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A Musing Pediatrician

If I've Heard it Once

Gregory Lawton, MD, Pediatrics, General, 06:29AM Jun 18, 2013


"How do I get her off the bottle?"

Sure, just tossing the bottle out is effective. After all, if there are no bottles around, there's not really a choice. Either the toddler adapts and gets over it or has a knock-down, drag-out hissy fit and has to adapt several hours later. The end will be the same; the difference will be in the mileage.


However, I advise a more Machiavellian approach. It involves vinegar. "Take a bottle of milk, add in one tablespoon (15 ml) of white vinegar, and give it to them with a straight face," I tell parents. By doing this, acting entirely oblivious to the fact that the milk tastes odd, and placing perfectly good milk (minus the vinegar) in a cup nearby, you are encouraging the toddler to make her own choice.
There is no power struggle because the parents have been advised to sidestep the struggle.
Oh, and those stubborn ones who drink the slightly-acidified (read buttermilk) milk, either add more vinegar next time or try a dash of Tabasco sauce.

"What can I do to get him interested in the potty?"

This one I particularly like, as it involves confronting the parent with a question that naturally leads to a "oh, I never thought of it that way" moment.


"Tell me," I ask them, "where do you keeps the diapers and wipes in the home." Most parents tell me that they have a stash in the bedroom, family room, even living room. They may even boast that they have potty chairs in the same rooms, "to encourage them." Then I spring the trap. "Why do you have a potty in the family room? Is that where you go to the bathroom?" The parent furrows their brow. Apparently they never thought of it that way.

Before the parents can come back with either a witty retort or a left hook, I quickly add this. "If you want them to think about the bathroom as a special room for only certain activities, then take everything associated with the bathroom out of every other room and PUT IT IN THE BATHROOM."
I look at it this way. By having all the diapers and wipes in the bathroom, then you are making it necessary to LITERALLY go to the bathroom to get the stuff to get changed. Essentially, without saying a word, you are enabling the connection to be made between excretory functions and the special room associated with such functions. Six diapers a day? Six trips to the bathroom a day. "Hmmmm," thinks the toddler. "Must be something special about this place."

"My five year old knows how to push EVERY ONE of my buttons!"

This is the kid who knows what they want, how they want it, and have figured out the way to get it. They have mastered tantrums, breath-holding, screaming, throwing, you name it. Their parents are in a knockdown-drag out power struggle. And they are losing. Chances are, they have a strong willed child (neither a crime, nor that unusual) but have erred in either not setting limits or in giving in too easily.
I introduce them to the concept of a token economy. My variation works like this:


1 - During a quiet moment, create a list of examples of "good choices or actions." Perhaps saying "please or thank you." Maybe fetching a requested item or putting something away. If there is a new sibling (a big stressor as far as a five year old is concerned), maybe doing something nice for this new sibling.


2 - Draw up a list of examples of "bad choices or actions."


3 - Like a menu, put token amounts next to each item. For instance, saying please is worth one token, putting away a floor of toys is worth two tokens, and hitting a sibling costs three tokens.


4 - Get a clear token jar, and start each morning with at least five tokens. As the morning progresses, add or subtract tokens based on good or bad choices. Make the child aware at the time why tokens are being added or subtracted. Come lunch time, it's time to cash in a given number of tokens. Having frequent "cash-in" times during the day helps a child make connections between choices and consequences.

5 – Determine ahead of time what these tokens can buy. The “currency” has to be valued by the child. Is it more time at the park, more reading time before bed, time with a video or game on a tablet or Smartphone? Parents may need to be creative, but I ask them to think about what their child is always asking to do to which they are always saying “no.” This might just be the currency.

Each of these questions is fairly typical from parents seeking help or guidance. There is nothing particularly profound in the responses. The central theme is control. If you cede some control to the child, even imaginary control, you create a partner. A partner is someone who has “skin in the game” and a sense that they have a say in what happens to them during the course of the day. The key is this, however: it is the parent who is aware of things even behind the scenes. We know what is behind the curtain. It is still our show. The child is given a leading role, but is not the director.

We set up the bottle situation. The child just thinks they have a choice.

We set up the bathroom situation. The child doesn’t think going into the bathroom to get the changing supplies is a step in the direction of “going to the bathroom” even though it is.

We set up the token economy. The child starts to focus on the ability to get rewards based on behavior or choices. They didn’t know you were planning to stay at the park for 40 minutes but “thought” they were rewarded for good choices with an extra 10 minutes.

Welcome to Parenting: The Production!
About This Blog

My main job, as a general pediatrician, is “to explain, to reassure, and to know when to refer,” because most of what I see is a variation of normal. This blog discusses the art and science of pediatrics as well as the challenges and rewards of seeing newborns through to adulthood. It also looks at events in the world and how those events affect children, parents, and, the pediatricians who care for them. Look for it twice a month.

Look for me on Facebook at A Musing Pediatrician,
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Follow me on Twitter at @amusingpedsdoc, https://twitter.com/amusingpedsdoc

Disclosure: L. Gregory Lawton, MD, has disclosed no relevant financial relationships.Poll: Do you feel you have the time, expertise, and materials necessary to manage concussions in your patients? Yes - I have this now.|Not yet - but I will be getting this soon.|No - I don't feel prepared.|I don't think this is an area for the general pediatrician or family practice doctor.|

  • Gregory Lawton

    Dr. Gregory Lawton is a pediatrician with the Children's Hospital of Philadelphia (CHOP). He attended Jefferson Medical College in Philadelphia on a scholarship from the US Air Force and completed his pediatric residency at a teaching affiliate of the University of California, Davis at Travis Air Force Base, California.

    From 2000 to 2003, he served as the pediatrician at Hanscom AFB in Massachusetts.  

    He exchanged the polyester Air Force uniform for cotton fiber in 2003 when he moved to the Philadelphia suburbs to work for the Children's Hospital of Philadelphia.  He sees patients at CHOP Care HighPoint.

 
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