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BEHAVIOR: ASK THE EXPERTS
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Q The mother of a 4-year-old boy says that her child's behavior is uncontrollable. The boy grabs other children's private parts in public and laughs inappropriately. He was found naked under the bed sheets with a cousin, whom he told how to make his penis bigger. The child's mother is very young and seems resigned to his behavior. The boy was in a receiving home overnight two years ago for burns. Mom alleges he was abused there. Furthermore, she says the boy's father stimulated the child orally; the father denies the accusation.
I have already requested a psychiatric interview for possible sexual abuse or molestation.
Bina Adigopula, MDLa Mesa, CA
AAs you have recognized, this 4-year-old boy is very likely to have been sexually abused or molested. His "uncontrollable behavior" is probably driven by anxiety and is highly sexual. His grabbing of other children's "private parts," explicit sexual knowledge, and use of that knowledge in bed with a cousin are all obvious inappropriate behaviors. Although some of his behavior could be related to anxiety, attention seeking, or comorbid conditions such as depression or attention deficit disorder, the overwhelming likelihood is that much of the behavior is secondary to sexual abuse or molestation.
A second area of serious concern is the mother's functioning. Why is this "very young" mother "resigned"? Is she unable to discipline her son and help him control his behavior? Is she depressed or using substances that result in abuse or neglect? Was she neglected or physically or sexually abused as a child? Does she have physical limitations that make it hard for her to protect her child or provide adequate care? The child was removed from home for two days at age 2 for burns, and the mother accuses the father of abusing him sexually. Was it she who was responsible for the burns or for the sexual abuse? Some gentle questioning, if you are comfortable in your relationship with her, may help narrow the list of possible reasons for her "resignation."
Although we pediatricians tend to accept and value a parent's report, the safety of the child has to be our primary concern. This child is in danger. He is at direct risk if the mother or father is the perpetrator of sexual abuse, if there is domestic violence in what appears to be a very hostile relationship between the parents, or if the mother cannot control her son's behavior. I fully agree that a child psychiatric evaluation needs to be obtained, but I recommend that it be in the context of an immediate referral to a children's protective services agency. I would explain to the mother that though you believe her, a physician is required under the law to report any suspicion of abuse. This reporting, though it may turn out to be unnecessary in the present case, has protected many children from danger and must occur. After this required first step, you can do your best to maintain a relationship with the mother and offer to serve as her advocate in the evaluation process.
Michael S. Jellinek, MDBoston, MA
QDuring an annual physical, I noticed my 8-year-old patient anxiously biting his nails. Close examination revealed that his nails were bitten almost down to the cuticles and the skin over his fingertips and knuckles was quite raw. On questioning, his mother explained that he has "always" bitten his nails. Apparently, episodes of paronychia and bleeding are frequent. The child is an excellent student and seems to push himself to be the best in everything he does. His mother describes him as "high strung" and "compulsive." The history revealed no recent psychosocial stressors. The child is otherwise in excellent health with no significant past medical history. We have tried to break the nail-biting habit with bitter medicine applications, wearing mittens (poor compliance), positive reinforcement with rewards for less biting, and relaxation therapy, but the behavior continues. Do you have any suggestions?
Anu Diwakaran, MDSt. Louis, MO
AYou've tried many ways to help your patient stop biting his nails, without success. I'd go back to the beginning and ask your young patient how he feels about his nail biting and whether he'd like to stop. Changing a well-established behavioral pattern like persistent nail biting requires motivation to change and a willingness to solve the problem and endure some discomfort. You might focus his attention on the problem by helping him come up with a list of pros and cons for his nail biting. On the con side, he might agree that biting his nails causes pain, infections, and ugly fingers and embarrasses him. But on the pro side, the habit might be a nearly unconscious way to relieve stress, and trying to stop might cause him more distress than he wants to deal with.
If your patient clearly indicates that he wants to stop, ask him what he thinks might work. Wearing Band-Aids on the fingers can serve as a reminder and allows the nails to heal. If he agrees to try the bitter topical medication again, he can apply it himself; I would not consider using it against his will. Chewing sugarless gum may distract him from nail biting. He might enjoy buying nail clippers or other nail-care items and keeping them in his book bag or pocket. Ask the boy to think about when he bites his nails. While he is reading? While watching TV or playing computer games? While sitting in math class? It might be possible to help him anticipate those times and to work out a distraction strategy.
It may well be, however, that your patient is not ready to change his habit. Neither negative reinforcementnagging, shaming, punishing, using bitter medicationnor positive reinforcement will make him stop until he is ready. I would not worry that this boy's nail biting indicates significant psychopathology, and obsessive-compulsive disorder also seems unlikely. I'd let your patient know that you'll be happy to help him figure out ways to stop biting his nails, when he's ready. In the meantime, ask his parents and family to ignore the behavior and to stop all nagging, threats, and scolding.
Carole A. Stashwick, MD Lebanon, NH
DR. STASHWICK is Associate Professor of Pediatrics and Director, Adolescent Program, Children's Hospital of Dartmouth, Lebanon, NH.
Julia McMillan. Behavior: Ask the experts. Contemporary Pediatrics 2000;8:39.