Behavior: Toddlers

The best time for parents and toddlers is a 1-on-1 interaction with no goals, no rules and nothing but relaxed fun. Turn off the TV, the DVD and even the music. With that wonderful silence, you will find yourself talking to your child. Every time the toddler’s finger points to something, say the name. Keep up a running commentary –“you’re drawing with a red crayon” and keep the smiles, hugs and positive comments coming often. As your toddler goes from the table to the chair to the floor to the window, go with him. Let the child lead you. No plan, no specific game - just you and your child exploring the world together.

     When he can’t get up on the chair or gets caught when he crawls under the table, he will start to whine and cry. As long as he isn’t in any danger don’t rush to help him. Remember that anytime you reinforce a behavior, you increase the likelihood that that behavior will occur again.  Putting him in the chair when he whines to get into the chair teaches him to whine to get what he wants. Always be careful of the behavior that you reinforce – only give positive attention to behavior that you want to see more of. When he is struggling, give the quiet reassurance that helps him calm down – “I’m here”; “Everything is O.K.”; “You can do it”. This not only helps him learn to settle himself down, it helps him to try other ways to solve his own problems – and you will be amazed at how he will stop whining and begin to work out something new.

     When his natural exploration leads him into a behavior that is not acceptable, say a firm, clear “NO!” Be sure that when you say “NO” that the child stops the behavior immediately and it is O.K. if you see fear and a tear – it means you got the message across. Don’t use “no” as the beginning of a sentence anytime you want to simply change a behavior: “No, honey, we don’t want you to play with that”; “No, honey, Daddy doesn’t like that.” The word ‘no” is saved for the times when you really need to say “NO!” - otherwise the child gets used to hearing it and will start to ignore it. Don’t get angry and don’t escalate  (“No, honey,don’t do that” ; “NO,,honey, don’t do that!” ; “NO!! I’VE TOLD YOU THREE TIMES NOT TO DO THAT!!!”) If the behavior warrants a “NO”, say it. If not, say the rule without the “no” attached. - We don’t play in the toilet” – or steer the child away from the behavior before it occurs. There is nothing more obvious than a toddler’s behavior – you can see in their eyes what they plan to do next. Avoiding trouble while keeping things relaxed and positive beats getting into trouble and then having a negative interaction.

ADHD - Diagnosis

     Children with Attention Deficit/Hyperactivity Disorder have a neurologic problem in a portion of their brain that controls what is called “Executive Function”. This is the ability to organize, focus, control behavior and consider consequences. These children may have inattentive, hyperactive or impulsive behaviors or any combination of the three. Younger children with ADHD have more hyperactive behaviors. Older children and adolescents with ADHD have more inattentive behavior. Hyperactive behavior is seen more often in boys. The current recommendation is that any child 4 through 18 years of age who has academic or behavioral problems and symptoms of inattention, hyperactivity or impulsivity should be evaluated for ADHD. 

     Because ADHD is basic neurologic problem, the child always has some symptoms. Part of the diagnosis of ADHD is that the child is affected in more than one setting – at home, at school, at play and in other social situations. If a child is doing fine in school but having problems at home, a family problem may be the cause. If a child is doing fine at home but poorly in school, especially in one class, a teacher-interaction or a bullying problem may exist.

     There are a number of different written forms which are used to evaluate ADHD – Vanderbilt forms, Connors forms, SNAP forms and soon-to-be-released DSM – V forms. All of these have similar questions and serve as rating scales which help to determine what kinds of problems and what degree of impairment a child has. To get a clear picture of ADHD, we need to get information from the parents, the child, the school and any other caregivers involved with the child. 

     When considering ADHD, we need to evaluate other problems such as anxiety, depression, behavior problems, learning/language deficits or personality disorders which can go along with ADHD. It is also important to be sure that the child is not suffering from hearing or vision problems, chronic illness, seizures, autism, infection, sleep apnea or any other problem which is not ADHD but can give a child ADHD-like symptoms.

     The most important factor in evaluation ADHD is the degree of impairment. A child may have “a lot of energy” or he may be “spacey” at times, but if he is not able to do the things he wants to do or succeed in the things he is capable of doing because of ADHD symptoms, he needs help.

ADHD Basics

     Because ADHD is such a difficult problem, I will write a number of articles on it. This first article will attempt to cover the basic things parents should know about ADHD.

     ADHD is a disorder that causes many symptoms, but these symptoms can be generally placed into three major categories: inattentiveness, hyperactivity and impulsivity. Because all children are, at one time or another, inattentive, hyperactive and impulsive, people often question whether ADHD isn’t just a kid being a kid. The difference is that, with ADHD, these things impair the child’s ability to do the things he wants to do. The symptoms are present almost all the time and the child cannot control them. Parents complain that the child “Doesn’t listen”, “Can’t focus”, “Doesn’t finish tasks”, “Gets frustrated easily”, “Doesn’t think about consequences”, Can’t sit still” and “Can’t organize tasks or time”. As the child advances in school, these problems only get worse. These children usually have higher intelligence but are not able to work up to their ability because of the ADHD symptoms.

     ADHD is not a result of either bad parenting or misbehavior in the child. It is not due to allergy or a dietary problem. It is not due to toxins in the environment or a lack of vitamins in the child. Some children who have had brain trauma develop ADHD symptoms, but most ADHD clearly is hereditary. The genetic cause for ADHD has not been identified yet, but there is no doubt that it exists. People who have ADHD have it as a part of the neurologic makeup they are born with. It is usually easy to find the parent or relative who had the same problems when in school even though they may not have been diagnosed as having ADHD. I frequently saw parents who, when they understood ADHD and saw their child getting better, would go to their own doctor for help.

      Part of the frustration that comes with ADHD is caused by the child being smart enough to recognize that, no matter how hard he tries, he just can’t “get things right”. I always felt the name “attention deficit disorder” was misleading because these children don’t seem to have a deficit in their ability to pay attention – just the opposite! They pay attention to everything going on around them! Through the day, we have lots of things happening around us – sights, sounds, and smells – but we can tune out the things we don’t care about and focus on the things we want to. Imagine how hard it would be for you if you were sitting in class, the teacher was writing on the board and the kid behind you sneezes. You turn to look at the kid and then a truck goes by outside the window and your attention is drawn to that and when you turn back to the teacher, she has gone from “A” to “D” and you’ve missed a portion of what she was saying. We all have problems staying focused if the subject we are trying to pay attention to isn’t very interesting to us but, if you have ADHD, it is almost impossible.

     Along with being more intelligent, there are other positive traits that come along with having ADHD. These children seem to be more creative and inventive. They have more energy and, if they are really interested in something, they can “hyper-focus” and stay engrossed in one thing for hours. They can be the inventors, the scientists, the poets, and the entrepreneurs, but, just as easily, they can be the drop-outs, the misfits and the failures.

     In future articles, I’ll discuss the criterion used to diagnose ADHD and the treatments for it.

       

Ticks and Tick Diseases

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     There has been a dramatic increase in tick-related diseases over the last ten years. Doctors don’t know if the diseases are actually increasing or whether we are more aware of them now and therefore diagnose them more often. Before 1976, no one diagnosed Lyme disease because we didn’t know about it. Rocky Mountain Spotted Fever was known because it can cause a severe illness in children but other common tick-related diseases were rarely talked about and almost never diagnosed. An old saying in medicine is that a doctor doesn’t make a diagnosis of a disease that he doesn’t think of. Three of the common tick diseases are carried by deer ticks, so the increase in the deer population could also be causing increased disease. People are living in and hiking through rural areas more often, which also gives them more exposure.

     Most of the diseases that are transmitted by tick bite are mild and don’t cause much more than fever. In fact, if someone has a fever between spring and fall, especially a fever that lasts longer than a normal viral fever (See “Fever” articles) or a fever with no other symptoms, they may very well have a tick-related disease.  Lyme disease can cause a round, red rash – commonly on the head, neck, arms, and legs – that gradually expands. It can also cause joint pain, headaches and weakness of the nerves and muscles in the face with eyelid or mouth droop. Rocky Mountain Spotted Fever can cause meningitis, shock and death.

     Making the diagnosis of tick-caused disease is difficult because the blood tests used to diagnose these diseases are complex, hard to interpret and often don’t turn positive until weeks after the tick bite. It is also hard to distinguish between a new infection and a previous infection.

     Recommendations to prevent infections transmitted by tick bite are often impractical. It is difficult to keep children in long sleeves and long pants tucked into the socks. The most important thing parents can do is to find and remove the ticks early. It is thought that a tick needs to be attached to the skin for longer than 72 hours in order to transmit disease. A tick that is not engorged with blood and is walking on the child is not a risk. When a child is outside, use DEET-containing insect repellant products. They can be 10 – 30% concentration and should be used in any child over 2 months of age. After being outside, children should have a shower or bath to wash off the DEET and then be closely inspected by the parent. If uncertain whether an insect is a tick or not, bring it to the child’s caregiver for identification. If the tick is firmly attached to the child’s skin, have your caregiver remove it if you are uncomfortable doing so. The latest home remedy is to soak a cotton ball with liquid soap, swab the tick with it a few times and then leave the cotton ball on the tick for awhile. I don't know if it actually works. At one time, there was a vaccine for Lyme disease, but it is no longer available.

     Treatments used for the diseases caused by tick-bite are antibiotics. Amoxicillin is commonly used for Lyme and Doxycycline is effective for most of the other diseases. Doxycycline is a tetracycline-type antibiotic and doctors worry that it can cause staining of teeth, but when it is used in the right dose, it has not been found to stain permanent teeth and, for diseases like Rocky Mountain Spotted fever, it could be life-saving.

Fluoride; Who Needs It?

     Some doctors prescribe fluoride supplementation for their young patients and some don’t. Dentists warn against both too much and too little fluoride. What should a parent do?

      Fluoride decreases the growth of bacteria in the mouth that cause tooth decay. In the 1930’s and 40’s, studies showed that fluoride in public water supplies reduced dental decay. In 1945, fluoride was first added to the water supply in Grand Rapids, Michigan and, since that time, it has been estimated that water fluoridation has reduced dental cavities in the American population by about 60%. That means a significant decrease in both the discomfort and the cost of dental problems in American children.

     Even though most water supplies have fluoride, some children may not have an adequate amount. Well water may have some natural fluoride but it may not have enough. There are still some areas in the country that do not have fluoridated water and some home water purification systems remove fluoride. Breast milk does not contain fluoride, even if the mother is drinking water with fluoride.  Powdered or concentrated formulas do not contain fluoride, but the water used to reconstitute them may have fluoride. Bottled water may or may not have fluoride. Children with inadequate fluoride are at risk for increased dental problems. Other children at risk for tooth decay are children who snack on sugary snacks and drinks (including milk) or who go to bed with bottles that contain liquids with sugar.

     On the other hand, the American Dental Association warns against too much fluoride. Too much fluoride over a long period of time can cause staining of tooth enamel and weakening of the tooth enamel. Because there are many sources of fluoride in today’s society, parents need to be aware of how much fluoride their child is getting.  Along with water, fluoride is in toothpaste, mouthwash and in fluoride dental applications. Doctors also prescribe fluoride supplementation, especially to breast-fed infants. At the American Academy of Pediatric Dentistry web site (www.aapd.org) parents can find a risk assessment tool to help determine how much fluoride their child may need. Parents then need to speak with their child’s caregiver or dentist about supplementation.

Eczema

     Eczema or “atopic dermatitis” is a chronic skin condition causing patches of red, dry, itchy, skin. In infants and younger children the red patches are on the face, in the neck folds, on the trunk and on top of the forearms. In older children it is frequently on the hands, in the front of the elbows and behind the knees. 60% of children with eczema develop it before their first birthday. 85% develop it before age 5. Many experts feel that there is a connection between eczema and allergies.  Some 60% of children with eczema have food allergies. Up to 80% of older children with eczema are reported to have hay fever and 50% are reported to have asthma. This is why an infant with eczema needs to be evaluated for food allergy. The most common infant food allergies are milk, soy, eggs and peanut but parents should speak with their caregiver before eliminating a food from the child’s diet.

     Children with eczema have an abnormal skin surface that does not hold moisture as well as normal skin. If normal skin is wet, it is fine, and if it is dry, it is fine, but even normal skin gets chaffed and red if it goes from wet to dry. Children with eczema have a lot of difficulty when their skin goes from wet to dry. This is why eczema is worse in areas of the body where sweat collects or in areas that frequently get wet, like the hands. Moisture in the skin surface is also important for the skin to act as a barrier against chemicals and irritants. Children with eczema have less moisture in their skin and are more sensitive to irritants.

     If a child has food allergies, avoidance of the food will improve their eczema. But all children with eczema are improved with frequent moisturizing of the skin. It is especially important to apply moisturizing lotion or cream immediately after the skin has been wet – immediately after baths and showers, in sweaty areas and right after hand washing. Avoid the skin going wet-to-dry. Any areas of the body that have the dry, red patches need moisturizing even more often.

     The second problem that children with eczema have is itching. Some experts say that the itching is such a key part of eczema that parents need to think of eczema as “an itch that rashes” rather than “a rash that itches”. Parents often report that the child began itching before the rash appeared. Treating the itch involves eliminating any offending allergy agents and giving the child antihistamines. Older antihistamines like diphenhydramine (Benadryl) or hydroxyzine (Atarax) sometimes make children crabby or tired but I have found that the “non-sedating” antihistamines don’t relieve itching as well. Parents should try both (only one at a time). The goal is to eliminate the itch without causing side effects. Another treatment for the itching is steroid creams. Lower percentage steroid creams can be purchased without a prescription and should be tried because they often help. Stronger steroid creams should only be used under the care of a physician.

Bedwetting

    Children can occasionally wet the bed up to age 7 and, as long as the child has no other problems, it is considered to be normal. If a child has not had problems with urinating or stooling and then begins to have new problems going to the bathroom, especially if he has new symptoms such as back pain or abdominal pain, he needs to be seen by his caregiver.  Constipation is a common reason for urination problems like bedwetting (See “Constipation – Tummy Pain” article).

     Experts in enuresis (bedwetting) tell us that bedwetting has nothing to do with sleep patterns. However, parents continue to say that their children who wet the bed are very sound sleepers and can’t be awakened. Sometimes, not even the wet bed wakes them up. The children will often say that they dreamed that they had to go to the bathroom. They made sure that they were on a toilet and started to urinate only to find that they were still in bed. This makes bedwetting frustrating for both parents and children. The child may also feel embarrassment because bedwetting can be viewed (especially by siblings) as “being a baby”. I usually start conversations about bedwetting by telling the child he doesn’t have a wetting problem, he has a sleep problem. It seems easier for them to accept that they just don’t wake up to go the bathroom. I have also found that bedwetting at an older age runs strongly in families. I ask which adult in the family was a very sound sleeper and wet the bed when they were older. It helps the child to know that an adult he respects had the same problem. There should be no guilt, shame, anger, blame or punishment when dealing with bedwetting.

     When the parents and the child recognize that an over-tired child who has had a lot to drink in the evening is likely to wet the bed, it gives everyone ways to avoid bedwetting. Limiting liquids before bed is the start. Because any liquid containing sugar or caffeine seems to increase bedwetting, give the child water rather than milk or juice in the evening. When you limit late afternoon and evening fluids, allow the child increased fluids earlier in the day.  Don’t limit fluids when the child is ill. If the child has been allowed to get over-tired, expect a wet bed and plan for it.  Have a change of sheets near the bed to minimize the hassle of changing in the middle of the night. Experts recommend against pull-ups because they feel the child doesn’t learn anything by using them, but I think that, especially on a night when the probability is high that the child will wet the bed, pull-ups are OK, as long as the child is not upset or embarrassed by them.

     Charts that keep track of wet and dry nights can help motivate the child, as long as the child is the one who is responsible for the chart and can do it the way he wants to. The more the child is involved with deciding how to stay dry, the more success for everyone. Treats and small rewards can help a little, but children soon get bored with them. Waking the child up to urinate when the parents go to bed can also help bedwetting, but its not a long-term fix.

     Bedwetting alarms work but only if parents understand how they work. They are a learning tool and learning takes time. At first, the child doesn’t even wake up with the alarm. The parent should wake the child, tell him to finish urinating in the toilet and get him back into a dry bed. Once the child learns to wake up with the alarm, he begins to learn to wake up with the sensation of urinating. Then he learns to wake up just before he urinates when his bladder is full. Given enough time and patience, 66% of children using the alarm get dry and 50% of them stay dry. That’s a better success rate than any other treatment.

     Desmopressin is a prescription-only medication that can give a child a dry night or a dry weekend whenever he needs it. It is good for sleepovers or weeks at camp but shouldn’t be used as a long-term treatment for bedwetting because of its side effects.

     Most important is that the parents and the child approach bedwetting as a temporary inconvenience that can be managed and will ultimately resolve itself. Positive attitude and patience with celebration of dry nights and minimal disappointment on wet nights will help everyone.

Rash Behiind the Ears

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     It is common, especially in infants, to get a red, raw, cracked rash behind the ears right where the ear meets the head. The cowboys in the Old West used to say that someone was “wet behind the ears” – this meant they were inexperienced: a baby. At four months of age, all infants begin to drool and chew. When they lie down, the drool can pool behind their ears and also in the creases of their neck. The area gets wet, dries and then gets wet again.

     Normal skin does fine if it is moist and it also does fine if it is dry. Skin does not do well if it continually goes from wet to dry. This is the reason that people who have problems maintaining moisture on their skin, like people with eczema, have dryness and itching when their skin goes from wet to dry often – like with repeated hand washing. These people need to learn to apply moisturizing lotion immediately to any area that has gotten wet or all over their bodies immediately after a shower. Anyone with dry or sensitive skin will usually find that their skin improves if they do this.

     But babies (and adults) with normal skin will also get a raw, red rash in areas that get wet off and on. Moisturizing lotions or ointments or even petroleum jelly behind the ear before nap-time and when the infant wakes up will help protect the area. If an adult gets this rash, it is usually a woman who has the habit of tucking her hair behind her ear when it is wet.

     As I mentioned in “Diaper Rash”, normal, intact skin is the best protection we have against the bacteria and yeast spores that are always on our skin. Any time our skin is irritated or open, we run the risk of getting it infected. If the rash behind the ears or in the neck folds isn’t clearing or getting worse, consider possible infection. A bacterial infection may be red, weeping, swollen or sore. A yeast infection is often a slowly expanding, bright red area that itches a lot. For a bacterial infection, use the antibacterial ointment that you can purchase without a prescription. In fact, because it is an ointment, it can serve both as protection and treatment when the infant has the rash. For a yeast infection, use one of the anti-yeast, anti-athlete’s foot products. As always, if the rash is getting worse, see your caregiver. You may need oral medication.