NY Times and Manners

new_york_times:http://www.nytimes.com/2009/01/13/health/13klas.html

By PERRI KLASS, M.D.
Published: January 12, 2009

For years, I took care of a very rude child. When he was 3, I called him rambunctious — and I talked to his mother about “setting limits.” At 4, I called him “demanding.” At 5, he was still screaming at his mother if she didn’t do what he wanted, he still swatted me whenever I tried to examine him, and his mother asked me worriedly if I thought he was ready for kindergarten.

Should doctors broach the subject of manners with their patients' parents? Join the discussion.
I could go on (he didn’t have an easy time in school), but it would sound like a Victorian tale: The Rude Boy. I never used the word “rude” or even “manners” when I spoke to his mother. I don’t describe my patients as rude or polite in the medical record. But I do pass judgment, and so does every pediatrician I know.

It’s always popular — and easy — to bewail the deterioration of manners; there is an often quoted (and often disputed) story about Socrates’ complaining that the young Athenians have “bad manners, contempt for authority.” Sure, certain social rubrics have broken down or blurred, and sure, electronic communication seems to have given adults as well as children new ways to be rude. But the age-old parental job remains.

And that job is to start with a being who has no thought for the feelings of others, no code of behavior beyond its own needs and comforts — and, guided by love and duty, to do your best to transform that being into what your grandmother (or Socrates) might call a mensch. To use a term that has fallen out of favor, your assignment is to “civilize” the object of your affections.
My favorite child-rearing book is “Miss Manners’ Guide to Rearing Perfect Children,” by Judith Martin, who takes the view that manners are at the heart of the whole parental enterprise. I called her to ask why.

“Every infant is born adorable but selfish and the center of the universe,” she replied. It’s a parent’s job to teach that “there are other people, and other people have feelings.”
The conversations that every pediatrician has, over and over, about “limit setting” and “consistently praising good behavior” are conversations about manners. And when you are in the exam room with a child who seems to have none, you begin to wonder what is going on at home and at school, and questions of family dysfunction or neurodevelopmental problems begin to cross your mind.

Dr. Barbara Howard, an assistant professor of pediatrics at the Johns Hopkins School of Medicine and an expert on behavior and development, told me that a child’s manners were a perfectly appropriate topic to raise at a pediatric visit.

“It has a huge impact on people’s lives — why wouldn’t you bring it up?” she said. “Do they look you in the eye? If you stick your hand out do they shake it? How do they interact with the parents; do they interrupt, do they ask for things, do they open Mommy’s purse and take things out?”

Dr. Howard suggested that the whole “manners” concept might seem a little out of date — until you recast it as “social skills,” a very hot term these days. Social skills are necessary for school success, she pointed out; they affect how you do on the playground, in the classroom, in the workplace.

We also think of social skills as a profound set of challenges that complicate the lives of children — and adults — on what is now called the autism spectrum. Children with autism, whether mild or severe, have great difficulty learning social codes, deciphering subtle body language or tone of voice, and catching on to the rules of the game.

Therapy for these children can include systematic training in social skills, sometimes using scripts for common human interactions. And one lesson, Dr. Howard said, “is that you can teach this stuff, and we maybe aren’t teaching it as well as we should be to children who are developing normally.”

And of course, one of the long-term consequences of being a rude child is being a rude adult — even a rude doctor. There are bullies on the playground and bullies in the workplace; it can be quite disconcerting to encounter a mature adult with 20 or so years of education under his belt who still sees the world only in terms of his own wants, needs and emotions: I want that so give it to me; I am angry so I need to hit; I am wounded so I must howl.

I like Miss Manners’ approach because it lets a parent respect a child’s intellectual and emotional privacy: I’m not telling you to like your teacher; I’m telling you to treat her with courtesy. I’m not telling you that you can’t hate Tommy; I’m telling you that you can’t hit Tommy. Your feelings are your own private business; your behavior is public.

But that first big counterintuitive lesson — that there are other people out there whose feelings must be considered — affects a child’s most basic moral development. For a child, as for an adult, manners represent a strategy for getting along in life, but also a successful intellectual engagement with the business of being human.

I did not enjoy visits with my rude patient. Despite his generally good health and his normal developmental milestones, I couldn’t help feeling that the adult world had failed to guide and protect him. He was loud and demanding and insistent, but one of his basic needs had not been met: no one had taught him manners.

As a pediatrician, I worry about the trajectories of children’s growth and development: measuring a baby’s head size, weighing a toddler, asking about the language skills of a preschooler. Manners are another side of the journey every child makes from helplessness to autonomy. And a child who learns to manage a little courtesy, even under the pressure of a visit to the doctor, is a child who is operating well in the world, a child with a positive prognosis.