Barbara J. Howard, MD

Do you breathe a sigh of relief when fathers are present for the visit? Or maybe if they are not? Even though the number of fathers as primary caregivers is increasing, most pediatric visits are still with mothers. Working with mothers probably has been your main experience and training. Whether you are a female or male clinician, you also may think working with the mother is just easier, and you may feel your heart sink when a father is present! If he is alone with the child, is he going to have the information about the child that you need? If he is present along with the mother, is the conversation going to take twice as long? Please note that by "father," I am referring to any adult male involved in the regular care of the child. Proof of paternity not required.

Don’t give up so fast! There are many reasons to put in the effort to engage fathers, especially in visits concerning child behavior problems. Fathers bring a unique perspective and added information on the child. Their ideas should be heard simply because it concerns the child. And they may, in fact, be part of the cause of the problem. In all cases, you, the mother, and the child need the father to be part of the solution. His involvement is often the key to an effective resolution of a child behavior problem.

So how to engage fathers? First, invite them! How many times had I gotten midway into a visit and asked the mother about what the father thinks, just to have her say, "Well, he’s out in the waiting room (or car). Do you want me to get him?" before I learned this lesson? Head that one off by making it clear when the appointment is made for all behavior problem visits that the presence of all key caregivers is hoped for. Get your staff to send all parties into the room, too. And when you go in the room, ask if anyone else came along.

Once you are in the room, be sure you know who is present. Sometimes I formally introduce myself, hoping for a counter intro to help me out. Some offices take photos of each family member for the EHR and, by the way, to prevent insurance fraud. What a help that is!

When should you turn to the father? I always talk to the child first and get as much information and rapport as possible with him or her. In reviewing family relationships, I always ask the young child if the father is "nice, or mean, or what," ask him to give examples of what they like to do together, and ask him to say what is "the hardest part" of living with dad. Kids are brutally honest, if not always accurate. A child who can’t think of a single joint activity probably has had few. For a father (or mother) to hear these answers can be a more effective wake-up call than anything you can say.

I like to take advantage of the adult interview time to have the child do a "family kinetic drawing" with instructions to "draw everyone in your family doing something." When finished, the picture may reveal fun times, isolation in boxes, or even some members left off altogether. I have had children put in mom’s boyfriend, or leave off the new baby; once a boy even depicted himself throwing a grenade at his father. Asking the child to tell a story about the drawing often gives invaluable information to check out with the parents, especially the father.

Then ask the father for his concerns or understanding about the child. A father is in the awkward position of not knowing what the mother may have reported about him, and may think you are already biased against him. A father may defer, but don’t let him off the hook. Push for his opinions and examples, emphasizing that his "male point of view" is valuable even if he is not home as much as the mother. Use your body language (such as an outstretched arm, leaning in) and steady eye contact to ensure that the father is not blocked out by the mother from contributing to the story. Her dominance may be revealing of family dynamics, but then engaging him is even more important.

What do you need to know from the father? At least you need to ask: What are your concerns about your daughter? What do you think is causing this behavior? How much of a problem do you think this is? What have you tried so far? What do you think might help? Those are the obvious questions you would ask about any problem and of any caregiver. You can even have a "virtual family visit" when the father is not present by asking the mother, "What would her father say?" about these questions.

But, to get more valuable information from the father, I also ask: How would your parents have handled that when you were growing up? How did that work out? What do you want your relationship with him to be like when he is a man? Expectations that can throw the father-child relationship out of whack usually come from the father’s own past.

How can you tell when it is family dynamics that are causing or interfering with the resolution of child behavior problems? It can help to consider common scenarios. Be open to being totally wrong, but listen to the family’s examples for "syndromes" of what may be happening at home. Some examples:

• Father is pressuring child to succeed, or pressuring the child to be aggressive, and the child rebels.

• Father steps in when mother is having trouble and thereby undermines her authority, making the child sassy.

• Mother steps in when she thinks father is being too tough, undermining him, making the child oppositional.

• Father feels child management is "not his responsibility," but then blocks mother’s efforts when he can’t stand the child’s crying.

How can you interpret these dynamics to help move the family to more adaptive patterns? At the risk of seeming too traditional, draw a family system figure showing the "ideal" of two parents with a close and equal relationship with the child below them (with lower power), but equal relationships with each. Ask each parent how they would draw their own family balance. Then problem solve with them on how they can make their balance more like your figure. This might mean mother deferring to father more, father showing more affection to mother, or both at least not interfering in the other’s management of child behaviors.

We clinicians need to watch out – we are not immune to bias about fathers that can be subtly transmitted and interfere with good care and problem-solving. Maybe we are more inclined to think that men will overuse corporal punishment, be uninvolved, or initiate domestic violence or sexual abuse. We may add this prejudice to race or culture bias. Bias may also make us expect men to be more effective in child management, or more brave or reliable. Our biases can come from general statistics or from our own family experiences. To really engage fathers, we need to step back and be open to each parent for their strengths and weaknesses, regardless of gender.

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 financial disclosures. E-mail her at [email protected].

Do you breathe a sigh of relief when fathers are present for the visit? Or maybe if they are not? Even though the number of fathers as primary caregivers is increasing, most pediatric visits are still with mothers. Working with mothers probably has been your main experience and training. Whether you are a female or male clinician, you also may think working with the mother is just easier, and you may feel your heart sink when a father is present! If he is alone with the child, is he going to have the information about the child that you need? If he is present along with the mother, is the conversation going to take twice as long? Please note that by "father," I am referring to any adult male involved in the regular care of the child. Proof of paternity not required.

Don’t give up so fast! There are many reasons to put in the effort to engage fathers, especially in visits concerning child behavior problems. Fathers bring a unique perspective and added information on the child. Their ideas should be heard simply because it concerns the child. And they may, in fact, be part of the cause of the problem. In all cases, you, the mother, and the child need the father to be part of the solution. His involvement is often the key to an effective resolution of a child behavior problem.

So how to engage fathers? First, invite them! How many times had I gotten midway into a visit and asked the mother about what the father thinks, just to have her say, "Well, he’s out in the waiting room (or car). Do you want me to get him?" before I learned this lesson? Head that one off by making it clear when the appointment is made for all behavior problem visits that the presence of all key caregivers is hoped for. Get your staff to send all parties into the room, too. And when you go in the room, ask if anyone else came along.

Once you are in the room, be sure you know who is present. Sometimes I formally introduce myself, hoping for a counter intro to help me out. Some offices take photos of each family member for the EHR and, by the way, to prevent insurance fraud. What a help that is!

When should you turn to the father? I always talk to the child first and get as much information and rapport as possible with him or her. In reviewing family relationships, I always ask the young child if the father is "nice, or mean, or what," ask him to give examples of what they like to do together, and ask him to say what is "the hardest part" of living with dad. Kids are brutally honest, if not always accurate. A child who can’t think of a single joint activity probably has had few. For a father (or mother) to hear these answers can be a more effective wake-up call than anything you can say.

I like to take advantage of the adult interview time to have the child do a "family kinetic drawing" with instructions to "draw everyone in your family doing something." When finished, the picture may reveal fun times, isolation in boxes, or even some members left off altogether. I have had children put in mom’s boyfriend, or leave off the new baby; once a boy even depicted himself throwing a grenade at his father. Asking the child to tell a story about the drawing often gives invaluable information to check out with the parents, especially the father.

Then ask the father for his concerns or understanding about the child. A father is in the awkward position of not knowing what the mother may have reported about him, and may think you are already biased against him. A father may defer, but don’t let him off the hook. Push for his opinions and examples, emphasizing that his "male point of view" is valuable even if he is not home as much as the mother. Use your body language (such as an outstretched arm, leaning in) and steady eye contact to ensure that the father is not blocked out by the mother from contributing to the story. Her dominance may be revealing of family dynamics, but then engaging him is even more important.

What do you need to know from the father? At least you need to ask: What are your concerns about your daughter? What do you think is causing this behavior? How much of a problem do you think this is? What have you tried so far? What do you think might help? Those are the obvious questions you would ask about any problem and of any caregiver. You can even have a "virtual family visit" when the father is not present by asking the mother, "What would her father say?" about these questions.

But, to get more valuable information from the father, I also ask: How would your parents have handled that when you were growing up? How did that work out? What do you want your relationship with him to be like when he is a man? Expectations that can throw the father-child relationship out of whack usually come from the father’s own past.

How can you tell when it is family dynamics that are causing or interfering with the resolution of child behavior problems? It can help to consider common scenarios. Be open to being totally wrong, but listen to the family’s examples for "syndromes" of what may be happening at home. Some examples:

• Father is pressuring child to succeed, or pressuring the child to be aggressive, and the child rebels.

• Father steps in when mother is having trouble and thereby undermines her authority, making the child sassy.

• Mother steps in when she thinks father is being too tough, undermining him, making the child oppositional.

• Father feels child management is "not his responsibility," but then blocks mother’s efforts when he can’t stand the child’s crying.

How can you interpret these dynamics to help move the family to more adaptive patterns? At the risk of seeming too traditional, draw a family system figure showing the "ideal" of two parents with a close and equal relationship with the child below them (with lower power), but equal relationships with each. Ask each parent how they would draw their own family balance. Then problem solve with them on how they can make their balance more like your figure. This might mean mother deferring to father more, father showing more affection to mother, or both at least not interfering in the other’s management of child behaviors.

We clinicians need to watch out – we are not immune to bias about fathers that can be subtly transmitted and interfere with good care and problem-solving. Maybe we are more inclined to think that men will overuse corporal punishment, be uninvolved, or initiate domestic violence or sexual abuse. We may add this prejudice to race or culture bias. Bias may also make us expect men to be more effective in child management, or more brave or reliable. Our biases can come from general statistics or from our own family experiences. To really engage fathers, we need to step back and be open to each parent for their strengths and weaknesses, regardless of gender.

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 financial disclosures. E-mail her at [email protected].

Do you breathe a sigh of relief when fathers are present for the visit? Or maybe if they are not? Even though the number of fathers as primary caregivers is increasing, most pediatric visits are still with mothers. Working with mothers probably has been your main experience and training. Whether you are a female or male clinician, you also may think working with the mother is just easier, and you may feel your heart sink when a father is present! If he is alone with the child, is he going to have the information about the child that you need? If he is present along with the mother, is the conversation going to take twice as long? Please note that by "father," I am referring to any adult male involved in the regular care of the child. Proof of paternity not required.

Don’t give up so fast! There are many reasons to put in the effort to engage fathers, especially in visits concerning child behavior problems. Fathers bring a unique perspective and added information on the child. Their ideas should be heard simply because it concerns the child. And they may, in fact, be part of the cause of the problem. In all cases, you, the mother, and the child need the father to be part of the solution. His involvement is often the key to an effective resolution of a child behavior problem.

So how to engage fathers? First, invite them! How many times had I gotten midway into a visit and asked the mother about what the father thinks, just to have her say, "Well, he’s out in the waiting room (or car). Do you want me to get him?" before I learned this lesson? Head that one off by making it clear when the appointment is made for all behavior problem visits that the presence of all key caregivers is hoped for. Get your staff to send all parties into the room, too. And when you go in the room, ask if anyone else came along.

Once you are in the room, be sure you know who is present. Sometimes I formally introduce myself, hoping for a counter intro to help me out. Some offices take photos of each family member for the EHR and, by the way, to prevent insurance fraud. What a help that is!

When should you turn to the father? I always talk to the child first and get as much information and rapport as possible with him or her. In reviewing family relationships, I always ask the young child if the father is "nice, or mean, or what," ask him to give examples of what they like to do together, and ask him to say what is "the hardest part" of living with dad. Kids are brutally honest, if not always accurate. A child who can’t think of a single joint activity probably has had few. For a father (or mother) to hear these answers can be a more effective wake-up call than anything you can say.

I like to take advantage of the adult interview time to have the child do a "family kinetic drawing" with instructions to "draw everyone in your family doing something." When finished, the picture may reveal fun times, isolation in boxes, or even some members left off altogether. I have had children put in mom’s boyfriend, or leave off the new baby; once a boy even depicted himself throwing a grenade at his father. Asking the child to tell a story about the drawing often gives invaluable information to check out with the parents, especially the father.

Then ask the father for his concerns or understanding about the child. A father is in the awkward position of not knowing what the mother may have reported about him, and may think you are already biased against him. A father may defer, but don’t let him off the hook. Push for his opinions and examples, emphasizing that his "male point of view" is valuable even if he is not home as much as the mother. Use your body language (such as an outstretched arm, leaning in) and steady eye contact to ensure that the father is not blocked out by the mother from contributing to the story. Her dominance may be revealing of family dynamics, but then engaging him is even more important.

What do you need to know from the father? At least you need to ask: What are your concerns about your daughter? What do you think is causing this behavior? How much of a problem do you think this is? What have you tried so far? What do you think might help? Those are the obvious questions you would ask about any problem and of any caregiver. You can even have a "virtual family visit" when the father is not present by asking the mother, "What would her father say?" about these questions.

But, to get more valuable information from the father, I also ask: How would your parents have handled that when you were growing up? How did that work out? What do you want your relationship with him to be like when he is a man? Expectations that can throw the father-child relationship out of whack usually come from the father’s own past.

How can you tell when it is family dynamics that are causing or interfering with the resolution of child behavior problems? It can help to consider common scenarios. Be open to being totally wrong, but listen to the family’s examples for "syndromes" of what may be happening at home. Some examples:

• Father is pressuring child to succeed, or pressuring the child to be aggressive, and the child rebels.

• Father steps in when mother is having trouble and thereby undermines her authority, making the child sassy.

• Mother steps in when she thinks father is being too tough, undermining him, making the child oppositional.

• Father feels child management is "not his responsibility," but then blocks mother’s efforts when he can’t stand the child’s crying.

How can you interpret these dynamics to help move the family to more adaptive patterns? At the risk of seeming too traditional, draw a family system figure showing the "ideal" of two parents with a close and equal relationship with the child below them (with lower power), but equal relationships with each. Ask each parent how they would draw their own family balance. Then problem solve with them on how they can make their balance more like your figure. This might mean mother deferring to father more, father showing more affection to mother, or both at least not interfering in the other’s management of child behaviors.

We clinicians need to watch out – we are not immune to bias about fathers that can be subtly transmitted and interfere with good care and problem-solving. Maybe we are more inclined to think that men will overuse corporal punishment, be uninvolved, or initiate domestic violence or sexual abuse. We may add this prejudice to race or culture bias. Bias may also make us expect men to be more effective in child management, or more brave or reliable. Our biases can come from general statistics or from our own family experiences. To really engage fathers, we need to step back and be open to each parent for their strengths and weaknesses, regardless of gender.

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 financial disclosures. E-mail her at [email protected].

Can you remember the name of that kid who wet his pants in your second grade class? I can. Daytime wetting, now properly called daytime incontinence (wetting when awake), affects 2%-7% of children and really makes a mark, and not just on the sofa! Technically, according to DSM-IV, it is defined by two or more wetting episodes per week for 3 months in a child 5 years or older (mental age) that are not due to substances or another medical disorder.

School-aged children are painfully aware of those who are different, especially in a way that appears to be a developmental deficiency. Being called a "baby" is never a compliment to 6- to 12-year-olds. Wetting your pants is sure to be noticed and the child is certain to be labeled. But daytime wetting is not a simple matter of a developmental delay. It is most helpful to divide incontinence into problems of storage and of release. These categories also help you decide what assessments need to be done.

A child who can hold urine fine all night but wets during the day has a release problem, not a storage problem. A child with renal disease, sickle cell disease, hyperthyroidism, diabetes mellitus or diabetes insipidus, or who uses diuretics and thus creates excess dilute urine will have trouble containing her urine both night and day. A child who has an erratic spray of urine or has to grunt and strain to void has a release problem that is either structural or more likely a learned dyssynergy. The early or midpubescent girl who laughs until she wets has giggle micturition (and often also has attention-deficit/hyperactivity disorder [ADHD] underlying it that can be helped by stimulants, if indicated by other criteria). The girl who voids, wipes, stands up, and discovers wet panties has vaginal reflux. Such girls often are overweight. They can resolve the incontinence by sitting backward on the toilet to spread the legs, relaxing, and then standing over the toilet before sitting down to wipe again (and ideally losing weight). Thus both history and observation of voiding can help sort out the cause. A bladder ultrasound to check bladder capacity and postvoid residual may be needed in a few cases, but history or a diary will usually suffice.

It is helpful to normalize wetting by saying, "This is really common but really embarrassing," and assuring them that you know how to help them control it. Asking, "How hard has this been for you?" and "Is this something you want to fix?" will help you assess their motivation. All the behavioral strategies for wetting require the child’s participation to be effective.

The new epidemic I am seeing in daytime wetting I now dub Internet incontinence! Most daytime activities are not so captivating for a child as to keep the child from the socially face-saving act of heading for the bathroom on time, but electronic games can clearly do that! Some children have this priority-setting problem when playing outside with friends, but there is usually a tree handy (for boys), so it does not come to clinical attention. Cases of video game addiction in Japanese teens have included starvation as well as "voiding in place" and even required a special new kind of hospital detox program!

"But how can I get him/her to go to the bathroom?" the parents moan. Without being sarcastic, you can problem solve this situation with the parent and child together: Suggest setting a timer to go off every hour to remind the child to go to the bathroom. If the pants are dry at that time plus the child goes willingly, then they may resume their activities. If the pants are wet or the child is uncooperative, there will be a consequence. No electronics for 1 hour is a logical one, but not being able to play outside with friends would be appropriate for the "playground pee-er."

This is a good occasion to discuss the amount of electronics the child is engaged in and their effect on the child and family life. Rewards for being dry also are helpful. Once this is working, the interval between bathroom trips can be gradually increased to 2, then 3 hours.

Any child with new-onset daytime wetting should be checked for bacteriuria and more importantly stress. Twenty-five percent will have a urinary tract infection as the cause and antibiotics as the treatment – more girls than boys. Keep in mind that 20% of young children have a period of "toilet-training relapse" after age 6 years. These cases do not count in the estimate that 43% of those with daytime incontinence have a structural lesion. Lesions should be sought with a voiding cystourethrogram and ultrasound only if behavioral management is adhered to but ineffective. Spine films or magnetic resonance imaging are indicated only if there is an abnormal spine exam or motor or sensory exam of the lower extremities or anal sphincters as the nerves innervating the bladder sphincters enter the sacral cord in proximity to those. Neurologic functional reasons for daytime incontinence include maturational delay of the sacral voiding reflex, low bladder sensory awareness, poor bladder compliance, and dyssynergy between detrusor contraction and sphincter relaxation, an acquired behavior.

The more common preexisting condition for daytime incontinence, however, is constipation. A full sigmoid colon or rectal vault not only presses on the bladder, reducing its capacity, but also periodically stimulates the sacral nerves responsible for releasing urine. The child should be asked about large, hard infrequent stools, and even soiling, as this is often kept secret from the parents. The abdominal exam may not reveal this; a scan of the kidneys, ureters, and bladder may be needed. There is also a voiding dysfunction syndrome in some children under age 7 years with urinary incontinence, urinary tract infections, frequency, urgency, and constipation or encopresis in which there may be postvoid residual.

Even though the child appears to have a urine problem, treatment of constipation is the first line in care for every child with daytime incontinence and very often solves the wetting immediately. Don’t be shy in prescribing a capful of propylene glycol (Miralax), dissolved in any liquid for 15 minutes and consumed twice a day over a weekend, to clear out the retained stool. The usual maintenance of ½ capful of Miralax at night plus 5 minutes of toilet sitting using a timer in the morning and after dinner for 6 months is necessary, but not likely to be effective without a clean out first.

The next most common factor in daytime incontinence is ADHD (41%). Many aspects of having ADHD make this the case: A child with ADHD may be inattentive to the "need to go," has trouble shifting attention away from that video game, sits too briefly to defecate and gets constipated, may be taking stimulants that predispose to constipation, and is more likely to have comorbid learning disabilities or anxiety leading to stress. Optimizing management of ADHD, if present, should be part of the plan for managing incontinence.

Stress as a cause of daytime wetting is well known and even joked about by grown men when they say they were "scared s-less." But significant stress is not confined to the battlefield. A loud teacher, a new baby at home, school work that exceeds the child’s abilities, a bully at the bus stop, or having to give an oral presentation all can raise tension enough to reduce bladder capacity, increase bladder irritability, and result in daytime incontinence, particularly in children who are more sensitive as a result of having other coexisting stresses, low skills, a slow-to-warm-up temperament, or preexisting anxiety disorder.

In addition to working to alter any changeable stresses, you can teach the child relaxation techniques such as deep breathing, tightening then relaxing muscle groups, or imagining a peaceful safe place to go to in their mind. More severe stress such as from abuse (10%-15% of all children), domestic violence, marital discord (45%), or viewing violence (25%) can certainly cause incontinence and deserves to be addressed.

Parents may be angry and humiliated by the child’s wetting or embarrassed by what they have already tried to address it, including corporal punishment. The child, thinking that this is something she/he should be able to control, is often reluctant to even speak about it. Having private conversations with the child and the parents separately may be necessary to get a clear history and uncover the relevant factors. Trivial as "peeing your pants" sounds, solving daytime incontinence can be satisfying for the clinician and life changing for the child.

Dr. Howard is an 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 IMNG Medical Media. E-mail her at [email protected].

Can you remember the name of that kid who wet his pants in your second grade class? I can. Daytime wetting, now properly called daytime incontinence (wetting when awake), affects 2%-7% of children and really makes a mark, and not just on the sofa! Technically, according to DSM-IV, it is defined by two or more wetting episodes per week for 3 months in a child 5 years or older (mental age) that are not due to substances or another medical disorder.

School-aged children are painfully aware of those who are different, especially in a way that appears to be a developmental deficiency. Being called a "baby" is never a compliment to 6- to 12-year-olds. Wetting your pants is sure to be noticed and the child is certain to be labeled. But daytime wetting is not a simple matter of a developmental delay. It is most helpful to divide incontinence into problems of storage and of release. These categories also help you decide what assessments need to be done.

A child who can hold urine fine all night but wets during the day has a release problem, not a storage problem. A child with renal disease, sickle cell disease, hyperthyroidism, diabetes mellitus or diabetes insipidus, or who uses diuretics and thus creates excess dilute urine will have trouble containing her urine both night and day. A child who has an erratic spray of urine or has to grunt and strain to void has a release problem that is either structural or more likely a learned dyssynergy. The early or midpubescent girl who laughs until she wets has giggle micturition (and often also has attention-deficit/hyperactivity disorder [ADHD] underlying it that can be helped by stimulants, if indicated by other criteria). The girl who voids, wipes, stands up, and discovers wet panties has vaginal reflux. Such girls often are overweight. They can resolve the incontinence by sitting backward on the toilet to spread the legs, relaxing, and then standing over the toilet before sitting down to wipe again (and ideally losing weight). Thus both history and observation of voiding can help sort out the cause. A bladder ultrasound to check bladder capacity and postvoid residual may be needed in a few cases, but history or a diary will usually suffice.

It is helpful to normalize wetting by saying, "This is really common but really embarrassing," and assuring them that you know how to help them control it. Asking, "How hard has this been for you?" and "Is this something you want to fix?" will help you assess their motivation. All the behavioral strategies for wetting require the child’s participation to be effective.

The new epidemic I am seeing in daytime wetting I now dub Internet incontinence! Most daytime activities are not so captivating for a child as to keep the child from the socially face-saving act of heading for the bathroom on time, but electronic games can clearly do that! Some children have this priority-setting problem when playing outside with friends, but there is usually a tree handy (for boys), so it does not come to clinical attention. Cases of video game addiction in Japanese teens have included starvation as well as "voiding in place" and even required a special new kind of hospital detox program!

"But how can I get him/her to go to the bathroom?" the parents moan. Without being sarcastic, you can problem solve this situation with the parent and child together: Suggest setting a timer to go off every hour to remind the child to go to the bathroom. If the pants are dry at that time plus the child goes willingly, then they may resume their activities. If the pants are wet or the child is uncooperative, there will be a consequence. No electronics for 1 hour is a logical one, but not being able to play outside with friends would be appropriate for the "playground pee-er."

This is a good occasion to discuss the amount of electronics the child is engaged in and their effect on the child and family life. Rewards for being dry also are helpful. Once this is working, the interval between bathroom trips can be gradually increased to 2, then 3 hours.

Any child with new-onset daytime wetting should be checked for bacteriuria and more importantly stress. Twenty-five percent will have a urinary tract infection as the cause and antibiotics as the treatment – more girls than boys. Keep in mind that 20% of young children have a period of "toilet-training relapse" after age 6 years. These cases do not count in the estimate that 43% of those with daytime incontinence have a structural lesion. Lesions should be sought with a voiding cystourethrogram and ultrasound only if behavioral management is adhered to but ineffective. Spine films or magnetic resonance imaging are indicated only if there is an abnormal spine exam or motor or sensory exam of the lower extremities or anal sphincters as the nerves innervating the bladder sphincters enter the sacral cord in proximity to those. Neurologic functional reasons for daytime incontinence include maturational delay of the sacral voiding reflex, low bladder sensory awareness, poor bladder compliance, and dyssynergy between detrusor contraction and sphincter relaxation, an acquired behavior.

The more common preexisting condition for daytime incontinence, however, is constipation. A full sigmoid colon or rectal vault not only presses on the bladder, reducing its capacity, but also periodically stimulates the sacral nerves responsible for releasing urine. The child should be asked about large, hard infrequent stools, and even soiling, as this is often kept secret from the parents. The abdominal exam may not reveal this; a scan of the kidneys, ureters, and bladder may be needed. There is also a voiding dysfunction syndrome in some children under age 7 years with urinary incontinence, urinary tract infections, frequency, urgency, and constipation or encopresis in which there may be postvoid residual.

Even though the child appears to have a urine problem, treatment of constipation is the first line in care for every child with daytime incontinence and very often solves the wetting immediately. Don’t be shy in prescribing a capful of propylene glycol (Miralax), dissolved in any liquid for 15 minutes and consumed twice a day over a weekend, to clear out the retained stool. The usual maintenance of ½ capful of Miralax at night plus 5 minutes of toilet sitting using a timer in the morning and after dinner for 6 months is necessary, but not likely to be effective without a clean out first.

The next most common factor in daytime incontinence is ADHD (41%). Many aspects of having ADHD make this the case: A child with ADHD may be inattentive to the "need to go," has trouble shifting attention away from that video game, sits too briefly to defecate and gets constipated, may be taking stimulants that predispose to constipation, and is more likely to have comorbid learning disabilities or anxiety leading to stress. Optimizing management of ADHD, if present, should be part of the plan for managing incontinence.

Stress as a cause of daytime wetting is well known and even joked about by grown men when they say they were "scared s-less." But significant stress is not confined to the battlefield. A loud teacher, a new baby at home, school work that exceeds the child’s abilities, a bully at the bus stop, or having to give an oral presentation all can raise tension enough to reduce bladder capacity, increase bladder irritability, and result in daytime incontinence, particularly in children who are more sensitive as a result of having other coexisting stresses, low skills, a slow-to-warm-up temperament, or preexisting anxiety disorder.

In addition to working to alter any changeable stresses, you can teach the child relaxation techniques such as deep breathing, tightening then relaxing muscle groups, or imagining a peaceful safe place to go to in their mind. More severe stress such as from abuse (10%-15% of all children), domestic violence, marital discord (45%), or viewing violence (25%) can certainly cause incontinence and deserves to be addressed.

Parents may be angry and humiliated by the child’s wetting or embarrassed by what they have already tried to address it, including corporal punishment. The child, thinking that this is something she/he should be able to control, is often reluctant to even speak about it. Having private conversations with the child and the parents separately may be necessary to get a clear history and uncover the relevant factors. Trivial as "peeing your pants" sounds, solving daytime incontinence can be satisfying for the clinician and life changing for the child.

Dr. Howard is an 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 IMNG Medical Media. E-mail her at [email protected].

Can you remember the name of that kid who wet his pants in your second grade class? I can. Daytime wetting, now properly called daytime incontinence (wetting when awake), affects 2%-7% of children and really makes a mark, and not just on the sofa! Technically, according to DSM-IV, it is defined by two or more wetting episodes per week for 3 months in a child 5 years or older (mental age) that are not due to substances or another medical disorder.

School-aged children are painfully aware of those who are different, especially in a way that appears to be a developmental deficiency. Being called a "baby" is never a compliment to 6- to 12-year-olds. Wetting your pants is sure to be noticed and the child is certain to be labeled. But daytime wetting is not a simple matter of a developmental delay. It is most helpful to divide incontinence into problems of storage and of release. These categories also help you decide what assessments need to be done.

A child who can hold urine fine all night but wets during the day has a release problem, not a storage problem. A child with renal disease, sickle cell disease, hyperthyroidism, diabetes mellitus or diabetes insipidus, or who uses diuretics and thus creates excess dilute urine will have trouble containing her urine both night and day. A child who has an erratic spray of urine or has to grunt and strain to void has a release problem that is either structural or more likely a learned dyssynergy. The early or midpubescent girl who laughs until she wets has giggle micturition (and often also has attention-deficit/hyperactivity disorder [ADHD] underlying it that can be helped by stimulants, if indicated by other criteria). The girl who voids, wipes, stands up, and discovers wet panties has vaginal reflux. Such girls often are overweight. They can resolve the incontinence by sitting backward on the toilet to spread the legs, relaxing, and then standing over the toilet before sitting down to wipe again (and ideally losing weight). Thus both history and observation of voiding can help sort out the cause. A bladder ultrasound to check bladder capacity and postvoid residual may be needed in a few cases, but history or a diary will usually suffice.

It is helpful to normalize wetting by saying, "This is really common but really embarrassing," and assuring them that you know how to help them control it. Asking, "How hard has this been for you?" and "Is this something you want to fix?" will help you assess their motivation. All the behavioral strategies for wetting require the child’s participation to be effective.

The new epidemic I am seeing in daytime wetting I now dub Internet incontinence! Most daytime activities are not so captivating for a child as to keep the child from the socially face-saving act of heading for the bathroom on time, but electronic games can clearly do that! Some children have this priority-setting problem when playing outside with friends, but there is usually a tree handy (for boys), so it does not come to clinical attention. Cases of video game addiction in Japanese teens have included starvation as well as "voiding in place" and even required a special new kind of hospital detox program!

"But how can I get him/her to go to the bathroom?" the parents moan. Without being sarcastic, you can problem solve this situation with the parent and child together: Suggest setting a timer to go off every hour to remind the child to go to the bathroom. If the pants are dry at that time plus the child goes willingly, then they may resume their activities. If the pants are wet or the child is uncooperative, there will be a consequence. No electronics for 1 hour is a logical one, but not being able to play outside with friends would be appropriate for the "playground pee-er."

This is a good occasion to discuss the amount of electronics the child is engaged in and their effect on the child and family life. Rewards for being dry also are helpful. Once this is working, the interval between bathroom trips can be gradually increased to 2, then 3 hours.

Any child with new-onset daytime wetting should be checked for bacteriuria and more importantly stress. Twenty-five percent will have a urinary tract infection as the cause and antibiotics as the treatment – more girls than boys. Keep in mind that 20% of young children have a period of "toilet-training relapse" after age 6 years. These cases do not count in the estimate that 43% of those with daytime incontinence have a structural lesion. Lesions should be sought with a voiding cystourethrogram and ultrasound only if behavioral management is adhered to but ineffective. Spine films or magnetic resonance imaging are indicated only if there is an abnormal spine exam or motor or sensory exam of the lower extremities or anal sphincters as the nerves innervating the bladder sphincters enter the sacral cord in proximity to those. Neurologic functional reasons for daytime incontinence include maturational delay of the sacral voiding reflex, low bladder sensory awareness, poor bladder compliance, and dyssynergy between detrusor contraction and sphincter relaxation, an acquired behavior.

The more common preexisting condition for daytime incontinence, however, is constipation. A full sigmoid colon or rectal vault not only presses on the bladder, reducing its capacity, but also periodically stimulates the sacral nerves responsible for releasing urine. The child should be asked about large, hard infrequent stools, and even soiling, as this is often kept secret from the parents. The abdominal exam may not reveal this; a scan of the kidneys, ureters, and bladder may be needed. There is also a voiding dysfunction syndrome in some children under age 7 years with urinary incontinence, urinary tract infections, frequency, urgency, and constipation or encopresis in which there may be postvoid residual.

Even though the child appears to have a urine problem, treatment of constipation is the first line in care for every child with daytime incontinence and very often solves the wetting immediately. Don’t be shy in prescribing a capful of propylene glycol (Miralax), dissolved in any liquid for 15 minutes and consumed twice a day over a weekend, to clear out the retained stool. The usual maintenance of ½ capful of Miralax at night plus 5 minutes of toilet sitting using a timer in the morning and after dinner for 6 months is necessary, but not likely to be effective without a clean out first.

The next most common factor in daytime incontinence is ADHD (41%). Many aspects of having ADHD make this the case: A child with ADHD may be inattentive to the "need to go," has trouble shifting attention away from that video game, sits too briefly to defecate and gets constipated, may be taking stimulants that predispose to constipation, and is more likely to have comorbid learning disabilities or anxiety leading to stress. Optimizing management of ADHD, if present, should be part of the plan for managing incontinence.

Stress as a cause of daytime wetting is well known and even joked about by grown men when they say they were "scared s-less." But significant stress is not confined to the battlefield. A loud teacher, a new baby at home, school work that exceeds the child’s abilities, a bully at the bus stop, or having to give an oral presentation all can raise tension enough to reduce bladder capacity, increase bladder irritability, and result in daytime incontinence, particularly in children who are more sensitive as a result of having other coexisting stresses, low skills, a slow-to-warm-up temperament, or preexisting anxiety disorder.

In addition to working to alter any changeable stresses, you can teach the child relaxation techniques such as deep breathing, tightening then relaxing muscle groups, or imagining a peaceful safe place to go to in their mind. More severe stress such as from abuse (10%-15% of all children), domestic violence, marital discord (45%), or viewing violence (25%) can certainly cause incontinence and deserves to be addressed.

Parents may be angry and humiliated by the child’s wetting or embarrassed by what they have already tried to address it, including corporal punishment. The child, thinking that this is something she/he should be able to control, is often reluctant to even speak about it. Having private conversations with the child and the parents separately may be necessary to get a clear history and uncover the relevant factors. Trivial as "peeing your pants" sounds, solving daytime incontinence can be satisfying for the clinician and life changing for the child.

Dr. Howard is an 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 IMNG Medical Media. E-mail her at [email protected].

Dr. T. Berry Brazelton was recently honored by President Obama with the 2012 Presidential Citizens Medal. While the youngest pediatricians may not know Dr. Brazelton’s name, we all live with benefits from his ongoing lifetime of work increasing knowledge about young children.

Dr. Brazelton arranged his own unique training in pediatrics, psychiatry, and psychology. As one of his Fellows, I experienced his depth of understanding every day, but only learned years later that he also had analytic training. He observed the amazing capabilities of newborn infants and their impact on their parents at a time when even their ability to see and hear was not generally known. As an intern, seeing his film of a newborn turning to look into his eyes, which he has seen so many times he has to leave the room when it is shown, moved my career into developmental behavioral pediatrics. From these observations he developed the Brazelton Neonatal Assessment Scale, bringing science to the study of infant interaction and earning respect for child psychological factors in medical care that ultimately changed policies ranging from NICU noise control to parental leave – a benefit readers may have experienced personally.

Official White House Photo by Chuck Kennedy

Dr. Brazelton provided leadership to several organizations at key times, ensuring their success, from the Society for Developmental and Behavioral Pediatrics (SDBP), to the National Center for Clinical Infant Programs and Zero to Three.

As clinical professor at Harvard Medical School, he founded the Child Development Unit, a multidisciplinary training program for pediatric fellows, nurses, social workers, psychologists, and a range of short- as well as long-term learners of other disciplines, who subsequently have spread his attitudes about the value of the early years as leaders in departments of pediatrics, foundations, the American Academy of Pediatrics, SDBP, Zero to Three, etc. It was a wonderful place to be a Fellow, as the world’s experts on early childhood visited and we all sat as equals discussing the newest discoveries. The Brazelton Institute now teaches internationally.

Dr. Brazelton has a sonorous voice, a toothy smile crinkling his entire face, sparkling eyes, and expressive hands that come together to convey his joy in life and all its children in an unforgettable fashion. He was almost a Broadway star, but chose to bring his dramatic flair to inspire parents and learners. He showed his Fellows that being down to earth and having fun while teaching make it more effective. His cable TV series "What Every Baby Knows" supported an entire generation of parents in understanding their children as individuals and honoring their role. I saw mothers, who had relied on his wisdom from the show, hearing his voice in person come to tears. The Brazelton Touchpoints Center now supports families in 100 communities to ensure that all children "grow up to become adults who can cope with adversity, strengthen their communities, engage as active participants in civic life, steward our fragile planet’s limited resources, and nurture the next generation to be prepared to do the same." Without your knowing it, Dr. Brazelton may have already done that for you.

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). E-mail Dr. Howard at [email protected].

Dr. T. Berry Brazelton was recently honored by President Obama with the 2012 Presidential Citizens Medal. While the youngest pediatricians may not know Dr. Brazelton’s name, we all live with benefits from his ongoing lifetime of work increasing knowledge about young children.

Dr. Brazelton arranged his own unique training in pediatrics, psychiatry, and psychology. As one of his Fellows, I experienced his depth of understanding every day, but only learned years later that he also had analytic training. He observed the amazing capabilities of newborn infants and their impact on their parents at a time when even their ability to see and hear was not generally known. As an intern, seeing his film of a newborn turning to look into his eyes, which he has seen so many times he has to leave the room when it is shown, moved my career into developmental behavioral pediatrics. From these observations he developed the Brazelton Neonatal Assessment Scale, bringing science to the study of infant interaction and earning respect for child psychological factors in medical care that ultimately changed policies ranging from NICU noise control to parental leave – a benefit readers may have experienced personally.

Official White House Photo by Chuck Kennedy

Dr. Brazelton provided leadership to several organizations at key times, ensuring their success, from the Society for Developmental and Behavioral Pediatrics (SDBP), to the National Center for Clinical Infant Programs and Zero to Three.

As clinical professor at Harvard Medical School, he founded the Child Development Unit, a multidisciplinary training program for pediatric fellows, nurses, social workers, psychologists, and a range of short- as well as long-term learners of other disciplines, who subsequently have spread his attitudes about the value of the early years as leaders in departments of pediatrics, foundations, the American Academy of Pediatrics, SDBP, Zero to Three, etc. It was a wonderful place to be a Fellow, as the world’s experts on early childhood visited and we all sat as equals discussing the newest discoveries. The Brazelton Institute now teaches internationally.

Dr. Brazelton has a sonorous voice, a toothy smile crinkling his entire face, sparkling eyes, and expressive hands that come together to convey his joy in life and all its children in an unforgettable fashion. He was almost a Broadway star, but chose to bring his dramatic flair to inspire parents and learners. He showed his Fellows that being down to earth and having fun while teaching make it more effective. His cable TV series "What Every Baby Knows" supported an entire generation of parents in understanding their children as individuals and honoring their role. I saw mothers, who had relied on his wisdom from the show, hearing his voice in person come to tears. The Brazelton Touchpoints Center now supports families in 100 communities to ensure that all children "grow up to become adults who can cope with adversity, strengthen their communities, engage as active participants in civic life, steward our fragile planet’s limited resources, and nurture the next generation to be prepared to do the same." Without your knowing it, Dr. Brazelton may have already done that for you.

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). E-mail Dr. Howard at [email protected].

Dr. T. Berry Brazelton was recently honored by President Obama with the 2012 Presidential Citizens Medal. While the youngest pediatricians may not know Dr. Brazelton’s name, we all live with benefits from his ongoing lifetime of work increasing knowledge about young children.

Dr. Brazelton arranged his own unique training in pediatrics, psychiatry, and psychology. As one of his Fellows, I experienced his depth of understanding every day, but only learned years later that he also had analytic training. He observed the amazing capabilities of newborn infants and their impact on their parents at a time when even their ability to see and hear was not generally known. As an intern, seeing his film of a newborn turning to look into his eyes, which he has seen so many times he has to leave the room when it is shown, moved my career into developmental behavioral pediatrics. From these observations he developed the Brazelton Neonatal Assessment Scale, bringing science to the study of infant interaction and earning respect for child psychological factors in medical care that ultimately changed policies ranging from NICU noise control to parental leave – a benefit readers may have experienced personally.

Official White House Photo by Chuck Kennedy

Dr. Brazelton provided leadership to several organizations at key times, ensuring their success, from the Society for Developmental and Behavioral Pediatrics (SDBP), to the National Center for Clinical Infant Programs and Zero to Three.

As clinical professor at Harvard Medical School, he founded the Child Development Unit, a multidisciplinary training program for pediatric fellows, nurses, social workers, psychologists, and a range of short- as well as long-term learners of other disciplines, who subsequently have spread his attitudes about the value of the early years as leaders in departments of pediatrics, foundations, the American Academy of Pediatrics, SDBP, Zero to Three, etc. It was a wonderful place to be a Fellow, as the world’s experts on early childhood visited and we all sat as equals discussing the newest discoveries. The Brazelton Institute now teaches internationally.

Dr. Brazelton has a sonorous voice, a toothy smile crinkling his entire face, sparkling eyes, and expressive hands that come together to convey his joy in life and all its children in an unforgettable fashion. He was almost a Broadway star, but chose to bring his dramatic flair to inspire parents and learners. He showed his Fellows that being down to earth and having fun while teaching make it more effective. His cable TV series "What Every Baby Knows" supported an entire generation of parents in understanding their children as individuals and honoring their role. I saw mothers, who had relied on his wisdom from the show, hearing his voice in person come to tears. The Brazelton Touchpoints Center now supports families in 100 communities to ensure that all children "grow up to become adults who can cope with adversity, strengthen their communities, engage as active participants in civic life, steward our fragile planet’s limited resources, and nurture the next generation to be prepared to do the same." Without your knowing it, Dr. Brazelton may have already done that for you.

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). E-mail Dr. Howard at [email protected].

One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.

Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.

But what about the parent who is more anxious than their child’s illness warrants?

Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.

Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.

One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!

The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!

Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.

So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?

I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.

Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!

But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.

But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.

One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.

So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?

Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.

Several of the steps that allow you to successfully reassure the caller are the same as those you need to make a good assessment. I like to speak to the child himself, if he is old enough. Not only is this good medicine and reassuring to you when he says happily that he is just watching a little TV, but it also reassures the parent that you really care about what’s going on and are collecting all the relevant data.

Collecting more data is an important way to calm down an anxious parent, allow her to gather her thoughts, and also let her know that you’re taking her seriously. Her anxiety extends from fear of illness to fear that she won’t be able to get the care she thinks her child needs. Asking the parent to push around on the belly of the crying baby, time respirations, take the temperature, send a photo of the rash, or try a dose of ibuprofen and then call you back engages the parent in action that itself reduces anxiety.

As a last resort, you might ask to speak with someone (less anxious) who was there earlier when the symptoms began or who just isn’t so upset.

So, I know what you’re thinking at 3 a.m. – or at least I know what I’m thinking. How can I get off the phone as quickly as possible?

As an experienced clinician, you may know in the first second, hearing that barking cough in the background, what the problem is. But giving advice at that point often backfires because the parent thinks you are brushing him off.

Believe it or not, one of the best, most efficient ways to reassure an anxious parent is to take an exhaustive history of the illness, moment by moment. This is important because it reassures the parent that you’re taking his concerns seriously. Otherwise, he feels compelled to repeat and rephrase or raise other concerns until he is convinced that you understand. This technique has actually been measured to take only 2 minutes or so and to be faster than responding to individual questions.

After you’ve heard the story, it’s best to provide "echoing" or active listening, reflecting back the key items of content, but also to gauge the parent’s emotions. "When he coughs so hard that he vomits, it can make you worry that he might stop breathing" might be an example of wording. This does not plant new fears (he already owns all of the worst ones), but instead, if you have guessed wrong about the extent of his concern, he will reassure you!

Asking what she’s afraid might happen and also what other people are saying about the symptoms or have told her to do, can be the key to a satisfied caller. Often, there’s a grandparent in the background who is spreading worry around, suggesting folk remedies or criticizing the parent, and the call is really for a second opinion or back up for the decision the parent has already made.

The next step is to go over your differential diagnosis so that she knows that you thought about the bad stuff that’s in the back of her mind, be it appendicitis or Lyme disease. Explain your reasoning for the course of action you propose she take between now and the morning. Be sure to make a plan that includes what she should be looking for to determine whether things are getting better or worse. Reviewing the details of what she should do, even coaching her to write it down, is also a way to keep her from calling you back 45 minutes later when you finally fall back to sleep!

Finally, there sits Pandora’s Box. It’s very important to ask, "Is there anything else you are worried about right now?" when anxiety seems to be out of proportion to the symptoms she is describing. Unexplainable anxiety sometimes indicates domestic violence, suicidal ideation, or child abuse about-to-happen that could be prevented. A call about a child’s symptoms is the only way some people know to cry for help.

Always offer anxious parents the option of going to the emergency department. Some families may be afraid that you’re blocking their access or won’t approve an ED visit to their insurance. As long as they are worried about that, they will hype up their complaints to make sure that they have that opportunity.

But what to do about the fact that it is 3:15 a.m. and now you are angry? Anger not only interferes with your judgment, but is likely to keep you awake for the rest of the night. It helps me to remember that people call because they’re either scared or lacking information about child health or both.

To address gaps in knowledge, after you’ve come up with a plan, it’s reasonable to tactfully educate the parent about alternatives to ringing up the on-call doctor. The message that parents hear on our after-hours call number includes a reminder to check our practice website for answers, if it all possible, before paging us. There are instructions on the website about common illnesses, basic care, and guidelines for when to call. Introducing those supports has greatly reduced the number of calls we get at night.

Keep in mind that both the parent’s strong emotions and yours come from a dedication to taking good care of the child. And in cases in which the child isn’t the real reason for the call, they likely have another very significant problem making them raise an alarm.

Sometimes, we physicians don’t do a good job taking care of ourselves in the service process. If you have a lot of trouble being exhausted from being on call, consider negotiating a better call schedule, such as being off the next morning or simply spacing out your call nights in a different way.

Some other things that you can do to experience less distress about anxious parents in the middle the night is to look in the record, if it’s a patient from your practice, or contact their primary care doctor to find out more about the family and why they might have made a call when it didn’t seem warranted. That may or may not make you more sympathetic but will definitely make you better prepared next time you’re on call when you’re pretty likely hear from them again.

Debriefing aggravating calls with a colleague also can be helpful in several ways. Just having a chance to ventilate can relieve stress. Sometimes, a colleague will see things in the case that you didn’t. In any case, it will help prepare them for that same anxious parent the next time they are on call!

Finally, follow up with the family to find out how the illness turned out. You may even hear an apology for that 3 a.m. call or, better yet, a thank you!

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 for Frontline Medical Communications. E-mail her at [email protected].

One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.

Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.

But what about the parent who is more anxious than their child’s illness warrants?

Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.

Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.

One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!

The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!

Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.

So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?

I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.

Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!

But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.

But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.

One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.

So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?

Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.

Several of the steps that allow you to successfully reassure the caller are the same as those you need to make a good assessment. I like to speak to the child himself, if he is old enough. Not only is this good medicine and reassuring to you when he says happily that he is just watching a little TV, but it also reassures the parent that you really care about what’s going on and are collecting all the relevant data.

Collecting more data is an important way to calm down an anxious parent, allow her to gather her thoughts, and also let her know that you’re taking her seriously. Her anxiety extends from fear of illness to fear that she won’t be able to get the care she thinks her child needs. Asking the parent to push around on the belly of the crying baby, time respirations, take the temperature, send a photo of the rash, or try a dose of ibuprofen and then call you back engages the parent in action that itself reduces anxiety.

As a last resort, you might ask to speak with someone (less anxious) who was there earlier when the symptoms began or who just isn’t so upset.

So, I know what you’re thinking at 3 a.m. – or at least I know what I’m thinking. How can I get off the phone as quickly as possible?

As an experienced clinician, you may know in the first second, hearing that barking cough in the background, what the problem is. But giving advice at that point often backfires because the parent thinks you are brushing him off.

Believe it or not, one of the best, most efficient ways to reassure an anxious parent is to take an exhaustive history of the illness, moment by moment. This is important because it reassures the parent that you’re taking his concerns seriously. Otherwise, he feels compelled to repeat and rephrase or raise other concerns until he is convinced that you understand. This technique has actually been measured to take only 2 minutes or so and to be faster than responding to individual questions.

After you’ve heard the story, it’s best to provide "echoing" or active listening, reflecting back the key items of content, but also to gauge the parent’s emotions. "When he coughs so hard that he vomits, it can make you worry that he might stop breathing" might be an example of wording. This does not plant new fears (he already owns all of the worst ones), but instead, if you have guessed wrong about the extent of his concern, he will reassure you!

Asking what she’s afraid might happen and also what other people are saying about the symptoms or have told her to do, can be the key to a satisfied caller. Often, there’s a grandparent in the background who is spreading worry around, suggesting folk remedies or criticizing the parent, and the call is really for a second opinion or back up for the decision the parent has already made.

The next step is to go over your differential diagnosis so that she knows that you thought about the bad stuff that’s in the back of her mind, be it appendicitis or Lyme disease. Explain your reasoning for the course of action you propose she take between now and the morning. Be sure to make a plan that includes what she should be looking for to determine whether things are getting better or worse. Reviewing the details of what she should do, even coaching her to write it down, is also a way to keep her from calling you back 45 minutes later when you finally fall back to sleep!

Finally, there sits Pandora’s Box. It’s very important to ask, "Is there anything else you are worried about right now?" when anxiety seems to be out of proportion to the symptoms she is describing. Unexplainable anxiety sometimes indicates domestic violence, suicidal ideation, or child abuse about-to-happen that could be prevented. A call about a child’s symptoms is the only way some people know to cry for help.

Always offer anxious parents the option of going to the emergency department. Some families may be afraid that you’re blocking their access or won’t approve an ED visit to their insurance. As long as they are worried about that, they will hype up their complaints to make sure that they have that opportunity.

But what to do about the fact that it is 3:15 a.m. and now you are angry? Anger not only interferes with your judgment, but is likely to keep you awake for the rest of the night. It helps me to remember that people call because they’re either scared or lacking information about child health or both.

To address gaps in knowledge, after you’ve come up with a plan, it’s reasonable to tactfully educate the parent about alternatives to ringing up the on-call doctor. The message that parents hear on our after-hours call number includes a reminder to check our practice website for answers, if it all possible, before paging us. There are instructions on the website about common illnesses, basic care, and guidelines for when to call. Introducing those supports has greatly reduced the number of calls we get at night.

Keep in mind that both the parent’s strong emotions and yours come from a dedication to taking good care of the child. And in cases in which the child isn’t the real reason for the call, they likely have another very significant problem making them raise an alarm.

Sometimes, we physicians don’t do a good job taking care of ourselves in the service process. If you have a lot of trouble being exhausted from being on call, consider negotiating a better call schedule, such as being off the next morning or simply spacing out your call nights in a different way.

Some other things that you can do to experience less distress about anxious parents in the middle the night is to look in the record, if it’s a patient from your practice, or contact their primary care doctor to find out more about the family and why they might have made a call when it didn’t seem warranted. That may or may not make you more sympathetic but will definitely make you better prepared next time you’re on call when you’re pretty likely hear from them again.

Debriefing aggravating calls with a colleague also can be helpful in several ways. Just having a chance to ventilate can relieve stress. Sometimes, a colleague will see things in the case that you didn’t. In any case, it will help prepare them for that same anxious parent the next time they are on call!

Finally, follow up with the family to find out how the illness turned out. You may even hear an apology for that 3 a.m. call or, better yet, a thank you!

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 for Frontline Medical Communications. E-mail her at [email protected].

One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.

Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.

But what about the parent who is more anxious than their child’s illness warrants?

Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.

Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.

One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!

The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!

Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.

So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?

I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.

Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!

But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.

But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.

One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.

So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?

Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.

Several of the steps that allow you to successfully reassure the caller are the same as those you need to make a good assessment. I like to speak to the child himself, if he is old enough. Not only is this good medicine and reassuring to you when he says happily that he is just watching a little TV, but it also reassures the parent that you really care about what’s going on and are collecting all the relevant data.

Collecting more data is an important way to calm down an anxious parent, allow her to gather her thoughts, and also let her know that you’re taking her seriously. Her anxiety extends from fear of illness to fear that she won’t be able to get the care she thinks her child needs. Asking the parent to push around on the belly of the crying baby, time respirations, take the temperature, send a photo of the rash, or try a dose of ibuprofen and then call you back engages the parent in action that itself reduces anxiety.

As a last resort, you might ask to speak with someone (less anxious) who was there earlier when the symptoms began or who just isn’t so upset.

So, I know what you’re thinking at 3 a.m. – or at least I know what I’m thinking. How can I get off the phone as quickly as possible?

As an experienced clinician, you may know in the first second, hearing that barking cough in the background, what the problem is. But giving advice at that point often backfires because the parent thinks you are brushing him off.

Believe it or not, one of the best, most efficient ways to reassure an anxious parent is to take an exhaustive history of the illness, moment by moment. This is important because it reassures the parent that you’re taking his concerns seriously. Otherwise, he feels compelled to repeat and rephrase or raise other concerns until he is convinced that you understand. This technique has actually been measured to take only 2 minutes or so and to be faster than responding to individual questions.

After you’ve heard the story, it’s best to provide "echoing" or active listening, reflecting back the key items of content, but also to gauge the parent’s emotions. "When he coughs so hard that he vomits, it can make you worry that he might stop breathing" might be an example of wording. This does not plant new fears (he already owns all of the worst ones), but instead, if you have guessed wrong about the extent of his concern, he will reassure you!

Asking what she’s afraid might happen and also what other people are saying about the symptoms or have told her to do, can be the key to a satisfied caller. Often, there’s a grandparent in the background who is spreading worry around, suggesting folk remedies or criticizing the parent, and the call is really for a second opinion or back up for the decision the parent has already made.

The next step is to go over your differential diagnosis so that she knows that you thought about the bad stuff that’s in the back of her mind, be it appendicitis or Lyme disease. Explain your reasoning for the course of action you propose she take between now and the morning. Be sure to make a plan that includes what she should be looking for to determine whether things are getting better or worse. Reviewing the details of what she should do, even coaching her to write it down, is also a way to keep her from calling you back 45 minutes later when you finally fall back to sleep!

Finally, there sits Pandora’s Box. It’s very important to ask, "Is there anything else you are worried about right now?" when anxiety seems to be out of proportion to the symptoms she is describing. Unexplainable anxiety sometimes indicates domestic violence, suicidal ideation, or child abuse about-to-happen that could be prevented. A call about a child’s symptoms is the only way some people know to cry for help.

Always offer anxious parents the option of going to the emergency department. Some families may be afraid that you’re blocking their access or won’t approve an ED visit to their insurance. As long as they are worried about that, they will hype up their complaints to make sure that they have that opportunity.

But what to do about the fact that it is 3:15 a.m. and now you are angry? Anger not only interferes with your judgment, but is likely to keep you awake for the rest of the night. It helps me to remember that people call because they’re either scared or lacking information about child health or both.

To address gaps in knowledge, after you’ve come up with a plan, it’s reasonable to tactfully educate the parent about alternatives to ringing up the on-call doctor. The message that parents hear on our after-hours call number includes a reminder to check our practice website for answers, if it all possible, before paging us. There are instructions on the website about common illnesses, basic care, and guidelines for when to call. Introducing those supports has greatly reduced the number of calls we get at night.

Keep in mind that both the parent’s strong emotions and yours come from a dedication to taking good care of the child. And in cases in which the child isn’t the real reason for the call, they likely have another very significant problem making them raise an alarm.

Sometimes, we physicians don’t do a good job taking care of ourselves in the service process. If you have a lot of trouble being exhausted from being on call, consider negotiating a better call schedule, such as being off the next morning or simply spacing out your call nights in a different way.

Some other things that you can do to experience less distress about anxious parents in the middle the night is to look in the record, if it’s a patient from your practice, or contact their primary care doctor to find out more about the family and why they might have made a call when it didn’t seem warranted. That may or may not make you more sympathetic but will definitely make you better prepared next time you’re on call when you’re pretty likely hear from them again.

Debriefing aggravating calls with a colleague also can be helpful in several ways. Just having a chance to ventilate can relieve stress. Sometimes, a colleague will see things in the case that you didn’t. In any case, it will help prepare them for that same anxious parent the next time they are on call!

Finally, follow up with the family to find out how the illness turned out. You may even hear an apology for that 3 a.m. call or, better yet, a thank you!

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 for Frontline Medical Communications. E-mail her at [email protected].

One of the things I love about being a pediatrician is that I get to think about some of life’s deeper questions with the families under my care. How can we help him be kinder to his sister? Will she still love me if let her cry it out at bedtime? What can we do so that he knows the difference between right and wrong? Parents worry about these issues and are sometimes in conflict with each other, as well as with the habits they have from their own upbringing on what to do.

Fortunately, nature is on our side. Dr. Marc D. Hauser in his book "Moral Minds: How Nature Designed Our Universal Sense of Right and Wrong" (New York: HarperCollins Publishers, 2006) describes how biology determines what is experienced as right or wrong, predisposing humans to behaviors that not only promote their own survival but that of their social group as well. But broad biological forces don’t help with day-to-day child rearing decisions – or do they?

While most parents asking for our help with discipline say that the main thing they want is to "Stop him from being bad"; protecting the child from harm comes in the next breath, especially for younger children. When parents give an example of important discipline they are sure you will understand and endorse, it is most often a smack they deliver to keep the child from running into the street. This example is useful in conversations about discipline as it is actually a well-intentioned desire to teach the child life skills, personal survival being the first. The smack is effective, not because of its pain on the skin but rather because of the accompanying emotional scream of fear the parent delivers simultaneously, conveying that survival is at stake. "To teach" is the underlying origin of the word discipline, and teaching not only personal survival but also social survival should be the overarching goals.

What are some of the other life skills parents struggle to teach their charges in the ultimately short 18 years they get to do this? To wait your turn, to share, to clean up, to bathe regularly, to leave other people’s stuff alone, to tell the truth (and later to not always say it so bluntly). This reminds me of the Boy Scout law and also the ever-true quote "Everything I need to know I learned in kindergarten." How come this learning is attributed to kindergarten and not to the parents? Probably because the teaching in kindergarten is made completely clear, written on the board, reviewed every day, applied to everyone equally, and, in the best programs, made into a cheerful group game by a beloved teacher. All parents can aspire to and learn from these methods!

The best, and actually the easiest method of discipline, is establishing structure – otherwise called routines – just like kindergarten. When children experience a structure for the day – meals at the table, clean up after play, hand washing before eating, bedtimes with a book – they feel like a part of the family and derive meaning for their lives. With routines, children cease resisting even things they would prefer not to do, such as go to bed. Routines promote socialized behaviors in any environment, from palace to homeless shelter. The family is basically making clear the rules, saying, "Here is how we do it." Children are very interested in learning this and watch closely to see if this is how the grown-ups really behave. Having your actions match your words rather than being hypocritical is one of the ways having children makes us clean up our acts!

With young children, modeling the desired behavior is by far the best way to teach it. Actually, that applies at all ages and, even though ’tweens and teens will moan, they are still watching. Kindness to siblings, forgiveness for lapses, restraining anger when frustrated, pitching in to clean up, and persistence on difficult tasks are desired behaviors that are somewhat hard to describe. Of course, the opposite is also true – demonstrating angry, out-of-control behaviors has an even bigger impact, as they are often associated with high dramatic emotion that puts a special mark on them in the child’s memory. "You reap what you sow" applies well to parent modeling.

Not all desired behaviors can be taught by modeling, however. It is a slow method and also depends on a child’s interest in and ability to copy. With the drive for autonomy, children may even do the opposite of what they see done! The best way to teach a desired behavior when it is complicated or not being picked up by observation includes saying exactly and simply what is wanted – "Please pick up your jacket"– and providing immediate reinforcement of approximations of the desired behavior. Younger children learn best with concrete rewards – a sticker, a trinket, or a pat on the head with a description of what they did that was good and a happy smile. Using smaller rewards helps even stingy parents reward every time they should, and keep the child from having tantrums over huge prizes they crave but have not yet earned. Larger rewards or consequences actually have been shown to reduce a child’s sense of responsibility for a behavior, presumably as they justify their compliance as intended solely to get the prize. Gradually, praise suffices. Praise is still best when it includes a specific description of the steps accomplished – "Good job finding so many of your toys" – and including the social value – "It makes me feel proud that you are getting to be a good helper".

The next step up in reinforcement is to elicit self-praise to encourage ownership of positive acts. When a child completes his homework a parent might ask, "How do you think you did today?" In the end, one hopes that youth (and adults) are rewarded by satisfaction beyond just following the rules as they adhere to higher principles even when no one is watching.

The approach of praise and rewards sounds great, but you will quickly hear from parents, in perhaps a sarcastic tone, "But what do I do if that doesn’t work?" Especially with younger children and those who are more intense, active, or negative by temperament, consequences are also needed to help socialize. The best consequences don’t come from parents at all. Natural consequences -– from biting the breast that ends the feeding to wearing shorts and getting cold – may be better remembered when no comments are added. Hard as it is not to say, "I told you so," silence or even sympathy helps the child feel that their parent is on their side while making it clear who chose the result.

Natural consequence are not always safe (think physical survival) nor are their effects always immediately evident, however. Children may not see that they are losing friends by tattling, for example (social survival). Part of the art of discipline is to figure out appropriate planned consequences that are prompt, logically related to the misbehavior, and of the right size, smaller being better. For infants, the main consequence of significance is loss of pleasure or interest, for example being removed from mom’s lap if they pull her hair. "I won’t let you hurt me" is the message optimally also delivered verbally and with some voiced emotion. Infants as young as 9 months can have their behavior altered by use of 15 seconds of time out – a combination of physical removal and loss of adult attention. Toddlers care about this, too, but most of all they don’t like the loss of freedom if they are restrained, made to sit, or grasped and silently taken to participate in the task, which I teach as "One request, then move."

From preschool on, loss of privileges is often the consequence most meaningfully related to offenses, such as the toy goes in time out if it is used in a dangerous way. Keeping "toy time out" short conveys confidence that the child can learn to do better and gives more opportunities for practice. The brief explanation that should go along with it – "You can’t play with this bat if you swing it near the breakable dishes" – also teaches the causal connection.

Teaching social survival skills should center on education about the child’s effects on others and the need to repair mistakes. Whenever possible, children who have made a mistake can give the other child an extra turn, compensate for a broken toy with one of their own, or work to earn money to pay for it. The apologies which are essential for social survival are better learned by the adult modeling them – "I am so sorry he hurt you" – rather than forced from a still angry child. Even preschool children and definitely older ones can be involved in the process of self-assessing appropriate consequences by being asked, "What do you think should happen as a result?"

Just as for rewards, immediate consequences are better, while they can still remember what they did and connect the deed to the result. Smaller is better here, too. Parents, even overly compassionate ones, are more likely to invoke a consequence and do it consistently, if it is small. Children punished too harshly remember feeling more hurt and angry than feeling sorry for their misdeed. Smaller consequences also help a child infer self-responsibility rather than dwelling on how mean their parent is. Parents are more willing to take this advice when they are reminded that teaching survival skills is the goal, not retribution.

What is effective for modeling, rewarding, and giving consequences depends on individual child temperament, past experiences that may numb or prime their reactions, and current privileges that may make them turn up their nose at a small reward. More importantly, how effective parents are as teachers of these life skills depends on their relationship with the child. A child will not regret losing attention or approval if there is none. Showing disappointment or anger when a child misbehaves may even backfire if the child is angry at the adult and wants to hurt them as they were hurt, for example in reaction to corporal punishment.

While typically developing children of all ages also respond to disapproval from their caregivers, there are some important disadvantages to using disapproval as a teaching tool even though it comes quite naturally to parents. Children are calmer, more observant, and more likely to model after and seek to please parents who show affection, acceptance, and positive regard for them. Shaming may stop a behavior and get a child to show remorse, but it undermines the power of the relationship for all the other teaching that is needed.

Perhaps the most universally accepted moral rule parents want to teach is the Golden One – "Do unto others as you would have them do unto you." This is really the key lesson for group survival and also for the survival task of being a socially acceptable/desirable social partner like finding a mate! Providing an explanation of social impact and not just a reward or a consequence helps teach the child the social principles they need to know. Including "I messages" about how the adult feels – "It makes me feel sad and like I can’t trust you when you take things that are not yours" – is far more instructive than "I have told you not to steal things!" Negative labels such as calling a child a thief, often an echo from the parent’s own experiences as a child, print a negative label in child’s mind that they may live down to, weakens their relationship with the parent by conveying a lack of acceptance, and shuts down their ability to listen to the lesson. This can be a hard reaction to change for some parents. A better alternative is to limit "scoldings" and try to begin them with a statement about the child’s core values before giving a consequence. An example might be saying, "I know you are a really good friend to Matt and want him to have fun when he comes over, but you didn’t follow the rule about football in the house, so he will have to go home now." Rather than apologize for giving a child consequences, a parent can express positive intent, for example saying, "I know you are a good person, and I am going to teach you not to do bad things so you and others will know that, too."

Over the years as parents teach children the survival rules we call discipline, they have the additional opportunity to teach some of the skills that contribute to personal well being and a happy life. They can teach self knowledge – "You get so excited that it is hard for you to wait but..."; elicit from them new strategies for self control – "What could you do differently next time?"; and promote self-compassion – "You are good at heart and learning every day. I am sure you will do better next time."

In providing discipline for children, as those moral icons the Rolling Stones reminded us, "You can’t always get what you want, but you get what you need."

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 Elsevier. E-mail her at [email protected].

One of the things I love about being a pediatrician is that I get to think about some of life’s deeper questions with the families under my care. How can we help him be kinder to his sister? Will she still love me if let her cry it out at bedtime? What can we do so that he knows the difference between right and wrong? Parents worry about these issues and are sometimes in conflict with each other, as well as with the habits they have from their own upbringing on what to do.

Fortunately, nature is on our side. Dr. Marc D. Hauser in his book "Moral Minds: How Nature Designed Our Universal Sense of Right and Wrong" (New York: HarperCollins Publishers, 2006) describes how biology determines what is experienced as right or wrong, predisposing humans to behaviors that not only promote their own survival but that of their social group as well. But broad biological forces don’t help with day-to-day child rearing decisions – or do they?

While most parents asking for our help with discipline say that the main thing they want is to "Stop him from being bad"; protecting the child from harm comes in the next breath, especially for younger children. When parents give an example of important discipline they are sure you will understand and endorse, it is most often a smack they deliver to keep the child from running into the street. This example is useful in conversations about discipline as it is actually a well-intentioned desire to teach the child life skills, personal survival being the first. The smack is effective, not because of its pain on the skin but rather because of the accompanying emotional scream of fear the parent delivers simultaneously, conveying that survival is at stake. "To teach" is the underlying origin of the word discipline, and teaching not only personal survival but also social survival should be the overarching goals.

What are some of the other life skills parents struggle to teach their charges in the ultimately short 18 years they get to do this? To wait your turn, to share, to clean up, to bathe regularly, to leave other people’s stuff alone, to tell the truth (and later to not always say it so bluntly). This reminds me of the Boy Scout law and also the ever-true quote "Everything I need to know I learned in kindergarten." How come this learning is attributed to kindergarten and not to the parents? Probably because the teaching in kindergarten is made completely clear, written on the board, reviewed every day, applied to everyone equally, and, in the best programs, made into a cheerful group game by a beloved teacher. All parents can aspire to and learn from these methods!

The best, and actually the easiest method of discipline, is establishing structure – otherwise called routines – just like kindergarten. When children experience a structure for the day – meals at the table, clean up after play, hand washing before eating, bedtimes with a book – they feel like a part of the family and derive meaning for their lives. With routines, children cease resisting even things they would prefer not to do, such as go to bed. Routines promote socialized behaviors in any environment, from palace to homeless shelter. The family is basically making clear the rules, saying, "Here is how we do it." Children are very interested in learning this and watch closely to see if this is how the grown-ups really behave. Having your actions match your words rather than being hypocritical is one of the ways having children makes us clean up our acts!

With young children, modeling the desired behavior is by far the best way to teach it. Actually, that applies at all ages and, even though ’tweens and teens will moan, they are still watching. Kindness to siblings, forgiveness for lapses, restraining anger when frustrated, pitching in to clean up, and persistence on difficult tasks are desired behaviors that are somewhat hard to describe. Of course, the opposite is also true – demonstrating angry, out-of-control behaviors has an even bigger impact, as they are often associated with high dramatic emotion that puts a special mark on them in the child’s memory. "You reap what you sow" applies well to parent modeling.

Not all desired behaviors can be taught by modeling, however. It is a slow method and also depends on a child’s interest in and ability to copy. With the drive for autonomy, children may even do the opposite of what they see done! The best way to teach a desired behavior when it is complicated or not being picked up by observation includes saying exactly and simply what is wanted – "Please pick up your jacket"– and providing immediate reinforcement of approximations of the desired behavior. Younger children learn best with concrete rewards – a sticker, a trinket, or a pat on the head with a description of what they did that was good and a happy smile. Using smaller rewards helps even stingy parents reward every time they should, and keep the child from having tantrums over huge prizes they crave but have not yet earned. Larger rewards or consequences actually have been shown to reduce a child’s sense of responsibility for a behavior, presumably as they justify their compliance as intended solely to get the prize. Gradually, praise suffices. Praise is still best when it includes a specific description of the steps accomplished – "Good job finding so many of your toys" – and including the social value – "It makes me feel proud that you are getting to be a good helper".

The next step up in reinforcement is to elicit self-praise to encourage ownership of positive acts. When a child completes his homework a parent might ask, "How do you think you did today?" In the end, one hopes that youth (and adults) are rewarded by satisfaction beyond just following the rules as they adhere to higher principles even when no one is watching.

The approach of praise and rewards sounds great, but you will quickly hear from parents, in perhaps a sarcastic tone, "But what do I do if that doesn’t work?" Especially with younger children and those who are more intense, active, or negative by temperament, consequences are also needed to help socialize. The best consequences don’t come from parents at all. Natural consequences -– from biting the breast that ends the feeding to wearing shorts and getting cold – may be better remembered when no comments are added. Hard as it is not to say, "I told you so," silence or even sympathy helps the child feel that their parent is on their side while making it clear who chose the result.

Natural consequence are not always safe (think physical survival) nor are their effects always immediately evident, however. Children may not see that they are losing friends by tattling, for example (social survival). Part of the art of discipline is to figure out appropriate planned consequences that are prompt, logically related to the misbehavior, and of the right size, smaller being better. For infants, the main consequence of significance is loss of pleasure or interest, for example being removed from mom’s lap if they pull her hair. "I won’t let you hurt me" is the message optimally also delivered verbally and with some voiced emotion. Infants as young as 9 months can have their behavior altered by use of 15 seconds of time out – a combination of physical removal and loss of adult attention. Toddlers care about this, too, but most of all they don’t like the loss of freedom if they are restrained, made to sit, or grasped and silently taken to participate in the task, which I teach as "One request, then move."

From preschool on, loss of privileges is often the consequence most meaningfully related to offenses, such as the toy goes in time out if it is used in a dangerous way. Keeping "toy time out" short conveys confidence that the child can learn to do better and gives more opportunities for practice. The brief explanation that should go along with it – "You can’t play with this bat if you swing it near the breakable dishes" – also teaches the causal connection.

Teaching social survival skills should center on education about the child’s effects on others and the need to repair mistakes. Whenever possible, children who have made a mistake can give the other child an extra turn, compensate for a broken toy with one of their own, or work to earn money to pay for it. The apologies which are essential for social survival are better learned by the adult modeling them – "I am so sorry he hurt you" – rather than forced from a still angry child. Even preschool children and definitely older ones can be involved in the process of self-assessing appropriate consequences by being asked, "What do you think should happen as a result?"

Just as for rewards, immediate consequences are better, while they can still remember what they did and connect the deed to the result. Smaller is better here, too. Parents, even overly compassionate ones, are more likely to invoke a consequence and do it consistently, if it is small. Children punished too harshly remember feeling more hurt and angry than feeling sorry for their misdeed. Smaller consequences also help a child infer self-responsibility rather than dwelling on how mean their parent is. Parents are more willing to take this advice when they are reminded that teaching survival skills is the goal, not retribution.

What is effective for modeling, rewarding, and giving consequences depends on individual child temperament, past experiences that may numb or prime their reactions, and current privileges that may make them turn up their nose at a small reward. More importantly, how effective parents are as teachers of these life skills depends on their relationship with the child. A child will not regret losing attention or approval if there is none. Showing disappointment or anger when a child misbehaves may even backfire if the child is angry at the adult and wants to hurt them as they were hurt, for example in reaction to corporal punishment.

While typically developing children of all ages also respond to disapproval from their caregivers, there are some important disadvantages to using disapproval as a teaching tool even though it comes quite naturally to parents. Children are calmer, more observant, and more likely to model after and seek to please parents who show affection, acceptance, and positive regard for them. Shaming may stop a behavior and get a child to show remorse, but it undermines the power of the relationship for all the other teaching that is needed.

Perhaps the most universally accepted moral rule parents want to teach is the Golden One – "Do unto others as you would have them do unto you." This is really the key lesson for group survival and also for the survival task of being a socially acceptable/desirable social partner like finding a mate! Providing an explanation of social impact and not just a reward or a consequence helps teach the child the social principles they need to know. Including "I messages" about how the adult feels – "It makes me feel sad and like I can’t trust you when you take things that are not yours" – is far more instructive than "I have told you not to steal things!" Negative labels such as calling a child a thief, often an echo from the parent’s own experiences as a child, print a negative label in child’s mind that they may live down to, weakens their relationship with the parent by conveying a lack of acceptance, and shuts down their ability to listen to the lesson. This can be a hard reaction to change for some parents. A better alternative is to limit "scoldings" and try to begin them with a statement about the child’s core values before giving a consequence. An example might be saying, "I know you are a really good friend to Matt and want him to have fun when he comes over, but you didn’t follow the rule about football in the house, so he will have to go home now." Rather than apologize for giving a child consequences, a parent can express positive intent, for example saying, "I know you are a good person, and I am going to teach you not to do bad things so you and others will know that, too."

Over the years as parents teach children the survival rules we call discipline, they have the additional opportunity to teach some of the skills that contribute to personal well being and a happy life. They can teach self knowledge – "You get so excited that it is hard for you to wait but..."; elicit from them new strategies for self control – "What could you do differently next time?"; and promote self-compassion – "You are good at heart and learning every day. I am sure you will do better next time."

In providing discipline for children, as those moral icons the Rolling Stones reminded us, "You can’t always get what you want, but you get what you need."

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 Elsevier. E-mail her at [email protected].

One of the things I love about being a pediatrician is that I get to think about some of life’s deeper questions with the families under my care. How can we help him be kinder to his sister? Will she still love me if let her cry it out at bedtime? What can we do so that he knows the difference between right and wrong? Parents worry about these issues and are sometimes in conflict with each other, as well as with the habits they have from their own upbringing on what to do.

Fortunately, nature is on our side. Dr. Marc D. Hauser in his book "Moral Minds: How Nature Designed Our Universal Sense of Right and Wrong" (New York: HarperCollins Publishers, 2006) describes how biology determines what is experienced as right or wrong, predisposing humans to behaviors that not only promote their own survival but that of their social group as well. But broad biological forces don’t help with day-to-day child rearing decisions – or do they?

While most parents asking for our help with discipline say that the main thing they want is to "Stop him from being bad"; protecting the child from harm comes in the next breath, especially for younger children. When parents give an example of important discipline they are sure you will understand and endorse, it is most often a smack they deliver to keep the child from running into the street. This example is useful in conversations about discipline as it is actually a well-intentioned desire to teach the child life skills, personal survival being the first. The smack is effective, not because of its pain on the skin but rather because of the accompanying emotional scream of fear the parent delivers simultaneously, conveying that survival is at stake. "To teach" is the underlying origin of the word discipline, and teaching not only personal survival but also social survival should be the overarching goals.

What are some of the other life skills parents struggle to teach their charges in the ultimately short 18 years they get to do this? To wait your turn, to share, to clean up, to bathe regularly, to leave other people’s stuff alone, to tell the truth (and later to not always say it so bluntly). This reminds me of the Boy Scout law and also the ever-true quote "Everything I need to know I learned in kindergarten." How come this learning is attributed to kindergarten and not to the parents? Probably because the teaching in kindergarten is made completely clear, written on the board, reviewed every day, applied to everyone equally, and, in the best programs, made into a cheerful group game by a beloved teacher. All parents can aspire to and learn from these methods!

The best, and actually the easiest method of discipline, is establishing structure – otherwise called routines – just like kindergarten. When children experience a structure for the day – meals at the table, clean up after play, hand washing before eating, bedtimes with a book – they feel like a part of the family and derive meaning for their lives. With routines, children cease resisting even things they would prefer not to do, such as go to bed. Routines promote socialized behaviors in any environment, from palace to homeless shelter. The family is basically making clear the rules, saying, "Here is how we do it." Children are very interested in learning this and watch closely to see if this is how the grown-ups really behave. Having your actions match your words rather than being hypocritical is one of the ways having children makes us clean up our acts!

With young children, modeling the desired behavior is by far the best way to teach it. Actually, that applies at all ages and, even though ’tweens and teens will moan, they are still watching. Kindness to siblings, forgiveness for lapses, restraining anger when frustrated, pitching in to clean up, and persistence on difficult tasks are desired behaviors that are somewhat hard to describe. Of course, the opposite is also true – demonstrating angry, out-of-control behaviors has an even bigger impact, as they are often associated with high dramatic emotion that puts a special mark on them in the child’s memory. "You reap what you sow" applies well to parent modeling.

Not all desired behaviors can be taught by modeling, however. It is a slow method and also depends on a child’s interest in and ability to copy. With the drive for autonomy, children may even do the opposite of what they see done! The best way to teach a desired behavior when it is complicated or not being picked up by observation includes saying exactly and simply what is wanted – "Please pick up your jacket"– and providing immediate reinforcement of approximations of the desired behavior. Younger children learn best with concrete rewards – a sticker, a trinket, or a pat on the head with a description of what they did that was good and a happy smile. Using smaller rewards helps even stingy parents reward every time they should, and keep the child from having tantrums over huge prizes they crave but have not yet earned. Larger rewards or consequences actually have been shown to reduce a child’s sense of responsibility for a behavior, presumably as they justify their compliance as intended solely to get the prize. Gradually, praise suffices. Praise is still best when it includes a specific description of the steps accomplished – "Good job finding so many of your toys" – and including the social value – "It makes me feel proud that you are getting to be a good helper".

The next step up in reinforcement is to elicit self-praise to encourage ownership of positive acts. When a child completes his homework a parent might ask, "How do you think you did today?" In the end, one hopes that youth (and adults) are rewarded by satisfaction beyond just following the rules as they adhere to higher principles even when no one is watching.

The approach of praise and rewards sounds great, but you will quickly hear from parents, in perhaps a sarcastic tone, "But what do I do if that doesn’t work?" Especially with younger children and those who are more intense, active, or negative by temperament, consequences are also needed to help socialize. The best consequences don’t come from parents at all. Natural consequences -– from biting the breast that ends the feeding to wearing shorts and getting cold – may be better remembered when no comments are added. Hard as it is not to say, "I told you so," silence or even sympathy helps the child feel that their parent is on their side while making it clear who chose the result.

Natural consequence are not always safe (think physical survival) nor are their effects always immediately evident, however. Children may not see that they are losing friends by tattling, for example (social survival). Part of the art of discipline is to figure out appropriate planned consequences that are prompt, logically related to the misbehavior, and of the right size, smaller being better. For infants, the main consequence of significance is loss of pleasure or interest, for example being removed from mom’s lap if they pull her hair. "I won’t let you hurt me" is the message optimally also delivered verbally and with some voiced emotion. Infants as young as 9 months can have their behavior altered by use of 15 seconds of time out – a combination of physical removal and loss of adult attention. Toddlers care about this, too, but most of all they don’t like the loss of freedom if they are restrained, made to sit, or grasped and silently taken to participate in the task, which I teach as "One request, then move."

From preschool on, loss of privileges is often the consequence most meaningfully related to offenses, such as the toy goes in time out if it is used in a dangerous way. Keeping "toy time out" short conveys confidence that the child can learn to do better and gives more opportunities for practice. The brief explanation that should go along with it – "You can’t play with this bat if you swing it near the breakable dishes" – also teaches the causal connection.

Teaching social survival skills should center on education about the child’s effects on others and the need to repair mistakes. Whenever possible, children who have made a mistake can give the other child an extra turn, compensate for a broken toy with one of their own, or work to earn money to pay for it. The apologies which are essential for social survival are better learned by the adult modeling them – "I am so sorry he hurt you" – rather than forced from a still angry child. Even preschool children and definitely older ones can be involved in the process of self-assessing appropriate consequences by being asked, "What do you think should happen as a result?"

Just as for rewards, immediate consequences are better, while they can still remember what they did and connect the deed to the result. Smaller is better here, too. Parents, even overly compassionate ones, are more likely to invoke a consequence and do it consistently, if it is small. Children punished too harshly remember feeling more hurt and angry than feeling sorry for their misdeed. Smaller consequences also help a child infer self-responsibility rather than dwelling on how mean their parent is. Parents are more willing to take this advice when they are reminded that teaching survival skills is the goal, not retribution.

What is effective for modeling, rewarding, and giving consequences depends on individual child temperament, past experiences that may numb or prime their reactions, and current privileges that may make them turn up their nose at a small reward. More importantly, how effective parents are as teachers of these life skills depends on their relationship with the child. A child will not regret losing attention or approval if there is none. Showing disappointment or anger when a child misbehaves may even backfire if the child is angry at the adult and wants to hurt them as they were hurt, for example in reaction to corporal punishment.

While typically developing children of all ages also respond to disapproval from their caregivers, there are some important disadvantages to using disapproval as a teaching tool even though it comes quite naturally to parents. Children are calmer, more observant, and more likely to model after and seek to please parents who show affection, acceptance, and positive regard for them. Shaming may stop a behavior and get a child to show remorse, but it undermines the power of the relationship for all the other teaching that is needed.

Perhaps the most universally accepted moral rule parents want to teach is the Golden One – "Do unto others as you would have them do unto you." This is really the key lesson for group survival and also for the survival task of being a socially acceptable/desirable social partner like finding a mate! Providing an explanation of social impact and not just a reward or a consequence helps teach the child the social principles they need to know. Including "I messages" about how the adult feels – "It makes me feel sad and like I can’t trust you when you take things that are not yours" – is far more instructive than "I have told you not to steal things!" Negative labels such as calling a child a thief, often an echo from the parent’s own experiences as a child, print a negative label in child’s mind that they may live down to, weakens their relationship with the parent by conveying a lack of acceptance, and shuts down their ability to listen to the lesson. This can be a hard reaction to change for some parents. A better alternative is to limit "scoldings" and try to begin them with a statement about the child’s core values before giving a consequence. An example might be saying, "I know you are a really good friend to Matt and want him to have fun when he comes over, but you didn’t follow the rule about football in the house, so he will have to go home now." Rather than apologize for giving a child consequences, a parent can express positive intent, for example saying, "I know you are a good person, and I am going to teach you not to do bad things so you and others will know that, too."

Over the years as parents teach children the survival rules we call discipline, they have the additional opportunity to teach some of the skills that contribute to personal well being and a happy life. They can teach self knowledge – "You get so excited that it is hard for you to wait but..."; elicit from them new strategies for self control – "What could you do differently next time?"; and promote self-compassion – "You are good at heart and learning every day. I am sure you will do better next time."

In providing discipline for children, as those moral icons the Rolling Stones reminded us, "You can’t always get what you want, but you get what you need."

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 Elsevier. E-mail her at [email protected].

Has the "autism epidemic" gotten you spooked and feeling helpless?

Does seeing even one lovely, apparently normal-looking toddler in your practice become an isolated, self-absorbed, autistic preschooler break your heart and give you an extra edge of worry over every child you see?

As a primary care pediatrician, you can do a few important things to help your patients and also to assure yourself that you are doing your part (although this article is intentionally limited in scope).

The first thing to remember is that autism can be detected at a very young age via validated parent-report screening tools. Once it’s been detected, early intervention – available for free through state programs nearly everywhere, or through private services – can make a substantial difference in producing long-term outcomes of better communication, better social interaction, and the ability to be in mainstream school classes.

Use a validated screening tool such as M-CHAT (Modified Checklist for Autism in Toddlers) or CSBS DP (Communication and Symbolic Behavior Scales Developmental Profile). Both are free. The American Academy of Pediatrics recommends using a specific screen for autism twice, at 18 months and again at either 24 or 30 months on all children, whether you or the family have concerns or not. Repeated screening is needed because of the relatively common (25%-50%) occurrence of apparent regression from 18 months to 3 years in autistic children.

How can these tools detect autism more effectively than can parental concern? Screeners ask about specific examples of critical but subtle aspects of social interaction that are core features of autism, but are not things that parents typically think about. A key deficit is in autism is "joint attention," a form of social-emotional reciprocity, referring to the child’s seeking to share their interests or being interested in something shared by others; it typically develops in the second half of the first year and is consistent by 14 months. Although joint attention makes toddlers great fun as you share the excitement of seeing the world through their eyes, it is also critical to learning from the experiences of others. Like eye contact, joint attention may not be totally absent in toddlers with autism, but it is notably weaker and inconsistent.

The other two core features of autism are a qualitative impairment in communication, and restricted or repetitive behaviors. The wide range of normal language development in toddlers results in some false-positive screens for autism, which actually represent either variations in language acquisition or true delays or disorders of language development that deserve intervention but do not require the scary label of possible autism. At least two kinds of restricted behaviors – not just repeated movements like flapping – will be required in the new DSM-5, one of which can be hypo- or hypersensory reactivity. Keep in mind that many normal toddlers have funny gestures or habits that parents endorse in the screening tool (such as "unusual finger movements near his/her face") but that are actually quite common in typically developing children.

No screening tool is perfect, however, especially those based on parent report. Less-well–educated parents are more likely to misinterpret items, and – in my experience – more-anxious parents overinterpret behaviors as abnormal as they worry their way through the early years. One way to reduce overreferrals via M-CHAT is having you or another trained professional administer the M-CHAT follow-up interview, a validated algorithm for asking specific questions to refine or obtain examples of the child’s behavior related to those items contributing to the failed score. This interview can be done via a paper manual (and may require a separate visit because of the extra time required) or via an electronic decision-support system such as CHADIS (Child Health and Development Interactive System) that efficiently selects the right items for review and rescores the result.

In addition to the screen, the interview can be billed under CPT code 96110. Many states and insurers allow two 96110 codes at the same. A new scoring method called Best7 by the authors of the M-CHAT considers a failure of any two of seven critical items (numbers 2, 5, 7, 9, 14, 15, and 20). When both standard scoring (failure of two critical items [numbers 2, 7, 9, 13, 14, and 15] or three total items) and Best7 scoring are used, there are fewer missed cases but more referrals.

Use your clinical judgment, even when a screening tool is passed, to pursue evaluation for a child who does not relate or who seems not to be developing as you would expect. One tricky example is the toddler or preschooler who, as his parents proudly report, can "read." If this is a skill that the child exercises repeatedly to the exclusion of more-typical play, or if the child has other peculiarities of interaction, this "hyperlexia" may actually not be a gift, but rather a sign of autism, and it should not reassure you that all is well.

And then comes the Big Gulp: the moment when you need to tell the parents that their child has failed a screen for autism. You are better prepared for this than you might think, as this conversation requires the same skills you have used to interpret tests and x-rays in the past.

I start out reminding parents about the questionnaire, and reiterate that this screen was "done to detect any problems in development, language, or interaction (such as autism or language delays) that need to be addressed." It is only fair to let parents know that the screen was for autism, even though the "A" word is one that evokes panic that we wish we could avoid. "Autism" can be rolled in with some of the other possible reasons for a "fail" score in your discussion. It is much worse for parents to hear this word for the first time in the course of an evaluation by strangers than it would have been from you.

If you have done the M-CHAT follow-up interview, you will have their examples of the child’s concerning behaviors. If not, ask for examples – even if you are certain there is a problem – to have specific behaviors to refer to when you next recommend further evaluation. Using structured items to interact with the child yourself – such as PAFOS (Pediatric Autism Features Observation Scale) in CHADIS, or the Autism Mental Status Examination – will give you more confidence as well as data to help you convince the parents about referral. Although your own data may aid communication, primary care observations are not reliable predictors, so the lack of confirmatory observations should not deter referral.

Instead, use them to say, "Did you notice how, when I pointed to the light, Aaron did not look up or show any interest?" and then ask if the parents have noticed this and what they think is the reason. You can go on to say that the responsive behavior is "something we expect at this age. Sometimes children who are not interested in things that are pointed out to them have a problem like autism. There are good ways to teach a child these skills, but first we need to be sure if this is a problem for him."

With any bad news, I want to be sure that the family knows that I am on their side and will work with them through anything necessary that results from a referral. I like to say, "I hope I am wrong, but we need to find out" in order to leave the family essential room for hope.

No screening test is perfect, nor is any informal observation in the course of a visit – you can say this, too. Autism is a very difficult condition to explain, and asking one parent to convey the message to the other caregivers on his or her own is not ideal. I always offer to make a call or another visit to explain my concerns to the other caregivers if the parent would like this support. It is well known that referrals are more likely to be completed when family members agree that there is a significant problem, that intervention can be helpful, and that there is family support for going. Given the critical importance of the earliest intervention possible to optimize outcome, working carefully in making a referral for treatment is well worth the effort.

Whether the family initially accepts evaluation or not, ensuring a follow-up visit with you is critical. That requires a tracking system or registry for children with positive screens, which is something electronic health records do not usually do. Whether because of cost, availability of appointments, psychological denial, or lack of family agreement, a surprisingly low percentage of parents follow through on referrals, even with the current public awareness of autism. It is crucial that you see the child again within a few months to check on their status, the results of any testing, and family acceptance. If there is a different diagnosis – such as a language delay – then support the family in addressing it.

When a child screens positive, it is important to initiate a referral for intervention at the same time as referral for a more-definitive assessment, unless evaluations are readily available. The precious months spent waiting for a full evaluation can be a very valuable time of intervention to help the child progress and also to contribute "response to intervention" information that can help with diagnosis and/or school placement.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is an assistant professor of pediatrics at 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 Elsevier. E-mail her at [email protected].

Has the "autism epidemic" gotten you spooked and feeling helpless?

Does seeing even one lovely, apparently normal-looking toddler in your practice become an isolated, self-absorbed, autistic preschooler break your heart and give you an extra edge of worry over every child you see?

As a primary care pediatrician, you can do a few important things to help your patients and also to assure yourself that you are doing your part (although this article is intentionally limited in scope).

The first thing to remember is that autism can be detected at a very young age via validated parent-report screening tools. Once it’s been detected, early intervention – available for free through state programs nearly everywhere, or through private services – can make a substantial difference in producing long-term outcomes of better communication, better social interaction, and the ability to be in mainstream school classes.

Use a validated screening tool such as M-CHAT (Modified Checklist for Autism in Toddlers) or CSBS DP (Communication and Symbolic Behavior Scales Developmental Profile). Both are free. The American Academy of Pediatrics recommends using a specific screen for autism twice, at 18 months and again at either 24 or 30 months on all children, whether you or the family have concerns or not. Repeated screening is needed because of the relatively common (25%-50%) occurrence of apparent regression from 18 months to 3 years in autistic children.

How can these tools detect autism more effectively than can parental concern? Screeners ask about specific examples of critical but subtle aspects of social interaction that are core features of autism, but are not things that parents typically think about. A key deficit is in autism is "joint attention," a form of social-emotional reciprocity, referring to the child’s seeking to share their interests or being interested in something shared by others; it typically develops in the second half of the first year and is consistent by 14 months. Although joint attention makes toddlers great fun as you share the excitement of seeing the world through their eyes, it is also critical to learning from the experiences of others. Like eye contact, joint attention may not be totally absent in toddlers with autism, but it is notably weaker and inconsistent.

The other two core features of autism are a qualitative impairment in communication, and restricted or repetitive behaviors. The wide range of normal language development in toddlers results in some false-positive screens for autism, which actually represent either variations in language acquisition or true delays or disorders of language development that deserve intervention but do not require the scary label of possible autism. At least two kinds of restricted behaviors – not just repeated movements like flapping – will be required in the new DSM-5, one of which can be hypo- or hypersensory reactivity. Keep in mind that many normal toddlers have funny gestures or habits that parents endorse in the screening tool (such as "unusual finger movements near his/her face") but that are actually quite common in typically developing children.

No screening tool is perfect, however, especially those based on parent report. Less-well–educated parents are more likely to misinterpret items, and – in my experience – more-anxious parents overinterpret behaviors as abnormal as they worry their way through the early years. One way to reduce overreferrals via M-CHAT is having you or another trained professional administer the M-CHAT follow-up interview, a validated algorithm for asking specific questions to refine or obtain examples of the child’s behavior related to those items contributing to the failed score. This interview can be done via a paper manual (and may require a separate visit because of the extra time required) or via an electronic decision-support system such as CHADIS (Child Health and Development Interactive System) that efficiently selects the right items for review and rescores the result.

In addition to the screen, the interview can be billed under CPT code 96110. Many states and insurers allow two 96110 codes at the same. A new scoring method called Best7 by the authors of the M-CHAT considers a failure of any two of seven critical items (numbers 2, 5, 7, 9, 14, 15, and 20). When both standard scoring (failure of two critical items [numbers 2, 7, 9, 13, 14, and 15] or three total items) and Best7 scoring are used, there are fewer missed cases but more referrals.

Use your clinical judgment, even when a screening tool is passed, to pursue evaluation for a child who does not relate or who seems not to be developing as you would expect. One tricky example is the toddler or preschooler who, as his parents proudly report, can "read." If this is a skill that the child exercises repeatedly to the exclusion of more-typical play, or if the child has other peculiarities of interaction, this "hyperlexia" may actually not be a gift, but rather a sign of autism, and it should not reassure you that all is well.

And then comes the Big Gulp: the moment when you need to tell the parents that their child has failed a screen for autism. You are better prepared for this than you might think, as this conversation requires the same skills you have used to interpret tests and x-rays in the past.

I start out reminding parents about the questionnaire, and reiterate that this screen was "done to detect any problems in development, language, or interaction (such as autism or language delays) that need to be addressed." It is only fair to let parents know that the screen was for autism, even though the "A" word is one that evokes panic that we wish we could avoid. "Autism" can be rolled in with some of the other possible reasons for a "fail" score in your discussion. It is much worse for parents to hear this word for the first time in the course of an evaluation by strangers than it would have been from you.

If you have done the M-CHAT follow-up interview, you will have their examples of the child’s concerning behaviors. If not, ask for examples – even if you are certain there is a problem – to have specific behaviors to refer to when you next recommend further evaluation. Using structured items to interact with the child yourself – such as PAFOS (Pediatric Autism Features Observation Scale) in CHADIS, or the Autism Mental Status Examination – will give you more confidence as well as data to help you convince the parents about referral. Although your own data may aid communication, primary care observations are not reliable predictors, so the lack of confirmatory observations should not deter referral.

Instead, use them to say, "Did you notice how, when I pointed to the light, Aaron did not look up or show any interest?" and then ask if the parents have noticed this and what they think is the reason. You can go on to say that the responsive behavior is "something we expect at this age. Sometimes children who are not interested in things that are pointed out to them have a problem like autism. There are good ways to teach a child these skills, but first we need to be sure if this is a problem for him."

With any bad news, I want to be sure that the family knows that I am on their side and will work with them through anything necessary that results from a referral. I like to say, "I hope I am wrong, but we need to find out" in order to leave the family essential room for hope.

No screening test is perfect, nor is any informal observation in the course of a visit – you can say this, too. Autism is a very difficult condition to explain, and asking one parent to convey the message to the other caregivers on his or her own is not ideal. I always offer to make a call or another visit to explain my concerns to the other caregivers if the parent would like this support. It is well known that referrals are more likely to be completed when family members agree that there is a significant problem, that intervention can be helpful, and that there is family support for going. Given the critical importance of the earliest intervention possible to optimize outcome, working carefully in making a referral for treatment is well worth the effort.

Whether the family initially accepts evaluation or not, ensuring a follow-up visit with you is critical. That requires a tracking system or registry for children with positive screens, which is something electronic health records do not usually do. Whether because of cost, availability of appointments, psychological denial, or lack of family agreement, a surprisingly low percentage of parents follow through on referrals, even with the current public awareness of autism. It is crucial that you see the child again within a few months to check on their status, the results of any testing, and family acceptance. If there is a different diagnosis – such as a language delay – then support the family in addressing it.

When a child screens positive, it is important to initiate a referral for intervention at the same time as referral for a more-definitive assessment, unless evaluations are readily available. The precious months spent waiting for a full evaluation can be a very valuable time of intervention to help the child progress and also to contribute "response to intervention" information that can help with diagnosis and/or school placement.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is an assistant professor of pediatrics at 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 Elsevier. E-mail her at [email protected].

Has the "autism epidemic" gotten you spooked and feeling helpless?

Does seeing even one lovely, apparently normal-looking toddler in your practice become an isolated, self-absorbed, autistic preschooler break your heart and give you an extra edge of worry over every child you see?

As a primary care pediatrician, you can do a few important things to help your patients and also to assure yourself that you are doing your part (although this article is intentionally limited in scope).

The first thing to remember is that autism can be detected at a very young age via validated parent-report screening tools. Once it’s been detected, early intervention – available for free through state programs nearly everywhere, or through private services – can make a substantial difference in producing long-term outcomes of better communication, better social interaction, and the ability to be in mainstream school classes.

Use a validated screening tool such as M-CHAT (Modified Checklist for Autism in Toddlers) or CSBS DP (Communication and Symbolic Behavior Scales Developmental Profile). Both are free. The American Academy of Pediatrics recommends using a specific screen for autism twice, at 18 months and again at either 24 or 30 months on all children, whether you or the family have concerns or not. Repeated screening is needed because of the relatively common (25%-50%) occurrence of apparent regression from 18 months to 3 years in autistic children.

How can these tools detect autism more effectively than can parental concern? Screeners ask about specific examples of critical but subtle aspects of social interaction that are core features of autism, but are not things that parents typically think about. A key deficit is in autism is "joint attention," a form of social-emotional reciprocity, referring to the child’s seeking to share their interests or being interested in something shared by others; it typically develops in the second half of the first year and is consistent by 14 months. Although joint attention makes toddlers great fun as you share the excitement of seeing the world through their eyes, it is also critical to learning from the experiences of others. Like eye contact, joint attention may not be totally absent in toddlers with autism, but it is notably weaker and inconsistent.

The other two core features of autism are a qualitative impairment in communication, and restricted or repetitive behaviors. The wide range of normal language development in toddlers results in some false-positive screens for autism, which actually represent either variations in language acquisition or true delays or disorders of language development that deserve intervention but do not require the scary label of possible autism. At least two kinds of restricted behaviors – not just repeated movements like flapping – will be required in the new DSM-5, one of which can be hypo- or hypersensory reactivity. Keep in mind that many normal toddlers have funny gestures or habits that parents endorse in the screening tool (such as "unusual finger movements near his/her face") but that are actually quite common in typically developing children.

No screening tool is perfect, however, especially those based on parent report. Less-well–educated parents are more likely to misinterpret items, and – in my experience – more-anxious parents overinterpret behaviors as abnormal as they worry their way through the early years. One way to reduce overreferrals via M-CHAT is having you or another trained professional administer the M-CHAT follow-up interview, a validated algorithm for asking specific questions to refine or obtain examples of the child’s behavior related to those items contributing to the failed score. This interview can be done via a paper manual (and may require a separate visit because of the extra time required) or via an electronic decision-support system such as CHADIS (Child Health and Development Interactive System) that efficiently selects the right items for review and rescores the result.

In addition to the screen, the interview can be billed under CPT code 96110. Many states and insurers allow two 96110 codes at the same. A new scoring method called Best7 by the authors of the M-CHAT considers a failure of any two of seven critical items (numbers 2, 5, 7, 9, 14, 15, and 20). When both standard scoring (failure of two critical items [numbers 2, 7, 9, 13, 14, and 15] or three total items) and Best7 scoring are used, there are fewer missed cases but more referrals.

Use your clinical judgment, even when a screening tool is passed, to pursue evaluation for a child who does not relate or who seems not to be developing as you would expect. One tricky example is the toddler or preschooler who, as his parents proudly report, can "read." If this is a skill that the child exercises repeatedly to the exclusion of more-typical play, or if the child has other peculiarities of interaction, this "hyperlexia" may actually not be a gift, but rather a sign of autism, and it should not reassure you that all is well.

And then comes the Big Gulp: the moment when you need to tell the parents that their child has failed a screen for autism. You are better prepared for this than you might think, as this conversation requires the same skills you have used to interpret tests and x-rays in the past.

I start out reminding parents about the questionnaire, and reiterate that this screen was "done to detect any problems in development, language, or interaction (such as autism or language delays) that need to be addressed." It is only fair to let parents know that the screen was for autism, even though the "A" word is one that evokes panic that we wish we could avoid. "Autism" can be rolled in with some of the other possible reasons for a "fail" score in your discussion. It is much worse for parents to hear this word for the first time in the course of an evaluation by strangers than it would have been from you.

If you have done the M-CHAT follow-up interview, you will have their examples of the child’s concerning behaviors. If not, ask for examples – even if you are certain there is a problem – to have specific behaviors to refer to when you next recommend further evaluation. Using structured items to interact with the child yourself – such as PAFOS (Pediatric Autism Features Observation Scale) in CHADIS, or the Autism Mental Status Examination – will give you more confidence as well as data to help you convince the parents about referral. Although your own data may aid communication, primary care observations are not reliable predictors, so the lack of confirmatory observations should not deter referral.

Instead, use them to say, "Did you notice how, when I pointed to the light, Aaron did not look up or show any interest?" and then ask if the parents have noticed this and what they think is the reason. You can go on to say that the responsive behavior is "something we expect at this age. Sometimes children who are not interested in things that are pointed out to them have a problem like autism. There are good ways to teach a child these skills, but first we need to be sure if this is a problem for him."

With any bad news, I want to be sure that the family knows that I am on their side and will work with them through anything necessary that results from a referral. I like to say, "I hope I am wrong, but we need to find out" in order to leave the family essential room for hope.

No screening test is perfect, nor is any informal observation in the course of a visit – you can say this, too. Autism is a very difficult condition to explain, and asking one parent to convey the message to the other caregivers on his or her own is not ideal. I always offer to make a call or another visit to explain my concerns to the other caregivers if the parent would like this support. It is well known that referrals are more likely to be completed when family members agree that there is a significant problem, that intervention can be helpful, and that there is family support for going. Given the critical importance of the earliest intervention possible to optimize outcome, working carefully in making a referral for treatment is well worth the effort.

Whether the family initially accepts evaluation or not, ensuring a follow-up visit with you is critical. That requires a tracking system or registry for children with positive screens, which is something electronic health records do not usually do. Whether because of cost, availability of appointments, psychological denial, or lack of family agreement, a surprisingly low percentage of parents follow through on referrals, even with the current public awareness of autism. It is crucial that you see the child again within a few months to check on their status, the results of any testing, and family acceptance. If there is a different diagnosis – such as a language delay – then support the family in addressing it.

When a child screens positive, it is important to initiate a referral for intervention at the same time as referral for a more-definitive assessment, unless evaluations are readily available. The precious months spent waiting for a full evaluation can be a very valuable time of intervention to help the child progress and also to contribute "response to intervention" information that can help with diagnosis and/or school placement.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is an assistant professor of pediatrics at 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 Elsevier. E-mail her at [email protected].

Have you ever had a child end up in your office who had been ejected from day care? Or been in a quandary over how worried to be about bruises on a child that were said to be caused by a rough sibling?

You are not alone in facing such disturbing clinical situations. These all-too-common problems are on the rise and require a thorough look and broad differential diagnosis.

It turns out that 25%-40% of boys and 10%-28% of girls aged 2-5 years are rated by their preschool teachers as having moderate to high levels of aggression. (You may be shocked to learn that 40% of adult violent behavior started before the individual was 8 years old.) For a child older than 3 years to be aggressive enough for parents or care providers to call for help is a significant problem which, if left unaddressed, can evolve into a lifetime of dysfunction.

Age 3 is a pivotal age, as aggression is normal and even expected before then. All infants bite once they cut teeth. Kids also experiment with their mouths: You may have had the surprise of cuddling a smiling 9- to 12-month-old just to have him sink his teeth into your shoulder. And both male and female 15- to 18-month-olds will knock over a peer to get a desired toy (instrumental aggression) without a thought.

But aggression that is intended to hurt others (hostile aggression) – not just to get something – should have peaked by age 2½ years and be on the decline by age 3. That means that 3-year-olds who are regarded as aggressive have not progressed as they should have. And before trying to send these young children off to a (difficult-to-access) mental health evaluation, you are in a key position to try to figure out why this is so.

Just as warriors resort to biting only in extremis, preschool children are usually at the end of their ropes when they use aggression repeatedly. It is useful to think about the ways in which the following needs are not being met, rendering these kids so unable to cope.

• Need for assistance in regulating their state of arousal. From the beginning, children need help in managing not only their periods of upset but also their sleeping and waking. The epidemic of inadequate sleep is a great place to look for a simple cause of aggression, or factors aggravating it. In fact, hours of sleep are inversely correlated with behavior problems of all kinds in young children (and probably in older ones, too). Ask parents to keep a sleep diary for their child; it can be a real eye-opener for them as well as a clue for you.

Some environments – for example, those that are noisy (perhaps even blasting TV or videos full of stimulating images) or crowded, or those that lack a clear schedule or routine – make the management of arousal more difficult. On top of this is the direct modeling of aggression that can occur for children as young as 15 months when they watch media violence. Parents may not even realize what their child is experiencing unless they drop in unexpectedly at their child’s day care center, which I strongly recommend they do.

Not all kids are equally likely to react aggressively to overstimulating or chaotic environments, but note any kind of CNS impairment (such as autism spectrum disorders, lead poisoning, prenatal drug exposure, or even irregular temperament). These can set a child up for a less-robust ability to adapt. The most important condition to consider when a child is overly aggressive, however, is ADHD. More than 65% of children who go on to be diagnosed with oppositional defiant disorder (which often presents with early aggression) have ADHD. When symptoms of ADHD are significant, it is never too soon for a full evaluation and consideration of treatments.

• Need for frequent and nutritious meals. Inadequate frequency and perhaps poor-quality food can also set a child on edge. In this age of obesity, we may forget that kids actually need to eat every 3-4 hours, albeit with nutritious, low-sugar foods. I see kids who are shipped to day care after eating a doughnut at 5:45 a.m. who are hitting peers by 10 when they have not yet had a snack.

• Need for mastery. By age 1 year, children have a strong need for mastery which, if thwarted, can make them strike out at others. Ask about a specific incident to sort out what is bringing on the aggressive behavior. A child who lashes out mainly during "art" may be frustrated by his poor fine motor skills and the dent in his self-esteem when he can only scribble and his neighbor has drawn a tree. Kids with lags in expressive language are actually four times as likely to be aggressive and to persist in such behavior, as they do not have the ability to negotiate situations verbally to get what they want – a skill lacking even in some adults!

Some parents and some child care providers don’t let these children exercise the skills they do have – for example, by overprotecting the child, being intrusive, or failing to provide play opportunities – and anger can be the result. Sometimes, the clue is right in front of you during the office visit when a parent won’t let the child explore the room, take toys you hand her, or even answer your questions. So even though a developmental screen is definitely needed when you evaluate aggression, don’t forget to ask about opportunities for the child to try to master things. Of course, the opposite may also be a factor in aggression: A child who has few limits may be wildly out of control, with aggression the ultimate behavioral result.

• Need for positive emotional tone. Positive attention is important for children as they try to acquire self-regulation. Although playfulness may seem like a far reach for stressed families, your suggestions of ways to have fun with the child – even 10 minutes a day of one-on-one special time – can often start to reset the tone of the relationship.

Aggressive behavior sometimes develops when it is the only way children can get the attention they crave from their caregivers. That’s why first attending to the victim of aggression rather than to the perpetrator can be helpful. Teaching parents to put marks on the child’s hand for little demonstrations of positive behavior (aiming for 10 per hour with a reward for "a bunch") can also shift the interaction from reactions that reinforce bad behavior toward those that acknowledge the good.

Sometimes, the source of aggression is no surprise as you enter the exam room to see the parent smacking or screaming at the child for every little thing. Although the cause of the aggression may seem obvious, the solution may not be; such parenting was likely learned when those parents were children themselves, making the behavior extra hard to change. But just because these habits were acquired early does not mean that the parents are actually happy with them. Even among parents who believe in spanking, 85% say that they would rather not spank their children but did not know an alternative.

Rather than reprimand the parent, you can comment, "He sure seems to be a handful," but then follow up with "How is that for you?" This question alone can be an important first step to uncovering a mother who is depressed (35%-50% of mothers of children younger than age 5 years) or who experiences partner violence (3-10 million in the United States), or a father who is stressed by working long hours plus caring for small children. Problem solving with such parents about ways to take a break, to get some help, or to get out of a negative situation may be needed. Although helping them to connect their stresses with the child’s aggression can sometimes be all that is needed to get them to act, efforts to motivate them by focusing on the need to change "for the child’s sake" have been shown to be less effective than first addressing and empathizing with the parents’ own distress.

A good strategy is to first ask permission to discuss the problem of the child’s behavior. This less-judgmental approach will be more likely to get you an opening to explore their situation, consider alternatives, teach "time out," offer advice, or at least schedule a follow-up appointment that will include relevant family members. Parents who are distressed by an aggressive child won’t know that you can help unless you offer.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at [email protected].

Have you ever had a child end up in your office who had been ejected from day care? Or been in a quandary over how worried to be about bruises on a child that were said to be caused by a rough sibling?

You are not alone in facing such disturbing clinical situations. These all-too-common problems are on the rise and require a thorough look and broad differential diagnosis.

It turns out that 25%-40% of boys and 10%-28% of girls aged 2-5 years are rated by their preschool teachers as having moderate to high levels of aggression. (You may be shocked to learn that 40% of adult violent behavior started before the individual was 8 years old.) For a child older than 3 years to be aggressive enough for parents or care providers to call for help is a significant problem which, if left unaddressed, can evolve into a lifetime of dysfunction.

Age 3 is a pivotal age, as aggression is normal and even expected before then. All infants bite once they cut teeth. Kids also experiment with their mouths: You may have had the surprise of cuddling a smiling 9- to 12-month-old just to have him sink his teeth into your shoulder. And both male and female 15- to 18-month-olds will knock over a peer to get a desired toy (instrumental aggression) without a thought.

But aggression that is intended to hurt others (hostile aggression) – not just to get something – should have peaked by age 2½ years and be on the decline by age 3. That means that 3-year-olds who are regarded as aggressive have not progressed as they should have. And before trying to send these young children off to a (difficult-to-access) mental health evaluation, you are in a key position to try to figure out why this is so.

Just as warriors resort to biting only in extremis, preschool children are usually at the end of their ropes when they use aggression repeatedly. It is useful to think about the ways in which the following needs are not being met, rendering these kids so unable to cope.

• Need for assistance in regulating their state of arousal. From the beginning, children need help in managing not only their periods of upset but also their sleeping and waking. The epidemic of inadequate sleep is a great place to look for a simple cause of aggression, or factors aggravating it. In fact, hours of sleep are inversely correlated with behavior problems of all kinds in young children (and probably in older ones, too). Ask parents to keep a sleep diary for their child; it can be a real eye-opener for them as well as a clue for you.

Some environments – for example, those that are noisy (perhaps even blasting TV or videos full of stimulating images) or crowded, or those that lack a clear schedule or routine – make the management of arousal more difficult. On top of this is the direct modeling of aggression that can occur for children as young as 15 months when they watch media violence. Parents may not even realize what their child is experiencing unless they drop in unexpectedly at their child’s day care center, which I strongly recommend they do.

Not all kids are equally likely to react aggressively to overstimulating or chaotic environments, but note any kind of CNS impairment (such as autism spectrum disorders, lead poisoning, prenatal drug exposure, or even irregular temperament). These can set a child up for a less-robust ability to adapt. The most important condition to consider when a child is overly aggressive, however, is ADHD. More than 65% of children who go on to be diagnosed with oppositional defiant disorder (which often presents with early aggression) have ADHD. When symptoms of ADHD are significant, it is never too soon for a full evaluation and consideration of treatments.

• Need for frequent and nutritious meals. Inadequate frequency and perhaps poor-quality food can also set a child on edge. In this age of obesity, we may forget that kids actually need to eat every 3-4 hours, albeit with nutritious, low-sugar foods. I see kids who are shipped to day care after eating a doughnut at 5:45 a.m. who are hitting peers by 10 when they have not yet had a snack.

• Need for mastery. By age 1 year, children have a strong need for mastery which, if thwarted, can make them strike out at others. Ask about a specific incident to sort out what is bringing on the aggressive behavior. A child who lashes out mainly during "art" may be frustrated by his poor fine motor skills and the dent in his self-esteem when he can only scribble and his neighbor has drawn a tree. Kids with lags in expressive language are actually four times as likely to be aggressive and to persist in such behavior, as they do not have the ability to negotiate situations verbally to get what they want – a skill lacking even in some adults!

Some parents and some child care providers don’t let these children exercise the skills they do have – for example, by overprotecting the child, being intrusive, or failing to provide play opportunities – and anger can be the result. Sometimes, the clue is right in front of you during the office visit when a parent won’t let the child explore the room, take toys you hand her, or even answer your questions. So even though a developmental screen is definitely needed when you evaluate aggression, don’t forget to ask about opportunities for the child to try to master things. Of course, the opposite may also be a factor in aggression: A child who has few limits may be wildly out of control, with aggression the ultimate behavioral result.

• Need for positive emotional tone. Positive attention is important for children as they try to acquire self-regulation. Although playfulness may seem like a far reach for stressed families, your suggestions of ways to have fun with the child – even 10 minutes a day of one-on-one special time – can often start to reset the tone of the relationship.

Aggressive behavior sometimes develops when it is the only way children can get the attention they crave from their caregivers. That’s why first attending to the victim of aggression rather than to the perpetrator can be helpful. Teaching parents to put marks on the child’s hand for little demonstrations of positive behavior (aiming for 10 per hour with a reward for "a bunch") can also shift the interaction from reactions that reinforce bad behavior toward those that acknowledge the good.

Sometimes, the source of aggression is no surprise as you enter the exam room to see the parent smacking or screaming at the child for every little thing. Although the cause of the aggression may seem obvious, the solution may not be; such parenting was likely learned when those parents were children themselves, making the behavior extra hard to change. But just because these habits were acquired early does not mean that the parents are actually happy with them. Even among parents who believe in spanking, 85% say that they would rather not spank their children but did not know an alternative.

Rather than reprimand the parent, you can comment, "He sure seems to be a handful," but then follow up with "How is that for you?" This question alone can be an important first step to uncovering a mother who is depressed (35%-50% of mothers of children younger than age 5 years) or who experiences partner violence (3-10 million in the United States), or a father who is stressed by working long hours plus caring for small children. Problem solving with such parents about ways to take a break, to get some help, or to get out of a negative situation may be needed. Although helping them to connect their stresses with the child’s aggression can sometimes be all that is needed to get them to act, efforts to motivate them by focusing on the need to change "for the child’s sake" have been shown to be less effective than first addressing and empathizing with the parents’ own distress.

A good strategy is to first ask permission to discuss the problem of the child’s behavior. This less-judgmental approach will be more likely to get you an opening to explore their situation, consider alternatives, teach "time out," offer advice, or at least schedule a follow-up appointment that will include relevant family members. Parents who are distressed by an aggressive child won’t know that you can help unless you offer.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at [email protected].

Have you ever had a child end up in your office who had been ejected from day care? Or been in a quandary over how worried to be about bruises on a child that were said to be caused by a rough sibling?

You are not alone in facing such disturbing clinical situations. These all-too-common problems are on the rise and require a thorough look and broad differential diagnosis.

It turns out that 25%-40% of boys and 10%-28% of girls aged 2-5 years are rated by their preschool teachers as having moderate to high levels of aggression. (You may be shocked to learn that 40% of adult violent behavior started before the individual was 8 years old.) For a child older than 3 years to be aggressive enough for parents or care providers to call for help is a significant problem which, if left unaddressed, can evolve into a lifetime of dysfunction.

Age 3 is a pivotal age, as aggression is normal and even expected before then. All infants bite once they cut teeth. Kids also experiment with their mouths: You may have had the surprise of cuddling a smiling 9- to 12-month-old just to have him sink his teeth into your shoulder. And both male and female 15- to 18-month-olds will knock over a peer to get a desired toy (instrumental aggression) without a thought.

But aggression that is intended to hurt others (hostile aggression) – not just to get something – should have peaked by age 2½ years and be on the decline by age 3. That means that 3-year-olds who are regarded as aggressive have not progressed as they should have. And before trying to send these young children off to a (difficult-to-access) mental health evaluation, you are in a key position to try to figure out why this is so.

Just as warriors resort to biting only in extremis, preschool children are usually at the end of their ropes when they use aggression repeatedly. It is useful to think about the ways in which the following needs are not being met, rendering these kids so unable to cope.

• Need for assistance in regulating their state of arousal. From the beginning, children need help in managing not only their periods of upset but also their sleeping and waking. The epidemic of inadequate sleep is a great place to look for a simple cause of aggression, or factors aggravating it. In fact, hours of sleep are inversely correlated with behavior problems of all kinds in young children (and probably in older ones, too). Ask parents to keep a sleep diary for their child; it can be a real eye-opener for them as well as a clue for you.

Some environments – for example, those that are noisy (perhaps even blasting TV or videos full of stimulating images) or crowded, or those that lack a clear schedule or routine – make the management of arousal more difficult. On top of this is the direct modeling of aggression that can occur for children as young as 15 months when they watch media violence. Parents may not even realize what their child is experiencing unless they drop in unexpectedly at their child’s day care center, which I strongly recommend they do.

Not all kids are equally likely to react aggressively to overstimulating or chaotic environments, but note any kind of CNS impairment (such as autism spectrum disorders, lead poisoning, prenatal drug exposure, or even irregular temperament). These can set a child up for a less-robust ability to adapt. The most important condition to consider when a child is overly aggressive, however, is ADHD. More than 65% of children who go on to be diagnosed with oppositional defiant disorder (which often presents with early aggression) have ADHD. When symptoms of ADHD are significant, it is never too soon for a full evaluation and consideration of treatments.

• Need for frequent and nutritious meals. Inadequate frequency and perhaps poor-quality food can also set a child on edge. In this age of obesity, we may forget that kids actually need to eat every 3-4 hours, albeit with nutritious, low-sugar foods. I see kids who are shipped to day care after eating a doughnut at 5:45 a.m. who are hitting peers by 10 when they have not yet had a snack.

• Need for mastery. By age 1 year, children have a strong need for mastery which, if thwarted, can make them strike out at others. Ask about a specific incident to sort out what is bringing on the aggressive behavior. A child who lashes out mainly during "art" may be frustrated by his poor fine motor skills and the dent in his self-esteem when he can only scribble and his neighbor has drawn a tree. Kids with lags in expressive language are actually four times as likely to be aggressive and to persist in such behavior, as they do not have the ability to negotiate situations verbally to get what they want – a skill lacking even in some adults!

Some parents and some child care providers don’t let these children exercise the skills they do have – for example, by overprotecting the child, being intrusive, or failing to provide play opportunities – and anger can be the result. Sometimes, the clue is right in front of you during the office visit when a parent won’t let the child explore the room, take toys you hand her, or even answer your questions. So even though a developmental screen is definitely needed when you evaluate aggression, don’t forget to ask about opportunities for the child to try to master things. Of course, the opposite may also be a factor in aggression: A child who has few limits may be wildly out of control, with aggression the ultimate behavioral result.

• Need for positive emotional tone. Positive attention is important for children as they try to acquire self-regulation. Although playfulness may seem like a far reach for stressed families, your suggestions of ways to have fun with the child – even 10 minutes a day of one-on-one special time – can often start to reset the tone of the relationship.

Aggressive behavior sometimes develops when it is the only way children can get the attention they crave from their caregivers. That’s why first attending to the victim of aggression rather than to the perpetrator can be helpful. Teaching parents to put marks on the child’s hand for little demonstrations of positive behavior (aiming for 10 per hour with a reward for "a bunch") can also shift the interaction from reactions that reinforce bad behavior toward those that acknowledge the good.

Sometimes, the source of aggression is no surprise as you enter the exam room to see the parent smacking or screaming at the child for every little thing. Although the cause of the aggression may seem obvious, the solution may not be; such parenting was likely learned when those parents were children themselves, making the behavior extra hard to change. But just because these habits were acquired early does not mean that the parents are actually happy with them. Even among parents who believe in spanking, 85% say that they would rather not spank their children but did not know an alternative.

Rather than reprimand the parent, you can comment, "He sure seems to be a handful," but then follow up with "How is that for you?" This question alone can be an important first step to uncovering a mother who is depressed (35%-50% of mothers of children younger than age 5 years) or who experiences partner violence (3-10 million in the United States), or a father who is stressed by working long hours plus caring for small children. Problem solving with such parents about ways to take a break, to get some help, or to get out of a negative situation may be needed. Although helping them to connect their stresses with the child’s aggression can sometimes be all that is needed to get them to act, efforts to motivate them by focusing on the need to change "for the child’s sake" have been shown to be less effective than first addressing and empathizing with the parents’ own distress.

A good strategy is to first ask permission to discuss the problem of the child’s behavior. This less-judgmental approach will be more likely to get you an opening to explore their situation, consider alternatives, teach "time out," offer advice, or at least schedule a follow-up appointment that will include relevant family members. Parents who are distressed by an aggressive child won’t know that you can help unless you offer.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at [email protected].

"What can I do?" This plea to you the pediatrician makes your stomach turn upside down. "What am I supposed to do about that?" you ask yourself. You’re not there to see what is happening, and the parent isn’t either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool. The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grownups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem "All I Need to Know I Learned in Kindergarten" describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as "inclusion/exclusion," where one day they say, "Oh, you’re my best friend. Let’s go have our secret club." But the next day they say, "You’re not my friend anymore. I’ve got a new best friend. You can’t play with me." In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, "This kid called me names," parents can ask, "What kind of names?" to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a "whore" or using a racial epithet.

Don’t forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don’t have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, ‘That doesn’t look like a truck," the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring "perspective taking" (considering another’s point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher’s attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice. Generally teachers can explain the timing of a child’s troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to "keep a stiff upper lip" or "be a big soldier." A better approach is to say, "Yes, it’s tough when kids talk to you like that" or "I understand this really makes you sad and you feel like crying." It also helps when parents share a similar experience from their own childhood. For example, parents can say, "You know, when I was your age, I had an experience like this – I had a kid who was always on my case."

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see SocialStories.com or anything by Carol Gray).

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, "How was it for you when you were little? Did you ever run into anything like this?" may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example. Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child’s behavior. A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child’s behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to "pull the kid." Any school that ignorant of normal child development cannot be fixed.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her.

"What can I do?" This plea to you the pediatrician makes your stomach turn upside down. "What am I supposed to do about that?" you ask yourself. You’re not there to see what is happening, and the parent isn’t either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool. The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grownups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem "All I Need to Know I Learned in Kindergarten" describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as "inclusion/exclusion," where one day they say, "Oh, you’re my best friend. Let’s go have our secret club." But the next day they say, "You’re not my friend anymore. I’ve got a new best friend. You can’t play with me." In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, "This kid called me names," parents can ask, "What kind of names?" to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a "whore" or using a racial epithet.

Don’t forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don’t have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, ‘That doesn’t look like a truck," the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring "perspective taking" (considering another’s point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher’s attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice. Generally teachers can explain the timing of a child’s troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to "keep a stiff upper lip" or "be a big soldier." A better approach is to say, "Yes, it’s tough when kids talk to you like that" or "I understand this really makes you sad and you feel like crying." It also helps when parents share a similar experience from their own childhood. For example, parents can say, "You know, when I was your age, I had an experience like this – I had a kid who was always on my case."

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see SocialStories.com or anything by Carol Gray).

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, "How was it for you when you were little? Did you ever run into anything like this?" may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example. Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child’s behavior. A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child’s behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to "pull the kid." Any school that ignorant of normal child development cannot be fixed.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her.

"What can I do?" This plea to you the pediatrician makes your stomach turn upside down. "What am I supposed to do about that?" you ask yourself. You’re not there to see what is happening, and the parent isn’t either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool. The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grownups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem "All I Need to Know I Learned in Kindergarten" describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as "inclusion/exclusion," where one day they say, "Oh, you’re my best friend. Let’s go have our secret club." But the next day they say, "You’re not my friend anymore. I’ve got a new best friend. You can’t play with me." In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, "This kid called me names," parents can ask, "What kind of names?" to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a "whore" or using a racial epithet.

Don’t forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don’t have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, ‘That doesn’t look like a truck," the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring "perspective taking" (considering another’s point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher’s attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice. Generally teachers can explain the timing of a child’s troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to "keep a stiff upper lip" or "be a big soldier." A better approach is to say, "Yes, it’s tough when kids talk to you like that" or "I understand this really makes you sad and you feel like crying." It also helps when parents share a similar experience from their own childhood. For example, parents can say, "You know, when I was your age, I had an experience like this – I had a kid who was always on my case."

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see SocialStories.com or anything by Carol Gray).

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, "How was it for you when you were little? Did you ever run into anything like this?" may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example. Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child’s behavior. A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child’s behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to "pull the kid." Any school that ignorant of normal child development cannot be fixed.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her.

Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.

You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.

It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.

Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.

Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.

In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.

Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.

I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.

Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.

If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.

Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.

Long-term studies now show that young adults appropriately treated for ADHD with medication are somewhat more likely to experiment with illegal drugs, but less likely to become addicted to them. Your patients should be accustomed to discussions with you about potential side effects, and this is one of them. The success orientation of most college students should help when counseling them about the potential social as well as physical problems of caffeine, alcohol, and illegal substances. And don’t forget to provide collegiate athletes with a letter about their medicines to avoid problems when they are drug tested.

Prepare your patients with ADHD for a greater need to organize their academic work in college. This can be tricky for them because ADHD interferes with executive functioning. And the older you are, the more of an executive you really need to be. A college student needs to organize his own class schedule, manage homework, and figure out how much time to dedicate to studying. A student with ADHD might be a "man of the moment" and not even consider studying on Monday for an examination for a class he has only on Fridays.

Kids with ADHD are likely to have made it into college with a lot more guidance (or nagging!) from parents or teachers about organization than average.

The good news is that many colleges now offer assistance with organization and study skills for freshmen. You can do a great service by suggesting they research which schools offer these accommodations before they apply and take advantage of these accommodations when they arrive. If formal support is not available, older students can be hired to help a freshman navigate the new challenges of college.

ADHD does not often "travel alone." Learning disabilities and mood disorders are the most common comorbidities.

It is unlikely that a new learning disability will be discovered during college. Most of your patients will already know if they are a slow reader or weak in math and have been helped in earlier parts of their education. College, in many ways, is more forgiving than high school because students have more flexibility to choose classes that align with their strengths.

Students may be unaware, however, that they can request front and center seating in lecture halls or classrooms to help them stay focused as well as extended time, tutoring, and a class scribe, recorded classes, or lecture note transcripts – great resources for kids with ADHD whether they have learning disabilities or not.

Monitor your patients with ADHD for new onset or worsening of the common comorbidities of mood disorders, particularly depression, anxiety, and tic disorders. The likelihood for these conditions to emerge continues to rise throughout adolescence.

Use a standard screening tool at each visit for college-age patients, one that looks for these mood disorders and any suicidality. The stress of college pressure and loneliness is hard on any kid but, combined with the academic weaknesses and predisposition to depression found with ADHD, can be fatal. I prefer an online instrument that patients can complete before coming home from college for a break, such as the CHADIS system.

Teenagers and young adults are more honest about providing potentially negative or sensitive information about themselves to a computer compared with a paper questionnaire, and especially compared with a face-to-face conversation with a doctor. Interestingly, they are more honest and elaborate more on risk behaviors when online, even though they know their physician is going to see the information.

If you are not in a good position to manage your college-aged patients yourself, help them transition to an adult care provider proficient in the management of ADHD. Family physicians often are a better choice than internists because they care for children and are more likely to have experience treating ADHD. But make this decision only if you must, as continuing your long term relationship and support can make a big difference at this delicate transition. Besides, you then get to see them grown up and share in their success!

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. Dr. Howard disclosed that she is cocreator of CHADIS. E-mail her.

Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.

You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.

It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.

Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.

Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.

In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.

Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.

I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.

Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.

If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.

Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.

Long-term studies now show that young adults appropriately treated for ADHD with medication are somewhat more likely to experiment with illegal drugs, but less likely to become addicted to them. Your patients should be accustomed to discussions with you about potential side effects, and this is one of them. The success orientation of most college students should help when counseling them about the potential social as well as physical problems of caffeine, alcohol, and illegal substances. And don’t forget to provide collegiate athletes with a letter about their medicines to avoid problems when they are drug tested.

Prepare your patients with ADHD for a greater need to organize their academic work in college. This can be tricky for them because ADHD interferes with executive functioning. And the older you are, the more of an executive you really need to be. A college student needs to organize his own class schedule, manage homework, and figure out how much time to dedicate to studying. A student with ADHD might be a "man of the moment" and not even consider studying on Monday for an examination for a class he has only on Fridays.

Kids with ADHD are likely to have made it into college with a lot more guidance (or nagging!) from parents or teachers about organization than average.

The good news is that many colleges now offer assistance with organization and study skills for freshmen. You can do a great service by suggesting they research which schools offer these accommodations before they apply and take advantage of these accommodations when they arrive. If formal support is not available, older students can be hired to help a freshman navigate the new challenges of college.

ADHD does not often "travel alone." Learning disabilities and mood disorders are the most common comorbidities.

It is unlikely that a new learning disability will be discovered during college. Most of your patients will already know if they are a slow reader or weak in math and have been helped in earlier parts of their education. College, in many ways, is more forgiving than high school because students have more flexibility to choose classes that align with their strengths.

Students may be unaware, however, that they can request front and center seating in lecture halls or classrooms to help them stay focused as well as extended time, tutoring, and a class scribe, recorded classes, or lecture note transcripts – great resources for kids with ADHD whether they have learning disabilities or not.

Monitor your patients with ADHD for new onset or worsening of the common comorbidities of mood disorders, particularly depression, anxiety, and tic disorders. The likelihood for these conditions to emerge continues to rise throughout adolescence.

Use a standard screening tool at each visit for college-age patients, one that looks for these mood disorders and any suicidality. The stress of college pressure and loneliness is hard on any kid but, combined with the academic weaknesses and predisposition to depression found with ADHD, can be fatal. I prefer an online instrument that patients can complete before coming home from college for a break, such as the CHADIS system.

Teenagers and young adults are more honest about providing potentially negative or sensitive information about themselves to a computer compared with a paper questionnaire, and especially compared with a face-to-face conversation with a doctor. Interestingly, they are more honest and elaborate more on risk behaviors when online, even though they know their physician is going to see the information.

If you are not in a good position to manage your college-aged patients yourself, help them transition to an adult care provider proficient in the management of ADHD. Family physicians often are a better choice than internists because they care for children and are more likely to have experience treating ADHD. But make this decision only if you must, as continuing your long term relationship and support can make a big difference at this delicate transition. Besides, you then get to see them grown up and share in their success!

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. Dr. Howard disclosed that she is cocreator of CHADIS. E-mail her.

Thought that kid with ADHD with his frequent prescriptions and sassy attitude would get off your schedule when he got into college? Actually, he needs you and your advice even more now that he will be managing more on his own.

You are one of the important relationships in the patient’s life that it is usually better not to shake up – not with all the other changes happening after high school graduation. This is a scary time for him without his usual supports and scary for you as well in that you will have less contact with your patient, less direct feedback from parents and teachers, and lower overall ability to supervise (compared with your role with younger children and adolescents). All the good communication you should have developed over his childhood will now pay off as a higher level of trust is required and appropriate now that your patient is a young adult.

It is not just you who will be getting less feedback –students get less frequent feedback on their performance as well. Some might not realize that their symptoms interfered with their academic functioning until they see their grades at the end of first semester. They might think everything is great, in complete denial that their symptoms are not well controlled.

Managing medicines is tricky for them as well as for you. ADHD symptoms make it more challenging for these kids to remember to take their medication. I talk to them in advance about establishing a new routine that takes into account their varying class schedules, privacy, and medication theft concerns.

Recommend that they use a pill tray marked with days of the week and times, and fill it weekly, so they can remember which pills they have already taken or missed.

In addition, work with them to adjust their medication to their new schedules. In high school, kids with ADHD typically take a long-acting stimulant that covers 10 hours. In college, some days may start at noon and others at 7 a.m., and many run until 3 a.m. I have quite a few college kids who switch to short-acting stimulants to take advantage of greater dosing flexibility. That way, they can more effectively control when they study, eat, and sleep. Ensuring enough and regular sleep and eating is harder, but also critical to college success.

Also consider switching some college students to a medication formulation that is more difficult to snort or sell or give to other students. Forms that are more difficult to abuse include OROS controlled-release methylphenidate (Concerta, Ortho McNeil Janssen); lisdexamfetamine (Vyvanse, Shire Pharmaceuticals); atomoxetine (Strattera, Eli Lilly); extended-release guanfacine (Intuniv, Shire); and long-acting clonidine (Kapvay, Shionogi Pharma). Although OROS methylphenidate and lisdexamfetamine are first-line medicines for ADHD, these others may be useful and may keep a risk taker from getting into trouble.

I have a very frank and honest discussion with kids with ADHD before they leave for college. I tell them they have to protect their supply of medications. If someone else steals their pills or they give them away, I tell them I am not able to prescribe more. Kids take this seriously – if they do lose some of their medication, they come crawling into my office saying: "Please, you have to believe me. I lost four of them. Please let me have another prescription." I also address the very real risks for injury and death if someone for whom these medications were not intended takes them inappropriately. I tell them this is just one more of the big responsibilities of adulthood.

Help these kids with suggestions on safe and private storage of their medication. They may be sharing a bathroom and are almost certainly sharing living space in college, so they need a way to hide their stimulants or lock them up. For example, you can suggest they purchase a fake shaving cream can from a joke store, one that includes a hidden compartment on the bottom.

If you haven’t already, counsel your patients with ADHD about the enormous risks of driving without being on their medicine. The dangers are similar to those of driving while intoxicated with alcohol. That is a very sobering thought – automobile crashes are the No. 1 reason a young person dies in this country.

Interactions with alcohol and other substances that college students may use is another very real risk for patients taking stimulants for ADHD. Even excessive caffeine intake can be risky, as stimulant medication already increases the likelihood for cardiac arrhythmia.

Long-term studies now show that young adults appropriately treated for ADHD with medication are somewhat more likely to experiment with illegal drugs, but less likely to become addicted to them. Your patients should be accustomed to discussions with you about potential side effects, and this is one of them. The success orientation of most college students should help when counseling them about the potential social as well as physical problems of caffeine, alcohol, and illegal substances. And don’t forget to provide collegiate athletes with a letter about their medicines to avoid problems when they are drug tested.

Prepare your patients with ADHD for a greater need to organize their academic work in college. This can be tricky for them because ADHD interferes with executive functioning. And the older you are, the more of an executive you really need to be. A college student needs to organize his own class schedule, manage homework, and figure out how much time to dedicate to studying. A student with ADHD might be a "man of the moment" and not even consider studying on Monday for an examination for a class he has only on Fridays.

Kids with ADHD are likely to have made it into college with a lot more guidance (or nagging!) from parents or teachers about organization than average.

The good news is that many colleges now offer assistance with organization and study skills for freshmen. You can do a great service by suggesting they research which schools offer these accommodations before they apply and take advantage of these accommodations when they arrive. If formal support is not available, older students can be hired to help a freshman navigate the new challenges of college.

ADHD does not often "travel alone." Learning disabilities and mood disorders are the most common comorbidities.

It is unlikely that a new learning disability will be discovered during college. Most of your patients will already know if they are a slow reader or weak in math and have been helped in earlier parts of their education. College, in many ways, is more forgiving than high school because students have more flexibility to choose classes that align with their strengths.

Students may be unaware, however, that they can request front and center seating in lecture halls or classrooms to help them stay focused as well as extended time, tutoring, and a class scribe, recorded classes, or lecture note transcripts – great resources for kids with ADHD whether they have learning disabilities or not.

Monitor your patients with ADHD for new onset or worsening of the common comorbidities of mood disorders, particularly depression, anxiety, and tic disorders. The likelihood for these conditions to emerge continues to rise throughout adolescence.

Use a standard screening tool at each visit for college-age patients, one that looks for these mood disorders and any suicidality. The stress of college pressure and loneliness is hard on any kid but, combined with the academic weaknesses and predisposition to depression found with ADHD, can be fatal. I prefer an online instrument that patients can complete before coming home from college for a break, such as the CHADIS system.

Teenagers and young adults are more honest about providing potentially negative or sensitive information about themselves to a computer compared with a paper questionnaire, and especially compared with a face-to-face conversation with a doctor. Interestingly, they are more honest and elaborate more on risk behaviors when online, even though they know their physician is going to see the information.

If you are not in a good position to manage your college-aged patients yourself, help them transition to an adult care provider proficient in the management of ADHD. Family physicians often are a better choice than internists because they care for children and are more likely to have experience treating ADHD. But make this decision only if you must, as continuing your long term relationship and support can make a big difference at this delicate transition. Besides, you then get to see them grown up and share in their success!

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. Dr. Howard disclosed that she is cocreator of CHADIS. E-mail her.