Pediatric Primary Care Case Studies (44 page)

Establishing a routine will help change the learned behavior of having a bottle as a transitional object. First, all family members need to be committed to this plan. Families need to be prepared, because the first night without a bottle is usually the most difficult. The family should realize that Natalia will continue to cry until she unlearns the old pattern of the parent and bottle putting her to sleep. Grandma should be committed to the plan and agree not to intervene. You need to reinforce that all children, especially babies, cry when their schedule and environment change. Crying is their only way to communicate before they are able to talk (Pediatric Advisor, 2008a; Pediatric Advisor, 2008b). Crying
for brief periods is not harmful. Furthermore, increasing touch, physical contact, and affection during the day can help Natalia adjust to this new task.

You recommend that Nicole offer Natalia a bottle approximately 1 hour before bedtime. It is important to establish a nightly routine that Natalia can count on. This can include a bath, then bottle, then being read a book, and then laying her in the crib under the same conditions that she will wake up to in the nighttime.

One challenging factor with this family is the fact that the parents and baby share a bedroom. Hanging a blanket on the side of the crib that faces the parents’ bed can be helpful with separation, because then Natalia cannot see her parents upon awakening. You should remind this family that Natalia may open her eyes and make other movements during the partial awakenings that occur as she cycles through the phases of sleep. This is normal and not a signal to intervene. These awakenings are especially common in children 6 to 12 months of age (Pediatric Advisor, 2008b; Pohl & Renwick, 2002).

The most important fact that needs to be impressed on the family is that Natalia’s sleep behaviors may take several nights to weeks to change. Also, this new plan should be started at a time when one or the entire family can afford to lose some sleep for about a week. This helps with consistency with the plan.

You make these recommendations and the mother agrees that the plan is worth trying. Grandma agrees and they leave, saying they are hopeful that it will work as planned.

When should you see this family again?

You ask the family to return in about 2 to 3 weeks. You reassure them that when following a consistent plan, most infants show improvement in a few days and will be sleeping through the night in 1 to 2 weeks.

What complications might occur?

The family should be encouraged to return sooner if:

•   They feel that the sleep disturbance is due to a physical cause.

•   Someone in the family cannot tolerate the crying at night.

•   The steps outlined do not improve the baby’s sleep habits within 2 weeks.

•   Any other questions or concerns arise.

At follow-up in 2 weeks, Dad accompanies Nicole and Natalia. He does not have any questions and relays to you that the first few nights were fairly sleepless. But, the couple continued with the plan and put a blanket on the side of the crib so Natalia could not see them. They admit to continuing to be awakened by Natalia’s movements and verbalizations through the night. They feel certain their movements may also disturb Natalia. They have discussed this with the paternal grandmother and are currently converting a room
for Natalia. Mom is aware that this will change Natalia’s sleeping environment once again and is taking steps to place familiar items and materials in that room to help with this transition. She also acknowledges that she may have to start back at the beginning to help re-establish good sleep hygiene in Natalia.

Key Points from the Case

1. Sleep assessment should be a part of every well-child visit. The healthcare provider should ask the caregiver if he or she is satisfied with their child’s current sleep pattern and follow up on any concern that is expressed (Nativio, 2002).

2. Sleep problems are common in children.

3. Counseling families with anticipatory guidance regarding what is a normal sleep pattern as their child grows can give parents the tools they need to intervene as situations arise with their children.

4. Education about the effect on sleep of temperamental style, developmental stages, and changes in the environment will empower parents and enhance the parent–child relationship.

5. Families need to decide if the plan is workable for them and adapt it as necessary.

REFERENCES

Boynton, R. W., Dunn, E. S., & Stephens, G. R. (1994).
Manual of ambulatory pediatrics
(3rd ed.). Philadelphia, PA: JB Lippincott.

Chamness, J. A. (2008). Taking a pediatric sleep history.
Pediatric Annals, 37
(7), 502–508.

Ferber, R. (2006).
Solve your child’s sleep problems
. New York: Simon & Schuster.

Kemp, C. (2005).
Mexican & Mexican-Americans: Health beliefs and practices
. Retrieved April 14, 2009, from
http://bearspace.baylor.edu/Charles_Kemp/www/hispanic_health.htm

KidsHealth. (2007).
All about sleep
. Retrieved July 7, 2008, from
http://kidshealth.org/PageManager.jsp?dn=KidsHealth&lic=1&ps=107&cat_id=190&article_set=10233

National Sleep Foundation. (2009).
Understanding children’s sleep habits
. Retrieved April 14, 2009, from
http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2419295/
k.5AAB/Childrens_Sleep_Habits.htm

Nativio, D. G. (2002). Behavioral sleep problems in childhood.
American Journal for Nurse Practitioners, 6
(3), 30–32.

Pediatric Advisor. (2008a). Sleep patterns in babies. Retrieved July 23, 2008, from
http://www.cpnonline.org/CRS/CRS/pa_sleepbab_pep.htm

Pediatric Advisor. (2008b). Awakenings from being held until asleep (trained night crier). Retrieved April 14, 2009, from
http://www.cpnonline.org/CRS/CRS/pa_nightcr_hhg.htm

Pohl, C., & Renwick, A. (2002). Putting sleep disturbances to rest.
Contemporary Pediatrics, 19
(11), 74–95.

Schachter, F., Fuchs, M., Bijur, P., & Stone, R. (1989). Co-sleeping and sleep problems in Hispanic-American urban young children.
Pediatrics, 84
(3), 522–530.

Schmitt, B. D. (1992).
Instructions for pediatric patients
. Philadelphia, PA: W. B. Saunders.

Schultz, J. R. (2001). Sleep and bedtime behaviors. In R. C. Baker (Ed.),
Pediatric primary care: Well-child care
(pp. 283–290). Philadelphia, PA: Lippincott Williams & Wilkins.

Chapter 12

The Child Who Is Very Busy and Doesn’t Listen

Larry W. Lynn

The incidence of attention deficit hyperactivity disorder (ADHD) has increased dramatically in the past two decades. Current studies estimate up to 8.7% of individuals under 18 years of age are affected by ADHD (Froelich, Lamphear, & Epstein, 2007). Parents of children with ADHD and other individuals are concerned these children are unable to function well at home and in the community, unable to maximize their own potential, and certainly strain their parents’ satisfaction and joy in parenting. Practitioners must be vigilant to thoroughly evaluate and appropriately treat patients presenting with possible ADHD. This includes performing a detailed history and physical examination, utilizing behavioral screening tools, ordering appropriate laboratory tests, closely working with psychologists, and titrating medications to an optimal dose.

Educational Objectives

1.   Use DSM-IV-TR criteria to develop conversational questions with parents and child as part of the assessment process when screening patients for possible ADHD.

2.   Develop differential diagnoses to rule out other behavioral problems.

3.   Identify strategies to collaborate with parents, teachers, and psychologists as a treatment team to assist in patient management.

4.   Identify strategies to best utilize follow-up appointments in person or by telephone to assist in treatment decisions.

5.   Understand the appropriate use of various psychoactive medications for the treatment of ADHD.

6.   Know the warnings about treating children and adolescents with stimulant and nonstimulant medications to control ADHD symptoms.

7.   Consider the implications of ADHD as a lifelong condition that can possibly lead to problems throughout the lifetime for affected individuals.

   Case Presentation and Discussion

Jason Black is an 8-year-old male child who presents to your office accompanied by his mother for a behavioral consultation. He began third grade 3 months ago and is having academic and behavioral problems at school. Despite the efforts of his parents and teachers to help him organize, Jason remains unorganized with his work and belongings. He often fails to bring homework home and frequently forgets to turn in completed assignments at school. He is restless and impulsive. He often blurts out answers in class, interrupting the teacher or his classmates. He tends to violate the personal space of his peers and interferes with their play and interaction during recess and physical education. As a result, he is being socially isolated by peers.

At home, he fails to follow through with parental instructions. He often loses important items such as homework and even his favorite toys. His room is described by his mother as “looking like a tornado came through.” The parents have tried time out, restricting activities, and spankings but have seen no improvement in his behavior. He is beginning to see himself as different and describes himself as “dumb” and states, “I have no friends.” His teacher suggested the parents seek medical advice and “get some medicine to calm him down.” The mother knows there is a problem with Jason’s behavior, but is concerned for him to be labeled with ADHD. She is also concerned with the negative comments she reads on various Web sites about treating children with medications to control the symptoms of ADHD. She describes feeling lost because she doesn’t know how to help her child.

What questions would you ask Jason and his mother to expand on the information above?