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Rush to Judgment

I have this patient, 9 years old, and I think her mother is doing a less than admirable job. The child is as healthy as a horse, but her mother is convinced she's extremely delicate, and every little symptom becomes a major tragedy. Kelly (names and identifying characteristics have been changed) can't go swimming because she has a runny nose. She has to stay home for two days because her stomach hurts. And you should see how her mom carries on when Kelly needs a shot or a blood test, working the poor kid up to the point of tears. This mother is what I would call a drama queen; she seems eager for the pathos of a sickly child.

Then there's Michael, a 2-year-old with severe eczema, whose parents are at the other extreme. I got him an appointment with a dermatologist, and they didn't show up. Last time I saw him, his skin looked pretty bad, and it was clear that he was uncomfortable. I asked his father what they were putting on it and he told me they had run out of the creams I had prescribed a couple of months ago. Michael's mother chimed in, sounding aggrieved: The creams weren't working. Every time they stopped using them, the eczema just came back.

Albert has a mother who seems just plain clueless. Albert is 7, and he gets fatter and fatter, way off his growth chart. He sits in the exam room drinking a soda while his mother holds another one at the ready and tells me that she doesn't understand his weight problem, he doesn't eat a thing, he has no appetite at all. It must be metabolic, so why don't I do some blood tests? Albert hears the words "blood tests" and begins to protest, so she promises him if he's good, they'll go to Kentucky Fried Chicken when they're done at the clinic.

Oh, dear. This isn't coming out right. I set out to explore the issue of being judged as a parent by your pediatrician, but instead I keep coming back to parents I have judged and, needless to say, found wanting.

I'm not talking about real problem parents, those whom I would consider reporting for some sort of neglect. I have to report parents every now and then as part of my job, if a child actually seems to be in danger. But not for everyday things. Not because the parents are loony tunes or sometimes don't seem to know their child at all. These are ordinary, well-meaning people who I happen to think aren't doing a very good job with their children. People I would grade B- or C+, not people I would flunk.

Listen, I know it's an anxiety we all have in common as parents. What if someday, somehow, you're stamped as a bad mother? It's an anxiety that hovers in the background whenever your 2-year-old throws a tantrum in public and you try to talk to her in sweet and reasonable-sounding tones you hope will work  -- and also win over all the disapproving onlookers. It's the anxiety that hovers even while you pack your child's lunch, wondering whether anyone is noticing how often the little plastic containers are filled with dubiously nutritious fare. The world seems to be full of people who might be passing judgment.

When you go to your pediatrician, you're most vulnerable because something might be wrong with your child. The last thing you want to hear is that it's your fault. If you go to your pediatrician for a checkup and answer questions about your home and your child-rearing practices, you may wonder what kind of judgment is being made. I know how that feels; I take my own children to their doctor and answer the same questions. I do feel that I have a little more at stake than most, since I'm sure I'm being judged as a pediatrician as well as a mother, and so I've been known at times to practice a certain defensive technique (which, by the way, I'm not recommending). In other words, I've been known to lie to my pediatrician: "No, we never give her a bottle at night any more," I'll say piously. "No, we never let him sleep in our bed."

Of course, I never lie about what my child does or doesn't do. Only about the things I do or don't do. I don't pretend, for instance, that my child is potty trained, but I do pretend that I'm unfailingly wise and understanding when she has an accident. And when the pediatrician nods approvingly, I'm always surprised to find that I feel every bit as smug as I might feel if my good reports were founded in fact.

But while I tend to worry that my own pediatrician may pass judgment on me for being too lax or not paying enough attention, I tend to judge the parents I see in my practice for just the opposite, being too anxious or too wrapped up in their children's symptoms. The parents I judge most harshly are those who know too much about their children's bowel movements, for example. As a parent, I forget every diaper the minute I change it, and as soon as the diaper era is over, I pursue a don't ask, don't tell policy.

On the other hand, I have several times ended up in the doctor's office with a sick child who should have been seen sooner. I remember calling the pediatrician one morning to say that my 1-year-old had a fever. "How high?" came the slightly bored voice of the woman whose job it is to take all the messages from all the parents about all the fevers.

"104.6°F," I said.

"How long has it been that high?" she asked, sounding more interested. (At least I wasn't one of those mothers who thinks a 100°F temperature is an emergency.)

"Four days," I said, cringing a bit.

"I'll have the doctor call you right away," she said, and I can just imagine the comment she made when she put my slip on top of the pile of all the calls from people whose children had a temperature of 100 or a funny-looking bowel movement.

So yes, I judge parents, and sometimes react negatively. I see them handle tricky situations with their children, and sometimes I think to myself that I would never handle things that way. But the truth is, watching a broad range of parents has been very educational for me, not only as a pediatrician, but also as a mother. I've learned an awful lot about how to handle children and their behavior and their problems and their illnesses: Don't make a big deal out of a doctor examining your child. Always use bribes before threats.

But despite my willingness to sort out the lousy and the clueless and the pretty worthless, I have to come back to this lesson: I've learned there are plenty of ways to raise children. There are plenty of good ways to raise children, some more anxious, others more casual.

Most of the time, a pediatrician isn't dealing with bad parents, but rather with less-than-shining moments in a long and difficult endeavor. And, in my professional judgment, you cannot possibly be a good parent unless you have your share of clueless moments.

Contributing editor Perri Klass, M.D., mother of three, is a pediatrician at Boston Medical Center.

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