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Q When I asked a casual question about how things are going at a 15-month-old girl's well-child visit, the child's parents, both present, expressed deep concern that she cries whenever her father tries to interact with her. They add that she cries whenever any male with a low voice tries to hold her or talk to her. Although Mother is the main caregiver, Father says he has been present in the home since his daughter's birth.
The possibility of sexual abuse has been ruled out by the parents and the genital exam is normal. They have attempted to gradually introduce the father into play activities but, even though Mother comforts her, the child continues to cry. Father is devastated. Any suggestions?
A Having a clingy response to the mother with apparent fear of others is so characteristic of 15- to 18-month-olds as to have a name: "rapprochement" stage, roughly translated as "returning." It seems to represent a child's new cognitive awareness of her separateness from a parent and an awareness of her own vulnerability. At times, this developmental stage, which may persist until age 2, begins so suddenly that it alarms parents into thinking that something frightening has happened to the child.
Child or sexual abuse should be asked about, but usually there is nothing of note. That this child is afraid of deep-voiced males raises a bit of concern about trauma, but the behavior commonly occurs without that as the cause. This stage is often upsetting to the excluded parentusually the fatherwho has often been close to the child. If grandparents are the ones excluded, they accuse the parents of "spoiling" the child.
First, reassure both parents that the behavior is normal for age. Then advise them to press on having the child interact with the parent who has been temporarily excluded. This actually works better when the favored parent leaves the room, or even the housepossibly for several hours. Time alone with the child will give the avoided parent the chance to work through the child's discomfort and discover an activity the child enjoys.
The child's clinging, when the father is the one left out, may be reinforced by a mother who, deep down, likes the child's preference for her or lacks confidence in how well the father can cope. The mother may subtlyor not so subtly!"rescue" the child as soon as crying occurs. Inadvertently, she may even set the father up to fail by hovering and showing anxiety.
Other times when clinginess comes on or worsens are when the mother is upset with the child's demands, overwhelmed with life stresses, or generally depressed. In that case, the child may cling out of concern that the mother may not like the child anymore.
Managing a situation like this is based on understanding and then dealing with the cause, followed by building the relationship through daily play directed by the child's interests. A severe case may require therapy for mother and child.
Q A 4-year-old boy is wetting his pants at school. His explanation is: "I can't wait for my turn in the bathroom." He is dry at home at all times and enjoys going to school. Any advice?
A The child does not meet the technical definition of diurnal enuresis, which is urinary incontinence past 4 years of age, because of his age and being dry at home at all times. The enuresis workup should always include a complete history, with a focus on a family history of enuresis; the child's pattern of wetting; report of any interventions that were tried; and a thorough physical exam that emphasizes the spinal, neurologic, and genital aspects.
Assuming that everything is found to be normal, the most likely cause is the boy's "I don't hafta's" (to quote the Berenstain Bears of children's literature) until it is too late! Many children are enchanted with the independence of not wearing diapers. They are also often so overly distracted by such activities as playing, school work, or friends that they completely forget until their bladder is so full that they have episodes of incontinence while waiting in line. Here is a simple, practical intervention: Have the teacher send the boy to the bathroom at halfway points in the morning and afternoon. Observe whether this helps him stay dry.
Q Recently I gave a routine checkup to a 3-year-old boy. The mother asked whether it is normal for him to be so interested in his "privates." She said he rubs his genitals many times a day. He also puts a finger in his anus, and has even asked his mother to do so on several occasions.
He lives with his mother and grandparents, and attends day care. No boyfriends or other adults take care of him. His mother frequently "pops in" unannounced at day care and has never been worried about sexual abuse there. He has no other significant behavioral or emotional problems. He has not shown any other sexual behavior. His exam, including a careful external exam of the anus, is normal.
I have seen female toddlers insert foreign bodies into the vagina, but do not know of any toddlers who stimulate the anus like this child does. Is this seen more often than I am aware of, or is abuse the major consideration?
A I believe a 3-year-old child who rubs his genitals is displaying a normal developmental variant unrelated to inserting his finger in his anus. Pinworm infestation is probably the most likely cause of his behavior and his requests. A psychological basis for his behavior is most unlikely.
Behavior: Ask the experts. Contemporary Pediatrics 2002;2:49.