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Q Some teenagers in my practice present an exasperating problem. These young people have a normal physical exam, deny drug or alcohol use, may have tried cigarettes, and may have had sex a few times, using a condom. They have admitted the sexual experience in private during well-child visits. Parents of these patients complain that the teens are not motivated and have no real interests. They seem to lack direction and struggle through school; several have come close to failing a grade. When I talk to these teens about their parents' concern and how I share it, they usually shrug off my comments and have no response. How can I break this chain of apathy, and where do my responsibilities, as a pediatrician, lie?
A Your question is difficult to answer. It goes far beyond usual office pediatrics and addresses the fabric of our family life and society. I will answer your query as well as I canperhaps some readers would like to send in their own reply.
I commend you for attracting adolescents to your practice and for seeing them in private. That they are willing to tell you about some of their behaviors says a good deal about the trust they have developed in you. You are right to be concerned about their well-being and their future. As physicians for children and adolescents, it is our responsibility to prepare our young people as best we can for good physical and emotional health in adulthood.
One thought that I have kept in mind in my years in practice with adolescents (and as a parent of adolescents) is that one needs to call things the way one sees them, nonjudgmentally and without accusations. This means that you should let your adolescent patients know your concernsabout their lack of success in school or about difficulties at home or poor decision making in the use of substances, sexual activity, and other risky behaviors. Adolescents often "shrug off" (or seem to) our comments, but I believe that they are listening. It is important that adults other than their parents set up guideposts for them to follow.
I'm also increasingly convinced that all children (including adolescents) want to please their parents and other important adults in their life, and they want to be successful in school and with their peersbut sometimes they get off track. Every adolescent needs at least one adult whom they respect to invest in him or herto see something special about her, to inspire her to a higher level, and to serve as a model for how she might live her life. That adult person can be a beloved aunt or grandparent, neighbor, coach or clergyman; it also can be you, the adolescent's physician. You can listen to your patient's concerns, you can help her negotiate with her parents as she gains more and more independence, you can hold up a mirror to the teen by saying what you see, and you can share your own concerns about this young person's decision making.
Making suggestions about what activities the teen might enjoy participating in also sends a clear message that you value your patient as a person, that you care enough to invest energy in her. Find out what special skills this adolescent has and encourage activities that draw on them: volunteering in a senior or day-care center; working as a lifeguard or a camp counselor; participating in activities that require skill in computers, mechanics, physics, art, music, or drama; seeking out summer experiences that will test the teen's limits and strengths, such as wilderness training, working with the underserved, or taking an advanced precollege course.
Keep in mind that, for some young people, apathy is a marker for depression. Inquire about home relationships, sleep, change in appetite, peer experiences, school performance, and possible sexual abuse, and assess for sadness, substance use, and suicidality. Arrange to see your apathetic patients more frequently than every year or two. Schedule check-in visits for acne, contraception, a pelvic exam, and follow-up discussions. Your patient will get the message very quickly that you care about her. Don't give up on these adolescents and don't underestimate your ability to influence them. Some of their behavior is off-putting bravado.
Q An 18-month-old boy has recently started to gag himself and throw up, which greatly distresses his parents. He does this five or six times a week. No warning signs precede the behavior, and the vomiting follows no particular pattern. The toddler does have a history of gastroesophageal reflux, but he outgrew it around his first birthday. He is otherwise active and well. He has no secondary symptoms from the emesis, such as respiratory distress or weight loss. Nothing has changed in his diet or social environment. The child's physical exams have been normal on three different occasions. I did refer him for both an ENT and GI exam just to make sure there are no local anatomic reasons for the behavior; both specialists think it is behavioral. In case the behavior is a way to get attention, I encouraged the parents to make the cleanup brief and matter of fact and not to force-feed the child after he vomits. What do you suggest?
A This is a tough diagnostic dilemma. Is it nature? Is it nurture? Or is it an unlucky confluence of the two? The behavior sounds like ruminationthat is, a child who for some reason is making himself regurgitate stomach contents. But that is only descriptive; it tells us neither how nor why he does it.
The history of reflux is to be expected. After all, why vomiting as a symptom, rather than, say, crying or aggression? Symptom choice is always revealing and usually suggests some endogenous predisposition, like a difficult temperament or some somatic issue.
Let's assume that either a past or current propensity for reflux has something to do with this situation. Making this a behavioral diagnosis reflects the commonand usually inaccuratetheory that such problems must be either "organic or inorganic," rather than a complex transaction of the two. I might pursue further medical considerations. Would a pH probe be useful? Should you consider empirically starting a promotility agent for a short time to see if the symptoms abate and the cycle can be broken?
While the organic factor may help explain symptom choice, it doesn't explain the seeming volitional nature of the gagging. What is it about self-induced gagging that might be reinforcing for this child? Since such behavior is so regressive, I'd first make sure that the child's cognitive and emotional development are on track. Rumination has been described as a self-organizing, self-soothing sensation in some children. Might the behavior be a reaction to some sort of unspecified stress or lack of attention in the child's life? Are there other "sensory integration/sensory diet" issues that might respond to occupational therapy? I'd advise the parents to keep a detailed description of when the behavior occurs and what immediately precedes and follows the event. Perhaps you can discern some pattern. If some potential trigger emerges, clearly the treatment should deal with it.
But, as we all know, some worrisome symptoms in young children remain unexplained and resolve as mysteriously as they began. If the evaluation reveals no medical, psychosocial, temperamental, or developmental factors, and if the behavior seems to have no untoward effects, then reducing possible secondary gain and watchful waiting is the way to go. I'd advise the parents to continue to be matter of fact about cleaning up the child and pay no further attention to the behavior. If symptoms do not abate by the time the child is 2 years old, I'd revisit the work-up to ensure that nothing has been missed.
Editor's note: For a discussion of the interplay of organic and nonorganic causes of gastroenterologic disorders, see "Practical approaches to common gastrointestinal symptoms" in the April 2000 issue, also accessible at www.contpeds.com .
Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2001;6:37.