Behavior: Ask the experts




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Q The parents of a 4-year-old girl are distressed by a change in their daughter's behavior since she began school. She used to enjoy going to friends' houses, where she happily played, but now she does not want to go anywhere without her mother. She does go to school happily, however. Is this normal separation anxiety behavior?

Muhammad Waseem, MDBronx, NY

A "Fear of separation" is the major component of separation anxiety. The child with separation anxiety is excessively distressed by separating from a parent, persistently worries about separation or "losing" the parent, and is concerned that some event will result in being separated from the parent. The situation you describe probably does not constitute separation anxiety.

Nonetheless, you should explore the parents' views about the impact of separations on the child, their resources for dealing with the separations, and the nature of the family's support system for the child. The way the parents deal with separations like going to a friend's house probably will determine whether the girl's ability to deal with brief separations improves or deteriorates.

Several studies have confirmed that anxiety in parents begets anxiety in children. Many times, parents unwittingly convey their anxiety about separations to their children. I like to suggest that parents practice being as matter of fact as possible about separations. They can do this by planning many brief separations, say eight to 10 within one week, that last only until the parent and child no longer feel anxious. The mother might arrange with a friend to watch her daughter, for example. The mother says goodbye as calmly as possible and then leaves. She then telephones her friend and once she has confirmed that her daughter is having a good time, returns to pick her up. After following this regimen for one week, the preschooler usually is handling separations just fine

Edward R. Christophersen, PhDKansas City, MO

DR. CHRISTOPHERSEN is Professor of Pediatrics at The Children's Mercy Hospital, Kansas City, MO.


Q Many parents have told me that eating sugar causes their children's behavior to become worse. Is this observation scientifically valid? If not, how would you advise proceeding with families who make such claims? If an association between sugar and problem behaviors has been proven, how should pediatricians, day-care workers, and teachers act on this information?

Gary Gorlick, MDLos Angeles, CA

A It is critical to understand exactly what symptoms parents who see a correlation between eating sugar and problem behaviors are talking about and under what conditions these symptoms arise. Are they perhaps describing a food allergy or intolerance? Does the child in question have an insufficient diet, and is he or she eating large amounts of one food group and none of the others?

A meta-analysis of the reported studies on the association between sugar and problem behaviors (Wolraich ML et al: JAMA 1995;274:1617) found that sugar (mainly sucrose) does not affect the behavior or cognitive performance of children. The number of studies performed at that time could not eliminate the possibility of a small effect but not one that could explain large changes in behavior. More studies are needed to look at the potential effect of sugar on particular groups of children.

Why the results of controlled studies differ so much from parents' impressions has often been attributed to the effects of parents' beliefs and expectations and confounding factors. Sugar is commonly consumed in large quantities at special events like parties, for example, but it may be the excitement of the event itself that causes the behavior changes rather than the sugar the child has eaten.

Hyperactivity and problem behaviors will continue to frustrate parents until research uncovers their causes and develops effective treatment. Until then, it is best to find a middle ground with any family that sees a correlation between eating sugar and problem behaviors. The best advice for these families is to apply to sugar consumption the adage "all things in moderation."

Marilyn Augustyn, MDBoston, MA 

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


Q Two brothers ages 6 and 7 years spend about four hours every day playing with their Pokémon cards. Their school work is fine, and they eat and sleep well. They are not getting as much physical exercise as they used to, however. What do you suggest?

Solomon J. Cohen, MDKennebunkport, ME

A That these brothers play with their Pokémon cards four hours a day suggests a troublesome absence of parental discretion and guidance. Surely these young children should have more in their lives than a developmentally inappropriate obsession with the Pokémon fad! The children and their parents merit a thorough diagnostic appraisal and a written prescription for both recovery and health promotion. Both parents should be present for this evaluation. A successful outcome also depends on getting the parents to recognize your knowledge of what is best for the health of 6- and 7-year-old boys. Such recognition is an essential therapeutic tool.

In addition to promoting physical activity, your health prescription may include enhancing the boys' social interactions with their parents and with peers, commending them for their academic progress, and encouraging extracurricular activities, such as reading, hobbies, crafts, the performing arts, and family chores. In addition to team games such as soccer and baseball, individual or group recreational activities may include swimming, karate, roller blading, tennis, and winter sports. Buttressed by parental interest and support, most boys of this age want to be active and are more easily motivated to participate in these activities than older children. It is not clear what has been missing in this family.

Fulfillment of the health prescription will require parental understanding, endorsement, leadership, and support, along with the children's agreement. As you discuss the recommendations, number them and jot them down in abbreviated form on a prescription form, which you should sign along with the children and parents. Emphasize how important it is for the parents to be role models. They can fulfill this function through their own physical activity, their willingness to help organize or coach a team, their agreement to register the children for teams, or by fostering family participation in walking, jogging, running, or bicycle riding.

This clinical vignette supports the practice of posing selected trigger questions during health-supervision consultations: "How does Johnny spend his day outside of school?" What does he do with his allowance?" "What do you do as a family?" Because parents and children may not realize why such questions are useful for evaluating health, they may not spontaneously report the amount of time their child spends on solitary activities such as computer games, television, or Internet chat rooms. Analogous to "empty" calories, such developmentally empty hours may be injurious to children's health.

Morris Green, MDIndianapolis, 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.


Julia McMillan. Behavior: Ask the experts. Contemporary Pediatrics 2000;9:36.

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