Case One
A young mother came to see the family therapist. She and her husband, an executive in the computer industry, have three children: ages 2,7,8. Their major problem was their oldest son. He had become difficult since age 2 ½. He had recently been diagnosed with ADHD and medication had been prescribed. The son seemed to have difficulty with everything: sports, schools, and friendships. His teachers say that he is a bright child yet his grades do not confirm this. The child is active in Scouts and he also takes piano lessons. The child complains about having to do both, though. He has few friends and is seldom invited to functions with children his own age.  The parents are quite concerned about their oldest child.

Question:
Discuss possible causes for the son’s behavior. Does he have ADHD? What would you suggest to the parents?

  Notes on Case One
When children become difficult at a young age such as 2 1/2 and when that child has not been difficult before that age, we look first to see what might have changed for the child. Has the environment changed? Has the diet or activity level changed? Some young children have a low tolerance for change (review the chapter on temperament) and change can disrupt their lives.

The first step would be to have the parents keep a detailed behavioral log for two weeks to determine what specific behaviors are problematic and what is happening when the behavior occurs.

One possible explanation is allergies. A pediatric allergist can test potential allergens, which might include animals, new carpet inhalants, or food additives. Sometimes young children can be allergic to common foods and their reactions can include behavioral problems.

Sensory integration disorder is another possibility. SI is a disorder that frequently appears between ages two and three, the ages at which a child begins to socialize in the wider world. In this disorder, a child has difficulty processing all of the sensory input that we normally receive. They either overreact or underreact. The symptoms look similar to ADHD. SI is treatable by occupational therapists that use special exercises to help the child overcome the deficits. Occupational therapists can also suggest activities, such as karate or swimming, which might be better for the son since these activities are more methodical and rhythmic and occur in more controlled environments.

The son might have ADHD but evaluation by a pediatric psychologist is necessary for that diagnosis. Family pediatricians may not have the specialized training needed for diagnosis. There should be a concern about children becoming reliant on medication. We do not have long-term studies on the effects of that medication.

There are many potential reasons for the difficult behavior. It is important to thoroughly evaluate the situation and not make quick determinations as to the cause and the treatment.

Case Two
The family in this case has two children. The youngest is a three-year-old girl. The parents are concerned because they cannot tell whether or not she enjoys her preschool. The teacher is also unable to say that the young girl enjoys the school. The child goes to school two days a week, for 2.5 hours each day. There are 30 children in the class although they are broken into smaller groups for special activities. The young girl has trouble making the shift to the smaller groups and will often cling to her teacher.

The first month at the school, the young girl did not speak at all. At school she is often anxious and cries. At home she is a happy and contented child who chatters about everything. She has occasional temper tantrums but is generally well behaved and obedient. She is a sensitive child, though, and is sometimes shy around even relatives that she knows well. She has always been this shy, unlike her brother who is happy-go-lucky and can be a challenge. It is puzzling to the parents why social situations can make a child who is usually so happy so anxious. They don’t want her to suffer from the social anxiety that so many family members endure. There have been some medical emergencies in the family this year and the parents are concerned that these have deeply affected the child.

  Question:
Discuss what might be going on with the child. Suggest some things that might ease the situation.

  Notes on Case Two:
It is possible the child may be reacting to the medical emergencies but there seems to be some evidence that the child’s temperament is also a contributing factor. It is even possible that there is a genetic basis for the child’s shyness. The major problem, however, is likely the preschool situation.

There are very few three year olds who do well in a class of 30 children. A child who is normally shy would be even more likely to have adjustment problems. The National Association for the Education of Young Children recommends groups of no larger than 14-16 for three year olds.  There should also be 2 adults at all times with children this age since things can happen very quickly and children of that age need constant supervision. In large groups, two things can happen: one, the bossy children take over and run the group or two, the adults run the show and direct every move the children make. Neither alternative is likely to be work well for the young girl. Thus a situation with smaller groups is likely to be better for this child.

According to research, about one in ten children are quite shy by age two but 9 out of 10 of them outgrow it to some degree, if adults nurture them. Very shy children such as this child may need to wait until later ages to start preschool so the young girl may do better in a group environment if she is a year older. For now, she might do better in smaller playgroups so she learns some social skills. Very often, children’s play is teaching them the very skills they need for school.

The parents need to remember not to compare the development of their two children. They need to not form expectations that the young girl will repeat her brother’s development. Each child develops at his or her own pace which does not mean anything is wrong if the pace is slower than that of an older sibling.

  Case Three
In this case, a family with three girls is concerned about their seven year old. She was good sleeper until four months ago when she began to wake up many time during the night and she has recently begun getting up when she wakes She is afraid that burglars may be in the house. At other times, she just wakes up and cannot get back to sleep.

The family life is stable with no change lately. Bedtime and bedtime routines are consistent and the child is not allowed to have caffeine (chocolate, soda, etc.) at night. The family lives in a very safe neighborhood.

When the child wakes and comes into the parents’ bedroom, they will sometimes let her sleep on the floor near their bed. On occasion, they stay with her in her room for a short time but that doesn’t often take care of the problem. Some nights she is too scared to calm down even if one of the parents sleeps with her.

Question:
Discuss reasons why the child might be having trouble sleeping. Suggest some ways to deal with the situation.

Notes on Case Three:
The age seven can be a difficult time. Children are often undergoing growth spurts and they are between two cognitive stages. The first hormones of puberty begin to show up at this age and it can take some time to adjust to those. (It doesn’t mean that a 7 year old is in full puberty but rather the process of puberty is along one).

The fears probably began with a bad dream, which the child doesn’t remember. One way to begin to deal with the fears is to acknowledge that they are real. Walk through the house during the daytime with the child and point out where all of the noises come from. (loose shutters, etc.)

She will sleep better if she gets plenty of exercise during the day and eats some food with tryptophan shortly before bedtime. Tryoptophan is a natural substance that helps with sleep. Warm milk, turkey or bananas are good sources of tryptophan.

Have her day her prayers and give her some religious talisman to hang over her bed. These can be comforting. Native American dream catchers are wonderful symbols.

When she wake, which will likely continue for some time, take her back to her room. Help her think about pleasant things. Remembering pleasant things can help east the anxiety and allow her to drift to sleep. Talk to her in soft monotones. Get her to do some slow deep breathing and muscle relaxation.  After a few times, she should learn to put herself back to sleep.

White noise machines can block out the house noises or soft music may help.

As a last resort, having one of her sisters sleep with her for a few days may help.