May 30, 2009

Claire 6: Tastes Like Chicken

They came into the office in the late afternoon. I turned off the phones in the office (though callers could still leave messages). I directed Claire to the most comfortable chair, and her mom sat next to her. Claire was in the office to be taught some relaxation techniques. On the one hand, I thought that helping her get through her anxiety would allow her to focus better. On the other hand, she really did have a problem with paying attention. So I didn't know if the technique I was going to use—which requires you to focus very intensely—was going to work for her. I asked if she had any questions before we begin. She asked if I were going to turn her into a chicken. “Yes,” I said.

I had her put her arms out in front of her. She pulled up while I tried to push them down. I told her to remember that feeling of tension in her muscles. She followed my direction beautifully and slowly reduced the force of her arms; I adjusted my pressure to match. I asked her to close her eyes.

I asked when her school year ended. How did she sleep last night? What did she have for lunch? Was lunch good? Does she usually eat that for lunch? Is she hungry right now? I asked her to think about what lunch tasted like. Every flavor in every different thing she had for lunch. After I asked, she said she felt relaxed.

I told her to tense up her toes like she did with her arms when I was pushing against them. Then slowly relax them. Then her ankles and her calf muscles and her thighs and her hips...all the way up to her neck.

She was going in to a warm pool, not too hot, just perfectly warm and comfortable. She dips her toes in to test it and it's nice and warm. So she steps slowly into the pool. At first, the warmth is just on her toes and the soles of her feet, and then the tops of her feet and then her ankles, and then...the pool is up to her shoulders, and then, nice and warm, up to her neck muscles. The warmth is helping all her muscles be relaxed. She is feeling very relaxed. She can feel this way whenever she wants. All she has to do is think of the warm pool on the soles of her feet and then slowly going all around her body making her feel comfortable and relaxed and taking all her tension away. I told her to count to five with me and then she would open her eyes feeling very rested.

I had been completely focused on Claire, who sat quietly with eyes closed on the comfortable chair across from me. Speaking continuously without a pause takes practice and strong focus. So I had forgotten completely about her mom, who was sitting on a chair next to her, yet totally out of my attention. Apparently, she had been doing everything I had been asking Claire to do. When she spoke first, it was unexpected. “Wow. I feel great.” Within a few minutes, Claire did too. She had been an excellent subject, and I think she was in a nice trance-like state.

This kind of hypnosis, guided imagery, focused relaxation, or whatever, has several practical uses. For Claire, I wanted to get at two specific anxiety symptoms that she was having trouble with. Often, she said, she'd have trouble falling asleep because thoughts would rush around in her head while she was in bed with the light off. She managed this by reading, but that just kept her up later. And she had a lot of anxiety-provoking tasks in school which made her perform, she knew, far below her capabilities.

I told her she could do this herself, and no one needed to know. When she was in bed, I suggested that she not try to ignore the rushing thoughts, but to think about each one and make a list of them in her mind. Stop them from rushing and get a leash on those thoughts. Then keep the list in her mind while she thought about the soles of her feet just touching the surface of that warm pool, then the tops of her feet....

I called the next day to make an appointment for lesson 2. Claire said that she felt great and had done it herself. I said that I hoped she didn't mind acting like a chicken. She didn't.

Next in Claire's story: teaching her self-hypnosis

May 27, 2009

Jeremy--Teacher says he doesn't pay attention

Jeremy’s mother called me today and said that his school requested an ADHD evaluation because he wasn’t paying attention. He just turned 10, and was struggling in school.

Several years ago, his mother told me that his school wanted to ‘retain’ him, which used to be called getting left back when I was a child. At that time, I told her in clear terms what I thought of ‘retention,’ which is a common suggestion for elementary school kids. This will be a topic of its own series of posts. I suggested she request an IEP, which I attended with her. They didn’t retain him, and he was given some special help in a couple of subjects. Since that time, he has kept up with his grade until now.

Jeremy has never been in trouble. He’s kind and polite to everyone. But there’s something different about him. When he speaks, the words make sense but the rhythm of his speech is off. Often, he will sound a little like a computer speaking, with flat intonation that masks emotional content. This speech issue is just one aspect of some social difficulties. He likes most other kids, but seems to have a lot of trouble reading and reacting to them in a typical way. He does have a breaking point, where frustration and loneliness make him sad and upset. He is a bully magnet.

He also has never been given a diagnosis. His parents can’t afford several thousand dollars to get him tested for all kinds of learning disabilities, and he might have some. The school and school district (and state, for that matter) have no money and are cutting some of these special ed and tutorial programs.

His teacher told mom that he couldn’t concentrate in class and he has requested being allowed to sit in the hall and do his required work in a more quiet environment. The teacher took this as oppositional and sent him to detention, where he had never been before. That afternoon, he told his mom that he loved detention since it was really quiet and he could really focus on his schoolwork. He accomplished several days of homework assignments in 1 hour of detention, completely without direction or supervision.

A picture was emerging. I asked more questions about all kinds of sensory input. Mom said that he was indeed sensitive to ambient noise and found it hard to concentrate in noisy environments. He also was very sensitive to smells, tastes, and the textures of his clothes. He was always cautious about people touching him.

So I could see that he did have an attention problem. But it sure didn’t smell like ADHD to me. He had no attention problem at home or anywhere else except for the classroom. He didn’t have this problem last year, with the teacher who adored him. He didn’t have it in my office, where he would sit and look through a book as his mother and I talked. People who have ADHD have it everywhere they go. They have it on weekends and weekdays, at school, at home, at work, in their conversations and their personal relationships.

I had suspected a diagnosis for Jeremy for years, but what good would a label do for him? I decided to broach this topic with his mother.

I told her about the things I had noticed: the speech issue, the social stuff, the sensory sensitivities. These all could be minor features of autism. But clearly, there were many features of severe autism he didn’t have. He spoke appropriately for his age. He didn’t seem to have any hand-flapping or other repetitive movements, and he was definitely interested in making connections with others. This was an autistic spectrum disorder. There just aren’t enough specific diagnoses to fit everybody on the autistic spectrum. The official ones are Autistic Disorder and Asperger’s Disorder. He didn’t have either of these. Everybody else, pretty much, gets lumped into Pervasive Developmental Disorder--Not Otherwise Specified.

The reason I brought this up with his mother was the result of a 2004 California Law called the Individuals with Disabilities Education Improvement Act [IDEA]. (Other states also have special education laws, and this link has links to the laws in other states.) If a child is diagnosed with dyslexia, for example, the school may get them reading help, if the school can afford it. But the law is explicit for the diagnosis of Autism--the state must provide the needed services. It's possible that if he were diagnosed with autism, that might open up opportunities for him to receive services his family might not afford. But will teachers expect less of him? Will he expect less from himself?

I hate assigning labels. They pigeonhole our children in ways that are convenient only for the industrial institutional system of education and the cultural biases of limited expectations. I am truly fortunate to have learned from and worked with creative teachers, fabulous professors, and brilliant colleagues with inept social skills, inarticulate conversation, or quirky nonconformist interests. Maybe they, too, met the criteria for PDD-NOS. I'm sure that the list of Nobel Prize winners includes a lot of people with these traits.

May 24, 2009

Claire 5: The Medication Paradox

About a week after starting medication, I called Claire's mother to check on any progress or side effects. Her mom is a very intelligent and perceptive well-educated woman. I respected her opinion.

“I don't think the medicine is doing anything,” she said. “Claire seems exactly the same.” I told her I was glad there weren't any obvious side effects. “I just don't think it has any effect on her,” her mother said helpfully. It was still early, I said, and suggested she continue the medication for the moment, which her mother was willing to do.

At the moment, it is very hard or impossible to predict which medicine will work best—or work at all—in which person. This is especially true for psychoactive medications. But it's pretty common for people to know that they act or feel differently when they are taking certain drugs, even if they aren't prescribed for their psychiatric effects. Prednisone, for example, is a medicine used for inflammation and asthma that often makes people act in surprising ways. Birth-control pills can have this effect. It was disappointing but not shocking that my first choice for a prescription was not doing what I thought it might. Still, I wanted to be thorough.

“Is she getting her homework done?” I asked. Her mother said that she hadn't been getting any reports of assignments not handed in. “But is she remembering the assignments?” To this, her mother said that Claire had started to use an online calendar for her assignments so she hasn't forgotten any yet. “How about exams. When are they coming up?” Her mom said that she had a history quiz and did well and hadn't mentioned it beforehand. Without my asking, her mother added that Claire probably just wasn't very worried about it. And so our conversation went. I asked about how she was getting along with her classmates and her siblings. I asked how her motivation was in general, if she had shown any interest in new things, if she was worried about her friends or how she looked or how she was doing in school.

There were a lot of changes, all improvements, all pretty small and hard to notice by themselves. I pointed this out tho her mom, who had to pause for a moment. All the changes occurred around the same time, a couple of days after she came to my office. The only thing that changed was the start of medication.

It was a revelation to Claire's mother that maybe the medication was helping—a lot, as it turns out. Yet she had been convinced that it was doing nothing at all.

Although this post is another true chapter in Claire's story, it is an experience I have had dozens of times. What is the ideal psychologically-effective medication? I think it's something that helps patients with the things they struggle with, but leaves them feeling and appearing just the same to themselves and those around them, with every ability unchanged. When a medicine isn't working, the targeted problems don't improve. When there are side effects, the specific problems might improve, but new problems arise (such as sleepiness, for example, or inability to sleep).

Claire herself had been equally convinced that the medicine was ineffective. She felt the same, she said. It was true, she acknowledged, that her assignments were getting remembered and done and that she studied for and wasn't too worried about that history test. But that wasn't because of the medicine, she told me. It was hard for her to remember the way she was even 2 weeks before, and how worried she was about everything. She wasn't very worried right now, and she felt that's the way it has always been.

This is a very serious problem for people who take medicine to control a chronic problem, such as asthma or depression. They start taking a very effective medication, which really works to control their symptoms. After a while without the problem symptoms, they get to feeling that the problem is gone so they no longer need the medication. They stop the medication and the problem returns.

With ADHD, the kids often get brought to me when they have been getting into trouble at school. With good therapy, they do well in school. But when they do well with medication, they get the feeling that they don't need the medication. When they stop, and start getting into trouble again, they will find specific explanations that don't include the fact that they stopped their medication.

There is, I believe, a medication paradox. If you take your medication, then you feel like you don't need it. If you don't take it, you will need it.

Next post in Claire's story: I make her believe she is a chicken.

The photograph at the top is from my collection and is by Emmet Gowin.

May 21, 2009

The Telephone Paradox -- Follow Up

When I wrote the post called The Telephone Paradox, I thought it would be interesting to my readers. Mostly, I think, these are parents and parents of patients of mine. I know that at least a few other doctors read some of the pieces. Since I'm a member of a private listserv focusing on telemedicine through the American Academy of Pediatrics, I let the administrator know about the post in case it would be of interest to colleagues.

In that post, I noted my experience in giving my patients open, unlimited access to calling me any time, at home, on weekends, or at night. I found that the number of phone calls I received actually went down, and the ones I did get were all appropriate and important.

I was not prepared for what happened.

Some responses were flatly doubtful. Many doctors commented that they absolutely knew that my observations were in error, and that I must have a very unusual practice if all kinds of wacky people weren't calling me through the night for foolish reasons. They didn't quite say that I made it all up, but they clearly thought that was a possibility. The most hostile comment came from someone who worked at a for-profit call center. She claimed that waking up doctors in the middle of the night was extremely dangerous because they were likely to make hazardous errors in judgment. She said that people with genuinely sick children would not call when they should because they'd be intimidated by the fact the doctor himself would be answering the phone.

But there were a surprising number of comments noting similar experiences to mine. Typically doctors from small practices, they, too, thought they were the only ones with this experience. These doctors said that they rarely, if ever, were bothered unnecessarily. Patients were respectful of their time and sleep, and they were glad to get the calls they did get.

I redoubled my efforts to search the medical literature. This has never been studied. So while I can discuss my personal experience, and others their experiences, I have nothing to report as supported by statistics.

What I believe is that I have stumbled upon a great example of conventional wisdom. Everybody, including the most exalted experts, believes the world is flat. They are so sure of it that they don't want to send out an expedition to the edge to find out for sure. Why bother when they already know the truth. Yet I, in my little boat, have sailed to where the edge was supposed to be and it's not there at all. So I found out there is a whole industry of for-profit call centers, with people who make a living working in them and managing them. Their purpose is to relieve doctors of the burden of patient calls, a burden that is strongly supported by conventional wisdom.

I made a decision to try and avoid alienating my colleagues (at least for this--I've got some whoppers in the pipeline), and didn't argue with any of them. I had my say in the post, and I thought it was a good idea to let others comment as they might. It gradually became clear that there are no data supporting anything that was said. The person who claimed that patients would be intimidated by calling the doctor had a particularly difficult task if she were ever asked to prove that somehow the medical care of a patient would be improved with less communication with their own doctor. Though I have no data either, at least I have my own genuine experience, and others have had the same experience. Those that have not had this experience have never tried giving out their home phone number, so they believe their experience confirms the conventional wisdom. Since they've never tried it any other way, I don't think it really does.

My readers and my patients know that I question dogma about, well, everything. At least my patients can call me.

May 18, 2009

ADHD: Claire 4--Breaking the news

As difficult as it might be to tell parents that I know what’s wrong with their child, is often much more difficult to present a complicated interaction of several different problems. In Claire’s case, because she was older, there was the additional issue of telling her directly.

I believed she had an anxiety disorder. She might or might not have an attention problem. It’s conceivable she could have a subtle learning issue. I asked her parents to come to the office with her so I could lay it all out for them.

Because of a busy schedule, Claire could join us only after we had started. I scheduled 90 minutes for the conference. I showed the parents the Vanderbilt ADHD questionnaires that I had received and explained my scoring and interpretation. I showed them the anxiety questionnaires.

There were a few key pieces of information I thought were extremely important. First, Claire’s reaction when her mother told her about my plan to look into these problems. This suggested that she knew we had hit upon something important to her, and she was relieved about it. Second, the high scores that she herself gave for some of the statements on the anxiety questionnaires (“I am a worrier;” “I feel worried about things that have already happened;” “People tell me that I worry too much.”)

The anxiety-specific screening tools allow me to be more specific about what could be going on. Claire and her parents indicated that she didn’t have significant separation anxiety or somatic symptoms such as headaches or stomach aches. But she seemed to have generalized anxiety and social anxiety, and she’s anxious about going to school for many reasons.

Just informing this family about what I’ve discovered isn’t very helpful without some plan to deal with it.

A therapist might help, and anxiety disorders are often helped by cognitive behavioral therapy. This kind of therapy helps the patient be aware of the thoughts and feelings that are a problem for them. Once aware of these thoughts, they are taught techniques to get these thoughts under control. Though often effective with bright, cooperative people like Claire, this takes practice and time to learn.

When I was in my last year of medical school, my research work with pain control for cancer patients helped me win a brief fellowship for a training course run by the New England Society of Clinical Hypnosis. Though the workshop I attended taught the use of hypnosis with adult patients, it’s something I sometimes use with children. I suggested to Claire and her parents that she might benefit from some relaxation techniques, and some guided imagery whether through meditation or self-hypnosis (which I could help her with) could be helpful when she was in a stressful situation.

Aerobic exercise can also be helpful for mood disorders including anxiety and depression. If she could find something she liked, it could be therapeutic for her.

An anti-anxiety antidepressant medication could be very helpful. Its big advantage is that it might work right away to help relieve some of the worst symptoms and make her feel better, so she’d have an easier time making some of these other changes.

But none of these ideas, even if they help her, will give her the skills she will need for life. So we would still need to change the way she organizes her day and her assignments and her life. I suggested getting at least a week’s worth of assignments at a time from each teacher, and immediately entering those assignments onto an online calendar. That way, she’d never lose them and could check them from anywhere—and so could her parents.

This is a new concept for this teenager and her family. More updates to come.

The photograph is from my collection and is by Richard Avedon.

May 15, 2009


Après moi, le déluge

When Ted Sr. and Tammy were dating, he didn't mention that he wet the bed until he was 11. Here's a secret that men know: discussing your bedwetting history is not the surest way to score with chicks. Luckily, at a family Christmas dinner shortly after their engagement, Ted's mother discussed this history openly for the benefit of everyone present, including the inlaws he just met.

But this is an unusual circumstance. Usually, when a child is brought to me because of bedwetting, the mom doesn't know the 'family' history--which usually means the dad's history. It's not unusual for boys to be older than girls when they finally stay dry at night. And there's often a family history when the problem is lasting well into elementary school.

So Tammy knew this history when she brought me Teddy Jr., who's unusually bright and articulate, and 7. He was keenly embarrassed by his need for a pull-up at night. He couldn't go on sleep-overs, and was afraid to go to summer camp. Mostly, he felt bad in the morning when he had an accident. He was open about feeling like this was his fault, and hopeless because nothing his parents tried really helped. At first they didn't let him drink at bedtime, then an hour before, then nothing after dinner. They tried waking him up when they went to sleep. They tried waking up in the middle of the night and dragging him to the bathroom then. But it was either too early or too late.

Bedwetting is usually not a problem with kidneys, bladder, metabolism, or how much a kid drinks. (Though I check all of these out just to be sure.) It's about sleep. When we're asleep and our bladders get full, a signal is sent to the brain. The signal wakes us up, and though we try to stay in bed, we reluctantly drag ourselves up long enough to do what we have to do. Kids often sleep so deeply that they sleep through this alarm. As they get older, the sleep cycles of children change enough to let them hear that alarm, so they can wake up and stub their toes like the rest of us.

So perhaps it comes as no surprise that one of the most successful interventions is a bedwetting alarm. It's a simple device that sounds a loud alarm when it senses moisture. The first few times it goes off are obviously after the accident happens. But just like an adult who wakes up just before the alarm goes off, the child's brain reprograms the sleep cycle to a shallower level when the alarm is anticipated. This allows them to hear the signal from the bladder. I advised them that in order to be effective, the alarm has to be loud enough to wake up a kid who has this problem because he sleeps so deeply. So it's going to wake up everyone in the house. Some alarms have a vibrate feature, so they don't awaken everyone. These never work, because they don't wake up the bedwetter either. And some kids just aren't ready. If it doesn't work in a couple of weeks, put it away and try again in a few months. I explained this concept to the parents and to Ted Jr., who got it right away and wanted to try it. After I told him why it was happening, he looked really happy. He believed it wasn't his fault.

May 12, 2009

ADHD: Claire 3--Unexpected Insight

A couple of weeks ago, I gave Claire and her parents questionnaires to fill out. I asked Claire herself to fill one out, and there were separate questionnaires for her teachers, too. The questionnaires were developed and tested by some smart people at Vanderbilt University, and have been adopted as the standard assessment of ADHD by the American Academy of Pediatrics and the National Initiative for Children’s Healthcare Quality. They are designed to distinguish those with the inattentive type of ADHD from those with hyperactivity. They also sneak in a few screening questions for other issues. All the questions need to be rated from “Never” (0) to “Very Often” (3).

Surprisingly, the teachers and parents didn’t really score the questions about inattention too highly. An example might be, “Has difficulty keeping attention to what needs to be done.”

But Claire herself rated as “Very Often” the statement, “Is self-conscious or easily embarrassed.” The statements, “Is fearful, anxious, or worried,” and “Is afraid to try new things for fear of making mistakes” were also rated highly by Claire, her parents and her teachers.

When I scored the Vanderbilt forms, an unanticipated pattern emerged. She did have some attention issues. These were right on the margin of meeting the official diagnostic criteria for ADHD—Inattentive Type. She did have some sort of issue with paying attention. But there was a loud and clear signal about anxiety. So I sent her mom some anxiety-specific questionnaires, and once again asked Claire and her parents to fill these out.

When they were returned, an anxiety problem was clearly identified. Claire and her parents had noticed that she was often worried and often worried about what people thought of her. At least some of the behaviors that her teachers noticed in class, such as never participating in class discussions or volunteering answers, were because she was afraid, not because she was distracted.

Parents are often concerned about ADHD medication. Part of being a careful prescriber, of course, is having judgment and experience in the use of medication. And part is being disciplined about it. I have no a priori problem with prescribing medication where I believe the benefits outweigh the risks. A couple of months ago I wrote about a boy whose life at school and at home, and his social interactions even with his friends, was very difficult when he wasn’t taking his meds. But an advantage of seeing so many kids with ADHD and managing so many medications is knowing that stimulant medications, in some people, can make anxiety worse. In those with an anxiety disorder, the medications are often less effective.

When the screening questionnaires were designed, it was essential to screen for anxiety and depression. A depressed child might be sitting at the back of the class uninterested in the topic of the moment, might avoid social interactions, might forget assignments and not care about exams. This child, too, won’t benefit from ADHD medications yet acutely needs our help. If the child is very worried about what others think, she won’t speak up in class. She might ‘forget’ homework or other tasks if she’s afraid of what they indicate about her and her understanding of the material. So though girls with ADHD are often not diagnosed at all, it’s important to keep an open mind as we look for the underlying problem.

Next Post in Claire's story: I meet with the family.

The photograph is from my collection and is by Alfred Stieglitz.

May 9, 2009

Sleepwalker Now has Bad Dreams

His mom said that he's been sleepwalking for at least a few months. He'd been waking up in the middle of the night, getting out of bed and going to the kitchen or living room. He doesn't do anything in particular, but doesn't answer if you talk to him. After a few minutes, he goes back to bed. She was used to this.

But she was worried when, two weeks ago, he started waking up screaming and crying about an hour after going to sleep. Even after being comforted and going back to sleep, he's been waking up a little later—sometimes 30 minutes, sometimes 90 minutes later—screaming and crying. This has been happening at least 5 nights a week for the last couple of weeks, and mother is exhausted. Alec told her he wanted to talk to me.

Alec is 10, and that's pretty close to the peak age for sleepwalking. At 11 or so, studies show about 1 in every 6 or 7 kids sleepwalk, boys more than girls. It's usually harmless, they usually grow out of it, and it's not usually a sign of any particular problem. If they leave the house, or if the sleepwalking is happening a lot, or if the kid is getting injured, you need to see a doctor. But this wasn't sleepwalking any more.

Did something happen to him? His mother didn't say this out loud, and neither did I. But I was sure worried. When he came into the office, I asked. I asked if anyone was being mean to him at school—any teachers, any students? How about at home? Did something happen? Did somebody say something to him? Is he worried about something bad happening to him or somebody he cares about? All the answers were no. I asked his mother to leave us alone, and I asked him my usual screening questions. Did he feel sad? Did he think about running away? Did he think about hurting himself? I asked him again if anyone was mean to him or anything bad happened. What, exactly, was he thinking about? Maybe there was a clue there. He said that he remembered these scary thoughts and dreams. He pictures the scary posters from the horror section in the video store. He has images in his mind from movies he has seen, sometimes even a year ago and more. He hasn't seen any new scary movies, or heard any new scary stories.

I pointed out that his exposure to these scary materials wasn't ideal, but it wasn't new. Why, at this moment, should these things suddenly acquire such power? I made his mother go through the calendar day by day around the time this started. His mother said that they were all particularly exhausted the first night since that was the night his older brother Jason's spring break was over and he went back to boarding school.

Jason didn't share a room with Alec, but they were very close. When their parents got divorced, Alec became even more dependent on Jason. Jason kept scary things from affecting him. Jason was his protector.

The scary images were already there, waiting. When Jason left, Alec was defenseless.

Unfortunately, the school Jason attended doesn't allow phone calls more than once a week. So I suggested buying a ton of cheap postcards. Every night before bed, Alec will write to his brother. It doesn't matter what he says. He needs to keep that connection alive at bedtime to keep the monsters in their place.

Please see my post on Swine Flu.

May 6, 2009

ADHD: Claire 2--Looking for the ADHD diagnosis

Did Claire have ADHD? She was forgetful, distracted, and had trouble paying attention. After her mother and I agreed on a plan, her mother had to tell her about it. Smartly, she waited for the right opportunity—in the car.

The car is often the perfect place for a serious topic. It’s isolated so you have privacy. No one will interrupt and siblings are not around. There’s physical closeness but there’s no chance of forced prolonged eye contact, so the passing outside world is a helpful relief valve.

Claire’s mother reported following my script closely. She said that she had seen my blog story about girls with ADHD and wondered about Claire. She outlined some of the features of ADHD in girls that often get missed. She talked it over with me on the telephone, and I suggested a formal evaluation, including input from parents, teachers, and Claire herself.

Claire’s eyes started to tear. Her mother didn’t expect this reaction, and asked her what was wrong.

She said that she was incredibly relieved that maybe there was a reason for her being the way she is, and that it wasn’t her fault.

She had been well aware of being ‘spacey’ and disorganized, and she didn’t like it. But both from herself and everyone around her—friends, family, teachers—she kept getting reinforcing feedback that supported the idea that this was just who she was, as unchangeable as her height or her voice. Unlike most of the evaluations I do for kids who are much younger, this one is a crucial new part of this teenager’s identity. We will all have to walk very carefully.

Once through the initial suggestion, Claire was excited about the prospect. I don’t think she liked the idea of ADHD, exactly, but she genuinely liked the plan to figure out what the issues might be.

A therapist, who had not noticed a particular problem when talking to Claire, suggested neuropsychological testing. This is an expensive and detailed group of tests in which every aspect of her learning and understanding is carefully analyzed. It’s the essential tool for figuring out exactly what a kid’s learning disability is. But Claire was a voracious reader who read for pleasure, so it’s unlikely she’s got a reading disability. She’s not great at math, though. But her attention problems are in all her classes, not just math. In addition, a child being tested for hours has to be able to keep focused on the exam tasks. So in general, I try to get an attention issue under control before having kids do this kind of testing.

I sent questionnaires to Claire and her parents, and separate questionnaires for her teachers.

I often feel uncomfortable bringing up a new diagnosis to a parent. It’s hard to tell someone that their child has asthma or eczema or pneumonia. But almost always, this news is met with some sense of relief by the parent. They knew something was wrong, which is why they brought the child into my office and complained of a cough for 2 months or a rash that didn’t go away. Nobody’s happy about it. But now it has a name, and things with names can be discussed, can be treated, can be joked about, and can be looked up on the internet.

Much more to this story as it unfolds....

The photograph above is from my collection and is by Lewis Carroll.

May 3, 2009

Too Many Clean Diapers

As devices go, babies are pretty basic. They eat. They sleep. They poop.

New parents give so much, so fully. Shouldn't they expect something in return? So maybe it's natural that some parents ascribe to the baby's material productivity some kind of assessment of their parenting prowess.

Ellen was about 4 weeks old when her parents brought her in. They were generous enough to let me hold her and play with her while they told me why they were in my office. She hadn’t pooped in 4 days. Last week, she went 3 days, then several times a day for a few days, and now nothing for 4 days in a row. I was kind of listening to them, but I was having a lot of fun making Ellen smile, which she did easily. I asked them if she was this happy at home. She was happy, ate well, didn’t throw up, slept well, and was nursing like a champ. Her weight gain was perfect.

I told them what I knew at the time. Breastfed babies have unpredictable stooling patterns. Medically, I wouldn’t diagnose her as constipated unless she went at least 5 days. They were pretty amazed by this, and though they didn’t seem worried, I got the impression they weren’t fully satisfied, either.

There were many things that could be done to help the process along. An old remedy is to add sugar syrup (Karo syrup) to a baby’s bottle. Another is to sneak in a little pear juice. Taking advantage of the baby’s autonomic nervous system, a little direct anal stimulation will usually provide an effective reminder (that's why they usually go after getting their temperature taken).

They called me the following day, at 5 days. I tried to be reassuring.

They called me on the morning of day 6 to report that nothing productive had occurred. I called one of the very smart specialists in pediatric gastroenterology at Children’s Hospital Oakland. The specialist chuckled a little and said that he’s seen healthy breastfed babies go a long time.

I didn’t hear from them the next day, so I called to ask about the blessed event. I got a surprising response.

On the insistence of the baby’s grandmother, they reported being fortunate to get an urgent appointment with the grandmother’s chiropractor. He diagnosed the problem as a misalignment of the baby’s coccyx. In an additionally fortunate stroke, he was confident he could realign the baby’s lowermost spine to alleviate this problem. In order to reach the coccyx, which is deeply protected in the center of the pelvis, he put on a glove and pressed directly on the baby’s anal and perianal area.

Sure enough, said the parents, the baby went within an hour. They were told, however, that this alignment procedure was only temporary and the baby had a tendency to sacro-coccygeal subluxation. For this chronic problem, they would have to return once or twice a week for the foreseeable future. Each visit was $100.

They continued to see me for scheduled check-ups. Every few days, Ellen got a realignment. They never again had a problem with constipation.

The astute reader will notice that in the uppermost photograph of the felt-and-velcro skeleton which hangs in my office, a creative anatomist placed the pelvis and thorax upside-down. The sacrum and coccyx are oriented correctly, however. By giving medical experts of varying ages the opportunity to share their expertise, I have access to a valuable consulting resource. It could be argued that the implementation of a 21st-century perspective requires a voice born in the 21st-century. The occasional redesign of the human form is a small price to pay for this cutting-edge knowledge, especially from someone who has just learned to walk.

For the neuroanatomicially curious, the nerves controlling sphincter muscles and thus pooping emerge from the cauda equina tail of the spinal cord at the S3 and S4 segments of the sacrum, above the coccyx. For this reason,
one could live life with a subluxed, broken, deformed, or absent coccyx and poop like a champion. There are champions for this, aren't there? I'm not much of a sports fan so I don't know for sure.