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Q A 2-year-old boy hides his face when he notices a stranger looking at him. If a stranger insists on talking to him, he cries. Is this normal?
A These behaviors are very likely normal, depending on their intensity, persistence, and associated manifestations. This child's shyness and rather intense fear of strangers may be viewed as a reflection of such age-appropriate developmental themes as the importance of ongoing, secure attachment to familiar caregivers such as parents and the struggle for autonomy and independence characteristic of the "terrible twos." This struggle is typically accompanied by some anxiety, which may manifest as reemergence of the separation anxiety and fear of strangers more characteristic of 9- to 12-month-olds.
If the behaviors that worry the parents occur only briefly and in select circumstances, and are not accompanied by other social interactions of concern (such as with parents, siblings, peers, or familiar adults), it is appropriate to demystify the behaviors. Do this by invoking such developmental themes as attachment, autonomy/independence, and preoperational intelligence, and by monitoring the child to ensure that these stage-related behaviors are transient and appropriate. Encourage the parents to reassure the child when he is upset.
If these behaviors are particularly intense, persistent, or accompanied by other fears or problems with social interaction, however, further developmental evaluation may be indicated.
Q I need advice about finding an appropriate approach to sleep disorders in children with ADHD. What options do parents have, other than giving an additional dose of stimulant before bedtime?
A Many children (as well as adolescents and adults) with ADHD have a problem getting to sleep. Although some observers associate this difficulty with patients' stimulant medication, I believe the problem develops because of the medication wearing off. Practitioners often prescribe the third dose of daily stimulant medication to be given, if needed, after school, in which case it wears off around bedtime. A dose of medication after dinner instead of in the afternoon or, if necessary, a fourth dose several hours before bedtime may be more beneficial to these patients.
With regard to other options, the waters become more murky, although a variety of regimens have been tried.
Regardless of the strategy parents use to induce sleep, they should minimize the child's exposure to stimulation around bedtime by, for example, avoiding use of the computer, watching television, or listening to lively music. The goal is for the child to feel relaxed and positive about family interactions and free of stress. Some of my patients have worked with a psychologist who uses hypnotism, which sometimes is helpful.
Many children continue to have trouble getting to sleep regardless of the intervention. I firmly believe that pediatricians should avoid using powerful psychoactive drugs primarily to induce sleep, especially in children who are being medicated for other problems, including ADHD.
Q A 4-year-old boy in my practice is reluctant to defecate in the toilet. Whenever he has to defecate, he asks for pull-ups. He has no problem urinating in the toilet. Mom has tried the potty training chair without success. The child is not constipated, and the clinical exam is noncontributory. He has no siblings.
A Your first priority is to keep this boy from becoming constipated. For this reason, his parents should not withhold pull-ups and diapers, which usually results in withholding of stools, leading to painful bowel movements, more holding back, and impactions.
This is how I recommend the parents proceed:
Providing an incentive for releasing a normal-sized bowel movement into the toilet is an essential part of the program. The best incentives are privileges or food treats, not possessions. Good food treats are ice cream sundaes, popsicles, candy, or soda pop. Video treats are also motivating, such as one hour of movie time or computer game time. Incentives vary with the child and often are arrived at after the pediatrician asks about the child's favorite activity or toy. Some children will perform for extra bike time or reading time with Dad. Encourage the parent to "make the child an offer he can't refuse."
Incentives don't work with some strong-willed children. They need to have a disincentive added to their treatment program. The one I've found to be most powerful is to put the child into a video-free world. That means no TV, video, or computer game time until the child learns to use the toilet or potty for bowel movements. The parent should substitute lots of physical affection and parent contact time. For every normal-sized bowel movement the child releases into the toilet, he receives two hours' access to TV, video, or computers. Otherwise, all TV and video viewing is in a closed room that only poop-trained children have access to. This keeps the child's siblings from becoming too upset.
With simultaneous use of incentive and disincentive programs, the average child responds in one or two weeks, and even recalcitrant poopers within two months.
Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2001;7:31.