Manual of Ambulatory Pediatrics – Common Childrearing Concerns

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Manual of Ambulatory Pediatrics 2010
Common Childrearing Concerns 

TEMPER TANTRUMS

Temper tantrums are part of the development process of learning to cope with frus- tration and gain self-control. Temper tantrums occur at one time or another in 70%–75% of children ages 18 months to 5 years.

Five sequential stages in the development of self-control are identified:

  • Passive acceptance: bewilderment and noncompliance
  • Physical aggression: biting, hitting, throwing objects, running, stamping feet
  • Verbal aggression: screaming, using “no,” name calling, making demands, using expletives
  • Socially acceptable behavior: bargaining, accepting alternative means or goals
  • Cooperation: compromising own wishes and maintaining self-control

These stages may overlap, but they resolve quickly in normally developing children.

I.   Manifestations of frustration

  1. Infant
    1. Uncontrolled crying can be caused by baby’s inability to stop once he or she has
    2. Requires quiet soothing and rocking to let baby know there is comfort
    3. If such crying spells occur frequently, physical and environmental factors need
  2. Toddler
    1. Still completely ego-centered: Own needs and wishes come first
    2. Does not tolerate fatigue, hunger, pain, overstimulation well
    3. Schedule, physical condition, nutrition, and family patterns of behavior should be
    4. Best to head off temper tantrums by carefully noting precipitating events and trying to avoid them
  1. Having to make choices can be frustrating to a toddler. A definite schedule and decisive tone of voice (“Now it is time to ” “Now it is time for bed.”) can help toddler accept the rules and standards of the world.
  1. Preschool child
    1. Verbal aggression best ignored
    2. Adults are excellent role Parents should express frustration in positive ways.
    3. A 4-year-old realizes he or she can get attention by using forbidden words.
      1. If the child is getting enough attention and having success in daily routine, this language will soon
      2. Playing word games with child and listening to his or her stories seem to be the best ways to handle this
    4. Preschoolers are learning socially acceptable ways of handling frustration.
      1. Language skills should now be sufficient for child to state wishes and
      2. Child is learning to
    5. A 4-year-old is usually still working on these skills and may still occasionally lose control and have a temper An adult should help him or her develop positive ways of handling frustration.
    6. By age 5, the child has become an expert in Girls learn this skill earlier than boys; boys need more supervision and male role models to help them control their behavior through words rather than aggression.
    7. Learning self-control enhances self-esteem; punishment control only lessens child’s feeling of being able to control
  2. School-age child
    1. If uncontrolled outbursts of frustration persist at this age, referral to appropriate professionals is
    2. School, family, and environmental pressures must be evaluated before new skills in behavior control can be
    3. Frequent outbursts at this age may be suggestive of behavioral prob- lems, depression, or secondary to undiagnosed learning
    4. Child’s ability to control own behavior is seen in his or her success with peers and teachers, in school and at
    5. School-age child has come a long way since toddlerhood; with care- givers providing good examples and guidance, child has learned to stand up for what he or she thinks is right and yet is willing to coop- erate and bargain when

II.   Caregivers’ responsibilities

  1. Appreciate that they are role models with respect to behavior patterns for coping with anger and
  2. Demonstrate processes of bargaining, accommodation, compromise, and cooperation.

 

  1. Review the successes or problems the child is encountering with each developmental
  2. Understand the child’s individual temperament and let a fiery-tempered child know that he or she must work harder than others to build behavior control.
  3. Respect the child’s need to protect own self-esteem and growing need for independence.
  4. Identify precipitating events that lead to loss of self-control, and head them
  5. Create a family environment in which all members are expected to respect and help one
  6. Help the child develop positive ways of expressing anger and frustration to experience the satisfaction of learning to control
    1. Set up time-out periods or a thinking bench to be used when child’s behavior is
    2. Watch for and praise successful attempts at self-control.
    3. Help child develop a vocabulary to express feelings, and talk about one’s own feelings so that the child will learn how adults handle their
    4. Help child learn songs and poems to use to relieve anger and frustration.
    5. Provide child with plenty of opportunity for physical
    6. Make available a caring adult with whom the child can share
    7. Understand that parents’ own emotional states may be reflected in child’s

III.   Tips for handling temper tantrums

  1. Infant: Hold closely, rock, play music,
  2. Toddler
    1. Pick up, hold under caregiver’s arm (child may be frightened by loss of control), keep calm,
    2. Do not reason or
  3. Preschooler
    1. Do not allow child to hurt self or others; hold under caregiver’s arm if
    2. Walk out of room if
    3. Do not try to reason or
    4. Do not take the episode too Respond with a casual state- ment, such as, “Oops, see if you can’t hold on to your temper” or “Now that you are 4, you don’t need to do that anymore; tell me why you are angry.”
    5. Praise child for getting behavior under
    6. Do not use threats or
  4. In public
    1. Remove child from scene; walk with child outside until he or she calms
    2. Take child home if

 

 

  1. Help child practice how to act in public and set limits he or she knows about before going
  2. Carefully study child’s world to make sure such episodes are not his or her only way of getting
  1. Refer to limit-setting

IV.   Risk factors

  1. Children who are too quiet, too good, and too shy: Their behavior may be controlled by low self-esteem or fear of
  2. Sudden burst of destructive acts toward self or others may occur, as child has not learned a positive way to cope with
  3. Early identification and family interaction need further investigation or referral for these destructive
  4. High-risk tantrum styles in children ages 3–6 years have been identified by Belden, Renick Thomson, & Luby (2008) as:
    1. Tantrums marked by self-injury (most often associated with depression)
    2. Tantrums marked by violence to others or objects
    3. Tantrums in which children cannot calm themselves without help
    4. Tantrums lasting more than 25 minutes
    5. Tantrums occurring more than 5 times per day or between 10 and 20 times per

These children should be considered for referral or further evaluation, con- sidering that these styles are more likely to be associated with behavioral or emotional problems.

Belden, A., Renick Thomson, N., & Luby, J. L. (2008). Temper tantrums in healthy vs. depressed and disruptive preschoolers: Defining tantrum behaviors associated with clin- ical problems. Journal of Pediatrics, 152(1), A2.

TOILET TRAINING

Toilet training is a developmental task of toddlerhood. Success will help the tod- dler continue to develop awareness of his or her own ability for self-control and self-esteem. There appears to be a critical period at about 18 to 24 months of age when the child becomes aware of body functions; attempts at training too early or too late may influence long-range behavior.

I.   Indications of readiness

  1. Maturation of muscles and nerves to allow voluntary sphincter control
  2. Myelination occurs in a cephalocaudal direction, so the ability to walk well indicates that myelination has occurred in the trunk of the body and that sphincter control is
  1. Body awareness: Toddler shows discomfort in soiled diapers, can antici- pate the need to go, and is developing some
  2. Toddler can follow simple directions and use language to make wishes known.
  3. Toddler can anticipate and postpone events in daily
  4. Toddler is not under any new
  5. Toddler has loving caregivers to look to for approval and

II.   Technique

  1. Pre-training when the above indicators are present
    1. Have child observe others using
    2. Talk about it as an expected accomplishment; comment with appro- priate word when child is observed having bowel movement (BM) so that he or she becomes aware that this will get
    3. Have potty chair or insert ring for toilet seat
    4. Use training pants
    5. Toddler shows awareness of plan by bringing to caregiver’s attention that he or she is having a BM. This is the beginning of gaining the child’s cooperation and may take more time and effort than
    6. This is only one of the many tasks the toddler is attempting to master at this age, so frequent lapses may
  2. Bowel control
    1. First make sure toddler is becoming aware of the connection between the potty chair and the
    2. If child’s bowel movements are regular, use the potty chair at those times.
    3. If no regularity is apparent, watch for signal from child and then take him or her to the This is where patience and perse- verance by the caregivers are rewarded.
    4. Leave child on potty chair for only a short time; long sitting ses- sions may lead him or her to rebel. Child may be afraid of the toilet
    5. Do not distract child with books or toys; he or she is there for one reason.
    6. Treat success as a normal Over-enthusiasm may cause child to use toileting as a way to get attention; positive feedback should be reserved for other daily activities.
    7. If training is unsuccessful, reevaluate maturation indicators and repeat pre-training It seems to take more time and effort to train boys than girls, particularly if they are larger than average.
  3. Daytime bladder control
    1. Follows BM control, because voiding signal is less intense
    2. Watch for increasingly long periods of dryness; this signifies an increase in bladder
    3. Put child on potty chair before and after meals, naps, and playtime; treat as usual part of daily
    4. Dress child in clothing that is easy to
  4. Boys may prefer to sit backward on toilet
  5. Treat success
  6. Nighttime bladder control
    1. Follows daytime control; may not be accomplished until after age 3 years
    2. Bladder must have capacity of 8 oz before child is able to be dry all night.
    3. Getting child up at night may be helpful in the short-term but is not a good long-term solution to nighttime
    4. Put child on toilet or potty chair as soon as awake, whether dry or not, to develop
    5. Outside pressure makes child feel inadequate and discouraged with ability to please those important to him or
    6. In a happy, healthy child, bladder control is a natural process that takes
    7. Limit use of pull-ups which might actually lengthen the time to toilet
  7. Success
    1. Depends on toddler’s physical maturation
    2. Depends on parents’ positive attitudes and patience in following through and helping child
  8. Problems: See enuresis in Part II, p.

Toilet training links (podcast). (2007, July). Contemporary Pediatrics, 24(7), 67.

LIMIT SETTING

Discipline can best be defined as training that helps a child develop self-concept and character. Parents are often hesitant to set firm and consistent limits on their children because they are afraid of damaging their psyche or fear that their children won’t love them or feel loved by them if they are stern. On the contrary: Being allowed to act in a way the child knows should not be tolerated because it causes him or her to feel anxiety and insecurity. Children feel their parents do not love them if parents fail to make an effort to help them develop inner controls.

The ultimate goal for any child is parental approval; children will do their best to live up to parental expectations. For example, if a mother conveys the impres- sion that she does not expect her toddler to go to bed without a struggle, a struggle will surely ensue. If parents expect their son only to get by in school, he probably will; if the same parents were to expect A’s, the child would probably strive to achieve them. Parental disapproval helps children develop a conscience; they know that, after committing a naughty deed, they have not measured up.

Health care providers involved in routine physical concerns must not neglect the issue of discipline, especially as the child develops initiative and autonomy. The following points can be discussed with parents, and it is generally helpful to raise the issue before the need arises and to reinforce significant areas when the parents have a specific concern.

I.   Principles of limit setting

  1. United front
    1. Parents must be in
    2. Parents must agree on what limits will be
    3. Parents must agree on penalties for
  2. Consistency
    1. Rules must be consistently
    2. Expectations must be
    3. Child should not be allowed to perform unacceptable behaviors at some times and be punished for similar behaviors at other
  3. Limits clearly delineated
    1. Parental expectations must be
    2. Rules and regulations must be
  4. Behavioral expectations in relation to child’s developmental and intellec- tual level
    1. A 12-month-old cannot be relied on not to touch something because mother or father said
    2. A 2-year-old does not understand what can happen if he or she goes in the street or gets into a car with a
    3. A school-age child can be expected to understand that he or she must go home after school before playing with
    4. If expectations are made clear to the child, he or she will strive to achieve
  5. Bumping point: Every parent has a point up to which he or she can be pushed. Children quickly learn this point and use it to their own
  6. Unemotional approach
    1. Children repeat behaviors that they know get a parental response, whether positive or
    2. A toddler learning to walk takes another step when parents laugh and
    3. The perfect entertainment for a school-age child on a boring rainy day is to tease a sibling and watch Mom
    4. Overreacting under stress and in anger leads to irrational threats and perhaps
  7. Stress that the deed is bad, not the
    1. Attack the deed, not the child; this preserves the child’s respect for self and
    2. Breaking windows (throwing stones, and so forth) is not an accept- able thing to
    3. Children need to know, however, that they are responsible for their actions.
  8. Immediacy of action
    1. For most effective learning, especially with a toddler or preschool child, the consequences of inappropriate behavior should not be delayed.
    2. With older children and adolescents, a conference with parents may be more appropriate; in this case, the consequence is
    3. Do not say, “Wait until your father gets home!” This threat can cause an enormous amount of anxiety for a child and makes it appear not only that Dad is the bad guy, but also that Mom does not care enough to set limits. Alternatively, for a child whose parent comes home from work and then usually spends their time in front of the TV, a secondary gain may be involved in the form of atten- tion (albeit negative attention).

II.   Punishment

  1. Punishment must fit the
    1. There should be a logical connection between the two; banning after-school play for 2 weeks for an infraction unrelated to such activity is usually not only inappropriate, but also
    2. Punishment should not exceed the child’s
    3. Punishment should not negate educational
    4. Coming in half an hour after curfew does not warrant restricting an adolescent for 1 or 2 months; instead, make the curfew half an hour earlier next time and give the child one of the parent’s tasks the next day because Dad is so tired from waiting and
    5. As the child gets older, parental disapproval is often the only punish- ment needed; guilt at letting parents down is often punishment enough.
  2. Punishment should
    1. Punishment is done for and with children, not to
    2. Spanking
      1. Produces an external rather than an internal motive for control- ling the impulse and therefore does not help develop child’s conscience
      2. Cancels the crime
      3. Relieves sense of guilt too readily
      4. Parental anger often escalates with spanking, resulting in injury
    3. Isolation
      1. Appropriate length of time (one minute per year of age) is preferable to isolating for a specified length of time once child is old enough to understand what behaviors are
    4. Sit on chair: Tell child timer is set for 3 minutes; do not say, “Sit there until I tell you that you can get ”
    5. Restrictions on privileges
      1. For bike rule infraction, take bike
      2. TV restrictions work well for most
  3. Best not to restrict learning experiences, such as a scout camping trip
  4. Withhold positive rewards, such as social or verbal
  5. Never offer a reward that cannot be

III.   Key points to remember

  1. Treat children with
    1. This teaches them to respect in
    2. Allow them to share in decision-making
    3. Children model behaviors they see in parents; be the kind of person you expect your child to
    4. Earliest approach to limit setting is based on baby’s ability to
  2. Threats are
    1. Any self-respecting child will try to see whether parents will follow through; threats are an invitation for unwanted
    2. Threats are often made in a moment of anger and may be unreasonable.
  3. An ounce of prevention is worth a pound of cure and is certainly easier on
    1. Clearly define
    2. Remove
    3. Do not pick on insignificant
    4. Do not threaten with punishment that you cannot or are unwilling to carry
    5. Distract child if it looks as though he or she is getting in
    6. When child is losing control, pick up and remove him or
    7. If you know the child has misbehaved, do not ask whether he or she has done the misdeed. Confront child with it and thereby avoid tempting him or her to

Faber, A. (2004). How to talk so kids will listen and listen so kids will talk. New York: Harper- Collins.

Sears, W. (1995). The discipline book. Boston: Little Brown.

Turecki, S. (1995). Normal children have problems too. New York: Bantam Books. Turecki, S. (2000). The difficult child. New York: Bantam Books.

SIBLING RIVALRY

Sibling rivalry occurs when children feel displaced, frustrated, angry, and unloved. It is normal for an older child to feel jealous at the arrival of a new baby. Competi- tion and feelings of envy can also occur among older siblings; fighting between brothers and sisters is common. However, if such behavior is allowed to continue, it can persist into adolescence and even adulthood.

Often the arrival of a second child occurs when the first child is at the develop- mentally stressed age of 2 years. All children show signs of regression after the birth of a sibling, and it is best to allow this regression to occur without interference. If the parents continue to reinforce positive behavior, the older child will gradually begin to feel as important and loved as the younger sibling, and the relationship between the two will become stronger and more supportive.

Parents are responsible for establishing a positive, supportive environment in which competition among siblings is reduced and replaced by a caring, concerned, and affectionate relationship. This takes place over a long period of time. Parents must be fair and consistent in teaching children both by example and by good man- agement of negative behavior.

One successful method used to change negative behavior is time out. This is a proven method in which the fighting children are separated and sent to separate rooms. All the combatants are treated equally, with no favoritism. Parents must praise and encourage positive play, rewarding good behavior and discouraging name calling, baiting, and arguments.

Feelings of jealousy naturally occur at the birth of siblings. If this event does not interfere with the time spent with the older child or affect the love and affection shown, these feelings eventually dissipate.

The age of the child is an important factor in sibling rivalry. The younger the older child, the greater will be the degree of rivalry. Children age 5 years or older are fairly secure and therefore less intensely jealous of a new baby. Anticipatory guidance is advisable; parents should set the stage well in advance of the birth. A few simple practices may help decrease the jealousy between the first child and the new baby (see following outline).

Parents must be fair about the attention they give each child. If a child matures in a loving, sharing, charitable environment, he or she will have the self-esteem needed to grow into a well-rounded, strong adult who likes and enjoys his or her siblings.

I.   The birth of a new baby

  1. Before the baby is born
    1. Take the older child to the prenatal exam to hear the baby’s heartbeat.
    2. Allow the child to feel the baby move in Mom’s
    3. When talking about the new baby, use terms such as our baby and describe what babies do (e.g., wear diapers, coo, smile).
    4. Borrow a small baby or visit a friend with a newborn to acquaint the child with
    5. Have a special time each day, called our time, to be spent reading or playing with just the older
    6. Read books together (many are available at the library) about arrival of new
    7. Supply the older child with a doll, a baby of his or her
    8. Establish the older child in a new bed or room long before the baby is
    9. After the baby arrives:
      • Allow the child to visit you in the hospital each
      • Phone the child daily from the
      • Bring a special gift to the child when you come home with the
      • Allow the child to assist in baby care by bringing you diapers and so forth.
      • Spend some time each day exclusively with each

II.   Sibling interaction

  1. Siblings interact independently of other family relationships; relation- ships with parents and extended family members may be more or less intense or more or less
  2. Birth order influences development of the sibling Because all chil- dren in the family both initiate behaviors and react to others’ behaviors, this development continues into and through adulthood.
  3. Families provide a social arena in which children learn to explore lan- guage, observe behavior (both negative and positive), and learn to assess their influence on other people. Therefore, children’s personalities out- side the family and their ability to deal socially with others are first established with family
    1. Children without siblings are more critical of themselves and often find peer relationships more uncomfortable and difficult to sustain than do children with Single children relate to older people and adults much more successfully than to children their own age. Single children are perfectionists, expecting perfect behavior from others as well as from themselves. As Leman states in The Birth Order Book, only children often quietly wish they could move in, take over, and “do it right” (see Suggested Reading, p. 195).
    2. First-born children are often confident, conscientious, organized children who grow up to be hard-driving, successful A lot of pressure is exerted on the oldest child, who receives more attention and more discipline and has more expectations made on him or her. He or she is the pathfinder and the one to whom all the other children in the family look up.
    3. Middle children learn social skills early in life. They learn how to negotiate and that it is futile to compare themselves constantly with others. They are forced to form their own identities, usually by adolescence, and grow up to be people-oriented
    4. Last-born children are often pleasant, cheerful, outgoing, and uncomplicated. They can be impatient, spoiled, and Last- born children live in the shadow of their older siblings. They are often criticized and not taken seriously. Often they get attention by clowning, making jokes, or behaving badly in school, but they secretly want to be very successful.
  4. Gender influences the interaction between Rivalry is likely to be most intense in a family with two boys; however, if such brothers are born close together, there is less chance for the older one to establish clear superiority. In a family with two girls, rivalry is likely to be much less serious. In a family with a girl and a boy, rivalry is may be less serious if strengths of each sex are emphasized.
  1. Sibling rivalry is an important consideration in the age spacing of chil- dren in The children closest in age often share experiences and friends and therefore form a stronger bond than do siblings born 8 or 9 years apart. Siblings born close together become more reciprocal in their relationship and are more intimate and intensely involved with each other than are siblings born years apart.

III.   Parents can influence sibling rivalry.

  1. Set a good example; be supportive of all the children in the family, and reinforce positive behavior within the
  2. Teach the children to be loyal to each other regardless of the anger they feel toward each other; allow competition between them to be verbalized and to be resolved openly and
  3. Verbalize the frustration the angry child is feeling; always show concern and compassion for the
  4. Try to teach the children constructive ways of expressing feelings of rivalry rather than punishing them for negative
  5. Expect the children to be accountable for their words and actions, and thereby teach them coping
  6. Be consistent; the punishment should fit the
  7. Separate the children for a period of time if they are constantly fighting (time out).
  8. Treat the children with respect, and show confidence in their ability to get

IV.   Sibling rivalry in step-families

  1. Difficult problem: Family system is complex due to the large number of people involved, and often parents are preoccupied with their own new marriage.
  2. Special attention should be focused on cementing a bond between step- parent and step-child. Allow time to build a caring
  3. Children in step-families are often angry and sad at the loss of their original
  4. Children should be taught that sharing is a key component to success, and the advantages of sharing within the family should be pointed out to
  5. Step-families must clearly and consciously work out the rules of the family; children should be included in this
  6. Adolescents find the new family structure in step-families difficult; often they withdraw from both parents and become closer to their

V.   Siblings of handicapped children

  1. Sibling relationships between handicapped and non-handicapped chil- dren are more complex; special problems arise due to the intense nature of the relationship.
  2. Siblings of a handicapped child may:
    1. Resent the attention and time given to the handicapped child
    2. Fear catching the condition
  3. Feel anger toward the disabled child because they feel ignored and unappreciated by parents
  4. Feel upset by the unfairness of the family situation; long for a normal family
  5. Feel embarrassed by the handicapped sibling
  6. Feel guilty about their hostility toward their sibling
  7. Feel confused about their role in caring for the sibling
  8. Fear that outsiders won’t accept the handicapped child
  9. Parents of a handicapped child
    1. Communicate with the handicapped child; be truthful about the degree of the handicap and open about the problems of working with him or
    2. Treat all the children individually, reinforcing their positive characteristics.
    3. Schedule quality time to be spent with the non-disabled
    4. Strive to attain a normal home life by providing a comfortable home environment that welcomes the participation of other children in family
    5. Establish or join a support group in which each family member obtains a balanced perspective on his or her role in the family and can compare his or her experiences with those of

Faber, A. (2004). Siblings without rivalry: How to help your children live together so you can live too. New York: HarperCollins.

LOSS AND GRIEF

Commonly held understandings of grief, such as believing that the only way to adjust to loss is to confront directly one’s intense emotional reactions or that the objective of “grief work” is to detach from what is lost, have come under increas- ing scrutiny and criticism in the last few years. Today grief is understood to be an individual and unique response to loss. The term grief work is used to describe the process of adapting to loss, without presupposing what that process is. The research of Stroebe, Stroebe, Hansson, and Schut (2001), widely reported in both popular and professional literature discredits the necessity of directly confronting the strong emotions of grief to adjust successfully to a loss. While this is an important contri- bution to our understanding of grief, it should not be interpreted to mean that grief work does not occur, nor that those in grief do not need support. Rather, the reac- tion to the work by Stroebe et al. emphasizes the need for careful understanding of terms and highlights the importance of research-based practice.

The reactions of grief are felt holistically—physically, emotionally, spiritu- ally, cognitively, and socially. Having a loved person die often raises concern about one’s own vulnerability. The grieving child or the caregiver may worry excessively about every manifestation of grief and need reassurance that their grieving reac- tions, although individually unique, are most usually culturally and universally nor- mal. All too often, however, the normal reactions of grief are misdiagnosed in children and adolescents as depression, attention deficit, conduct, and oppositional defiant disorders. A complete and accurate loss history as part of the total assess- ment process is critical to the differential diagnosis of loss and grief and appropri- ate interventions.

I.   Anticipatory Grief

  1. Take advantage of teachable moments and situations where children can learn about the natural cycle of life and death to promote coping with sadness and loss without overwhelming intense
  2. Grief starts when we know someone is
  3. An important task of anticipatory grief is to finish the business of
  4. It is important to say what needs to be said. Suggestions from hospices include, “I forgive ” “Forgive me.” “Thank you.” “I love you.” and “Goodbye.”
  5. Allow children to be with their dying person as much or as little as they want.
  6. Encourage children to express their
  7. Give children information about all the changes along the way to help them prepare for the
  8. When a child’s dying loved person has had repeated recoveries from numerous health crises, help the child understand that death is the likely outcome this time so that goodbyes are

II.   Traumatic Grief

  1. Some children and teens experience the death of a loved person as trau- matic regardless of the cause of
  2. In traumatic grief, thoughts and memories of the loved person bring terror, intense fear and physical stress reactions so that the child/teen cannot process his or her grief
  3. Traumatic grief can dramatically affect physical, social, emotional, and spiritual well-being.
  4. If a child/teen has symptoms of traumatic stress or avoids talking about the person who died consider referring the child/teen and caregiver for assessment and treatment by a clinician experienced in treating emotional difficulties, traumatic stress and childhood/adolescent grief and
  5. Symptoms of Post-Traumatic Stress Disorder
    1. Continue for a month or more and fall into the following general categories:
      1. Reexperiencing
      2. Hyperarousal
      3. Avoidance

III.   Indications for intervention

  1. While most grieving reactions are normal (see Box 1-1), evaluation for intervention is indicated when the grieving reaction:

BOX 1–1 Common Grief Reactions

EMOTIONAL

  • Agitation Disbelief                  • Regret
  • Anger/rage Fear                         • Relief
  • Anxiety Guilt                       • Sadness
  • Apathy Helplessness               • Shame
  • Appearance of being Hysteria                   • Shock

unaffected                     • Irritability                  • Uselessness

  • Betrayal Loneliness                 • Vulnerability
  • Crying/not crying Moodiness               • Worry about being
  • Depression Numbness                  taken care of
  • Despair Powerlessness             • Yearning

 

COGNITIVE

  • Absentmindedness Inability to think
  • Asking why, why, why Low self-image
  • Blaming oneself or others Memory loss
  • Changes in academic performance Nightmares
  • Confusion Preoccupation
  • Continuously thinking about the loss Regression
  • Difficulty making decisions Retelling the story of the death
  • Disbelief and end-of-life rituals
  • Dreams of the deceased Self-destructive thoughts
  • Forgetfulness Thoughts of being watched by
  • Inability to concentrate the deceased or other

 

PHYSICAL

  • Accident proneness Increased somatic complaints
  • Anxiety Listlessness
  • Appetite changes (increase Muscle tension or decrease)          • Muscle weakness
  • Auditory and visual hallucinations Pounding heart
  • Deep sighing Risk-taking behaviors (smoking,
  • Dizziness sexual activity, alcohol, drugs)
  • Dry mouth Shortness of breath
  • Enuresis Skin sensitivity
  • Extreme quietness Sleep pattern changes (increase
  • Fatigue or decrease)
  • Headaches Stomachaches
  • Heaviness or empty feelings Temporary slowing of reactions in one’s body • Tightness in the chest
  • Hot or cold flashes Tightness in the throat, difficulty
  • Hyperactivity swallowing
  • Imitates behaviors of the deceased Trembling, uncontrollable may include symptoms of the illness       • Worry about own health
  • Immune system compromise

(increased colds and infections)                                       (continued)

BOX 1–1 Common Grief Reactions (Continued)

SOCIAL

  • Aggressiveness Seeking approval and assurance
  • Attention seeking (class clown, from others

acts out)                                    • Speaking of the loved person in

  • Being constantly active the present tense
  • Clinging Underachieving
  • Excessive touching or Withdrawing from friends

withdrawal from touch                      and family

  • Isolation Withdrawing from social
  • Overachieving activities
  • Rejecting old friends and seeking new friends

 

SPIRITUAL

  • Experiencing a lack of security and trust
  • Feeling a loss of control
  • Feeling alienated
  • Feeling forsaken, abandoned, judged, or condemned
  • Feeling lost and empty
  • Feeling spiritually connected to the person who died
  • Losing a sense of meaning and purpose in life
  • Needing to give or receive forgiveness
  • Needing to give or receive punishment
  • Needing to prove one’s self worth
  • Praying more or less
  • Questioning of religious beliefs and practices
  • Searching for a reason to continue living
  • Searching for justice
  • Searching for what was lost
  • Sensing the presence of God
  • Sensing the presence of the person who died
  • Struggling to define beliefs

 

 

  1. Continues for several weeks without improvement
  2. Jeopardizes normal development over the long-term
  3. Interferes significantly with social functioning
  1. Prompt evaluation and intervention are indicated when a child or teenager has:
    1. Behaviors that endanger the health and safety of self or others (such as alcohol and drug abuse or suicidal ideation or intent)
    2. An overall sense of unworthiness (an indicator of depression rather than the deep sadness of grief)
    3. Persistent guilt

IV.   Variables

  1. Many variables influence the grief process:
    1. Age of both the griever and the deceased
    2. Type of death (illness, sudden, accident, suicide, murder)
    3. Relationship of the griever with the deceased
    4. Parental grieving style
    5. Individual personality, mental health status, and ability to cope
    6. Family stability
    7. Relationship strengths or weaknesses
    8. Taking on the role of caregiver for siblings or parent(s)
    9. Having the surviving parent initiate new relationships
  2. Secondary and often intangible losses compound a significant loss, requiring the griever to cope with innumerable Examples of secondary losses are:
    1. Hopes and dreams
    2. Security
    3. Family
    4. Identity
    5. Income
    6. Changes such as moving or attending a new school

V.   Developmental issues, tasks, and needs

Understanding the intellectual and emotional development of children, the tasks of grieving, and grieving needs enables caregivers to support and help children not just survive their loss, but to incorporate their grief into their normal growth and development. It is important to recognize that tasks and needs are not rigid or sequen- tial, but rather a way to organize the often chaotic, changing, and confusing, journey from what was, to what is, and what will be. With each successive developmental stage, children experience their knowledge about death and their grief in new ways and with new understanding. Grieving is a process that requires the griever to choose to perform a balancing act of coping with and making meaning in a world that will never be the same as it was.

  1. Intellectual and emotional understanding of death and grief
    1. Infants and toddlers (ages 0 to 2, approximately)
      1. Understanding
        • Death has no meaning, but they understand that a significant person is
        • Grief may be communicated by crying, agitation, searching, or
        • Sleep and appetite changes are
      2. Interventions
        • Comfort and nurturing in a secure, routine environment
        • Often find comfort in a linking object
      3. Preschool (ages 3 to 5, approximately)
        1. Understanding
          • Understanding of death is incomplete; believe that some functions of the deceased continue, like feeling, thinking, and bodily functions, such as

 

 

  • Use the word ‘dead’ often and seemingly appropriately, but do not understand what it
  • May think death is like sleep so fear sleep and darkness
  • Often think their thoughts or actions caused the death
  • Grief expressed in bits and pieces; may be crying one moment, playing and laughing the next
  • Regressive behaviors
  • Think of heaven as a place to visit and expect loved one to return, especially for special occasions, like
  1. Interventions
    • Concrete explanations: Dead people can’t breathe, move, hear, see, or feel
    • Frequent repetition
    • Comfort and reassurance that he or she did not cause the death
    • Comfort, reassurance, and nurturing in a secure, routine environment
  2. Grade school (ages 6 to 12, approximately)
    1. Understanding
      • Aware of the universality and permanence of death; begin- ning to grasp causality and personal mortality
      • Increase in concern about their possible death or death of relatives
      • Curious about the details and may focus on post-death decay
      • May still not have the words to express feelings and thoughts
      • Do not want to appear different or strange by expressing sad affect in front of their friends
    2. Interventions
      • Reassure them that the world continues and that they and their caregivers will most likely live a long
      • Answer questions in concrete
      • Allow a variety of holistic reactions by offering choice in activities.
    3. Adolescents (ages 12 to 18, approximately)
      1. Understanding
        • Cognitive understanding of biology of death, but have not developed personal meaning or spiritual integration
        • Want to explore theoretical, spiritual, and philosophic ques- tions about what happens after death
        • Expect world to operate in an orderly fashion and be fair and just
        • Understand others’ points of view and feel empathy, while still egocentric
        • The need to be connected, included, and supported conflicts with need for autonomy and
        • May deny their grief to appear normal to their peers
        • Gender differences in expression of grief may

 

 

  • Males tend to be at the more active (cognitive, doing, problem-solving) end of the continuum of grief
  • Females tend toward the more emotional (feeling, talk- ing) expression of
  1. Interventions
    • Appreciate that they are more apt to talk with
    • Consider referral to a peer support
  2. Adapting to loss and grief:
    1. Task: Acknowledging the reality of the loss
      1. Need adequate information
        • Provide developmentally appropriate, accurate facts about death and how the death
        • Avoid common clichés (lost, passed) and instead use the con- crete words of death: Died, suicide, pain,
        • Counteract magical thinking (inaccurate conclusions about death and grief, resulting in the child feeling responsible for the death; for example, a sick child hugged grandma who then died from a heart attack and believes she killed grandma).
        • Help children understand that grieving a significant other’s death will change but will continue throughout their
        • Repeat information as needed, and provide more as
      2. Need involvement and inclusion
        • Encourage the child to make educated choices about as much as
        • Include children in planning and participating in end-of-life rit- uals as much as they desire, but first provide age-appropriate information about what will be seen, heard, smelled, and
        • Allow children to say good-bye to the physical body if they want.
        • Advocate for their choice concerning disclosure at school, on teams, and so forth. Request that the teacher or coach talk with the child to determine his or her wishes before assum- ing they should tell the child’s
      3. Need reassurance
        • Accurately reassure children of their personal safety and the safety of significant
        • Assure children they are not to blame for the
        • Provide comfort, respect, and listen, listen,
        • Let them know who will provide care and love for
      4. Task: Choosing to experience the lessons of grief and live in a forever-changed
        1. Need validation of individual feelings
          • Recognize that each person’s grief is
          • Talking and crying are only two ways to express grief, and neither are necessary. Allow the child to grieve in the way that is right for him or Sports, creative arts, and play may all be expressions of grief.
  • Children and teens may be able to tell you what color they feel or beat a rhythm when they cannot put their feelings into
  • Connections with peers experiencing a similar loss may help children and teens regain a sense of being
  • Encourage focusing on the positive, rather than the
  • Be patient with the grieving process. Grief takes enormous energy and diverts it from other tasks, such as school
  1. Need help with overwhelming feelings
    • Encourage play, drawing, drama, and
    • Accept and help the child or teen understand the multitude of emotions and the quick movement from a down feeling to an up
    • Expect and tolerate frequent, daily, emotional outbursts and grief attacks; consider establishing a safe place where chil- dren can go when they are
    • Help to name feelings, identify their cause, and choose healthy coping
    • Recognize that no one can take away the griever’s pain, but others can and should provide acknowledgment, comfort, and information as desired by the
    • Help children or teenagers identify a support network and a repertoire of healthy coping
    • Watch for signs of suicidal ideation or Bereavement is a risk factor for suicide. Encourage caregivers to remove lethal means from the home of vulnerable children and teenagers.
  2. Need continued routine activities
    • Maintain normal bedtimes, meals, and daily
    • The old advice not to make any major changes for a year still holds
    • Help and teach children to be aware of their needs and to communicate their needs to their support
  3. Need modeled grief
    • Encourage parents to model healthy grieving and get support if
    • It is ok to cry; it is ok not to cry. Crying and sadness are among the many possible reactions to
    • Let children know they cannot protect adults from the adult’s pain. They should not be the
  4. Task: Developing new ways of connecting to the deceased person as a continuing important part of
    1. Need opportunities to remember
      • Listen to repeated
      • Help the child or teenager choose keepsakes and linking objects.
      • Encourage or help the child to create memory boxes, books, photo albums, or
  • Create with the child special rituals for anniversaries, birth- days,
  • Plant a tree or flowers in
  • Visit the grave or memorial site
  1. Task: Finding personal meaning and significance in the changes and finding ways of living joyfully and meaningfully again (Often referred to in current literature as post-traumatic )
    1. Need careful listening
    2. Need fears and anxieties
      • Allow time for the unique expression of grief, knowing that grief takes as long as it takes and that adjustment is measured in weeks and months, not hours or
      • Allow children to explore their new thoughts, feelings, and behaviors.
      • Normalize and support change, learning, and growth through healthy coping with cognitive, emotional, physical, social, and spiritual
      • Reassure that living joyfully and meaningfully does not mean forgetting.

VI.   Quick guidelines

  1. Death, change, loss, and grief are all part of the normal, developmental life
  2. Grief is
  3. Grief takes as long as it
  4. Progress is measured over weeks and months, not hours or
  5. There is no one right way to
  6. Trust the
  7. Listen to heal the things that cannot be
  8. Remembering is
  9. Routine is
  10. Silence is
  11. Use concrete words: Death, dead, die, and
  12. Experiencing of extraordinary events is quite
  13. Dead people were not perfect, nor did their griever always love
  14. All endings are
  15. Living joyfully and meaningfully does not mean

FOR PROFESSIONALS

Christ, G. H. (2000). Healing children’s grief: Surviving a parent’s death from cancer. New York: Oxford University Press.

Cohen, J. A., Debinger, E., & Mannarino, A. P. (2006). Treating trauma and traumatic grief in children and adolescents. NY: Guilford.

Goldman, L. (2000). Life and loss: A guide to help grieving children (2nd ed.). Philadelphia: Accelerated Development.

Levine, P., Kline, M. (2007). Trauma through the eyes of a child: Awakening the ordinary miracle of healing. Berkeley: North Atlantic Books.

Lieberman, A. F., Compton, N. C., Van Horn, P., & Chosh Ippen, C. (2003). Losing a parent to death in the early years: guidelines for the treatment of traumatic bereavement in infancy and early childhood. Washington DC: Zero to Three Press.

Schwiebert, P., & DeKlyen, C. (2004). Tear soup: A recipe for healing after loss. Portland, OR: Grief Watch.

Silverman, P. R. (2000). Never too young to know: Death in children’s lives. New York: Oxford University Press.

Stroebe, W., Stroebe, M., Hansson, R., & Schut, H. (2001). Handbook of bereavement research: Consequences, coping and care. Cambridge, England: Cambridge University Press.

Worden, J. W. (2002). Children and grief: When a parent dies. New York: Guilford Press.

WEBSITES

Association for Death Education and Counseling. Information, resources, and links: http://www.adec.org

Compassion Books. Resources selected by knowledgeable professionals related to loss and grief: http://www.compassionbooks.com

The Dougy Center: The National Center for Grieving Children and Families. Information, resources, and links: http://www.dougy.org

Hospice Foundation of America. Resources and links: http://www.hospicefoundation.org Tragedy Assistance Program for Survivors. Service and support for survivors of loved ones

who died in military service: http://www.taps.org

Tear Soup. Book, resources, links,  and  newsletter:  http://www.tearsoup.com/tearsoup/ The National Child Traumatic Stress Network. Evidence-based information, education,

resources, and links for professionals and caregivers: http://www.NCTSN.org

The National Institute for Trauma and Loss in Children. Education for professionals and excellent caregiver resources: http://www.tlcinstitute.org

FOR CAREGIVERS

Cameron, J. B. (2006). Understanding and supporting a child or teen coping with a death: A guide for parents and caregivers. Tuckahoe, NY: The Bereavement Center of Westchester.

Winsch, J. L. (1995). After the funeral. New York: Paulist Press.

White, A. M. (2005). Buzzy Jellison the funeral home cat. Peterborough, NH: Winthrop Publishing.

Wolfelt, A. D. (2001). Healing a child’s grieving heart: 100 practical ideas for families, friends, and caregivers. Fort Collins, CO: Companion Press.

WEBSITES

Compassion Books. Resources selected by knowledgeable professionals related to loss and grief: http://www.compassionbooks.com

The Dougy Center: The National Center for Grieving Children and Families. Information, booklets, resources, and links: http://www.dougy.org

Tear Soup. Book, information, resources, links, and newsletter: http://www.tearsoup.com/ tearsoup/

FOR CHILDREN

Brown, L. K., & Brown, M. (2004). When dinosaurs die: A guide to understanding death.

New York: Grand Central Pub.

The Dougy Center for Grieving Children. (2001). After a murder: A workbook for grieving kids. Portland, OR: Author.

The Dougy Center for Grieving Children. (2001). After a suicide: A workbook for grieving kids. Portland, OR: Author.

Holmes, M. M. (2002). A terrible thing happened. Washington DC: Magination Press. Thomas, P. (2005). A first look at death: I miss you. London: Hodder Pub.

Viorst, J. (2002). The tenth good thing about Barney. Lexington, KY: Book wholesalers.

FOR TEENAGERS

Grollman, E. A., & Malikow, M. (1999). Living when a young friend commits suicide: Or even starts talking about it. Boston: Beacon Press.

Hipp, E. (1995). Help for the hard times: Getting through loss. Center City, MN: Hazelden.

O’Toole, D. (1995). Facing change: Falling apart and coming together again in the teen years. Burnsville, NC: Companion Press.

CHILD ABUSE

By definition, child abuse is divided into four groups: physical abuse, emotional or physical neglect, emotional abuse, and sexual abuse.

Physical abuse may be present in a child with evidence of bruises, lacerations, head trauma, human bites, burns, hematomas, fractures or dislocations, or injury to the abdomen (evidenced by a ruptured liver or spleen or fractured ribs), all seen in the physical examination.

Emotional and physical neglect are more difficult to identify, more subtle in their presentation, and more likely to have been going on for some time. Such neglect implies that the caregiver cannot care for the child or protect the child from danger. Examples are the child who is emotionally distraught or the child with fail- ure to thrive, who often has an inadequate diet, shows signs of poor growth, is depressed and developmentally delayed, and occasionally (but not always) is dirty and unkempt.

Emotional abuse is exemplified by the child who seems unable to relate to others and is apathetic, lacking any emotion because he or she is constantly berated, beaten, rejected, or ignored. Infants as well as older children can be emotionally abused.

Sexual abuse, the sexual exploitation of infants or children by an adult, may include exhibitionism, fondling or digital manipulation, masturbation, or vaginal or anal intercourse. The sexual abuser may be a stranger, but more often is someone known to the family or even a member of the family. Father–daughter incest accounts for 75% of all cases of incest.

Child abuse is most often identified in the pediatric office; the nurse practitioner or pediatrician must be able to recognize the signs and symptoms of such abuse.

I.   Physical abuse

  1. Physical signs
    1. Bruises: Explained or often unexplained welts or abrasions on the face, body, back, thighs; may also be several surface areas in differ- ent stages of healing, often recurring and suggesting the shape of the article used to inflict them (belt, whip)
  2. Evidence of human bites
  3. Ocular insult
  4. Fractures or dislocations in various stages of healing
  5. Unexplained rupture of spleen, liver, or pancreas
  6. Neurologic findings
  7. Signs of poisoning
  8. Unexplained burns: May appear on soles, palms, back, buttocks, or genitalia, often in pattern of cigarette, cigar, electric burner, or iron; rope burns around neck, body, or extremities
  9. Behavioral signs
    1. Excessively aggressive or withdrawn
    2. Suspicious of adults
    3. Speaks in dull voice
    4. Often feels he or she deserves the battering
    5. Lies very quietly during examination with vacant stare
    6. May not report injury inflicted by parent
    7. Seeks affection inappropriately
    8. Has poor self-esteem

II.   Physical neglect

  1. Physical signs
    1. Failure to thrive (poor growth pattern, developmental delay, malnourishment)
    2. Inappropriate dress
    3. Poor hygiene
    4. Lack of supervision in dangerous activities, or abandonment
    5. Absence of medical care; unattended physical problems
  2. Behavioral signs
    1. Excessive crying
    2. In infants, ruminating behavior
    3. Begging for food
    4. Poor school attendance, delinquency, falling asleep in school, stealing
    5. Alcohol or drug abuse
    6. States that no one cares

III.   Emotional neglect

  1. Physical signs
    1. Failure to thrive
    2. Hyperactivity
    3. Speech disorder
  2. Behavioral signs
    1. Developmental delays
    2. Habitual sucking, rocking, ruminating, head banging, or destructive or antisocial behavior
    3. Sleep disorders, repeated nightmares, constant waking to see whether parents are there
    4. Phobias
    5. Difficulty in learning, poor school performance
    6. Inability to play for any length of time
  3. Inappropriate adult behavior; not childlike
  4. Wounding of self or attempted suicide

IV.   Sexual abuse

  1. Physical signs
    1. Genital, urethral, vaginal, or anal bruising or bleeding
    2. Swollen, red vulva or perineum
    3. Positive culture for sexually transmitted disease (gonococcus, venereal warts)
    4. Recurrent urinary tract infections
    5. Recurrent streptococcal pharyngitis
    6. Recurrent abdominal pain
    7. Enuresis
    8. Encopresis
    9. Pregnancy
    10. Foreign body in genital area
  2. Behavioral signs
    1. Knows and uses sexual terms
    2. Excessive sexual play
    3. Sleep disturbances (nightmares)
    4. Appetite disturbances
    5. Avoidance behavior or excessively aggressive behavior
    6. Temper tantrums
    7. Poor school attendance, performance
    8. Excessive masturbation
    9. Running away
    10. Suicide attempts

V.   Role of medical provider

  1. Identify and make diagnosis of child
  2. Openly and candidly discuss abuse with
  3. Treat for medical injuries or
  4. Report to department of welfare or child protection unit, again notifying parent.
    1. To protect child
    2. Initiate steps to ensure that abuse will not
    3. Failure to report child abuse is a class A
  5. Request referral or consultation to medical or surgical staff, social worker, or other specialists as

VI.   Predisposing factors

  1. Most abusive parents were abused children and show little ability to cope with adult life. Although they resent their own upbringing, they look for approval from other adults by repeating the abusive
  2. Many abusive caregivers are impulsive, immature people who cannot solve their own They have trouble establishing meaningful relation- ships and feel alone, stressed, and overwhelmed. They are mistrustful of others and therefore unwilling to ask for help in caring for their children.
  3. Other factors that predispose a caregiver to child abuse: Mental illness, inability to control temper, unrealistic expectations of a child at a specific age, and particularly inability to handle parental stress or stress caused by poverty, unemployment, or chronic illness of the child.
  1. The caregiver may not have bonded with a child at birth and therefore feels insecure about his or her parenting
  2. Abuse can be seen in all social and economic
  3. In many cases, one parent is the active abuser, and the other parent condones this behavior; therefore, it

VII.  Management

  1. Complete medical history must be outlined in the Review the former medical record, especially noting dates and occurrences of unexplained trauma, burns, or broken bones.
  2. Thorough physical examination must be performed and appropriate laboratory work and x-ray studies
  3. Any positive physical findings should be photographed, and a collaborat- ing physician called in to verify the
  4. A social worker provides the necessary psychological workup, helping with the plan of care and contacting local
  5. Always notify the parents and explain to them that you are reporting the diagnosis.
  6. Severity of the abuse determines the need for follow-up The primary concern in working with families involved in child abuse is to protect the child. The health care team determines the need for hospital care or the need to separate the child from the family.
  7. After making the diagnosis and plan of care, report the findings to the appropriate agencies within 24 to 48

CHILD ABUSE

American Academy of Pediatrics. (2007). Child abuse. Available at: http://www.aap.org/ publiced/BK0_ChildAbuse.htm

Child Welfare Information Gateway. (2001). Acts of omission: An overview of child neglect.

Available at: http://www.childwelfare.gov/pubs/focus/acts

Child Welfare Information Gateway. (2006). Recognizing child abuse and neglect: Signs and symptoms. Available at: http://www.childwelfare.gov/pubs/factsheets/signs.cfm

Herbert, M., Parent, N., Daignault, I., Tourigny, M. (2006). A typological analysis of behav- ioral profiles of sexually abused children. Child Maltreatment, 11(3), 203–216.

National Institute of Neurological Disorders and Stroke. (2007). Shaken baby syndrome. Avail- able at: http://www.ninds.nih.gov/disorders/shakenbaby/shakenbaby.htm

Nemours Foundation. (2005). Munchausen by proxy syndrome. Available at: http://kidshealth. org/parent/general/sick/munchausen.html

WEBSITES

Identifying Child Abuse and Neglect. Resources and information from the Child Welfare Information Gateway website about signs and symptoms of child maltreatment, includ- ing training resources: http://www.childwelfare.gov/can/identifying

Preventing Child Abuse and Neglect. Resources and information from the Child Welfare Information Gateway website: http://www.childwelfare.gov/preventing

BÀI LIÊN QUAN