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Tips on tics
As an experienced clinician who has seen tics and habits in your patients come and go, you may be surprised by the amount of concern parents express about them. At times, it seems, and may be, that the parent’s attention to the habit actually keeps it going! This does not always mean that the child keeps doing the habit to aggravate the parent, as parental correction may amp up the child’s anxiety, which may make the habit worse.
As with other parent concerns, both empathizing with their worry and providing evidence-based information is helpful in relieving their distress.
Habits are complex behaviors done the same way repeatedly. Habits can have a strong protective effect on our lives and be a foundation for success when they ensure that we wash our hands (protection from infection), help us know where the keys are (efficiency), or soothe us to sleep (bedtime routines).
Tics are “involuntary” (meaning often, but not always, suppressible), brief, abrupt, repeated movements usually of the face, head, or neck. More complex, apparently meaningless movements may fall into the category of stereotypies. If they last more than 4 weeks, are driven, and cause marked dysfunction or significant self-injury, they may even qualify as stereotypic movement disorder.
It is good to know that repeated behaviors such as thumb sucking, nail/lip biting, hair twirling, body rocking, self biting, and head banging are relatively common in childhood, and often (but not mostly) disappear after age 4. I like to set the expectation that one habit or tic often evolves to another to reduce panic when this happens. Thumb and hand sucking at a younger developmental age may be replaced by body rocking and head banging, and later by nail biting and finger and foot tapping.
Even in college, habits are common and stress-related such as touching the face; playing with hair, pens, or jewelry; shaking a leg; tapping fingers; or scratching the head. Parents may connect some of these to acne or poor hygiene (a good opening for coaching!) but more importantly they may be accompanied by general distress, anxiety, obsessive-compulsive symptoms, and impulsive aggressive symptoms, which need to be looked for and addressed.
Stereotypies occur in about 20% of typically developing children (called “primary”) and are classified into:
• Common behaviors (such as, rocking, head banging, finger drumming, pencil tapping, hair twisting),
• Head nodding.
• Complex motor movements (such as hand and arm flapping/waving).
Habits – including nail biting, lip chewing, and nose picking – also may be diagnosed as stereotypic movement disorders, although ICD-10 lists includes them as “other specified behavioral and emotional disorders.”
For both conditions, the behavior must not be better accounted for by a compulsion, a tic disorder, part of autism, hair pulling (trichotillomania), or paroxysmal dyskinesias.
So what is the difference between motor stereotypies and tics (and why do you care)? Motor stereotypies begin before 3 years in more than 60%, whereas tics appear later (mean 5-7 years). Stereotypies are more fixed in their pattern, compared with tics that keep shifting form, disappearing, and reappearing. Stereotypies frequently involve the arms, hands, or the entire body, while tics involve the eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged (most more than 10 seconds) than tics, which are mostly brief, rapid, random, and fluctuating.
One key distinguishing factor is that tics have a premonitory urge and result in a sense of relief after the tic is performed. This also means that they can be suppressed to some extent when the situation requires. While both may occur more during anxiety, excitement, or fatigue, stereotypic movements, unlike tics, also are common when the child is engrossed.
Tics can occur as a side effect of medications such as stimulants and may decrease by lowering the dose, but tics also come and go, so the impact of a medication can be hard to sort out.
One vocal or multiple motor tics occurring many times per day starting before age 18 years and lasting more than 1 year are considered chronic; those occurring less than 1 year are transient. Chronic multiple motor tics accompanied by vocalizations, even sniffing or throat clearing, qualify as Tourette syndrome. The feared component of Tourette of coprolalia (saying bad words or gestures) is fortunately rare. These diagnoses can only be made after ruling out the effects of medication or another neurological condition such as Sydenham’s chorea (resulting from infection via group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever) or PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).
The importance of distinguishing tics from stereotypies is in the treatment options, differential diagnosis, and prognosis. Some families (and certainly the kids themselves) do not even notice that they are moving abnormally even though 25% have at least one family member with a similar behavior. But many parents are upset about the potential for teasing and stigmatization. When you ask them directly what they are afraid of, they often admit fearing an underlying diagnosis such as intellectual disability, autism, or Tourette syndrome. The first two are straightforward to rule in or out, but Tourette can be subtle. If parents don’t bring up the possibilities, it is worth telling them directly which underlying conditions can be ruled out.
There are many conditions comorbid with tics including attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), learning disorder (LD), behavioral, developmental or social problems, and mood or anxiety disorders. This clearly means that a comprehensive evaluation looking specifically for these conditions is needed when a child has chronic tics. Typically developing children with complex arm or hand movements also are more likely to have ADHD (30%), LD (20%), obsessive-compulsive behaviors (10%), or tics (18%).
Tics and stereotypies may be annoying, but generally are not harmful or progressive, although repeated movements such as skin or nose picking may result in scars or infections, and severe head banging can lead to eye injuries. Frequently repeated motor acts can cause significant muscle pain and fatigue. The most common problems are probably injury to self-esteem or oppositional behavior as a result of repeated (and fruitless) nagging or punishment by parents, even if well-meaning.
Since they occur so often along with comorbid conditions, our job includes determining the most problematic aspect before advising on a treatment. Both tics and stereotypies may be reduced by distraction, but the effect on stereotypies is faster and more certain. You can make this intervention in the office by simply asking how the child can tell when they make the movement and have them plan out what they could do instead. An example might be to shift a hand flapping movement (that makes peers think of autism) into more acceptable fist clenching. Habit reversal training or differential reinforcement based on a functional analysis can be taught by psychologists when this simple suggestion is not effective. When tics are severe, teacher education and school accommodations (504 Plan with extended time, scribe, private location for tic breaks) may be needed.
Medication is not indicated for most tics because most are mild. If ADHD is present, tics may actually be reduced by stimulants or atomoxetine rather than worsened. If the tic is severe and habit reversal training has not been successful, alpha agonists such as clonidine or guanfacine, or typical or atypical neuroleptics may be helpful. Even baclofen, benzodiazepines, anticonvulsants, nicotine, and Botox have been used. These require consultation with a specialist.
As for other chronic medical conditions, tics and persisting stereotypies deserve a comprehensive approach, including repeated education of the parent and child, evaluation for comorbidity, school accommodations, building other strengths and social support, and only rarely pulling out your prescription pad.
Dr. Howard is an assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
As an experienced clinician who has seen tics and habits in your patients come and go, you may be surprised by the amount of concern parents express about them. At times, it seems, and may be, that the parent’s attention to the habit actually keeps it going! This does not always mean that the child keeps doing the habit to aggravate the parent, as parental correction may amp up the child’s anxiety, which may make the habit worse.
As with other parent concerns, both empathizing with their worry and providing evidence-based information is helpful in relieving their distress.
Habits are complex behaviors done the same way repeatedly. Habits can have a strong protective effect on our lives and be a foundation for success when they ensure that we wash our hands (protection from infection), help us know where the keys are (efficiency), or soothe us to sleep (bedtime routines).
Tics are “involuntary” (meaning often, but not always, suppressible), brief, abrupt, repeated movements usually of the face, head, or neck. More complex, apparently meaningless movements may fall into the category of stereotypies. If they last more than 4 weeks, are driven, and cause marked dysfunction or significant self-injury, they may even qualify as stereotypic movement disorder.
It is good to know that repeated behaviors such as thumb sucking, nail/lip biting, hair twirling, body rocking, self biting, and head banging are relatively common in childhood, and often (but not mostly) disappear after age 4. I like to set the expectation that one habit or tic often evolves to another to reduce panic when this happens. Thumb and hand sucking at a younger developmental age may be replaced by body rocking and head banging, and later by nail biting and finger and foot tapping.
Even in college, habits are common and stress-related such as touching the face; playing with hair, pens, or jewelry; shaking a leg; tapping fingers; or scratching the head. Parents may connect some of these to acne or poor hygiene (a good opening for coaching!) but more importantly they may be accompanied by general distress, anxiety, obsessive-compulsive symptoms, and impulsive aggressive symptoms, which need to be looked for and addressed.
Stereotypies occur in about 20% of typically developing children (called “primary”) and are classified into:
• Common behaviors (such as, rocking, head banging, finger drumming, pencil tapping, hair twisting),
• Head nodding.
• Complex motor movements (such as hand and arm flapping/waving).
Habits – including nail biting, lip chewing, and nose picking – also may be diagnosed as stereotypic movement disorders, although ICD-10 lists includes them as “other specified behavioral and emotional disorders.”
For both conditions, the behavior must not be better accounted for by a compulsion, a tic disorder, part of autism, hair pulling (trichotillomania), or paroxysmal dyskinesias.
So what is the difference between motor stereotypies and tics (and why do you care)? Motor stereotypies begin before 3 years in more than 60%, whereas tics appear later (mean 5-7 years). Stereotypies are more fixed in their pattern, compared with tics that keep shifting form, disappearing, and reappearing. Stereotypies frequently involve the arms, hands, or the entire body, while tics involve the eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged (most more than 10 seconds) than tics, which are mostly brief, rapid, random, and fluctuating.
One key distinguishing factor is that tics have a premonitory urge and result in a sense of relief after the tic is performed. This also means that they can be suppressed to some extent when the situation requires. While both may occur more during anxiety, excitement, or fatigue, stereotypic movements, unlike tics, also are common when the child is engrossed.
Tics can occur as a side effect of medications such as stimulants and may decrease by lowering the dose, but tics also come and go, so the impact of a medication can be hard to sort out.
One vocal or multiple motor tics occurring many times per day starting before age 18 years and lasting more than 1 year are considered chronic; those occurring less than 1 year are transient. Chronic multiple motor tics accompanied by vocalizations, even sniffing or throat clearing, qualify as Tourette syndrome. The feared component of Tourette of coprolalia (saying bad words or gestures) is fortunately rare. These diagnoses can only be made after ruling out the effects of medication or another neurological condition such as Sydenham’s chorea (resulting from infection via group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever) or PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).
The importance of distinguishing tics from stereotypies is in the treatment options, differential diagnosis, and prognosis. Some families (and certainly the kids themselves) do not even notice that they are moving abnormally even though 25% have at least one family member with a similar behavior. But many parents are upset about the potential for teasing and stigmatization. When you ask them directly what they are afraid of, they often admit fearing an underlying diagnosis such as intellectual disability, autism, or Tourette syndrome. The first two are straightforward to rule in or out, but Tourette can be subtle. If parents don’t bring up the possibilities, it is worth telling them directly which underlying conditions can be ruled out.
There are many conditions comorbid with tics including attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), learning disorder (LD), behavioral, developmental or social problems, and mood or anxiety disorders. This clearly means that a comprehensive evaluation looking specifically for these conditions is needed when a child has chronic tics. Typically developing children with complex arm or hand movements also are more likely to have ADHD (30%), LD (20%), obsessive-compulsive behaviors (10%), or tics (18%).
Tics and stereotypies may be annoying, but generally are not harmful or progressive, although repeated movements such as skin or nose picking may result in scars or infections, and severe head banging can lead to eye injuries. Frequently repeated motor acts can cause significant muscle pain and fatigue. The most common problems are probably injury to self-esteem or oppositional behavior as a result of repeated (and fruitless) nagging or punishment by parents, even if well-meaning.
Since they occur so often along with comorbid conditions, our job includes determining the most problematic aspect before advising on a treatment. Both tics and stereotypies may be reduced by distraction, but the effect on stereotypies is faster and more certain. You can make this intervention in the office by simply asking how the child can tell when they make the movement and have them plan out what they could do instead. An example might be to shift a hand flapping movement (that makes peers think of autism) into more acceptable fist clenching. Habit reversal training or differential reinforcement based on a functional analysis can be taught by psychologists when this simple suggestion is not effective. When tics are severe, teacher education and school accommodations (504 Plan with extended time, scribe, private location for tic breaks) may be needed.
Medication is not indicated for most tics because most are mild. If ADHD is present, tics may actually be reduced by stimulants or atomoxetine rather than worsened. If the tic is severe and habit reversal training has not been successful, alpha agonists such as clonidine or guanfacine, or typical or atypical neuroleptics may be helpful. Even baclofen, benzodiazepines, anticonvulsants, nicotine, and Botox have been used. These require consultation with a specialist.
As for other chronic medical conditions, tics and persisting stereotypies deserve a comprehensive approach, including repeated education of the parent and child, evaluation for comorbidity, school accommodations, building other strengths and social support, and only rarely pulling out your prescription pad.
Dr. Howard is an assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
As an experienced clinician who has seen tics and habits in your patients come and go, you may be surprised by the amount of concern parents express about them. At times, it seems, and may be, that the parent’s attention to the habit actually keeps it going! This does not always mean that the child keeps doing the habit to aggravate the parent, as parental correction may amp up the child’s anxiety, which may make the habit worse.
As with other parent concerns, both empathizing with their worry and providing evidence-based information is helpful in relieving their distress.
Habits are complex behaviors done the same way repeatedly. Habits can have a strong protective effect on our lives and be a foundation for success when they ensure that we wash our hands (protection from infection), help us know where the keys are (efficiency), or soothe us to sleep (bedtime routines).
Tics are “involuntary” (meaning often, but not always, suppressible), brief, abrupt, repeated movements usually of the face, head, or neck. More complex, apparently meaningless movements may fall into the category of stereotypies. If they last more than 4 weeks, are driven, and cause marked dysfunction or significant self-injury, they may even qualify as stereotypic movement disorder.
It is good to know that repeated behaviors such as thumb sucking, nail/lip biting, hair twirling, body rocking, self biting, and head banging are relatively common in childhood, and often (but not mostly) disappear after age 4. I like to set the expectation that one habit or tic often evolves to another to reduce panic when this happens. Thumb and hand sucking at a younger developmental age may be replaced by body rocking and head banging, and later by nail biting and finger and foot tapping.
Even in college, habits are common and stress-related such as touching the face; playing with hair, pens, or jewelry; shaking a leg; tapping fingers; or scratching the head. Parents may connect some of these to acne or poor hygiene (a good opening for coaching!) but more importantly they may be accompanied by general distress, anxiety, obsessive-compulsive symptoms, and impulsive aggressive symptoms, which need to be looked for and addressed.
Stereotypies occur in about 20% of typically developing children (called “primary”) and are classified into:
• Common behaviors (such as, rocking, head banging, finger drumming, pencil tapping, hair twisting),
• Head nodding.
• Complex motor movements (such as hand and arm flapping/waving).
Habits – including nail biting, lip chewing, and nose picking – also may be diagnosed as stereotypic movement disorders, although ICD-10 lists includes them as “other specified behavioral and emotional disorders.”
For both conditions, the behavior must not be better accounted for by a compulsion, a tic disorder, part of autism, hair pulling (trichotillomania), or paroxysmal dyskinesias.
So what is the difference between motor stereotypies and tics (and why do you care)? Motor stereotypies begin before 3 years in more than 60%, whereas tics appear later (mean 5-7 years). Stereotypies are more fixed in their pattern, compared with tics that keep shifting form, disappearing, and reappearing. Stereotypies frequently involve the arms, hands, or the entire body, while tics involve the eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged (most more than 10 seconds) than tics, which are mostly brief, rapid, random, and fluctuating.
One key distinguishing factor is that tics have a premonitory urge and result in a sense of relief after the tic is performed. This also means that they can be suppressed to some extent when the situation requires. While both may occur more during anxiety, excitement, or fatigue, stereotypic movements, unlike tics, also are common when the child is engrossed.
Tics can occur as a side effect of medications such as stimulants and may decrease by lowering the dose, but tics also come and go, so the impact of a medication can be hard to sort out.
One vocal or multiple motor tics occurring many times per day starting before age 18 years and lasting more than 1 year are considered chronic; those occurring less than 1 year are transient. Chronic multiple motor tics accompanied by vocalizations, even sniffing or throat clearing, qualify as Tourette syndrome. The feared component of Tourette of coprolalia (saying bad words or gestures) is fortunately rare. These diagnoses can only be made after ruling out the effects of medication or another neurological condition such as Sydenham’s chorea (resulting from infection via group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever) or PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).
The importance of distinguishing tics from stereotypies is in the treatment options, differential diagnosis, and prognosis. Some families (and certainly the kids themselves) do not even notice that they are moving abnormally even though 25% have at least one family member with a similar behavior. But many parents are upset about the potential for teasing and stigmatization. When you ask them directly what they are afraid of, they often admit fearing an underlying diagnosis such as intellectual disability, autism, or Tourette syndrome. The first two are straightforward to rule in or out, but Tourette can be subtle. If parents don’t bring up the possibilities, it is worth telling them directly which underlying conditions can be ruled out.
There are many conditions comorbid with tics including attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), learning disorder (LD), behavioral, developmental or social problems, and mood or anxiety disorders. This clearly means that a comprehensive evaluation looking specifically for these conditions is needed when a child has chronic tics. Typically developing children with complex arm or hand movements also are more likely to have ADHD (30%), LD (20%), obsessive-compulsive behaviors (10%), or tics (18%).
Tics and stereotypies may be annoying, but generally are not harmful or progressive, although repeated movements such as skin or nose picking may result in scars or infections, and severe head banging can lead to eye injuries. Frequently repeated motor acts can cause significant muscle pain and fatigue. The most common problems are probably injury to self-esteem or oppositional behavior as a result of repeated (and fruitless) nagging or punishment by parents, even if well-meaning.
Since they occur so often along with comorbid conditions, our job includes determining the most problematic aspect before advising on a treatment. Both tics and stereotypies may be reduced by distraction, but the effect on stereotypies is faster and more certain. You can make this intervention in the office by simply asking how the child can tell when they make the movement and have them plan out what they could do instead. An example might be to shift a hand flapping movement (that makes peers think of autism) into more acceptable fist clenching. Habit reversal training or differential reinforcement based on a functional analysis can be taught by psychologists when this simple suggestion is not effective. When tics are severe, teacher education and school accommodations (504 Plan with extended time, scribe, private location for tic breaks) may be needed.
Medication is not indicated for most tics because most are mild. If ADHD is present, tics may actually be reduced by stimulants or atomoxetine rather than worsened. If the tic is severe and habit reversal training has not been successful, alpha agonists such as clonidine or guanfacine, or typical or atypical neuroleptics may be helpful. Even baclofen, benzodiazepines, anticonvulsants, nicotine, and Botox have been used. These require consultation with a specialist.
As for other chronic medical conditions, tics and persisting stereotypies deserve a comprehensive approach, including repeated education of the parent and child, evaluation for comorbidity, school accommodations, building other strengths and social support, and only rarely pulling out your prescription pad.
Dr. Howard is an assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Language development is the canary in the coal mine
The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.
Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.
The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.
These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.
Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.
School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.
Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.
But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.
The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.
Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.
What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.
Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.
After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.
After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.
The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.
As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.
Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.
Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.
The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.
These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.
Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.
School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.
Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.
But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.
The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.
Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.
What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.
Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.
After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.
After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.
The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.
As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.
Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.
Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.
The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.
These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.
Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.
School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.
Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.
But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.
The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.
Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.
What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.
Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.
After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.
After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.
The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.
As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.
Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Prepping for new babies in the family
If I were only to give a few bits of advice to families preparing for a new baby, while physical health problems in the mother or child are the biggest concerns of prospective parents, my coaching also would be aimed at safeguarding relationships in the new family constellation.
I find that having a prenatal visit at least by 34 weeks’ gestation for first-time parents is invaluable to getting to know them so that you are not a stranger after delivery and you can communicate more effectively if there are difficulties.
As for other topics that may not seem like a topic to be raised with a pediatrician, pregnancy fears may need to be prompted. You might say, "Most mothers in the second trimester have scary dreams about their future baby. Has this happened to you?" This gives parents a chance to express concerns, often about birth defects, but sometimes about how they or their partner will be caring for the baby. This can be a chance to ask about how the pregnancy has affected their relationship so far, and how they hope it will change once the baby comes.
The prenatal visit is a time to inform parents about practical matters such as your office’s practices regarding on call, insurance, your website, and the expectation for previsit questionnaires. After taking pregnancy and family histories, the other main topics are plans for circumcision and breast-feeding. This is the time for recommending prenatal labor and delivery classes for both fathers and mothers.
Possibly the most important topic for prospective parents, however, is quite different from these issues so clearly related to health – it is about building relationships. Fathers can be easily engaged on the topic about whether to circumcise or not, but having fathers sign on to supporting breast-feeding may not seem as obviously important. Not only do some couples have low comfort in talking about or exposing the mother’s breasts, but some fathers are even possessive of them and unwilling to share with the baby. A discussion about how the father can be the one to bring the baby from the crib for the middle-of-the-night breast-feeding and then burp, change, and return the infant to the crib is a way to support the (exhausted) mother.
Fathers need to know how important their help and support are to the new mother. Mothers need to be heard by the father (and anyone else who will listen) about their fears and pain during delivery, for as many times as it takes. He needs to tell her how brave she was and how grateful he is. Our son bought his wife a "push present" to acknowledge this marathon achievement!
Fathers also need to understand that things don’t just go back to "normal" once the baby has arrived. The support of the father at this special time is symbolic to the mother of the future of their relationship. I can’t tell you how many mothers, disgruntled with their marriages years into parenting, will call up examples of lack of support in the newborn period as the beginning of the deterioration of their relationship. The mother is exhausted from the well-termed "labor," literally and figuratively "drained" by breast-feeding and the interrupted sleep of the first months. She needs her partner to step up with both hands to help – and express sympathy – to show that he is part of the new parenting team.
I think it is important to emphasize that relationships do change – have to change – when a baby arrives. This can be a coming-together in sharing the chores as well as joys of parenting, or a splintering from lack of the communications co-parenting requires. Egocentricity that sufficed in a marriage without children no longer works when the exponential increase in life demands begins. Lack of social support is the number one risk factor for marital discord and child behavior problems; the main social support in American families is the spouse/partner. A golden rule for each parent to follow is, "Ask what you can do to help."
Other supports in addition to the spouse/partner are important, too. To start this topic you might ask: "How are you going to involve others in and out of the family with this child?" There is a need for both engagement and sometimes limit-setting on others that can be a new kind of task and stress for the couple. The task may involve at first negotiating visits and time with grandparents from each side versus privacy for the parents, then later determining family dietary practices for the new child as she grows; compromising on cultural discipline styles; deciding on how religious practice will be conveyed or not; and even setting limits on toys and gifts.
I encourage parents to engage commitment from other, unrelated adults as "godparents" as an important adjunct to biological family support. This can be especially useful for small or isolated families or those distancing themselves from their own relatives. Such early engagement can begin a lifelong bond that provides both the parents and child significant support over the years. In the case of future divorce (greater than 50%) or death of a parent, a godparent becomes an even more valuable source of stability.
For parents having their first child, the advice is much different than for families having a second child. For second-time parents, I am sometimes asked about when to tell the siblings about sleeping arrangements or how to ease the change when a new baby is coming. But one special opportunity to foster a positive relationship between the siblings occurs in the narrow window between the time of telling the child (second trimester is probably best due to the high rate of early miscarriage) and the birth. This is a time current children can attend so-called "sibling preparation" classes. Along with a strong relationship with the father, expression of empathy, optional involvement in caring for the baby, avoidance of gory details of the delivery and not forcing photos, attendance at these classes has been shown to improve sibling adjustment to the baby.
Parents who can’t take the older child to a sibling class can follow some of the principles themselves. The important points are to tell the sibling that a new baby is coming "because we love children," not as a playmate (since they are not much fun for a long time); that babies cry and sleep and spit up a lot in the beginning (realism), but eventually will be able to smile and play; and especially that "we (the parents) took care of you when you were little, and we will do the same for this baby." A review of the older child’s baby pictures can be a good way to start the conversation.
Siblings who are told in strong ways about the new baby’s point of view (Boy, he sure is hungry! Hungry enough to scream!) have more positive relationships later. While some behavioral regression (50%) and jealousy are common, most children quickly come to care about their new baby, and become loving, protective, and the best playmates and models for new skills a child ever has.
Finally, don’t forget to recommend daily "special time" for each parent with the older child(ren) starting prenatally and continuing forever, to reduce jealousy and provide reassurance that he is still loved no matter who else joins the family!
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
If I were only to give a few bits of advice to families preparing for a new baby, while physical health problems in the mother or child are the biggest concerns of prospective parents, my coaching also would be aimed at safeguarding relationships in the new family constellation.
I find that having a prenatal visit at least by 34 weeks’ gestation for first-time parents is invaluable to getting to know them so that you are not a stranger after delivery and you can communicate more effectively if there are difficulties.
As for other topics that may not seem like a topic to be raised with a pediatrician, pregnancy fears may need to be prompted. You might say, "Most mothers in the second trimester have scary dreams about their future baby. Has this happened to you?" This gives parents a chance to express concerns, often about birth defects, but sometimes about how they or their partner will be caring for the baby. This can be a chance to ask about how the pregnancy has affected their relationship so far, and how they hope it will change once the baby comes.
The prenatal visit is a time to inform parents about practical matters such as your office’s practices regarding on call, insurance, your website, and the expectation for previsit questionnaires. After taking pregnancy and family histories, the other main topics are plans for circumcision and breast-feeding. This is the time for recommending prenatal labor and delivery classes for both fathers and mothers.
Possibly the most important topic for prospective parents, however, is quite different from these issues so clearly related to health – it is about building relationships. Fathers can be easily engaged on the topic about whether to circumcise or not, but having fathers sign on to supporting breast-feeding may not seem as obviously important. Not only do some couples have low comfort in talking about or exposing the mother’s breasts, but some fathers are even possessive of them and unwilling to share with the baby. A discussion about how the father can be the one to bring the baby from the crib for the middle-of-the-night breast-feeding and then burp, change, and return the infant to the crib is a way to support the (exhausted) mother.
Fathers need to know how important their help and support are to the new mother. Mothers need to be heard by the father (and anyone else who will listen) about their fears and pain during delivery, for as many times as it takes. He needs to tell her how brave she was and how grateful he is. Our son bought his wife a "push present" to acknowledge this marathon achievement!
Fathers also need to understand that things don’t just go back to "normal" once the baby has arrived. The support of the father at this special time is symbolic to the mother of the future of their relationship. I can’t tell you how many mothers, disgruntled with their marriages years into parenting, will call up examples of lack of support in the newborn period as the beginning of the deterioration of their relationship. The mother is exhausted from the well-termed "labor," literally and figuratively "drained" by breast-feeding and the interrupted sleep of the first months. She needs her partner to step up with both hands to help – and express sympathy – to show that he is part of the new parenting team.
I think it is important to emphasize that relationships do change – have to change – when a baby arrives. This can be a coming-together in sharing the chores as well as joys of parenting, or a splintering from lack of the communications co-parenting requires. Egocentricity that sufficed in a marriage without children no longer works when the exponential increase in life demands begins. Lack of social support is the number one risk factor for marital discord and child behavior problems; the main social support in American families is the spouse/partner. A golden rule for each parent to follow is, "Ask what you can do to help."
Other supports in addition to the spouse/partner are important, too. To start this topic you might ask: "How are you going to involve others in and out of the family with this child?" There is a need for both engagement and sometimes limit-setting on others that can be a new kind of task and stress for the couple. The task may involve at first negotiating visits and time with grandparents from each side versus privacy for the parents, then later determining family dietary practices for the new child as she grows; compromising on cultural discipline styles; deciding on how religious practice will be conveyed or not; and even setting limits on toys and gifts.
I encourage parents to engage commitment from other, unrelated adults as "godparents" as an important adjunct to biological family support. This can be especially useful for small or isolated families or those distancing themselves from their own relatives. Such early engagement can begin a lifelong bond that provides both the parents and child significant support over the years. In the case of future divorce (greater than 50%) or death of a parent, a godparent becomes an even more valuable source of stability.
For parents having their first child, the advice is much different than for families having a second child. For second-time parents, I am sometimes asked about when to tell the siblings about sleeping arrangements or how to ease the change when a new baby is coming. But one special opportunity to foster a positive relationship between the siblings occurs in the narrow window between the time of telling the child (second trimester is probably best due to the high rate of early miscarriage) and the birth. This is a time current children can attend so-called "sibling preparation" classes. Along with a strong relationship with the father, expression of empathy, optional involvement in caring for the baby, avoidance of gory details of the delivery and not forcing photos, attendance at these classes has been shown to improve sibling adjustment to the baby.
Parents who can’t take the older child to a sibling class can follow some of the principles themselves. The important points are to tell the sibling that a new baby is coming "because we love children," not as a playmate (since they are not much fun for a long time); that babies cry and sleep and spit up a lot in the beginning (realism), but eventually will be able to smile and play; and especially that "we (the parents) took care of you when you were little, and we will do the same for this baby." A review of the older child’s baby pictures can be a good way to start the conversation.
Siblings who are told in strong ways about the new baby’s point of view (Boy, he sure is hungry! Hungry enough to scream!) have more positive relationships later. While some behavioral regression (50%) and jealousy are common, most children quickly come to care about their new baby, and become loving, protective, and the best playmates and models for new skills a child ever has.
Finally, don’t forget to recommend daily "special time" for each parent with the older child(ren) starting prenatally and continuing forever, to reduce jealousy and provide reassurance that he is still loved no matter who else joins the family!
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
If I were only to give a few bits of advice to families preparing for a new baby, while physical health problems in the mother or child are the biggest concerns of prospective parents, my coaching also would be aimed at safeguarding relationships in the new family constellation.
I find that having a prenatal visit at least by 34 weeks’ gestation for first-time parents is invaluable to getting to know them so that you are not a stranger after delivery and you can communicate more effectively if there are difficulties.
As for other topics that may not seem like a topic to be raised with a pediatrician, pregnancy fears may need to be prompted. You might say, "Most mothers in the second trimester have scary dreams about their future baby. Has this happened to you?" This gives parents a chance to express concerns, often about birth defects, but sometimes about how they or their partner will be caring for the baby. This can be a chance to ask about how the pregnancy has affected their relationship so far, and how they hope it will change once the baby comes.
The prenatal visit is a time to inform parents about practical matters such as your office’s practices regarding on call, insurance, your website, and the expectation for previsit questionnaires. After taking pregnancy and family histories, the other main topics are plans for circumcision and breast-feeding. This is the time for recommending prenatal labor and delivery classes for both fathers and mothers.
Possibly the most important topic for prospective parents, however, is quite different from these issues so clearly related to health – it is about building relationships. Fathers can be easily engaged on the topic about whether to circumcise or not, but having fathers sign on to supporting breast-feeding may not seem as obviously important. Not only do some couples have low comfort in talking about or exposing the mother’s breasts, but some fathers are even possessive of them and unwilling to share with the baby. A discussion about how the father can be the one to bring the baby from the crib for the middle-of-the-night breast-feeding and then burp, change, and return the infant to the crib is a way to support the (exhausted) mother.
Fathers need to know how important their help and support are to the new mother. Mothers need to be heard by the father (and anyone else who will listen) about their fears and pain during delivery, for as many times as it takes. He needs to tell her how brave she was and how grateful he is. Our son bought his wife a "push present" to acknowledge this marathon achievement!
Fathers also need to understand that things don’t just go back to "normal" once the baby has arrived. The support of the father at this special time is symbolic to the mother of the future of their relationship. I can’t tell you how many mothers, disgruntled with their marriages years into parenting, will call up examples of lack of support in the newborn period as the beginning of the deterioration of their relationship. The mother is exhausted from the well-termed "labor," literally and figuratively "drained" by breast-feeding and the interrupted sleep of the first months. She needs her partner to step up with both hands to help – and express sympathy – to show that he is part of the new parenting team.
I think it is important to emphasize that relationships do change – have to change – when a baby arrives. This can be a coming-together in sharing the chores as well as joys of parenting, or a splintering from lack of the communications co-parenting requires. Egocentricity that sufficed in a marriage without children no longer works when the exponential increase in life demands begins. Lack of social support is the number one risk factor for marital discord and child behavior problems; the main social support in American families is the spouse/partner. A golden rule for each parent to follow is, "Ask what you can do to help."
Other supports in addition to the spouse/partner are important, too. To start this topic you might ask: "How are you going to involve others in and out of the family with this child?" There is a need for both engagement and sometimes limit-setting on others that can be a new kind of task and stress for the couple. The task may involve at first negotiating visits and time with grandparents from each side versus privacy for the parents, then later determining family dietary practices for the new child as she grows; compromising on cultural discipline styles; deciding on how religious practice will be conveyed or not; and even setting limits on toys and gifts.
I encourage parents to engage commitment from other, unrelated adults as "godparents" as an important adjunct to biological family support. This can be especially useful for small or isolated families or those distancing themselves from their own relatives. Such early engagement can begin a lifelong bond that provides both the parents and child significant support over the years. In the case of future divorce (greater than 50%) or death of a parent, a godparent becomes an even more valuable source of stability.
For parents having their first child, the advice is much different than for families having a second child. For second-time parents, I am sometimes asked about when to tell the siblings about sleeping arrangements or how to ease the change when a new baby is coming. But one special opportunity to foster a positive relationship between the siblings occurs in the narrow window between the time of telling the child (second trimester is probably best due to the high rate of early miscarriage) and the birth. This is a time current children can attend so-called "sibling preparation" classes. Along with a strong relationship with the father, expression of empathy, optional involvement in caring for the baby, avoidance of gory details of the delivery and not forcing photos, attendance at these classes has been shown to improve sibling adjustment to the baby.
Parents who can’t take the older child to a sibling class can follow some of the principles themselves. The important points are to tell the sibling that a new baby is coming "because we love children," not as a playmate (since they are not much fun for a long time); that babies cry and sleep and spit up a lot in the beginning (realism), but eventually will be able to smile and play; and especially that "we (the parents) took care of you when you were little, and we will do the same for this baby." A review of the older child’s baby pictures can be a good way to start the conversation.
Siblings who are told in strong ways about the new baby’s point of view (Boy, he sure is hungry! Hungry enough to scream!) have more positive relationships later. While some behavioral regression (50%) and jealousy are common, most children quickly come to care about their new baby, and become loving, protective, and the best playmates and models for new skills a child ever has.
Finally, don’t forget to recommend daily "special time" for each parent with the older child(ren) starting prenatally and continuing forever, to reduce jealousy and provide reassurance that he is still loved no matter who else joins the family!
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Talking With Families About Corporal Punishment
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Talking with families about corporal punishment
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
One of the issues that can push your button as a pediatrician is hearing from your nurse that the parent you are about to see hit the child in the waiting room. Sometimes, the parent even hits the child right in front of you during the visit!
Your first reaction may be to want to tell the parents not to spank. But how well does that advice work?
Parents tend to use the same methods of child rearing that were used for them when they were growing up. This is deeply ingrained and tends to be accepted as "natural" even when they do not rationally believe in it. This requires that any intervention about corporal punishment be a conversation, not an edict from you. They may nod their heads if you tell them not to spank, but shut out any future advice from you on this topic.
There are some real facts that can help you address the parents’ reasons for spanking. The first "fact" that pediatricians often pull out is that "hitting the child does not work." Wrong. Hitting a child works fast to stop an unwanted behavior – but it has side effects. If you deny this, you lose credibility. If you acknowledge this, you will have the ears of the parents. Then you can point out some related truths – the child will soon go back to the same behavior whether hit or not because that is what young children do. Avoiding repeat behavior requires adjusting the environment, removing the child, and often changing the mood of the interaction. It is a fact that painful punishments must be progressively increased to maintain effectiveness and make nonpainful interventions less effective. I sometimes muse, "What are the teachers going to do at school if only hitting can control his behavior?"
The next fact is that other consequences, notably time out, work just as well as spanking to reduce unwanted behaviors, but without the side effects. What are these side effects? There are immediate side effects of corporal punishment, even if no bruising or harm occurs, and also long-term side effects. The immediate side effects are to increase the child’s aggressiveness to peers, siblings, and often the parent, and to increase fear of the parent. Fear of the parent undermines the child’s wanting to do as the parent asks, makes the child avoid the parent – making him/her less available to all parenting, and interferes with the problem solving that the child needs to do when facing a stressful situation such as conflict with a sibling. Longer term fear of the parent makes a child sneaky and less likely to admit mistakes. That is certainly not what anyone wants, especially when the child becomes a teen.
It may be hard to believe, but 25% of infants 1-6 months and 50% of infants 6-12 months are spanked for discipline. The implication is that it is never too early to have a conversation about discipline – certainly by 12 months of age. This early teaching helps parents establish control and helps prevent the early use of corporal punishment. Help parents understand that infants cannot learn to avoid a behavior from being struck; they can only become confused and frightened of their parent. In fact, 0- to 23-month-old white (not black or Latino) children had worse behavior at 6 years if they were frequently spanked, even controlling for maternal warmth (Pediatrics 2004;113:1321-1330).
Hitting a child is especially dangerous for children under age 2 years due to their size and head/body proportions. At this stage, a hit by an adult is more likely to cause serious injury even when the adult thought they were under control and managing the amount of force used. It is sobering to know that one-third of child abuse occurs to children under 6 months of age. If evidence of abuse is seen, it is your obligation to report it immediately. But you have a lot more value in educating about effective and safe discipline early on to prevent this. The American Academy of Pediatrics recommends that parents be "assisted in the development of methods other than spanking for managing undesired behavior" and that means you!
But doesn’t a toddler need discipline to learn how to behave? We know that verbal correction without action actually increases noncompliance in toddlers. But in one study, two-thirds of children under age 6 years were hit in the last week, on average 3 times per week. This is because toddlers and preschoolers typically misbehave every 6-8 minutes! Some consequence is needed as a back-up to reasoning to decrease recurrence of misbehavior, but noncorporal consequences are equally effective. The more children ages 3-6 years are spanked, the greater their antisocial behavior 2 years later, controlled for baseline behavior. Even IQ is lower at age 4 years when there is more spanking.
Asking older children "What happens if you do something bad" is a regular part of my visits. Why? Because 60% of 10- to 12-year-olds are struck and have increased aggression and decreased self-esteem as a result. Don’t forget that 40% of 14-year-olds and 25% of 17-year-olds are still hit even though the result is that 8- to 17-year olds who are struck have increased delinquency, controlling for family violence, alcohol, and parenting competence.
Most parents do not want to hit their child. Actually, 85% of parents who believe in spanking say that it was the wrong thing to have done the last time they used it. Yet about 90% of parents hit their 3-year-olds. Why? Parents who hit say that they don’t know what else to do when their children act out. They may try not to spank, but end up spanking out of anger and frustration. And hitting not only stops behavior, but also relieves the anger parents feel in dealing with their child. Even though they may regret it afterward, it feels good to them at the time.
How can you approach this touchy subject with your patients? The first principle is to resist your impulse to correct the parent and instead say nothing – at least right away. Carry on your visit and observe the child’s behavior. Some misbehavior is likely to appear. Then comment on what you see about child – "He sure is busy!" Then ask, "How is that for you?", or "How bad does it get?" Be nonjudgmental. Instead praise acceptable techniques they already use well, such as distracting the child or removing temptation.
Because parenting is learned from our own experiences, it is important to explore how the parents were raised. You might start by asking, "How would your parents have handled that behavior when you were growing up?" then "What have you decided about how you want to discipline your children?" Often, you will find that they do not want to repeat history, but don’t know other ways. Now you have an opening to offer other effective techniques. You might even ask permission, for example, "Would you like to hear about some other things that can work?" The main strategies you can teach quickly include first paying attention to acceptable behavior, and also proper use of Time Out. For toddlers and preschoolers, I also teach parents to use "only one request then move" the child silently to do as told.
Your advice will be more effective when you individualize the plan to make small adjustments to their current parenting with which the family can agree and be successful. For example, if one parent is willing to try these alternatives but the other is not or is unsure I suggest an agreement for use of Time Out instead of hitting for 2-3 weeks by the willing parent and noninterference plus limits on physical punishment (spank on clothed buttocks only) by the other parent. What usually happens is that the "Time Out parent" has success in this time period, and the other parent sees this and adopts the same method. It is really important to schedule one or more follow up visits soon, at least by phone, to reinforce their success and problem solve any difficulties. Changing such an ingrained habit is difficult but worthwhile and deserves your support.
Advising to avoid corporal punishment can be even more difficult for some doctors and in some settings. You may have been raised with spanking yourself and see it as not harmful or even helpful to your own development. Remember, spanking only increases the chances of a poor outcome by a factor of four, so most people grow up fine! The parents’ or your religion may even advise the use of spanking. I like to translate "spare the rod" as meaning "draw a line in the sand with the rod" to set limits. You may be of a different culture than your patient in which their belief is that corporal punishment is the key to neighborhood survival and gaining the child’s respect. But a child who is hit is actually more likely to bring him/herself trouble through aggression or delinquency.
To be effective in counseling about corporal punishment, you need to be clear about your own ideas on the acceptability of hitting. You need to be rational and avoid strong emotions during the visit. Instead, show empathy to the difficulties of parenting and work to understand and address the parents’ justifications for spanking with the facts. If you have shown knowledge of behavior and development in the regular care you provide, you will be a credible source and influence on this important area.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
We already tried that ... Refining your behavior management plans
It is the rare family of a child with behavior problems that has not already tried a plan from a book or advice from friends or relatives. They may even have done what their parents did to them, whether it worked or not! The first message you hear in the visit may be "We already tried the star chart thing."
Can you really provide any better advice for changing behavior than what they have already heard?
Unlike casual sources, you know the family well and are a trusted counselor. You may guess meanings the behavior has such as avoiding upset for their "delicate" preemie by not enforcing limits.
But the main way you can provide more effective advice is by knowing the scientific basis for behavior change methods. First, understand the W’s – What is the specific current behavior and What is the desired behavior?; Who is present, When and Where is the behavior most often happening? What does the presence of this behavior mean to the child and family?
You need a thorough understanding of the behavior to advise ways to prevent it by avoiding or reducing demands that the child cannot meet. Reframe the issue as the child lacking skills needed to act appropriately and suggest ways to build them.
The use of rewards or consequences can then be targeted to encouraging skill building or reducing established behavior patterns. In general, positive reinforcement or rewards are more effective than consequences. Why reward? Changing behavior is hard work for the child (and parent), and positive reinforcement helps both initiate and maintain a behavior.
The most effective positive reinforcers are things that are valued by the child, are available infrequently otherwise, are novel, are given contingent on the desired behavior, are related to the desired action, are dosed appropriately; can be delivered immediately and consistently after the desired behavior occurs, and are acceptable to the parent.
Bigger rewards may be needed to start new behaviors (a Barbie got our shy daughter onto the soccer field the first time), but smaller rewards have advantages. Parents will more cheerfully and consistently deliver a 25-cent Pokemon card every time the child cooperates with homework than a $25 video game. Smaller reinforcers also mean less is needed to maintain the behavior. Children are smart – if it takes the promise of Disneyland to sleep in their own bed then it must be pretty bad! Larger rewards also result in less self-satisfaction; the child justifies going along with the plan to get the reward rather than because it was a good idea.
With the ultimate goal of behaving for their own sake, rewards (and later even praise) should be used sparingly and phased out quickly. As children mature, they can be encouraged to self-evaluate, such as asking, "How do you think you handled that?"
Food rewards should be avoided as they can promote emotional attachment to unhealthy snacks, although for children with autism or intellectual disabilities it may be the only effective reinforcement.
All new behaviors are learned better when the reason for change is explained; the child participates in choosing the new behavior and its reward; the desired behavior is named, modeled, and then practiced; and the reinforcement is accompanied by verbal praise. So-called "differential reinforcement" works best when incompatible behavior is rewarded, for example spitting toothpaste in the sink is incompatible with spitting on a sibling.
All inadvertent positive reinforcement for the undesired behavior must be avoided. The subterfuge may be subtle, for example biting may be reinforced if one adult rushes to the child, giving special attention even to scold. Even seemingly aversive things may be positive reinforcers if they result in increasing rather than decreasing a behavior.
Of course, for most children no reward is needed to gain cooperation – just ask! For tougher situations, the optimal frequency of reward comes from a "schedule of reinforcement." At first, reinforcement is likely needed every time and for little pieces of the ultimately desired action ("shaping"). For example, cleaning up toys has to start with the parent picking up 99 and the child 1 (with praise!).
Once the child is doing the new behavior fairly consistently with reinforcement, start "fading" the prompts and rewards. This increases "acting well" spontaneously and helps generalization. You hardly need to teach a parent to fade rewards as they naturally tend to forget, delay, or give fewer prompts. Rewards also can be decreased in amount, delayed, or reserved for increasingly elaborated positive behaviors – all helping solidify the new behavior.
Consequences are mainly needed for younger children and as back up to reinforcement. Similar principles apply to consequences. Consequences are most effective when used infrequently but consistently for the same behavior, unwanted by the child, done immediately after the unwanted behavior, related to the nature of the misbehavior and dosed appropriately (smaller is better!), and acceptable to the parents. The child should have a "clean slate" after the consequence to help restore the relationship. Painful, harsh, scary, or injurious consequences are neither acceptable nor effective.
Two methods of behavior modification I find easy to teach and implement are marks and points.
Marks make reinforcing behavior easy and fun for children 2-7 years old. The adult marks with a pen on the child’s hand along with verbal praise for each behavior "just a little bit better than usual," such as tantrums lasting 1 minute instead of 2, aiming for 6-10 marks per hour. High frequency helps adults notice more and smaller "okay" behaviors, often a deficit. At the end of the marking period each day, give a small reward (such as extra play time, grab bag prize, pennies) for having a "bunch" to confer value to the marks. Give bonus marks for outstanding or spontaneous behaviors (Hey, they’re free!). Marks are faded out when behavior has improved and parents are noticing and praising good behavior. While removal of marks for inappropriate behavior can be used, I do not recommend it as parents are often in a punitive cycle in that case and need to refocus on the positive.
For older children, a "token economy" (star chart) using points, stars, or poker chips is an evidence-based method for behavior change when done correctly. Optimal implementation includes outlining the plan with parent and child together so that the desired behaviors, rewards, and costs are clear and relevant. Together they set the "price" for behaviors (such as 5 earned for 30 minutes of TV without fighting or 10 lost for a squabble). While token economies work for chore compliance, the focus here is for behavior. A key component motivating participation is charging for things taken for granted such as TV, computer, outside play time. Give "bonus points" for initiating, extra acts of kindness, etc. "Purchases" for basics or privileges are deducted from the total kept on a card or a subset of freedoms can be allowed based on a minimum total "in the bank."
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
It is the rare family of a child with behavior problems that has not already tried a plan from a book or advice from friends or relatives. They may even have done what their parents did to them, whether it worked or not! The first message you hear in the visit may be "We already tried the star chart thing."
Can you really provide any better advice for changing behavior than what they have already heard?
Unlike casual sources, you know the family well and are a trusted counselor. You may guess meanings the behavior has such as avoiding upset for their "delicate" preemie by not enforcing limits.
But the main way you can provide more effective advice is by knowing the scientific basis for behavior change methods. First, understand the W’s – What is the specific current behavior and What is the desired behavior?; Who is present, When and Where is the behavior most often happening? What does the presence of this behavior mean to the child and family?
You need a thorough understanding of the behavior to advise ways to prevent it by avoiding or reducing demands that the child cannot meet. Reframe the issue as the child lacking skills needed to act appropriately and suggest ways to build them.
The use of rewards or consequences can then be targeted to encouraging skill building or reducing established behavior patterns. In general, positive reinforcement or rewards are more effective than consequences. Why reward? Changing behavior is hard work for the child (and parent), and positive reinforcement helps both initiate and maintain a behavior.
The most effective positive reinforcers are things that are valued by the child, are available infrequently otherwise, are novel, are given contingent on the desired behavior, are related to the desired action, are dosed appropriately; can be delivered immediately and consistently after the desired behavior occurs, and are acceptable to the parent.
Bigger rewards may be needed to start new behaviors (a Barbie got our shy daughter onto the soccer field the first time), but smaller rewards have advantages. Parents will more cheerfully and consistently deliver a 25-cent Pokemon card every time the child cooperates with homework than a $25 video game. Smaller reinforcers also mean less is needed to maintain the behavior. Children are smart – if it takes the promise of Disneyland to sleep in their own bed then it must be pretty bad! Larger rewards also result in less self-satisfaction; the child justifies going along with the plan to get the reward rather than because it was a good idea.
With the ultimate goal of behaving for their own sake, rewards (and later even praise) should be used sparingly and phased out quickly. As children mature, they can be encouraged to self-evaluate, such as asking, "How do you think you handled that?"
Food rewards should be avoided as they can promote emotional attachment to unhealthy snacks, although for children with autism or intellectual disabilities it may be the only effective reinforcement.
All new behaviors are learned better when the reason for change is explained; the child participates in choosing the new behavior and its reward; the desired behavior is named, modeled, and then practiced; and the reinforcement is accompanied by verbal praise. So-called "differential reinforcement" works best when incompatible behavior is rewarded, for example spitting toothpaste in the sink is incompatible with spitting on a sibling.
All inadvertent positive reinforcement for the undesired behavior must be avoided. The subterfuge may be subtle, for example biting may be reinforced if one adult rushes to the child, giving special attention even to scold. Even seemingly aversive things may be positive reinforcers if they result in increasing rather than decreasing a behavior.
Of course, for most children no reward is needed to gain cooperation – just ask! For tougher situations, the optimal frequency of reward comes from a "schedule of reinforcement." At first, reinforcement is likely needed every time and for little pieces of the ultimately desired action ("shaping"). For example, cleaning up toys has to start with the parent picking up 99 and the child 1 (with praise!).
Once the child is doing the new behavior fairly consistently with reinforcement, start "fading" the prompts and rewards. This increases "acting well" spontaneously and helps generalization. You hardly need to teach a parent to fade rewards as they naturally tend to forget, delay, or give fewer prompts. Rewards also can be decreased in amount, delayed, or reserved for increasingly elaborated positive behaviors – all helping solidify the new behavior.
Consequences are mainly needed for younger children and as back up to reinforcement. Similar principles apply to consequences. Consequences are most effective when used infrequently but consistently for the same behavior, unwanted by the child, done immediately after the unwanted behavior, related to the nature of the misbehavior and dosed appropriately (smaller is better!), and acceptable to the parents. The child should have a "clean slate" after the consequence to help restore the relationship. Painful, harsh, scary, or injurious consequences are neither acceptable nor effective.
Two methods of behavior modification I find easy to teach and implement are marks and points.
Marks make reinforcing behavior easy and fun for children 2-7 years old. The adult marks with a pen on the child’s hand along with verbal praise for each behavior "just a little bit better than usual," such as tantrums lasting 1 minute instead of 2, aiming for 6-10 marks per hour. High frequency helps adults notice more and smaller "okay" behaviors, often a deficit. At the end of the marking period each day, give a small reward (such as extra play time, grab bag prize, pennies) for having a "bunch" to confer value to the marks. Give bonus marks for outstanding or spontaneous behaviors (Hey, they’re free!). Marks are faded out when behavior has improved and parents are noticing and praising good behavior. While removal of marks for inappropriate behavior can be used, I do not recommend it as parents are often in a punitive cycle in that case and need to refocus on the positive.
For older children, a "token economy" (star chart) using points, stars, or poker chips is an evidence-based method for behavior change when done correctly. Optimal implementation includes outlining the plan with parent and child together so that the desired behaviors, rewards, and costs are clear and relevant. Together they set the "price" for behaviors (such as 5 earned for 30 minutes of TV without fighting or 10 lost for a squabble). While token economies work for chore compliance, the focus here is for behavior. A key component motivating participation is charging for things taken for granted such as TV, computer, outside play time. Give "bonus points" for initiating, extra acts of kindness, etc. "Purchases" for basics or privileges are deducted from the total kept on a card or a subset of freedoms can be allowed based on a minimum total "in the bank."
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
It is the rare family of a child with behavior problems that has not already tried a plan from a book or advice from friends or relatives. They may even have done what their parents did to them, whether it worked or not! The first message you hear in the visit may be "We already tried the star chart thing."
Can you really provide any better advice for changing behavior than what they have already heard?
Unlike casual sources, you know the family well and are a trusted counselor. You may guess meanings the behavior has such as avoiding upset for their "delicate" preemie by not enforcing limits.
But the main way you can provide more effective advice is by knowing the scientific basis for behavior change methods. First, understand the W’s – What is the specific current behavior and What is the desired behavior?; Who is present, When and Where is the behavior most often happening? What does the presence of this behavior mean to the child and family?
You need a thorough understanding of the behavior to advise ways to prevent it by avoiding or reducing demands that the child cannot meet. Reframe the issue as the child lacking skills needed to act appropriately and suggest ways to build them.
The use of rewards or consequences can then be targeted to encouraging skill building or reducing established behavior patterns. In general, positive reinforcement or rewards are more effective than consequences. Why reward? Changing behavior is hard work for the child (and parent), and positive reinforcement helps both initiate and maintain a behavior.
The most effective positive reinforcers are things that are valued by the child, are available infrequently otherwise, are novel, are given contingent on the desired behavior, are related to the desired action, are dosed appropriately; can be delivered immediately and consistently after the desired behavior occurs, and are acceptable to the parent.
Bigger rewards may be needed to start new behaviors (a Barbie got our shy daughter onto the soccer field the first time), but smaller rewards have advantages. Parents will more cheerfully and consistently deliver a 25-cent Pokemon card every time the child cooperates with homework than a $25 video game. Smaller reinforcers also mean less is needed to maintain the behavior. Children are smart – if it takes the promise of Disneyland to sleep in their own bed then it must be pretty bad! Larger rewards also result in less self-satisfaction; the child justifies going along with the plan to get the reward rather than because it was a good idea.
With the ultimate goal of behaving for their own sake, rewards (and later even praise) should be used sparingly and phased out quickly. As children mature, they can be encouraged to self-evaluate, such as asking, "How do you think you handled that?"
Food rewards should be avoided as they can promote emotional attachment to unhealthy snacks, although for children with autism or intellectual disabilities it may be the only effective reinforcement.
All new behaviors are learned better when the reason for change is explained; the child participates in choosing the new behavior and its reward; the desired behavior is named, modeled, and then practiced; and the reinforcement is accompanied by verbal praise. So-called "differential reinforcement" works best when incompatible behavior is rewarded, for example spitting toothpaste in the sink is incompatible with spitting on a sibling.
All inadvertent positive reinforcement for the undesired behavior must be avoided. The subterfuge may be subtle, for example biting may be reinforced if one adult rushes to the child, giving special attention even to scold. Even seemingly aversive things may be positive reinforcers if they result in increasing rather than decreasing a behavior.
Of course, for most children no reward is needed to gain cooperation – just ask! For tougher situations, the optimal frequency of reward comes from a "schedule of reinforcement." At first, reinforcement is likely needed every time and for little pieces of the ultimately desired action ("shaping"). For example, cleaning up toys has to start with the parent picking up 99 and the child 1 (with praise!).
Once the child is doing the new behavior fairly consistently with reinforcement, start "fading" the prompts and rewards. This increases "acting well" spontaneously and helps generalization. You hardly need to teach a parent to fade rewards as they naturally tend to forget, delay, or give fewer prompts. Rewards also can be decreased in amount, delayed, or reserved for increasingly elaborated positive behaviors – all helping solidify the new behavior.
Consequences are mainly needed for younger children and as back up to reinforcement. Similar principles apply to consequences. Consequences are most effective when used infrequently but consistently for the same behavior, unwanted by the child, done immediately after the unwanted behavior, related to the nature of the misbehavior and dosed appropriately (smaller is better!), and acceptable to the parents. The child should have a "clean slate" after the consequence to help restore the relationship. Painful, harsh, scary, or injurious consequences are neither acceptable nor effective.
Two methods of behavior modification I find easy to teach and implement are marks and points.
Marks make reinforcing behavior easy and fun for children 2-7 years old. The adult marks with a pen on the child’s hand along with verbal praise for each behavior "just a little bit better than usual," such as tantrums lasting 1 minute instead of 2, aiming for 6-10 marks per hour. High frequency helps adults notice more and smaller "okay" behaviors, often a deficit. At the end of the marking period each day, give a small reward (such as extra play time, grab bag prize, pennies) for having a "bunch" to confer value to the marks. Give bonus marks for outstanding or spontaneous behaviors (Hey, they’re free!). Marks are faded out when behavior has improved and parents are noticing and praising good behavior. While removal of marks for inappropriate behavior can be used, I do not recommend it as parents are often in a punitive cycle in that case and need to refocus on the positive.
For older children, a "token economy" (star chart) using points, stars, or poker chips is an evidence-based method for behavior change when done correctly. Optimal implementation includes outlining the plan with parent and child together so that the desired behaviors, rewards, and costs are clear and relevant. Together they set the "price" for behaviors (such as 5 earned for 30 minutes of TV without fighting or 10 lost for a squabble). While token economies work for chore compliance, the focus here is for behavior. A key component motivating participation is charging for things taken for granted such as TV, computer, outside play time. Give "bonus points" for initiating, extra acts of kindness, etc. "Purchases" for basics or privileges are deducted from the total kept on a card or a subset of freedoms can be allowed based on a minimum total "in the bank."
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Transition to DSM-5 for Autism
With prevalence of as much as 1 in 88 according to the Centers for Disease Control and Prevention, you are no doubt caring for many children with autism. It can be an intimidating task when families, anxious to assure that their children get the best care, seek your opinion and support on the changes brought by DSM-5.
The DSM classification system aims to provide mental health diagnostic criteria with ever improving validity and reliability. Most changes in the DSM-5 published in May 2013 were made based on research and field trials. For autism, DSM-5 consolidates the four separate disorders of DSM-IV into a single condition with different levels of symptom severity in two core domains. Thus, the prior diagnoses falling under pervasive developmental disorders of autistic disorder, Asperger’s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified are now all called autism spectrum disorder. Rett syndrome has been pulled out because its specific genetic cause is now known.
This means diagnoses with which you are familiar and that are being carried by your existing patients are gone. Both families and organizations are on edge, shaken by having terms they had come to accept, often with great difficulty, are gone. They are even more concerned that the changes in classification will alter their child’s eligibility for services.
So what are the new DSM-5 criteria for autism spectrum disorder (ASD)? There are now two rather than three core features for a child to have an ASD diagnosis: 1) deficits in social communication and interaction; and 2) presence of restricted, repetitive interests or behaviors. The required deficits must be persistent and may be present now or by history.
The social communication and interaction symptoms may include such things as the failure to be interested in interaction with peers, poor pragmatic language, and poor eye contact that you already know.
The second criterion, restricted, repetitive patterns of behavior interests or activities, requires at least two of the following:
• Stereotyped or repetitive motor movements, use of objects, or speech. Thus echolalia, mimicking movie scripts, twirling objects, or flapping would count.
• Insistence on sameness, inflexible routines, or ritualized behavior. This includes the rigidity or upset about change seen in Asperger.
• Highly restricted, fixed interests abnormal in intensity or focus. This captures obsessions with train schedules, fans, etc.
• Hyper- or hyporeactivity to sensory or unusual interest in sensory aspects. This criterion was only a mention in DSM-IV, rather than a potential diagnostic element. It includes the problems with food textures, inability to tolerate the movie soundtrack or oblivion to pain sometimes observed.
Significant impairment in functioning is still required, but it is now to be judged by the amount of support required for the child to cope with daily living. Severity for each of the two areas (social communication and restricted, repetitive behaviors) should be separately described using levels:
• Level 3: Requiring very substantial support.
• Level 2: Requiring substantial support
• Level 1: Requiring support.
There is table in the DSM-5 that more fully explains the levels and gives examples.
Those children about whom no one was complaining because of careful family accommodation now qualify, since onset before age 3 years is no longer required; only at an "early age."
Because autism often appears in children with intellectual disability or global developmental delay, these diagnoses take precedence for diagnosis unless social communication is below that expected for the child’s general developmental level. In that case, diagnoses of both intellectual disability and ASD apply.
While other features associated with autism are acknowledged in the description of ASD, they no longer drive the diagnosis. Associated factors should be described as part of the diagnoses, such as association with a known medical (attention-deficit/hyperactivity disorder) or genetic condition (Fragile X) or environmental factor; with or without intellectual disability; with or without language impairment; and any other neurodevelopmental, mental, or behavioral disorder. Any catatonia should be noted.
The change with possibly the greatest and most uncertain impact is the pull-out of a new disorder: social communication disorder. This is to be used for children with social language deficits if the criterion for repetitive and restricted behaviors is not met. These, usually higher-functioning children are the most likely to be removed from ASD diagnosis by the DSM-5 revisions. There are risks in this move as criteria are quite strict for the communication problems but overlap language disorder. The assessment tools needed for determining these criteria are not well developed and speech-language pathologists may not be well prepared to assess the repetitive behaviors to rule in or rule out ASD. Services for this diagnosis may be restricted to the speech-language component instead of including the social skills deficits and more intense treatment now provided for children classified as ASD.
As for changed diagnoses resulting in changed services, there is some good news: There may not be any service changes at all for your current patients. The DSM-5 Neurodevelopmental Disorders Work Group states that these changes will not affect children with a current diagnosis; no children will lose their current diagnoses on the spectrum. For services based on diagnosis, some children may not qualify in the future, but when services are based on severity children will likely qualify based on the new levels.
But what about the children yet to be diagnosed? One goal for reorganization in the DSM-5 was to improve specificity, but sensitivity may suffer, particularly for children previously called PDD NOS. Huerta et al. studied this using a cross classification of children already diagnosed to see which ones might be excluded under DSM-5 (Am. J. Psychiatry 2012;169:1056-64). She found that the DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses, perhaps the most vulnerable to exclusion. The sensitivity of the DSM-5 criteria was high, even in girls and children younger than 4 years. This would be good news for retaining services.
But other studies on previously diagnosed cases do not agree. These studies using various existing samples predict that least 12% and potentially more than 40% of children who would have been classified as ASD under DSM-IV will not be under DSM-5, especially the most high functioning. Failure to meet criteria in the social communication domain was the most common reason for exclusion (39%) in one study. In addition, ASD prevalence is predicted to drop from 11.3% to 10.0% using the DSM-5 criteria (JAMA Psychiatry 2014 [doi: 10.1001/jamapsychiatry.2013.3893]). DSM-5 changes also will make it difficult for ongoing longitudinal research studies to compare with previous data.
Because the DSM-5 diagnosis of ASD is here to stay, what can you do to ease the transition? First, be able to explain the changes as described here. Then, implement or look for all aspects of the descriptors about comorbidity and severity when you are monitoring services being provided or advocating for more. Take special care that social communication disorder is diagnosed correctly and that both language and social skills are addressed. And encourage parents to join the national registries such as Autism Speaks and the Autism Speaks Autism Treatment Network and the Interactive Autism Network, which will help current and future research as DSM-5 efficacy is examined and even more changes made.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
With prevalence of as much as 1 in 88 according to the Centers for Disease Control and Prevention, you are no doubt caring for many children with autism. It can be an intimidating task when families, anxious to assure that their children get the best care, seek your opinion and support on the changes brought by DSM-5.
The DSM classification system aims to provide mental health diagnostic criteria with ever improving validity and reliability. Most changes in the DSM-5 published in May 2013 were made based on research and field trials. For autism, DSM-5 consolidates the four separate disorders of DSM-IV into a single condition with different levels of symptom severity in two core domains. Thus, the prior diagnoses falling under pervasive developmental disorders of autistic disorder, Asperger’s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified are now all called autism spectrum disorder. Rett syndrome has been pulled out because its specific genetic cause is now known.
This means diagnoses with which you are familiar and that are being carried by your existing patients are gone. Both families and organizations are on edge, shaken by having terms they had come to accept, often with great difficulty, are gone. They are even more concerned that the changes in classification will alter their child’s eligibility for services.
So what are the new DSM-5 criteria for autism spectrum disorder (ASD)? There are now two rather than three core features for a child to have an ASD diagnosis: 1) deficits in social communication and interaction; and 2) presence of restricted, repetitive interests or behaviors. The required deficits must be persistent and may be present now or by history.
The social communication and interaction symptoms may include such things as the failure to be interested in interaction with peers, poor pragmatic language, and poor eye contact that you already know.
The second criterion, restricted, repetitive patterns of behavior interests or activities, requires at least two of the following:
• Stereotyped or repetitive motor movements, use of objects, or speech. Thus echolalia, mimicking movie scripts, twirling objects, or flapping would count.
• Insistence on sameness, inflexible routines, or ritualized behavior. This includes the rigidity or upset about change seen in Asperger.
• Highly restricted, fixed interests abnormal in intensity or focus. This captures obsessions with train schedules, fans, etc.
• Hyper- or hyporeactivity to sensory or unusual interest in sensory aspects. This criterion was only a mention in DSM-IV, rather than a potential diagnostic element. It includes the problems with food textures, inability to tolerate the movie soundtrack or oblivion to pain sometimes observed.
Significant impairment in functioning is still required, but it is now to be judged by the amount of support required for the child to cope with daily living. Severity for each of the two areas (social communication and restricted, repetitive behaviors) should be separately described using levels:
• Level 3: Requiring very substantial support.
• Level 2: Requiring substantial support
• Level 1: Requiring support.
There is table in the DSM-5 that more fully explains the levels and gives examples.
Those children about whom no one was complaining because of careful family accommodation now qualify, since onset before age 3 years is no longer required; only at an "early age."
Because autism often appears in children with intellectual disability or global developmental delay, these diagnoses take precedence for diagnosis unless social communication is below that expected for the child’s general developmental level. In that case, diagnoses of both intellectual disability and ASD apply.
While other features associated with autism are acknowledged in the description of ASD, they no longer drive the diagnosis. Associated factors should be described as part of the diagnoses, such as association with a known medical (attention-deficit/hyperactivity disorder) or genetic condition (Fragile X) or environmental factor; with or without intellectual disability; with or without language impairment; and any other neurodevelopmental, mental, or behavioral disorder. Any catatonia should be noted.
The change with possibly the greatest and most uncertain impact is the pull-out of a new disorder: social communication disorder. This is to be used for children with social language deficits if the criterion for repetitive and restricted behaviors is not met. These, usually higher-functioning children are the most likely to be removed from ASD diagnosis by the DSM-5 revisions. There are risks in this move as criteria are quite strict for the communication problems but overlap language disorder. The assessment tools needed for determining these criteria are not well developed and speech-language pathologists may not be well prepared to assess the repetitive behaviors to rule in or rule out ASD. Services for this diagnosis may be restricted to the speech-language component instead of including the social skills deficits and more intense treatment now provided for children classified as ASD.
As for changed diagnoses resulting in changed services, there is some good news: There may not be any service changes at all for your current patients. The DSM-5 Neurodevelopmental Disorders Work Group states that these changes will not affect children with a current diagnosis; no children will lose their current diagnoses on the spectrum. For services based on diagnosis, some children may not qualify in the future, but when services are based on severity children will likely qualify based on the new levels.
But what about the children yet to be diagnosed? One goal for reorganization in the DSM-5 was to improve specificity, but sensitivity may suffer, particularly for children previously called PDD NOS. Huerta et al. studied this using a cross classification of children already diagnosed to see which ones might be excluded under DSM-5 (Am. J. Psychiatry 2012;169:1056-64). She found that the DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses, perhaps the most vulnerable to exclusion. The sensitivity of the DSM-5 criteria was high, even in girls and children younger than 4 years. This would be good news for retaining services.
But other studies on previously diagnosed cases do not agree. These studies using various existing samples predict that least 12% and potentially more than 40% of children who would have been classified as ASD under DSM-IV will not be under DSM-5, especially the most high functioning. Failure to meet criteria in the social communication domain was the most common reason for exclusion (39%) in one study. In addition, ASD prevalence is predicted to drop from 11.3% to 10.0% using the DSM-5 criteria (JAMA Psychiatry 2014 [doi: 10.1001/jamapsychiatry.2013.3893]). DSM-5 changes also will make it difficult for ongoing longitudinal research studies to compare with previous data.
Because the DSM-5 diagnosis of ASD is here to stay, what can you do to ease the transition? First, be able to explain the changes as described here. Then, implement or look for all aspects of the descriptors about comorbidity and severity when you are monitoring services being provided or advocating for more. Take special care that social communication disorder is diagnosed correctly and that both language and social skills are addressed. And encourage parents to join the national registries such as Autism Speaks and the Autism Speaks Autism Treatment Network and the Interactive Autism Network, which will help current and future research as DSM-5 efficacy is examined and even more changes made.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
With prevalence of as much as 1 in 88 according to the Centers for Disease Control and Prevention, you are no doubt caring for many children with autism. It can be an intimidating task when families, anxious to assure that their children get the best care, seek your opinion and support on the changes brought by DSM-5.
The DSM classification system aims to provide mental health diagnostic criteria with ever improving validity and reliability. Most changes in the DSM-5 published in May 2013 were made based on research and field trials. For autism, DSM-5 consolidates the four separate disorders of DSM-IV into a single condition with different levels of symptom severity in two core domains. Thus, the prior diagnoses falling under pervasive developmental disorders of autistic disorder, Asperger’s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified are now all called autism spectrum disorder. Rett syndrome has been pulled out because its specific genetic cause is now known.
This means diagnoses with which you are familiar and that are being carried by your existing patients are gone. Both families and organizations are on edge, shaken by having terms they had come to accept, often with great difficulty, are gone. They are even more concerned that the changes in classification will alter their child’s eligibility for services.
So what are the new DSM-5 criteria for autism spectrum disorder (ASD)? There are now two rather than three core features for a child to have an ASD diagnosis: 1) deficits in social communication and interaction; and 2) presence of restricted, repetitive interests or behaviors. The required deficits must be persistent and may be present now or by history.
The social communication and interaction symptoms may include such things as the failure to be interested in interaction with peers, poor pragmatic language, and poor eye contact that you already know.
The second criterion, restricted, repetitive patterns of behavior interests or activities, requires at least two of the following:
• Stereotyped or repetitive motor movements, use of objects, or speech. Thus echolalia, mimicking movie scripts, twirling objects, or flapping would count.
• Insistence on sameness, inflexible routines, or ritualized behavior. This includes the rigidity or upset about change seen in Asperger.
• Highly restricted, fixed interests abnormal in intensity or focus. This captures obsessions with train schedules, fans, etc.
• Hyper- or hyporeactivity to sensory or unusual interest in sensory aspects. This criterion was only a mention in DSM-IV, rather than a potential diagnostic element. It includes the problems with food textures, inability to tolerate the movie soundtrack or oblivion to pain sometimes observed.
Significant impairment in functioning is still required, but it is now to be judged by the amount of support required for the child to cope with daily living. Severity for each of the two areas (social communication and restricted, repetitive behaviors) should be separately described using levels:
• Level 3: Requiring very substantial support.
• Level 2: Requiring substantial support
• Level 1: Requiring support.
There is table in the DSM-5 that more fully explains the levels and gives examples.
Those children about whom no one was complaining because of careful family accommodation now qualify, since onset before age 3 years is no longer required; only at an "early age."
Because autism often appears in children with intellectual disability or global developmental delay, these diagnoses take precedence for diagnosis unless social communication is below that expected for the child’s general developmental level. In that case, diagnoses of both intellectual disability and ASD apply.
While other features associated with autism are acknowledged in the description of ASD, they no longer drive the diagnosis. Associated factors should be described as part of the diagnoses, such as association with a known medical (attention-deficit/hyperactivity disorder) or genetic condition (Fragile X) or environmental factor; with or without intellectual disability; with or without language impairment; and any other neurodevelopmental, mental, or behavioral disorder. Any catatonia should be noted.
The change with possibly the greatest and most uncertain impact is the pull-out of a new disorder: social communication disorder. This is to be used for children with social language deficits if the criterion for repetitive and restricted behaviors is not met. These, usually higher-functioning children are the most likely to be removed from ASD diagnosis by the DSM-5 revisions. There are risks in this move as criteria are quite strict for the communication problems but overlap language disorder. The assessment tools needed for determining these criteria are not well developed and speech-language pathologists may not be well prepared to assess the repetitive behaviors to rule in or rule out ASD. Services for this diagnosis may be restricted to the speech-language component instead of including the social skills deficits and more intense treatment now provided for children classified as ASD.
As for changed diagnoses resulting in changed services, there is some good news: There may not be any service changes at all for your current patients. The DSM-5 Neurodevelopmental Disorders Work Group states that these changes will not affect children with a current diagnosis; no children will lose their current diagnoses on the spectrum. For services based on diagnosis, some children may not qualify in the future, but when services are based on severity children will likely qualify based on the new levels.
But what about the children yet to be diagnosed? One goal for reorganization in the DSM-5 was to improve specificity, but sensitivity may suffer, particularly for children previously called PDD NOS. Huerta et al. studied this using a cross classification of children already diagnosed to see which ones might be excluded under DSM-5 (Am. J. Psychiatry 2012;169:1056-64). She found that the DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses, perhaps the most vulnerable to exclusion. The sensitivity of the DSM-5 criteria was high, even in girls and children younger than 4 years. This would be good news for retaining services.
But other studies on previously diagnosed cases do not agree. These studies using various existing samples predict that least 12% and potentially more than 40% of children who would have been classified as ASD under DSM-IV will not be under DSM-5, especially the most high functioning. Failure to meet criteria in the social communication domain was the most common reason for exclusion (39%) in one study. In addition, ASD prevalence is predicted to drop from 11.3% to 10.0% using the DSM-5 criteria (JAMA Psychiatry 2014 [doi: 10.1001/jamapsychiatry.2013.3893]). DSM-5 changes also will make it difficult for ongoing longitudinal research studies to compare with previous data.
Because the DSM-5 diagnosis of ASD is here to stay, what can you do to ease the transition? First, be able to explain the changes as described here. Then, implement or look for all aspects of the descriptors about comorbidity and severity when you are monitoring services being provided or advocating for more. Take special care that social communication disorder is diagnosed correctly and that both language and social skills are addressed. And encourage parents to join the national registries such as Autism Speaks and the Autism Speaks Autism Treatment Network and the Interactive Autism Network, which will help current and future research as DSM-5 efficacy is examined and even more changes made.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Mommy Wars – Supporting working mothers
"Mommy Wars." It even has a name. This refers to the conflict between mothers working only at home versus mothers with outside employment. As the story goes, each group looks down on the other – the at-home mom decrying the lack of caring for the family of the employed, and the employed smirking at the intellectual plateau and lack of earnings of the home mom.
I think the much bigger Mommy War is inside the individual woman, however. Am I doing right by my family? Am I fulfilling my potential? Am I contributing enough to the family income? Am I going brain dead? Am I devoting enough time to raising my children? Should I be saving the world as I dreamed in college?
As a pediatrician, I see the emotional turmoil, ambivalence, and stress of mothers contributing, at its worst, to child behavior problems, maternal depression, and marital problems and, in its mildest form, to exhausted mothers not having much fun.
How can we, as pediatricians, support families in dealing with this issue of our time? While parents and families have to decide for themselves, we have an opportunity to help families clarify their values for parenting and family life.
It turns out that the best parenting occurs when a woman is satisfied with her role – whether at home full time or working outside – and with her marriage. While not all mothers have any choice about working (or being married), being satisfied can be promoted by mindful consideration and acceptance of the choices they do make. You can initiate even a brief pros and cons discussion about their family choices – a sort of problem solving counseling – to assist in the evolution of more satisfaction with "what is."
You can point out that there are many benefits to children who have working mothers. The added income can provide important resources such as educational opportunities, sports, and the arts. Having a mother who studies, collaborates, or creates value through her work provides a natural role model for the child’s future success in a career, as well as in being a parent. This is especially valuable for girls who may have the same dilemma about work in the future, but also for boys who may have greater respect for women in the workplace as well as in their future homes. Children may see more clearly the value in getting an education, and may have a better appreciation for the hard work it takes to get there when they observe their mothers in this role. Resentment is not likely as long as the mother shows affection and makes sure she knows them well.
Often a mother’s main concern, whether working outside the home or not, is whether she is giving her children enough love and attention. One fact I pass along is that studies show that the average at-home mother spends 20 minutes per day of one-on-one time playing with her child. I recommend moms spend 15 minutes of Special Time every day with each child, following their lead in play. This is like gold to the parent-child relationship, whether it is problematic or not. Having some fun with your child every day also gives some payback for this hard work. This guaranteed time makes the child feel loved, reduces behavior problems, and assuages some of the mother’s guilt so that she can keep to needed childrearing limits.
After residency, the most stressful part of my medical career was not medical; it was worrying about child care. Each (of the many) child care providers we employed had strengths and weaknesses not apparent in the hiring process, but in this case the impact was on our children. Many families have unreasonable fears that limit their child care choices, greatly affecting their overall family functioning. They may feel that a child care center is safer, based on old news stories of rare nanny abuse or abduction, when a well-chosen live-in or at least home-based caregiver could greatly ease family stress (and reduce viral infections to boot). By asking about how they are making child care decisions, you can give perspective on these relative risks.
Another question, stated tearfully, is whether her baby will "love her the best" if he goes to day care. The enthusiastic embrace the child has for the child care provider is regarded with mixed feelings by many mothers. You can reassure them that, even for infants, blood is thicker than water, and that the primary bond with mom will prevail! I emphasize that it is not possible to have an excess of people who love you!
Even in families with supportive husbands who endorse an equal role in parenting, mothers have been noted to do 75% of the maintenance of the family and house. This role discrepancy can be accepted or it can be a source of significant discontent. Asking "How do you [and your partner, husband, mother-in-law, etc.] work as a team?" can open the subject for discussion, if needed. Helping mothers negotiate tasks with whomever the other adults may be can ease tensions that could adversely affect the children. I recommend weekly family meetings to keep roles and responsibilities on the table for negotiation, making a trade of tasks as needed.
I remember being amazed by a dynamic friend who had children and a career that involved many presentations at night and on weekends. I asked her how she did it. She replied without hesitation, "I don’t sleep." Lack of sleep is epidemic in the United States, but it has extra potential impact on mothers. It can lead to irritability, depression, lack of sexual interest, inefficiency in every setting, and even car crashes. Asking how much sleep the parents are getting may not seem like a pediatric question, but it can reveal unnecessary stresses.
One thing you may discover is that the mother is up cleaning the house at 11 p.m. I hate Martha Stewart. What real mother can make little costumes for her candlesticks, which Martha advertises as "Easy Decorating for the Holidays"? Yet some women have trouble lowering their standards for "housekeeping" to a feasible level when they have children, much less children and outside employment. You can help provide the perspective that dust kittens in the living room and an occasional frozen dinner are a small price to pay for having family fun and maintaining sanity.
Did you hear about the father of two young girls who was told he had 1 year to live after his cancer diagnosis? He thoughtfully took on the project of aligning eight of his friends with different personal strengths to be godparents for his children, knowing that he would not be there. It struck me that this is an excellent idea for all of us. We can’t be everything to our children, whether we are home full time or working out of the house, but we can use our good judgment to arrange supplementary positive relationships for them. Asking a good friend to sign up as godmother tends to bring a commitment and involvement as well as support for the mother herself. If a family does not have friends for this role, it is time to make some. A religious community is often a good place to start. Finding a few people with whom you can exchange favors, borrow the jumper cables, or stand at the bus stop, turns out to be the best and most lasting way to way establish social support.
I was once in a work group on child development that included leaders in the field of relationship theory. One professor in his 60s revealed that his best friends now were the parents of his children’s preschool friends. Keeping up such a support system for parents of friends and relatives is a key protective factor, not only to prevent adult depression, but for child behavior outcomes as well. Often, work outside the home provides extra social support through colleagues and friends, but it is not inevitable and needs to be fostered. Mothers may be encouraged to have a "mother’s night out" and one for dad, also, to maintain this without feeling guilty. In fact, giving the other parent a chance for a regular "Dad’s night with the kids" is a gift. New adventures, play, a deepened relationship, and more confidence as a parent are wonderful side effects of mom’s absence and vice versa.
Many mothers are caught up in their present dilemma and may not see these two things:
• Part-time work may be a compromise they could negotiate, if feasible financially.
• The 20 or so years of staying home with children still allow for another phase of life in which mothers could accomplish their career goals.
After our discussions, a number of the mothers of my patients have chosen to stop working for a period of time, and they, their children, and their husbands all have benefitted from the decision.
The most important thing affecting your ability to support working mothers may be your own situation! It may be harder to be compassionate with the whining of mothers of your patients if you are giving up precious family time to practice medicine. Their pain may cause enough conflict in you to interfere with your ability to support them. It is important to examine your own thinking, ambivalence, satisfaction, or pain in the choices you have made so that you can respond objectively to theirs.
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. She has a husband, two biological children, and two stepchildren. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
"Mommy Wars." It even has a name. This refers to the conflict between mothers working only at home versus mothers with outside employment. As the story goes, each group looks down on the other – the at-home mom decrying the lack of caring for the family of the employed, and the employed smirking at the intellectual plateau and lack of earnings of the home mom.
I think the much bigger Mommy War is inside the individual woman, however. Am I doing right by my family? Am I fulfilling my potential? Am I contributing enough to the family income? Am I going brain dead? Am I devoting enough time to raising my children? Should I be saving the world as I dreamed in college?
As a pediatrician, I see the emotional turmoil, ambivalence, and stress of mothers contributing, at its worst, to child behavior problems, maternal depression, and marital problems and, in its mildest form, to exhausted mothers not having much fun.
How can we, as pediatricians, support families in dealing with this issue of our time? While parents and families have to decide for themselves, we have an opportunity to help families clarify their values for parenting and family life.
It turns out that the best parenting occurs when a woman is satisfied with her role – whether at home full time or working outside – and with her marriage. While not all mothers have any choice about working (or being married), being satisfied can be promoted by mindful consideration and acceptance of the choices they do make. You can initiate even a brief pros and cons discussion about their family choices – a sort of problem solving counseling – to assist in the evolution of more satisfaction with "what is."
You can point out that there are many benefits to children who have working mothers. The added income can provide important resources such as educational opportunities, sports, and the arts. Having a mother who studies, collaborates, or creates value through her work provides a natural role model for the child’s future success in a career, as well as in being a parent. This is especially valuable for girls who may have the same dilemma about work in the future, but also for boys who may have greater respect for women in the workplace as well as in their future homes. Children may see more clearly the value in getting an education, and may have a better appreciation for the hard work it takes to get there when they observe their mothers in this role. Resentment is not likely as long as the mother shows affection and makes sure she knows them well.
Often a mother’s main concern, whether working outside the home or not, is whether she is giving her children enough love and attention. One fact I pass along is that studies show that the average at-home mother spends 20 minutes per day of one-on-one time playing with her child. I recommend moms spend 15 minutes of Special Time every day with each child, following their lead in play. This is like gold to the parent-child relationship, whether it is problematic or not. Having some fun with your child every day also gives some payback for this hard work. This guaranteed time makes the child feel loved, reduces behavior problems, and assuages some of the mother’s guilt so that she can keep to needed childrearing limits.
After residency, the most stressful part of my medical career was not medical; it was worrying about child care. Each (of the many) child care providers we employed had strengths and weaknesses not apparent in the hiring process, but in this case the impact was on our children. Many families have unreasonable fears that limit their child care choices, greatly affecting their overall family functioning. They may feel that a child care center is safer, based on old news stories of rare nanny abuse or abduction, when a well-chosen live-in or at least home-based caregiver could greatly ease family stress (and reduce viral infections to boot). By asking about how they are making child care decisions, you can give perspective on these relative risks.
Another question, stated tearfully, is whether her baby will "love her the best" if he goes to day care. The enthusiastic embrace the child has for the child care provider is regarded with mixed feelings by many mothers. You can reassure them that, even for infants, blood is thicker than water, and that the primary bond with mom will prevail! I emphasize that it is not possible to have an excess of people who love you!
Even in families with supportive husbands who endorse an equal role in parenting, mothers have been noted to do 75% of the maintenance of the family and house. This role discrepancy can be accepted or it can be a source of significant discontent. Asking "How do you [and your partner, husband, mother-in-law, etc.] work as a team?" can open the subject for discussion, if needed. Helping mothers negotiate tasks with whomever the other adults may be can ease tensions that could adversely affect the children. I recommend weekly family meetings to keep roles and responsibilities on the table for negotiation, making a trade of tasks as needed.
I remember being amazed by a dynamic friend who had children and a career that involved many presentations at night and on weekends. I asked her how she did it. She replied without hesitation, "I don’t sleep." Lack of sleep is epidemic in the United States, but it has extra potential impact on mothers. It can lead to irritability, depression, lack of sexual interest, inefficiency in every setting, and even car crashes. Asking how much sleep the parents are getting may not seem like a pediatric question, but it can reveal unnecessary stresses.
One thing you may discover is that the mother is up cleaning the house at 11 p.m. I hate Martha Stewart. What real mother can make little costumes for her candlesticks, which Martha advertises as "Easy Decorating for the Holidays"? Yet some women have trouble lowering their standards for "housekeeping" to a feasible level when they have children, much less children and outside employment. You can help provide the perspective that dust kittens in the living room and an occasional frozen dinner are a small price to pay for having family fun and maintaining sanity.
Did you hear about the father of two young girls who was told he had 1 year to live after his cancer diagnosis? He thoughtfully took on the project of aligning eight of his friends with different personal strengths to be godparents for his children, knowing that he would not be there. It struck me that this is an excellent idea for all of us. We can’t be everything to our children, whether we are home full time or working out of the house, but we can use our good judgment to arrange supplementary positive relationships for them. Asking a good friend to sign up as godmother tends to bring a commitment and involvement as well as support for the mother herself. If a family does not have friends for this role, it is time to make some. A religious community is often a good place to start. Finding a few people with whom you can exchange favors, borrow the jumper cables, or stand at the bus stop, turns out to be the best and most lasting way to way establish social support.
I was once in a work group on child development that included leaders in the field of relationship theory. One professor in his 60s revealed that his best friends now were the parents of his children’s preschool friends. Keeping up such a support system for parents of friends and relatives is a key protective factor, not only to prevent adult depression, but for child behavior outcomes as well. Often, work outside the home provides extra social support through colleagues and friends, but it is not inevitable and needs to be fostered. Mothers may be encouraged to have a "mother’s night out" and one for dad, also, to maintain this without feeling guilty. In fact, giving the other parent a chance for a regular "Dad’s night with the kids" is a gift. New adventures, play, a deepened relationship, and more confidence as a parent are wonderful side effects of mom’s absence and vice versa.
Many mothers are caught up in their present dilemma and may not see these two things:
• Part-time work may be a compromise they could negotiate, if feasible financially.
• The 20 or so years of staying home with children still allow for another phase of life in which mothers could accomplish their career goals.
After our discussions, a number of the mothers of my patients have chosen to stop working for a period of time, and they, their children, and their husbands all have benefitted from the decision.
The most important thing affecting your ability to support working mothers may be your own situation! It may be harder to be compassionate with the whining of mothers of your patients if you are giving up precious family time to practice medicine. Their pain may cause enough conflict in you to interfere with your ability to support them. It is important to examine your own thinking, ambivalence, satisfaction, or pain in the choices you have made so that you can respond objectively to theirs.
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. She has a husband, two biological children, and two stepchildren. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
"Mommy Wars." It even has a name. This refers to the conflict between mothers working only at home versus mothers with outside employment. As the story goes, each group looks down on the other – the at-home mom decrying the lack of caring for the family of the employed, and the employed smirking at the intellectual plateau and lack of earnings of the home mom.
I think the much bigger Mommy War is inside the individual woman, however. Am I doing right by my family? Am I fulfilling my potential? Am I contributing enough to the family income? Am I going brain dead? Am I devoting enough time to raising my children? Should I be saving the world as I dreamed in college?
As a pediatrician, I see the emotional turmoil, ambivalence, and stress of mothers contributing, at its worst, to child behavior problems, maternal depression, and marital problems and, in its mildest form, to exhausted mothers not having much fun.
How can we, as pediatricians, support families in dealing with this issue of our time? While parents and families have to decide for themselves, we have an opportunity to help families clarify their values for parenting and family life.
It turns out that the best parenting occurs when a woman is satisfied with her role – whether at home full time or working outside – and with her marriage. While not all mothers have any choice about working (or being married), being satisfied can be promoted by mindful consideration and acceptance of the choices they do make. You can initiate even a brief pros and cons discussion about their family choices – a sort of problem solving counseling – to assist in the evolution of more satisfaction with "what is."
You can point out that there are many benefits to children who have working mothers. The added income can provide important resources such as educational opportunities, sports, and the arts. Having a mother who studies, collaborates, or creates value through her work provides a natural role model for the child’s future success in a career, as well as in being a parent. This is especially valuable for girls who may have the same dilemma about work in the future, but also for boys who may have greater respect for women in the workplace as well as in their future homes. Children may see more clearly the value in getting an education, and may have a better appreciation for the hard work it takes to get there when they observe their mothers in this role. Resentment is not likely as long as the mother shows affection and makes sure she knows them well.
Often a mother’s main concern, whether working outside the home or not, is whether she is giving her children enough love and attention. One fact I pass along is that studies show that the average at-home mother spends 20 minutes per day of one-on-one time playing with her child. I recommend moms spend 15 minutes of Special Time every day with each child, following their lead in play. This is like gold to the parent-child relationship, whether it is problematic or not. Having some fun with your child every day also gives some payback for this hard work. This guaranteed time makes the child feel loved, reduces behavior problems, and assuages some of the mother’s guilt so that she can keep to needed childrearing limits.
After residency, the most stressful part of my medical career was not medical; it was worrying about child care. Each (of the many) child care providers we employed had strengths and weaknesses not apparent in the hiring process, but in this case the impact was on our children. Many families have unreasonable fears that limit their child care choices, greatly affecting their overall family functioning. They may feel that a child care center is safer, based on old news stories of rare nanny abuse or abduction, when a well-chosen live-in or at least home-based caregiver could greatly ease family stress (and reduce viral infections to boot). By asking about how they are making child care decisions, you can give perspective on these relative risks.
Another question, stated tearfully, is whether her baby will "love her the best" if he goes to day care. The enthusiastic embrace the child has for the child care provider is regarded with mixed feelings by many mothers. You can reassure them that, even for infants, blood is thicker than water, and that the primary bond with mom will prevail! I emphasize that it is not possible to have an excess of people who love you!
Even in families with supportive husbands who endorse an equal role in parenting, mothers have been noted to do 75% of the maintenance of the family and house. This role discrepancy can be accepted or it can be a source of significant discontent. Asking "How do you [and your partner, husband, mother-in-law, etc.] work as a team?" can open the subject for discussion, if needed. Helping mothers negotiate tasks with whomever the other adults may be can ease tensions that could adversely affect the children. I recommend weekly family meetings to keep roles and responsibilities on the table for negotiation, making a trade of tasks as needed.
I remember being amazed by a dynamic friend who had children and a career that involved many presentations at night and on weekends. I asked her how she did it. She replied without hesitation, "I don’t sleep." Lack of sleep is epidemic in the United States, but it has extra potential impact on mothers. It can lead to irritability, depression, lack of sexual interest, inefficiency in every setting, and even car crashes. Asking how much sleep the parents are getting may not seem like a pediatric question, but it can reveal unnecessary stresses.
One thing you may discover is that the mother is up cleaning the house at 11 p.m. I hate Martha Stewart. What real mother can make little costumes for her candlesticks, which Martha advertises as "Easy Decorating for the Holidays"? Yet some women have trouble lowering their standards for "housekeeping" to a feasible level when they have children, much less children and outside employment. You can help provide the perspective that dust kittens in the living room and an occasional frozen dinner are a small price to pay for having family fun and maintaining sanity.
Did you hear about the father of two young girls who was told he had 1 year to live after his cancer diagnosis? He thoughtfully took on the project of aligning eight of his friends with different personal strengths to be godparents for his children, knowing that he would not be there. It struck me that this is an excellent idea for all of us. We can’t be everything to our children, whether we are home full time or working out of the house, but we can use our good judgment to arrange supplementary positive relationships for them. Asking a good friend to sign up as godmother tends to bring a commitment and involvement as well as support for the mother herself. If a family does not have friends for this role, it is time to make some. A religious community is often a good place to start. Finding a few people with whom you can exchange favors, borrow the jumper cables, or stand at the bus stop, turns out to be the best and most lasting way to way establish social support.
I was once in a work group on child development that included leaders in the field of relationship theory. One professor in his 60s revealed that his best friends now were the parents of his children’s preschool friends. Keeping up such a support system for parents of friends and relatives is a key protective factor, not only to prevent adult depression, but for child behavior outcomes as well. Often, work outside the home provides extra social support through colleagues and friends, but it is not inevitable and needs to be fostered. Mothers may be encouraged to have a "mother’s night out" and one for dad, also, to maintain this without feeling guilty. In fact, giving the other parent a chance for a regular "Dad’s night with the kids" is a gift. New adventures, play, a deepened relationship, and more confidence as a parent are wonderful side effects of mom’s absence and vice versa.
Many mothers are caught up in their present dilemma and may not see these two things:
• Part-time work may be a compromise they could negotiate, if feasible financially.
• The 20 or so years of staying home with children still allow for another phase of life in which mothers could accomplish their career goals.
After our discussions, a number of the mothers of my patients have chosen to stop working for a period of time, and they, their children, and their husbands all have benefitted from the decision.
The most important thing affecting your ability to support working mothers may be your own situation! It may be harder to be compassionate with the whining of mothers of your patients if you are giving up precious family time to practice medicine. Their pain may cause enough conflict in you to interfere with your ability to support them. It is important to examine your own thinking, ambivalence, satisfaction, or pain in the choices you have made so that you can respond objectively to theirs.
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. She has a husband, two biological children, and two stepchildren. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.
He should know better ...
Every parent would probably include on a wish list for their child that he or she should be a "good moral person." Believe it or not, the foundations of morality are being laid in the first few years. But the way caregivers try to instill morality can actually backfire in painful ways right before your clinical eyes and are worth monitoring.
Moral behavior is partly inherent and partly learned. And the learning comes more from the Do’s than from the Don’ts.
The Do’s that help instill a moral sense start with the ways caregivers nurture, model for, talk to, and provide opportunities for the child to practice empathic behavioral and rule-governed behavior.
When a new mother leaves a 2-month-old baby to cry saying, "My mom says he will get spoiled if I pick him up all the time," I know there will be a lot of work ahead. By responding promptly to crying, the infant learns about compassion and trust in relationships, and the secure attachment relationship that develops from such contingent responsiveness can help him respond kindly to others, rather than with the aggression one might consider "bad." Meeting a child’s needs promotes empathy and confidence later, and makes the child want to please the beloved caregiver.
When a 4-month-old grabs his mother’s hair and "won’t" let go (because he can’t release), watch out for an interpretation that he is "mean." It’s time to educate the parent that babies need to practice their newest skills – such as reaching and grasping – and that they have no mental capacity to intend to hurt. Instead of a responsibility to stamp out this behavior, the parent has the long-term task of protecting the child from offending, for example by keeping earrings out of range and providing toys to exercise new abilities.
Did you ever notice how an 8-month-old will get nervous when you zoom in with the stethoscope, and will crane his neck to look up at his mother’s face? This social referencing is his way of checking to see how he should feel about you and the world. A mother who hugs, smiles, and reassures, then urges the child to reach for the proffered instrument, is teaching optimism. An anxious, absent, or critical response can teach the child that he’d better be on guard and strike before he is struck (called hostile bias attribution), predicting later anxiety and aggression. Parents’ reactions shape future patterns: If they overreact, they transmit fear; if they give inadequate cues, they leave the child anxious; if they punish the child for exploring, he will later sneak.
Good news! Babies are wired to be kind! From the gooey cracker a 9-month-old lovingly offers his dad to the 12-month-old’s finger point to share the wonder of an airplane high in the sky, babies love to share. If parents miss the intent or scold the mess, this generosity of spirit can be dampened. You can help parents understand that sharing attention is a moral act – a gift to the other – coming from parent to child or vice versa.
Toddler temperament also plays into family perceptions of the child as being good or bad. Impulsive, highly active children not only do things repeatedly that the parent doesn’t want, but do it at great speed. Sometimes this is the first sign of attention-deficit/hyperactivity disorder (ADHD) in which the child does not outgrow impulsive behaviors, bad and good. When parents can accept this as the child’s "style," they can accommodate or even capitalize on it (e.g., Olympic gymnasts), rather than providing constant criticism that undermines the child’s desire to please and be like them.
But what about when children do something wrong or dangerous? This is where the "Don’ts" of moral teaching come in.
While redirecting and distracting may suffice for babies, physical setting of limits by taking things away or not giving items in the first place is crucial for older children. It directly conveys rules, reassures them that adults will protect them from offenses, and also pushes them to develop frustration tolerance and the ability to delay gratification – key components of moral behavior. I find it useful to tell parents that overindulgent or laissez-faire parenting is depriving them of these crucial skills!
By 12 months, the baby – now a toddler – has ideas of his own and wants to try everything over and over, like dropping food from high chair to floor. This can be viewed as an achievement or perceived as defiance when a parental warning sparks a smirk and another try at Newton’s experiment. Besides needing repetition to learn, toddlers show their pleasure in figuring out a rule, even if it is a rule "not to throw food"! Sometimes we have to head off conclusions that the smirk portends becoming a sociopath – on the contrary, it means the child is discovering boundaries.
In toddlers, who are under construction in all sorts of ways, rules are not only constantly being tested, but also only partially internalized. Children may seem callous when curious about deformities and other broken things, poking at your new scar or teasing the cat at 14-18 months, but these are signs of cognitive growth. The child may even be able to resist doing one forbidden thing, but act aggressively to something else due to having only partial self-control.
Words finally become the main path for moral development during the first few years. Even in adulthood we use symbols of the devil on one shoulder and angel on the other whispering in the ears of a person making a moral choice. By 18 months, toddlers may say "no" or "hot" to a danger, but they only do this is if the parent is watching. It is no surprise that parents say, "Sure, he understands the meaning of no" when a shouted "no" stops the toddler in his tracks, if only briefly. But children can’t resist temptation based on words alone when the parent is not around, until 24 months, and even then that skill varies by temperament.
How does talking about right and wrong work? Children of mothers who verbalize a sibling’s point of view with strong emotion have more friendly behavior 14 months later, ask mom for help with conflicts, and have more feeling words, conciliation skills, and reference to rules (but also teasing) at 24 months.
The preschooler may call someone a "poopy-head," but often refrains from other hurting. Language has come to replace action!
By recognizing and reframing the ways parents perceive and label their children’s early skills, you can help promote both moral development and positive self-esteem.
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Every parent would probably include on a wish list for their child that he or she should be a "good moral person." Believe it or not, the foundations of morality are being laid in the first few years. But the way caregivers try to instill morality can actually backfire in painful ways right before your clinical eyes and are worth monitoring.
Moral behavior is partly inherent and partly learned. And the learning comes more from the Do’s than from the Don’ts.
The Do’s that help instill a moral sense start with the ways caregivers nurture, model for, talk to, and provide opportunities for the child to practice empathic behavioral and rule-governed behavior.
When a new mother leaves a 2-month-old baby to cry saying, "My mom says he will get spoiled if I pick him up all the time," I know there will be a lot of work ahead. By responding promptly to crying, the infant learns about compassion and trust in relationships, and the secure attachment relationship that develops from such contingent responsiveness can help him respond kindly to others, rather than with the aggression one might consider "bad." Meeting a child’s needs promotes empathy and confidence later, and makes the child want to please the beloved caregiver.
When a 4-month-old grabs his mother’s hair and "won’t" let go (because he can’t release), watch out for an interpretation that he is "mean." It’s time to educate the parent that babies need to practice their newest skills – such as reaching and grasping – and that they have no mental capacity to intend to hurt. Instead of a responsibility to stamp out this behavior, the parent has the long-term task of protecting the child from offending, for example by keeping earrings out of range and providing toys to exercise new abilities.
Did you ever notice how an 8-month-old will get nervous when you zoom in with the stethoscope, and will crane his neck to look up at his mother’s face? This social referencing is his way of checking to see how he should feel about you and the world. A mother who hugs, smiles, and reassures, then urges the child to reach for the proffered instrument, is teaching optimism. An anxious, absent, or critical response can teach the child that he’d better be on guard and strike before he is struck (called hostile bias attribution), predicting later anxiety and aggression. Parents’ reactions shape future patterns: If they overreact, they transmit fear; if they give inadequate cues, they leave the child anxious; if they punish the child for exploring, he will later sneak.
Good news! Babies are wired to be kind! From the gooey cracker a 9-month-old lovingly offers his dad to the 12-month-old’s finger point to share the wonder of an airplane high in the sky, babies love to share. If parents miss the intent or scold the mess, this generosity of spirit can be dampened. You can help parents understand that sharing attention is a moral act – a gift to the other – coming from parent to child or vice versa.
Toddler temperament also plays into family perceptions of the child as being good or bad. Impulsive, highly active children not only do things repeatedly that the parent doesn’t want, but do it at great speed. Sometimes this is the first sign of attention-deficit/hyperactivity disorder (ADHD) in which the child does not outgrow impulsive behaviors, bad and good. When parents can accept this as the child’s "style," they can accommodate or even capitalize on it (e.g., Olympic gymnasts), rather than providing constant criticism that undermines the child’s desire to please and be like them.
But what about when children do something wrong or dangerous? This is where the "Don’ts" of moral teaching come in.
While redirecting and distracting may suffice for babies, physical setting of limits by taking things away or not giving items in the first place is crucial for older children. It directly conveys rules, reassures them that adults will protect them from offenses, and also pushes them to develop frustration tolerance and the ability to delay gratification – key components of moral behavior. I find it useful to tell parents that overindulgent or laissez-faire parenting is depriving them of these crucial skills!
By 12 months, the baby – now a toddler – has ideas of his own and wants to try everything over and over, like dropping food from high chair to floor. This can be viewed as an achievement or perceived as defiance when a parental warning sparks a smirk and another try at Newton’s experiment. Besides needing repetition to learn, toddlers show their pleasure in figuring out a rule, even if it is a rule "not to throw food"! Sometimes we have to head off conclusions that the smirk portends becoming a sociopath – on the contrary, it means the child is discovering boundaries.
In toddlers, who are under construction in all sorts of ways, rules are not only constantly being tested, but also only partially internalized. Children may seem callous when curious about deformities and other broken things, poking at your new scar or teasing the cat at 14-18 months, but these are signs of cognitive growth. The child may even be able to resist doing one forbidden thing, but act aggressively to something else due to having only partial self-control.
Words finally become the main path for moral development during the first few years. Even in adulthood we use symbols of the devil on one shoulder and angel on the other whispering in the ears of a person making a moral choice. By 18 months, toddlers may say "no" or "hot" to a danger, but they only do this is if the parent is watching. It is no surprise that parents say, "Sure, he understands the meaning of no" when a shouted "no" stops the toddler in his tracks, if only briefly. But children can’t resist temptation based on words alone when the parent is not around, until 24 months, and even then that skill varies by temperament.
How does talking about right and wrong work? Children of mothers who verbalize a sibling’s point of view with strong emotion have more friendly behavior 14 months later, ask mom for help with conflicts, and have more feeling words, conciliation skills, and reference to rules (but also teasing) at 24 months.
The preschooler may call someone a "poopy-head," but often refrains from other hurting. Language has come to replace action!
By recognizing and reframing the ways parents perceive and label their children’s early skills, you can help promote both moral development and positive self-esteem.
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Every parent would probably include on a wish list for their child that he or she should be a "good moral person." Believe it or not, the foundations of morality are being laid in the first few years. But the way caregivers try to instill morality can actually backfire in painful ways right before your clinical eyes and are worth monitoring.
Moral behavior is partly inherent and partly learned. And the learning comes more from the Do’s than from the Don’ts.
The Do’s that help instill a moral sense start with the ways caregivers nurture, model for, talk to, and provide opportunities for the child to practice empathic behavioral and rule-governed behavior.
When a new mother leaves a 2-month-old baby to cry saying, "My mom says he will get spoiled if I pick him up all the time," I know there will be a lot of work ahead. By responding promptly to crying, the infant learns about compassion and trust in relationships, and the secure attachment relationship that develops from such contingent responsiveness can help him respond kindly to others, rather than with the aggression one might consider "bad." Meeting a child’s needs promotes empathy and confidence later, and makes the child want to please the beloved caregiver.
When a 4-month-old grabs his mother’s hair and "won’t" let go (because he can’t release), watch out for an interpretation that he is "mean." It’s time to educate the parent that babies need to practice their newest skills – such as reaching and grasping – and that they have no mental capacity to intend to hurt. Instead of a responsibility to stamp out this behavior, the parent has the long-term task of protecting the child from offending, for example by keeping earrings out of range and providing toys to exercise new abilities.
Did you ever notice how an 8-month-old will get nervous when you zoom in with the stethoscope, and will crane his neck to look up at his mother’s face? This social referencing is his way of checking to see how he should feel about you and the world. A mother who hugs, smiles, and reassures, then urges the child to reach for the proffered instrument, is teaching optimism. An anxious, absent, or critical response can teach the child that he’d better be on guard and strike before he is struck (called hostile bias attribution), predicting later anxiety and aggression. Parents’ reactions shape future patterns: If they overreact, they transmit fear; if they give inadequate cues, they leave the child anxious; if they punish the child for exploring, he will later sneak.
Good news! Babies are wired to be kind! From the gooey cracker a 9-month-old lovingly offers his dad to the 12-month-old’s finger point to share the wonder of an airplane high in the sky, babies love to share. If parents miss the intent or scold the mess, this generosity of spirit can be dampened. You can help parents understand that sharing attention is a moral act – a gift to the other – coming from parent to child or vice versa.
Toddler temperament also plays into family perceptions of the child as being good or bad. Impulsive, highly active children not only do things repeatedly that the parent doesn’t want, but do it at great speed. Sometimes this is the first sign of attention-deficit/hyperactivity disorder (ADHD) in which the child does not outgrow impulsive behaviors, bad and good. When parents can accept this as the child’s "style," they can accommodate or even capitalize on it (e.g., Olympic gymnasts), rather than providing constant criticism that undermines the child’s desire to please and be like them.
But what about when children do something wrong or dangerous? This is where the "Don’ts" of moral teaching come in.
While redirecting and distracting may suffice for babies, physical setting of limits by taking things away or not giving items in the first place is crucial for older children. It directly conveys rules, reassures them that adults will protect them from offenses, and also pushes them to develop frustration tolerance and the ability to delay gratification – key components of moral behavior. I find it useful to tell parents that overindulgent or laissez-faire parenting is depriving them of these crucial skills!
By 12 months, the baby – now a toddler – has ideas of his own and wants to try everything over and over, like dropping food from high chair to floor. This can be viewed as an achievement or perceived as defiance when a parental warning sparks a smirk and another try at Newton’s experiment. Besides needing repetition to learn, toddlers show their pleasure in figuring out a rule, even if it is a rule "not to throw food"! Sometimes we have to head off conclusions that the smirk portends becoming a sociopath – on the contrary, it means the child is discovering boundaries.
In toddlers, who are under construction in all sorts of ways, rules are not only constantly being tested, but also only partially internalized. Children may seem callous when curious about deformities and other broken things, poking at your new scar or teasing the cat at 14-18 months, but these are signs of cognitive growth. The child may even be able to resist doing one forbidden thing, but act aggressively to something else due to having only partial self-control.
Words finally become the main path for moral development during the first few years. Even in adulthood we use symbols of the devil on one shoulder and angel on the other whispering in the ears of a person making a moral choice. By 18 months, toddlers may say "no" or "hot" to a danger, but they only do this is if the parent is watching. It is no surprise that parents say, "Sure, he understands the meaning of no" when a shouted "no" stops the toddler in his tracks, if only briefly. But children can’t resist temptation based on words alone when the parent is not around, until 24 months, and even then that skill varies by temperament.
How does talking about right and wrong work? Children of mothers who verbalize a sibling’s point of view with strong emotion have more friendly behavior 14 months later, ask mom for help with conflicts, and have more feeling words, conciliation skills, and reference to rules (but also teasing) at 24 months.
The preschooler may call someone a "poopy-head," but often refrains from other hurting. Language has come to replace action!
By recognizing and reframing the ways parents perceive and label their children’s early skills, you can help promote both moral development and positive self-esteem.
Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
He just won’t poop
One of the problems that evokes consternation in doctors and parents alike is stool refusal in an otherwise normal child. While you may be completely comfortable solving problems of encopresis in school-aged children, the recalcitrant preschooler who will urinate in a toilet or potty chair but simply won’t deliver a poop there brings parents to their knees. They imagine their dreams of Harvard going down the drain – instead of the stools that belong there. On a more practical level, that pricey deposit for preschool, or any preschool attendance at all, appears to be on the line, making parents do desperate things.
The usual scenario for stool refusal is a bright 3- to 4-year-old who has succeeded in using the potty a few times and then simply stops using it for stools. Urination in the toilet may or may not continue, but when it comes time to defecate, the child either hides behind the sofa or demands a diaper.
Sometimes stool refusal presents with the child assuming an arching rigid posture. This has brought families to me as a consultant with concern about possible seizures or other serious medical conditions such as a bowel stricture. It looks to the parents as though the child is trying his best to get the stool out when in fact it is a valiant effort to keep it in.
The reason this syndrome is called stool refusal instead of encopresis is that it occurs only in children younger than the cutoff of a mental age of 4 years. While you might consider this a failure of "toilet learning," these children understand completely what is expected of them in the area of using the potty. They show this knowledge and the presence of the neurological integrity needed to control voids by successfully urinating in the toilet.
How much easier it would be to just finish the job! What are they thinking?! Thinking is exactly part of the problem in stool refusal.
Some children develop stool refusal after having a painful poop due to constipation, diaper rash, or diarrhea. It seems that they decide, "Well, if it’s going to hurt, I’m just not going to poop anymore!" The subsequent withholding of stools then makes them harder, larger, and more painful, confirming their fears and strengthening their determination. Logical arguments about the inevitability of defecation do not prevail with preschoolers.
Sometimes stool refusal develops during that predictable period of oppositionality around 2 to 2.5 years. Anna Freud – yes, indeed, the daughter of Sigmund – was interested in the development of toileting control, and described one of the essential ingredients to toileting success as being "the child’s desire to please the parent." She even wisely recommended that teaching this task should not be undertaken when the child is in a phase of resisting every other command the parent makes! This advice is often forgotten in the urgency of the mother’s desire to return to the workplace or enroll the child in a particularly desirable day care. As the famous Dr. Barry Zuckerman points out, the anus is one of the "five orifices only the child can control" (two eyes, one mouth, urethra, and anus). If there is to be a control battle between parent and child, going to sleep, eating, and voiding are likely to be the battlefields.
The child’s own ideas about growing up are often captured in this huge social milestone. Parents may even feed into the refusal by exhorting the child to be a "Big Girl" and use the potty so that she can go to school, when the child herself would much rather stay home with mommy!
Some children develop fear of the toilet after a scary slip inside a seat not designed for tiny buttocks or when the automatic flush mechanism at a public restroom triggers a torrent (which is easily avoided by placing a sticky note over the electric eye).
Some children suddenly refuse to poop in the toilet as they become aware that things that go down the toilet never come back. That is one reason they are fascinated – or even obsessed – with flushing the toilet over and over again: It’s like watching a horror movie. And they are being asked to take that lovely poop, apparently so treasured by parents and grandparents as to elicit praise and presents, and make it disappear!
And not only that, the process of toilet learning occurs right at the age when toddlers look around them and notice gender differences. This is more striking when there is a little sister co-bathing or when parents go naked with the child present. And the little boys can’t help but see that half the population has lost their precious penis. Where did it go? No wonder they hang onto it. At 3-4 years of age, children do not understand about possible and impossible transformations. The disappearing turd certainly suggests its terrible fate.
Understanding which of the factors just described are at work is key to resolving stool refusal. The first rule of thumb is to assume that constipation was either a contributing factor or has occurred secondarily, and to aggressively give laxatives aiming for at least two inevitable stools per day. It is important not to have any more painful stools, and it is also easier to retrain a more common occurrence. I use MiraLax powder, usually 1-2 tbsp, dissolved and allowed to sit for 10 minutes in any desirable drink, which is then given at bedtime. Inform the parent that the dire warnings on the label about chronic use do not apply to their child. Continue the laxative until stooling in the toilet is completely without a struggle.
For the other causes, taking a regular history of daily functioning – such as mealtimes, bedtime, separations, sibling aggression, or regression – will usually reveal the dynamics, whether they are control issues, sibling jealousy, fear of the toilet or of school, or general attention-seeking. Translating the hypothesized dynamic to the parents is terribly important to acknowledge the meaning the child and often the family have given this behavior.
In the case of fear of falling in, using a potty chair firmly planted on the ground, and then progressive desensitization, practicing sitting while clothed, reading stories about toileting, and maybe a toilet scrapbook will gradually work as long as the child is not pressured.
To reassure about nurturance, instituting "Special Time" will help with sibling jealousy. This is also crucial when stool refusal is occurring with attention-seeking as the cause. I also recommend encouraging "infantilizing" during Special Time. This might mean offering a pacifier, feeding the child with a spoon or bottle, holding him or her in loving arms, and talking to them in baby talk. These instructions often meet with shock, especially from the parents who need them the most, as they directly confront their fear that this child will never grow up! It is extremely powerful for a parent to show, as well as tell, their child that "You will be my baby forever." All children have a strong drive to grow up, but some need this reassurance that growing up does not have to mean losing the safety and nurturing they associate with being an infant.
When power struggles appear to be the problem, it is best to put the child back in diapers all day while the parents work on a more appropriate balance between control and nurturance. Panties are a privilege to be earned. Using cloth diapers can make this step more effective as they are less comfortable when soiled. Be aware that the child is likely to revert in urinating as well once in diapers, but this does not require any different management. The parent and any other caregivers must show no emotion when the child soils or wets the diaper, but neither should they be in a hurry to change the child, instead postponing this attention for at least a few minutes. When they do clean up, it should be done silently and with neutral affect. This process helps remove any secondary gain that stool refusal was providing.
To address the child’s opposition, more work may be needed. The first step is usually reducing the number of demands the parent gives the child each day, but following through on each command by physically moving the child to do the task after only "one request." If parents are interfering in each other’s management of the child’s behavior, this should be corrected as well because the toileting dysfunction may be a reaction to tension in this dynamic.
Given that boys, in particular, may have the penis anxiety described above, I always reassure them with my "Penis Talk" that "boys are made with a penis and girls with a vagina. When you get big like daddy, you will have a big penis, too. Your penis cannot fall off, and no one can ever take it away."
As part of normal toilet learning, children should be taught to recognize the feelings they have when "their poop or pee wants to come out." We do not need to teach a child to think of their feces as having feelings since animism comes naturally! The additional information I add is about the desire of their stools to attend the "Poop Party under the house! Poops can only get there when passed into the potty chair or toilet, though, not by being dumped in from the diaper as some clever children may assert. I then turn to the parent to ask, "Do your poops go the Poop Party?" providing a knowing wink if necessary. But sadly sympathize with the child that, "Too bad, your poops don’t get to go." Suddenly, doubt has been generated in the child about their choice to withhold!
If the child does not ask to use the potty after several weeks of really implementing these techniques, having several soft stools per day, and having previously shown the understanding and ability to use the potty, the method of room restriction can be used. In this method the child is restricted to one room of the house, perhaps naked, along with a potty chair starting half an hour before the time that has been determined to be typical for a stool to occur. In the room, the child can play but should not get special attention or use any electronics, and cannot leave. Once the potty has been used for a poop, he will be free to leave, go outside, and have other privileges for the rest of that day until the next scheduled stool. If he instead poops in his diaper, he continues to be restricted for the rest of the day. This plan is continued until the child is successful, which usually takes no more than 3 days.
Typically, the above approaches (not including the need for room restriction) will result in a child requesting to use the potty or toilet within 2-3 weeks. It is critical to coach all caregivers to act indifferent to this request, shrug, and say, "Okay, if you want to." Once a child does what they experience as conceding to using the toilet, there should be no prizes, calls to grandma, or celebrations as these can cause a reversal of the child’s willingness to show autonomy in this function. After all, it’s his poop!
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant financial disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
One of the problems that evokes consternation in doctors and parents alike is stool refusal in an otherwise normal child. While you may be completely comfortable solving problems of encopresis in school-aged children, the recalcitrant preschooler who will urinate in a toilet or potty chair but simply won’t deliver a poop there brings parents to their knees. They imagine their dreams of Harvard going down the drain – instead of the stools that belong there. On a more practical level, that pricey deposit for preschool, or any preschool attendance at all, appears to be on the line, making parents do desperate things.
The usual scenario for stool refusal is a bright 3- to 4-year-old who has succeeded in using the potty a few times and then simply stops using it for stools. Urination in the toilet may or may not continue, but when it comes time to defecate, the child either hides behind the sofa or demands a diaper.
Sometimes stool refusal presents with the child assuming an arching rigid posture. This has brought families to me as a consultant with concern about possible seizures or other serious medical conditions such as a bowel stricture. It looks to the parents as though the child is trying his best to get the stool out when in fact it is a valiant effort to keep it in.
The reason this syndrome is called stool refusal instead of encopresis is that it occurs only in children younger than the cutoff of a mental age of 4 years. While you might consider this a failure of "toilet learning," these children understand completely what is expected of them in the area of using the potty. They show this knowledge and the presence of the neurological integrity needed to control voids by successfully urinating in the toilet.
How much easier it would be to just finish the job! What are they thinking?! Thinking is exactly part of the problem in stool refusal.
Some children develop stool refusal after having a painful poop due to constipation, diaper rash, or diarrhea. It seems that they decide, "Well, if it’s going to hurt, I’m just not going to poop anymore!" The subsequent withholding of stools then makes them harder, larger, and more painful, confirming their fears and strengthening their determination. Logical arguments about the inevitability of defecation do not prevail with preschoolers.
Sometimes stool refusal develops during that predictable period of oppositionality around 2 to 2.5 years. Anna Freud – yes, indeed, the daughter of Sigmund – was interested in the development of toileting control, and described one of the essential ingredients to toileting success as being "the child’s desire to please the parent." She even wisely recommended that teaching this task should not be undertaken when the child is in a phase of resisting every other command the parent makes! This advice is often forgotten in the urgency of the mother’s desire to return to the workplace or enroll the child in a particularly desirable day care. As the famous Dr. Barry Zuckerman points out, the anus is one of the "five orifices only the child can control" (two eyes, one mouth, urethra, and anus). If there is to be a control battle between parent and child, going to sleep, eating, and voiding are likely to be the battlefields.
The child’s own ideas about growing up are often captured in this huge social milestone. Parents may even feed into the refusal by exhorting the child to be a "Big Girl" and use the potty so that she can go to school, when the child herself would much rather stay home with mommy!
Some children develop fear of the toilet after a scary slip inside a seat not designed for tiny buttocks or when the automatic flush mechanism at a public restroom triggers a torrent (which is easily avoided by placing a sticky note over the electric eye).
Some children suddenly refuse to poop in the toilet as they become aware that things that go down the toilet never come back. That is one reason they are fascinated – or even obsessed – with flushing the toilet over and over again: It’s like watching a horror movie. And they are being asked to take that lovely poop, apparently so treasured by parents and grandparents as to elicit praise and presents, and make it disappear!
And not only that, the process of toilet learning occurs right at the age when toddlers look around them and notice gender differences. This is more striking when there is a little sister co-bathing or when parents go naked with the child present. And the little boys can’t help but see that half the population has lost their precious penis. Where did it go? No wonder they hang onto it. At 3-4 years of age, children do not understand about possible and impossible transformations. The disappearing turd certainly suggests its terrible fate.
Understanding which of the factors just described are at work is key to resolving stool refusal. The first rule of thumb is to assume that constipation was either a contributing factor or has occurred secondarily, and to aggressively give laxatives aiming for at least two inevitable stools per day. It is important not to have any more painful stools, and it is also easier to retrain a more common occurrence. I use MiraLax powder, usually 1-2 tbsp, dissolved and allowed to sit for 10 minutes in any desirable drink, which is then given at bedtime. Inform the parent that the dire warnings on the label about chronic use do not apply to their child. Continue the laxative until stooling in the toilet is completely without a struggle.
For the other causes, taking a regular history of daily functioning – such as mealtimes, bedtime, separations, sibling aggression, or regression – will usually reveal the dynamics, whether they are control issues, sibling jealousy, fear of the toilet or of school, or general attention-seeking. Translating the hypothesized dynamic to the parents is terribly important to acknowledge the meaning the child and often the family have given this behavior.
In the case of fear of falling in, using a potty chair firmly planted on the ground, and then progressive desensitization, practicing sitting while clothed, reading stories about toileting, and maybe a toilet scrapbook will gradually work as long as the child is not pressured.
To reassure about nurturance, instituting "Special Time" will help with sibling jealousy. This is also crucial when stool refusal is occurring with attention-seeking as the cause. I also recommend encouraging "infantilizing" during Special Time. This might mean offering a pacifier, feeding the child with a spoon or bottle, holding him or her in loving arms, and talking to them in baby talk. These instructions often meet with shock, especially from the parents who need them the most, as they directly confront their fear that this child will never grow up! It is extremely powerful for a parent to show, as well as tell, their child that "You will be my baby forever." All children have a strong drive to grow up, but some need this reassurance that growing up does not have to mean losing the safety and nurturing they associate with being an infant.
When power struggles appear to be the problem, it is best to put the child back in diapers all day while the parents work on a more appropriate balance between control and nurturance. Panties are a privilege to be earned. Using cloth diapers can make this step more effective as they are less comfortable when soiled. Be aware that the child is likely to revert in urinating as well once in diapers, but this does not require any different management. The parent and any other caregivers must show no emotion when the child soils or wets the diaper, but neither should they be in a hurry to change the child, instead postponing this attention for at least a few minutes. When they do clean up, it should be done silently and with neutral affect. This process helps remove any secondary gain that stool refusal was providing.
To address the child’s opposition, more work may be needed. The first step is usually reducing the number of demands the parent gives the child each day, but following through on each command by physically moving the child to do the task after only "one request." If parents are interfering in each other’s management of the child’s behavior, this should be corrected as well because the toileting dysfunction may be a reaction to tension in this dynamic.
Given that boys, in particular, may have the penis anxiety described above, I always reassure them with my "Penis Talk" that "boys are made with a penis and girls with a vagina. When you get big like daddy, you will have a big penis, too. Your penis cannot fall off, and no one can ever take it away."
As part of normal toilet learning, children should be taught to recognize the feelings they have when "their poop or pee wants to come out." We do not need to teach a child to think of their feces as having feelings since animism comes naturally! The additional information I add is about the desire of their stools to attend the "Poop Party under the house! Poops can only get there when passed into the potty chair or toilet, though, not by being dumped in from the diaper as some clever children may assert. I then turn to the parent to ask, "Do your poops go the Poop Party?" providing a knowing wink if necessary. But sadly sympathize with the child that, "Too bad, your poops don’t get to go." Suddenly, doubt has been generated in the child about their choice to withhold!
If the child does not ask to use the potty after several weeks of really implementing these techniques, having several soft stools per day, and having previously shown the understanding and ability to use the potty, the method of room restriction can be used. In this method the child is restricted to one room of the house, perhaps naked, along with a potty chair starting half an hour before the time that has been determined to be typical for a stool to occur. In the room, the child can play but should not get special attention or use any electronics, and cannot leave. Once the potty has been used for a poop, he will be free to leave, go outside, and have other privileges for the rest of that day until the next scheduled stool. If he instead poops in his diaper, he continues to be restricted for the rest of the day. This plan is continued until the child is successful, which usually takes no more than 3 days.
Typically, the above approaches (not including the need for room restriction) will result in a child requesting to use the potty or toilet within 2-3 weeks. It is critical to coach all caregivers to act indifferent to this request, shrug, and say, "Okay, if you want to." Once a child does what they experience as conceding to using the toilet, there should be no prizes, calls to grandma, or celebrations as these can cause a reversal of the child’s willingness to show autonomy in this function. After all, it’s his poop!
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant financial disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
One of the problems that evokes consternation in doctors and parents alike is stool refusal in an otherwise normal child. While you may be completely comfortable solving problems of encopresis in school-aged children, the recalcitrant preschooler who will urinate in a toilet or potty chair but simply won’t deliver a poop there brings parents to their knees. They imagine their dreams of Harvard going down the drain – instead of the stools that belong there. On a more practical level, that pricey deposit for preschool, or any preschool attendance at all, appears to be on the line, making parents do desperate things.
The usual scenario for stool refusal is a bright 3- to 4-year-old who has succeeded in using the potty a few times and then simply stops using it for stools. Urination in the toilet may or may not continue, but when it comes time to defecate, the child either hides behind the sofa or demands a diaper.
Sometimes stool refusal presents with the child assuming an arching rigid posture. This has brought families to me as a consultant with concern about possible seizures or other serious medical conditions such as a bowel stricture. It looks to the parents as though the child is trying his best to get the stool out when in fact it is a valiant effort to keep it in.
The reason this syndrome is called stool refusal instead of encopresis is that it occurs only in children younger than the cutoff of a mental age of 4 years. While you might consider this a failure of "toilet learning," these children understand completely what is expected of them in the area of using the potty. They show this knowledge and the presence of the neurological integrity needed to control voids by successfully urinating in the toilet.
How much easier it would be to just finish the job! What are they thinking?! Thinking is exactly part of the problem in stool refusal.
Some children develop stool refusal after having a painful poop due to constipation, diaper rash, or diarrhea. It seems that they decide, "Well, if it’s going to hurt, I’m just not going to poop anymore!" The subsequent withholding of stools then makes them harder, larger, and more painful, confirming their fears and strengthening their determination. Logical arguments about the inevitability of defecation do not prevail with preschoolers.
Sometimes stool refusal develops during that predictable period of oppositionality around 2 to 2.5 years. Anna Freud – yes, indeed, the daughter of Sigmund – was interested in the development of toileting control, and described one of the essential ingredients to toileting success as being "the child’s desire to please the parent." She even wisely recommended that teaching this task should not be undertaken when the child is in a phase of resisting every other command the parent makes! This advice is often forgotten in the urgency of the mother’s desire to return to the workplace or enroll the child in a particularly desirable day care. As the famous Dr. Barry Zuckerman points out, the anus is one of the "five orifices only the child can control" (two eyes, one mouth, urethra, and anus). If there is to be a control battle between parent and child, going to sleep, eating, and voiding are likely to be the battlefields.
The child’s own ideas about growing up are often captured in this huge social milestone. Parents may even feed into the refusal by exhorting the child to be a "Big Girl" and use the potty so that she can go to school, when the child herself would much rather stay home with mommy!
Some children develop fear of the toilet after a scary slip inside a seat not designed for tiny buttocks or when the automatic flush mechanism at a public restroom triggers a torrent (which is easily avoided by placing a sticky note over the electric eye).
Some children suddenly refuse to poop in the toilet as they become aware that things that go down the toilet never come back. That is one reason they are fascinated – or even obsessed – with flushing the toilet over and over again: It’s like watching a horror movie. And they are being asked to take that lovely poop, apparently so treasured by parents and grandparents as to elicit praise and presents, and make it disappear!
And not only that, the process of toilet learning occurs right at the age when toddlers look around them and notice gender differences. This is more striking when there is a little sister co-bathing or when parents go naked with the child present. And the little boys can’t help but see that half the population has lost their precious penis. Where did it go? No wonder they hang onto it. At 3-4 years of age, children do not understand about possible and impossible transformations. The disappearing turd certainly suggests its terrible fate.
Understanding which of the factors just described are at work is key to resolving stool refusal. The first rule of thumb is to assume that constipation was either a contributing factor or has occurred secondarily, and to aggressively give laxatives aiming for at least two inevitable stools per day. It is important not to have any more painful stools, and it is also easier to retrain a more common occurrence. I use MiraLax powder, usually 1-2 tbsp, dissolved and allowed to sit for 10 minutes in any desirable drink, which is then given at bedtime. Inform the parent that the dire warnings on the label about chronic use do not apply to their child. Continue the laxative until stooling in the toilet is completely without a struggle.
For the other causes, taking a regular history of daily functioning – such as mealtimes, bedtime, separations, sibling aggression, or regression – will usually reveal the dynamics, whether they are control issues, sibling jealousy, fear of the toilet or of school, or general attention-seeking. Translating the hypothesized dynamic to the parents is terribly important to acknowledge the meaning the child and often the family have given this behavior.
In the case of fear of falling in, using a potty chair firmly planted on the ground, and then progressive desensitization, practicing sitting while clothed, reading stories about toileting, and maybe a toilet scrapbook will gradually work as long as the child is not pressured.
To reassure about nurturance, instituting "Special Time" will help with sibling jealousy. This is also crucial when stool refusal is occurring with attention-seeking as the cause. I also recommend encouraging "infantilizing" during Special Time. This might mean offering a pacifier, feeding the child with a spoon or bottle, holding him or her in loving arms, and talking to them in baby talk. These instructions often meet with shock, especially from the parents who need them the most, as they directly confront their fear that this child will never grow up! It is extremely powerful for a parent to show, as well as tell, their child that "You will be my baby forever." All children have a strong drive to grow up, but some need this reassurance that growing up does not have to mean losing the safety and nurturing they associate with being an infant.
When power struggles appear to be the problem, it is best to put the child back in diapers all day while the parents work on a more appropriate balance between control and nurturance. Panties are a privilege to be earned. Using cloth diapers can make this step more effective as they are less comfortable when soiled. Be aware that the child is likely to revert in urinating as well once in diapers, but this does not require any different management. The parent and any other caregivers must show no emotion when the child soils or wets the diaper, but neither should they be in a hurry to change the child, instead postponing this attention for at least a few minutes. When they do clean up, it should be done silently and with neutral affect. This process helps remove any secondary gain that stool refusal was providing.
To address the child’s opposition, more work may be needed. The first step is usually reducing the number of demands the parent gives the child each day, but following through on each command by physically moving the child to do the task after only "one request." If parents are interfering in each other’s management of the child’s behavior, this should be corrected as well because the toileting dysfunction may be a reaction to tension in this dynamic.
Given that boys, in particular, may have the penis anxiety described above, I always reassure them with my "Penis Talk" that "boys are made with a penis and girls with a vagina. When you get big like daddy, you will have a big penis, too. Your penis cannot fall off, and no one can ever take it away."
As part of normal toilet learning, children should be taught to recognize the feelings they have when "their poop or pee wants to come out." We do not need to teach a child to think of their feces as having feelings since animism comes naturally! The additional information I add is about the desire of their stools to attend the "Poop Party under the house! Poops can only get there when passed into the potty chair or toilet, though, not by being dumped in from the diaper as some clever children may assert. I then turn to the parent to ask, "Do your poops go the Poop Party?" providing a knowing wink if necessary. But sadly sympathize with the child that, "Too bad, your poops don’t get to go." Suddenly, doubt has been generated in the child about their choice to withhold!
If the child does not ask to use the potty after several weeks of really implementing these techniques, having several soft stools per day, and having previously shown the understanding and ability to use the potty, the method of room restriction can be used. In this method the child is restricted to one room of the house, perhaps naked, along with a potty chair starting half an hour before the time that has been determined to be typical for a stool to occur. In the room, the child can play but should not get special attention or use any electronics, and cannot leave. Once the potty has been used for a poop, he will be free to leave, go outside, and have other privileges for the rest of that day until the next scheduled stool. If he instead poops in his diaper, he continues to be restricted for the rest of the day. This plan is continued until the child is successful, which usually takes no more than 3 days.
Typically, the above approaches (not including the need for room restriction) will result in a child requesting to use the potty or toilet within 2-3 weeks. It is critical to coach all caregivers to act indifferent to this request, shrug, and say, "Okay, if you want to." Once a child does what they experience as conceding to using the toilet, there should be no prizes, calls to grandma, or celebrations as these can cause a reversal of the child’s willingness to show autonomy in this function. After all, it’s his poop!
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant financial disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
