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What Type of Problems is Bullying Associated With?

Donna M. D'Alessandro, M.D. — Mon, 14 May 2012 15:05:40 +0000

Patient Presentation
An 8-year-old male came to clinic for health supervision. His mother said that he seemed to be on the losing end of verbal playground confrontations and was not being included in organized soccer and football games at school. These were games that he loved to play and there had been no problems until the new school year began. The patient was having no other social problems. The pertinent physical exam showed a healthy male with growth parameters in the 10-25% and his examination was normal.

The diagnosis of a healthy male was made. More history showed that a new boy had started school in the fall who was almost a year older and physically larger. The patient stated that the new boy usually picked the teams and decided who would play each recess. The patient and another boy who was also physically smaller were not included very often but were told “you can play in a little while” which didn’t happen by the end of the recess. This occurred before school and during recesses. The patient related that the new boy also was loud in the classroom and lunchroom and would make fun of others, particularly younger children or those that were physically smaller. He would call hiimnames such as “baby” and “twerp.” The new boy would not physically hurt someone but would take advantage of mishaps such as mis-talking or dropping an object to make fun of a person, and when he did so it was quite loud. The patient didn’t feel he could do anything about this. The mother was surprised to hear these details.

The physician and mother agreed that contacting the school counselor to help address the playground and lunchroom relational dynamics would be a good first step. Additionally, the mother thought the counselor could also help her to make the classroom teachers aware of the problem. At followup a few weeks later, the patient reported that he was getting to play with all the kids and do the things he liked to do. The mother reported that counselor and teachers were working with the new boy to give him positive outlets for his leadership abilities (i.e. lunchroom helper) and opportunities to work with smaller children (i.e. reading with first grade students). They also did specific student pairings in academic groups to help the new boy and the other victims learn more about each other as people. On the playground, the teachers reiterated and monitored the school rules that everyone gets a chance to play in activities. The patient said that the new boy was “nicer” now.

Discussion
Bullying is the use of power and aggression to cause distress or control another person. Bullying is an aggressive behavior conducted from a position of power (which may be obvious or not obvious to others such as size, strength, social status, etc.) and is repeated over time. Although repeated behavior is a key element (and necessarily excludes normal negative interactions such as verbal disagreements), one episode of use of power and aggression is many times seen by children as bullying. Direct bullying is an observable behavior including verbal aggression (e.g. insults, threats, sexual or racial harassment) and physical aggression (e.g. hitting, kicking, punching, etc.) Indirect bullying is sometime called relational aggression and may be unobservable or covert manipulation of social relationships (e.g. rumor spreading, gossiping, exclusion) that hurts or excludes a victim. Cyberbullying is one example of indirect bullying.

Although bullying is seen in all age levels, most people talk about bullying in children and teens.
There are basically 4 groups: children that bully, children that are victims, children that bully and are victims, children that are neither.
A 2009 study in Massachusetts of 5800 middle and high school students (~2900 in each group) found that children who bullied or were bully-victims had higher odds-ratios of being a victim of physical violence and especially of being witness to domestic violence. This increased odds-ratio for domestic violence and bully-victims is especially important as the bully-victims would have the experience of seeing both bully and victim in the domestic violence situation.

Percentage		Neither	Bully		Victim 	Bully-Victim
Middle School		56%		7.5%		26.8%	9.6%
High School		69.5%	8.4%		15.6%	6.5%

Odds Ratios
Middle School
Being physically
hurt				--		4.4		2.9		5.0
Witnessing family
violence 			--		2.9		2.6		3.9

High School
Being physically
hurt				-- 		3.8		2.8		5.4
Witnessing family
violence			-- 		2.7		2.3		6.8

After identifying a possible bullying situation, physicians can ask the “5W’s and H” questions to help determine what type of help may be appropriate for an individual situation.

Who do you bully/who bullys you?
What do you do to others/what do others do to you? (e.g. gossiping, insults, hitting, etc.)
When and how often do you bully/are you bullied?
Where do you bully/where are you bullied?
Why do you bully others/why do you think you are bullied?
How do you think the kids feel when you bully them or how do you feel when you are bullied?

Bullying is a multifaceted, relational problem, so multimodal approaches helping individuals, families and the community appear to be the best. Study results appear mixed when looking at the specific types of interventions and their efficacy. School based programs have been evaluated and again their effectiveness is mixed. The CDC recommends: “1) establish a social school environment that promotes safety; 2) provide access to health and mental health services; 3) integrate school, family and community prevention efforts; and 4) provide training to enable [school] staff members to promote safety and prevent violence effectively…. [C]omprehensive strategies that encompass the school, family and community are most likely to be effective.”

Learning Point
Bullying has been associated with poor school/academic achievement, mental health problems, physical health symptoms, substance abuse and other forms of violence. Indicators of children who bully or are victims often are the same including: physical symptoms such as headache or stomachache, difficulty sleeping, enuresis, school problems including absenteeism, dropping out or low grades, drug and alcohol abuse, anxiety and depression and even suicidal thoughts, attempts or completions. Children who bully may also display manipulation and/or aggression towards family members or animals, show little concern for others feelings or posess items/money that are unexplained. Children who are victims may display injuries or have damaged items or clothing. They may need money, be hungry after school or lose items. They may also threaten or carry out injury to themself or others.

Questions for Further Discussion
1. What resources are available in your community for bullying and/or domestic violence?
2. What attributes could be protective against bullying?
3. When does bullying reach the level that the law enforcement needs to be involved?

Related Cases

Bullying

Behavior Problems

Psychiatry and Psychology

School

Social Services

School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Bullying

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Mishna F. Learning disabilities and bullying: double jeopardy. J Learn Disabil. 2003 Jul-Aug;36(4):336-47.

MMWR. The Effectiveness of Universal School-Based Programs for the Prevention of Violent and Aggressive Behavior. August 10, 2007. Vol. 56. No. RR-7. Available from the Internet at http://www.cdc.gov/mmwr/pdf/rr/rr5607.pdf (rev. 8/7/2007, cited 3/8/2012).

Vreeman RC, Carroll AE. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007 Jan;161(1):78-88.

Lamb J, Pepler DJ, Craig W. Approach to bullying and victimization. Can Fam Physician. 2009 Apr;55(4):356-60.

Centers for Disease Control and Prevention (CDC). Bullying among middle school and high school students–Massachusetts, 2009. MMWR . 2011 Apr 22;60(15):465-71. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6015a1.htm (rev. 4/22/2011, cited 3/8/2012).

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Interpersonal and Communication Skills
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

Systems Based Practice
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Should I Counsel a Mother Using a Bedside Co-Sleeper?

Donna M. D'Alessandro, M.D. — Mon, 07 May 2012 00:16:25 +0000

Patient Presentation
A 4-month-old female came to clinic for well child care. The mother reported using a bassinet-style co-sleeper next to her bed for the infant to sleep in. She liked this because she could roll over at night and take the infant into her bed to breastfeed and return the infant to the co-sleeper easily. The mother was a non-smoker and non-drinker. The past medical history showed a full-term infant without prenatal or natal problems. The pertinent physical exam showed a smiling infant with growth parameters between 75-90%. The physical examination was unremarkable.

The diagnosis of a healthy infant was made. The resident physician was not sure how she should counsel the mother about the co-sleeping arrangement. The attending physician tried to quickly look up the American Academy of Pediatrics (AAP) recommendations but could not find the relevant information during clinic. The attending did say that he himself did not recommend co-sleepers because he was afraid of entrapment in the area between the bassinet and the adult bed, in addition to having loose adult bedding around the infant. He did note that there were some co-sleeping products that wall off an area of the adult bed to make a separate sleeping area for the infant in the adult bed. This he did not recommend and knew that the AAP also did not recommend it. The following day, the attending had more time to review the AAP guidelines which does not make a recommendation for or against bedside co-sleepers.

Discussion
Infant sleeping practices are different around the world, but need to provide a warm, safe sleeping environment with as little inconvenience and cost for the family. The AAP recommends that infants use a crib, bassinet, playpen, portable crib, or play yard with a firm mattress with no loose bedding (including pillows, stuffed animals, sleep positioners such as wedges, etc.). “Room-sharing without bed-sharing is recommended” by the AAP to prevent suffocation, strangulation, and entrapment of the infant in an adult bed. The AAP’s extensive technical report with specific recommendations for safe infant sleeping environments are available (see To Learn More below).

Learning Point
Co-sleepers that are located in the adult bed are not recommended by the AAP. Bedside co-sleepers that are located separate from the adult bed but next to it are neither recommended or not recommended by the AAP on the basis that there is not enough data to make a recommendation. The AAP also does not recommend bed rails for infants. Bedrails are placed along the side of the bed and are intended to prevent a larger child such as an older toddler, preschooler or school age child from falling off the side of the bed. Car seats and other sitting devices are also not recommended as places for infants to sleep.

The U.S. Consumer Product Safety Commission and ASTM International are currently working on standards for bedside co-sleepers but these recommendations have not been published. Consumer Reports, an independent, non-profit consumer advocacy organization, does not recommend either co-sleepers that are located in the adult bed or beside the adult bed. They recommend a separate crib for infants and children up to ~4 years of age.

Questions for Further Discussion
1. What are some common sleeping arrangements in your practice location?
2. What parent recommendations do you offer for different sleeping arrangements?
3. How common is sudden infant death syndrome (SIDS) and/or deaths from sleeping environment in your practice location?

Related Cases

Infant and Newborn Care

Sudden Infant Death Syndrome

Safety Issues

Health Maintenance and Disease Prevention

General Pediatrics

Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: SIDS and Infant and Newborn Care..

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Arm’s Reach Concepts Recalls Infant Bed-Side Sleepers Due to Entrapment, Suffocation and Fall Hazards. Consumer Product Safety Commission. Available from the Internet at http://www.cpsc.gov/cpscpub/prerel/prhtml11/11187.html (rev. 4/5/2011, cited 3/2/2012).

American Academy of Pediatrics Technical Report. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2011:128;e1341-e1367.

Bassinet Buying Guide. Consumer Reports. Available from the Internet at http://www.consumerreports.org/cro/babies-kids/baby-toddler/bassinets/bassinet-buying-advice/index.htm (rev. 1/2012, cited 3/2/12).

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.

Practice Based Learning and Improvement
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.

Interpersonal and Communication Skills
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

Systems Based Practice
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Are the Different Types of Conjoined Twins?

Donna M. D'Alessandro, M.D. — Mon, 30 Apr 2012 00:15:23 +0000

Patient Presentation
While volunteer teaching in the human body curriculum of a local elementary school, the students asked a pediatrician several questions about twins. They were especially interested in conjoined twins since there had been some recent media stories about a set of conjoined twins. He explained that people weren’t sure exactly how conjoined twins happened, but the usual thought was that it was due to cells not splitting apart completely. The students also wanted to know why conjoined twins were sometimes called Siamese twins. He said he didn’t know this answer, but later looked up the answer using the Internet and sent the answer to the children.

Discussion
Conjoined twins (CT) have sparked people’s interest for thousands of years. The Roman god Janus with two heads and faces is one example. The Greek mythological creature the centaur is another example being part human and part horse. The Babylonian god Marduk was a “double-god” with 4 ears and 4 eyes to be able to see and hear everything.

In Kent, England in ~1100 A.D., the Biddenden maids, Mary and Eliza Chulkhurst, supposedly were CT joined at the hip and shoulder and lived for 34 years. After their death they gave land to the local church and biscuits/cakes with their likeness has been given to the poor at Easter in their honor since. One of the most famous sets of conjoined twins were Chang and Eng Bunker. Born in Siam (modern day Thailand) they were thought to give rise to the common term “Siamese twins” for CT. They were joined at the lower chest and livers, lived for 64 years, married sisters and had 21 children between them. They traveled throughout the world as entertainers including working with the famous P.T. Barnum.

The developmental cause of the malformation CT is uncertain with different data supporting a problem with fission (or incomplete clevage along the plane in a single embryo) or fusion (of two separate embryos). The prevalence is estimated to be 1;50,000 pregnancies but 1;200,000 live births. There is great variation, but it appears that CT are more common in females and in some places in the world including South America. Survival is low and many die in the early natal period or as part of surgical separation. As with all people, each set of CTs and each person within the set is unique. The exact location, organs involved, circulation status to the organs and many other factors help to determine survivability as well as the possibility of attempting surgical separation. A multidisciplinary team approach to surgical separation is necessary including extensive pre-surgical radiologic imaging and planning as well as ethical considerations.

Learning Point
The types of conjoined twinning are usually noted by the union site with the suffix “pagus” attached. Pagus means fixed or solid.
The table below lists the CT types, union site, primary shared structures and the incidence from the International Clearinghouse for Birth Defect Surveillance and Search in 2011.
See also line drawings of different types of CT.

Thoracopagus

Location: Chest and thorax to umbilicus
Sternum, diaphragm upper abdominal wall, has heart and liver abnormalities
Incidence: 42%

Parapagus

Location: Ventrolateral fusion of lower abdomen and pelvis, has genitourinary anomalies
Incidence:14.5%

Omphalopagus

Location: May be same as thoracopagus but has two separate hearts
Incidence:5.5%

Cephalopagus

Location: Head but not face or foramen magnum, brains are usually separate
Skull, meninges and venous sinuses involved
Incidence:5.5%

Craniopagus

Location: Head at any location
Incidence:3.4%

Ischiopagus

Location: Hip from umbilicus to conjoined pelvis
Genitourinary and gastrointestinal tracts often involved
May have different number of legs (i.e. 2, 3 or 4)
Incidence:1.8%

Rachipagus

Location: Spine with vertebral and neural tube defects
Incidence:1.0%

Pyopagus

Location: Buttocks with sacrum and coccyx anomalies
Incidence:1.0%

Parasitic

Location: Incomplete twin attached to other twin at any location
Incidence:3.0%

Type Not Specified

Incidence:21.4%

Questions for Further Discussion
1. What would be the role of a general pediatrician on the multidisciplinary team caring for CTs?
2. What ethical issues arise when considering surgical separation of CT?
3. How common are monozygotic or dizygotic twins?
4. What medical complications can occur because of multiple births?

Related Cases

Twins, Triplets, Multiple Births

Birth Defects

Genetic Disorder

Syndromes

Minor Congenital Anomaly

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Twins, Triplets and Multiple Births and Birth Defects.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Wikipedia. Biddenden Maids. Available from the Internet at http://en.wikipedia.org/wiki/Biddenden_Maids (rev. 1/13/2012, cited 2/29/2012).

Find A Grave. Chang and Eng Bunker. Available from the Internet at http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=1250 (rev. 1/1/2001, cited 2/29/2012).

McHugh K, Kiely EM, Spitz L. Imaging of Conjoined Twins. Pediatr Radiol. 2006;36:899-910.

Mutchinick OM, Luna-Muñoz L, Amar E, et.al.. Conjoined twins: a worldwide collaborative epidemiological study of the International Clearinghouse for Birth Defects Surveillance and Research. Am J Med Genet C Semin Med Genet. 2011 Nov 15;157C(4):274-87.

Lee M, Gosain AK, Becker D. The bioethics of separating conjoined twins in plastic surgery. Plast Reconstr Surg. 2011 Oct;128(4):328e-334e.

ACGME Competencies Highlighted by Case

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Causes Vaginal Discharge?

Donna M. D'Alessandro, M.D. — Mon, 23 Apr 2012 00:17:00 +0000

Patient Presentation
A 1-month-old female came to clinic with a 2 day history of increased vaginal discharge. The mother noted that there was an increase in the amount but that the discharge continued to be clear-colored and have a thin consistency. The infant had had increased amounts of stools 4 days ago and the mother noted a red rash on the perineum that she had been using a barrier cream on. The infant was otherwise asymptomatic, and the mother had no concerns about potential sexual or physical abuse. The past medical history revealed a full-term infant female.

The pertinent physical exam showed a well-appearing female growing on the 10-50% growth curves and with normal vital signs. Her perineal area showed moderate generalized erythema of the convex and concave areas of the perineum, labia and buttocks. There were satellite lesions on lower abdomen and inner thighs. Normal appearing vaginal secretions were seen. Her anatomical structures were normal in appearance. The diagnosis of candidal diaper dermatitis causing vulvovaginitis was made and anti-fungal cream was recommended. The mother was educated about normal changes in vaginal secretions in young children.

Discussion
Vulvovaginitis can occur at any age but is a very common problem in prepubscent females. In this age group it is often caused by irritants and non-specific inflammation. In adolescents and adult females, sexually transmitted infections become another common problem. Sexual abuse can occur at any age.

Normal vaginal secretions are usually thin, and clear to white with a variable amount. Vaginal discharge that is a different consistency, malodorous, accompanied by blood, pain, pruritis, or dysuria is usually not physiologic. Abdominal pain, emesis and fever may indicate pelvic inflammatory disease.

If bloody, consider foreign body, Shigella, Streptococcus, abuse, estrogen withdrawal, and menses.
If white, cottage-cheese like, consider Candida.
If white-yellow, consider normal variation, irritation and Chlamydia.
If yellow-green, and thick, consider foreign body, Neisseria gonorrhea and trichomonas.

Non-specific vaginal discharge is usually treated by removing the irritant, sitz baths and education about proper hygiene and increasing air flow to the area. Treatment should also be given for specific causes

Learning Point
The differential diagnosis of vulvovaginitis includes:

Normal variation
- Newborn – thin discharge, may have blood with estogen withdrawal
- After newborn through puberty – thin mucoid discharge
- After puberty – leukorrhea – thin, clear to yellow, not malodorous
- Pregnancy – may increase the amount
Irritants – one of the most common causes
- Poor hygiene
- Bubble bath and soaps
- Douches, spermicides, and latex
- Masturbation
- Restrictive clothing
Infectious – may be due to actual infection and/or abnormal balance of vaginal flora
- Bacterial
  - Chlamydia
  - Escherichia coli
  - Gardnerella
  - Gonorrhea
  - Herpes
  - Staphylococcal
  - Streptococcal
  - Shigella
  - Trichomonas
  - Ureaplasma urealyticum
- Fungal
  - Candida
  - Tinea cruris
- Parasite
  - Pinworm
  - Pediculosis pubis
  - Scabies
Dermatologic
- Eczema
- Lichen sclerosis et atrophicus
Foreign body
- Retained tampon
- Sand
- Toilet paper
- Multiple other objects
Systemic illness
- Crohn’s disease
- Diabetes
- Scarlet fever
Other
- Tumor
- Sexual abuse
- Congenital abnormality
- Urethral prolapse

Questions for Further Discussion
1. How can sexual abuse present? See also What Are Some of the Presentations for Child Abuse and Neglect? http://www.pediatriceducation.org/2005/06/06/
2. What are the legal requirements for treating minors with sexually transmitted diseases?
3. What local resources are avaiable for gynecological consultation in your location?

Related Cases

Vaginal Diseases

Vulvar Disorders

Infant and Newborn Care

Vaginal Discharge

Adolescent Medicine

General Pediatrics

Obstetrics / Gynecology

Newborn

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vaginal Diseases, Vulvar Disorders and Infant and Newborn Care.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:338-339.

Sifuentes M. Vaginitis. In Pediatrics a Primary Care Approach. Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;279-282.

Garden AS. Vulvovaginitis and other common childhood gynaecological conditions. Arch Dis Child Educ Pract Ed. 2011 Apr;96(2):73-8.

ACGME Competencies Highlighted by Case

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital