, MD, Chapel Hill, NC

A Although children do not always listen to their parents, theyalmost always listen to what their parents say about them to others. I generallytake the parent aside and gently point this out. Abolishing the litany of"he's always bad" can be difficult, but the criticism may inspireeven worse behavior. After all, it represents parental attention, even ifit's negative.

Suggest that the parent try to catch the child being "good"instead of paying attention to the "bad" things the child does.You might say, "Well, you've mentioned some of John's behaviors thatdisplease you. I would be even more interested in hearing some of the thingsthat you really enjoy about John--things that he does very well, that makeyou proud to be his parents." With time and lots of positive attentionto "good deeds," plus less yelling or threatening for "baddeeds," the child will learn more productive behaviors. Similarly,it helps if the pediatrician catches the parent being "good,"and compliments her on new positive parenting skills.

Howard Markel, MD, PhD, Ann Arbor, MI

DR. MARKEL is Associate Professor of Pediatrics and Communicable Diseasesand Director, Historical Center for the Health Sciences, The Universityof Michigan Medical School, Ann Arbor, MI.

SCREAMING DURING BMs

Q A 12-month-old girl with constipation that has resulted in painfulfissures screams and cries when she has a bowel movement. This has goneon for a long time even though her constipation has been treated aggressivelyand the fissures are now healed. I suspect these episodes are a trainedresponse to previously painful bowel movements. Changing the child's soileddiapers has become an ordeal because of the child's crying. What can I advisethe parents to do?

Eve H. Switzer, MD, Enid, OK

A It seems that your patient still has two constipation-relatedproblems. First, she screams and cries whenever she has a bowel movement.Although you say that her constipation is resolved, I would go out of myway to make her bowel movements very soft for several months. You coulduse mineral oil, lactulose, or possibly a high-sorbitol fruit juice, suchas pear juice. You are right that her crying may be caused by the memoryof painful bowel movements. I've seen this many times in this age group.(Caution: The most common physical cause for persistent crying during defecation,even with soft stools, is perianal cellulitis caused by Group A streptococcus.Untreated, this condition can persist for many months.)

The second problem is that changing the child's poopy diapers also causescrying. The parent should offer special toys that the child has access toonly during this event, use lots of warm water in cleaning off the skinto avoid any pain, and be upbeat about changing her. If the girl holds backbowel movements, you want her instead to look forward to releasing them.Giving the child her favorite food immediately after a bowel movement mayaccomplish this.

Barton Schmitt, MD, Denver, CO

DR. SCHMITT is Professor of Pediatrics, University of Colorado Schoolof Medicine, and Director of General Consultative Services, The Children'sHospital of Denver, CO. He is a member of the Contemporary Pediatrics EditorialBoard.

DRESSING TWINS ALIKE

Q Parents of identical twins often like to dress the childrenin identical outfits. Is this harmful to their development? Is it all rightto continue this practice when the twins begin school?

Solomon J. Cohen, MD, Kennebunkport, ME

A Twins are born with a special gift. When raised together, theyhave the opportunity to experience each stage of development both as anindividual and as a part of a set of twins. The physical or psychologicalpresence of one twin gives texture to the social world of the other. Beinga twin is not necessarily more difficult than growing up as a singleton,but it is different.

With twins, the process of psychological separation from family thatbegins in the second year and continues through adolescence is double layered.All toddlers use emerging skills in self-regulation--as they walk, eat,play, sleep, and become toilet trained--to gain emotional independence anda sense of self. Twin toddlers also begin to look for ways to define themselvesas separate and different from their sibling. To accomplish this, they sortout similarities and differences during many repetitive interactions asthey play. When they are 3 and 4 years old, they couple fantasy and imaginaryplay with their new language skills to further both identification withthe twin and separation.

Dressing twins in similar clothes has a long tradition. It reflects theirparents' recognition of a common origin and birth date. For most parentsthe "cuteness factor" is undeniable. I don't see a problem withthis practice as long as parents also foster individual identification anda sense of self. Pediatricians can encourage parents of twins to recognizeindividual achievements early in the lives of their twins. Parents can respondto differences in temperament, language, social interaction, and play. Mostmilestones of development will offer an opportunity to observe and respondto twins' differences as well as similarities. Parents can encourage developmentof individual identities by choosing different-sounding names and referringto the other twin by name or as "your brother" or "your sister"rather than as "your twin." They also should provide praise anddiscipline individually and support each child's preferences for toys andsome play situations.

If parents dress their twins alike, pediatricians should encourage themto differentiate the twins' outfits in some small way at least once or twicea week by the time the children are 2 or 3 years of age. In this way, theycan gradually wean the twins away from dressing identically, allowing themto develop their own ways of dressing at the same time they are becomingindividuals in other areas.

Using the clothing issue as a springboard, the pediatrician can offeranticipatory guidance about broad issues of identity and autonomy amongtwins. I can't recall any adolescent twins who have come to my office dressedin identical outfits.

Martin T. Stein, MD, San Diego, CA

DR. STEIN is Professor of Pediatrics at the University of Californiaat San Diego School of Medicine.




BEHAVIOR: Ask the experts. Contemporary Pediatrics 1999;0:047.