Symposium on Behavioral Pediatrics
Behavior Problems in Early Childhood Edwin A. Sumpter, M.D.*
All children present behavior difficulties for their parents as' part of their normal development. As awareness and perception increase, children must cope with an environment that seems to change and expand. In the early years, the anxiety produced by these coping efforts is likely to lead to relatively easily decipherable behavioral responses. In later childhood, unsuccessfully accomplished developmental tasks begin to cause more subtle, complex and internalized emotional responses, and the behavioral messages are not so easily decoded. The extent to which the practicing pediatrician becomes involved in the emotional problems of the school-age child will vary according to his skill and interest. If other resources are available to parents, he may choose to avoid this area altogether. However, questions about developmental behavior in the younger child are an inevitable part of well-child visits, and dealing with them must be designed into the office routine. It is sometimes difficult to be sensitive to such concerns in the face of the fatigue and irritability resulting from a busy day. The tearful mother asking for help in dealing with the tantrums of a child who is at the moment dismantling the examining room is likely to get a perfunctory response at best, a situation that is neither satisfying to her nor gratifying to the physician. An approach to the office management of behavior problems in young children can evolve on a strictly pragmatic basis when a physician has only pediatric, not psychiatric, training and experience. Three basic assumptions are (1) medical care is incomplete without consideration of emotional health; (2) parental feelings must be recognized and accepted; and (3) informing parents about physical and mental growth and development must be routine.
PARENT EDUCATION To be optimally helpful to their children, parents must have some fundamental understanding of the processes of growth and develop*Associate Professor of Pediatrics, University of Massachusetts School of Medicine, Worcester Pediatric Clinics of North America- Vol. 22, No.3, August 1975
663
664
EDWIN
A.
SUMPTER
ment. Theories and schema are legion; the practicing pediatrician will have developed his own conceptualizations which, subjective though they may be, have made sense to him and which seem to work. Child rearing practices often reflect cultural values more than medical absolutes, and it is easy for the physician, from his position of authority, unwittingly to impose his values on the patient and parents, convinced that he is offering objective medical guidance. It is most important that he respect his patients' viewpoints, especially when they are at variance with his own. This does not preclude "anticipatory guidance" on the general principles of personality development, temperament and discipline. THE PRENATAL VISIT. A brief prenatal visit with both prospective parents is a most appropriate time for beginning these discussions. A family history and conversation about the progress of the pregnancy and any pertinent medical problems will often provide an impression of the family's cultural attitudes, level of education, experience with children, and environmental and emotional factors, all of which will bear on their responses to the stresses of having a new baby. Emphasis is properly placed on the primary role of "common sense" and intuition in dealing with many everyday questions. So few problems presented by new babies have only one solution that parents must be encouraged to respond in ways that make sense to them. The pediatrician's role is to help them develop confidence and independence, not to be compulsively directive about every detail. Fostering too great a dependence upon the pediatrician may be welcomed by some mothers, but is hardly of service to them and can paralyze effective parenting. The plethora of books and articles giving advice to parents can be more confusing than helpful. The physician can help to sort out a few items that are generally useful, pointing out that none is likely to fit the parents' own style in every situation. Some of these are listed as references 1,6, 8, and 10-12. The usual prenatal visit in my own practice takes about 15 minutes, and the charge for it is included in the newborn hospital care fee. Obstetricians in the area are aware of this policy and so inform any patients that they refer. THE TWO-WEEK VISIT. For the first baby, a visit at two weeks of age is recommended, as this may be a most trying time for the first-time mother. Support and guidance may be needed, and a two-week visit also affords an opportunity to observe the parental reactions to the unaccustomed stresses and fatigue of this period. Usually at this time there arise the first discussions of temperamental attributes and ~heir contribution to the uniqueness of personality development. Temperament is defined as the manner in which a child responds to environmental stimuli. Thomas, Chess and Birch 17 described nine objective characteristics of temperament, many of which are apparent in the first few weeks of life. Some of these may be brought to the attention of the parents in simple, nontechnical language as indications of the individuality of the child. There is already enough parental uncertainty at this stage without adding to it the constant fear of "making mistakes" that will somehow
BEHAVIOR PROBLEMS IN EARLY CHILDHOOD
665
damage the child psychologically. There is neither practical value nor scientific accuracy in the "blank slate" concept of personality development, wherein the child becomes whatever the environment dictates. Rather, parents can be offered the idea that all factors - temperament, environment and intellectual capacity - bear upon personality, and that mother and father alone will not be his shapers and molders. THE FIVE TO SIX MONTH VISIT. Another principle in personality growth can be anticipated at five or six months. Apprehension at the app;roach of a stranger becomes likely, because the child has learned to discriminate his mother uniquely and has grown in intellect and perception enough to know that a stranger is untried territory. This is a simple case of what will become an increasingly complex maturational process: recognition of a new environment, and the anxiety reaction that results from the attempt to deal with it. ONE YEAR VISIT. At about one year, the youngster is beginning to assert his independence and some general principles of discipline are being introduced. Emphasized at this time are useful alternatives to endless scoldings and hand slaps, such as direct intervention, distraction and adjustments of the environment. Parental expectations are often beyond the child's developmental capacity. There is sometimes concern that the child will be "spoiled" if he fails to learn who is the boss. The concept that to discipline is to teach, not necessarily to punish, may be new to some parents. Now is also the time to anticipate the capricious eating habits of the second year, mealtimes being common settings of parent-child conflict. Toilet training begins to be discussed,3 for if this guidance is postponed for another six months, inappropriate efforts may already be under way. Caution the parents about the possibly demanding year ahead and the abrupt changes of mood that may be observed. LATER LIFE. It is much more difficult to generalize about wellchild discussions beyond age 12 months. The parent-child relationships and the child's development, by that time, are individually diverse. However, there can be a continuing effort to anticipate difficulties such as phobias, stuttering and temper tantrums, and to suggest ways of handling them if they do occur. There is little objective evidence that such an approach prevents or aborts behavior problems or enhances the effectiveness of the pediatrician's role. It does establish a common conceptual framework for both the patient and the physician, for later use when troublesome problems are encountered such as those that follow.
COLIC Colic is fussing of a severity sufficient to test the family's and the physician's ability to tolerate it. This functional definition is only partly facetious, in that it recognizes the role of those around the baby, and their counselors, in the escalation process. There are babies who would be a source of consternation to one mother but only a minor challenge to another. Others would be exceedingly difficult even for the most sea-
666
EDWIN
A.
SUMPTER
soned and stable parents. Identical observations could be made about the parent-physician relationship. It is helpful to recognize the similarity of the affective responses in the links of this chain. The mother with a fussy baby feels frustration, anger, guilt and fatigue, and the physician receiving her calls may react with similar feelings ·when his therapeutic efforts seem to fail. If the only response consists of telephoned suggestions for manipulations of the diet and environment, without clarifying the basic process, anxious inquiries will continue. A pattern of mutually reinforcing and escalating anxiety is established between parents and physician, similar to the one that already exists between baby and parents. Colic typically begins at 2 or 3 weeks of age with increasingly intense and prolonged fussy periods, usually late in the day and in the evening, lasting from a few to many hours. A peak of intensity is ordinarily reached at 6 to 8 weeks, after which the difficulties diminish until a state of relative peace is reached by 3 or 4 months. The baby is likely to hyperreact to stimuli, to be unpredictable as to rhythm, negative in mood, and intolerant of environmental changes. Colic is as likely to occur in later as in first-born children, and in nursed as well as bottlefed babies. In a diary study of a group of Boston mothers who considered their infants "normal" as far as crying was concerned, crying for no discernible reason was recorded for 1112 to 4 hours per day at 6 weeks of age. 2 A mother with a low tolerance level might well interpret as "colic" the crying of an infant at the fussier end of this spectrum, even in the absence of the full-blown symptom complex. The first contact with the physician is customarily a telephone call, often in the evening after several hours of inconsolable crying has caused an overflow of parental anxiety and frustration. If there is a clear pattern, the family needs more than telephone management through formula changes, introduction of solids, and entreaties to "be patient." The baby and, if possible, both parents should be seen promptly. A thorough examination enables the physician to allay parental anxiety about any immediately threatening disease process. Part of the examination is observation of how the parents handle the baby when he cries. The natural reaction of a frustrated mother is to pace furiously, rock, pat, jounce, and otherwise signal her agitation to an already overstimulated baby. While keeping in mind organic disease such as milk allergy and intussusception, the physician needs to inquire about activity level, rhythmicity, adaptability, intensity, responsiveness to stimuli and mood of the child. A family problem may contribute to tension-for example, disagreements with relatives, a demanding older sibling, illness in a family member or an economic or job problem. The first step in therapy is assurance that the problem is taken seriously, which will have been indicated by a prompt response. Even though there may be a need for a trial period to rule out milk allergy in a bottle-fed baby, discussion of the nature and likely course of colic is indicated at the first examination. It is suggested that most babies cry
BEHAVIOR PROBLEMS IN EARLY CHILDHOOD
667
daily for no apparent reason, that they seem to absorb environmental stimuli with a resulting increase in tension throughout the day until release comes through crying in the evening. Frantic calming efforts actually increase the input and the tension. It is made clear that the problem will probably worsen before it improves, and that it will probably last until 3 or 4 months of age. Parental feelings of frustration and anger may be unconscious and should be identified as acceptable reactions. If parents are aware of these attitudes, they are likely to feel guilty and depressed. For some young parents, a defusing of feelings and a reassuring response is all they need and want. They are then able to proceed in their own fashion with a little further assistance from the physician. Fussiness will continue, but their tolerance has increased. For most parents, however, more specific therapy and follow-up is needed. If the baby is bottle-fed, a trial of a milk-free diet is instituted. In my practice there is usually no other food being given at the early age when colic most often begins. If there is, it would also be stopped to rule out the possibility of allergy or intolerance. Inexplicably, there is often a period of a few days of improvement with any formula change, regardless of whether or not there is an allergy, and this is explained to the parents. Unless improvement can be maintained for a week or more, the fo:r;mula change is not given credit for it. Milk allergy probably causes relatively few cases of colic, though the incidence varies greatly in the studies reported. 9 Nevertheless, the possibility of prompt resolution of the problem justifies the effort. If the baby is being nursed and there is no obvious maternal dietary idiosyncrasy, or after the milk-free trial in the bottle-fed baby, sedative medication containing phenobarbital is prescribed for use 15 to 30 minutes before each feeding, four times a day, with the assurance being given that it is safe and not habit-forming. Some parents are apprehensive about drugs and consider that using them is an admission of defeat. Even if they choose not to use medication immediately, they know that it is available should they become sufficiently desperate. Techniques of handling the baby with less stimulation are demonstrated. Feeding may not satisfy the need for sucking as a tension release. Though some orthodontists would disagree, the use of a pacifier in the first few months of life seems quite reasonable. As soon as possible, and at regular intervals, mother and father should arrange for a baby-sitter and go out together, if only for a few hours. This recommendation requires repeated reinforcement. New parents, however exhausted, find it difficult to get away from their babies without feeling negligent. The parents are instructed to call back at a specified day and time in order to give a progress report. It is important to give the impression that the parents and the physician are working together on the problem and that contact is being maintained until they can handle it alone. No promise of "cure" is implied. Though the problem persists, with parental understanding and acceptance of the situation, the optional use of medication, and the passage of time, the physician's role usually becomes a minor one.
668
EDWIN
A.
SUMPTER
There are rare cases of extraordinary severity and persistence. Parental desperation may be such that hospitalization for a short period may be necessary for reassessment of the diagnosis as well as relief. The family situation should be re-examined and psychiatric referral made if the parents seem to be the major contributors to the perpetuation of the process. However colic is managed, all of the parties survive. Whether the experience enhances or undermines the confidence of the parents in themselves and their pediatrician is not as certain. The factors and relationships involved are so complex that it is unrealistic to expect universal success.
SLEEP PROBLEMS Few behavior problems in the young child are as potentially devastating to parental morale and patience as those involving sleep. These often begin at 6 to 9 months, when the child is still too young for the parents to interpret the night-time crying, thus adding to their concern about its possible organic basis and increasing their anxiety. In the case of the 2 year old who is unreasonably extending the bedtime ritual, or awaking and crying for attention in the middle of the night, there may be less concern about illness but no less anger and frustration. Obviously the physician must be confident that there is not an ear infection or pinworm infestation, two common causes of restless sleep in the small child. Parents are usually aware that they are reinforcing undesirable behavior and perhaps have attempted to allow the baby to cry it out, but lost their resolve as they pictured him somehow hurting himself or because of their concern for the neighbors. As in treating colic, it is important to offer a sympathetic and non-judgmental ear and to advise that feelings of anger are no cause for guilt. Present the concept that separation anxiety is part of the problem, and that games such as hide-and-seek or peek-a-boo, played other than at bedtime, may help the child to see that separation is only temporary and not a threat. There is no reason not to use a night light if it proves reassuring. Otherwise, alternatives are very few. Response keeps the problem going. Not responding requires an explanation to the neighbors about the plan and then letting the baby cry. Parents must be assured that the child will not be harmed by crying for a long time, and that the crying will diminish when there is no response. They are also told that though answering every cry will perpetuate the problem, this Joo is unlikely to harm the child. The tolerance and stamina of some parents enables them to carry out a program of responding to crying with relatively little fatigue or resentment. For them, continuing to "spoil" the baby will be the preferred alternative. This choice has obvious implications about their vulnerability to future manipulations by the child. The parents of the older child who crawls out of bed are instructed to make it safe for him to do so without getting out of the room where he can injure himself or make his way to the parents' room. If he
BEHAVIOR PROBLEMS IN EARLY CHILDHOOD
669
chooses to sleep on the floor, rugs and a sleeper suit make sense. Crib nets are not recommended, because children have been known to become entangled in them. In a few severe cases, chloral hydrate, 50 mg. per kg. at bedtime, is recommended for 7 to 10 consecutive nights in an effort to alter the sleep pattern, but it is only occasionally successful.
HEAD BANGING Head banging is not particularly common and is likely to cause great concern to parents. It is sufficiently dramatic to be worth a note in a medical history, and it ~ay retrospectively be related to other problems. Several studies of normal children, however, have indicated the benign nature of the activity. Kravetz et al. '3 found an incidence of 3.6 per cent in a pediatric practice population of 1168, with a ratio of 31/2 boys to one girl. In a study of 135 head bangers followed for several years, the average age of onset was about 8 months: and the habit was commonly preceded by body rocking for some weeks.'4 The activity usually occurred at bedtime, lasted from a few minutes to over an hour, and was rarely accompanied by crying. The average duration was 17 months, over half of the children having stopped by age 4. About 30 per cent of cases were chronic, some lasting into late childhood. In none of these was there any evidence of injury, and not even in the chronic cases were there any distinguishing personality characteristics. DeLissovoy7 recorded similar findings in a study of 33 head bangers. Followup questionnaires were completed by parents of 19 of the children 5 years later. From the questions asked it was concluded that the children were of average ability and temperament, but greater than average activity level, and with marked increase in rhythmic responses. In all cases coordination was described as excellent.
These studies and personal observations suggest that treatment need involve only reassurance that the activity is another form of tension release and rhythmic activity, and indicates no dire emotional or neurological aberration. The crib should be padded, and anchored so that it cannot march across the floor, and the child should be otherwise left alone. Loud ticking clocks and metronomes set to the rhythm of the head banging have worked to eliminate the activity in a small percentage of children and to intensify it in others; in most they have no effece In the child still head banging past 3 years of age, psychiatric opinion is sought to reassure the pediatrician and reinforce his counsel to parents.
PROBLEMS PRESENTING IN TI{E 2 TO 4 YEAR OLD CHILD All of the problems so far discussed are managed by well-child visits, anticipatory educational efforts, telephone calls, and perhaps a few acute illness office visits. These comprise a large part of the behavioral problems seen in my own practice. With the first independence/de-
670
EDWIN
A.
SUMPTER
pendence struggles of the second year and beyond, behavior problems become more complex and require more time than the well-child visit allows. Chamberlin,4 in a study of patients from several pediatric practices including this one, found that major sources of parental concern in the 2 year old were (1) annoying habits such as thumb sucking, "security blanket," and head banging; (2) problems with expression of aggression such as temper tantrums and peer relationships; and (3) stubbornness and difficult-to-control behavior. In the 4 year old, major problems were seen as (1) inhibited behavior manifested as shyness and fear of new situations; (2) sibling and peer relationships; and (3) indications of immature behavior such as failure to be toilet-trained, unwillingness to separate from the parents, and continued thumb sucking. The same study showed that the problems of greatest concern to parents may not be the same ones that they bring to the pediatrician. Problems with expression of aggression and difficultto-control behavior seem to be most commonly identified in pediatric practice. Physical examination of an exuberant 21f2 year old boy required considerable patience because of his insistent curiosity and energy. At the close of the visit his mother asked whether it was typical for a child to have a temper tantrum every time he could not get his own way. Questioning soon showed that she was having a difficult time setting limits, and that reassurance would not satisfy her need to improve the situation. In one of the periods set aside each week for this purpose, both parents were seen and were asked to give an account of a typical day with precise descriptions of difficult encounters including details of tactics and words used. A known history of marital conflict was taken into account; guilt arising from the marital difficulties led to tentative and inconsistent behavior that actually fostered the child's undesirable characteristics. The boy constantly tested his parents, receiving in return first scoldings, then warnings, then shouts and sometimes an angry spanking, followed by much cuddling and attention. Some techniques of behavior modification were suggested. The parents were instructed to call in 2 weeks with a progress report, and they were urged to seek marriage counseling. Contact by telephone was made every few weeks thereafter. For about a year there has been a considerable improvement in behavior and a gain in parental confidence, though the marital troubles have not been resolved.
This typical history illustrates an approach that can be used for most problems of this age group. In the first session with the parents, the interview is patterned after the description of Chamberlin.s A "blow-byblow" account of a typical day is more useful than a mere description of behavior, which does not adequately clarify the parents' role. Repeated questions such as What did he do? Then what did you do? Then what did he do? and so on to the final resolution of the scene bring the physician as close to personal observation as he can get. As in this case, the parents' own narrative may increase their understanding of the selfdefeating pattern in which they are enmeshed. There are certain principles in the tactical suggestions that are made. Negative and positive reinforcement of behavior are discussed, emphasizing brief "time out" periods,1s distraction, and other alternatives to spanking and shouting. Concentration on only one problem area
BEHA VIOR PROBLEMS IN EARLY CHILDHOOD
671
is urged, with attempts to improve by taking one small step at a time. Parents are cautioned that any new approach is likely to be met with a testing period of intensification of the undesirable behavior, and that improvement will take weeks, not days. Since most problems are repetitive and predictable, responses should be thought out ahead of time, when tempers are cool and minds are rational. Both parents should agree on tactics, then recall and try to use the plan in the heat of the encounter. Depending on individual needs and educational level, a number of books can be recommended on general development of personality and temperament,6. 11 behavior modification,15 and communication with children. 8 ,10 The goals of intervention by the pediatrician obviously are limited. Given a basically stable family, most of the problems enumerated above are handled in one or two 45 to 60-minute sessions plus brief follow-up contacts. The relative value fee for such sessions is 21f2 to 3 times that of an acute illness visit. In my experience, two weekly time periods of 1 hour each usually suffice to meet the demands of the limited counseling described. Even though telephone time must be added to this, the time investment is still not large enough to be an economic hardship. On the foundation of an established relationship, and observations of the child's development over a period of many months, the pediatrician's efforts may be more promptly fruitful than those of a consultant who must start from scratch. When to refer to a psychiatrist or child guidance facility depends upon the pediatrician's assessment of his own abilities and interest in these problems. In my practice, a child is referred who is failing to achieve developmental tasks, in a family that appears to be unstable and unresponsive to the kinds of limited counseling described above. In a less severe disturbance, a psychiatrist may serve only as a diagnostic consultant, returning the patient to the pediatrician with recommendations that enable him to continue care himself, or in concert with the psychiatrist. If the problem is such that long-term family or child therapy is indicated, the pediatrician plays only a supporting role.
CONCLUSION The approach to management of behavior problems outlined here is the outgrowth of experience in a general pediatric practice. The pediatrician often has the therapeutic advantage of an already established relationship with a family. His continuing intimate associations with growing children uniquely qualify him to provide complete medical care to the child and to counsel and inform the parents. The anxious parent confronting the pediatrician with a behavior problem at an inconvenient moment may be a cause of some frustration, but the effective management of that problem can be as professionally gratifying as anything the pediatrician may undertake.
672
EDWIN
A.
SUMPTER
REFERENCES 1. Brazelton, T. B.: Infants and Mothers: Differences in Development. New York, Delacorte Press, 1969. 2.· Brazelton, T. B.: Crying in infancy. Pediatrics, 29:579,1962. 3. Brazelton, T. B.: A child-oriented approach to toilet training. Pediatrics, 29:121,1962. 4. Chamberlin, R W.: Management of preschool behavior problems. Pediat. Clin. N. Amer., 21 :1,1974. 5. Chamberlin, R W., personal communication. 6. Chess, S., Thomas, A., and Birch, H. G.: Your Child Is a Person. New York, Viking Press, 1965. 7. deLissovoy, V.: Head banging in early childhood. Child Devel., 33:43,1962. 8. ·Ginott, H. G.: Between Parent and Child. New York, Avon Books, 1971. 9. Glaser, J., Bakwin, R M., Breslow, L., Cobb, J. C., Fries, J. N., Levine, M. I., Martin, F. J., Rambar, A. C., and Ratner, B.: Colic in infants: Excerpts from a panel discussion. Pediatrics, 18 :828, 1956. 10. ·Gordon, T.: Parent Effectiveness Training. New York, Peter H. Wyden, 1970. 11. Ilg, F. L., and Ames, L. B.: Child Behavior. New York, Harper & Brothers, 1955. 12. Illingworth, R, and Illingworth, C.: Babies and Young Children. Fifth edition. Baltimore, Williams & Wilkins Co., 1972. 13. Kravetz, H., Rosenthal, V., Teplitz, Z., Murphy, J. B., and Lesser, R E.: A study of head banging in infants and children. Dis. Nerv. Sys., 21 :203, 1960. 14. Kravetz, H., and Boehm, J. J.: Rhythmic habit patterns in infancy: Their sequence, age of onset and frequency. Child Devel., 42 :399, 1971. 15. Patterson, G. R, and Gullion, M. E.: Living with Children. Champaign, Ill., Research Press, 1973. 16. Spock, B.: Baby and Child Care. New York, Pocket Books, 1970. 17. Thomas, A., Chess, S., and Birch, H. G.: Temperament and Behavior Disorders in Children. New York, New York University Press, 1968. University of Massachusetts School of Medicine 55 Lake Avenue North Worcester, Mass. 01605
Behavior Problems in Early Childhood Edwin A. Sumpter, M.D.*
All children present behavior difficulties for their parents as' part of their normal development. As awareness and perception increase, children must cope with an environment that seems to change and expand. In the early years, the anxiety produced by these coping efforts is likely to lead to relatively easily decipherable behavioral responses. In later childhood, unsuccessfully accomplished developmental tasks begin to cause more subtle, complex and internalized emotional responses, and the behavioral messages are not so easily decoded. The extent to which the practicing pediatrician becomes involved in the emotional problems of the school-age child will vary according to his skill and interest. If other resources are available to parents, he may choose to avoid this area altogether. However, questions about developmental behavior in the younger child are an inevitable part of well-child visits, and dealing with them must be designed into the office routine. It is sometimes difficult to be sensitive to such concerns in the face of the fatigue and irritability resulting from a busy day. The tearful mother asking for help in dealing with the tantrums of a child who is at the moment dismantling the examining room is likely to get a perfunctory response at best, a situation that is neither satisfying to her nor gratifying to the physician. An approach to the office management of behavior problems in young children can evolve on a strictly pragmatic basis when a physician has only pediatric, not psychiatric, training and experience. Three basic assumptions are (1) medical care is incomplete without consideration of emotional health; (2) parental feelings must be recognized and accepted; and (3) informing parents about physical and mental growth and development must be routine.
PARENT EDUCATION To be optimally helpful to their children, parents must have some fundamental understanding of the processes of growth and develop*Associate Professor of Pediatrics, University of Massachusetts School of Medicine, Worcester Pediatric Clinics of North America- Vol. 22, No.3, August 1975
663
664
EDWIN
A.
SUMPTER
ment. Theories and schema are legion; the practicing pediatrician will have developed his own conceptualizations which, subjective though they may be, have made sense to him and which seem to work. Child rearing practices often reflect cultural values more than medical absolutes, and it is easy for the physician, from his position of authority, unwittingly to impose his values on the patient and parents, convinced that he is offering objective medical guidance. It is most important that he respect his patients' viewpoints, especially when they are at variance with his own. This does not preclude "anticipatory guidance" on the general principles of personality development, temperament and discipline. THE PRENATAL VISIT. A brief prenatal visit with both prospective parents is a most appropriate time for beginning these discussions. A family history and conversation about the progress of the pregnancy and any pertinent medical problems will often provide an impression of the family's cultural attitudes, level of education, experience with children, and environmental and emotional factors, all of which will bear on their responses to the stresses of having a new baby. Emphasis is properly placed on the primary role of "common sense" and intuition in dealing with many everyday questions. So few problems presented by new babies have only one solution that parents must be encouraged to respond in ways that make sense to them. The pediatrician's role is to help them develop confidence and independence, not to be compulsively directive about every detail. Fostering too great a dependence upon the pediatrician may be welcomed by some mothers, but is hardly of service to them and can paralyze effective parenting. The plethora of books and articles giving advice to parents can be more confusing than helpful. The physician can help to sort out a few items that are generally useful, pointing out that none is likely to fit the parents' own style in every situation. Some of these are listed as references 1,6, 8, and 10-12. The usual prenatal visit in my own practice takes about 15 minutes, and the charge for it is included in the newborn hospital care fee. Obstetricians in the area are aware of this policy and so inform any patients that they refer. THE TWO-WEEK VISIT. For the first baby, a visit at two weeks of age is recommended, as this may be a most trying time for the first-time mother. Support and guidance may be needed, and a two-week visit also affords an opportunity to observe the parental reactions to the unaccustomed stresses and fatigue of this period. Usually at this time there arise the first discussions of temperamental attributes and ~heir contribution to the uniqueness of personality development. Temperament is defined as the manner in which a child responds to environmental stimuli. Thomas, Chess and Birch 17 described nine objective characteristics of temperament, many of which are apparent in the first few weeks of life. Some of these may be brought to the attention of the parents in simple, nontechnical language as indications of the individuality of the child. There is already enough parental uncertainty at this stage without adding to it the constant fear of "making mistakes" that will somehow
BEHAVIOR PROBLEMS IN EARLY CHILDHOOD
665
damage the child psychologically. There is neither practical value nor scientific accuracy in the "blank slate" concept of personality development, wherein the child becomes whatever the environment dictates. Rather, parents can be offered the idea that all factors - temperament, environment and intellectual capacity - bear upon personality, and that mother and father alone will not be his shapers and molders. THE FIVE TO SIX MONTH VISIT. Another principle in personality growth can be anticipated at five or six months. Apprehension at the app;roach of a stranger becomes likely, because the child has learned to discriminate his mother uniquely and has grown in intellect and perception enough to know that a stranger is untried territory. This is a simple case of what will become an increasingly complex maturational process: recognition of a new environment, and the anxiety reaction that results from the attempt to deal with it. ONE YEAR VISIT. At about one year, the youngster is beginning to assert his independence and some general principles of discipline are being introduced. Emphasized at this time are useful alternatives to endless scoldings and hand slaps, such as direct intervention, distraction and adjustments of the environment. Parental expectations are often beyond the child's developmental capacity. There is sometimes concern that the child will be "spoiled" if he fails to learn who is the boss. The concept that to discipline is to teach, not necessarily to punish, may be new to some parents. Now is also the time to anticipate the capricious eating habits of the second year, mealtimes being common settings of parent-child conflict. Toilet training begins to be discussed,3 for if this guidance is postponed for another six months, inappropriate efforts may already be under way. Caution the parents about the possibly demanding year ahead and the abrupt changes of mood that may be observed. LATER LIFE. It is much more difficult to generalize about wellchild discussions beyond age 12 months. The parent-child relationships and the child's development, by that time, are individually diverse. However, there can be a continuing effort to anticipate difficulties such as phobias, stuttering and temper tantrums, and to suggest ways of handling them if they do occur. There is little objective evidence that such an approach prevents or aborts behavior problems or enhances the effectiveness of the pediatrician's role. It does establish a common conceptual framework for both the patient and the physician, for later use when troublesome problems are encountered such as those that follow.
COLIC Colic is fussing of a severity sufficient to test the family's and the physician's ability to tolerate it. This functional definition is only partly facetious, in that it recognizes the role of those around the baby, and their counselors, in the escalation process. There are babies who would be a source of consternation to one mother but only a minor challenge to another. Others would be exceedingly difficult even for the most sea-
666
EDWIN
A.
SUMPTER
soned and stable parents. Identical observations could be made about the parent-physician relationship. It is helpful to recognize the similarity of the affective responses in the links of this chain. The mother with a fussy baby feels frustration, anger, guilt and fatigue, and the physician receiving her calls may react with similar feelings ·when his therapeutic efforts seem to fail. If the only response consists of telephoned suggestions for manipulations of the diet and environment, without clarifying the basic process, anxious inquiries will continue. A pattern of mutually reinforcing and escalating anxiety is established between parents and physician, similar to the one that already exists between baby and parents. Colic typically begins at 2 or 3 weeks of age with increasingly intense and prolonged fussy periods, usually late in the day and in the evening, lasting from a few to many hours. A peak of intensity is ordinarily reached at 6 to 8 weeks, after which the difficulties diminish until a state of relative peace is reached by 3 or 4 months. The baby is likely to hyperreact to stimuli, to be unpredictable as to rhythm, negative in mood, and intolerant of environmental changes. Colic is as likely to occur in later as in first-born children, and in nursed as well as bottlefed babies. In a diary study of a group of Boston mothers who considered their infants "normal" as far as crying was concerned, crying for no discernible reason was recorded for 1112 to 4 hours per day at 6 weeks of age. 2 A mother with a low tolerance level might well interpret as "colic" the crying of an infant at the fussier end of this spectrum, even in the absence of the full-blown symptom complex. The first contact with the physician is customarily a telephone call, often in the evening after several hours of inconsolable crying has caused an overflow of parental anxiety and frustration. If there is a clear pattern, the family needs more than telephone management through formula changes, introduction of solids, and entreaties to "be patient." The baby and, if possible, both parents should be seen promptly. A thorough examination enables the physician to allay parental anxiety about any immediately threatening disease process. Part of the examination is observation of how the parents handle the baby when he cries. The natural reaction of a frustrated mother is to pace furiously, rock, pat, jounce, and otherwise signal her agitation to an already overstimulated baby. While keeping in mind organic disease such as milk allergy and intussusception, the physician needs to inquire about activity level, rhythmicity, adaptability, intensity, responsiveness to stimuli and mood of the child. A family problem may contribute to tension-for example, disagreements with relatives, a demanding older sibling, illness in a family member or an economic or job problem. The first step in therapy is assurance that the problem is taken seriously, which will have been indicated by a prompt response. Even though there may be a need for a trial period to rule out milk allergy in a bottle-fed baby, discussion of the nature and likely course of colic is indicated at the first examination. It is suggested that most babies cry
BEHAVIOR PROBLEMS IN EARLY CHILDHOOD
667
daily for no apparent reason, that they seem to absorb environmental stimuli with a resulting increase in tension throughout the day until release comes through crying in the evening. Frantic calming efforts actually increase the input and the tension. It is made clear that the problem will probably worsen before it improves, and that it will probably last until 3 or 4 months of age. Parental feelings of frustration and anger may be unconscious and should be identified as acceptable reactions. If parents are aware of these attitudes, they are likely to feel guilty and depressed. For some young parents, a defusing of feelings and a reassuring response is all they need and want. They are then able to proceed in their own fashion with a little further assistance from the physician. Fussiness will continue, but their tolerance has increased. For most parents, however, more specific therapy and follow-up is needed. If the baby is bottle-fed, a trial of a milk-free diet is instituted. In my practice there is usually no other food being given at the early age when colic most often begins. If there is, it would also be stopped to rule out the possibility of allergy or intolerance. Inexplicably, there is often a period of a few days of improvement with any formula change, regardless of whether or not there is an allergy, and this is explained to the parents. Unless improvement can be maintained for a week or more, the fo:r;mula change is not given credit for it. Milk allergy probably causes relatively few cases of colic, though the incidence varies greatly in the studies reported. 9 Nevertheless, the possibility of prompt resolution of the problem justifies the effort. If the baby is being nursed and there is no obvious maternal dietary idiosyncrasy, or after the milk-free trial in the bottle-fed baby, sedative medication containing phenobarbital is prescribed for use 15 to 30 minutes before each feeding, four times a day, with the assurance being given that it is safe and not habit-forming. Some parents are apprehensive about drugs and consider that using them is an admission of defeat. Even if they choose not to use medication immediately, they know that it is available should they become sufficiently desperate. Techniques of handling the baby with less stimulation are demonstrated. Feeding may not satisfy the need for sucking as a tension release. Though some orthodontists would disagree, the use of a pacifier in the first few months of life seems quite reasonable. As soon as possible, and at regular intervals, mother and father should arrange for a baby-sitter and go out together, if only for a few hours. This recommendation requires repeated reinforcement. New parents, however exhausted, find it difficult to get away from their babies without feeling negligent. The parents are instructed to call back at a specified day and time in order to give a progress report. It is important to give the impression that the parents and the physician are working together on the problem and that contact is being maintained until they can handle it alone. No promise of "cure" is implied. Though the problem persists, with parental understanding and acceptance of the situation, the optional use of medication, and the passage of time, the physician's role usually becomes a minor one.
668
EDWIN
A.
SUMPTER
There are rare cases of extraordinary severity and persistence. Parental desperation may be such that hospitalization for a short period may be necessary for reassessment of the diagnosis as well as relief. The family situation should be re-examined and psychiatric referral made if the parents seem to be the major contributors to the perpetuation of the process. However colic is managed, all of the parties survive. Whether the experience enhances or undermines the confidence of the parents in themselves and their pediatrician is not as certain. The factors and relationships involved are so complex that it is unrealistic to expect universal success.
SLEEP PROBLEMS Few behavior problems in the young child are as potentially devastating to parental morale and patience as those involving sleep. These often begin at 6 to 9 months, when the child is still too young for the parents to interpret the night-time crying, thus adding to their concern about its possible organic basis and increasing their anxiety. In the case of the 2 year old who is unreasonably extending the bedtime ritual, or awaking and crying for attention in the middle of the night, there may be less concern about illness but no less anger and frustration. Obviously the physician must be confident that there is not an ear infection or pinworm infestation, two common causes of restless sleep in the small child. Parents are usually aware that they are reinforcing undesirable behavior and perhaps have attempted to allow the baby to cry it out, but lost their resolve as they pictured him somehow hurting himself or because of their concern for the neighbors. As in treating colic, it is important to offer a sympathetic and non-judgmental ear and to advise that feelings of anger are no cause for guilt. Present the concept that separation anxiety is part of the problem, and that games such as hide-and-seek or peek-a-boo, played other than at bedtime, may help the child to see that separation is only temporary and not a threat. There is no reason not to use a night light if it proves reassuring. Otherwise, alternatives are very few. Response keeps the problem going. Not responding requires an explanation to the neighbors about the plan and then letting the baby cry. Parents must be assured that the child will not be harmed by crying for a long time, and that the crying will diminish when there is no response. They are also told that though answering every cry will perpetuate the problem, this Joo is unlikely to harm the child. The tolerance and stamina of some parents enables them to carry out a program of responding to crying with relatively little fatigue or resentment. For them, continuing to "spoil" the baby will be the preferred alternative. This choice has obvious implications about their vulnerability to future manipulations by the child. The parents of the older child who crawls out of bed are instructed to make it safe for him to do so without getting out of the room where he can injure himself or make his way to the parents' room. If he
BEHAVIOR PROBLEMS IN EARLY CHILDHOOD
669
chooses to sleep on the floor, rugs and a sleeper suit make sense. Crib nets are not recommended, because children have been known to become entangled in them. In a few severe cases, chloral hydrate, 50 mg. per kg. at bedtime, is recommended for 7 to 10 consecutive nights in an effort to alter the sleep pattern, but it is only occasionally successful.
HEAD BANGING Head banging is not particularly common and is likely to cause great concern to parents. It is sufficiently dramatic to be worth a note in a medical history, and it ~ay retrospectively be related to other problems. Several studies of normal children, however, have indicated the benign nature of the activity. Kravetz et al. '3 found an incidence of 3.6 per cent in a pediatric practice population of 1168, with a ratio of 31/2 boys to one girl. In a study of 135 head bangers followed for several years, the average age of onset was about 8 months: and the habit was commonly preceded by body rocking for some weeks.'4 The activity usually occurred at bedtime, lasted from a few minutes to over an hour, and was rarely accompanied by crying. The average duration was 17 months, over half of the children having stopped by age 4. About 30 per cent of cases were chronic, some lasting into late childhood. In none of these was there any evidence of injury, and not even in the chronic cases were there any distinguishing personality characteristics. DeLissovoy7 recorded similar findings in a study of 33 head bangers. Followup questionnaires were completed by parents of 19 of the children 5 years later. From the questions asked it was concluded that the children were of average ability and temperament, but greater than average activity level, and with marked increase in rhythmic responses. In all cases coordination was described as excellent.
These studies and personal observations suggest that treatment need involve only reassurance that the activity is another form of tension release and rhythmic activity, and indicates no dire emotional or neurological aberration. The crib should be padded, and anchored so that it cannot march across the floor, and the child should be otherwise left alone. Loud ticking clocks and metronomes set to the rhythm of the head banging have worked to eliminate the activity in a small percentage of children and to intensify it in others; in most they have no effece In the child still head banging past 3 years of age, psychiatric opinion is sought to reassure the pediatrician and reinforce his counsel to parents.
PROBLEMS PRESENTING IN TI{E 2 TO 4 YEAR OLD CHILD All of the problems so far discussed are managed by well-child visits, anticipatory educational efforts, telephone calls, and perhaps a few acute illness office visits. These comprise a large part of the behavioral problems seen in my own practice. With the first independence/de-
670
EDWIN
A.
SUMPTER
pendence struggles of the second year and beyond, behavior problems become more complex and require more time than the well-child visit allows. Chamberlin,4 in a study of patients from several pediatric practices including this one, found that major sources of parental concern in the 2 year old were (1) annoying habits such as thumb sucking, "security blanket," and head banging; (2) problems with expression of aggression such as temper tantrums and peer relationships; and (3) stubbornness and difficult-to-control behavior. In the 4 year old, major problems were seen as (1) inhibited behavior manifested as shyness and fear of new situations; (2) sibling and peer relationships; and (3) indications of immature behavior such as failure to be toilet-trained, unwillingness to separate from the parents, and continued thumb sucking. The same study showed that the problems of greatest concern to parents may not be the same ones that they bring to the pediatrician. Problems with expression of aggression and difficultto-control behavior seem to be most commonly identified in pediatric practice. Physical examination of an exuberant 21f2 year old boy required considerable patience because of his insistent curiosity and energy. At the close of the visit his mother asked whether it was typical for a child to have a temper tantrum every time he could not get his own way. Questioning soon showed that she was having a difficult time setting limits, and that reassurance would not satisfy her need to improve the situation. In one of the periods set aside each week for this purpose, both parents were seen and were asked to give an account of a typical day with precise descriptions of difficult encounters including details of tactics and words used. A known history of marital conflict was taken into account; guilt arising from the marital difficulties led to tentative and inconsistent behavior that actually fostered the child's undesirable characteristics. The boy constantly tested his parents, receiving in return first scoldings, then warnings, then shouts and sometimes an angry spanking, followed by much cuddling and attention. Some techniques of behavior modification were suggested. The parents were instructed to call in 2 weeks with a progress report, and they were urged to seek marriage counseling. Contact by telephone was made every few weeks thereafter. For about a year there has been a considerable improvement in behavior and a gain in parental confidence, though the marital troubles have not been resolved.
This typical history illustrates an approach that can be used for most problems of this age group. In the first session with the parents, the interview is patterned after the description of Chamberlin.s A "blow-byblow" account of a typical day is more useful than a mere description of behavior, which does not adequately clarify the parents' role. Repeated questions such as What did he do? Then what did you do? Then what did he do? and so on to the final resolution of the scene bring the physician as close to personal observation as he can get. As in this case, the parents' own narrative may increase their understanding of the selfdefeating pattern in which they are enmeshed. There are certain principles in the tactical suggestions that are made. Negative and positive reinforcement of behavior are discussed, emphasizing brief "time out" periods,1s distraction, and other alternatives to spanking and shouting. Concentration on only one problem area
BEHA VIOR PROBLEMS IN EARLY CHILDHOOD
671
is urged, with attempts to improve by taking one small step at a time. Parents are cautioned that any new approach is likely to be met with a testing period of intensification of the undesirable behavior, and that improvement will take weeks, not days. Since most problems are repetitive and predictable, responses should be thought out ahead of time, when tempers are cool and minds are rational. Both parents should agree on tactics, then recall and try to use the plan in the heat of the encounter. Depending on individual needs and educational level, a number of books can be recommended on general development of personality and temperament,6. 11 behavior modification,15 and communication with children. 8 ,10 The goals of intervention by the pediatrician obviously are limited. Given a basically stable family, most of the problems enumerated above are handled in one or two 45 to 60-minute sessions plus brief follow-up contacts. The relative value fee for such sessions is 21f2 to 3 times that of an acute illness visit. In my experience, two weekly time periods of 1 hour each usually suffice to meet the demands of the limited counseling described. Even though telephone time must be added to this, the time investment is still not large enough to be an economic hardship. On the foundation of an established relationship, and observations of the child's development over a period of many months, the pediatrician's efforts may be more promptly fruitful than those of a consultant who must start from scratch. When to refer to a psychiatrist or child guidance facility depends upon the pediatrician's assessment of his own abilities and interest in these problems. In my practice, a child is referred who is failing to achieve developmental tasks, in a family that appears to be unstable and unresponsive to the kinds of limited counseling described above. In a less severe disturbance, a psychiatrist may serve only as a diagnostic consultant, returning the patient to the pediatrician with recommendations that enable him to continue care himself, or in concert with the psychiatrist. If the problem is such that long-term family or child therapy is indicated, the pediatrician plays only a supporting role.
CONCLUSION The approach to management of behavior problems outlined here is the outgrowth of experience in a general pediatric practice. The pediatrician often has the therapeutic advantage of an already established relationship with a family. His continuing intimate associations with growing children uniquely qualify him to provide complete medical care to the child and to counsel and inform the parents. The anxious parent confronting the pediatrician with a behavior problem at an inconvenient moment may be a cause of some frustration, but the effective management of that problem can be as professionally gratifying as anything the pediatrician may undertake.
672
EDWIN
A.
SUMPTER
REFERENCES 1. Brazelton, T. B.: Infants and Mothers: Differences in Development. New York, Delacorte Press, 1969. 2.· Brazelton, T. B.: Crying in infancy. Pediatrics, 29:579,1962. 3. Brazelton, T. B.: A child-oriented approach to toilet training. Pediatrics, 29:121,1962. 4. Chamberlin, R W.: Management of preschool behavior problems. Pediat. Clin. N. Amer., 21 :1,1974. 5. Chamberlin, R W., personal communication. 6. Chess, S., Thomas, A., and Birch, H. G.: Your Child Is a Person. New York, Viking Press, 1965. 7. deLissovoy, V.: Head banging in early childhood. Child Devel., 33:43,1962. 8. ·Ginott, H. G.: Between Parent and Child. New York, Avon Books, 1971. 9. Glaser, J., Bakwin, R M., Breslow, L., Cobb, J. C., Fries, J. N., Levine, M. I., Martin, F. J., Rambar, A. C., and Ratner, B.: Colic in infants: Excerpts from a panel discussion. Pediatrics, 18 :828, 1956. 10. ·Gordon, T.: Parent Effectiveness Training. New York, Peter H. Wyden, 1970. 11. Ilg, F. L., and Ames, L. B.: Child Behavior. New York, Harper & Brothers, 1955. 12. Illingworth, R, and Illingworth, C.: Babies and Young Children. Fifth edition. Baltimore, Williams & Wilkins Co., 1972. 13. Kravetz, H., Rosenthal, V., Teplitz, Z., Murphy, J. B., and Lesser, R E.: A study of head banging in infants and children. Dis. Nerv. Sys., 21 :203, 1960. 14. Kravetz, H., and Boehm, J. J.: Rhythmic habit patterns in infancy: Their sequence, age of onset and frequency. Child Devel., 42 :399, 1971. 15. Patterson, G. R, and Gullion, M. E.: Living with Children. Champaign, Ill., Research Press, 1973. 16. Spock, B.: Baby and Child Care. New York, Pocket Books, 1970. 17. Thomas, A., Chess, S., and Birch, H. G.: Temperament and Behavior Disorders in Children. New York, New York University Press, 1968. University of Massachusetts School of Medicine 55 Lake Avenue North Worcester, Mass. 01605
