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I enjoyed reading "Promoting parental 'presence'" (January)--anexcellent article and excellent choice of author. My only caveat? A suggestedreading list for parents would have been helpful. I'm sure Dr. Green hashis personal favorites. Here are a few of mine: Parent Effectiveness Training:The Tested New Way to Raise Responsible Children, by Thomas Gordon; SettingLimits: How To Raise Responsible, Independent Children by Providing ClearBoundaries, by Robert J. Mackenzie; The Difficult Child by Stanley K. Tureckiand Leslie Tonner; and any of the books by Dr. Benjamin Spock.
Marc Wager, MD
New Rochelle, NY
"Promoting parental 'presence'" is a very good article, butI would have appreciated more discussion of children who are in day care10 to 12 hours a day. Parents often have no idea what discipline methodsare being used with their children. Because their own interactions basicallyconsist of giving the child supper and putting him or her to sleep, theyhave little opportunity to exercise "presence."
With regard to the trigger questions Dr. Green mentions, I have foundthis one extremely useful: "Is having a 2-year-old (or 4-year-old,etc.) what you expected?"
David H. Austein, MD
Morris Green's article emphasized the important lesson that often thebest way to help children is to help and support parents. It illustratesthat a family-centered intervention is often more effective than a child-centeredintervention for psychosocial problems where children affect parents andparents affect children. Parents do welcome pediatricians' expressed concernand active help for their needs (either by the pediatrician or by way ofreferral). Dr. Green has shared some very effective techniques.
William N. Coleman, MD
Chapel Hill, NC
The author replies: I appreciate Dr. Wager's kind words and the listof books that he recommends to parents. I keep copies of these volumes inthe office so that parents may briefly look through them at the end of thesession.
Dr. Austein's observations about children who are in day care 10 to 12hours a day is an important one, and I should have discussed that experiencemore fully. To have presence, a parent has to be present an adequate periodof time. I like the suggested trigger question, and I shall add it to myrepertoire.
Morris Green, MD
I would offer a slightly different approach to the toddler who is afraidof the animals on his wallpaper border, as described in "Behavior:Ask the experts" (February). I believe that having parents give theirchild suggestions about how to deal with actual lions in their bedroom (suchas to sing them to sleep or wait for the lion tamer to put the lions backin their cages) might indicate to the child that the parent also believesthere are lions in the bedroom.
Instead, I prefer a more realistic approach. After acknowledging thechild's fears and assuring him that many children have similar anxieties,I advise the parents to assure the child that there are no real lions orother scary things in his room and that the parents will protect him andnot let any such things into their house. They then can teach the childto use his imagination to think nonthreatening thoughts or offer an alternateactivity, such as singing a lullaby or reading a story, to distract or relaxhim. Having a consistent wind-down activity at bedtime as part of a regularroutine will also help avoid turning these bedtime fears into attention-seekingor stalling behavior.
Cynthia R. Ellis, MD
Dr. Kemper's ideas are well thought out and may even work. But if theinfant is truly afraid of the wallpaper border and simple remedies havefailed, I suggest a much easier approach. Just rip the border down. Wallpaperborders go on after paint or other papers and come off easily. The toddlerwould benefit immediately, and the parents would not have to spend nightsanalyzing and concocting remedies for the child's anxieties. This strategyfits in well with today's drive-through medical environment.
Stuart Feinstein, MD
The author replies: I think Dr. Ellis perhaps misunderstood that I wasengaging the child's imagination in dealing with an imaginary monster situation.Of course parents can reassure the child that there are no "real"monsters and that the parents will protect them from "real" harm.But imaginary things are also scary for many children (and adults). Manytechniques can be used, from engaging imaginary allies, to distraction,to denial. Prevention is always a good idea, and I endorse the idea of avoidingscary stories, like those on the evening news or family squabbles, beforebedtime. As Dr. Ellis suggests, routines also are reassuring.
I love Dr. Feinstein's approach--just to pull down the wallpaper. Verypractical!
Kathi J. Kemper, MD
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