March 29, 2009

Postpartum Depression: Andrea gets help, gets sleep.

I attended a seminar run by psychologists Shoshanna Bennett and Pec Indman through an amazing outfit called Postpartum Support International. The seminar was advertised as for healthcare professionals, and lasted 2 full days. It was crowded and expertly run, in the meeting room of a nice hotel. I think I was the only man there. I was the only physician there. There were no obstetricians, no neonatologists, no psychiatrists. I have to add that I can’t be 100% certain of this, but I looked at a lot of name badges and a list of attendees. There were a lot of midwives and doulas and nurses. Even though there’s a reputation of caring associated with these providers, their involvement with the mother is usually limited in duration. So it seems to me that the natural focus for dealing with postpartum depression was a pediatrician, who would be seeing the mother and baby often in those first weeks and months, and who wasn’t afraid of the extra time it would take to ask the question, “how do you feel?”

A few years ago, when I started my own practice, this would be an important goal. It required a change in scheduling and a change in commitment to the mother-baby unit.

Many of the guidelines for newborn care are a compromise, meant to attempt to optimize the balance between a lot of care, therefore costing more, that catches almost every problem, and little care that misses a lot of problems but costs much less. So the general guideline for pediatricians is a visit within 48 hours of leaving the hospital, then again at 2 weeks, then 2 months, and so on. The interval between visits gradually increases. These dates were arrived at by committee, and are meant to give each baby an acceptable amount of care. The schedule ignored the mother.

The obstetrical follow-up calendar saw the mother at 6 weeks. It ignores the baby.

The seminar at PSI was transformative. I started to ask several questions of all the new mothers. I haven’t kept track over the years, but my sense is that it’s closer to about 50% who have some symptoms.

Not all the symptoms last. Sometimes it really kicks in about day 3 or 4 of the baby’s life. At this crucial time, especially with a first baby, the mother is trying to breastfeed but she’s just not producing a lot yet. The baby has used up the reserve tank with which most newborns come equipped. The baby is much more awake than that first day, crying often to let you know how hungry it is. The mother hasn’t slept much in 3, maybe 4 or 5 days. It’s enough to make anybody reach for a bottle.

Andrea's baby was thriving. I was sorry she had stopped breastfeeding, but I knew that wasn’t yet a lost cause. I recommended a lactation consultant. But the baby was growing well, so this wasn't my first priority. That was sleep. I asked Andrea and her husband to help me make a list of absolutely everyone they could call on for help. Even if it was somebody who could watch the baby for a few minutes while Andrea took a shower, or someone who could join her when she did some shopping. As in many families, there was a grandparent at the top of this list. I used Andrea's cell phone to call her mother to ask if she’d like to watch the baby for a few hours. She was thrilled. I called Andrea’s husband and asked him to take the baby for a few hours, taking over from Andrea’s mother. The baby wasn’t breastfeeding at the moment, and another few hours of formula wasn’t going to make a difference. I suggested she ask her mother to watch the baby in Andrea’s apartment, and suggested that Andrea sleep in her mother’s house. I asked her to return the next day with the baby.

The next day, it should be obvious, was a revelation to both Andrea and me. A single uninterrupted stretch of sleep changed a lot about her view of the baby and her view of her self and her future. For the next 30 days or so, I saw Andrea and her baby or spoke to her on the phone at least once a day. I spoke to her husband, too, and asked him to come to as many baby visits as he could. She was gradually convinced that she wasn’t in this enterprise alone.

Note: Perhaps its no surprise that sleep deprivation has ominous effects for the new parent. It causes: "decreased global emotional intelligence... reduced self-regard, assertiveness, sense of independence... reduced empathy toward others and quality of interpersonal relationships..reduced impulse control... reduced positive thinking and action orientation... and greater reliance on formal superstitions and magical thinking processes." So it worsens interpersonal functioning, self-esteem, and stress management, while increasing your reliance on superstition. Perfect for new parents.

March 27, 2009

Postpartum Depression: Andrea opens my eyes

I met Jabrea for the first time when she was about an hour old. Her mother, Andrea, was in the delivery bed, exhausted but smiling broadly. Her husband and sisters and parents were all huddled around me as I did my exam. "What does Jabrea mean?" I asked her.

"Nothing," she said, "I just liked the way it sounded."

"I have a suggestion for you. People will ask her and you about it her whole life. Tell them it means 'beautiful princess.'" She liked this idea. Now, 8 years later, sometimes her parents call her 'BP,' though it's usually when she doesn't clean up her room.

Andrea was a happy and healthy young woman, with a supportive family and husband. I wasn't worried about her or the baby. She was a middle child, and her younger sister was still in school. Her older sister already had 2 young children.

She brought the baby to me for follow-up shortly after leaving the hospital. The baby was adorable and everybody in the office fawned over her. We went into an exam room and I asked, "How are things going?" Immediately, she burst into tears. "Everything's going great," she said, crying. I asked all the usual questions--breastfeeding, sleep, poop, rashes, breathing, eye contact, and so on. She answered them all without any cause for concern. While crying loudly. Eventually, I did ask her why she was crying. She said, “I don’t know.” I told her in the most convincing manner I could that the baby looked great and that I thought she was doing a great job. The baby was 2 days old. The next usually-scheduled visit was at 2 weeks of age.

That visit was more difficult, though the baby continued to look great, was gaining weight well, and seemed developmentally normal in every way. No matter how confident I tried to appear, Andrea kept crying. The visit was scheduled for 15 minutes (some clinics schedule 10 minutes), but I couldn’t move to the next patient. There was something here that I had to understand. I had to try and make things better. A long time ago, I was taught to approach complex problems in physics by breaking the problem down into more comprehensible pieces. Not having any idea or training in any other method, I tried this. I asked her about every detail of her life with the baby. She told me, after a lot of very specific questions, that she had stopped breastfeeding. She did this because she wasn’t a good mother: her body couldn’t do it, her breasts hurt, she could never do the things that her older sister could do so effortlessly, she could never do what came so easily to every mother she heard about or read about in baby books. Worse than this, her completely innocent baby would suffer from her incompetence. She would lose the benefits of breastfeeding, she would lose the better immune system and better nutrition and now she has doomed her daughter to having serious illnesses and eating disorders. Worse still, she would never bond with her mother and always know that her mother didn’t care enough about her to live with the pain. Andrea knew this to be true because the baby no longer wanted her, and was rejecting her. The baby clearly knew that her mother didn’t have want she wanted and needed. The baby didn’t need her for anything, and neither did anybody else.

What was I actually observing? In the little exam room, there was a pervasive sadness and feeling of despair and failure. Andrea had no history of psychiatric problems, and it didn’t occur to her to seek professional help. Indeed, she didn’t think anything was wrong with her. She was simply a concerned and observant parent who wanted to be sure her baby was OK. She didn’t think of herself as depressed. She acknowledged that she cried an unusual amount, and she said that her husband was frustrated because he was unable to cheer her up. She didn’t think he understood the baby as well as she did and would only let him take care of her when she was there to supervise closely.

I bought a book. Beyond the Blues by Shoshanna Bennett and Pec Indman.

Every day in my practice, I was seeing mothers with newborns. I started asking a question I had never before asked. “How are you feeling?”

Postpartum depression had never been mentioned in the psychiatry section of medical school. It had never been mentioned in my pediatric residency. Maybe I had heard the term but now, looking back, I don’t think I ever thought about it. Apparently, it is at least mentioned in the training of Ob/Gyn doctors, I guess when they aren't doing surgery. They typically see the woman for follow-up 6 weeks after she leaves the hospital.

Maybe it’s obvious that if you don’t ask a question, you probably won’t find out an answer. There’s an unspoken secret in some areas of medicine, however. Sometimes there’s information a doctor doesn’t want to know, and questions the doctor doesn’t want to ask. Asking about how the patient feels is likely to evoke an answer that will take a lot more time to deal with in a competent way that if the patient is never asked. Some doctors and clinics go so far as to spell it out. They tell the patient that each visit deals with one problem. So it’s either the rash or the headache, not both. The questions they ask for each problem are extremely specific. This helps manage the limited visit time in an optimal way for the institution, not for the patient. The patient’s time, indeed the patient’s health, is not the most important factor in this model of care.

Because so much of postpartum depression isn’t noticed by anyone in the medical field and because many of those suffering with it don’t report it or seek treatment for it, we really don’t know how common it is. But it’s common. Maybe as high as 15% or 20% in some published sources.

Nobody I knew had a clue about this. I felt like I had discovered an underground epidemic, which was everywhere I looked, hidden in plain sight, right in front of me all the time. I decided to learn more.

Next Post: Andrea, getting help and getting sleep.

March 25, 2009

Slow Medicine: The Telephone Paradox

When I tell other doctors that my patients have my home phone number, they simply don't believe me. I tell them that calls to my office in the evening and on weekends or holidays get automatically routed to my cellphone or home phone. There is no answering service or triage nurse.

I set this up because the job of the answering service (this is one of the selling points they use for doctors) is to minimize the number of calls they put through. They seem to be measuring their effectiveness by how impenetrable a barrier they are for the patients. When your child is sick, if you want to talk to a doctor—forget the possibility of talking to your doctor—you have to sell the person answering the phone on how desperate your situation is, but not so desperate that they tell you to go to the emergency room. I want to get those calls, and want to know what's going on with your kid.

But my colleagues don't believe it. They tell me that if they let patients call them at home, they would get calls through the night about trivial things. They would suffer and their patients wouldn't benefit. I used to work for a big group practice, and this seemed a reasonable summary of my experience, too. So nobody actually tried it.

Here's what I found. The more I gave out my home number, the fewer calls I got. When I opened my own practice, I could actually program the office phone to direct all the calls automatically. Patients didn't even need my home number, they could get me at home any time. I got almost no calls. In the last 2 years, I have been awakened by phone calls just 6 or 7 times. In each of these cases, I got out of bed, got dressed and either made a housecall then or met the family in the emergency room. So those few calls were well justified.

As I thought more about this paradox, I realized that the general population of doctors had become so convinced of the universality of their experience, that they didn't attempt to repeat my experiment. I think there's an interpretation that isn't so mysterious.

First, in my Slow Medicine practice, everybody knows me. They see the same doctor with every visit and talk to me with every phone call. This leads to a humanization of the doctor as more (and less) than a BMW with a white coat who barely makes eye contact in the five minutes he spends with you, forgetting your name. So I suspect people are more respectful of my private time, the way we all are with our own friends and family. They all know that when they call at night, they won't get an anonymous shift-worker at a call center.

Second, Slow Medicine is all about access to the doctor. Once the parent is convinced they really can get a hold of me anytime, they are more willing to try and handle minor problems on their own. The thinking, I suspect, is that if the child gets worse, they can always call then. That results in perceptive parents carefully observing their sick children. If they get worried, if it gets a little too much for them to feel comfortable with, they can always call me at that time. So parents handle a lot more on their own, I think. In this way, there is another paradox. The fewer calls I get, the more empowered and self-reliant the parents feel. They know I'm there to back them up, so they might be willing to take a few steps on their own.

I believe that the ability to get in touch with your child's personal doctor in a crisis is often very beneficial to the quality and continuity of their care. Besides, if you have confidence in your doctor, and can get your doctor on the phone, then you'll have confidence in the phone advice you get. It's logical that this confidence is itself reassuring, even without actually making the call. This paradox helps me sleep better. And maybe the parents of my patients, too.

March 24, 2009

The Power of Slow Medicine

I discovered the power of slowness even while being rushed to see more patients faster. Luckily, I have a good way with most children, and they aren't usually scared of me. But there's no practical way of examining a child within a minute of walking in the room. Like the rest of us, children get territorial about their personal space, and will be upset if you violate their boundaries. So the key to a cooperative examination is getting the child to invite me to share their space with them. This takes time and patience. I will often use a prop of some sort, such as my tie or a toy or stuffed animal to engage the child and get them to reach out to me. It's a subtle dance which can take more than a few minutes, especially for anxious children. The first part of my definition is literal: slow visits.

Slow visits allow the patient or parent to ask all their questions, to get comfortable with the surroundings. In medicine, there's something known as the 'doorknob question.' The patient is in the room with the doctor, and their visit is finished, and just as the doctor turns the knob to leave the room, the patient asks a really important question like, 'Oh, and doc, should I be worried about this chest pain I keep having?' I think there would be fewer doorknob questions if doctors weren't always reaching for doorknobs. The removal of time pressure in the visit allows the patient to express their anxiety, and gradually open up about important issues. It also allows them to explain complex related problems, like family or financial situations that might have an important impact on whether they will be able to take their medicine or follow the doctor's advice.

The goal would not be simply providing the minimal acceptable level of care. Having an expert doctor who knows who you are is like having a chef who knows how to take advantage of that local seasonal produce. It takes more skill to cook something fresh than to heat something in the microwave. Having uninterrupted access to your physician can keep you from unnecessary treatments and save your insurance company money.

When I see a sick child, I have a luxury that I didn't have when working in a busy clinic. In the clinic, it wasn't clear when or if the parent could bring the child back. So to be safe, we would sometimes prescribe medication on the assumption that the diagnosis would eventually require it. Because my current patients have open access to me, I will often choose not to treat the child at all. I tell the parents to call me right away if the child gets worse. If I don't hear from them, I'll call the next day to check up on the child. Often, my patient will get better on their own and won't need any medication at all. This system only works because when parents call, they talk directly to me. I know the situation and can evaluate the need for treatment at that time. If it were a doctor covering for me, this might be a problem. Either the covering doctor would be extra cautious and prescribe medication or possibly not take it as seriously because they wouldn't know the whole history. If the parent is even more removed from the doctor, by calling a call center, they often can only get a response by selling the person answering the phone on how awfully sick their child is.

About two months ago, I got a call one Sunday from a mother of two preschoolers. Both had fever and seemed to be in pain. I met them at my office, opened the office for them and treated them. I was later told by their insurer that Sunday visits aren't a covered service. The person I spoke to on the phone in the claims department suggested that I do what most practices would do on Sunday--send them to the emergency room. It didn't seem to matter that the ER would be way more expensive, slower, and scarier.

I wonder if slower, more customized, more personal care would end up costing less. I think there might be fewer tests, fewer ER visits, fewer prescriptions, better compliance with the doctor's advice, and a lot more medical problems might be caught early. That could result in better health outcomes, lower cost of care, and more satisfied patients. I suspect there aren't enough doctors who practice this way to do the research to prove it.

I practice slow medicine.

Next Post: Slow Medicine and the Telephone Paradox

March 23, 2009

Slow Medicine

What is Slow Medicine?

Berkeley, California is the epicenter in America of the Slow Food movement. It has gradually developed over the past 20 years or so as a response to Fast Food.

The idea, I think, is that food should be very fresh, as local as possible, as organic as possible, and prepared just before serving. Michael Pollan has written a lot about these ideas in his books about food. Alice Waters has written cookbooks that emphasize these priorities and has a fabulous restaurant here that puts the concepts into practice.

I think it's time for a similar revolution in medical care. So I'm inventing the term Slow Medicine.

At business school, I first learned of the existence of Hamburger University, near Chicago. One of my smartest professors would often go and teach a course there. What he taught was Industrial Production, ways of ensuring the consistency and high quality of the final product, produced in the most economical and fastest way. Hamburger U. is run by McDonald's, and is where they send most of their best managers for training, and where they develop new systems for service. McDonald's makes great products--delicious food that's fast and inexpensive, and can almost always be counted on to be consistent in quality whether ordered in Berkeley or Brooklyn.

A few years ago, I had the honor to serve on a panel discussion about the quality of medical care. On the panel were health plan administrators, state health officials, insurance plan managers, a few professors of health policy and medical practice, and me. (I met one of the professors in the hotel elevator, and introduced myself. He asked what I did, and I said that I was a primary care doctor. He huffed and said that he didn't understand why they invited me, since he was an expert on primary care and head of the department of primary care at a major medical school. I asked him politely if he took care of patients. He said he didn't, except for the 3 weeks a year he has to supervise medical residents in their clinic. Though he was invited, I presume, as the expert in 'primary care,' I was the only practicing doctor.) The organizers went around the room, and I learned a lot! What is called 'quality' as it applies to medical care is really a code word meaning consistency, efficiency, and the lowest acceptable standard of care at the lowest average cost. In the back of my mind rang familiar echoes of chain restaurant strategy and Hamburger U. When it was my turn, I pointed out that this is not at all what my patients would think of if they were asked about the quality of their medical care. The view of patients on medical quality just didn't matter. The quality debates occurring at the moment are dominated by healthcare institutions and insurers. They want consistent, if minimal, results for the least cost.

This industrial model of the provision of medical care is everywhere in America. Because doctors are paid per visit (just as with sweatshop workers, it's called piecework), there's a lot of pressure on them to do as many visits as possible per day. That's why when we see our doctors (me, too) we sometimes get 10 minutes or less. In order to provide minimal standards of consistent results (quality), the medical assistant might have us fill out a questionnaire first or give us a lab form. Chances are that the doctor doesn't know us, our issues or questions, or our concerns. I have been to doctors where I was told that I can only ask about one problem. Another problem is another visit. In what I'm calling the industrial model, patients are the raw materials and payment is the factory output.

The people that run our healthcare companies and institutions are generally nice people with families like the rest of us. They know what good medical care is and they want it, too. But the qualities we all really want are difficult to measure and hard to define. We all want a doctor who knows us and cares about us, and tries to do their best for us. But what we get is Fast Medicine.

Do you want fries with that?

Next Post: Why Slow Medicine might actually work.

March 21, 2009

Improving the Picky Eater Experience

Love your picky eater.

The perceptive parent knows by now that I will urge them to leave their assumptions at the door. Embracing the inner grandparent (‘well she has to eat something’) isn’t the right approach.

As the child’s need to experiment with control develops, it won’t take long for her to see how important her eating is for her parents. The perceptive child understands that the more emphasis you put on something, the more valuable it is for her to control.

Keep in mind that nobody can be forced to eat. There’s just no way without a hospital-type intervention. Once the child realizes this, the parent has lost all negotiation leverage. (Hey, the point of this series of posts about eating is that you never really had any leverage to begin with.) Think hard before begging or bribing your child, since this will often spiral into increasing demands for sweets or other things you might not want your child to have. Everybody is entitled to skip a meal now and then.

Try very very hard to have a family meal every day. Research has shown that in families who sit down together for dinner, there are fewer eating disorders, less obesity, even less delinquency. For just about everything, parents are the most important models of behavior for their children. Studies show that when the parents eat a varied diet, the kids are more likely to eat a varied diet. When the parents eat healthy, so do the children.

For the picky eater, that one string bean put on their plate can act like a fuse to an explosion. It’s a challenge to the way they have envisioned their mealtime. The perceptive parent will try to see this the way their child sees it, and not provoke him with a string bean. But if everybody’s eating together, and mom and dad are gushing with delight over their string beans, it might be natural for the 1 to 2 year old child to want to try some. Maybe you can tell them that it’s grown-up food and not for them! Mmm, good. This uses the child’s need for independence and control to promote interest in trying a string bean. If they do, make a big deal about how grown up he is and how proud of him you are.

Defusing the mealtime battleground is absolutely essential. When children are fighting for control, they are unlikely to relax and try something new. I always ask the parents, is it worth it? If the child takes one bite of broccoli, gags and cries, what did they learn? Certainly they didn’t get all the good nutrients from broccoli with that one little bite. What did they learn about food, about power, about their parents?

It’s interesting to ask parents about their own adult eating issues. Many of us still don’t like the stuff we refused as kids. We certainly didn’t learn to like it because our parents somehow forced us to eat it. Many of us vividly recall battles with our parents that we had while still in a high chair. Did those battles teach us to eat right?

Siblings and peer friends are also really valuable. When older picky eaters are asked, they will often say that they wanted to learn to eat certain foods because all their friends would eat it and they wanted to fit in.

It’s possible that the child’s pickiness is related to issues of anxiety and need for order. For these children, they will avoid certain social situations such as parties where they know a food they can’t stand will be eaten by everyone else. They may suddenly complain of a stomach ache or say they don’t want to go. It can be hard to distinguish social anxiety from food anxiety. Either way, however, the child is unusually sensitive, and the most important action for the parents is to be as supportive as possible of the child when they feel so vulnerable. Coaxing her into a traumatic situation won’t make her feel closer to you.

We might not be able to transcend the issues of genetic taste preferences and sensory intensity. We can, however, get through the control issues.

Giving them the sense of control that is one of their central drives in life at age 2 is a very powerful technique. Perceptive parents will use this to advantage. Start with asking for their advice. What shall we have in our salad tonight? Carrots or tomatoes? If the answer comes back ice cream, what will usually help is a gentle reminder that mommy and daddy will eat the salad too and ice cream in the salad is silly. Then take the child shopping. Remind them of their menu choices--not just for them but for the whole family. They get to pick out the tomatoes or the carrots. When you get home, they get to prepare the food they chose (maybe with some help and supervision). At dinner time, everybody gets to hear about how they chose the best tomatoes and how they washed them and maybe helped to cut them up and how really delicious the tomatoes are. This positive feedback cycle might work for broccoli, too, and for many foods that need washing or cooking or preparation. Children are more likely to try things they are invested in and already feel good about than things they feel threatened by. Doesn’t that make sense?

Giving the child a sense of ownership of their choices is a technique that perceptive parents will use in many different situations.

March 20, 2009

The Problem with Picky Eaters

Should we intervene with picky eaters?

This is both a medical and philosophical question. The medical question is easier, so I’ll deal with that first.

If the child’s picky eating has left them without enough vitamin intake (if they ate zero vegetables, for example), they probably should take a vitamin. Luckily, there’s a lot of good-tasting vitamin choices available. For iron deficiency, it’s a little more difficult, because the iron supplements often taste bad. But there’s now orange juice with iron, and vitamins with iron which might help. For kids who don’t have any dairy, there are many calcium-fortified foods and drinks. If the child has a problem with creamy-textured foods, that’s sometimes a problem with fat-soluble vitamins A, E, and D, which are usually found in milk. Most soy milk and rice milk is also fortified with these vitamins. But supplements are available for these too. In short, if there's a medical problem, we'll deal with it medically.

The philosophical question is related to the saying, ‘if it ain’t broke, don’t fix it.’ By the time they’re 2, half of all children are considered picky eaters by their parents. So if this is a pretty typical part of child development, do we need to change it? Should we even try?

Research has suggested some of the answers. It turns out that preschoolers who are very picky eaters were often picky toddlers, and these were picky babies who had difficulty nursing and were often fussy. When they became older children, better able to say what they didn’t like, they often had difficulty describing the hesitation they had with certain foods. But many of these very picky eaters remain very sensitive to certain flavors, textures, and smells. Some also were sensitive to other sensory inputs, such as noises, clothing textures, and temperature of the environment.

When I was in medical school, I had the great good fortune to work in a laboratory that studied taste and smell, run by a brilliant scientist named Linda Bartoshuk. Though I personally focused on some of the curious effects of hot peppers in the mouth, the lab studied many interesting phenomena. When I was there, I learned that what I had been taught about the sense of taste was mostly wrong. Bitter taste, in particular, seemed to be genetically determined. It was often more intense in women of childbearing age, and less intense in girls and older women. It was usually less intense in men. Some people simply could not taste one of the test chemicals, while for others it was intolerably intense. Researchers in the lab photographed tongues (including mine) with a microscope, and meticulously counted the taste buds. It turns out that there’s a wide variation in the number and kinds of taste buds people have. Both this and the variations in what we can taste and how intense that taste is can be related to how certain foods taste to us. Professor Bartoshuk and her former student Valerie Duffy, now a professor at the University of Connecticut, collaborated on a great research study that's important to the way we should probably look at this issue. These scientists looked at how intensely adults experienced bitter taste. Then they tested how much these same adults liked asparagus, kale, and brussels sprouts; they also asked about how many servings of vegetables these people ate. Maybe it's not a surprise that those who had the most unpleasant and intense bitter taste perception ate the fewest vegetables. So it's not because their parents were inept about teaching good eating habits. And not because their parents didn't find the right bribe to use to get them to have one more bite of vegetables. It's because the vegetables just didn't taste good.

I have always been interested in doing this kind of experiment in children, which nobody's done. But there are complex issues when experimenting on kids, and that's why it hasn't happened.

Knowing this influences my approach to this common question. The child may not, in fact, be perceiving as delicious what we perceive as delicious. To them, it might be too intensely flavored, even bitter enough to make them gag or vomit. This might be built into their tongues and brains, and won’t improve with nagging or bribing. In other words, it's not necessarily behavioral—which is why behavioral approaches may not work, and could return unwanted consequences.

We could end up causing lasting harm, leaving them with serious food and eating issues that might result in eating disorders and self-esteem issues when they are older.

It’s an unfortunate coincidence that this issue seems to coincide developmentally with the time that most kids are naturally learning to exert control on their environment and their parents. It will take an intelligent parent to figure out when these typical eating issues leave off and the child’s quest for independence and control take over.

So what is the perceptive parent to do? That's the next post.

March 18, 2009

In Search of the Picky Eater

Searching for food refusal in a 2-year-old's world.

Chances are good that your child is, was, or will be a picky eater. I'm confident about this because of how often I hear this concern and how intensely parents worry about it. It may be surprising to learn that there is no general agreement on what, exactly, defines a child as a picky eater.

Some researchers include kids who don’t have a problem eating--a long as it’s the same few foods. Others include kids who eat very slowly, are not taking in much volume of anything, and don’t gain weight well. There’s the kids who have a tantrum if the foods on their plate touch each other, and those who will only eat foods of one color (it’s usually not green). Some won’t try new foods, and some won’t eat foods of a certain texture or temperature or that look like some other foods.

I was very impressed by a research study from 2004. These scientists didn’t try to define picky eating. They let parents define it for themselves. They polled over 3000 parents and asked if their child was a picky eater. The age of the kids was limited from 4 to 24 months. They found that at 4 months, about 19% of the children were thought to be picky eaters, but at 24 months, it was 50%. So at 2 years old, half of all children are thought of as picky eaters by their parents.

Let’s take a step back here. What does normal mean? If half of all 2-year-olds are said to be picky, and I suppose the other half isn’t picky, which group represents normal 2-year-old eating?

The importance of this study is really a discovery about normal child development. As a result of this finding, the chances are that your picky-eating 2-year-old is normal.

Normal, for me, means that I don’t have to do a lot of tests, don’t have to worry about unusual food allergies, and can reassure the parents that their kid is just like half of all the other 2-year-olds out there.

So when would I be concerned? I ask the parents if there’s any sort of reaction which could be related to an allergy, such as a rash, breathing problems, or swelling. I look at the growth chart to see if the child is growing at the same rate as their peers. It’s OK if they’re a little skinnier than most, as long as their weight keeps rising along the same growth curve. Is their development normal? Are they doing all the typical things a 2-year-old does? Are they showing any signs of a nutritional deficiency of some sort?

Usually, when I get the answers to these basic questions, the parents need reassurance most of all. Normal doesn’t mean convenient. It also doesn't mean that we give in to the grandparents who insist that the child isn't getting enough.

Should we intervene with picky eaters? Maybe it's just a lifestyle choice. That's the next post.

March 13, 2009

Forbidden Fruit

There's something about what we can't have that's particularly appealing. There are plenty of people who believe that their most successful strategy is playing 'hard to get.' Sometimes this is in the context of dating, but it could be multinational conglomerates negotiating a deal. It could be you, buying a car. As every parent knows who has brought their 1 or 2 year old in to see me, a simple stick or a wooden block can be just as fascinating as an electronic toy. So if the little ones will be happy with a stick, what compels them to play with the complicated toys of their older siblings?

Yesterday, a wonderful family came to the office. I've known all 3 kids since they were newborns, and they are very comfortable with me and my office. The two boys, 5 and 7, knew where all the toys are and ran around being creative. Their 16-month-old sister ran as fast as she could to follow them. She wanted to play with their toys, go where they went, do what they did, even if she couldn't put together a puzzle or work some of the toys. This is the normal role of the younger sibling.

From an empathic perspective, it's easy to see that this sweet girl could seem like a pest to the big boys playing with cars and trains and building things with blocks. My office is pretty well stocked with toys, and there's a lot for a kid her age to do and play with. But she really, really wanted whatever her brothers had. This is a deep truth of siblings. The younger ones always want what the older ones have--more stuff, more choices, more respect.

As an older child (when I was in my 20’s) I had the privilege of being invited to a Madonna concert in Madison Square Garden in New York. Incidentally, she was fabulous. But it was a revelation to me to see that a lot of her fans were preteen girls, whole throngs of them, dressed just like her. I kept wondering how their parents could let them out of the house in those outfits. And where, even in New York, can you buy a bustier (some with tassels) in 4th-grade size? I wasn’t a pediatrician then, but I knew I was seeing something remarkable.

This isn’t coveting what we can’t have. It’s different from desiring what we can’t afford or fantasizing about what just isn’t realistic.

For a child, it’s a hazy glimpse into the future and wanting a taste of it now.

In the latest issue of one of the medical journals I receive, Pediatrics, there was a fascinating study from some smart and creative researchers in The Netherlands. They pondered the question of forbidden fruit, at least in the context of video games. In Europe, just as in the United States, there’s a game rating system in which games are rated for content and for suggested age-appropriateness. So a game like Charlie And The Chocolate Factory is rated E for Everyone. Grand Theft Auto IV, in which weapons are everywhere and ‘adult situations’ happen all the time (indeed, much more frequently than in actual adult life), is rated M for Mature, Age 17+. The European rating system has categories by age: 7+, 12+, 16+, 18+. The ratings are not meant to gauge how fun the game is. They’re designed for the guidance of an involved parent. But there might be a forbidden fruit factor here, which--just as the original forbidden fruit in the Garden of Eden--beckons children to want to play games their parents probably would prefer they didn’t.

They took a group of 310 children, aged 7-17. They grouped the children into three basic age groups: 7-8, 12-13, 16-17. There were about equal numbers of boys and girls. Before doing their experiment, they used some rating scales to find out more about the participating kids. They rated their personalities in various ways. They also invented descriptions of the games in a careful way so that this wouldn't be influential. (How could they be sure? They smartly got 76 15-year-olds to rate the descriptions.)

The experiment itself was pretty straightforward. The scientists asked the kids to rate how much they’d like to play each game. While they never asked the question, I suspect this measure is closely correlated with how much nagging of their parents they would be willing to do to acquire a given game.

They found that in every age group of children, the higher the age rating of the game, the more attractive it was. Even in 7-8 year olds, the games rated for 17+ were more appealing than those rated for 12+ and these were more appealing than those rated 8+. This was true for girls, too. When they took off the age ratings, and just showed the kids the violence ratings, the relationship held up. There wasn't much difference between games with no rating and games with a 'no violent content' rating. But the games labeled as having violent content were rated about 50% higher in likeability by every age group, even the 7-8 year olds (in fact, they found the strongest effect on the youngest kids), even the girls. Yes, even for the girls. They found a substantial forbidden fruit effect.

Part of the purpose of the experiment, I suspect, was an ongoing need to validate and examine the effectiveness of these kind of ratings and rating systems. We need to know, do they work?

As an aside, this applies to a complex sociological question. Did Prohibition work? Do smoking bans work? How about speed limits on the freeway? Is it helpful to raise the drinking age? I’m no expert, but the answer to all of these is…kind of. When we forbid something fun or perceived as potentially fun, the activity acquires an enhanced value. That’s a forbidden fruit effect, when what we’re trying to make less attractive becomes more attractive precisely because of our efforts. But the barriers we’ve erected to the convenience of smoking and drinking seem generally acknowledged to have reduced at least some of the pervasiveness of these issues in our youth.

The experimenters in Amsterdam wanted to examine this unintended consequence of video game ratings. I think there's a larger and empathic lesson here for those who take care of children. Strict prohibitions and rigid dogmatism are dangerous and can backfire. Virginity Pledges are most likely the result of parental pressure and expectations. How well do they work? Five years later, those who pledged and those who did not pledge had similar rates of sexually-transmitted disease, age at first sex, and number of partners. The pledgers were less likely to use condoms or birth control.

Setting limits is an important job for every parent. Safety is non-negotiable, and though most kids will adhere to safety limits, there are some fearless thrill-seekers out there who can be hard to manage. But what about these non-safety issues?

The empathic approach has some insights for me. One of the tricks I use when examining a child was developed when I was in training and I observed a senior, and I would have thought experienced, physician examining a preschooler. When the doctor tried to listen to the child's heart, the kid naturally reached for the stethoscope. The doctor firmly held away the child's hand. When she tried to look in the child's ears, the child wanted to play with the flashlight. The doctor held down the child, now crying. I knew there was a better way. Before I place the stethoscope on the child's chest, I offer it to them to check out and touch. It's not very threatening after a little while, and not so interesting either. I usually will let the child hold and play with my light. It's fine with me if we take turns. It's only fair if they get to look in my ears, too. Why does this work? Because I'm trusting them with my stuff. My grown-up, insanely-expensive medical equipment stuff.

Some of the most heavily-advertised products and movies are probably inappropriate for your children. But keep in mind that kids seem to grow up just fine in cultures where there's hunting, disease, and nudity. Well, maybe not all at the same time. I wonder how much of what we forbid our kids from experiencing is attractive to them because we forbid it. If there's a subtle mistake I see many parents making, it's not trusting their children enough.

One evening, I was invited for dinner by one of the families I take care of. When I saw their 5-year-old chopping a carrot on a cutting board, I was shocked. Gradually, my feelings changed to being really impressed. The girl is very smart and focused, but I was impressed with these parents. What could happen? Which of us hasn't cut ourselves in the kitchen? Another parent sent me the following link from Gever Tully, talking about 5 dangerous things you should let your children do . Rules and limits are made to keep kids in their place. Keep the 7-year olds playing with games that say they are for 7-year olds. Every child has an elemental need to reach beyond their years, whether putting on daddy's shoes or watching that scary movie. When they do these things, we have precious teachable moments about context and content. Letting them watch a movie by themselves cedes the teaching opportunity to the movie producer. (Have you ever met a movie producer? Do you really want them influencing your kid?) Watching a movie with the child and judgmentally pointing out character flaws is also unlikely to be helpful. But engaging the child in a discussion you assumed she couldn't have might be just the right empathic approach. Children respond when they are taken seriously and treated with respect, as a peer. Ask them what they think about how it would feel to be in the movie and get beat up by ninjas. Left on their own, they identify with the ninjas. Of course, you can’t do that unless you’re physically with the child, watching the same movie as they are, or playing a game with them.

Parents should resist the temptation to cede the world of their children completely over to them. By showing an interest in sharing their world, they see us as valuing our time with them and valuing their company. This is a keystone to establishing trust in the child/parent relationship. The converse is even more true. By giving the child responsibility to cut some vegetables we have invited her into our world. Think how deeply your child will know how much you trust him when you not only get him that 12+ rated game he wants, but you take the time and play it with him (yeah, we both know you'll lose by a humiliating margin to your 7-year-old). The experience he’ll remember from your helping him use real tools, not just play tools, isn’t some basic craft skill. He’ll remember when you opened the door into your world and invited him to join you in it.

I encourage parents to be very sparing about absolute rules. Children learn a lot about the world from their gradual exposure to it. But they learn most about how much their parents trust them by the confidence we show that we have in them. They learn much more viscerally and permanently about what they mean to us by our actions, not by our words. So let the kid chop carrots. Well, maybe when the doctor is already there.

Durer, Expulsion from the Garden of Eden 1510

March 5, 2009

My Child Hates Me

Hitting Mommy

"You will not be punished for your anger, you will be punished by your anger.” --Hindu Prince Gautama Siddhartha, the founder of Buddhism, 563-483 B.C.

A sensitive and intelligent mother started the visit by saying that her 3-year-old said, "I hate you." There had to be a lot more to the story, of course, so I said, "that must be very hard for you." Mom started to cry.

"She hits me," she said, very seriously as if confessing.

"How long has this been going on?" I asked. She said that her daughter has been hitting her and only her for about 6 months. Though she hasn't been hurting anyone else, she's been more difficult in preschool and quicker to fight over toys and play turns. She said that the child hits as hard as she can, with obvious intention to hurt.

It wasn't always like this, mom said as I started to examine her 6-month old baby. There used to be times of cuddling and laughing, and now it seems that the toddler is angry all the time. With gentle questioning, this mother admitted that her daughter still has happy times with dad, who is working long hours but is a big help when he's home. She admitted worrying about the future of her daughter, worrying if she will be violent as a teenager or adult. This made her very sad.

I felt sad for her, too. I told her the quote above, to help share my perspective--as on most child behavior issues--through an empathic view of the child. Siddhartha could easily have had preschoolers in mind. They don't want to be angry! It may seem like the child spent a lot of energy on her anger, but it wasn't a fun place to be for her. So I knew that she wasn't enjoying feeling or expressing this aggression, especially against her mother. And toddlers don't do things they don't enjoy for reasons of principle.

It should be obvious that the child's aggressive behavior towards mom started soon after the baby was born. When I pointed this out to the mother, however, she was surprised. She tried to retrace the calendar in her mind as a way of proving that it had nothing to do with the new baby. She failed, and realized it had everything to do with the baby.

This is not an unusual story, and many kids (as well as many dogs and cats) can get pretty resentful of the new baby.

Mom was surprised, however, because she said she had followed my advice from before the baby was born: make time to be one-on-one with the older child, so they know you are still interested in them and their priorities. She said she did this as much as possible. Depending on what time her husband came home, and the baby's nap schedule and feeding schedule (which varied every day), this could be a couple of hours or none. Sometimes the dad came home after bedtime, and he wouldn't see his daughter at all that day.

Now all the pieces fell into place. This 3-year-old had VPS, and a bad case of it. Vanishing Parent Syndrome, a problem that often arises as a complication of Concrete Thinking. (NB to the reader with OCD: Concrete Thinking is real, look it up. I just made up VPS.)

First, the problem arose because the parent has made a subtle but serious error in empathy. Mom was trying as hard as she could, and made as much time for the child as possible, but the kid is only 3 and cannot appreciate her mother’s sacrifice. It is perfectly understandable and natural for the loving parent to make the assumptions she did. But it's an error. Would you take your 3-year-old jogging? No, she wouldn't be able to keep up. Would you take her to a college lecture? No, because it wouldn't be reasonable to expect her to pay quiet attention for so long. Concrete thinking means that the child has a limited capacity to imagine herself in somebody else's shoes. Her ability to think abstractly in the future, which is to say imagine herself doing something tomorrow or next week, is absent.

So let me apply empathic analysis, a methodology I came up with to help work through challenging child behavior issues. Maybe she can't put herself in my place, but I can put myself in hers.

From the 3-year-old's point of view, these one-on-one sessions with mommy and daddy are great. But because she can't plan tomorrow or the next day, she is trapped into reacting to whatever is happening right now. She doesn't remember the hours spent with her yesterday--they might as well have been ancient history. Even if you remind her, she can't grasp the feeling it gave her yesterday when you were with her. Thus, it doesn't soothe her or relieve her need any more than the drink of water you had last week can relieve your thirst right now. In the same way, your promise of spending time with her tomorrow is of no value to her today. In this case, there wasn't even that promise. Maybe there would be time tomorrow, maybe not.

For the child living in the moment, as would be developmentally normal for a child this age, these times with her parents seem arbitrary and unpredictable. Though nice when they happen, they start and end for inconceivable reasons. The child has no confidence that these times will ever happen again.

When did this start? It's a mistake to think that the child has formed a conspiracy theory to explain it, with the newborn baby as the evil leader. Earlier, I said that I helped mom see that the problems started about the time when the baby arrived. But the baby didn’t do anything—it was the behavior of the parents that changed. The baby is an incidental artifact to the situation from the child’s point of view. It's the parents that this child depends upon, and it is their actions alone that she reacts to. So it's perfectly reasonable that a developmentally normal child will try one thing or another to regain the attention that she has inexplicably lost. Maybe it's refusing to go to sleep or eat. Maybe it's giving up the potty and going back to diapers. Maybe it's hitting mommy. She's creative, inventive, and needy. She has now learned that the hitting thing works, in a big way. Mom puts down the baby and talks directly to her--maybe not in the tone she hoped for, but at least, like a desperate salesman, she's got her foot in the door. The attention of her parents is the single most valuable thing in her world, yet her parents dole it out like worthless crumbs.

This mismatch between the priorities of the child and the priorities of the parent is a set up for relationship friction. Each party doesn’t understand why the other can’t see reality in the clear bright light of truth.

This sweet preschooler couldn’t jump up to her mother’s perspective, but maybe I could get mom to kneel down to hers. What I had to do was come up with a system that the child could rely upon, that the parents could live with, and that would still include the baby. I needed to work with the tools I had.

The child didn’t know numbers and couldn’t read, but did know colors. So I told the mother to get a big desk calendar at an office supply store. Every day had a plan. On weekends, daddy would go for a walk to the park and leave mom at home with the baby. Every weekend morning, even in a cold, drenching rain. This is crucial—the child thinks concretely, so she can’t abstractly imagine her own wet discomfort trying to play in the rain (and she might, in fact, enjoy it). So get over your petty adult comfort preferences and take her to the park, at the same time every weekend morning. If you go and she says she wants to go home, that’s OK, but that still means isolating dad and her from mom and baby and giving her one-on-one time with dad. These are orange days, and every weekend day must be colored orange. On green days, mom would do laundry when the baby was sleeping in the afternoon. And laundry was their special time to be alone together. The child was given special helping tasks and made to feel important and useful to mom. She knows a baby couldn’t do these things! By the time dad came home, mom would have specific things she could tell him about all the helpful things she did. On blue days mommy would go to the store with her and the baby. But before going to the store, she helped mommy make a list of things to buy. She helped take things off the shelves and put them in the cart. A baby couldn’t do that!

Every day, at bedtime, the child would put a dinosaur sticker in that day on the calendar. That was the end of that day. Goodnight, dinosaur!

Though the child had limited ability to picture the next day, this became a bedtime ritual. When the next day was green, she was reminded of the important job she had helping to sort light from dark wash, or adding the dryer sheets.

I can’t emphasize enough that for this plan to work, it needs to be cast in steel. It isn’t the tasks that change the toddler’s behavior, it’s the dependability. When she feels confident that she can count on the plan happening, she won’t feel the need to experiment with new and inventive attention-getting techniques. The plan is designed to build confidence, so it doesn’t matter if it’s only an hour a day of parent time. It matters a lot if the parent doesn’t follow through. That will erode the child’s confidence in the parents even more, with predictable increases in problems. So the key success factor here is the commitment of the parents to do what they contract to do.

Her parents told me that she’d sometimes ask to start the laundry first thing in the morning. When reminded that they have to wait for the baby to be asleep, she’d talk very quietly and sometimes sing softly to the baby to help initiate this process.

She stopped hitting mommy.

I need to add this caveat. There are kids this age who are aggressive, even hurtful. Not just with mom and dad, but with peers, strangers, grandparents. I’d guess that in the last 10 years, I’ve seen 1 child like this for sure, maybe a couple of other, less clear cases. This aggression and oppositionality can sometimes be perceived at a very early age. It’s not normal, and it obviously is going to have an impact on this child’s life. It seems to be caused by brain chemistry, not some external influence. The child should be carefully evaluated.