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Q A 2-year-old has suddenly become afraid of the wallpaper borderof animals in his bedroom. Bedtime has turned into a nightmare for the parents.Any advice?

L. Stewart Barbera, MD
Huntingdon Valley, PA

A Nightmares and bedtime anxieties are very common during thetoddler years. The focus can be scary animals chasing the child during dreams,monsters under the bed or in the closet, shadows transformed into crocodilesor bandits, or furniture and decorative objects seen as lions, spiders,or other scary creatures. Your first task is to take a thorough historyto assess the situation. You need to know when the fear began, major eventsin the child's or family's life (death, divorce, domestic violence, a move,an addition to the household, or a new day-care arrangement), the child'susual bedtime routine, what the parents have done so far to address thesituation, and how well their efforts have worked. The parents' own historyof nightmares and night-time anxieties and how their parents dealt withthem may help the parents see the similarities between their own and theirchild's experiences and strengthen the bond between parent and child.

Your main task is to reassure the family that the child's fears are normaland do not indicate a psychological problem or emotional weakness. Theyshould view this developmental milestone as an opportunity to teach theirchild new coping skills. Advise them to avoid exposing the child to frighteningimages in books, magazines, and television in the hours before bed and topostpone conflict-laden discussions until the morning. They never shoulddisparage the child's fears but should instead let him know that many childrenfear similar things and that they can learn to see them differently by usingtheir imaginations. If the wallpaper border looks like lions, for example,the parents might ask the child where the lion tamer is (in the closet?under the bed?) and how soon he will come to put the lions back in theircages. Or the parents might ask the child what he thinks would help thelions go to sleep--a song sung by the child or a story read by the parent,perhaps? Parents should offer alternatives with which they are comfortable,rather than giving the child an open-ended choice--he might ask to stayup much later, sleep with the parents, or offer another undesirable solution.

Kathi J. Kemper, MD
Boston, MA

DR. KEMPER is Director, Holistic Pediatric Education and Research, Children'sHospital, Boston, MA.


Q I would appreciate some advice on how to go about resolvingdifferences in opinion between a school and a pediatrician on the best wayto manage a child with a mental health or psychosocial problem. I have sucha problem with a 13-year-old patient who has been diagnosed as emotionallydisturbed and with attention deficit disorder. The boy is in a special schoolfor emotionally disturbed children and though he is doing quite well academically,the school psychologist has decided that he is too combative and can nolonger attend that school unless he takes a sedative. I agree with the child'sfather that the purpose of the medication is to "dope him up"and it is not medically indicated. How can I work with the school to resolveissues like this one?

Marc Wager, MD
New Rochelle, NY

A The pediatrician's role in this case and others like it is topromote the best possible outcome for the adolescent. That means servingprimarily as the student's advocate, not the advocate of the parents orthe school. This obligation requires you to be fully informed about theteenager's situation by obtaining and reviewing all existing information,including data from the school and any other available sources. If necessary,supplement what you have with additional questionnaires, such as those ofthe ANSER System. You will also need to communicate with the psychologistand teachers familiar with the child's performance and behavior. Everyoneinvolved must be clear about the meaning of terms such as "emotionallydisturbed," "sedative," "too combative," "dopehim up," "attention deficit disorder," and "doing quitewell academically."

It is, of course, essential to interview the parents and the adolescentdirectly. You need to learn their views, identify recent stresses or changesat home or school, explore possible precipitating factors for the combativeepisodes, determine what may be making it difficult for the young man toremain in the present school setting, and determine the least restrictivealternative environment that is available.

Alternatives for dealing with the situation are counseling, medication,further academic support, seeking another school, or family therapy. Shareyour recommendations and the underlying diagnostic reasoning with the parents,the teenager, and the school. It is also important to determine who willbe the boy's advocate and case manager on an ongoing basis. While it maynot be possible to make everyone happy, supporting the child's educationalneeds, rights, and overall well-being is the first consideration.

William Coleman, MD
Durham, NC

DR. COLEMAN is Associate Professor of Pediatrics, University of NorthCarolina Medical School, Chapel Hill, NC, and Assistant Consulting Professorof Pediatrics, Duke University Medical Center, Durham.


Q A 5-year-old boy in my practice has been causing his parentsmuch concern. Ever since he could talk, the boy has told his parents thathe wants to be a girl. He consistently wants to play with girls' toys andwear dresses. The parents have tried to quietly direct him to more "masculine"dress and activities, but they don't want to make him feel guilty or wrongabout his feelings. They bought him both dolls and trucks for his fifthbirthday, and he plays with both equally. The parents' marriage is stable,and they are very involved in the child's upbringing. How can I counselthis family?

Michael J. Harkness, MD
Paoli, PA

A By the time they are 5 to 6 years old, most children understandthat gender is fixed, stable, and determined by their genitalia. For this5-year-old boy, the clinical challenge is to distinguish between normaldevelopmental variability and more significant developmental difficulties.On the one hand, many preschool children dress up and make believe theybelong to the opposite gender. This boy's interest in toys common to bothgenders and a stable, supportive home situation also are reassuring. Thechild's persistent wish to be a girl, preference for activities girls typicallyprefer, and longstanding desire to dress in girls' clothes, however, suggestthat he might have some difficulties with gender identity.

You should commend the boy's parents for not punishing their son, offeringa range of gender-appropriateactivities and toys, and supporting the child'sself-esteem. Encourage them to guide their son's activities so as to avoidostracism and humiliation by his peers or older children.

Depending on the frequency and persistence of the behaviors these parentsdescribe, a referral for a psychological evaluation may be worthwhile tohelp distinguish between a passing preoccupation and the emergence of amore troublesome gender-identity disorder.

Paul H. Dworkin, MD
Hartford, CT

DR. DWORKIN is Director and Chairperson, Department of Pediatrics, St.Francis Hospital and Medical Center, Hartford, CT, and Professor, AssociateChairperson, and Head, Division of General Pediatrics, University of ConnecticutSchool of Medicine, Farmington.


Q A 21/2-year-old in my practice sucks histhumb and holds his penis when he is tired. He is not masturbating. Jamminghis hand into his diaper and holding his penis seems to be a comfortingbehavior just like sucking his thumb. What should I tell his parents abouthis behavior?

Mike Dubik, MD
Gaithersburg, MD

A For a 21/2 year-old to suck his thumbwhen he is tired is normal behavior, and you are probably right that holdinghis penis at the same time is also a self-comforting behavior. Advise theparents to ignore both behaviors with the expectation that they eventuallywill stop. Paying attention to the behaviors may prolong them.

William B. Carey, MD
Philadelphia, PA

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


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