BEHAVIOR:
ASK THE EXPERTS

2-YEAR-OLD HIDES FACE AROUND STRANGERS

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?

Muhammad Waseem, MD
Bronx, N.Y.

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.

Paul Dworkin, MD
Hartford, Conn.

DR. DWORKIN is professor and chairman of pediatrics, University of Connecticut School of Medicine; physician-in-chief, Connecticut Children's Medical Center; and director and chairman of pediatrics, St. Francis Hospital and Medical Center, Hartford, Conn.

SLEEP PROBLEMS IN ADHD

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?

Wanda Lo, MD
Los Osos, Calif.

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.

• Dietary measures. Some people believe that consuming foods high in tryptophan, such as milk, before bedtime has a calming effect on the child. Others think that the child should try eliminating, one at a time, foods consumed around bedtime to determine if any have an adverse effect on sleep. I have not found this technique helpful.

• Antihistamines. Many people use these agents to help ADHD patients get to sleep. I am not a fan of this strategy.

• Clonidine. Many practices add a small dose of clonidine to the child's stimulant medication. I have done so at times, but have come to believe that it is not a good idea to prescribe a medication for its side effect. Clonidine does work in many patients, however, and, at a small dosage, probably does not create a major problem. Some practitioners give clonidine to children who have severe conduct or oppositional behaviors, trying to treat both situations simultaneously. Whether combining clonidine and stimulant medications can have adverse effects on the cardiovascular system is open to question.

• Other medications. In children who seem severely depressed, one of the antidepressants, which have a soporific effect, could be helpful. Possibilities are trazodone (Desyrel), several of the tricyclics (we now know these medications may cause problems in children, however), and some of the newer antidepressants, which seem to produce the needed effect at bedtime. The most efficacious of the latter group appears to be mirtrazapine (Remeron). Neuroleptics, especially risperidone (Risperdal), have also been fairly effective in encouraging sleep and are often used in children who have severe aggressive behavior—so that we treat two conditions at the same time.

• "Natural" substances. Valerian, an herbal remedy, is widely used in Europe to help children with ADHD sleep. I have seen some positive results with valerian, but cannot be sure if more than a placebo effect is responsible. Melatonin, a posterior pituitary extract, is commonly used for sleep difficulties, including getting to sleep. I have used melatonin fairly extensively, at a dosage of 1 to 3 mg an hour before bedtime and have found it to be extremely successful in many patients. The drawback, of course, is that we don't have good evidence, especially in children, about adverse events that may develop in the future. Nightmares have been associated with continuous use of melatonin. [For a discussion of herbs and supplements for ADHD, see "At least it's natural . . . Herbs and dietary supplements in ADHD" in the September 2000 issue, also accessible at www.contpeds.com .]

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.

Martin Baren, MD
Orange, Calif.

DR. BAREN practices educational, behavioral, and developmental pediatrics in Orange, Calif.

4-YEAR-OLD WON'T DEFECATE IN TOILET

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.

Syed Rizvi
Harlingen, Texas

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:

• Put the child in charge of solving the problem. Do not even mention poop or potty when the child is around. Pretend that the potty problem is "boring." That helps to diminish the power struggle.

• Dress the child in underwear at the start of every day.

• Make pull-ups available for bowel movements, but put them in a distant room. Increase the inconvenience by insisting that the child get his own pull-up if he wants to use one.

• Make the potty chair convenient by keeping it in whatever room the child is in.

• Avoid all reminders to use the toilet, and don't make practice runs to the bathroom or force the child to sit on the potty.

• When the child is soiled, help him clean up. If he is uncooperative, "ground" him until he wants to be changed.

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.

Barton D. Schmitt, MD
Denver, Colo.

DR. SCHMITT is director, Encopresis- Enuresis Clinic, at The Children's Hospital of Denver. He also is professor of pediatrics at the University of Colorado School of Medicine and a member of the Contemporary Pediatrics editorial board.

 

Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2001;7:31.