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Q The 3-year-old sister of a newborn baby in my practice has takenher sibling's birth quite personally. I had prepared her and her motherwith handouts and anticipatory guidance, but nothing is working. We haveensured that Mom and the older sister have special time together, that thesister participates in all baby-related
activities, and that visitors and relatives know to give the older sisterattention before they converge on the baby. The older child is all kissesand sweetness when her time with the baby is supervised, but if Mom turnsaway the toddler becomes mean and hits and kicks the baby. We have triedtime-out, firm reprimands, and increased attention, but have not had muchsuccess. Any suggestions?

Anu Diwakaran, MD
St. Ignace, MI

A First, reassure the parents that the jealousy, resentment, andaggression the 3-year-old is showing toward her newborn sibling is normaland that it will subside. Since "nothing is working," I suggestthat you review your earlier recommendations, reevaluating their appropriateness,the family's ability to implement them, and the parents' general abilityto cope. You may find you need to modify these suggestions, or help thefamily set priorities and temporarily lower their expectations. Also tryto determine if anything else is adding to the family's stress, such aspostpartum depression or problems with a job or maternity leave, and addressthese issues.

Here are some other suggestions you may offer the parents:

  • Avoiding labeling the 3-year-old--don't call her "the hitter," or "the jealous one," for example.
  • Avoid comparing the child and the baby, even if the comparisons are complimentary, because the toddler may still see this as a sign that the baby is being favored.
  • Instead of giving attention to one child and then the other, interact frequently with both children simultaneously. In this way, you are more likely to attend to the 3-year-old before she has exceeded her limited ability to delay gratification.
  • Respect the need for privacy and the growing independence of the older sister. She need not be part of all the baby's activities and should have her own room and toys as well as time alone and with peers.
  • Make sure she spends time alone with both parents and with each parent separately.
  • Avoid telling the toddler to "grow up" or to act like a "big sister" when she clearly needs comfort and understanding. Teach the child empathy by demonstrating it yourself.
  • Avoid lengthy explanations and "should" lectures about how you expect the 3-year-old to act toward the baby, but do set and maintain limits and reasonable expectations.
  • Try to reduce opportunities for sister to hit the baby by, for example, giving the toddler tasks when Mom is busy and placing the baby in a place that is inaccessible to her.
  • When the toddler hits the baby, be firm about imposing time-out, and don't reinforce negative behavior with attention--even negative attention.
  • Acknowledge and reward improved behavior with attention and praise.

Encourage the parents to take some respite from the increased demandson their time and energy by getting help from a baby-sitter, house cleaner,relative, or friend who can do errands or take the older child on an outingfor a few hours.

William Coleman, MD
Chapel Hill, NC

DR. COLEMAN is Associate Professor of Pediatrics, University of NorthCarolina Medical School, Chapel Hill, NC, and Assistant Consulting Professorof Pediatrics, Duke University Medical Center, Durham.


Q Parents of adolescents with chronic disease often seem exasperatedby these children. This is particularly true when they are boys.

I have in my practice, for example, a 16-year-old hemophiliac who hasdifficulty getting along with his parents and siblings. The parents areaware of the severe conflicts their son faces and want help from a mentalhealth professional. How can I convince the young man to accept this assistanceso he will be able to benefit from the therapy?

Lawrence S. Rosenberg, MD
Johnstown, PA

A Chronic disease and adolescence are a difficult combination.Those of us who work with teenagers can only hope that even healthy teensgrow up, psychologically as well as physically, before they run into seriousproblems caused by high-risk activities. When a serious illness, such ashemophilia, AIDS, diabetes, or asthma, is added to the mix, the challengesare daunting. There seems to be no real difference in compliance betweenboys or girls; some kids are difficult patients and some are not.

What is most important is to win the teenager's trust and confidence.You can't do this overnight; it often requires many visits over a long periodof time. Remember, though, that since you are not the teenager's parent,you have more leeway to be frank and are less threatening than the fatheror mother, who has a far more difficult role. Offering good advice, cheeringthe teenager on when he manages to comply with the medical regimen, andacting as the teen's advocate is always worth the necessary investment oftime.

Once the young person trusts you, feel free to offer advice that he orshe may not like, such as "you really are causing more problems foryourself than necessary." Teenagers do not seem to mind straight talk--evennegative straight talk--as much as adults assume. If you don't get goodresults, obtain the advice and counsel of a mental health professional whospecializes in teenage issues. Tell the teenager that you are sending himto a psychiatrist not because you "think he's crazy," but becauseyou both need a little more help in finding solutions to the complianceproblems that have been identified. Finally, you need to follow up on yourpatient's (and parents') progress and continue to provide positive reinforcementfor the medical and treatment issues with which he manages to comply.

Howard Markel, MD, PhD
Ann Arbor, MI

DR MARKEL is Associate Professor of Pediatrics and Communicable Diseasesand Director, Historic Center for the Health Sciences, The University ofMichigan Medical School, Ann Arbor, MI.

Marian Freedman. BEHAVIOR: ASK THE EXPERTS. Contemporary Pediatrics 1999;9:31.

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