BEHAVIOR:ASK THE EXPERTS
BEHAVIOR:ASK THE EXPERTS
NAIL BITING
Q Quite a few parents in my practice are distressed that theirchildren bite their fingers and nails. Old-fashioned cures, like puttinghot sauce on the fingers, don't seem practical. Any suggestions?
Steven Hauben, MD
Phoenix, AZ
A When I am asked about how to get children to stop biting theirnails, two questions come to mind:
- Why do they need to stop?
- How do you get adults to stop biting their nails?
Let me answer the second question first. You don't get adults to stopbiting their nails unless they want to since nothing is really wrong withbiting one's nails. Nail biting looks unattractive and the nails never lookvery nice, but we let adults decide on the importance of these issues. Inthe scheme of bad habits, nail biting is really minor league.
On the other hand, we all want our children to stop biting their nailsfor the same reasons: It doesn't look right and their nails look terrible.About the only reason to worry about a child who bites his nails is thatthe habit may be a stress response--a red flag for other problems. Nailbiting is rarely the sole symptom of stress, however.
Most people suggest using a bad-tasting clear nail polish to stop nailbiting, but this technique hardly ever works. A daily sticker reward systemcan sometimes be effective.
To sum up, I would rarely do anything about nail biting. I would makesure that something unusually stressful is not going on in the child's life.Beyond that, I would give the habit little extra attention, though I mightset up a reward system for stopping. Finally, I would suggest to the familythat there are more important battles to fight and encourage them to ignorethe nail biting.
Leonard Rappaport, MD
Boston, MA
DR. RAPPAPORT is Associate Chief, Division of General Pediatrics, Children'sHospital of Boston.
THOUGHTS OF SUICIDE
Q The mothers of two young boys have come to me with similar anddisturbing problems. The mother of a 5-year-old boy whose grandfather haddied within the past year told me that her son said he wanted to kill himselfso he could "see his grandfather again." The same thing happenedwith a 412-year-old boy whose father died quitesuddenly and unexpectedly a year ago; the child had been through grief counselingwith his sibling and mother. This child also told his mother he wanted tokill himself so he could be with his daddy. Needless to say, these commentswere highly distressing to the children's mothers, who wanted to see a psychologistto learn how to respond. How can I advise them?
L. Stewart Barbera, MD
Huntingdon Valley, PA
A Suicidal ideation in these bereaved children is a red flag indicatingthat referral to psychologist, child psychiatrist, or behavioral pediatricianis indeed appropriate. The estimated 5% of children and adolescents wholose one or both parents before the age of 15 years are at risk of experiencingpsychologic sequelae to this major loss. Death of a parent or of a spouseis generally considered the most stressful of all life events, particularlyif the loss is sudden or unexpected. Children younger than 5 years, adolescentsunder 15, and boys who lose their fathers are at special risk. Young childrenalso may be especially vulnerable to the death of a grandparent with whomthey had a close relationship.
In addition to extending condolences when a parent of a child in one'spractice dies, the pediatrician may offer anticipatory guidance to the survivingspouse and children. This may consist of an appointment with the pediatrician,a referral to a bereavement counseling program, or periodic monitoring ofadaptation in subsequent health supervision or illness visits.
During this developmental surveillance over the next year or two, certainsymptoms or complaints warrant careful exploration and possible referralto a mental health professional. These indications include the bereavedchild's expressed hope for a reunion with the deceased--as in the casesyou cite--an ongoing sleep disorder, regression in behavior, guilt, withdrawal,excessive daydreaming, depression, persistent anxiety, anger, destructiveor aggressive acts, or a decline in school performance.
Morris Green, MD
Indianapolis, IN
DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana UniversitySchool of Medicine, Indianapolis, anda member of the Contemporary PediatricsEditorial Board.
GETTING GIRL TO SLEEP IN OWN BED
Q A 9-year-old has been sleeping with her mother since infancy.The mother wants the child to sleep in her own bedroom and is frustratedthat even when she carries her sleeping daughter back to her own bed, thechild returns to the mother's bed by morning. We offered two suggestions:Lock Mom's bedroom door until the behavior stops or offer positive reinforcementto the girl for sleeping in her own bed. A week later, the mother reportedsuccess with a third strategy: She placed a TV, VCR, and video games inthe girl's bedroom. Now the daughter is content to sleep in her own room.What methods doyou recommend to achieve separation from the parents' bed?
Jordan Spivack, MD, PhD
George Datto, MD
Philadelphia, PA
A Many children who have difficulty staying in their own bedsinitially fall asleep in their parents' bed. The parent then places thesleeping child in the child's bed as this mother did. This is problematicbecause during the night we all experience brief periods of waking betweensleep stages. Generally we rapidly return to sleep and have no memory ofwaking. If the environment in which we are sleeping has changed, however,we are apt to wake up more fully.
In addition, people use routines to help them fall asleep and may havedifficulty if some aspect of the routine is altered. The child who is accustomedto falling asleep in the parents' bed or cuddling with the parent will findit hard to fall asleep alone in his or her own bed. Any treatment plan shouldaim to have the child fall asleep in her own bed and on her own.
The child probably gets attention or other forms of reinforcement whenshe leaves her bed. Identifying these reinforcers and minimizing them, incombination with offering reinforcers for staying in bed--as you suggested--oftenis beneficial. The reinforcers are more likely to be effective with a childthe age of this girl than with preschool children, because she is old enoughto understand the relationship between a reinforcer received in the morningand behavior the night before.
If the child is anxious about being alone, it may help if the parentsits in a chair next to the child's bed until she has fallen asleep. Oncethe child has learned to fall asleep in her own bed, the parent can graduallymove the chair toward the door and eventually outside the child's room.
Locking the parents' door is not a desirable solution. It does not teachthe child to sleep in her own bed and may limit access to the parents shoulda child need them during the night. With some young children, calmly andconsistently carrying them back to their bed without talking to them maybe necessary.
Although putting a TV, VCR, and video games in the child's room appearsto be successful in this case, this strategy is not possible for many familiesand it sets a poor precedent. I also would be concerned about how long thechild is staying up to watch TV or play games. When these entertainmentswere introduced, she probably stayed up well past her usual bedtime andfell asleep in her own bed from sheer exhaustion. That it was her own bedis probably what made this intervention successful. A slightly later bedtimeor shorter nap is a useful technique, but in this case the ongoing stimulationin the child's room may be leading to sleep deprivation and daytime fatigue.The mother probably should place some limitations on use of the electronicequipment.
Nathan J. Blum, MD
Philadelphia, PA
DR. BLUM is Assistant Professor of Pediatrics, University of PennsylvaniaSchool of Medicine, Children's Seashore House, Philadelphia.
TODDLER WITH SIGNS OF AUTISM
Q I need help with a 3-year-old boy I started seeing recently.According to his parents, the boy spends hours playing alone and does notmake friends. Even on social occasions, he finds ways to be alone. He sometimesmakes funny noises, and though he speaks words, he is unable to make completesentences. During his visit to my office, he avoided eye contact. The childis otherwise healthy with excellent growth and development. His two siblingsare also healthy and normal. The parents are well educated.
Muhammad Waseem, MD
Bronx, NY
A The child's tendency to play alone, lack of friends, and inabilityto form complete sentences along with your observation that the boy doesnot maintain eye contact are diagnostically important. You are right tobe concerned about this child; your description suggests he may have autism,a neurologically based disorder characterized by impairments in reciprocalsocial interactions and in verbal and nonverbal communication. The causeof autism in a particular child generally is unknown.
Except for language delays, the clinical features of autism may not beapparent in the first two years of life and become progressively more obvious.Children should be putting two words together by age 2 and have more thana 50-word vocabulary. Other signs of autism include lack of awareness ofthe feelings of others, absent or impaired imitation and social play, failureto make friends, inability to communicate verbally and nonverbally, abnormalspeech production and speech content, preoccupation with objects, insistenceon following routines, and a restricted range of interests.
This child should be referred for further evaluation to confirm or ruleout the diagnosis and for management. If he is diagnosed with autism, orpervasive development disorder, the cornerstone of treatment will be earlyintervention and special education with an emphasis on behavioral management.No medication has been proven effective, although sometimes autism is associatedwith a symptom that can be treated pharmacologically, such as seizure disorderor certain types of severe behavioral upset.
Autism is a devastating disorder not only for the child but for the family.The child needs a lot of supervision, and his parents will require muchsupport, including respite care, participation in a support group for parentsand siblings, and family counseling.
Most children with autism remain substantially impaired and require carethroughout their lives in group homes or other such settings. About 5% to10% become independent adults, while 25% achieve some vocational and residentialindependence. Speech is an important predictor of outcome. It is a goodsign that this child can speak single words. He will require ongoing assessmentby a multidisciplinary child development team.
Barry S. Zuckerman, MD
Boston, MA
DR. ZUCKERMAN is Chief of Pediatrics and Medical Director, Boston MedicalCenter, and Professor and Chairman, Department of Pediatrics, Boston UniversitySchool of Medicine.
WE NEED YOUR HELP!
Please think about the most interesting or difficult behavioral or developmentalissues that have come up in your practice in recent weeks and write us aboutthem. We'll be grateful, other readers will be grateful, and you'll getsome good advice about your patient.
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Behavior Q/A
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