Archive for the ‘Behavior’ category

Should children hear voices in their heads?

July 11, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Missy wrote in: “My daughter casually mentioned last night that there is a person who is mean. I asked her more about it this morning and she says this person in her head tells her to say bad things. She says it sometimes scares her. She is 5 1/2 and is very imaginative. Mental illness does run in both sides of the family. How serious should we take this? What can we do? My daughter is funny, brilliant, and the sweetest child I have ever known. What can we do to help her?”

“Hearing voices” is common in children. A study of 3780 grade-school children in The Netherlands in 2009 found that over the course of a year, 9% of children reported hearing voices in their heads. Most of them weren’t bothered by it, though about 15% of them reported that the voices were troubling or disruptive. In a later study, the same authors found that most of these children (75%) said that the voices stopped within 5 years. So these voices are not usually a problem, and typically go away on their own.

Still, since Missy’s daughter is bothered by the voices, and they’re telling her to say “bad things,” I think a little more exploring is a good idea. I’d encourage the family to use these voices as a starting point to talk about what’s troubling her daughter, and (more importantly) what she can do about it. After all, for everyone, there’s always something that’s a problem. The goal isn’t to eliminate your child’s concerns or worries, but rather to teach them how to deal with them.

I’d start by telling the child that a lot of kids hear these things, or that Mommy used to hear them, too. (If that’s true – you might have to ask grandma.) How do the voices make you feel? Can the voices really make you do anything? What can you do if you don’t want to do the thing the voices say? Help your child understand that bad thoughts happen to everyone – but she doesn’t actually have to listen to them, and that she has the power to say to the voice, “No.” (Keep in mind that little kids are very concrete thinkers, and they are used to listening and obeying “rules”, and doing what they’re told. You may have to give her explicit permission, this time, to “disobey” the voice, and not feel badly about that.)

Ask her, “What is the voice telling you to do?” The answer might help both of you learn about what kinds of things are on your child’s mind. If the voice says “Push my little sister,” you could say, “I’ll bet sometimes you feel a little mad at your sister, and that’s OK. You can think those things, and that doesn’t make you bad.”

“Why” questions can sometimes be helpful, especially as kids grow a little older. “Why do you think a voice is telling you to steal candy?” Can open up a way to talk about the kinds of conflicting feelings that everyone has. On the one hand, you want the candy, because it tastes good; on the other hand, you know it’s not good for your teeth. These are tough dilemmas, for all of us, thinking things at the same time that contradict each other. Kids can start to understand how internal conflicts make all of us feel uncomfortable.

If the voices continue bothering a child, or seem to be contributing to behavior problems, the next step would be to get a referral to a mental health professional, typically a psychologist experienced with children. Ask your child’s doctor for references in your community.

While many children hear internal voices, it’s uncommon for teens and adults to continue to hear these (most of us perceive that our “internal monologue” is actually part of our own minds, and not projected from somewhere else.) As children mature into adults, continued thoughts “from outside”, especially if they’re “command thoughts” that tell you to do something, can be a sign of more-serious trouble. Other warning flags to look for include disturbances in mood or interactions with other people, hostility or paranoia, a lack of outward emotions, or unusual sleeping habits. While “hearing voices” isn’t especially worrisome in a child, seek additional help if this happens in teens or adults, especially when accompanied by other problems.

You're sort of confusing me, so, uh, begone... or, uh, y'know, however I get rid of you guys.

Gluten and children’s health: The New Boogeyman?

July 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”

Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?

Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.

wheatFirst, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.

Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.

Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.

So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.

But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?

Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.

And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.

So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.

 

*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.

 For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.

Whining and negativity in a nine-year-old girl

June 29, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Anna wrote in:

My daughter is now 9, and I’ve noticed a steady increase in negativity in the past several months.  She has become whinier, she has an attitude (more “entitled”), etc.  The latest is whenever I don’t let her have her way she says “you’re mean”. We try to enforce manners, for example, saying thank you when we give her something, but even the thank-yous seem grudging. I have a feeling most of this is normal (I hope), but do you have any suggestions to help me modify her behavior?

I’d look at this two ways: First, is there a reason for the change, especially a reason you could address? And second, forgetting about any possible reason or whatever, what can you do about whining and negativity to change a child’s behavior?

Why do kids act like this? Sometimes, there really is specific reason. A new sibling, marital discord, medical problems, bullying in school, a friend moving away, not getting enough sleep, over-scheduling, boredom, attention-seeking… all sorts of things. I’m not sure it’s always obvious, or that it’s always possible to know *for sure* what led to a behavior change, but sometimes there really is a reason staring you in the face. Perhaps that’s worth talking about, or at least thinking about.

One of the most common reasons for negativity and whining is attention-seeking. If a child doesn’t feel like she’s getting your attention—maybe you’ve been preoccupied with work—she may develop, let’s say, “maladaptive” ways to forcing you to pay attention to her. In other words, she may become a pain in the ass not because she’s a pain in the ass, but because she’s figured out that the behavior gets what she craves: more attention. One way to “fix” this is by giving more attention, but not at times that reward the whiney and negative behavior (see this prior post, under “love,” for a method called “magic time.”)

But sometimes there really doesn’t seem to be a specific reason, or at least not one that you can easily figure out. Maybe it’s just a phase, or a “normal thing.” Even without worrying about the specific “why”, there are ways to help a child change this behavior:

#1: Don’t reward it. She’s looking for a reaction. Don’t ignore her, but don’t get into it, either. Be bland and boring and non-reactive to negativity, and it tends to go away.

#2: At the same time, do reward times when she’s not negative, or at least when she’s less negative. Make sure to not only tell her that it makes you happy to hear her say something positive, but (more importantly) do what it is she’s asking for, if she’s asking for it in a reasonably nice way. Now, sometimes you just can’t do this (“Mom, can I please have a bazooka? No.”), but other times you might be saying “No” a little too reflexively, because, I know, they never stop asking for things. Surprise them with a yes, or even better, with some happy silliness:

 

Good: Child: “I want a bubble bath!”

Mom: “No.” (Looks away, bored. Not a lot more talking and explaining and attention.)

Better: Child says “Can I have a bubble bath?”

You: “Good idea!”

Best:    Child says “Can I please have a bubble bath?”

You: “That’s a great idea! I know—why not take some shaving cream and spray it on the wall of the tub, too?”

 

You’ll also want to set a good example. Kids only sometimes, barely, pay attention to what we say. But what they really pay attention to is what we’re doing and how we act. If you’re whining and negative and complaining, don’t be surprised if your kids do that too. Your kids learn far more by watching and modeling what you’re doing than by listening to your explanations. Be gracious with your partner and all of your children, say your own thank-yous (like you mean it!), and maybe even try to work in other expressions of gratitude. Kids notice these things.

Don’t stay mad. This is a tough one—but children, they don’t think like we do. You might still be steaming over those dirty looks at dinner (It’s tortellini for God’s sake! Eat it!), but 20 minutes later your child is over that and thinking about other things. Giving her grief, then, isn’t going to help.

Use humor, too. I know it can be hard, but next time your child tells you you’re mean, make a bear face and say “I’m going to eat you!” and chase her around the house. Mmm, tasty child!

Another idea: talk with a child about what would work best. Not when she’s all upset and whiney, but at another time, bring it up. “Sweetie, you seem to get so mad sometimes, is there something I can do to help keep you happy?” You might just learn something.

Every age brings its challenges—it’s not just terrible twos, but terrible threes and nines and (OMG!) sixteens. Though chasing your teenager around pretending to eat her might not be the best specific idea for that age, the basic principles are the same. Look for causes, reward what you want to encourage, and ignore what you want to discourage. Use humor, and try to solve problems as a family. Meanwhile, remember to forgive. You have bad days too. You’ll make it through, together.

Hey! Some of the best—heck, probably all of the best—ideas I give parents come from you guys. What other advice do you have for Anna? What did I say that was stupid and off-base? Add a comment! You’ll be glad you did! Probably!

Evaluating children for ADHD: Getting started

April 28, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

We frequently get this call at the office, something like this: “Brian’s teacher says he isn’t paying attention in class. The school wants us to get forms from his doctor to fill out to see if he has ADHD. Do I get those forms from you?”

I honestly don’t know how most pediatricians handle these calls, but I’ll tell you what I think parents faced with this situation ought to do.

I think it’s a mistake to assume children who aren’t doing well in school or aren’t paying attention in class should immediately be tested for ADHD. I can’t think of a single other medical symptom that’s evaluated like that—to start with one symptom, and immediately do one specific test to diagnose one specific diagnosis, over the phone, with no additional information or a physical exam or any consideration that there could be more than one possible diagnosis.

In medicine, what we’re supposed to do is start with a complaint or a symptom, get more information from a history and physical exam, and then develop what’s called a “differential diagnosis.” That’s a list of possibilities. Could be X, could be Y, could be Z. Then, if necessary, we use tests to narrow down the list, and then talk about treatment options for the diagnosis that’s either the most likely, or the most dangerous, or both. Let me give you an example:

Someone comes to see me with a pain in their foot. I don’t immediately assume it’s a broken toe and do an x-ray—I first ask when and how it happened. Maybe it started to hurt after you stepped on a bee, maybe it began after you swam in the Amazon river, maybe it began after you got a new pair of shoes. I then examine the foot. Maybe there’s a splinter or a swollen joint. Or maybe a piranha bite. I don’t know until I’ve asked the questions and done my exam. Only after that part do I consider whether I need an x-ray, or a blood test, or an Acme Piranha Repair Kit.

Yet, when kids aren’t paying attention in class, I often get calls to just do the ADHD testing. What if Junior isn’t paying attention because he’s not getting enough sleep? Or he has a hearing problem? Or a learning disability, or depression, or substance abuse? What if he’s being bullied, or has a vision deficit, or hypothyroidism? What if he doesn’t understand English well? What if his allergy medicine is making him dopey?

If the only thing we do is test for ADHD, we won’t even consider the possibility that something else might be going on. That’s a shame, and a disservice to the child and family.

Don’t start with testing. Start with a broad medical evaluation: a visit to the doctor for a complete history and physical. Then we’ll decide what ought to be done next.

Regular bedtimes improve behavior in kids

October 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

A British study published this month in Pediatrics confirmed what Grandmas have been saying: regular bedtimes can help children behave.

Researchers followed a cohort of 10,230 children born in 2000-2002, performing structured interviews at home visits by study nurses every few years through age 7. They asked about bedtime routines—what time the children went to bed, and whether that was a fairly regular time, or whether the time varied on different days. Validated questionnaires were also administered to help determine if behavioral problems were present, including questions about conduct problems, emotional difficulties, and trouble with peer relationships.

It turns out that the exact bedtime, itself, didn’t matter very much. Earlier bedtimes had a very mild and inconsistent effect of overall behavior. However, what did matter was how consistent the bedtimes were. More consistency across the years of the interviews was correlated with better behavior, and there was even a dose effect. The more years of irregular bedtimes, the worse the behavior seemed to be.

Now, there may be some reverse causality here—perhaps the ill-behaved children ended up with irregular bedtimes because their parents couldn’t get them to bed, instead of the other way around. But another observation from this study strengthens the case for a causal relationship: over time, if bedtimes become more regular, behavior does improve.

Early to bed, early to rise makes a man healthy wealthy and wise. But if you want a well-behaved child, it may be more important to have a regular bedtime than an early bedtime.

Score another one for Grandma!

When can kids walk themselves to school?

August 14, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

It’s back-to-school time! Now that your kids are a year older, is this the right time for them to walk themselves to school?

The highest risk group for pedestrian versus vehicle accidents is in the 5-9 year age group, with boys having far more accidents than girls. Most accidents occur in the late afternoon, probably because of reduced light and longer shadows, and the most common scenario is an accident occurring mid-block, when a child darts out from between parked cars.

Children themselves are at increased risk for several reasons:

  • They’re small and not as easily seen.
  • They’re not very good at judging the distance and speed of oncoming vehicles.
  • They assume if they can see the car, the car can see them.

There’s no accepted, national recommendation for kids on the best age to allow independent walking—it depends on the setting, the kind of neighborhood, the length of the walk, obstacles and intersections on the way, and the skills, maturity, and reliability of the child.

Even though there may be increased risks, encouraging your child to walk once it’s safe can be a great opportunity to encourage independence and self-confidence.

There are good ways to improve your child’s pedestrian skills, whether or not you encourage completely independent walking. Always model good skills—don’t just say that you have to look both ways, do it. And speak out loud what you’re seeing. It’s not just turning your head and then walking—say “I see that red car on the next block, it’s moving very slow,” or “I see that big truck, those can’t stop quickly, so even though it’s far away let’s give it time to pass,” or “I see that guy in the car talking on his phone. Since he’s on his phone, he’s not paying any attention to us. We better let him pass.”

Another idea: there’s a trend towards using what are called “walking buses”, where groups of neighborhood kids led or followed by just a few parents travel in a pack. That increases safety by increasing visibility, and also allows kids to learn from each other—if they’re paying attention during the walk.

You know your kids best, and you’re in the best position to judge if your own child is ready for independent walking. Consider a few trial runs, maybe with you tagging behind a few blocks—or let your children lead you to school, rather than the other way around, checking on traffic themselves. They may prove to you that they’re ready to do it themselves. After all, that’s the entire purpose of parenting, right?

Exercise: A simple treatment for ADHD

May 30, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Many years ago, I worked as a counselor at the city camp in North Miami Beach, Florida. Camp “No Mi Be” was attended by what seemed to be a countless number of very active, very inquisitive, and pretty-much-unstoppable 10 year old boys.

We learned quickly that the best way to start the day was with running. Run, run, run. We’d make the kids run back and forth to the fence, or run around the building, or whatever we could come up with. We’d challenge them to race us—it turned out that 16 year old legs, even on a non-athletic type like me, were long enough to beat any 10 year old. And it turned out that 10 year old boys, having lost races to their counselor 4 weeks in a row, would be more than happy to try again the next day.

Good times.

On those unfortunate rainy days, we’d run ‘em anyway. But on really really rainy days with lightning and hail, the wimp camp director would make us keep our monsters indoors all day. Those days were called “nightmares.” We counselors would end up hiding under desks.

So: a 2012 study looked at 20 kids with ADHD and 20 matched controls to see how they did on tests of attention and cognitive functioning after a twenty minute period of exercise, versus after a twenty minute period of sitting around. Surprise—both groups performed better on arithmetic and reading after exercise. The ADHD kids also showed improvements in their ability to regulate their behavior, with improved self-control after exercise.

Not a huge study—but it confirms what experienced teachers and 16 year old camp counselors know. Kids need exercise to settle their minds and get to work.

The AAP has weighed in on this, too. Recess at school is crucial and necessary, and it should be part of every school curriculum. Recess should not be withheld as a punishment for misbehavior or poor grades.

Kids of all ages, whether they have ADHD or not, need time for active play. I don’t think anyone is saying that exercise can “cure” ADHD, but it does seem to be one simple, safe intervention that ought to be part of every child’s day. Though I’m not sure it would be fair to expect the teachers to run back and forth to the fence, too….