Your Child's Developmental and Emotional Health -- Steven Parker, MD

Last Editorial Review: 6/4/2004

WebMD's pediatric expert, Steven Parker, MD, joined us to discuss the steps to take when your child may need extra help to grow and thrive.p>

By Steven Parker
WebMD Live Events Transcript

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live. Joining us now is WebMD's own pediatric expert Steven Parker, MD, who is here to discuss your child's physical and emotional development.

Member: Our 5-year-old son has been diagnosed with sensory integration disorder, and his pediatrician thinks he may have ADHD. Our son is totally defiant with us and will not do as we ask. Does this go along with the sensory integration disorder and the ADHD? How can we discipline him and gain some control of our house again?

Parker: That's a really great question. I'm afraid I won't be able to answer all of them, but I would like to clarify a few things.

First, what exactly is sensory integration disorder? This is a relatively new diagnosis and there is still a lot of controversy about whether it even exists and, if it does, what exactly that means. The diagnosis is usually made by occupational therapists, not physicians or psychologists. The idea behind it is to explain why some children seem to have such a hard time with various kinds of sensory input.

For example, some children absolutely hate to be touched or hate the feel of new clothing and insist on wearing the same old flannel shirt every day. Other children seem hypersensitive to sound and become overwhelmed when there is a lot of noise. Still other children have a hard time knowing where their bodies are in space. All of these may be indicative of "sensory" issues, which some would label as "sensory integration disorder."

While it is clear to me that children may have such sensory issues, the diagnosis of sensory integration disorder is less clear. It is not known, for example, if the kind of treatment provided for sensory integration disorder actually helps children or if this is something that gets better with time anyway. When this is a question, I suggest parents read the book The Out of Sync Child, which has some good advice about how to help children with sensory issues.

You also mentioned a concern that your child might have ADHD. This clearly can play a role in children who are oppositional and defiant and deserves further exploration. If indeed he is found to have ADHD and he receives effective treatment, his defiant behaviors may improve significantly.

Finally, you asked for advice on how to handle these kinds of behaviors. Clearly, the first order of business will be to decide what is causing them. Do sensory issues play a role? Does he have ADHD? Are there any stresses in his life, at home or at school that may be contributing?

Secondly, I am recommending a wonderful book for parents with difficult children. It is called The Explosive Child, by Ross Greene. I think it has a wonderful model for thinking about understanding difficult children and their discipline. Good luck!

Member: My 10-year-old is on Paxil. He has tons of fears of dying and or someone coming in and killing us all. Four years ago we lost [a] son to SIDS. [The 10-year-old] just now became angry and unhappy this last year. It does not affect his schoolwork. He is an honor roll child, but when he gets home his whole attitude changes. He fights a lot with his brother, and gets very angry with us. He also is very much into his Christianity. It's almost like he may be blaming us for his brother's death. Could this be true?

Parker: This sounds pretty complicated, so I'm not going to be able to answer your questions as well as the people who know him and you personally. It does seem that he is having fears and worries and emotions over and above what one might expect based only on the tragic loss your family four years ago. It is possible that he is showing signs of an anxiety disorder that he might have had anyway. Or, perhaps, he has somewhat obsessive thoughts and fears that he thinks about over and over again in his mind in an almost obsessive way. It also may be that he is reflecting some fears and emotions that the entire family shares.

The bottom line, as it sounds like you've wisely already done, is that he needs some professional help to figure out any kind of diagnosis, what might be causing it, what medications might be helpful (Paxil is thought to be effective for both anxiety and obsessions), and to let him talk about his feelings in a therapeutic way so he can move beyond them. Because he is getting help at such an early stage I would be quite optimistic that over time many of these issues will fade away. I wish you the best of luck.

Member: Yeah, I am trying to get him into all kinds of help; he starts therapy next week.

Moderator: Good luck to you!

Member: Can you speak to delayed development and how myelin deficiency could play a part in it? Also, could an arachnoid cyst on the temporal lobe be a potential cause of delayed development and autistic tendencies for a 13-month-old who never really regressed, but rather has not developed normally?

Parker: If I'm reading between the lines correctly, it sounds like your 13-month-old had an MRI that showed decreased myelinization and a cyst in the temporal lobe.

Member: Correct.

Parker: Whenever we see a brain that looks atypical, we naturally connect it to the developmental delays that we are seeing. So it is possible that cyst is part of the reason for your child's developmental delay. However, sometimes we see cysts in babies whose development is also perfectly normal. The brain is continuing to myelinate over the first few years so the delay in that area may also be a sign of an "immature brain." I doubt that it means there is a specific problem with myelinization; rather it means the brain is immature.

The bottom line is that you need to discuss these findings with a pediatric neurologist who can better help to put them in perspective.

But more importantly, I hope that early intervention has already begun to provide extra developmental services for your child. No matter what the brain looks like on MRI, the treatment for a child with developmental delays is the same: extra services that can be provided for free at The Early Intervention Program. Then, how a child progresses (or does not progress) over the next year or two is by far the best indicator about the nature of the problem. Best of luck.

Member: What kinds of developmental issues should a parent of a preemie look for? And are preemies more susceptible to them then a child who was full term?

Parker: Great questions. First, there are preemies and then there are preemies. It is amazing how well almost all preemies do in the end but, clearly, the smaller a preemie was, the more likely there could be long-term developmental challenges. For example, preemies who are above 1,500 grams (3.2 pounds) have very few issues whereas preemies who were born under 1,000 grams (two pounds) have quite a few more. But again, I want to emphasize that although the risk for developmental and behavioral problems in ex-preemies is greater than in full-term infants, most do not have problems and do incredibly well.

The first area to keep an eye is how well the baby moves. Many preemies have problems with "tone." That means some of their muscle groups (often the legs) are tighter than average. This often goes away after six to twelve months and is of no long-term significance. In a small percentage it may persist and indicate a problem with muscle movements, usually due to something that happened in the brain while the baby was sick. So I recommend that a physical therapist get involved early on if there are any problems with tone or meeting motor milestones. That way, if it goes away on its own, no harm done. But if the problem does persist, you started treatment early, which may help in the long run.

The second area I would watch for is language development. Many ex-preemies are slower in talking. Again, sometimes this improves on its own and is not a sign of any long-term trouble. In other children, slow language development can indicate a potential delay in cognitive development, or perhaps, a learning disability later on in life. That's why any preemie who does not have many words by 18 months I would refer to a speech therapist.

The bottom line: The needs of your child are really not much different than any other baby. More important than anything will be the love and nurturance that I know you will give. That's the best medicine of all!

Member: I know that all toddlers develop at his or her own pace, but when should a parent be concerned about a child's language development?

Parker: That's a good question because language development is so important and often the first area in which we notice a child may not be developing in the usual way. As a general rule, any child for whom a parent has a concern about language should have a hearing test. You just need to be sure that the child is hearing speech in the normal way. I have a very low threshold for referring a child of almost any age for a hearing test should anyone have a concern about a speech and language delay.

Second, I always want to be sure that the child's environment includes appropriate language stimulation. By that I mean that people are talking to the child a lot and perhaps reading to him or her every day and that child is not slow because no one is actually using language to communicate.

If the hearing is normal and the language environment is fine, then I usually don't worry about the child's language until about 18 months. Certainly a child who has only a few single words or less at 18 months should have a speech and language evaluation for delays. At that time it's important to decide if a child can understand what is said better than he or she can actually use expressive language. But this is best done through a formal speech and language evaluation.

Before 18 months, there is a lot of variation of when children begin to use meaningful language. Many normal children do not begin to talk until 15 months, which is why I tend to wait until 18 months before calling in the troops.

By two years of age, I would expect a child to be combining words together into at least two word sentences. He or she should also have a vocabulary of much greater than 50 words. If neither of these is true, again I would recommend a formal speed and language referral. My bottom line is that by two years of age (and often earlier) we can and should be able to know if a child has delayed language skills and begin to provide extra services by that time.

Member: When my niece's mother gets angry with her 3-year-old, she often yells saying, "Mommy doesn't like you when you're like that. Mommy doesn't even want to be around you." Later she says if she keeps acting a certain way she'll go to her dad's or aunt's house. My niece cries and asks repeatedly, "Mommy, why you no like me?" Her mom doesn't console her, nor does her mom explain the difference between disliking the behavior versus the child. Isn't this harmful to her emotional development?

Parker: I wish it had been your niece's mother who had written me instead of you. Clearly, what she is doing is a very worrisome and potentially destructive discipline technique. One of the most important things a parent can give to a child is the sense that he or she is loved no matter what happens and what negative behaviors she might do.

The threat of withdrawal of love and banishment to another house gives exactly the opposite message and can wreak havoc on the little girl's emotional well-being. I suspect her mother may have experienced a similar child-rearing style in her own life.

It's hard to know what to do when one sees this. I hope you can talk to your sister-in-law about your concerns in a non-judgmental, supportive way. Perhaps she would like a book or something to read about discipline or perhaps there are local parent support groups or parenting classes available that might interest her. It's a tough situation but I think you're right to be concerned.

Member: My 2-year-old has been found to be developmentally delayed and I need advice. How can I help him until his therapy starts with learning to feed himself, get him interested in scribbling, and playing with his toys properly so he is not always throwing them? The things I have tried are just not working.

Parker: Excellent question. The most important thing for your child is not that you learn to become a super teacher but that you remain a terrific parent. The most important things you can give your child are to continue to love him and care for him and give him a sense of love and security. No matter what happens with his developmental delays, that sort of parenting will be crucial in how he does in the long run.

So don't get all hung up in becoming his therapist. Having said that, his therapist will give you educational exercises and stimulation that will be helpful for him. While you're waiting for them, the only things I would suggest are a consistent kind of extra stimulation. By that I mean perhaps sitting and reading with him for 10 minutes twice a day, every day. It could mean sitting with him and having him attempt to use a crayon every day.

I don't think it's so important exactly what you do with him at this stage (you'll get help with that soon) but that he gets used to sitting down with you (and later with his Early Intervention therapist) to focus on a task. Then we'll see how things go over the next year or so, which is the best marker of how he's going to do later on. Good luck and keep me posted on the message board.

Member: My child is 8 years old and still wets the bed occasionally. Is further evaluation or treatment necessary?

Parker: It sounds like your 8 year old still has "primary enuresis." That means that he or she never had a dry period and has continued to wet the bed at night. This is not uncommon and often runs in families. It is not a sign of psychological distress and rarely is there a physical problem. It seems to have more to do with immaturity of the part of the brain that tells all us not to pee when we are asleep. Since it doesn't happen every night, you could do nothing. About 1 in 7 children grow out of it every year.

On the other hand, if it is causing your child or the family significant distress, there are effective treatments. Perhaps the best is a urine alarm, which wakes the child up as they're wetting the bed. This appears to "teach" the sleeping brain not to pee at night. However, it does take a few months and the child does need to want to do it. I suggest you discuss this with the pediatrician and decide which option would work best.

Moderator: Unfortunately, we are out of time. Thanks for joining us, members, and thanks to Steven Parker, MD, for being our guest. For more information on any pediatric issue or concern, visit Dr. Parker's Parenting message board here at WebMD. Just go to our member communities area and you'll find his message board.

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