Behavior: Ask the experts

BEHAVIOR: ASK THE EXPERTS

PARENTAL ANTIPATHY TO PLAYPENS

Q I am dismayed that so many new young parents refuse to consider using a playpen for their babies and toddlers, even after the child has a fall or other accident. What do you think about playpens?

Solomon J. Cohen, MDKennebunkport, ME

A Let us consider the virtues of the oft-maligned playpen: It provides a contained area in which to romp. It allows easy access to a variety of interesting inanimate objects. It gives the toddler a risk-free place to pull to a standing position and fall again. It affords an interesting vantage point from which to observe the rest of the world. It is free from rapacious siblings, allowing for complete autonomy. It is small and knowable. And it is safe. In other words, the playpen provides just what we tell parents toddlers need: reliable, consistent, understandable, and safe limits. In fact, the playpen has no drawbacks, as long as it is not used so much that the child is cut off from human interaction.

So why are some parents so opposed to playpens? I believe playpen antipathy arises when parents ascribe to infants and children adult cognitive insight and emotional response (adultomorphic fallacy). "After all, I would find being cooped up in an enclosed space like being in prison, so why would I be so cruel to my toddler?" But toddlers are not little adults, and placing them in a contained environment for a moderate period of time is no more noxious to most of them than freedom; both have their role in the life of a toddler. Occasionally, a temperamentally active toddler bridles at the incarceration, and it makes sense not to force him to stay in the playpen. But most toddlers readily acclimate to a playpen and even enjoy its familiarity and the control they can exercise there. Meanwhile, the parent enjoys a worry-free respite from supervising an active youngster.

Steven Parker, MDBoston, MA

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

TEEN WITH FRAGILE X SYNDROME

Q I have a 15-year-old boy in my practice who has fragile X syndrome. He has been on dextroamphetamine sulfate for many years without any problems, according to his mother. Recently, however, he has had many more mood swings than he used to and sometimes behaves aggressively. After these problems began, the boy's father left the family and, the mother says, divorce is inevitable. The boy is angry about the situation. The mother is concerned about how to handle this new social arrangement; her son is used to having his father around. I would appreciate any insights you can offer.

Carol L. Jacobs, MDLivingston, TX

A Parental conflict, separation, and divorce are complex circumstances for any adolescent to cope with. This teenager may find them an even greater challenge than his contemporaries. We do not know his cognitive level but can assume that it is somewhat lower than average. Similarly, the boy's emotional development may be less advanced than that of another child his age.

Adolescent boys with fragile X syndrome often have mood instability and aggression, as well as bouts of anxiety. The marital discord and divorce will most likely exacerbate these problems. Psychotic thinking also is not uncommon in fragile X syndrome. A sophisticated mental health evaluation would be useful to assess this child's level of anxiety, mood instability, and paranoid or psychotic thinking. In addition, cognitive testing might help to assess his IQ. Depending on the results of this evaluation, you might consider a referral for psychotherapy to address issues related to the divorce, help this teenager manage his anxiety, and teach him calming techniques to decrease his aggressive behavior. Psychopharmacologic therapy might be indicated as well. Serotonin specific reuptake inhibitors may alleviate anxiety and aggressive behavior, and carbamazepine, valproate, or gabapentin might even out his mood.

Given this young man's illness and associated difficulties, his parents need to be attentive to issues that always arise with regard to divorce: fear of loss, guilt, anger, and confusion about the future implications of his parents' separation. Parents can enhance the child's adjustment to this family disruption by attending carefully to the child's needs, as well as to their own. Children and adolescents do best if both parents follow these guidelines:

• Subject the child to as few changes as possible in living circumstances

• Work hard to maintain a good relationship with the child

• Maintain the same discipline strategies as they used before the divorce

• Keep to a regular schedule so the children's lives are as predictable as possible

• Remember that they continue to be the child's parents, even though they are no longer spouses, and make sure their actions are consistent with this concept. This may require keeping their feelings and behavior toward the ex-spouse out of the relationship with the child

• Do not criticize or argue with each other in the child's presence

• Do not use the children as messengers or spies, or as allies in parental communications

• Do not expect the child to provide them with emotional support or to share parental fears and concerns

I appreciate Dr. Randi Hagerman's consultation in the preparation of this response.

Ellen C. Perrin, MDWorcester, MA

DR. PERRIN is Professor of Pediatrics, University of Massachusetts Medical Center.

TODDLER BITES HER NAILS

Q An 18-month-old in my practice recently began biting her fingernails. She has not used a pacifier nor has she sucked her thumb or fingers in the past. Mom notes that the nail biting started shortly after she weaned the child. The infant's development is otherwise normal. She tends to bite her nails when she is tired or bored.

Ronda Dennis-Smithart, MDOskaloosa, IA

A Since nail biting is uncommon among toddlers, we don't have much empirical information to guide us. Extrapolating from what we know about nail biting in older children, however, allows us to draw some conclusions.

To determine why the child is biting her nails, it would be helpful to know how frequently and aggressively she engages in this habit and how long she has been doing it. What remedies have the parents tried and what have been the results? Are there circumstances in the child's life that would cause anxiety or stress? Did the child find weaning difficult? Could the child be imitating someone with whom she is in daily contact, such as a parent?

I suggest proposing to the parents the following management strategies:

• Ignore the problem. This probably is best, but also consider praising the child when she does not bite her nails at a time when she might be expected to.

• Find other things for the child to do when she is tired or bored.

• Avoid more vigorous interventions. Punishment, nagging, or painting the fingers with bitter substances is likely to be ineffective at best and counterproductive at worst. Habit reversal techniques, appropriate for older children, are not suitable for a toddler. If infection is present or the skin surrounding the nail is bleeding--a rare situation--temporary use of a protective dressing should be helpful.

William B. Carey, MDPhiladelphia, PA

DR. CAREY is Clinical Professor of Pediatrics, University of Pennsylvania School of Medicine, and Director of Behavioral Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia.

Marian Freedman. Behavior: Ask the experts. Contemporary Pediatrics 1999;12:33.