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BEHAVIOR: ASK THE EXPERTS
Q The mother of a 3-year-old girl is concerned that her daughtersteals the toys of other children. According to her mother, the child hasplenty of her own toys at home. She does not have any siblings. The girlis healthy and her development is normal for her age.
Muhammad Waseem, MD
A Not a court in the land would convict this "thievin' toddler"of larceny, and for good reason. "Stealing" implies that the perpetratortakes what belongs to another even though she understands personal propertyrights, knows her behavior will cause someone else loss or distress, andhas enough self-regulatory controls not to go after everything she desires.The thief also understands that society prohibits following natural egocentricinclinations.
The 3-year-old meets none of these developmental criteria, so it's nosurprise that this little girl--apparently an otherwise model citizen--engagesin socially unacceptable behavior every now and then. The stealing is areflection of her developmental level, not a marker of incipient criminaltendencies. Given her developmental limitations, it is unlikely her parentscan teach her why she shouldn't take others' belongings. (Perhaps they canstart when she's 4 and begins to appreciate the beauty of rules.) They can,however, teach her that taking other children's things is not acceptablebehavior. Toddlers are very pragmatic creatures and can quickly learn thata behavior is not in their best interest, even if it's not clear why it'sbad.
The parents, and any other caretakers of this little girl, should usethe standard behavior modification techniques that they probably alreadyuse for undesired behaviors: Catch her being good ("It's so nice theway you're sharing the toys"), give her time out for egregious stealingepisodes (particularly when they occur right after she has been warned notto take things), let her see the natural consequences of her act (returnthe pilfered item to its owner and ensure that the victim, not the thief,receives a lot of attention), and express disapproval when she takes anotherchild's toys. Finally, be sure the parents don't misinterpret the child'sbehavior, opening the door to unwarranted disparagement of their perfectlynormal daughter.
Steven J. Parker, MD
Q A 5-year-old girl in my practice refuses to speak in socialsituations, but can and does speak to certain people when she chooses (selectivemutism). What management suggestions do you have?
Joseph Curi, MD
A Children with selective mutism speak in some situations butnot in others. Their failure to speak is not chronic and does not impairplay, school, or socialization. You need to distinguish in which of twolarge groups of children with selective mutism this 5-year-old belongs:children with underlying mixed receptive expressive language disorders orchildren with anxiety disorders. These two groups are not clearly differentiatedbecause children with mixed receptive expressive language disorders maybe anxious. Typically, those with the language disorders first show signsof selective mutism during the preschool years, while those with anxietydisorders are more likely to be of school age. Your 5-year-old patient ison the border between these two age groups, which complicates matters.
You can most likely make the diagnosis from the history. When did thechild first achieve early language milestones? Have her language abilitiesregressed? Does she speak clearly? Does she fail to speak just in certainsituations, such as school or unfamiliar settings, or is it a more generalproblem? Does this little girl show symptoms of anxiety--difficulty separatingfrom her parents, excessive shyness, increasing withdrawal in social situations,phobias, and inhibitions in nonverbal areas--and do these characteristicsaffect normal development? Ask about how the child does in school and whethershe makes and keeps friends. Is she moody? Does she have hallucinations,engage in rituals, or show obsessive-compulsive characteristics? Any oralmotor dysfunction or a family history of selective mutism, separation anxiety,social phobia, panic disorders, affective disorders, or extreme shynessmay suggest in which of the two groups the child belongs. Psychic traumausually is not associated with selective mutism.
The physical examination is typically unrevealing, but pay particularattention to oral motor function. Listening to a tape recording of the childspeaking may be useful. If you are concerned about the girl's speech orlanguage, obtain an evaluation. If the recorded conversation seems full,easy, and age appropriate you may infer that anxiety is at the root of thechild's problem. If so, a psychiatric evaluation may assist in the diagnosisand treatment.
The goals of therapy are to alleviate anxiety and treat any underlyingdisorder. Depending on the cause of the selective mutism, family therapy,a pharmacologic or psychiatric approach, speech therapy, behavior modification,or some combination of these therapies may be the best way to go. Parentsmay want to obtain more information on selective mutism from the SelectiveMutism Foundation, Box 450632, Sunrise, FL 33345-0632.
Bruce K. Shapiro, MD
Q I just saw a 17-month-old twin who recently had several episodesof otitis media associated with ear tugging. Since then, she has begun topull out the hair behind her ear when she is teething and to pull out thehair in front as well. She also engages in these behaviors when she is angry,eating, or bored. She is the more aggressive twin and has begun to pullout not only her own hair but that of her twin and her 6-year-old sister.This trichotillomania is not self-comforting behavior. The mother has cutthe child's hair short, but the pulling continues and the child has begunto eat the hair. Please advise.
Hal Gordon, MD
A Initially, this infant's hair pulling may have been in responseto the pain of teething and otitis media, but at this point something morecomplex is going on. The child pulls her hair in several different situations,and the behavior is likely to have several different functions. A detaileddescription of what happens immediately before and after she pulls her hairwould be helpful in understanding the behavior. When does she pull her twinsister's hair, for example? Why is her 6-year-old sister allowing a 17-month-oldto pull her hair? You describe this infant as the "more aggressive"twin; if the hair pulling is an aggressive behavior, it should be managedin the same way one would manage hitting or biting. A stern No is sufficientfor many 17-month olds, but if the behavior continues, she should be removedbriefly from the situation and not receive any additional attention.
When the child pulls her hair when she is angry, do the parents acquiesceto her demands, reinforcing the behavior? Does pulling her hair while sheis eating get her their attention? You indicate that the hair pulling isnot a self-comforting behavior, but it may serve this function some of time.Like thumb sucking, it may also be self-stimulating when the child is bored.If the child sucks her thumb at the same time she pulls her hair, treatmentof the thumb sucking often stops the hair pulling.
General guidelines for treating hair pulling in young children are asfollows:
In children this age, I usually emphasize the first of these guidelinesby asking the parents to praise, pat, hug or otherwise show the child attentionat least 50 times a day when she is behaving appropriately. Treatment ofthis child is urgent because she is eating the hair and could develop ahair ball, which can obstruct the intestines. If the child continues topull her hair despite treatment, consider referral to a mental health professionalwho is knowledgeable about the behavioral treatment of habit disorders.
Nathan J. Blum, MD
Q Parents of children with a weight problem or enuresis oftenwant to discuss their child's problem in private without including the child.Typically, the child is at least 6, old enough and smart enough to knowwhat is going on. Trying to discuss these problems without including thechild may make the youngster believe he has a serious problem he knows nothingabout. What do you advise?
Theodora Ewusi-Mensah, MD
A I often encounter this problem when I do behavioral-developmentalconsultations. I agree that a child is likely to misinterpret a requestthat his or her problem be discussed out of earshot so I never agree toleave the child in the waiting area while I talk with the parents somewhereelse. If a parent says, "David, go back to the playroom; I want totalk with the doctor in private," I respond, "I need to have Davidhere when we are discussing his problem. I'll be happy to call you tomorrowto see how David is doing." When the visit is over, I may also tellthe parents, "You are welcome to make an appointment for yourself ifyou wish."
When I was in primary pediatrics, I forestalled problems of this sortby telling parents up front that I did not think it was in the child's bestinterests to send him out while we discussed him. I also noted that occasionsmight arise when parents might want to make an appointment by themselvesto make me aware of sensitive issues involving the family.
Parents accept these policies and understand them. To make them work,however, you must always remember to call a parent if you have said youwill do so.
Karen N. Olness, MD
. Behavior: Ask the experts. Contemporary Pediatrics 2000;1:52.