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BEHAVIOR: ASK THE EXPERTS
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Q An 8-year-old patient recently decided to eat only white foods. His diet consists of rice, crustless white bread, white chicken meat, turkey, whites-only omelets, milk, and vanilla ice cream. What does this mean? What action do you suggest, if anything?
Solomon J. Cohen, MDKennebunkport, ME
A What, no marshmallows? Clearly, this child is being raised in North America in the early 21st century in a family that is too stressed to resist the child's demands about food. This could describe just about any pediatrician's patients (and some pediatricians' children). It's a variant of normal behavior. The parents have several options: They can do nothing and let the child become a "normal" teenager who lives on Big Macs, fries, and pizza. They can watch him become an obese couch potato who goes on to develop type II diabetes and heart disease. At the other end of the spectrum, they could act like the food Gestapo, insisting that the boy eat only brown rice, raw vegetables, seaweed, and organic fruit, with an occasional serving of yogurt as a reward.
I suggest that you and the parents think about the family's goals for the boy's health. Consider the dietary guidelines set forth by the US Food and Drug Administration, the American Heart Association, the American Cancer Society, and other groups interested in promoting a healthy lifestyle. Keep in mind that we live in a society in which obesity is epidemic and fewer than 1% of children meet their recommended daily allowances through their typical diet. Help the family develop a diet plan that is consistent with their values and priorities and relies on realistic resources. Take one achievable step at a time, documenting and monitoring progress and jointly setting additional achievable goals. Build your relationship and build on success.
This will work differently for each family. For one family, it may mean simply adding a multivitamin each day to minimize frank nutritional deficiencies. For the patient you describe, it may mean adding one colorful item to the dinner menu or not allowing the child to eat a white food until he eats a colorful food. Just be sure to look at the whole situation, considering the family's values, culture, and community, weighing costs and benefits, and supporting the family in making complex choices.
Kathi J. Kemper, MDBoston, MA
Q My problem concerns a boy nearly 4 years old who lives with his mother and grandmother. The child is deaf and signs very little. Mom has put a potty chair in the bathroom, but he just doesn't seem to get it. There are no males in the picture to assist with the potty training. Do you have any suggestions?
Vernessa D. Ekelem, MDJackson, TN
A I discussed this question with Jean Hall, PhD, who is an expert in the education of the deaf and a mother. She said that potty training generally should not be a problem for deaf boys. If the child is otherwise normal, he should be able to understand picture books that demonstrate how boys urinate. If he is able to sign, parents should be able to convey directions in this way.
Is it possible that this little boy is delayed in some other ways? Is he in an early intervention program? Such a program would provide models for how boys void. I recommend that the family also consider contacting the local Society for the Deaf to identify other families with boys who are deaf. They can then ask these families for advice.
Karen N. Olness, MDCleveland, OH
Q The mother of a 7-year-old girl told me that she is concerned about her daughter's excessive masturbation. Mom reports that ever since the child "discovered herself" at the age of 4, she masturbates often. Recently, the child's teacher called Mom to report that she notices the child rubbing against chair legs or rubbing herself with her hands. There have been no new stressors at home or at school, but Mom reports that the child is an "overachiever"; if she is asked to do five problems for school, she will do 20, for example. How can I help the family and school cope with this problem? How concerned should I be about abuse? (There are no physical findings, and mother and child deny this possibility.)
Lynne S. Wirth, MDRaleigh, NC
A Many girls begin to masturbate about the age of 4, although some start earlier. This kind of touching feels good, and they are unaware of the effect their masturbation has on other people.
It would be helpful for the parents to tell their daughter that she should touch herself this way only when she is alone, not in public. This makes sense to most children since they tend to be increasingly private about many bodily functions. If the parents respond to the masturbation too dramatically, their reaction may reinforce the behavior and increase its frequency.
Since this child is so intense and self-pressured, she may masturbate to calm herself. It might make sense to teach her other ways to relax. Sexual abuse causes isolated masturbation only rarely, but it would be worthwhile to rule it out by quietly talking to the child to make sure that no one has touched her genitalia.
Leonard Rappaport, MDBoston, MA
DR. RAPPAPORT is Associate Chief, Division of General Pediatrics, Children's Hospital of Boston.
Morris Green. Behavior: Ask the experts.