BEHAVIOR:ASK THE EXPERTS

BEHAVIOR:ASK THE EXPERTS

TEEN WANTS TO GET PREGNANT

Q How should I approach an adolescent who wants to get pregnant?

Melissa Lemp, DO
St. Louis, MO

A Intended pregnancy may account for 20% or more of all adolescentpregnancies. Although it may be hard for health professionals to know whichpregnancies are intended, your patient has made her goal clear. This givesyou an opportunity to intervene--but with the caveat that your approachand advice may not dissuade her.

This young woman has shared with you her thinking about an enormous lifestep. I encourage you to explore the issue thoroughly with her, as we doall such decisions adolescents make. What is her sexual experience? Whatform of contraception is she using, and how reliably is she using it? Whatkind of relationships has she had with male partners and who is her currentpartner? Is there someone in her life who wants her to have a baby--herboyfriend, her mother, or grandmother, perhaps? Is this pregnancy an attemptto "seal" a relationship with her boyfriend?

What future plans does this adolescent have? Pregnancy and parenthoodmay be an option for teens who do not have many other life choices, or whodo not think they do. How does your patient do in school? What significantadults are part of her life and--an important issue--what do her parentsthink about teen pregnancy? Have the parents shared with their daughtertheir values about education and parenthood?

The potential for "reality testing," which may help the adolescentmake a decision about pregnancy, depends on her cognitive development, whatalternatives she recognizes for personal development, the social supportshe perceives, and a spectrum of other family and societal factors. Seeif you can arrange for your patient to volunteer or be employed as an aidein a day care or preschool or in a hospital pediatric unit. She might wantto take part in a high school "parenting" class (using a programmeddoll, egg, or bag of flour) or help provide overnight or weekend respitecare for a family with a child with special needs. Talk with her about thehow hard it is to manage a child 24 hours a day, including night feedingsand sick care, and to continue one's education and peer activities afterbecoming a parent.

Adolescent girls who take part in sports, music, or drama activitiesor who have recognized roles in school as peer counselors or other leadersare much more likely than other girls to delay initiation of intercourse,use contraception, and postpone childbearing. Does your community have aGirls' Club or another such organization that encourages these activities?Can this teen learn CPR, lifeguarding, or the principles of child care withthe goal of working in a day-care center or preschool? Does she have opportunitiesfor vocational training or college in the future, and does she know howto go about looking into those possibilities with her school guidance counselor?

Keep in mind that helping this young woman delay her decision to becomepregnant, even for a few months or a year, can be very worthwhile. It maybecome obvious to her, for example, that her relationship with her currentboyfriend is not working--and it may be he who is encouraging her to becomepregnant. If she continues to be sure she wants to have a child, a few extramonths will allow her to mature cognitively and physically, to test herrelationship with her partner, to further her education, to become awareof other opportunities for personal growth, and to enter parenthood withmore skills and greater understanding than if you and she had never talked.

Carole A. Stashwick, MD
Lebanon, NH

DR. STASHWICK is Associate Professor of Pediatrics, and Director, AdolescentProgram,
Children's Hospital of Dartmouth, Lebanon, NH.

2-YEAR-OLD WON'T EAT TABLE FOOD

Q The mother of a 2-year-old boy is concerned about her son'seating habits. He still eats stage 2 baby food. He also will eat Cheerios,crackers, and hash-browned potatoes, but not bread. He gags on any otherfood with texture and has a tantrum if he is offered table food. His teethare late erupting--he's had eight teeth since he was 15 months old--andhe didn't begin walking until 15 months. The parents believe that his eatinghabits have resulted from his lack of teeth. I suggested that they continueto offer him table food, but to be relaxed about it and give the problemtime to sort itself out. Do you have other suggestions?

Deanna Yen, MD
Knoxville, TN

A Your first task is to get some more information about this child.

• 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 seems unimportant here; 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,your advice has been quite suitable. If the child has an inflexible or sensitivetemperament, the situation calls for unusual amounts of parental tact andpatience.

William B. Carey, MD
Philadelphia, PA

DR. CAREY is Clinical Professor of Pediatrics, University of PennsylvaniaSchool of Medicine,
and Director of Behavioral Pediatrics, Division of General Pediatrics, Children'sHospital of Philadelphia.

TODDLER PULLS OUT HAIR

Q An 18-month-old boy in my practice has a large area of patchyalopecia along the right frontoparietal area; the scalp is not scarred.The mother first noticed the child twirling his hair about a month ago.Since then, he has developed the habit of pulling his hair out before bedtimeor naps. Although the boy's father once noticed some hair in his son's mouth,neither parent has actually seen him swallow it. The boy has no associatedrhythmic behaviors, such as rocking, head banging or thumb sucking, andno history of pica. His growth and development are normal. His mother isexpecting the birth of a sibling next month.

I have suggested to the parents that they give the child a crew cut andconsider applying grease or petroleum jelly to his scalp to prevent himfrom grabbing his hair. I also recommended trying to distract him from pullinghis hair but to avoid taking his hand away from his head. Do you have anyother suggestions?

Craig Singer, MD
Bloomfield, MI

AAs your description suggests, hair pulling in toddlers and preschoolchildren, unlike trichotillomania in adolescents, is not associated withother emotional or behavioral disorders. Instead, young children who pulltheir hair out often suck their thumbs, or have a similar habit, and treatmentof the thumb sucking often will stop the hair pulling. This child does nothave such habits, however.

Although parents often seek treatment for hair pulling because of theway it makes the child look, the habit presents a much more serious concern:Some children eat the hair and develop a hair ball, which may require surgicalremoval. Finding hair in the child's mouth would increase my worry aboutthis possibility.

Effective treatments for hair pulling in young children usually havethree components:

• Give the child more attention. Increased one-on-one time with the parent and day-care worker; increased attention, verbal praise, and nurturing during all activities; and a calm bedtime routine in which a parent participates should help. This strategy is more effective than trying to distract the child, which may reinforce the hair pulling because it represents attention. Distrction is not possible when the child is left alone at bedtime anyway.
• Make hair-pulling less pleasurable. This is the idea behind cutting the hair and applying petroleum jelly. Another strategy would be to have the child wear loose-fitting cotton socks on his hands (hand socks) during high-risk times, such as nap or bedtime. Allowing the child to select the hand socks may make this intervention more acceptable.
• Place the child in time-out when he pulls his hair. This may not be practical or necessary for this boy, since he pulls his hair primarily at nap time and bedtime, but it is useful in some cases. If the child pulls his hair during a time-out, hand socks can be used.

Nathan J. Blum, MD
Philadelphia, PA

DR. BLUM is Assistant Professor of Pediatrics, University of PennsylvaniaSchool of Medicine, Children's Seashore House, Philadelphia.

TODDLER WHO BITES

Q A 3-year-old in our practice tends to respond to disciplinein day care by biting other kids. The parents are upset because this isthe best day care they have used and they need to keep their child there.At home, the child bites his siblings. How can I help the parents solvethis problem?

Terry W. Torgenrud, MD
Tacoma, WA

A Let's consider the developmental context of this child's behaviorand then look at the social and psychological situation of this particularchild.

Three-year-olds grow new teeth at the same time that they are havingnew social experiences. Their reliance on oral exploration and consolationdiminishes, self-regulatory behaviors that use language and social signalsincrease, and they often experience extended caregiving outside their homefor the first time.

All children this age need to be guided toward socially acceptable communication.At their stage of cognitive development, they think egocentrically. Theybelieve that their own thoughts and actions strongly influence everything,from caregiver mood to the quality of meals. As a result, they are unusuallyself-sensitive and react strongly to how they feel they are treated by others.

Individual circumstances, of course, also influence a young child's responseto stress and challenge. I wish I knew more about your patient: how longhe has been in care outside the home, whether he talks as well as his peers,what the birth order in the family is. Does he have a younger sibling whostill gets attention for infantile behavior? Is he expressing the hard workof separating from his parents and fulfilling the expectations of otheradults at day care? Is he letting people know that his life contains toomuch change, too many demands, or even too much positive excitement? Whileadjusting to day care, your patient probably needs more down time and close,loving attention from his family at the end of each "work day."Ask his parents about their own feelings of stress and support, too.

I would observe the child in the office and also ask his parents andcaregivers to describe his temperament, particularly his habitual reactionto novelty, stimulation, and exhaustion. Speaking of which, is he gettingenough rest and sleep, at home and in day care?

With this information in hand, you can support the child and parentsin several important ways: by demonstrating your sympathetic concern, bydeclaring that biting is common in children this age, by drawing attentionto the parents' caring and the child's competencies, and by offering insightsbased on what they've said about sources of tension for the child.

More attention to the child when he is not biting should help. The parentsand day-care workers should remove him from the situation when he is outof control or hurting others, and then distract him into another activity;they shouldn't humiliate him or shower him with attention. Physical punishmentand verbal threats will not work and could make things worse.

Your time spent in conference with this family can defuse tension, helpthe parents reinterpret feelings and intentions, and provide needed supportat a delicate touch point in this child's development.

Peter A. Gorski, MD, MPA
Boston, MA

DR. GORSKI is Executive Director, Massachusetts Caring for ChildrenFoundation, Boston, MA,
and Assistant Professor of Pediatrics, Harvard Medical School, Boston.