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BEHAVIOR: ASK THE EXPERTS
Q The mother of an 11-year-old girl called me for advice about her daughter, who has suddenly started to have episodes of crying for no apparent reason. She simply dissolves into tears from time to time with no warning. The child's teacher is also concerned about the girl's emotional lability, though her grades are good. The youngster is eating and sleeping well and her mood generally seems quite upbeat. The child says she does not know why she suddenly feels like crying. Once the episode is over she feels better. She denies drug use and suicidal ideation and thoughts and says that things are going well at school, socially, and at home. Her physical exam in normal; sexual maturity is Tanner II. A urine drug screen, thyroid screen, and complete metabolic panel are all normal. She sees her school counselor once a week but continues to have these unexplained crying spells. What should I do next?
Anu Diwakaran, MDSt. Louis, MO
A You've certainly done a thorough work-up on a vexing problem. Ruling out organic problems such as drug abuse, thyroid dysfunction, metabolic problems, and delayed puberty are important first steps. But I would also like to know more about recent events in the family history. Have there been any deaths, disappointments, or traumas? What is traumatic for an 11-year-old can be markedly different from what is traumatic for an adult, so you will need to use creativity and patience in your questioning. Enlist the parents' help in this history taking as well. You say the girl has no suicidal ideation and gets good grades, but I wonder if she is experiencing any of the other DSM criteria for depression. Symptoms such as excessive boredom, fatigue, and negative thinking might suggest such a diagnosis. Is there a family history of depression?
Sometimes, though, youngsters have crying episodes that are not part of a pathologic or psychologic problem. Such outbursts are extremely puzzling to those who observe them. I suggest that you and the child's parents, school counselor, and teachers monitor this girl carefully while you sort things out.
Howard Markel, MD, PhDAnn Arbor, MI
DR. MARKEL is Associate Professor of Pediatrics and Communicable Diseases and Director, Historical Center for the Health Sciences, The University of Michigan Medical School, Ann Arbor, MI. He is the coauthor, with Frank Oski, of The Practical Pediatrician: The A to Z Guide to Your Child's Health, Behavior, and Safety, WH Freeman, 1996.
Q The parents of a 7-year-old boy are concerned that their son likes to give awaynot lendhis belongings. They don't know whether to celebrate his unselfish nature or be worried. They have told him to check with them first before giving something away.
Kim F. Burlingham, MDWinnsboro, TX
A This case raises interesting questions about the development of acquisitiveness and generosity in young children, topics that have not been studied in great detail. We do know that children's understanding of their own relationship with things begins as early as 9 months of age when "object permanence" begins. At that time, the child begins to recognize that a thing remains the same even though its location or orientation changes. When he is 2 and 3 and undergoing the socialization process, the child develops an understanding of who owns an object. He gleefully grabs a toy and shouts "mine." Then he hears either, "No, that's Sarah's" or "Yes, that is your train." Each birthday and holiday gift, wrapped and labeled with his name, reinforces the concept of ownership. As a result, by the age of 7, a child should have a clear understanding of what is whose.
In this case, one of three things may be happening:
Alternatively, the child may be a truly altruistic, generous individual, in which case his generosity should be praised and supported. Such a child needs to be protected by parents and other adults so his peers do not take advantage of him.
Judith S. Palfrey, MDBoston, MA
DR. PALFREY is Chief, Division of General Pediatrics, Children's Hospital, Boston; T. Berry Brazelton Professor of Pediatrics, Harvard Medical School, Boston; and a member of the Contemporary Pediatrics Editorial Board.
Q A 3-year-old girl who sleeps with her parents is causing a problem at bedtime. When the parents want to turn off the lights to go to sleep, she objects and if they turn off the lights, she cries. This situation developed about six months ago. The child has been sleeping with the parents since infancy. She is otherwise healthy and developmentally normal.
Muhammad Waseem, MDBronx, NY
A Your description of the problem suggests that the child goes to sleep before her parents (I certainly hope so) with the lights on, then objects when the parents want to go to sleep themselves and turn off the lights. Allowing the child to go to sleep with the lights on was a mistake to begin with. Beginning in infancy, children should become accustomed to falling asleep with nothing brighter than a dim night-light. They then develop the comforting association of sleep with darkness.
For this family, the lighting situation may be symptomatic of more general parental anxieties about separating from their "baby." I'd ask them about how they decided to begin sleeping with their daughter, what their feelings are now about the shared family bed, and when they plan to allow the child to sleep by herself. I wonder if both parents are happy about the current sleeping arrangement. If not, the tension between the couple may have triggered their daughter's behavior.
Here are some related issues that are worth pursuing with the parents: Are there other times during the day when they often experience conflicts with their daughtermeals, activities, separations? How do they feel about the child's emerging social autonomy and consequent exposure to peers and adults outside the family? Did the child start day care or preschool during the same period as the bedtime problem arose? If so, how does she like day care? Have the parents been stressed by recent changes in their personal or work lives? Do they have plans for conceiving another child? How much does the child's behavior or the shared bed interfere with their envisioned family life? Have they ever spent a night away from their daughter? Who stayed with her and how did the child and each parent react? What does each parent believe might be causing the child's protests? What does the child say about her concerns?
Peter A. Gorski, MD, MPABoston, MA
DR. GORSKI is President, WellChild Foundation, Boston, MA, and Assistant Professor of Pediatrics, Harvard Medical School, Boston.
Morris Green. Behavior: Ask the experts.