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QAn 8-year-old child in my practice is having difficulty withher fourth-grade classmates. Her teachers say that she acts overlyprotective, maternal, and bossy; as a result, she is frequentlyisolated and has no close friends. Both the teachers and her adoptivemother agree that she relates well to younger children and withadults.

The child has had many lengthy hospitalizations because ofshort gut syndrome, for which she recently had a small bowel transplantation.She takes several post-transplant medications but no longer requireshyperalimentation or gastrostomy tube feedings. She was in specialeducation classes in the past but is now mainstreamed, exceptin mathematics. The girl's biologic parents were unable to carefor her, and she spent several years in foster care until sherecently was adopted by the loving family with whom she has livedfor the past two years. These parents are not particularly concernedabout their daughter's behavior and feel her problems probablywill resolve on their own through routine interactions with herclassmates. What does concern them is that the school has recommendedthat they seek psychological counseling for their child. How shouldI advise them?

Chris Derauf, MD
Honolulu, HI

AThis 8-year-old has many medical and psychosocial risk factorsfor developmental or behavioral disorders. She is having troublewith her peers and her teachers describe her as isolated and withoutclose friends. If this description is accurate, I would be concernedabout the child. An inability to form any close friendships withpeers is often associated with significant problems in behavioraland emotional adjustment.

The reasons for this child's difficulty in forming relationshipswith her peers are hard to determine from this short history.Certainly, limited interpersonal experience because of her manyhospitalizations has not helped. The reasons for her placementin special education classes in the past also are not clear. Howis she doing academically? At 8 years old, she may be youngerthan many of her classmates in fourth grade. This could exacerbatelearning disorders and difficulties with language and in readingsocial cues and result in other developmental characteristicscommon to children who relate better to adults and younger childrenthan to peers. Until recently, this child has not had consistentadult caretakers, which may also affect her ability to form closerelationships. Her bossiness may be related to problems adaptingto the needs of others or regulating her emotions when other childrendo not do what she wants them to. Finally, given her chronic illness,she may be ostracized by classmates with mistaken beliefs aboutcontagion or other aspects of her condition.

Because this child's problems probably will not just go away,some intervention is important. Before a comprehensive treatmentplan can be developed, a thorough assessment of what is causingthe problems is required. The assessment should include an evaluationof why the parents are resisting counseling. Did they have a badexperience in the past? Are they concerned about labeling a childwho already is so different from her peers? Does the biologicfamily have a history of mental illness that the adoptive parentsare worried about?

It may be helpful to discuss with the parents the types ofinterventions that are likely to be helpful to children with difficultiesin social skills. Interventions at school or in other situationswhere the child is having difficulty are more likely to be effectivethan those carried out in individual therapy or in office-basedgroups. A psychologist, pediatrician, or other professional interestedin helping children with social skills should be able to directthe school and parents. At home, a first step may be to have thechild play with a single peer instead of a group, perhaps withthe parent helping to structure their activities. Parents mayalso want to invite another child to join the family on outings.They should consider having the child participate in supervisedgroup activities outside school. The school might provide facilitatorsto monitor and direct activities during lunch or recess so theyinclude all children. It may be helpful to educate the child'sclassmates about her illness. Another idea is to pair the childwith a student who can serve as a peer model. To be successful,whatever interventions are chosen should be planned jointly bythe parents, child, and school.

Nathan J. Blum, MD
Philadelphia, PA

Dr. Blum is Assistant Professor of Pediatrics, Universityof Pennsylvania School of Medicine and Children's Seashore House,Philadelphia.


QThe mother of a 12-year-old boy called me because one nightshe came upon her son wearing one of her dresses, a slip, anda pair of stockings. In answer to her questions, the boy openlytold his mother that for the past few months he has been dressingin her clothes at night after the rest of the family is asleep.He said he started doing so out of curiosity and found the activityarousing. The mother thinks he may be masturbating while wearingher clothes. She and the boy's father want to know if this isnormal behavior. Does it mean her son will be gay or a transvestite?Is there anything they can do to change this sexual orientationif it is abnormal? I advised the mother to keep the lines of communicationopen with her son and to minimize any stress in the family, especiallyover this issue, until they receive further help. What do youadvise?

Ira S. Rubin, MD, PhD
Naperville, IL

ACross-dressing or homosexual behavior often arouses shockand criticism, if not rejection. Parents have many expectationsand hopes for their children, related to academic performance,appearance, athletic ability, and gender-specific behaviors. Anydramatic lowering of these expectations or unanticipated changein how they are being met brings a sense of loss. Initial recommendationsthat show calm tolerance, such as your wise advice to "keepthe lines of communication open," are essential in helpinga child and his family deal with situations like the one you describe.

To understand the parents' sense of loss, you should acknowledgethe shock they feel in this situation, develop empathy for thegroundswell of feeling they are experiencing, be inquisitive ina way that allows the family to discuss all the facts in a nonjudgmentalatmosphere, and avoid offering blanket reassurance too soon andtoo quickly, which precludes further needed investigation. Wesuggest helping the family to formulate a plan before they leaveyour office after the initial consultation. The plan should includea referral to a mental health clinician and a follow-up appointmentwith you to discuss ongoing developments, how the parents arecoping, and the child's well-being during what must surely bean embarrassing and shaming situation for him. The mental healthclinician, it is hoped, will reach an understanding of the child'sbehavior and then provide guidelines for you, the family, andthe child.

There are several possible explanations for the boy's behavior.Since he finds it "arousing" to dress up in his mother'sclothing, including her undergarments, first in the differentialdiagnosis is that the boy is developing a transvestic fetish.Individuals with this fetish find it sexually arousing and soothingto wear garments of the opposite sex, specifically undergarments.Determining whether an adolescent with such a fetish will growup to become a transvestite or gay is a complicated matter. Many,if not most, transvestites are heterosexual, which means thatthe terms transvestite and gay should not simply be lumped together.The vast majority of gay individuals do not engage in transvesticfetishes. Although some gay men dress in "drag" forparties or shows, this tends to be theatrical and "campy"rather than sexually exciting. It also is very difficult to knowwhether a fetish in adolescence will be carried into adulthood.Specific behaviors adolescents engage in for short periods oftendon't develop into long-term patterns.

Gay children do sometimes have traits that we associate withthe opposite gender. Boys may appear effeminate, which can leadto problems at school because they do not "fit in" withother boys. These youngsters may identify strongly with the oppositesex and feel uncomfortable with certain aspects of their own sex.If these children cross-dress, the motivation is to identify withthe opposite sex, not sexual pleasure. Some boys dislike traditionallymasculine sports, such as football, and often prefer the companyof girls over boys. This description fits only a portion of thegay population, of course; many gay male adolescents do enjoyfootball, have male friends, and identify strongly with theirown sex.

From the information provided, we cannot draw any conclusionsabout this young man's sexual orientation, but his mother bringsup an interesting question. She asks if anything can be done tochange her son's sexual orientation "if it is abnormal."Many gays and lesbians lead happy, productive, and satisfyinglives and would be offended by the term "abnormal."Our society is slowly changing its views about gays and lesbians,becoming more understanding and tolerant of people's differences.Part of this societal change stems from the relatively new opennessand courage of gay men and women who are "coming out"and allowing their "straight" friends and family tosee that being gay can be perfectly "normal."

Changing a child's sexual orientation from homosexual to heterosexualis highly controversial. Many mental health professionals wouldargue that sexual orientation is established well before thisboy's age and cannot be changed. Attempts to change the sexualorientation are often futile, producing feelings of shame andguilt for something over which the patient has no control. Childrenmay try to suppress their atypical behavior and conform to societalexpectations. This may be useful for coping with peers and family,but may damage the child's self-esteem and later ability to leada healthy life--as we define it for any child--as a gay adult.Incidence of suicide is higher among gay teens than straight teens,which is probably associated with the feelings of isolation andrejection gay youths experience. The high suicide rate makes itall the more important to keep the lines of communication open.

Understanding and then helping a child whose behavior is shockingand in stark contrast with traditional gender-related behavioris a struggle for clinicians as well as parents. The goal shouldbe to provide understanding, acceptance, support, and referralfor treatment, when appropriate, so that the child's emotionalgrowth and identity formation are not impaired by fear of reprisal,ridicule, or shame.

Michael S. Jellinek, MD
Scott Rodgers, MD
Boston, MA

DR. JELLINEK is Senior Vice President For Administration andChief, Child Psychiatry Services, Massachusetts General Hospital,Boston,
and Professor of Psychiatry and of Pediatrics, Harvard MedicalSchool, Boston.

DR. RODGERS is a Senior Resident in child psychiatry at MassachusettsGeneral Hospital.


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