Behavior: Ask the experts


Behavior problems of interest to pediatricians with expert advice responding to questions.


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Q I would appreciate some guidelines that would help me answer parents' questions about whether their children are ready for school. Parents of a child who will be 5 years old in August, for example, asked me if they should wait a year before starting their child in kindergarten because he will be one of the youngest in his grade. Parents of another patient, a 6-year-old, are concerned that the school wants their child to repeat kindergarten because "he is not mature enough to move on to first grade." The development of both these children is appropriate for their age.

Kim Burlingham, MD

Winnsboro, TX

A The best guides to academic readiness, rather than age alone, are a child's social, emotional, and intellectual maturity; how much intellectual stimulation the child gets at home; and the parents' investment in education, as reflected in how much they read to the child, for example. Other factors are an understanding of why the parents or school believe the child should be in a class with younger children (if this is the case); reports from Head Start, other preschools, and child care programs; the results of the school's prekindergarten assessment; and the pediatrician's findings. The developmental surveillance the pediatrician provides through periodic health supervision visits also produces valuable information about a child's academic readiness.

Does the child interact and play cooperatively with other children, participate in other group activities, remain seated for appropriate periods of time, take turns, follow rules, share materials, ask questions, request needed help, follow directions, and communicate well? Is the child hyperactive, distractible, aggressive, withdrawn, disruptive, destructive, extremely shy, fearful or confused?

While some children who are barely 5 years old, do well in kindergarten, being the youngest in the kindergarten class, as the child in your first example would be, confers no long-term advantage. Indeed, children who are academically or socially challenged because they are young for their class may suffer negative effects. Early enrollment does not necessarily work better for girls than for boys.

Repeating kindergarten probably won't benefit the child described in the second vignette. Being held back neither promotes maturity nor boosts later academic achievement. Children who are older than their classmates because they have repeated a grade are at future risk of developing behavior problems or dropping out of school. Psychologic, medical, and other assessments can be used to determine if the child qualifies for special help under Section 504 of the Rehabilitation Act of 1973. If he does, the school's educational management team prepares a written transition plan, which might include, according to the act, "program modifications, instructional approaches, and the use of supplemental aids and services." Some schools have a transitional first grade or a special kindergarten for providing these services.

Morris Green, MD

Indianapolis, IN

DR. GREEN is Perry W. Lesh Professor of Pediatrics, Indiana University School of Medicine, Indianapolis, and a member of the Contemporary Pediatrics Editorial Board.


Q The parents of a normal, healthy 6-year-old girl are disturbed by their child's masturbation. This young girl discovered she liked the feeling of the center strap of the car seat rubbing against her genitals. Now she enjoys rubbing this area at any time, especially when she is bored. She does it in front of family members and company. Her parents have cajoled and admonished her and sent her to her room, where she now prefers to go to masturbate instead of having to restrain herself in front of the family. How should I advise this family?

Anjuli Suda, MD

Kinnelon, NJ

A Masturbation in childhood is now generally regarded as normal and harmless. The great majority of children probably masturbate, though how intensely they do it and how often varies. The only problem is that it is not acceptable to masturbate in front of other people, as this child initially did. Parents can simply tell the child that it is all right to masturbate, but not in public. By overreacting and attempting to prohibit masturbation, parents can adversely affect their relationship with their child and the child's self-esteem. This child requires counseling only if she would rather spend extended periods in self-stimulation rather than in conventional social interactions with other people and in activities appropriate for her age.

William B. Carey, MD

Philadelphia, PA

DR. CAREY is Clinical Professor of Pediatrics, University of Pennsylvania School of Medicine, and Director of Behavioral Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia.


Q A 17 1/2-month-old girl in my practice has refused to make eye contact with her mother since she was 6 months old. She makes eye contact with everyone else, including her 7- and 5-year-old siblings and her father. The child has no autistic tendencies and her development in all other ways is normal. Even when her mother specifically asks her daughter to look at her, the child refuses. Recently, she also began to pull her hair out and eat it whenever she gets frustrated. According to Mom, this is part of a "hair fetish"; when she feels scared or needs consolation, she sucks her thumb, and wants to be held by Mom, whose hair she strokes. Besides reassurance, what can I offer this family?

Ingrid L. Martinez-Andree, MD

Red Bluff, CA

A I'd begin by asking about the typical interactions between mother and child. Do they engage each other? Does the mother take joy in playing with the child, and does she play with her at all? If possible, watching the two of them interact in a play situation would be very helpful; perhaps you could "sneak a peek" while they are in the waiting room and observe if the mother talks to the child and vice versa. Does the child "check in" with the mother when she is playing by herself? Does the mother enjoy watching her child explore a new play environment?

Several questions to include in the history are of particular interest. Did the start of the gaze aversion coincide with a traumatic event in the infant's life? Was she separated from her mother for a long time? Is there any history of abuse or neglect? How is the child disciplined? Who is the primary caretaker during the day? Have there been any changes in the child's routine? What is bedtime like?

The gaze aversion might be a symptom of an attachment disorder between mother and child, for which several interventions are worth trying. The parents might prepare an album with photographs of the mother looking straight ahead and holding up objects, such as a toy, pet, or picture. The parent displays these pictures to the child while she sits on her mother's lap. The idea here is for the child to engage in "virtual" eye contact, which may be less likely to invite gaze avoidance than the real thing. "Floortime," an intervention developed by Stanley Greenspan, calls for parents to follow the child's lead in directed play for 20 to 30 uninterrupted minutes one to three times every day. During these sessions the mother should not pressure the child for eye contact. As the child becomes more confident in her relationship with her mother, her loving gaze should return. If it doesn't, I would refer the child to an infant mental health specialist with a family-centered approach.

As to the hair fetish, this is a fairly common self-calming behavior in young children and infants sometimes referred to as "silking." That is, some children run their fingers through the silk border of a blanket or strands of hair because it is a pleasurable experience they find calming. Mother could try substituting a stuffed animal or a blanket with a silk border for her hair or the child's hair.

Marilyn Augustyn, MD

Boston, MA

DR. AUGUSTYN is Assistant Professor and Director of Training, Division of Developmental and Behavioral Pediatrics, Boston Medical Center.


Q How can I help the parents of a 5-year-old girl who has developed urinary frequency when she is at home? She does not have the problem at school. The child was completely toilet trained at 2. She does not have enuresis and does not wake at night to void. Repeated urinalysis and cultures have been normal, as is her physical exam.

Hari Cheryl Sachs, MD

Rockville, MD

A Classic symptoms of daytime frequency-urgency syndrome are the need to urinate abruptly and frequently, sometimes several times an hour, and the passage of small amounts of urine each time. The urinary frequency disappears during sleep and the child does not wet during the day or night. The peak age for this disorder is 4 or 5 years. The syndrome usually reflects emotional tension and tends to begin one or two days after a stressful event. If the urine analysis and culture are normal, imaging studies and urologic referral are not indicated.

What is unusual about your patient is that the problem arises only at home. Most likely this is because of stress in the family—marital tensions, perhaps, or problems in the relationship between the child and her parents. Other issues to consider are illness in a family member, a recent death or move, or even child abuse. It is useful to ask if the child underwent any stresses or experienced changes in the family the week the problem began.

In addition to addressing the primary stressor, reassure the child that there is nothing wrong with her and that she will gradually get back to urinating every two or three hours. If the parents are separated or recently divorced, make sure the child understands that both parents love her and will continue to see her. Increasing the general level of harmony at home often will alleviate the condition. Parents should avoid punishing the child or criticizing her because this will only make the frequency worse. They should not even comment when she uses the toilet often or measure urine volumes or keep track of how often she urinates. Bladder stretching exercises are counterproductive and may precipitate wetting. Medications are not helpful.

With the suggested interventions, the urinary frequency usually disappears in a few weeks. If a stressor cannot be identified, reassuring the child and helping her relax generally eliminate the symptom in two or three months. If you uncover serious family problems, consider referral for mental health services.

Barton Schmitt, MD

Denver, CO

DR. SCHMITT is Professor of Pediatrics, University of Colorado School of Medicine, and Director of General Consultative Services, The Children's Hospital of Denver, CO. He also is a member of the Contemporary Pediatrics Editorial Board.

Morris Green. Behavior: Ask the experts.

Contemporary Pediatrics


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