BEHAVIOR:
ASK THE EXPERTS

WHEN SHOULD PARENTS STOP GETTING DRESSED IN FRONT OF THEIR CHILDREN?

Q Many mothers of male infants and toddlers in my practice ask me the same question: At what age (of the child) should a mother stop changing her clothes in front of her son? What makes a particular age the correct time? I cannot seem to find a developmentally and culturally satisfying answer. Any suggestions?

Stacey Maslow, MD
Boston, Mass.

A It is interesting that you pose the question in terms of sons. This is as much an issue for girls as for boys. Sometime during the preschool years, a child's natural curiosity begins to include anatomy—his or her own, other children's, and parents'. It is important to acknowledge the child's curiosity and yet emphasize that a person's body is private.

At around 3 years of age—sometimes sooner—children may begin to notice the differences between boys and girls. Their curiosity is really more about anatomy than sexuality. How a parent decides to handle such situations reflects the family's cultural values more than any developmentally right or wrong answers.

Children often ask questions of their parents, especially when they see them nude. They ask about why parents' bodies are different from children's bodies and why parents have body hair. Parents should answer these questions simply and directly.

Some families place high value on modesty; others prefer openness. The critical point for a child to understand is that modesty is not to be equated with shame. Modesty emphasizes self-respect and dignity; shame suggests that natural curiosity is somehow wrong or bad.

The child's and parent's level of comfort with nudity are probably the determining factors for when a parent should stop changing clothes in a child's presence. If a child is uncomfortable with a parent's nudity, the discomfort may manifest itself as anxiety or prolonged questioning. Then it may be time to stop changing in front of the child. If a parent feels uncomfortable, that is also the time to stop. When children sense parental discomfort, they may interpret it as shame.

Marilyn Augustryn, MD

DR. AUGUSTRYN is assistant professor and director of training, division of developmental and behavioral pediatrics, Boston Medical Center.

A CHILD WHO IS GIVEN TOO MUCH RESPONSIBILITY

Q A new patient in my practice, an 8-year-old boy who moved here from another state, has an unusual amount of family responsibilities for a child so young. The boy's mother is schooling him at home, and he is doing very well. The mother has a chronic illness and depends on the child for help with most of the tasks of daily living. He must remember when his mother should take her medication, for example, and keep track of dental and medical appointments for both his mother and himself.

I have talked with the mother about getting outside help. She says that her son enjoys helping her and that it is his responsibility. She has responded negatively to my suggestions that the child participate in extracurricular activities and that he return to school. She has also resisted my encouragement to become more independent and take more responsibility for her own care. The family is not eligible for any indigent or social services. There is no evidence of physical or mental abuse. How can I help this family without disrupting my relationship with the mother or my patient?

Stephen P. Combs, MD
Kingsport, Tenn.

A I agree that the situation is extremely frustrating. You have already taken the most important steps—expressing your concern about the boy's welfare and suggesting alternative arrangements. How much you can do beyond that depends on several factors. Are there other resources available to the mother? Where is the father? What about other relatives, friends, and neighbors? Evidently someone is available to get the mother to her medical and dental appointments.

What does the boy say about his home situation? You say the mother reports that he enjoys helping and is doing well in his school work, but is that really so? How are his behavioral and emotional adjustments? How strong are his social competence, scholastic performance, self-assurance, general contentment, and coping skills?

Although you may be concerned about confidentiality, you might consider contacting the mother's physician to find out the facts about her degree of disability. Is she really incapable of remembering to take her medicine and keep her appointments? If so, there must be a nursing service or social agency that provides homemaking services that could provide the home care she needs. If, as seems likely, she is exploiting her son unwisely and unfairly to the point of abuse or neglect, then legal pressures can be brought to bear.

William B. Carey, MD

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.

CHILD WHO TALKS LITTLE: CAUSE FOR CONCERN?

Q I have a 3-year-old Asian child in my practice who lives in a bilingual environment. His parents are concerned that he speaks very little, although he can talk in complete sentences when he wishes.

The parents report that he does not converse with adults like other 3-year-olds, yet he recognizes and writes both upper- and lower-case letters from A through Z and can identify numbers from 1 to 100, all colors, complex shapes, and at least 50 different animals. He is obsessed with books and not interested in playing with toys. He sings classical music in his native language, but speaks—when he speaks at all—only in English.

I sent him for a hearing evaluation, and the results came back normal. He is currently enrolled in speech therapy. The therapist says that his cognitive skills are above average but that he has to be taught to follow simple directions. His medical history is unremarkable. His parents talk to him a great deal and read to him.

Are any other evaluations needed at this stage? The parents are very worried.

Krish Laxman, MD
Dublin, Calif.

A The history suggests hyperlexia, an uncommon disorder characterized by precocious reading ability, a language disorder, and difficulty in social relationships. Even before 2 years of age, children with hyperlexia may show a striking ability to name letters of the alphabet and numbers. Some have an impressive memory for songs they have learned by rote. The history you give does not include information about your patient's social interaction. Children with hyperlexia are reported to have problems socializing with peers. Some demonstrate ritualistic behaviors such as those associated with autism.

I advise consultation with a language pathologist and with a child psychologist to assess the child's social skills. Enrollment in a small preschool group with the guidance of the speech pathologist and psychologist may help. I do not believe that the bilingual family environment is the cause of the child's failure to speak.

Morris Green, MD

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

[Editor's note: For more on the challenges facing bilingual children and their families, see "Language development in bilingual children: A primer for pediatricians" in the July 2001 issue.]

 

Behavior: Ask the experts. Contemporary Pediatrics 2002;5:46.