“Not Listening, Stubborn, and Problems With Sleeping”—Interpreting a Parent's Concerns at a 3-Year-Old's Health-Supervision Visit

Abstract

CASE. Max, a 3-year-old boy, is accompanied by his mother for a health supervision visit. Two previously scheduled well-child visits have been postponed by parents because of busy work schedules. On this visit, Max's mother says that Max seems very healthy but that she is feeling frustrated by his not listening, his stubbornness, and his lack of cooperation. Max refuses to fall asleep unless he is in his parents' bed and even then wakes up and disturbs his mother's sleep. The sleeping situation is particularly difficult because she and her husband both work long hours and commute to the Silicon Valley. This necessitates a tag team approach to parenting. Max's father takes him to child care (in a home-based program for 12 children) at 7:30 a.m. The father returns home in the evening at 8 or 9 p.m. Max's mother leaves home at 5 a.m. and picks Max up at 6 p.m. She says that the hours and the commute are draining but unavoidable because of their house payments and the uncertainty of the economy. With tears in her eyes, she says that she feels terrible admitting it, but she finds it easier to deal with the demands of work than with Max. During the physical examination, Max is squirmy but cooperative as long as the pediatrician keeps him distracted with a series of small toys. He plays with the wooden trains on the examination table and explores them closely, spinning their wheels. The physical examination is normal with one exception: Max is unwilling to interact with the examiner until she sits down, watches him explore the room, and comments on what he is doing without asking him questions. He then points to toys on the shelves he wants and takes them from her without making eye contact. Max's mother asks him to say thank you, but he does not respond. She says that he is much more talkative at home and is able to recite passages of dialogue from his favorite videos. The pediatrician notices that Max opened his mother's wallet and is playing with her credit cards. The mother says that stacking and playing with cards is a favorite activity. Max also loves videos and will watch his favorite tapes two or three times a day if he can. She is a little worried that the many hours of TV he watches each day may contribute to his having trouble sitting still for stories at child care. Max seems to like the child-care setting although he rarely plays with other children. However, he generally resists playing with parents as well, although he seems happy to see them when they come to pick him up and does not like being left in the morning. Max continues to play on the floor of the room and does not look up. Max was a full-term 8 lb, 5 oz baby without prenatal or perinatal problems. He was colicky until 5 months of age and had six ear infections, but none in the past 6 months. Max met early language milestones appropriately, cooing at 3 to 4 months, babbling at 6 months, using a few words by 18 months, and two-word sentences at 2 years. Motor milestones were delayed, but by 18 months he was walking independently. When asked about a family history of neurological or developmental difficulties, it was revealed that the mother's brother was diagnosed with schizophrenia during adolescence. The pediatrician realizes that she needs more time to assess Max. She asks his mother to schedule another appointment to evaluate his behaviors and development in more detail. J Dev Behav Pediatr 23:96-101, 2002.