"Maria is stubborn, willful and always full of energy. For the past 2 months, I [haven't been able to] leave her for a moment without her grabbing me and crying. She refuses to sit on the potty seat. Yesterday, she threw herself on the floor, yelling and kicking after I suggested she use the potty seat. Tantrums occur every day-sometimes in response to a simple request."
Maria's mother offered this vivid description of her child's behavior at a 2-year health supervision visit in response to the pediatrician's question, "Tell me how Maria has been recently." Maria had been followed since birth by her pediatrician. Maria was born to a single mother who works part-time and is enrolled in two college courses, and the gestation and perinatal periods were uncomplicated. A review of the medical record reveals that she was an especially active infant, experienced mild to moderate colicky behavior in the first 3 months, and achieved all of her motor, language, and social milestones at appropriate times.
After it was established that the frequent tantrums, clinging behaviors, and "stubbornness" had escalated considerably during the past 2 months, the medical history was directed toward any recent changes in the family, caretakers, or living situation. The combination of job and school had been a major focus of her mother's life for the past year. Recently, school work was more demanding and, after a change in supervisors, her work in a clothing store was less satisfying. Finances were marginal, but she was making ends meet with medical assistance from Medicald and with discounted child care at her college.
Maria's mother had always been a single parent, and her pediatrician was impressed with this mother's resiliency, flexibility, and ability to continue her education while raising a young child.
Sitting in her mother's lap throughout the visit, Maria played with a toy, snuggling close to her mother. She refused both eye contact and a play interaction with the pediatrician. (Her mother stated that this behavior was a typical response to people who Maria was not familiar with.) Verbal interchange was unsuccessful although it was noted that Maria responded to her mother's requests. Growth measurement, physical examination, and a screening developmental assessment were normal.