Behavior: Ask the experts


A smoking problem that can't be ignored, a toddler engaged in a mystery fast, is child's mimicry cause for concern? What is it about those URLs?



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Q The 42-year-old mother of two of my patients smokes, is obese, and has chronic obstructive pulmonary disease (COPD), which requires oxygen administration at home. Her two teenagers, a boy 16 years of age and a girl 15 years, are also obese and admit to smoking cigarettes. How can I effectively counsel this family?

Achilles Litao, MD
Bronx, N.Y.

A You must patiently and repeatedly explain to this family the huge risk of smoking in the presence of someone who is on oxygen. Almost as important are the long-term risks from smoking itself—which has already damaged the mother's health.

I rarely subscribe to telling horror stories, but your anticipatory guidance must stress the real risks of fire and explosion when mixing home oxygen therapy and cigarette smoking. Explain to the teenagers that, if they must smoke, it is vital that they do so outside the house to minimize the hazard.

The broader issue, of course, is the long-term danger of cigarette smoking itself. COPD requiring oxygen at the age of 42 is a tragedy. You can use the mother's health problem—graphically displayed in front of these teenagers every day—to help them understand the risks they are engaging in when they light up.

Long-term counseling, nicotine patches, and "quit smoking" programs are all important, but the family needs to be motivated to make these changes. Gentle but firm guidance and support of smoking cessation over a long period of time can help them succeed. Good luck. This is one of the hardest of all addictions to treat and, for your patients, to kick.

Howard Markel, MD, PhD

DR. MARKEL is associate professor of pediatrics and communicable diseases and director, Historical Center for the Health Sciences, The University of Michigan Medical School, Ann Arbor, Mich. He is coauthor of The Practical Pediatrician: The A to Z Guide to Your Child's Health, Behavior, and Safety.


Q I have a 16-month-old patient who has refused to eat or drink anything at day care for the past six weeks. Until recently, she ate both breakfast and lunch there. She shows no signs of illness, has no chronic medical problems, and takes no medications. The staff has reported no changes at day care or at home.

The girl wakes around 7 a.m. and is dropped off at day care by 8 a.m. On rare occasions, she drinks a little milk before being dropped off. She eats or drinks nothing between her arrival at day care and 4:30 p.m. when she is picked up. If she is offered food at day care—even by her mother—she screams. When she gets home in the afternoon, she eats one or two meals before going to bed. During the past week, she has been waking at night and asking for milk.

If her mother removes her from day care at lunchtime, the child eats normally. When she stays home weekends and Wednesdays, she eats a regular breakfast and lunch. Her diet is varied and has no special restrictions. She has gained only 8 ounces in the past six weeks

Chris Lawrence, MD
Middletown, Conn.

A A 15- to 18-month-old child commonly goes through a period of clinging to the primary caregiver—which may include reluctance to separate, hypersensitivity, and even whininess. The child you describe in such detail goes beyond typical behavior, however, and appears to be reacting to a violation of her level of comfort at day care. Organic causes of anorexia can be rejected because she seems to be eating enough over a 24-hour period to support growth. Her general health is reportedly good, and I assume that her cognitive, motor, communicative, and social development are proceeding within normal range for age. Temperamentally, I suspect that the girl has a high sensory threshold, which is associated with a tendency to become frustrated easily, stubbornness, and very intense persistent reactions. I wonder if she adapts easily to change.

I suggest you pursue in more depth what occurred six weeks ago at child care or at home. Ask the staff about changes or extraordinary occurrences in routines, staffing changes, interactions with other children, or alterations in the facilities around the time in question. Ask the parents about memorable events, stressors or changes in family relationships, changes in work or home schedules, separations, losses (including pets), illnesses, changes in diet, and even redecorating of the child's surroundings. Because the child refuses even her mother's feeding efforts at day care, I strongly suspect that something about that setting upsets the girl enough to make her keep her guard up during the time she spends there.

Look especially to the person with whom the child has the closest relationship at day care. This individual probably holds the key to helping the child recover her lost faith and sense of security. Most children at this age develop a primary emotional attachment to one caregiver—a parent at home and a substitute parent from the day-care staff. The staff member should be urged to spend more time alone with the young girl, quietly and calmly comforting her and encouraging her interests and pleasures.

Eating should not loom as a primary objective initially. Too much attention to eating only reinforces the child's fears and undermines success. I expect she will gradually recover her natural interest in eating with the other children once she feels emotionally secure in relationship to them and the caregivers. Encourage the caregivers to introduce eating in subtle ways during the course of other playful interactions or storytelling.

I would also discourage the parents from supplying the child with nighttime food or drink. This will only encourage a sleep disorder and diminish her morning appetite.

Peter Gorski, MD

DR. GORSKI is assistant professor of pediatrics, Harvard Medical School, Boston.


Q A 4 1/2-year-old girl in my practice closely observes the behavior of other people and then imitates them when they are not around. Her parents are concerned. They wonder if her behavior is normal for her age, or if something unusual is going on? She attends kindergarten and is well behaved in class. What would you suggest?

Muhammad Waseem, MD
Bronx, N.Y.

A You did not say what behavior the child is imitating. Obviously, if the behavior she imitates is troubling, then it should cause concern. Another critical consideration is whether the behavior results in a clinically significant impairment in performance. If there is no impairment, behaviors are usually considered to be normal.

A child of this age has a great imagination, which includes having make-believe friends. It takes just a slight stretch of the imagination to begin imitating someone else when that person is no longer around. Because the child's mimicry is not interfering with her performance in kindergarten and apparently is not affecting her behavior at home, reassure the parents that the behavior is normal for a child around 4 or 5 years of age.

Another issue to consider: Why is this child already in kindergarten at 4 1/2 years of age? She would have been about 4 when she started. You might want to discuss with the parents their expectations for their daughter. If they started her in kindergarten early, they may have unrealistically high expectations and may not give her a chance to enjoy her childhood.

Edward R. Christophersen, PhD

DR. CHRISTOPHERSEN is professor of pediatrics at Children's Mercy Hospital in Kansas City, Mo.


Q I am perplexed by a 4-year-old boy in my practice whose behavior changes dramatically when he has upper respiratory symptoms. He is intelligent and generally pleasant, but whenever he is congested his parents report episodes of "spacing out," babbling in gibberish, and being physically out of control and agitated. He smacks his head with his hands, covers his ears against loud noises, or acts aggressively toward siblings and peers. All of these behaviors do not match his usual temperament. His history is noteworthy for recurrent upper respiratory infections (URIs) with otitis media.

His parents have asked for guidance many times and are consistent in their dealings with him. From June until his first URI in September he is basically symptom free and has no behavior difficulties. As soon as the symptoms return, so do his behavior changes. His EEG is normal, and allergy tests are negative. He has taken antihistamines to help alleviate his symptoms, but they seem to exacerbate the behavior problems. The parents hesitate to have neuropsychological tests done because the difficult behavior disappears completely for long periods.

Deirdre Makinen, CPNP
Fairfax, Va.

A This boy exhibits remarkable behavior changes associated with URIs. It is unlikely that the various viruses that cause URIs are all having the same direct effect on his behavior. It is more likely that some aspect of the child's symptoms or their management is influencing his behavior. Keep in mind that more than one factor may be involved in this boy's behavior changes. Here are some of the factors I would consider:

• Sleep. Does the child sleep poorly when he has URIs? Sleep deprivation can contribute to irritability and aggressive behavior.

• Hearing loss and pain. Does the child get serous otitis media with associated hearing loss and pain when he gets URIs? Hearing loss could help explain why he seems "spaced out" and reacts abnormally to sounds. Hitting oneself is sometimes a response to painful stimuli.

• Appetite. Does the child eat poorly when he has URIs? Hunger increases irritability.

• Antihistamines and decongestants. You mention that antihistamines make the behavior worse. Some oral decongestants can also lead to unusual behaviors, including hallucinations.

I do not think neuropsychological testing will help this child because those tests are used mainly to identify cognitive strengths and weaknesses. If the suggestions I have offered are not helpful, however, I would recommend a consultation with a behaviorally trained mental health professional, who may be able to identify what is influencing the child's behavior.

Nathan 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;4:29.

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