February 15, 2009

Breakthrough with a Two-year-old's anxiety

Some time ago, I looked for but couldn't find the origins of the phrase 'terrible twos.'

I could not find who invented the terrible 2s. I think it's a great year. Finally, they are talking just enough to let you know what they want, sometimes. They are interested in everything and going everywhere. This is often inconvenient, but it's a wonderful thing to see in terms of their development. They often explore and are willing to put themselves in harm's way just for the thrill of your raising your voice and yanking them back to reality. They are busy discovering new techniques to meet their most important goal: getting the parent to play with them.

With that said, however, I got a call last week from a woman whose English was as bad as my Spanish. We had enough overlap to make an appointment. She brought her 2 year old for what she had called a check-up. As soon as they walked in the office, I know that no check up was going to be getting accomplished. They opened the door to the office, walked in, and the child started screaming. Not crying--that happens sometimes with very anxious children--screaming at full capacity as if in pain. The other kids in the office were startled. My medical assistant didn't know what to do. The child took one look at the student who was following me around that day and increased his volume higher.

I ushered out the other patients.

I asked mom to follow me into the room with the sofa. He never left her side, of course. I asked the mom, over his shrieks, if my student could observe and she was gracious about this. I observed the child for about 5 minutes, during which he played with none of the toys that are in all of my exam rooms. He simply stuck to his mother, screaming.

I told the student--something I almost never do--I'm going to need your help. She nodded OK. I told her to avoid all eye contact with the child, no matter what. Then I picked up the large basket of stuffed animals and puppets, and without warning, dumped the entire contents onto the floor in the middle of the room. He stopped, was silent and watched what might happen next. I picked up two hand puppets and told the student to pick up 2 also. She got the cow and the frog. Ignoring the child, she and I played with the puppets, moving their mouths and making animal sounds for at least 10 minutes. He left his mother and came to get a closer look. I took off one of the puppets and gave it to him. Then I sat on the floor and played puppets with him. After a little while, he would smile and laugh with certain puppet actions. I retrieved a Thomas and James train from the other room. He liked these a lot and I sat on the floor with him as we rolled them back and forth between us. I showed him my otoscope, which he liked holding--who doesn't like a flashlight?--so I let him hold it as he looked in my mouth and I in his. I let him play with my stethoscope, then back to Thomas, then back to the stethoscope. I let him listen to some of the stuffed animals. I said it was my turn, even though he didn't understand any English, and he let me listed to his heart and lungs and abdomen.

The whole exam took about 70-80 minutes, most of which was playing with him. When he left the office, he said goodbye and gave me a hug.

His mother told me that he had been very traumatized by the previous place they went for medical care. I'm proud to say that she also said that she had never seen him allow even as much exam as I got and that this represents a major breakthrough for him.

I got that sense as well, I'm glad to say. I grow increasingly convinced that rapport with a child cannot be established in minutes, and this is even more true for difficult children or those who have been hurt in the past. Our medical care delivery paradigm has been optimized for the shortest possible visit, and this will only exacerbate the trauma children (and adults!) experience when they go to the doctor.

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Please let me know what you think. Do you know a child or situation like this?