Q I am increasingly seeing children who have parents of the same sex. This brings up a whole host of questions. What should these parents tell their child to say to other children when their "mother and father" are discussed? What should the parents tell the child's teacher about written assignments or other matters pertaining to "mother and father"? Should the pediatrician speak with the teacher about these family units when the children are young, up to the sixth grade level, for example?
A This is an issue that pediatricians will face in relation to growing numbers of their patients. As a result of changing social attitudes and availability of various new reproductive technologies, increasing numbers of committed gay and lesbian couples are choosing to become parents. Ample evidence affirms that the parenting skills and attitudes of these parents and the emotional and developmental outcomes of their children are similar to those of heterosexual parents in every way. Even the social isolation and teasing that had been predicted to create difficulties for these children have not materialized as important concerns, largely because of the efforts that same-sex parents have made to educate their friends, extended families, schools , and communities.
How same-sex parents explain the absence of the other biologic parent will depend on their particular circumstances. As always, children should be told just as much as they are developmentally ready to hear. A growing number of books are available to help parents explain reproductive and family diversity to their children.
Pediatricians have an important role as advisors to these parents and to their children. Exactly how an individual child should respond to questions about his or her parents depends on the social climate of the particular community and the decision that the parents have made about the level of openness they can tolerate. For many parents it is still unsafe to be fully "out of the closet." For others, a supportive community makes it possible to avoid the complexity of maintaining secrets. Many parents have found ways to model and teach their children to respond to other children's (and adults') questions about their family structure and in so doing increase their children's understanding and tolerance of diversity.
Pediatricians can certainly encourage and support parents in explaining their family's constellation to school personnel, classrooms, and other community groups, such as churches. Creative teachers could take the opportunity to discuss changing definitions of families in our culture and to applaud the diversity in family structure that undoubtedly exists in each classroom. Books are available for every age level describing families in which parents are the same sex. Parents and pediatricians should work to ensure that these books are available in school and community libraries. Forms used by the school for transfer of information or permissions for field trips should have spaces for two parents to sign but need not specify "mother" and "father." The same revision would be useful in forms used in pediatric offices as well.
Pediatricians also can serve as consultants to community support groups and could be available to speak to individuals or groups who have questions about the developmental needs of children in these families. Clearly, they must be careful to check with individual family members before speaking directly about certain children or parents so as not to violate implicit boundaries of confidentiality.
Q The family of one of our patients is increasingly frustrated by their 6-year-old daughter, who refuses to speak in public. She is very vocal with her parents and a few family members, but won't talk with anyone else, including her teachers. The child's mother admits to being very shy as a child. How can I advise this family and the child's teachers, and where can they get some help with this selective mutism?
A Like you, all pediatricians should be aware of selective mutism and suspect it in the child who absolutely won't say a word in the office, but talks a blue streak at home. In my experience, it typically occurs in very shy, socially anxious children. Somehow, this social inhibition leads to mutism in unfamiliar situations, or often anywhere but in the home. This disorder can be socially and academically debilitating but generally responds well to tincture of time, sympathetic adults, behavior modification, and a coordinated school/family program of encouragement. Prozac has also been tried (of course!), apparently with excellent results. A useful resource for your patient's family is the Selective Mutism Foundation, Inc. It can be reached at PO Box 450632, Sunrise, FL 33345-0632.
Q The parents of a 3-year-old patient are concerned that their daughter talks during sleep and disturbs everyone. She starts doing this at about midnight. Any suggestions?
A I would want to know more about what is happening and how it is disturbing the family. Sleep-talking occurs during partial awakenings from non-REM sleep. It may be associated with moaning, crying, or thrashing about. The episode may be brief or last for 20 to 30 minutes or more. This is the same stage of sleep in which night terrors occur. If the child is not disturbed during the episode she will fall back to sleep on her own and have no memory of the event in the morning. Sometimes, parents fully awaken the child because the parent wants to find out what is bothering her. In these situations the child may have more difficulty falling back asleep. In addition, since the early phases of sleep are predominantly non-REM (most REM sleep occurs after at least four hours of sleep), when the child does fall back asleep she is likely to enter non-REM sleep. This makes more likely another episode of sleep-talking during the night.
Parents who are disturbed by aspects of partial awakening from non-REM sleep can be reassured that the child is not having a nightmare because such dreams occur during REM sleep, a time when most of the child's muscles are so relaxed that sleep-talk or thrashing about cannot take place. You also can tell them that the child does not respond to them because she is not yet fully awake. Parents may also be upset that their own sleep is disrupted, especially if the child stays up for a long time after the event. As noted above, this is more likely when parents fully arouse the child. Thus, parents should not disturb the sleep-talking child, allowing her to descend more readily into a deep sleep.
In young children, sleep-talking and night terrors should be considered normal variants of developmental changes in sleep architecture. They are more likely to occur if other events are disturbing the child's sleep, however. Maintaining good sleep hygiene is likely to minimize these disruptions and thus the frequency of sleep-talking. Components of good sleep hygiene include having a regular bedtime and wake-up time, following a consistent bedtime routine, not engaging in vigorous physical exercise or watching or reading frightening stories before bed, sleeping in a quiet and dark environment, and being put to bed while awake.
Behavior: Ask the experts. Contemporary Pediatrics 2001;2:29.