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Q The mother of three young girls in my practice seems close to a nervous breakdown and has a laundry list of concerns about her middle child, a girl who is 5 years old. Joan plays exclusively with girls and is not the least interested in having any contact with boys her age. She urinates in her pants during the day and on car trips, defiantly telling her mother No when gently prodded to go to the toilet before getting in the car. Joan's father does not have this problem when he takes the child in the car. Joan recently told her mother that a female playmate put her tongue in Joan's mouth. Joan cried when her mother gently asked her about the incident, which, Joan said, came about when she fell on her playmate with an open mouth. Joan once stated that she would like to have a baby when she grows up but does not want to get married.
Joan's mother has attributed her daughter's defiant behaviors to middle-child syndrome, but she is concerned about latent homosexuality, poor self-image, and exposure to alternative lifestyles. In addition, Joan is less modest than her two sisters; she likes to walk around naked in front of others, and this also worries the mother, as does her occasional masturbation in public. The three children live with their parents and their paternal extended family, and it seems like a stable home. The child has reached age-appropriate milestones. Inappropriate touching or abuse does not appear to be part of the situation. Do you see a pattern of possible pathology in this child?
Adam M. Stuart, MDFlorida City, FL
A This brief history is a microcosm of what a busy primary care pediatrician faces every day. It reveals variations of normal behavior, elements that beg for further information, and behaviors that could be quite worrisome. Your challenge is to sort out the differences and respond appropriately.
The mother in this family is described as seeming "close to a nervous breakdown" and is concerned about her middle daughter's behavior. Is this the normal stress of raising three young girls, or is she subject to additional stressors? Is this mother overwhelmed by her daily responsibilities, burdened by depression, facing tensions related to her marriage or extended family, abusing substances, or subject to financial difficulties? Have you cared for this family over time and, if so, have you seen the mother's ability to cope change or deteriorate?
That a 5-year-old girl is mildly difficult with her mother and more compliant with her father is not unusual or worrisome, in and of itself. As a middle child, she will be more invested than her siblings in what is called the Oedipal period and in gaining attention from her mother by both positive and negative behavior. What is more troubling, however, is that this defiance has reached the level of refusing to go to the bathroom and wetting herself when she is in her mother's care. Is the occasional masturbation in public part of this defiant pattern or incidental to being tired or anxious? How does the mother manage this behavior? Does the father support the mother's effort to eliminate negative or defiant behavior?
Elements of the history allude to sexualized behavior that again pose the question of whether the behavior is a normal variation or a quite serious problem. Playing only with girls, occasional masturbation, walking around naked in front of others, and wishing to have a baby without being married are variations of normal behavior. They also are consistent with defiant and mildly provocative behavior designed to get attention, apparently successfully, from a busy mother who is prone to keeping "laundry lists" of concerns as she attempts to cope with her life. A single, possibly embellished, incident of sexualized exploration with a playmate is not very concerning, and exposure to alternative lifestyles, if appropriate and supportive, also poses no risk. Joan's behavior to date does not warrant worrying about "latent homosexuality," and her eventual sexual orientation cannot be predicted. Although you doubt that Joan has been sexually abused, you should ask her directly about any inappropriate touching or sexual contact.
As to clinical management of this situation, I suggest gently asking the mother about the stress she is experiencing to assess if her focus on Joan is the mother's way of communicating her own need for help. I also recommend speaking to Joan's teacher or asking for her most recent school report to determine if any of the behaviors her mother notes are apparent at school or interfere with her performance or peer relationships, or if low self-esteem is evident. If the mother's stress level is not abnormally high, sexual abuse has not occurred, and teacher reports indicate that Joan is doing well, I would provide some behavioral recommendations that both parents can implement to address Joan's defiant attitude.
Michael S. Jellinek, MDBoston, MA
DR. JELLINEK is Senior Vice President for Administration and Chief, Child Psychiatry Service, Massachusetts General Hospital, and Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston.
Q The parents of a 4-year-old boy want to know if they should be concerned about a new behavior in their shy son. If they begin looking at their son, he covers his face with his hands. Though he looks at them between his fingers, he does not maintain eye contact. The boy is otherwise developmentally normal.
Muhammad Waseem, MDBronx, NY
A Preschool children often hide behind their hands, but it is unusual for a child to do this every time the parents look at the child. I'm also not sure what it means when the child is described as looking at his parents but not maintaining eye contact. More information would be helpful in determining if you should be concerned about this 4-year-old boy.
Does he make eye contact with his parents when they don't look at him first? Does he make eye contact with other adults and children? What do the parents mean when they describe their son as "shy"? What other interactions does the boy have with his parents? Does he turn to them for comfort and reassurance, or is he scared or indifferent in their presence? Does he interact appropriately with other adults? How does he play with peers? His developmental milestones are being met at the normal time, but are his communications and use of language typical of a 4-year-old? Does he engage in any other unusual or repetitive behaviors? If other interactions with his parents are appropriate and the answers to these additional questions are not concerning, the boy's parents do not need to worry about the behavior.
I would, however, also ask the parents questions to elicit how they may be reinforcing this behavior. Do they cover their faces or play peek-a-boo? Is covering the face part of some other game the parents and child play together? The parents also may be reinforcing the behavior by giving the child a lot of attention when they ask him to uncover his face. If this is the case, ignoring the behavior should cause it to decrease.
Nathan J. Blum, MDPhiladelphia, PA
DR. BLUM is Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine and Children's Seashore House of Children's Hospital of Philadelphia.
Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2000;11:34.