December 31, 2009

Television 3: Brave New World

Because I think television goes directly to our deepest unconscious, this post will have some provocative ideas I haven't heard before. Maybe you will have read it here first, and that seems like a good way to close out the year.

There's lots of evidence about all the correlations between TV viewing and all sorts of unfavorable impacts, some of which I have mentioned before. A few years ago, a friend from medical school told me about a study that showed that the more advertising a child was exposed to, the more they wanted fast food and popular toys. But this is a serious, deep bias.

Sure, we all hate advertising because it interrupts what we're focused on at the moment. And we don't like the idea that somebody thinks they can 'sell' us on something we don't already know we want. We really don't like the idea of some grown-up working for a multinational conglomerate selling something we don't want to feed or give to our innocent children.

But I think there's something else pervasive in advertising that hasn't hit the popular or political discourse on the evils of media exposure. It's the equally unrealistic positive portrayal of life. Typically the source of material for stand-up comedians, this outlook is what every ad agency wants to have you associate with their client's product. Maybe it's a frozen dinner that will result in your whole family sitting down to dinner together, including non-sullen teenagers and preschoolers for whom ice-cream would appear to be their only contact with meltdowns. The mother and teenage daughter who spend a leisurely walk on the beach laughing and sharing their tips on freshness. Yes, I'm very much making fun of these absurd caricatures of a life that nobody really has.

Television critics, however, can't have it both ways. There's lots of funding available to study all the ways in which television is harmful, exposure to media violence is harmful, exposure to advertising is harmful. It has so firmly become part of the common wisdom, that we take it for granted. So do the smartest scientists at the National Institutes of Health when they choose to fund these research projects.

There is no funding for researchers looking to show all the beneficial effects of television. Besides, they'd be risking their careers.

So though I made fun of the ridiculous way family life is shown in advertisements, those who have studied the effect on children have ignored this aspect of advertising. By their nature, most ads try to associate their products with the wholesome, healthy, happy, active and fun things we would all like to picture ourselves doing or being. If watching advertising is such a powerful negative influence, wouldn't these positive models be just as influential? If TV is such a powerful instigator of negative behavior, couldn't it also engender positive? All those situation comedies where people generally get along, family fights always end with a laugh and positive resolution within 24 minutes. The advertisements of siblings playing together, the family eating together, the teenagers being pals with mom and dad--why aren't these studied? If television is the powerful drug that many believe it to be, and if exposure to negative things shown on TV results in negative behavior (as is the conventional wisdom at the moment), shouldn't the positive stuff depicted result in positive behaviors? Here's a wild thought: if kids are watching as many hours of TV as it would seem, and it's a powerful influence, than just maybe we have better kids, less violence or negative behavior that we otherwise would have without the influence of all those positive models in advertisements and scripted shows where the family always comes together at the end.

And just because it's a drug doesn't mean it isn't therapeutic. Indeed, I have written again and again in these pages that my job is not to minimize the amount of medication a child gets. My job is to make them better. If it takes medication to get there, I'm for it.  It has become part of our modern lexicon to understand that many of us find ways, for better or worse, to self-medicate.  Sometimes this clearly often refers to serious untreated problems.  But it also includes retail therapy and chocolate therapy.  I propose that the giant elephant in the room of self-medication is television therapy.

Dr. Wolffe's Second Television Postulate:
If television is a drug, it could be effective, perhaps essential, for certain diagnoses.
If it is a drug, then it probably has what is generally called a therapeutic window. That's a way of looking at the dose of a drug. Too little, and there's not much chance of harm, but not much good effect, either. Too much, and the harm is more than the benefit. Somewhere in the middle is a dose that maximizes the benefit and minimizes the side effects.

Back in Television 2, I describe some of the children who are watching a lot of television. Whether caused by watching TV or the reason they watch so much TV, they are less active, fatter, and have poorer social skills. I suspect they are self-medicating with the television drug. It's a drug that addresses many different distinct problems. So if you're lonely and don't have a lot of friends, it provides some of the brain signals that you'd get from a non-judgmental friend. If you're depressed and can't stop thinking about how lousy your situation is, it boosts the chemicals in your brain that you might be able to get with a brief, small dose of antidepressant medication.

I wonder if it is actually underused as a drug. Maybe it's even underprescribed as a therapeutic intervention. That's not to say that kids should watch more TV. There are children who, at the end of their exhausting day, are tired and irritable, uncooperative and engaging in behaviors that show poor judgment, impulsivity, and oppositionality. Nearly every day, there's some sort of a blow-up around the same time. Do they have attention deficit disorder? They clearly have a problem with attention, but it seems to affect them only in the 45-60 minutes before dinner. Even if the kid's parent asked me to prescribe a medication for this, there's nothing that works so fast and lasts such a short time. Maybe this child needs 30 minutes of TV once a day before dinner. It starts working immediately. It redirects the child and will help focus attention, at least for 30 minutes or so. Five minutes isn't enough, five hours is too much. If we make this part of an unbending daily routine, and don't miss a dose, the child might look forward to this 30 minutes of television instead of flailing about looking for some undiverted parental attention, which is in short supply in the time just before dinner.
I know a pediatric dentist with small flat-screen televisions on the ceiling above each exam chair. Isn't it obvious why?

Why don't I have a video player the kids can watch—even if only for a couple of minutes prior to and during vaccinations? Wouldn't it keep the kids from ruminating anxiously about their shots? Wouldn't it distract them from the shots themselves? Why isn't there research on this?

Woody Allen, by the way, got to a similar place about 30 years ago. In his movie, Sleeper, he awakens after being cryogenically frozen for 200 years. His doctor offers him a cigarette and tells him that the newest research shows that it's the healthiest thing he can do.

December 28, 2009

Television 2: We have the technology

television-movie-4988 In Television 1, I pointed out that television is as much a part of our world as refrigerators or kitchen sinks with running water.  There are people who live without these, but they aren’t us.  And our kids probably won’t be them any time soon. Unlike common kitchen appliances, however, television, I believe, is a drug.

Dr. Wolffe's First Television Postulate:
Television is a drug.

Mostly for political and economic reasons, it has taken decades to get tobacco regulated as a drug.  Though used by Native Americans for ritual purposes long before Europeans arrived, it only became clear in the mid 20th century that this was more than a harmless pastime, like quilting or decorative embroidery.  These are gently pleasurable, help some people relax, and don’t hurt anybody else.  It's pretty tough picturing somebody holding up a convenience store in the middle of the night because they they finished their last skein of Pansy Purple #102 and they're feeling so desperate that they are willing to degrade themselves for the next fix.  It will be no surprise what the differences are, and I don't feel it's necessary to cite the references for tobacco use. So as you read the following list, try to think of it referring to someone in your family who:  smokes, gambles, exercises, shops, talks on the telephone, emails, texts, eats, diets, trades stocks, checks stock prices, reads news headlines, or collects something to such an extent that it has a negative impact on their health, appearance, close relationships, job, or life.

It’s addictive.
By addictive I mean that users can't stop whenever they want.  They do it automatically, on a very regular basis.  They feel bad and crave it when they don't use it.  They aren't the only ones who suffer--those close to them can see not-so-subtle changes in their mood, behavior, sleep patterns, and social interactions.  Many adults go to sleep with the TV on.  When it's off, they have a hard time falling asleep.  (It's not because it makes them sleepy--I'll write more of this after the new year in posts about bedtime.)

It can be harmful, even when used as designed.
There is a relationship between the level of harm and the amount you do.  Many people drink alcohol and don't have a problem with it.  Some people do have problems with it.  While there is research on the possible differences in brain chemistry or genetics between alcoholics and non-alcoholics, suffice it to say that some people find it very hard to keep to safe limits.  Ongoing recent research has examined problem gambling using some of the same methods.  There's some reason to suspect that people who can't stop eating the stuff they know is killing them, that exercise or diet or even shop to a level of self-harm have some fundamental neurochemical imbalance that compels them to do what they do.  Though there is much public hand-wringing about the harm caused by television, the research purporting television causing direct harm is deeply flawed.  But the epidemiology appears pretty clear.  Kids who watch more TV have fewer friends.  They do less physical activity.  They are fatter.  They eat more snack food.

Does the TV-watching cause these problems or do kids with these problems choose to watch TV?  I've thought a lot about this question, and I think for some kids it goes one way and for some it goes the other.  So, back to problem drinking:  for some, taking a couple of drinks impairs judgment and interferes with sound decision-making; for others, poor judgment and decision-making skills make them think that they don't have a problem with drinking.  So maybe the kids who have weak social skills or have never had fun by physical activity sit in front of the TV, they find there's something they can do just as well as the popular kids--maybe better.  There's something they can master and be authoritative about when with their peers (maybe Twilight or maybe it was Star Trek for you).  They can be completely open and unreserved with this nonjudgmental entity for which they are just as good a companion as their more successful siblings.  For them, it transports them to a safe and exciting world.  It also interrupts the stream of negative messages about failure, self image, popularity, and status that this child hears from others and from themselves.  It turns this endless loop off.  How, exactly it does this isn't entirely clear.  But the fact that it can suggests the converse question.  If a kid who doesn't have these weaknesses sits in front of the television for the 4 to 6 hours a day many kids watch TV, how might they be affected?  How ever many hours they watch, they aren't riding their bicycles or playing basketball in the driveway while they do it.  They are raiding the kitchen for snacks.  Even if they have a friend sitting next to them, they aren't practicing the subtle skills of social interactivity that make for popular playmates.  It changes what they do and how they act.  So either way, it's a drug.

It affects your body (including your brain).
Why does it calm the angry, tranquilize the oppositional, and make the rest of us into emotionally-blank drones who can't take our eyes away?  How, exactly, is that different from entertainment?  One difference, perhaps for some people (and children) more than others, is that the more you watch, the more you need to watch.  Television becomes part of your life.  When you travel, why do you turn on the television as soon as you go into the hotel room?  Do you let it play all night?  Why do we have to eat while watching (true for movies, too)?  I suspect that the hedonic sensation of eating reinforces the rise in calming and reassuring-type neurotransmitters that accompanies American Idol.  The research really isn't there yet to support fully the way I believe it works, but I think it's just around the corner.  It's very difficult for most people to stop the way they eat and lose the weight they know they need to lose.  No, it's not weak character or lack of 'willpower' (whatever that is).  Eating is so primal that the feedback we get from doing it causes deep and fundamental reactions in the parts of our brain that are invisible and uncontrolled by our intellect.  I think television pushes equally fundamental buttons.  Just like a drug.

December 25, 2009

Television 1: We don't have the technology.

 televisions broken china sepia Hypocrisy is the Achilles' heel of parenting.  Go ahead and hide it or deny it--your kids will find out.  They will find out that you have sex, that you don’t like one of your siblings, that you are depressed, that you read supermarket celebrity gossip magazines, and that you watch television.  Go ahead and try and hide it from them.  See how it works for you.  Here’s how it works for children.  They learn that you are intentionally deceitful.  That you lie to them and have been doing so for a long time.  Maybe they learn that you lie to your boss, your spouse, the IRS. Maybe they won't hold it against you, but they will learn from you.

In a previous post, I cited the good epidemiologic study which examined the sexual activity of teens who had taken a ‘virginity pledge’ compared with those who never pledged.  The pledgers initiated sexual activity at a younger age, and had more teen pregnancy.  Seriously, whose idea was it to have a teenager make such a pledge?  It doesn’t work.  These are good kids, who presumably made this kind of commitment to please their parents.  Or, at least what their parents said.

Here in Berkeley, there are plenty of families who don’t have a television, and make their kids play with wooden toys.  Among my favorite toys as a child were plain maple blocks that could be made into anything and couldn’t be  broken, couldn’t even be chipped.  I remember the LEGOs my parents brought  back from Denmark in the 1960’s.  Plastic, yes.  But it was just a box of uniform yellow blocks.  I could make them into anything.  Most construction sets are now marketed with precast purpose-designed parts. I think it takes less creativity, not more, to assemble the moonbase or skyscraper or castle out of these kits. Holding a piece of undifferentiated wood or generic plastic blocks and making zooming noises as it flies through the air is symbolic play at its best.

Still, it seems like a lot of the people I’ve met who have embraced this antitech lifestyle, who try so hard to compost whatever is left over from their visit to the farmer’s market, whose produce is carried home on bicycle panniers made of unbleached hemp fiber, live here.  And for the most part, nearly anywhere in the San Francisco Bay area is expensive.  How do they live?  Are they woodcarvers and henna artists?  Stonemasons and communal subsistence farmers?  There are no demographic statistics I can cite, but I live and work here and call it like I see it.  These parents are PhDs and knowledge-workers, making a great living from the service economy, high-tech industry, and new technologies.  Oh, did I mention the stock options?

The disavowal of technology in these families, I predict, will often not end well.  I think it’s likely that these successful, intelligent, well-off parents will probably sire intelligent kids that have all the advantages of growing up in a household with financial resources and high educational attainment.  But what will they think of their parents?  Every mobster’s kid knows how the family makes its money.  Why are these kids different?  Why are these parents ashamed of working for a Fortune 100 corporation?  If you’re a true believer, go for it.  Find some land and live off it, if you can.  You’ll need practical skills and knowledge that is hard to come by.  And you’ll need to work very, very hard.  Expect to be tired, and hungry, too.  At least your kids will eventually admire you for seeing one world and choosing a different one that is more meaningful to you.  (Think Amish.)  They will visit you in the compound/bunker and respect you for making a hard choice and being true to it.  Many times and in many contexts I have met adult children of parents who follow a strict code of some sort, usually religious.  Though the children have made different choices, the ones I have met mostly have no problem with the way their parents live, whether in Provo, Utah or Brooklyn, New York.  It’s the parents that are often intolerant of other choices.

There is also a curious denial of the ubiquity of television.  In New York, it’s in the taxis.  It’s in airports and some public transit stations.  It’s on your cell phone and laptop.  It might be on your watch.  It’s certainly in your child’s school, and every library.  Indeed, the grinding advance of electronic media suggests that books as we know them will be accessed on a screen by the time your little ones are doing research for their college term papers.  If you are deeply orthodox in some religion, it’s usually possible to find some educational institution to send your child.  Evangelical or Hasidic, Islamic, Catholic or Mormon, there are such places designed to facilitate your continuing enforcement of the walls you have erected around your child’s life experience.  Where will these children go?  To the university without computers?  Is that where you learned the skills you use every day to support your family?

Because of the insular quality that helps to define a cult, groups generally identified as cults have been heavily studied in social psychology, sociology, and other fields.  One important aspect of a cult is limitation of interaction with people and institutions outside of the cult.  I worry that the children without television will have some social limitations.  Will their parents limit their playmates to those living in similar households?  That sound fairly restrictive.  Will they be able to see TV at their friend’s house but not at home?  Won’t that make the parents appear hypocritical to the child?  Since they can’t share typical topics of conversation for kids--characters in the media, popular anything (music, TV, movies, games)--will they seem odd and out-of-touch to their peers?  Can you really limit their friends to members of this same cult?

It may sound like I’m in favor of wiring a cable box directly into the crib.  Not true!  I love those wooden blocks, and encourage their use (as long as they are from sustainable species).  This post is a warning to parents about the difficult line they draw with dogma.  The more rigid the belief system, the brighter and more inflexible this line is.  My concept of empathic parenting embraces the individuality of a child’s needs and talents.  Forcing every child’s unpredictably-shaped peg into a rigidly uniform hole seems to me likely to injure a lot of kids.

For more on the topic of television, stay tuned.  Same bat-time, same bat-channel.

December 22, 2009

Television Rules and Concrete Thinking

concrete mixer A parent recently asked me for advice about TV.  She said that they had just moved, and in the past few weeks, it’s been blissful living out of boxes with the TV not yet unpacked or hooked up.  They aren’t fighting with their 6th-grader about limits on viewing time, and all the things that go with it.  Her 12-year-old keeps asking about the television, however, and her husband is going to try to set everything up over the weekend.  What should she do?

She’s not particularly afraid of the content of what her son watches.  He’s a smart, nice kid who does well in school.  She’s more concerned about the hours he can spend doing nothing else.  She is not looking forward to the inevitable fights about limits on screen time, limits on times that he can watch, limits on TV when his homework isn’t yet done, and so on.

One issue is his age.  At 12, kids do a lot of concrete thinking (see Visit to The Other Parent).  That means that vague rules about priorities (homework is more important than television) are not as effective as concrete rules (no television until math homework due the following day is done).  So the rules have to use this inflexible way of looking at the world.  And they can’t be made up as you go along.  To the child (and to me) that will see capricious, arbitrary, punitive.  So the best way to make rules might be collaboratively, with the child actively involved.  Have a family meeting on the night before you unpack the box.  At the meeting, ask him what he wants and what he thinks you want.  Then ask what he thinks you’ll settle for.  You might be surprised at how realistic he is.  So I don’t anticipate a big fight when the rules are put to paper.  The same concrete thinking reduces his capacity to project scenarios ahead in which he would very much be interested in nagging you for an exception to the rules.  So fights over TV tend to arise at the time of the child’s temptation (when they want to watch something or play a video game, but their homework isn’t done or there’s some other commitment).  These conflicts don’t usually occur in the drafting session, when the rules--though worded concretely and specifically--require abstract thinking to foresee their application.  From a business negotiation point of view, this gives you an advantage in the formulation of the rules.  If you don’t do this, and let it go until his TV show is on and his big project is due tomorrow, he will have the advantage in the negotiation.  Even though it might not end well for him, there could be a considerable amount of bad feelings all around.  Keep the language simple, keep it to one side of one page.  Frame it, under glass.
break glass to release button
  In Emergency, Break Glass.
Oh, one more tip for concrete-thinkers:  rules are made to be kept, not broken.  He’s having friends over?  It’s Christmas?  The math homework still has to get done.  You can use his concrete thinking for his advantage and yours, by collaborating on (not imposing) some specific rules.  But those same concrete interpretations of the rules will conclude from every exception that arises that the rules are flexible with your mood/your whim/your schedule.  In other words, there are no rules at all.  Consistency is credibility in concrete thinking.

A lot of parents find rules easy to make and hard to keep.  They figure they are grown-ups and get to do what they want.  Well, in most ways, that’s completely true.  Do what you want.  But now that you’re a grown-up, you should know that there are consequences for your choices, and you should be able to anticipate most of these.

So in the example I’ve been mentioning, he is not allowed to watch TV until the math homework due the following day is done.  OK, he did it.  (How do you know?  Are you aware of his assignments?  Have you asked the teacher if he’s behind on turning homework in?  Does he need help with math?)  So, according to the rules, he’s allowed to watch TV for, let’s say, an hour.  But he still hasn’t cleaned up his room, and you asked him to do that a week ago.  Do you tell him he can’t watch TV?

Assuming you come up with some TV rules that you both agree to, have him sign the paper.  It’s probably the first contract of his life.  Every contract has a term.  (We know how long a marriage contract, for example, is supposed to last.)  So put an end date on the rules, and agree to revise them at the end of the term or some other natural date.  You have to sign the paper too.  When you do, know that this is not a parenting idea.  It’s your credibility with your kid.  Sure the rules may appear to be about him and his TV privileges.  But they require you to comply also.  Your enforcement tool is your power to disconnect the television.  His enforcement tool is his power to distrust you forever and not speak to you for the last 50 years of your life, keep your chicken2grandchildren from you, and make you pay for college tuition—for your therapist’s kid.   Do you really want to play chicken?

It never ceases to amaze me that the most insightful parents lose sight of this basic truth.  I’ll ask them about the things their parents did that most bothered them (and might bother them still).  They—you—remember these actions vividly, even 20 or 40 years later.  So why is it such a mystery when your kid is bothered by you doing it?

So can he watch TV or not?  Stay tuned.

December 18, 2009

Visit to The Other Parent

We have the technology.telephone3c At holiday time in particular, when school is out for a substantial amount of time, many of the children of divorced parents get to spend some quality time with the other parent.

A stepmother expressed her worry about this.  She said that  Luke, 13, is very excited about spending the holidays with his mom, who lives an airplane ride away.  She said that Luke has often said how much he misses her.  Despite this, however, she also notes that his mother doesn’t call, doesn’t write, doesn’t email.  His mom is not involved in his life.

Life at 13 is difficult.  On the one hand, kids this age can smell and taste the benefits of adulthood.  If we would let them, they’d drive.  So they see attractive things on the horizon that they believe they are perfectly capable of doing.  But they can’t quite figure out how to get from here to there.  They have no idea that to become a doctor (I get this question a lot), you actually have to spend a lot of time in classrooms and do a lot of homework.  Another problem that nearly all 13-year-olds share is concrete block concrete thinking.  You tell her to call if she gets out of school late.  She doesn’t call, it’s 8pm, and you have the police out looking for her when she walks in the door and asks what all the fuss is about.  ‘Why didn’t you call?’ you ask in the calmest tone you can pretend.  She answers that she was supposed to call if school got out late.  It didn’t.  She left school right on time, then went shopping with a friend.  She followed your directions to the letter.  But she missed the forest because all she could see was the one tree.  This kind of thinking leads to parental frustration and these younger teens thinking that their parents don’t understand them at all.  Maybe they’re right.

As the child gets to this point, like a scenic overlook where they binoculars_for25ccan see adulthood in the distance (but hopefully not with those awful binocular machines that always steal your 25¢  and never work right),they try to distance themselves from their parents and move closer to their peers.  This is a normal developmental stage, but it’s hard on the parents who can feel that they are losing the child.  If the parents hold on tighter, I usually see a much worse outcome in the long run.  You can’t hold back the tide, either of the ocean or of your child’s independence.  If you try, the end result is typically resentful and rebellious children who may or may not talk to you after they leave your household.  They will be independent whether or not you try to restrain them.  Why not make it work for the two of you?

Luke has concrete thinking.  So I worry that it has not occurred to him that something is wrong with this picture.  His mother isn’t in contact with him.  You, dear reader, are either a mother or have met one at some point in your life.  Does that sound right to you?  I don’t know if the problem is the mother’s alone (illness of some kind, including mental illness; substance use; shame or economics (can’t afford to call or visit, can’t write a letter, is embarrassed by meager circumstances compared with ex-spouse)), or if the father has explicitly or in some subtle way discouraged contact perhaps by intercepting letters or restricting phone use.  No matter what the reason, there’s a serious problem here.  Whatever Luke thinks life with mom--even for just a couple of weeks--is going to be like, he’s wrong.

This is the advice I gave.  We’ll see, after the holidays, what actually happened.

I suggested that his dad and stepmother give Luke a cell phone before he goes.  (If you think this is too indulgent, maybe you can find a fat bearded guy in a red suit to give it to him.)  This is really important.  It gives him a way to call you without using his mother’s phone, and without asking her permission.  It also gives you a place to call every day without leaving a message on her answering machine, without having her accuse you of interfering.  Most importantly, CALL HIM EVERY DAY.  Don’t call multiple times, don’t ask the minutia of what he did with mom as if to second-guess all of her decisions and plans.  (If that’s your goal, get help.)  The purpose is to tell him every day that you’re thinking of him, that you miss him, that you love him.  Don’t ask him anything.  Not even one question.  You are just calling to tell him that short message, not ask anything of him, nor interfere with his relationship with his mother.  He may say he doesn’t want you to call every day.  You might want to do it anyway.

Luke is one of my patients with ADD.  So I had further advice for his stepmother.  Get a second, prepaid cell phone.  Write down the serial number and all the numbers inside the phone, and the activation instructions that came with the phone.  Then, James Bond-like, sew this brand new but nonworking cell phone into the lining of his suitcase.  Ideally, without his knowledge.  Then, after he loses the phone you gave him, he will have one right there.  All he needs to do is call you, get the activation instructions, and turn it on.  Maybe you can even do it remotely.  He’s going to lose the phone you gave him.  So get over it now, be prepared with the online tools or toll-free number to turn off the lost phone.  Don’t blame him for it!  How can you blame him from something you knew was going to happen by reading this very paragraph?  You, dear reader, have been served.

OK, for those of you a little more domestically challenged, maybe you don’t have to sew it in the lining.  But sneak it in the bottom of his bag.

I know that once he’s got a cell phone, it will be tempting for him to use all the available airtime texting his friends.  Get a plan with expensive texts and tell him you will take the cost out of his allowance.  Or turn off the text function altogether.  As the owner of the phone, you can turn this feature on again if you need it by phoning the cellular company.

Do NOT tell him to call you at all.  If he wants to, he will.  If you want him to, he won’t.  If you force him to, he’ll resent doing it.  If you don’t want to follow my advice to call him every day with a quick ‘I miss you’ message, don’t tell him you will call him every day.  Never, ever, tell children this age you will do something that you don’t actually do.  They will remember it for the rest of their lives.  More on this later.

December 15, 2009


States-of-Matter taylor elementary
Of the approximately 100 members of my class at Yale School of Medicine, every single graduate—100%—were eating solid food.

With that admittedly anecdotal experience, I have reassured many parents that at some unpredictable point between 4 months of age and medical school, their baby will—I virtually guarantee it—eat solid food.

Jamie, barely 4 months, used to sleep 6 or even 8 hours at night last month.  But as the weeks went by, he was awakening more often.  His parents said that he’d get a good nursing at about 10pm and then he’d be out for about 3-4 hours.  Then when he awoke, he’d nurse again, out for 2 hours.  Then 1 hour intervals through the rest of the night.  The nursing was sometimes 15 minutes, sometimes 30.  What was happening?

Unlike The Human Pacifier, this 4-month old appeared to want to eat.  He wasn’t looking for reassurance or comfort during the night, he was really nursing.  There’s a behavioral aspect to frequent awakenings, that can become a problem as babies get older.  (I hasten to add that there’s no crying baby who doesn’t need attention and care.  Maybe there’s a sleep problem or a behavioral issue, but the approach to this should never include ignoring the baby, even if it does include a measured response.)

There’s no way to untangle the comfort provided by nursing with mommy in the middle of the night from the baby’s hunger.  Or is there?  In the 3-part Human Pacifier series [part 1, part 2, part 3], the baby was waking up to nurse for a minute or two, sometimes less.  He’d go to sleep right away after just a moment or two of snuggling with mom.  But Jamie’s mom didn’t have it any easier.  She, too, was getting up nearly through the night.  This baby was nursing pretty much to the capacity of the mother’s production.

Here’s what’s going on.  The baby is full when he’s going to sleep.  That’s why he has his longest sleep immediately after that last big feeding.  He was about 2 pounds less a month ago—that’s a big proportion of his body weight.  At the time, it was enough to keep him nearly through the night.  Now, it’s enough for 3 hours, maybe 4.  Then he wakes up hungry.  Nursing for 15 to 30 minutes is enough to take the edge off his hunger, and get him back to sleep.  It’s not enough to fill him.  The less-than-enough feeding may take the edge off, but it’s not enough to last long.  So this second feeding doesn’t last as long as the first.  He wakes up and mom does her best.  But 2 hours later, he doesn’t get the same amount he got after giving mom a 4-hour break.  Her manufacturing apparatus just isn’t set up for just-in-time inventory management.  He’ll get just enough to take the edge off again, but this time wakes up in an hour.  This is much less time than the factory needs to meet demand.  So from this feeding until morning, both baby and mother are locked in lactational Reaganomics—a trickle-down model of infant feeding.

So there’s a couple of logical approaches, with both possibly rooted in an econometric, perhaps even game theory perspective on infant rearing.  Isn’t this the approach most parenting authorities take?

First, we can decrease demand to match supply.  It’s hard to see Superman taking valuable time from his busy schedule and presumably many other commitments to fly really fast around the planet backwards and so turn back time to when the baby would stay full through the night.  There’s some ambiguity about how Superman ages, since he progressed from baby to newspaperman quickly but hasn’t changed much since the 1950’s.  I mention this because he’s going to have to accomplish this same task every month forever if we’re really intent about restraining the baby’s growing demand.

So, like true Reaganomics devotees, we need to focus on the supply side.  Here, there is a fork in the road.   There are many ways to try to increase milk supply.  This is a reasonable way to go, for a while.  Babies, however, can be relentless in their ever-increasing demands.  Will they never learn?  The other fork bypasses this captive supply chain and outsources the inventory management.  This baby was ready for solid food.

Human milk is really easy to digest.  There isn’t much else that goes through a baby’s stomach faster.  Solids get digested much slower, so they keep the baby full a lot longer.  For the record, the calorie content of solids is typically much less than breast milk or formula—so I don’t rush to start solids in babies who are having problems gaining weight.  Not every baby takes to solids right away, but the level of stress this induces occasionally confounds me.  I think of my fellow graduates and for god for country for yalecan’t think of a single one, not one, who wasn’t eating solid food.  I can’t authoritatively say that this was true at other medical schools, of course.

December 11, 2009

Patient Zero: The Hundred-Day Cough

Andy is about the healthiest 11-year-old in my practice.  If he didn’t keep bruising himself playing basketball, I don’t think he’d ever come to the office.  The cough he had was remarkable for another reason, too.  He wasn’t sick.  No fever, no trouble breathing.  No noisy breathing, not even a runny nose.  He didn’t even cough most of the time.  But every 5 or 10 minutes, he would cough and cough and not be able to stop for about 2 minutes.  During the 2 minutes, he had a lot of trouble getting a breath in between the coughs.  He only had this for a few days, however, so he got some cough medicine that helped to suppress the cough, and that helped him.  He was over the worst of it in a few days.

I’m fortunate that my patients and their families often recommend me to their friends.  So Andy’s best friend David was in the office the following week.  He had asthma, so his cough was just the latest in a series of exacerbations.  I increased his asthma medication, and he improved.  For a while.  Then he went back to coughing.  So he was back in the office, this time with what sounded like pneumonia.  He got antibiotics, and more asthma medication, and he improved.  For a while.  The cough he had was peculiar, and seemed to come in fits, just like Andy’s cough.  Sometimes, one of these coughing fits would stop right after he threw up.  For one visit, he and his mom brought along Sean, a friend from school.  Sean waited politely in my little waiting area.  After the first month of symptoms, two courses of antibiotics, tons of cough and asthma medicine which seemed less and less effective, I got lab tests.  He wasn’t thrilled about having to get a blood test.  On the way out of the office, he introduced me to Sean.  Sean was coughing, too.

  Though finding infective bacteria wasn’t likely after the antibiotics he received, I knew what I was looking for and ordered measurement of the antibodies in his blood against pertussis.  In the 19th century, it was sometimes called the Hundred Day Cough.  The kind that show a long-term memory in the immune system, IgG, would show a healthy response to his series of infant immunizations.  Another kind that I requested, IgM, would be evidence of an ongoing or very recent infection that his body was trying to fight off.  His pertussis IgM was very high.

After calling his parents to tell them that I had a diagnosis, my next call was to the office of Public Health.  Within 12 hours, they were mobilizing in one of the local middle schools.  David has an older brother in high school.  He was coughing, too.  Within 24 hours, they were at the high school, too.

Andy’s mom told me that she felt bad about him starting this growing number of cases.  It wasn’t anybody’s fault, I told her.  She knew about epidemics, and she called Andy Patient Zero.  Patient Zero is the very first case in an epidemic that can be identified.  All the other cases can be traced back to this one.

By Halloween, a couple of months had passed from the time that Andy first came to my office.  He wasn’t coughing any more; David’s older brother wasn’t coughing any more; even David wasn’t coughing any more.  I was at their house for a party on Halloween.  (I dressed up as a pediatrician who stayed late at the office. )  Andy’s friend Sean was there, coughing. 

I was introduced to Sean’s parents, who, in a friendly way, tried to explain that their decision not to have Sean vaccinated was just a personal choice, like being vegetarian or buying fair trade coffee.   Sean wasn’t my patient, and I left the conversation.

I pulled Andy’s mother aside and told her that he wasn’t Patient Zero.  Sean was. 

Given that unvaccinated children are 23 times more likely to get pertussis, it’s pretty likely that in my neighborhood, the kid that gets it first is probably unvaccinated.  David, who has asthma, really struggled with it and needed a lot of medication that he probably otherwise would have been able to avoid.  Sean too, I suspect, was suffering.  He had been coughing for about 2 months or more by Halloween.  In vaccinated kids, the mean duration of the worst cough is 29-39 days.  In the unvaccinated, 52-61 days.  That’s an average, so some will be longer and some shorter.  The incubation period for pertussis is 4-21 days.  Sean was the first to have the disease, and is probably spreading it even now, with every frequent cough.

Sean, I assume, and the 3 of my patients who got pertussis from him, will all be OK.  But when they come home from school, who gets it from them?  What about the grandparent with lung disease?  What if there’s a sibling getting chemotherapy?

Andy’s mother is pregnant.  When the newborn is home in a couple of months, will Sean come over to hang out with Andy and David?  How will she make decisions like this?  When I told her that it was nobody’s fault, I didn’t know what I know now.

December 8, 2009

Rule #6: Dr. Wolffe's 'Baby' Rule

First, an editorial note. I don't know if this is really rule #6. I think if I had called it rule #1 then it would seem to be the most important rule out of however-many rules there turn out to be. Rule #2 will have you wondering what is the rule that is so much more important than that. Rule #79 seems more like a guideline than a rule. I will post other rules as they arise, and will have to see where their numbers unfold.

6.  Dr. Wolffe's Baby Rule:  
Never apply any product to your baby that has “Baby” in the name.

Simple, right? Hospitals often give out free samples of products covered under Rule 6.  Feel free to use them on yourself. Don't start with that blame-the-drug-companies stuff, either. Pushed equally hard, and at considerably higher prices, are many product lines of 'natural' products targeted for use on babies. Are these products natural? In fact, they are designed to be marketed to parents who really want to use all the products covered under Rule 6, but who feel better about themselves by buying the products in a purportedly greener venue. I'll go through the usual suspects:

  1. Baby Shampoo. If your baby has any hair at all, how dirty does it get? Dreadlocks—I don't think so. Dripping with sweat from being overambitious on the stair-climber in the gym after work? Not likely. If your baby has cradle cap, especially if it's severe cradle cap, the baby might need a prescription shampoo. Baby shampoo won't help it.

  2. Baby Wash/Soap. You know that car that's jacked up on concrete blocks and wire milk crates in your front yard? The one that your neighbor applied for a court order to have you remove because it was bringing down property values? Let's say you're under that car replacing the starter motor that burned out when you let that dim cousin Dale (though everyone calls him LD which stands for 'Little Dale' because everyone calls his father Dale) use the car briefly in 1997 and he ground at least two teeth off the starter ring gear.  You're being a conscientious parent,

    watching the baby, who you have next to you on the wheeled creeper under the car. Loosening the transmission fluid cooling lines sends a gush of dirty transmission oil all over the baby. Now you're going to need some soap when you bathe the kid. Until that happens, however, nearly everything else that gets on the baby will come off with plain water and gentle wiping with your bare hand.

  3. Baby Oil. What is this stuff, anyway? How exactly are babies industrially processed to extract their oil? Is it refined? Crude? Extra virgin? It turns out to be mineral oil, refined from petroleum, plus fragrance. Your baby needs fragrance? If your baby smells unpleasant, that's a signal for you to be taking some sort of definitive action to remediate that issue.

  4. Baby Lotion. There's an old-fashioned expression: smooth as a baby's behind. How did it get that way? Not from lotion, I assure you. There are babies who have dry or problem skin. It's hard to imagine that a baby with very dry and sensitive skin is somehow going to be helped by a mix of heavily-fragranced, colored, saponified organic compounds. If you buy the 'natural' brand, it will probably also have calendula in it, which can really do some damage to sensitive skin. (See my post on this topic.) On a related note, the peeling skin of a newborn has nothing to do with the skin being dry. Everybody's skin would peel after a 9-month bath.

  5. Baby Powder. Powder is by definition dry, so is indeed a logical choice for absorbing liquids. Will it keep the baby dry? Do this yourself—put some in your hand and see what happens when you add a little liquid. Does it absorb much? Or does it turn into a strongly-smelling congealed abrasive? And what, exactly, happens to that cloud of particulates that seem to linger in the air that you and the baby are inhaling?
If this has left you feeling like you have to throw away your entire shopping list, don’t despair.  Here’s a Baby product to put on the list.
baby grand piano
And there’s always this.

December 4, 2009

Looks Like an Attention Problem: Part 1

The official diagnostic criteria for ADHD require that symptoms start before age 7.  In boys, particularly the hyperactive ones, they usually show up in my office while still in elementary school.

So I was skeptical when I met Franklin, 15 years old and brought at his own request for an ADHD evaluation.  Most kids don’t think there’s something ‘wrong’ with them.  Parents are reluctant to think this too, and most don’t want to think that their child might benefit from medication.  So in the context of both patients and parents reluctant to get this diagnosis, I couldn’t help but wonder if this teenager had a substance problem.

Indeed, his mother admitted that he had been requesting this evaluation since 7th grade, but his grades had been good and his mother couldn’t imagine that something could be wrong.

But I have to admit he looked the part.  Rail-thin, and constantly in motion.  When his knee stopped moving, his fingers would tap.  He fidgeted constantly in his chair.  I asked about what his classroom work was like and found the same classic answers.  He could do the work, but often forgot that there was an assignment, forgot to hand in assignments he did, and never knew when there was going to be a test.  His mother bought him an organizer.  Then another and another as he lost them in series.  When asked about a family history, she took the opportunity to  tell me that his younger sibling had no such troubles, and excelled in school.

In his favor, he hasn’t been a conduct problem.  He wasn’t constantly being sent to the principal’s office.  I sent them home with questionnaires for parents, teachers, and Franklin.  But before they left, I told his mother that I wanted to talk with him privately.

As fidgety in private as he was with his mother in the room, he told me that he was frustrated by attention issues.  He wanted to do his homework, but every time he sat down to do it, he’d end up in another part of the room, doing something else—within just a few minutes.  But the more he described the attention issues, the more his voice changed, and his face changed.  I asked him about depression symptoms, and he paused.  He thought he was depressed.  I asked if he thought about suicide.  He said he did, but didn’t everybody?

The questionnaires came back with a clear concentration of attention problems.  When I asked them about his attention symptoms, they clearly did start long before he was 7.

Though I think ADHD is too casually diagnosed and managed too haphazardly, it has been treated and studied for decades.  So there are really good data showing that careful medication improves just about everything.  Unmedicated teens with ADHD have higher rates of dropping out of school, substance abuse, suicide, failed relationships, teen pregnancy, and many more interactions with the criminal justice system.  So for the right person, in the hands of the right doctor, these medications are life-changing and are extremely effective.  Franklin’s core attention symptoms were so focal that I thought he would really benefit from a medicine that addressed these symptoms directly.

But I told him directly that the fact that he had been able to get by in school so far made me very optimistic that we’d figure out the attention part at some point.  But at this moment, I was most concerned about his depression.  I told him that I wanted to treat that first, and when the depression was under better control, I’d focus on the attention.  With his permission, I explained the plan to his mother.  He looked tremendously relieved.

In Franklin’s case, his attention symptoms were quite specific.  He was impulsive, forgetful, disorganized, hyperactive, and unfocused.  It would have been easy to treat this directly, and probably would have helped him feel better.  But I was worried about him, and that makes all the difference.

Depression, unlike Franklin’s attention problem, is not a focal problem.  It’s a pervasive stain that taints all the aspects of a persons life.  When you’re depressed, things planned for a couple of weeks in the future just don’t matter.  So they lose their importance.  If you don’t think that your life is going anywhere in 5 years, what possible meaning could the test in school have for you?  Why would your homework matter?  And if your class lapses even momentarily into boredom, paying attention to anything else seems like a perfectly logical choice.  As depression gets more severe, this time horizon gets closer.  When it doesn’t matter what happens that day or that hour, there’s not much that will motivate you to organize a whole semester of assignments.

I prescribed an antidepressant, which fortunately took effect within days.  If his mood stabilizes, I’ll start him on an attention medication.

The photograph at top is a portrait by Felix Nadar, the finest French portrait photographer of the 19th century.  It's of his son.  Except, perhaps, for his clothing, it is certainly a completely modern photograph.  It is in my collection, and used to belong to Andre Jammes.

December 1, 2009

The Thanksgiving Sleep

ThanksgivingFeast-negative One of the persistent questions that come up at Thanksgiving, by well-meaning distant relatives trying to fulfill their annual social obligations by making conversation with the doctor in the family, is why turkey makes people sleepy.  Is it, they wonder while showing evidence of scientific literacy, because of all the tryptophan? 

I typically answer that it's an interesting question.  As questions go, however, it's really not that interesting.  But I, too, have my annual social obligations.  So helping other people fulfill theirs helps me fulfill mine.

Even without the burden of family relationships, however, this question is a relevant one not just because of the recent holiday but also because of some research studies I've been reading that leave me both interested and disturbed.

No, it's not the turkey.  Turkey does have the amino acid tryptophan in it, but no more than many other foods.  It's the gigantic overeaten orgiastic tsunami of food that makes us sleepy.  The more stuff we have to digest, the more our bodies move blood flow to our intestines.  That leaves less blood for less essential organs such as, for example, the brain.  In order to metabolize just one slice of pie (though there were, to be fair, 3 different types of pie and a cake of some sort; so it was just one slice--of each), our body has to pump insulin into our bloodstream.  That can cause fluctuations in our blood sugar that leave us very sleepy, too.  So if you think that the vegan tofurkey is going to sharpen your wits, it won’t if you eat the same excessive amount of it and everything else as your mainstream relatives do.  Here in Berkeley, needless to say, one has the luxury of access to exotic and gourmet foods.  And to foods like tofurkey.  (For readers na├»ve to the special experience tofurkey provides, I would guess that fewer people choosing this product for thanksgiving end up as profoundly overindulgent at the thanksgiving feast.  Whether this is because of superior self-restraint or inferior sensory experience of the food itself would be a matter of speculation.)

Tryptophan is not manufactured in the body, so it's called an essential amino acid.  But it's in lots of common foods, so we usually get plenty of it.  In the body, it's used for many purposes, including the production of the neurotransmitter serotonin.  Serotonin also has many functions that we know of, and seems to be very important in the regulation of our mood.  Many antidepressant medications are designed to increase levels of serotonin.  There are several over-the-counter tryptophan products available at the drugstore.  But it's not a feel-good pill.  Too much serotonin can cause tremors, blood pressure problems, muscle damage, and worse.  This is called serotonin syndrome.  That's assuming that the tryptophan product isn't contaminated in some way.  Twenty years ago a new disease emerged called eosinophila-myalgia-syndrome.  Though symptoms varied, probably over 1000 people had painful symptoms and a couple of dozen died.  All had been taking tryptophan.  Tryptophan is sold in the United States as a supplement, unregulated.  It's sometimes sold as something to help you sleep, since so many people believe it's the component in turkey that causes sleepiness.  And some of the tryptophan is converted to serotonin which is then converted to melatonin which helps some people get to sleep.  How much tryptophan do you need to take to increase your melatonin levels enough to have an impact on your sleep?  Given that the tryptophan in your thanksgiving turkey isn't what's making you sleepy, it might be quite a bit.

None of this is the research I read.  What I found out about was the appealing idea of adding tryptophan to baby formula and baby cereal.  The idea is straightforward enough.  Feeding the baby the right product at bedtime could be helpful in keeping the baby asleep longer, and everybody is happier.

But I worry about a baby getting one of these nasty syndromes.  How much additional tryptophan is too much?  Both human milk and cow milk have about the same proportion of tryptophan, so either formula or nursing is likely safe in this regard.  But extra?  Of course there is a philosophical objection, even if it were completely safe.

Babies cry.  It's one of the main ways that they communicate.  They have other talents, to be sure, but they often cry when the need something from us.  Given that it may be inconvenient and frustrating to try and figure out what it is that they need, it has always been tempting to find a way to 'help' the baby stop crying.  There's a big difference between getting the baby to stop crying and meeting whatever its needs might be.  In the 19th century, there were several very effective nutritional supplements and tonics marketed for quieting babies.  The opium in them seemed to help right away.  It suppressed hunger, reduced pain, caused sleepiness.

I'm not claiming that tryptophan is equivalent to opium.  But I ask myself, 'who is this helping?  What patient am I treating?  Is the baby going to be better because of this?'  So, for now, I'm suggesting that parents resist the urge to give their babies extra tryptophan.  Wait until the kid can just eat turkey like the rest of us.