I have a 13-month-old male patient who has been in good health. He was born at 32 weeks' gestation but basically grew well and was discharged 10 days after birth.
I have a 13-month-old male patient who has been in good health. He was born at 32 weeks' gestation but basically grew well and was discharged 10 days after birth. His development has been normal. His mother used oxycodone/acetaminophen during pregnancy for colic from recurrent kidney stones. The parents complain that their son screams very loudly when in his car seat, and they are unable to concentrate on driving. He cries so loudly that he is heard by passengers in other vehicles, despite having the windows up. The behavior began several months earlier. The parents now find a baby-sitter or stay home to avoid this unpleasant experience. They have tried different car seats, distractions (eg, “sippy” cup or toy), and having other people place the child in the car seat. He cries regardless of the car seat's location. He has not been in a motor vehicle accident, and the parents deny hurting the toddler in any way with the car seat. His 3-year-old brother has never displayed this type of behavior. I would appreciate any ideas on how to address this issue.- Selmira Tellechea-Sanchez, MD
Dr Sanchez appears to have a difficult case; however, some historical facts related to the toddler's development to this point may be helpful in identifying the cause of the behavior. However, I can only hypothesize why this child has a car seat phobia.
The infant's prematurity could have created an environment for an abnormal behavior. The parents may have unconsciously felt that the child was fragile. This increased concern may have caused them to attend to the infant's needs more quickly and provide more holding and comforting. It would be interesting to know whether the mother was able to breast-feed, whether the infant was small for gestational age, or whether the mother somehow felt guilty that the child was born early and was therefore vulnerable. When the infant reached 7 or 8 months of age developmentally, placement in the car seat may have initiated a separation anxiety. He has to be in the car seat “alone” and cannot be held in the parent's arms-a rule that makes no sense to the infant. Thus, he uses his robust cry to change the situation. Now the crying has effectively allowed him to stay in constant contact with the parent or caregiver; it has become a behavior with a positive reward. This scenario can be very similar to that of the infant who always winds up in the parents' bed because she cannot stand to be in her crib alone.
Although this may be an oversimplification, the child's behavior essentially has a positive outcome/reinforcement. The plan would be to let the child know that the separation will end when the car ride is over. The parents and sibling can wear earplugs while the behavior is modified/extinguished. It is extremely important that the family members work on shrouding their feeling of stress and on replacing signs of stress with smiles and calmness. Perhaps they can try to make the car ride enjoyable-by singing songs, talking, and laughing. The child can sense parental stress and is likely to redouble his efforts at crying before completely extinguishing the behavior. The family will need to be steadfast and consistent with their behavior. The use of a transition object (such as a soft stuffed animal or blanket) for the child may also help. Hopefully, this is where the problem lies. Otherwise, referral to a behavioral therapist can be considered.
- John Harrington, MD
Associate Professor of Pediatrics
Eastern Virginia Medical School
Children's Hospital of The King's Daughters