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Extreme, persistent fear of storms, chewing her hair, habitually.
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Q A 5-year-old boy in my practice is terrified of thunderstorms. His fears began about a year ago, and they have become progressively worse. He starts to cry hysterically when the sky darkens, lightning strikes, rain comes down in torrents, or he hears thunder rumbling. He clings to his mother and shivers with fear. He will not listen to reason during a storm and seems to be almost in a trance, as though he were having a night terror. What's more, he refuses to get under the covers or retreat to the basement where the storm would be out of sight.
With my guidance, the parents have tried the following:
The child appears to believe that all these aids will help, but when another storm hits, he becomes agitated all over again. As soon as the bad weather passes, the boy returns to his usual self almost immediately. He is otherwise a happy, healthy child.
A Anxiety in young children may represent what the Diagnostic and Statistical Manual of Mental Disorders: Primary Care Version (DSM-IV-PC) categorizes as a developmental variation, problem, or disorder. Common anxieties include fear of separation, animals, monsters, the dark, sleeping alone, the potty, strangers, unfamiliar social situations, exposure to family arguments or violence, nightmares, corporal punishment, restraint, painful proceduresand thunderstorms.
In most cases, fearfulness is transient or easily managed in its developmental or temperamental variations. Children, such as this boy, who suffer excessive fearfulness, who are anxiety-prone, or whose parents are unduly anxious present a therapeutic challenge. Panicked behavior as described here usually occurs independent of stresses at home such as marital discord, violence, and abuse.
Because a series of thoughtful interventions have failed to reduce this child's distress, I recommend referring him to a child psychologist or other mental health professional who is experienced in behavioral therapy for anxiety problems. Systematic desensitization using muscle relaxation is one method that has been tried. The technique is based on the idea that a child cannot feel anxious and relaxed at the same time.
Other approaches use visual imagery, such as thinking of happy experiences; introducing a pleasant diversion, such as a game or attractive toy; and listening to a relaxation tape. With some children, conditioning methods such as positive reinforcement, shaping, and extinction are useful. Extinction of undesired behavior by withdrawal of its reinforcement, or the gradual shaping of desired behavior, are difficult to achieve without a skilled mental health professional. Cognitive behavior therapy, although beneficial in older children, is less effective in preschool children in whom play therapy may be more appropriate. For more information on this subject, read Drobes DJ, Strauss CD: Treatment of childhood anxiety disorders. Child Adololesc Psychiatr Clin North Am 1993;2(4):779.
Q The mother of an 8-year-old girl is concerned about her daughter's long-standing habit of chewing her hair. The habit is apparent, and the result is that she often wets the front of her blouse. Attempts at behavior modification have been unsuccessful and the girl does not want to give up her habit.
A My first question is: Does this habit need to be treated? If she were chewing on and ingesting a large amount of hair, she is at risk of developing a trichobezoar (hair ball). In the absence of hair ingestion, however, the girls' habit is primarily a cosmetic and social-acceptability issue.
If ingesting hair were the girl's only problem, cutting it short might work as an intervention. Because ingestion of hair is not the major concern, however, why do the parents want her treated? I would suggest talking to the parents and the child to find out why she refuses to quit. Does she really like having her blouses soaked with saliva? Or is she just so tired of being questioned about her habit that the easiest approach is to say that she does not want to stop? Has she given up hope of stopping? Has there been a lot of conflict in the family about her habit? (If so, a break from commenting on her habit that lasts from a few weeks to several months may be necessary for the parents before the child is ready to change.)
Treatment begins by identifying times when, or situations in which, the child is most likely to chew her hair. Does she do so when she is anxious, tired, bored, or distracted? If she is anxious, she may need to learn other strategies for managing her anxiety. If she does it when she is tired, bored, or distracted, she may not even be aware that she is doing it until someone points it out.
The treatment plan should train her to experience being told that she is chewing on her hair as help, not as a way to bother her.
Behavioral treatments for habits can work, but they are often unsuccessful because the goal that one must attain before earning a reward is set too high. For example, the goal might be: "complete cessation of the habit at all times." A more successful approach, however, is to identify one or two high-risk periods of 15 to 60 minutes, and to offer the child a reinforcing reward for not chewing her hair during this time. As she learns to control the habit during shorter periods, the length of the chewing-free period can be increased.
Habit reversal, a multicomponent, behavior-treatment package, has successfully altered many unacceptable habits in adults and children. A mental health professional skilled in using this approach should be consulted if the simpler plans I've described are unsuccessful.
Behavior: Ask the experts. Contemporary Pediatrics 2002;3:42.