Toilet tantrums that start with a flush

Q I have a 4-year-old female patient whose mother is concerned about obsessive-compulsive behavior. For example, when someone flushes a toilet at home, the girl insists that everyone in the vicinity be standing on nonlinoleum flooring (i.e., outside the bathroom) before the flush ends. If this demand isn't met, she bursts into tears, stomps her feet, or lies on the floor crying; this emotional upset lasts several minutes. The child is otherwise healthy and is very bright; there are no significant family or social issues and no family history of OCD.

The parents have tried to accommodate their daughter's needs when it seems reasonable, but they try not to capitulate every time. They ignore her when she throws tantrums, which eventually extinguishes the behavior, but they are concerned about the increasing intensity of her emotional response and don't want her compulsions to escalate. They have explained to her that they understand it upsets her when people are on the linoleum when the toilet finishes flushing but that such an intense response is not warranted. They have occasionally tried to apply worst-case scenario logic ("What's the worst thing that would happen if [compulsion isn't satisfied]?").

What advice can I offer to this family?

A An intriguing situation, and several questions come immediately to mind. Are there other comparable recurring events or is the toilet flushing ritual the only one of such quality and magnitude? That makes a big difference in the evaluation and management. Also, as usual in the understanding of behavior problems, but especially here, an assessment of the child's temperament would be helpful. Is this child an intense, negative, and inflexible one who reacts strongly to even small matters?

If the toilet routine is the only example of this sort of behavior, then applying the term obsessive-compulsive behavior to this girl is probably not appropriate. On the basis of available information, this sounds like an extreme manifestation of a child manipulating her parents and of parents having trouble setting limits on unacceptable behavior. I would call this more a dysfunctional parent-child relationship than a dysfunctional child.

A reasonable plan of management would be as follows:

Having made further inquiries to make sure there truly are no other problems, you should point out to the parents that they are being led into a bizarre reaction pattern in response to an irrational demand from their very young child.

The parents should discuss with their child what her fears might be and explain that her insistence on this routine is unacceptable behavior and will have to stop. Their compliance with her demands should be discontinued immediately. As usual in this situation, the child will probably get worse before she gets better, so the parents should be forewarned. After a few days, the child's insistence on the ritual should diminish and then disappear.

If this simple regimen is ineffective, there may be more here than meets the eye. If further interviewing uncovers additional underlying problems, ones that lie beyond the scope of pediatric counseling, referral to a mental health specialist may be indicated.

William B. Carey, MDDR. CAREY is director, behavioral pediatrics, division of general pediatrics, The Children's Hospital of Philadelphia.