Magical Thinking. Giftedness. PTBM.
Greetings! Welcome to another issue of DBP in 1-2-3, a newsletter devoted to child development and behavior from a medical perspective. This newsletter aims to present topics about developmental stages and expectations and not focus exclusively on diagnosis and treatment. All medical students get “child development 101” during their pediatric rotations, and developmental milestones are core competencies for residents sitting for the pediatric boards. Yet, I find that in practice, pediatric providers often rely more on checklists and parent surveys rather than their own eyes and curiosity. How can they be at fault here? Who has the time in primary care these days to sit and interact with a child, let alone a parent? What can one possibly observe in a ten-minute visit? Actually, quite a bit. One goal with this newsletter is to give providers practical and efficient ways to size up a child’s development and behavior, even in a hectic clinic setting. I intend to present topics in small, digestible chunks and guide you to additional resources when necessary or if you want to take a deeper dive. I am inspired by the book, Encounters with Children: Pediatric Behavior and Development by Suzanne Dixon and Martin Stein. This book was seminal in my decision to become a developmental-behavioral pediatrician. It brought home the point that child development is the basic science of pediatrics. I would add that the book also embraced the idea that interacting with and observing children was very much an art and more impactful in understanding a child’s well-being than memorizing a bunch of developmental milestones. Although Encounters with Children has not been updated in years (I’ve heard there are no plans to), it remains highly relevant for today’s practice. It should be on every pediatrician’s bookshelf.
#1 Magical Thinking
From the ages of 3-5 years, there is a blossoming of a child's imagination. It is a delightful phase of child development for caregivers (who can't resist being sucked into the make-believe world of a four-year-old?). For clinicians, it is a wonderful opportunity to peek into the window of the child's mind. Imaginary play and magical thinking are essential tools for a child's cognitive and social-emotional development. These tools help with executive functions, reasoning, social communication, and creativity. They allow the child to process events in their lives—from happy to stressful ones—and helps them work through their feelings safely and with flexibility.
Representation is when one thing stands for something else, and this underlies all imaginary and pretend play. Children older than three still engaged in mostly simple, imitative play (e.g., rolling a car back and forth, copying a parent feeding a plush animal) should raise red flags. Language also correlates strongly with play (and therefore, cognitive skills). High levels of imaginary play involve a lot of rich dialogue and details.
Not surprisingly, this is also a time of emerging fears, anxiety, and lying (though at this age, perhaps the more appropriate word should be "being untruthful" as toddlers/preschoolers do not intentionally deceive another person). These are born out of experiences, a more robust memory, and the ability to project what could happen. Fear can manifest as a flight or fight response. Some children will withdraw and hide when scared. Others will become aggressive or hyperactive. The emergence of fear in children should be expected and embraced. It's a chance for caregivers to empathize, reassure and help children cope. Excessive fear/anxiety may indicate problems coping with highly stressful or traumatic events. It may indicate delays in language, cognitive or social development.
From well-child to acute, any clinical encounter can give clinicians a quick qualitative assessment of a child's level of magical thinking. Some questions to consider:
How does the child respond to the rooming and physical exam activity? What are her coping skills to stress?
What toys/objects does the child bring into the office? What are his favorite toys at home?
Does the child show interest in books? Role-playing? Social play?
Does he tell stories, point to pictures or objects of interest, and try to get you or the caregiver's attention?
Many times before walking into the room, I pause at the door to listen to how the child and caregiver are interacting. It gives me a sample of their language and social skills unbiased by my presence as the "threatening" or "strange" doctor.
Although it is always nice to have a few toys and books for children in the exam room (hopefully more commonplace once the pandemic is in hindsight), there are many ways to assess a child's play and imaginary skills with nondescript objects. I love giving tongue suppressors to children and see what they would do with them. Would they build a house, pretend it's an airplane or skateboard? What would they do with an empty paper cup? Make a hat or drum? This may irk the medical assistants, but what would they do with exam room paper? I've seen children use it as a blanket for their stuffy or a cape for themselves. I've also seen autistic children tear it up into tiny pieces and put them neatly in piles. With a little bit of creativity, there are many opportunities to observe a child's level of imagination and consequently tell you a lot about their cognitive, language, and social-emotional development. Children who fail to meet your expectations of appropriate play should warrant further investigation, close monitoring, and possibly early intervention.
#2 Giftedness
Recently, a colleague reached out to me about a patient of hers who was considered gifted. The child and his current school did not seem to be a good fit, and the parents were looking into private school options and IQ testing. It got me thinking about some of the patients in my practice who are gifted but have significant behavioral and emotional challenges.
There are several definitions of giftedness. There is not a universally accepted one; however, one cited frequently comes from the National Association for Gifted Children:
Students with gifts and talents perform - or have the capability to perform - at higher levels compared to others of the same age, experience, and environment in one or more domains. They require modification(s) to their educational experience(s) to learn and realize their potential.
Simply put, a gifted child performs or has the capacity to perform significantly above age- or grade-level expectations. It is also important to know that a high IQ score in itself does not determine giftedness. Standardized tests cannot factor in a child's creativity and practical intelligence. High intelligence and superior academic performance typically come to mind when people hear the word "gifted," but there could be nonintellectual giftedness (e.g., music, art, athletics). Cultural factors and expectations also play a role in determining giftedness and what skills are valued in that society. Experts note that gifted children often present with "asynchronous development" associated with a heightened intensity that creates inner experiences and insights that are very different from the norm. With higher ability comes a potential vulnerability in these children's emotional well-being. Many are highly sensitive, easily overstimulated, hyperfocused, anxious, and socially awkward. This is especially notable in profoundly gifted children (IQ >160). As a result, parents (and teachers) often struggle in providing gifted children appropriate modifications in their learning and environment. There may be challenges in how these children relate to peers and respond to authority figures.
Not surprisingly, gifted children are commonly misdiagnosed. For instance, a distractible child who fails to complete tasks and is resistant to school work may be misdiagnosed with ADHD, inattentive type, or oppositional-defiant disorder instead of considering that he might have an active imagination and needs constant intellectual input to stay engaged. On the flip side, some children are described as "Twice-Exceptional" to indicate that they are both gifted and have a neurodevelopmental or psychiatric disorder. They may have advanced development in some areas and average or below average rates in others (i.e., asynchronous development).
Some key things to consider when trying to sort out giftedness from disorder/diagnosis:
Is there a developmental history of early achievement of milestones?
Are the behavior challenges pervasive (across different settings) or specific in context?
How do the behavior challenges change when the gifted child is in intellectually supportive settings?
Do the behaviors really lead to functional impairment (socially, adaptively, academically), or are they merely quirks and idiosyncrasies that cause minimal impairment or dysfunction.
Our job as pediatric providers, especially in primary care, is to identify children who may be gifted, rule out coexisting conditions, and provide support to families with gifted children. Gifted children often present with advanced verbal skills, highly self-directed interests, and expansive knowledge in a subject or activity when compared to their peer group. Pediatric providers should emphasize to families that gifted children should be expected to be independent with activities of daily living, respect and follow the rules at home, perform well at school, have friendships and healthy extracurricular activities. Pediatric providers can be a valuable resource in counseling families about assessments for giftedness (and assistance with referrals), nurturing the abilities of gifted children, and providing a balanced perspective given the high pressure and stakes that often surround gifted children. Not all need to be in a special school or skip a grade (there may be unintended adverse consequences to these interventions). Every child has different needs. Providers should take children's temperament into account. The good news from the research literature on gifted children is that most are well-adjusted, emotionally healthy individuals. The rate of psychopathology is not significantly greater than the general population.
There are several helpful resources for clinicians and families of gifted children. Below are just a few:
National Association for Gifted Children www.nagc.org
Duke University Talent Identification Program www.tip.duke.edu
Supporting the Emotional Needs of the Gifted sengifted.org
Twice-Exceptional Newsletter www.2enewsletter.com
Association for the Gifted http://cectag.com
Davidson Institute https://www.davidsongifted.org
Helping Gifted Children Soar: A Practical Guide for Parents and Teachers, 2nd ed. by Carol Strip Whitney and Gretchen Hirsch (2011)
Keys to Parenting the Gifted Child, 3rd ed. by Sylvia B Rimm (2006)
Misdiagnosis and Dual Diagnoses of Gifted Children and Adults: ADHD, Bipolar, OCD, Asperger's, Depression, and Other Disorders, 2nd edition by Webb, J.T., Amend, A.R., Beljan, P., Webb, N.E., Kuzujanakis, M., Olenchak, F.R., & Goerss (2016).
A Parent’s Guide to Gifted Children. by Webb J, Gore J, Amend E, et al. (2007).
Gifted Kids Survival Guide series of books by Judy Galbraith (2009 and 2011)
#3 PTBM
Families often assume I will recommend medication for their child with ADHD. It's quite common to preemptively get an "I don't want my child on meds" comment before even starting a discussion on treatment. I don't blame families with all the confusion and mixed messages out there. Stimulant medications have a bad rap in the lay/social media, from misinformed families or teachers and pseudo-experts, the latter often peddling their own "scientifically based" treatments. The fact of the matter is while there is a solid research evidence base behind stimulant medications for the treatment of ADHD (and at the forefront of treatment guidelines from the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry), it should not always be considered as a first-line treatment option for ADHD. A multimodal approach is recommended for all children with ADHD. There is solid evidence that suggests behavior modification in the form of parent training for behavior management (PTBM) should be considered first or simultaneously with stimulant medications. This is especially true for young children (< 6 years of age).
In the book ADHD: What Every Parent Needs to Know, authors Mark Wolraich, MD, and Joseph Hagan, MD, offer a succinct description of PTBM:
Parent training in behavior management (PTBM), a form of behavior therapy taught to parents, has been proven to be reliably effective in helping children, including those with ADHD, to use appropriate behavior and function in more positive ways. This form of therapy focuses on helping parents to recognize praise and reward appropriate behaviors and to decrease their child’s aggressive, noncompliant, or hyperactive behaviors.
The key factors behind this definition are 1) parents take center stage because research shows that "enhanced parenting skills" are needed to improve outcomes in children with ADHD (and that ADHD is not caused by faulty parenting), 2) positive interactions, active listening, consistency, and structure are important components of a successful plan, and 3) practice, practice, practice.
PTBM is very different from cognitive behavior therapy (CBT), which often gets confused with PTBM (as well as other modalities like play therapy or psychotherapy). CBT is designed to shape thinking patterns. It is effective in the treatment of anxiety and mood disorders in adolescents and older children. CBT has not been proven to be helpful in the treatment of childhood ADHD. PTBM is designed for adults to understand better, manage and shape a child's behavior.
There are many excellent resources out there for parents to learn and apply PTBM. The CDC is probably my favorite, and they have other good information about ADHD. PTBM comes in different forms and names (e.g., Incredible Years, PCIT, Triple P), but all operate on the same principles. Families often ask how long a typical program lasts (one month, six months, several years?). I tell them usually no more than 12 sessions (three months if done weekly) is sufficient. This gives ample time for parents to learn new skills, practice at home, and get feedback from the therapist. The sessions can be one-on-one or in a group of other parents with a trained and certified therapist (the person does not have to have a Ph.D. in psychology, and sometimes the best ones are parents themselves of a child with ADHD).
The biggest challenge for families, in my experience, has been in finding an available provider in the community, much less one that accepts medical insurance. It is deplorable that insurance companies make it difficult for families to get this important, evidence-based treatment a covered benefit. It's much easier to get medication paid for. No wonder many children are being overprescribed (adding to the negative stigma of medication for ADHD). That doesn't sit well with me, especially for younger children with ADHD.
Thanks for reading. This picture was drawn by a four-year-old boy with autism spectrum disorder obsessed with beanstalks. This was one of several pictures of beanstalks he drew during his visit with me.