BEHAVIOR:
ASK THE EXPERTS

WHY DOES THIS TODDLER FLINCH?

Q I provide care for a 26-month-old boy named Bo whose parents are concerned about his habit of flinching, which has developed over the last 12 months. When Bo is reprimanded or, especially, when he is approached, he flinches or winces and brings his hands up to his face. On one occasion, for example, in typical toddler fashion, he ignored three requests from his mother to leave the playground and get into the car. When, after the third request, she approached to carry him to the car, he flinched. Bo's mother says he seemed fine once she picked him up and didn't put up any more fuss than normal for his age. She tells me that a relative who has seen this type of behavior in abused dogs said that Bo's flinching is abnormal and may mean that her son is being physically abused.

Bo lives with his parents and his 4-month-old sister. Both parents work outside the home. He has attended the same in-home day care from infancy. His sister and two other children very close in age also attend. He loves going to the sitter's home, and his mother is confident that he is getting excellent care there. A boy who attends day care with Bo was hitting the other children at the time Bo started flinching. The hitting stopped, but the flinching continued. How should I advise the parents?

Robert Dixon, MD
Marietta, Ga.

A I can only speculate about answers to the numerous questions this vignette raises: Does Bo flinch when people other than his mother approach him? Does he have other unusual behavioral symptoms? Do the parents have problems in their marriage or at work? What disciplinary measures do they and the day-care provider use? Is Bo unusually fearful or sensitive? It is interesting that the flinching began around the time Bo's mother became pregnant with his sister and persisted for about a year before it was brought to your attention.

I suggest the parents ask the child-care provider why she thinks Bo flinches. If there is no evidence of abuse, parental disciplinary measures seem appropriate, and the child regularly receives praise, affection, and one-to-one time with his parents, I recommend extinguishing the behavior simply by ignoring it.

Morris Green, MD

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

A LONG AND PUZZLING SILENCE BETWEEN SIBLINGS

Q I have two patients, siblings, a 19-year-old girl and a 17-year-old boy, who stopped talking to each other during grade school. Nobody in the family remembers why. Any advice?

Achilees E. Litao, MD
Bronx, N.Y.

A This question is unusual. Siblings often have differences and may not get along for periods of time, but long estrangements are more common in adulthood than late childhood and adolescence. Many questions come to mind because your query contains so little information about the situation. I will assume this is an intact family that has lived together with this brother and sister not talking to each other from, let us say, fourth or fifth grade to the present day.

Imagine what life must have been like in this family for all those years: silent and awkward meal times, difficult vacations, little contact at the siblings' activities or sporting events, and visits from grandparents that were marked by tension. Could this brother and sister just be stubborn children who became entrenched in a kind of staring contest? I doubt it. The level of family pressure and the developmental changes of late childhood, puberty, and young adulthood would overwhelm simple stubbornness or rigid temperaments. Could the siblings have some form of social awkwardness, anxiety, or inability to relate? Again doubtful, because in most such circumstances, siblings find comfort in their mutual familiarity. I assume that family members, mutual friends, and others made a number of efforts to reverse the pattern of silence with no success.

So I am left with clinical speculation. I wonder if there is a family secret. Perhaps the silence is not the problem but the solution to a secret so fraught with anxiety or horror that avoiding revelation is worth this very costly remedy. Considering when the silence started, it is likely that the secret involves the whole family, but it is possible that it is known only to the two siblings. What could it be? Did one sibling feel massively betrayed by the other through some disclosure? Was a crime committed? Were sexual boundaries crossed between siblings or between a parent and a sibling? Was there some other basis for overwhelming jealousy or hatred? Did one parent swear one or both children to secrecy? I suspect the emotional burden on both siblings is high.

I would review each teen's major areas of functioning—school, friends, family, activities, and mood—to assess any damage from social isolation and underachievement. If my speculation is correct, it is unlikely that you will breach the wall of silence unless you have a long-term, trusting relationship with the siblings and can offer a strong assurance of confidentiality.

I usually try to develop a longer differential diagnosis for family-based behavior patterns. Because of the wide range of normal variations encountered in primary care pediatrics, I often favor less serious psychiatric disorders over more serious ones. I may be wrong, but this question has given us a chance to consider family behaviors that do not seem to make sense. Primary care pediatricians should consider that unusual behaviors may be solutions for family secrets. With trust and care, they are better explored than maintained.

Michael S. Jellinek, MD

DR. JELLINEK is senior vice president for administration and chief, Child Psychiatry Service, Massachusetts General Hospital, and professor of psychiatry and of pediatrics, Harvard Medical School.

CHILD REFUSES TO HAVE BOWEL MOVEMENTS IN THE TOILET

Q A 4-year-old boy in my practice has been toilet trained for urine for about a year. He began withholding bowel movements during toilet training, so I advised his mother to keep him in underpants but give him a diaper to use when he has bowel movements. This practice has prevented withholding and constipation, but the child still refuses to use the potty for bowel movements. His mother has tried different potties and all kinds of positive reinforcement, such as stickers and presents, but without success. What help can you offer?

Barbara Gardner, MD
Boca Raton, Fla.

A Surprisingly, this is not an unusual problem. One suburban private practice reported that it occurred in as many as 20% of children during toilet training. In most cases, it resolves by 4 years of age. Rarely, the behavior persists well beyond 4, and I occasionally see 5- to 7-year-olds who request a diaper for bowel movements.

Your advice that the family continue to give the child diapers for bowel movements is very important. When, as often happens, frustrated parents throw away the diapers, children may withhold bowel movements for days, which may lead some to develop encopresis from constipation and stool overflow.

When refusal to use the toilet for stool persists, as it has in this child, I believe it results from fear or a specific phobia related to using the toilet for bowel movements. Sometimes painful defecation is the reason, but in most cases the cause of the fear cannot be determined. Regardless of the cause, my first goal is to get the child to have soft bowel movements without straining. Two to three teaspoons of mineral oil twice a day often works.

My second goal is to develop a series of steps that allow the child to have bowel movements progressively closer to the toilet. The steps should be small, and it usually helps if the child earns a small reward each time he achieves success. As with all behavioral procedures, the child should earn the reward at least 70% to 80% of the time. If that is not happening, the steps you are asking the child to take are too large. In the case you describe, for example, the parents' offer to reward the child for having a bowel movement on the toilet did not work because the step was too large for the child.

The art of behavioral intervention is finding the correct series of steps. Here are some progressive steps I have used:

• The child may use the diaper for bowel movements but must empty the diaper into the toilet and dispose of the diaper with appropriate parental help.

• The child may use the diaper but must be in the bathroom when having a bowel movement and continue to help with cleanup.

• The child may use the diaper but must be seated when having a bowel movement. Give the child some choice about where to sit. It may be on the toilet or potty seat, on the toilet with the top down, or on some other chair that can be placed in the bathroom. If the bowel movement does not happen on the toilet or a potty, the next steps should aim to move the child closer to the toilet or a potty seat.

• A child who is having a bowel movement with the diaper on while sitting on the toilet or potty, may be able to progress directly to removing the diaper. If not, I have the parent and child work together to create a magic diaper. These diapers have a hole cut in the rear end so that the stool will fall into the potty or toilet when the child wears it while having a bowel movement on the toilet or potty. One or two bowel movements while wearing the magic diaper usually solve the problem.

In refractory cases, you may want to recommend an intervention that uses suppositories prior to having the child sit on the toilet. For more on this intervention see: Luxem MC, Christophersen ER, Purvis PC, et al: Behavioral-medical treatment of pediatric toileting refusal. J Dev Behav Pediatr 1997;18:34.

Nathan J. Blum, MD

DR. BLUM is assistant professor of pediatrics, University of Pennsylvania School of Medicine and Children's Seashore House of Children's Hospital of Philadelphia.

 

Behavior: Ask the experts. Contemporary Pediatrics 2002;6:30.