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Q I would like help with advising parents on how to talk about death and dying with their children. Can you offer guidelines and suggest books that I could recommend to parents?
A I'll frame this response in terms of the death of a grandparent, which is the most common and important death that children experience, and which is a loss complicated by the suffering of the child's parents as well. Parents should prepare a child for this event by commenting on the declining health of the grandparent: "Grandpa isn't strong enough to wrestle with you anymore," for example, or "Grandma sleeps all the time because she doesn't have the energy she used to." When children see that something is different or wrong, hiding information from them is confusing and frightening. After the age of 3, most children have learned from friends, stories, or television that people and pets can die. Even if they don't ask, they're probably wondering if their grandparent is going to die some day. Parents should address this issue as the problem evolves: "Grandpa is having trouble with his breathing, and we are feeling sad that he may die soon."
Parents also should help children find ways to bring aid and comfort to their grandparent, either at home or in the hospital, as he or she becomes progressively ill. Children like to feel part of the helping and grieving process. They might read books to the grandparent, sit with him watching television, or bring him food, especially if the child made it himself.
Finally, after the grandparent dies, parents should talk about the grandparent and use her name frequently. They should share stories and photographs so the child understands that even though Grandma died, the family still remembers her. Helping her child mourn the loss of the grandparent can be a challenging task for a parent who is mourning the profound loss of her own parent.
Here are other general suggestions for dealing with death to pass on to parents:
You do not need to hide your grief from your child. In fact, by expressing your grief in front of him, the child will learn how to mourn. At the same time, reassure your child that, even though you are upset and exhausted, you can still care for him.
The child can participate in religious or cultural rituals related to death and burial, although he should be old enoughabout the age of 4to understand what is going on. One parent or another adult should be available to the child during any ritual at which a grieving parent may be unable to respond to him.
The way a child responds to a death cannot be categorized as good or bad. Depending on age and temperament, the response to significant illness or death varies. For more information, I suggest referring parents to Talking to Children About Loss by Maria Trozzi.
Q A 7-year-old girl likes to dress like her older sibling, who is a boy. Should the parents worry? What should they do?
A Children often imitate their older siblings. In this instance, imitation may concern the parents because their daughter is not conforming to typical gender-based patterns of preferences in clothing, and perhaps in toys and activities. But if the child enjoys both pants and dresses (and dolls and trucks and sports and crafts), the parents need not worry. They should encourage her to maintain a range of interests, activities, and playmates.
The parents should take note of whether their daughter becomes rigid and consistently makes choices that are typical of boys, especially if she repeatedly says that she wants to be a boy. These behaviors may reflect gender dysphoria or early homosexuality. In that case, the parents would need to help their young child become comfortable with her identity as she develops.
Q The parents of a 14-month-old girl in my practice are worried about their daughter's masturbation, which began about 5 or 6 months of age. She crouches on the floor, crosses her legs at the ankles, and grips objects, such as a stuffed bear, against her genital area. She engages in this behavior for 15 minutes to, sometimes, an hour a day. She is more likely to masturbate when she is tired or fussy. I have observed her behavior; she is not having a seizure and is fully aware of her surroundings and will answer to her name. She is developing normally. The parents' anxiety is heightened by the fact that their 4-year-old son is autistic; they worry that this could be an early sign of the same condition. What is your opinion?
A You are raising two questions here. Is genital exploration and masturbation normal or abnormal when practiced to this degree? And are episodes of masturbation consistent with early autistic behaviors? In keeping with a general principle of behavioral pediatrics, I would not focus immediately on the specific behavior but attempt to understand this child and her family through a behavioral and developmental profile.
The toddler is, you report, "developing normally." Can she walk with a steady gait? Does she use her fingers to pick up small objects, including food? Does she grasp and drink from a cup? Do the parents have any concerns about her vision or hearing? Does she follow a simple direction? Does she say a few words in addition to "Mama" or "Dada"? Does she discriminate among her parents, a child-care worker, and a stranger? The answers to these focused questions may reveal developmental variations that suggest other concerns or conditions.
As many as one third of toddlers explore their genitals with their fingers, by rubbing together their thighs, or by rubbing against objects. The masturbation is usually intermittent and lasts for only a short time. It may be prompted by an episode of vulvovaginitis or urethral irritation; the child discovers that the rubbing is pleasurable and repeats it when he or she is bored or tired. In toddlers, episodes of abdominal pain, motor tics, or seizures may masquerade as masturbation. You made an important clinical observation when you noted that the child was aware of her surroundings when she was masturbating, indicating that a seizure was unlikely.
This child's masturbation is typical in that it is associated with being tired or fussy. What is atypical is the duration of an episode. Ask focused questions about family functioning, child-care personnel, and the possibility of sexual abuse. With a 4-year-old autistic son in the home, these parents are continuously challenged with behaviors that engage their attention. I would ask them directly if they think they have paid only limited attention to their daughter because their son requires so much energy and attention. Is she often tired and fussy because of inattention and lack of appropriate social stimulation? Providing toys and games and more social interchange when the child begins to masturbate may be helpful. A home visit from an early intervention specialist, if one is available, might be diagnostic and therapeutic.
The parents' concern that their daughter may be autistic needs to be addressed because autistic spectrum disorder has a prevalence of about 3% among siblings of autistic children. Any of the following observations require further evaluation: by 12 months, no babbling or gestural communication (such as pointing or waving goodbye), or a failure to orient to her own name; by 16 months, no single word; and, by 18 months, no pretend play or gaze monitoring. You can assess all these milestones on your own. The parents should be reassured by your finding that delays are absent.
Morris Green. Behavior: Ask the experts. Contemporary Pediatrics 2001;8:40.