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Q: The single, never-married motherof a 4-year-old is thinkingof initiating legal procedures to terminate the parental rights of her daughter'sfather. He has never been part of the child's life, and the mother feelsthat if he ever were to become interested in spending time with her, hisunhealthy lifestyle would be bad for her daughter. She also worries, however,that as the little girl grows, she will blame her mother for severing connectionswith her father. What would you advise?
Kim F. Burlingham, MD
A: This mother confronts a common situation in which a noncustodialparent does not maintain a close relationship with his child. Although terminationof the parental rights of the father may seem to allow a secure closureto an unhappy relationship, the mother rightly senses that being out ofsight does not mean the father will be out of mind as his maturing daughterbecomes more inquisitive about the who, why, when, and where of her earlieryears.
In addition to offering developmental advice, you may want to recommendthat this mother consult an attorney if she has not already done so. Ifthe mother later marries and her husband wishes to adopt the daughter, terminationof the biologic father's parental rights will be a legal issue. Short ofthat contingency, termination is an elective step for the mother to takeon the advice of her attorney. Since she clearly has reservations aboutthis, she may decide against such action at present.
There are other steps she can take to help ensure her daughter's self-esteemand identity as an adolescent and young adult woman in her relationshipsto male peers. For example, she can try to arrange for a male relative orfriend to spend time with the daughter and serve as a surrogate father.In addition, the mother should help her daughter feel comfortable askingquestions about her father, no matter how often or repetitiously, and lether see photographs of him if available. The youngster will probably becurious about him, just as adopted children are curious about their biologicparents. You may want to review questions the daughter is apt to ask sothe mother can plan how she will answer them truthfully without disparagingthe father.
During health supervision consultations, monitor how the child and motherare adapting to this critical situation in their lives.
Morris Green, MD
DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana UniversitySchool of Medicine, Indianapolis, and a member of the Contemporary PediatricsEditorial Board.
Q: A mother of a 3-year-old girl is concerned because the childinserts objects into all the orifices of her body. How should I advise her?
L. Stewart Barbera, MD
Huntingdon Valley, PA
A: To address this question, as with any potential illness orproblem, you need more information about signs and symptoms in the child.If she is in pain, you need to know its location, how it relates to eating,what exacerbates or relieves it, and if the pain radiates. Into which orificesdoes the child primarily stick objects? Has the behavior increased or decreasedover time? Does she engage in the behavior when she is with others or whenshe is alone? Are there any precipitating factors? Has the child been exposedto any sexual behavior, either at home, on television or videos, or in childcare? Are there other stresses in her life? Finally, when you examine hergenitals, is she excessively resistant or out of control?
Let's assume the child is sticking objects primarily in her vagina. Inmy experience, this is not common in 3-year-olds. Girls, especially youngones, put their fingers in their vagina and sometimes actually masturbate,but sticking objects in the vagina raises concerns about sexual abuse orexposure and merits a physical examination with this in mind. If the examis normal, I would share with the mother my concerns and discuss with herpossible explanations. If she has none to offer, suggest to her the importanceof monitoring her child's safety and checking if any of the child's caregivers, including baby sitters, may be exposing the child to sexual behavior,perhaps by bringing over sexually graphic videos.
The parents should act supportive but firmly tell the child not to stickobjects in any of her orifices, whether it is her nose, ears, or vagina.They should enforce this prohibition consistently, reacting the same wayto an object inserted in the vagina as to a pencil stuck up a nose--somethingall parents recognize as a safety issue.
Barry S. Zuckerman, MD
DR. ZUCKERMAN is Chief of Pediatrics and Medical Director, Boston MedicalCenter, and Professor and Chairman, Department of Pediatrics, Boston UniversitySchool of Medicine.
Q: Do you have any suggestions to help the family of a 5-year-oldboy who has never had a bowel movement in the toilet? The child is the youngestof three boys, and his parents are at the end of their patience.
The child has a normal physical exam, with a soft abdomen and soft stoolin the rectum. We have tried gradual behavior "shaping," withthe child initially sitting in the bathroom with his mother for five minutesa day. The parents also have rewarded him for sitting on the toilet to tryto defecate. Currently, he holds his bowel movements until he is at home,indicating that he knows this behavior is not acceptable at school amonghis peers. His mother describes the stools he produces after school as voluminousand soft, though he may also have smaller BMs in his pants during the day.
I interviewed the boy's father when this problem first became apparent.The father said that he was toilet trained at an early age. The child'sfather is angry with the lack of progress and is no longer involved withthe defecation problems of his youngest son.
William Buchholz, ARNP
A: Children who fail to toilet train are much more common thanyou might imagine, and the pattern of being trained for urine but not stoolsis the most prevalent. The reasons for difficulty with this developmentaltransition range from fear of the toilet or potty chair to behavioral resistanceto parents who may be overbearing. At my institution we have developed asix-week group intervention where children meet with one of our cliniciansfor an educational intervention while parents meet separately with one ofour psychologists for behavioral help.
The approach you have used makes a great deal of sense, but the behavior"shaping" you describe may need to be even more gradual. For example,the parents might first have the child go to the bathroom to have bowelmovements in the diaper, then have the bowel movements in the diaper whilesitting on the potty seat or toilet, then cut a hole in the diaper so thechild can have the bowel movement in the toilet with the diaper on--andthen move to the desired behavior. Each step needs much reinforcement fora least a week with no urging to move on to the last step until its time.This level of patience is the hardest part of the process for parents, soit helps for you to meet with them and the child every week to reinforcetheir progress and keep them on track.
If this strategy does not work, consider getting the help of a behavioralpsychologist. Medical management of constipation, which can result fromwithholding stool and may complicate training, may also be required.
Leonard Rappaport, MD
DR. RAPPAPORT is Associate Chief, Division of General Pediatrics, Children'sHospital of Boston.
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