Behavior: Ask the experts

BEHAVIOR: ASK THE EXPERTS

TEEN TRYING DRUGS AND ALCOHOL

Q How would you counsel a 16-year-old girl who is experimenting with drugs and alcohol? She never drinks when she will be driving, has one or two beers on the weekends at parties, and answers No to the CAGE questions. She has tried marijuana "once or twice" and liked it. She is perfectly willing to have a drug screen. The young woman is maintaining her usual straight A average in school and says she is not sexually active (she thinks using tampons is "gross"). Her parents are not worried about their daughter; they like that she participates in various activities and approve of her friends.

Hari Cheryl Sachs, MDRockville, MD

A You have two special challenges here. Your knowledge of this teen's experimentation probably comes with a "guarantee" of confidentiality and, more important, your patient doesn't see the occasional alcohol and marijuana use as a problem at all. This makes it difficult to avoid having your counseling come across as preaching or sermonizing.

I would start by getting as much information about this adolescent's behavior as you can, to determine the risks she is facing. What is her attitude toward tobacco use? Has she used it, and do her friends? Has she ever been drunk or seriously intoxicated? Has she ever made a decision she regretted while intoxicated with marijuana or alcohol? Has she ever been in an uncomfortable sexual encounter when she was drinking at a party, a "date near-rape" or other situation? Is she aware of any friends who have been in such a situation? Have any friends been in trouble with law enforcement or been in a car collision while intoxicated?

Make a strong statement about how concerned you are for the adolescent's health and well-being, such as, "As your doctor and someone who cares very much about your health, I need to tell you that I'm worried about your alcohol use." Be sure to refer to "young people" in general instead of "you" when you can. Tell your patient how troubled you are about the unwanted sexual encounters that intoxicated young women are subject to. Point out that half of girls who have first sexual intercourse by the age of 16 are intoxicated at the time, and half later regret their action. These young women are unlikely to use condoms at these encounters; they risk contracting a sexually transmitted disease (possibly HIV), pregnancy, and the collapse of their self-esteem—all because they are intoxicated.

I'd say it worries me that parties where guests are drinking may get out of hand and that even though she might not be drinking herself she might be in a car with a driver who was. I'd help her develop a "rescue" plan, calling her parents if she needs a ride home, for example. I'd remind her that police arrest everyone at a party where illegal substances are being used, not just those who are intoxicated.

While I'd definitely support this teen's plan not to be sexually active, I'd let her know that I fear that she might become the victim of "date rape" or "acquaintance rape" by being with someone who is intoxicated and overcame her. Finally, I'd express my concern that her marvelous, still-developing brain cells are being bathed in toxic chemicals when she has so many wonderful things yet to accomplish.

Carole Stashwick, MDLebanon, NH 

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

2-YEAR-OLD VOMITS AND CRIES AT BEDTIME

Q I have a 2-year-old in my practice who vomits easily with prolonged crying. This makes enforcing a bedtime routine extremely difficult. The child insists on going to bed very late (10 to 11 p.m.), and if her parents try to put her in the crib before she is ready, she cries until she vomits—usually after 15 to 20 minutes. They then have to take her out of the crib and clean her. If they place her right back in the crib, she will cry again until she vomits. She also sometimes vomits during the day if she cries too hard. The parents do not believe she is vomiting on purpose, but they are worried that they are spoiling her.

Sheryl Cohen, MDMission Hills, CA 

A This is a vexing situation, but the application of some relatively simple principles probably will be successful. I assume that the child has no other physical, developmental, or behavioral problems. It seems likely, however, that by now she has discovered that vomiting prolongs the day and may be exploiting this. It might be useful to explore whether the child has shown any other manifestation of separation anxiety.

Here are my suggestions for this child's parents:

• Readjust the child's sleep schedule so she follows an earlier and more regular bedtime. The parents could make this change abruptly, but it may be easier for everyone to gradually move the bedtime earlier by 15 minutes a day until they get to the desired time.

• Avoid feeding the child before bedtime.

• When the child is put to bed, tell her that there will be no more drinks, trips to the toilet, visits, or other "curtain calls."

• Ignore any cries for attention

Several approaches can be taken to the vomiting. Some observers believe that there is no harm in leaving the child in the vomitus for a few nights until she learns that this activity will not get her parents' attention. What these parents have been doing—taking the child out of the crib—represents the opposite extreme. This is likely to reinforce the annoying behavior. A response that falls between these two extremes may be best: Wipe off the child's mouth while she is still in the crib, lay a thick towel over the puddle, and leave the room as quickly as possible. The rest of the mess can wait until morning.

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.

TODDLER BITES AT DAY CARE

Q Jeff is a 28-month-old who has had a problem with biting for the past 10 months. As of about two months ago, Jeff's parents eliminated the problem at home by using time-outs and a star chart for bite-free days. The biting continues at day care, however, where Jeff bites other children, usually in retaliation for taking his toy or pushing him. Parents of these children are complaining, and the day-care director has become less understanding since Jeff bit her son. Time-outs at day care reportedly have not helped. What can I recommend?

John Bosley, MDEnglewood, CO

A Biting is a concealed weapon that may be brandished by an angry or frustrated toddler. When children in a day-care center have a verbal conflict, for example over a toy, a caregiver usually can resolve it easily; biting, however, tends to evoke zero tolerance by the angry parents of the injured child. Dependent on day care to continue their jobs, the anxious parents of the aggressive child often consult their pediatrician in ill-concealed desperation.

Correctly implemented, time-out is highly effective. When the child bites, the day-care worker should sit down next to the biter, establish eye contact, and state very firmly: "No biting! Biting hurts!" She then puts the child in time-out. Given the usual sanctions, it is surprising that this child has continued to bite for 10 months in day care, but not at home. Why has the behavioral management that succeeds at home not been transported to day care? It might be useful for the parents to share their approach with the day-care staff. A phone call from you to the director of the day-care center might also help resolve the problem.

I suspect that the close physical presence of the parents in the home may explain the difference between the child's behavior at home and in day care. Preventive intervention requires that the parent or other caregiver intercede quickly when aggression seems imminent. A complementary preventive strategy would be to teach the other children in the day-care center to call out, "Help!" when they feel threatened by the child. When an authoritative adult notes the early warning signals of anger, he or she should sit down with the child and touch him, which may disarm the threat. An angry child may also be distracted or moved to another activity. Such attention requires an adequate caregiver-to-child ratio.

Morris Green, MDIndianapolis, IN

DR.GREEN is Perry W. Lesh Professor of Pediatrics, Indiana University School of Medicine, Indianapolis, and a member of the Contemporary Pediatrics Editorial Board.

6-YEAR-OLD IS BULLIED BY PEERS

Q A 6-year-old boy in my practice is miserable because other kids pick on him. He is a clever child, though he doesn't seem to like playing games by the usual rules. Because he doesn't quite fit in, this child often is the target of taunting, which I'm sure is reinforced by his emotional reactions. The child clearly needs more self-confidence to shrug off his tormentors as well as some lessons in appropriate social behavior to help him get along. Any suggestions?

Roy Benaroch, MDRoswell, GA

A Childhood bullies are common. According to the National Association of School Psychologists, about one in seven school children—that's about 5 million kids—have either been a bully or been the victim of one. Bullies tend to zero in on children who appear vulnerable. Victims may be passive or anxious or stand out in some way, like this child who doesn't play games by the usual rules. Your description of the child as "clever" might have negative implications, meaning that he is crafty, manipulative, or cunning. This would invite taunting in this age group, where normalcy is critical to acceptance. Mild bullying may take the form of physical aggression, gossiping, embarrassing the victim, calling him names, or teasing. Moderate bullying includes demeaning or humiliating the victim or taking his possessions, while severe bullying consists of threats and violence.

To break the cycle, the first step is to reassure the boy that you and his parents can help him find effective ways to respond to the teasing and to change his behavior to stop it from happening. Parents can reinforce this message by reading with him such books as Arthur's April Fool, by Marc Brown, and Bullies are a Pain in the Brain, by Trevor Romain, which include practical suggestions for dealing with bullies. The parents should not overreact or try to take matters into their own hands, which often makes the situation worse. They should encourage their son to tell them how he feels; the very act of unburdening can help a child. They should role-play bullying with their son so he can practice his response. He should look the bully in the eye, for example, and say, "I don't like your teasing. Stop."

This child may be less apt to be bullied if he gets some additional practice with socially appropriate group activity. Suggest joining a structured after-school activity such as a martial arts class or a soccer team. These activities have appropriate adult supervision but will allow him to interact with other children. Joining the Cub Scouts or a Boys and Girls Club is another possibility. The child needs to boost his self-esteem both in response to the immediate problem and to enhance his future development.

Marilyn Augustyn, MDBoston, MA

DR. AUGUSTYN is Assistant Professor and Director of Training, Division of Developmental and Behavioral Pediatrics, Boston Medical Center.

READERS: QUESTIONS WANTED!

Do you have a question about behavior that you'd like us to have one of our consultants answer? Please send it to:

Behavior Q/A
Contemporary Pediatrics
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Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2000;4:45.