A 4-year-old boy is brought to the office for a routine visit. He is growing well and talking in short sentences. The patient can hop and copy a square. He has started to play board games with his brothers and sister but occasionally hits his siblings when he loses a game. His parents are concerned that he cannot yet tie his shoelaces and ask if it is normal for him to occasionally fondle his genitals in public or try to touch his brother's genitals while bathing. The mother says, "He has shown me dolls kissing each other's private parts a few times and has asked where babies come from. I haven't even had that talk with his 6-year-old brother. Is that a normal question for a 4-year-old to ask?" The parents are also concerned that the patient still sucks his thumb when anxious and occasionally wets his bed at night. He will be starting preschool soon. Which of the following behavior is concerning in this patient?

Question

A 4-year-old boy is brought to the office for a routine visit.  He is growing well and talking in short sentences.  The patient can hop and copy a square.  He has started to play board games with his brothers and sister but occasionally hits his siblings when he loses a game.  His parents are concerned that he cannot yet tie his shoelaces and ask if it is normal for him to occasionally fondle his genitals in public or try to touch his brother's genitals while bathing.  The mother says, "He has shown me dolls kissing each other's private parts a few times and has asked where babies come from.  I haven't even had that talk with his 6-year-old brother.  Is that a normal question for a 4-year-old to ask?"  The parents are also concerned that the patient still sucks his thumb when anxious and occasionally wets his bed at night.  He will be starting preschool soon.  Which of the following behavior is concerning in this patient?

Quizplus · Accepted Answer

11ec25c8_d802_9f2f_bc81_ffb180427373_MD0003_00 Young children are naturally curious about their bodies, and it is developmentally normal for toddlers and preschoolers to touch their own or other young children's genitals (Choice G). Occasional genital self-stimulation is also common (Choice B), as is asking about reproduction, playing "doctor" with other children, dressing in the typical clothing of the other gender, and attempting to undress themselves or others. These behaviors are usually brief and distractible and should not be stigmatized but rather redirected if socially inappropriate (ie, self-stimulation in public). These behaviors typically decrease as children approach adolescence, when they become more aware of social norms and expectations and have an increased need for privacy. There are, however, sexual behaviors that are of concern in young children, such as precocious sexual knowledge, preoccupation with masturbation, excessive or aggressive talk about sexuality, and simulating genital-genital, oral-genital, or anal-genital contact. The reports by this patient's mother about his simulation of oral sex using dolls should be explored further. Knowledge about the specific details of sexual acts would be of concern in a 4-year-old. Anogenital trauma, coercive sex play, or repeated urinary tract infections with no medical cause should also raise concerns about possible sexual abuse. (Choice A) It is common for young children to express frustration through physical aggression. This tends to improve as they become better able to verbalize their feelings, around age 5 or 6. (Choice C) Most children aren't able to tie shoelaces until around age 5; this patient is only age 4 and his other motor milestones (ie, hops, copies a square) are normal. (Choice D) Nocturnal enuresis is common in young children. If it occurs in children age >5 or is associated with other symptoms (eg, urgency, frequency, straining), further workup may be warranted. (Choice F) Most young children engage in some form of rhythmic activity for soothing purposes (eg, thumb sucking, rocking, nail biting). These activities tend to decrease with age. Educational objective: It is normal for curious young children to touch their own or other young children's genitals, undress themselves or others, and make masturbatory movements. These behaviors are typically brief, intermittent, and distractible. Age-inappropriate knowledge or simulation of sexual acts, however, should raise concern for possible abuse. References: Sexual behaviors in children: evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/21121534) The evaluation of children in the primary care setting when sexual abuse is suspected. (http://www.ncbi.nlm.nih.gov/pubmed/23897912) Childhood sexual abuse: identification, screening, and treatment recommendations in primary care settings. (http://www.ncbi.nlm.nih.gov/pubmed/27262010)

A 4-Year-Old Boy Is Brought to the Office for a Routine