January 29, 2010

Worst Possible Scenario Survey

This post isn’t just about pediatrics, it’s about a practical problem.  I don’t know the answer, so I need the help of my readers.  That means you.

Phyllis, 88, is brought to the hospital, via the Emergency Room, acutely ill.  No one at the hospital knows her personally, and the person can’t, for various reasons, help to identify who she designates as a decision-maker for her care.  She is not able to help with this crucial information.  Somebody in this circumstance is unlikely to be able to consent to certain aspects of their own care.  If she is not competent to designate a surrogate, it’s hard to imagine her being competent to consent to a complex procedure.

Let me clarify some assumptions.  The good people at the hospital don’t wait around for Phyllis's neer-do-well adult daughter (too close to home?) to call back from the spa before they perform CPR.  They have established protocols for life-saving interventions.  If you can’t tell them what you want, they will try to err on the side of keeping you going.  It’s reasonable to assume, in my experience, that the strangers who work at the hospital--even the ones with poor bedside manners and weak social skills--don’t mean you any harm and want to help you the best way they know how.  Yes, the courts can always appoint someone.  But that could take days or weeks, and would you be happier with who gets assigned to you get that way?

Maybe you don’t think this applies to you, and maybe you’re right.  Maybe you carry your living will or advanced healthcare directives, signed and notarized, next to your body everywhere you go.  Maybe it’s a long (usually several typed pages) tattoo.  But avoid it though we mostly do, any of us could be in this scenario.  Certainly, our aging parents could be.  And though I don’t like to bring it up, a child could be.

But I’m not asking about the immediate needs.  If you need an IV, they give you an IV.  But this is about the worst case scenario, not just a bad case.  Does your mother want to undergo an agonizing series of procedures to provide a possible but not guaranteed few extra weeks?  What about another round of chemotherapy when 4 awful previous trials didn’t help?  What about life support--would she want mechanical breathing, external heart or kidneys?  Under what circumstances yes or no?

I have written before about problems in medical ethics, and complained about ethicists who seem obsessed with these rare cases.  But this is a purely practical question.  I visit my mother every week—what would I want for her?

In the ethics discussion, I learned that this is pretty rare.  Though many people don’t have advanced directives, most have some connections to family or others who can help.  But several times a year, somebody like Phyllis is in the ER--very sick, not able to make her own decisions, not able to designate somebody to help with this serious decisions.  There isn’t one right answer of who, under these circumstances, should get this responsibility for, in essence, a stranger.  Who would you want?  Who would you want for your parent (the one you like)?  Who would you want for your child?

Here are some choices:
  • The doctor on duty should do it.  She or he is a pro and knows what’s best.
  • A small committee of experienced care providers should make these decisions.  The group would consist of a doctor, nurse, social worker.
  • A diverse committee should make these decisions.  This group has care providers like a doctor, nurse, and social worker, but would also include a layperson from the community, maybe a religious leader from the community.
  • A group of people with ethics experience who are extra careful not to impose their own biases onto this stranger.
  • It’s important that the people on the case NOT be directly involved in my care.  That way, they won’t push their own departments or pet procedures.  Maybe they will have a little better overall perspective on the risks and benefits of interventions.
  • Regular community doctors should be involved, since they have the most personal connections to patients facing these serious decisions.
  • Specialist physicians should be involved, such as intensive-care specialists or surgeons, since they have the most expert knowledge of the interventions that might be decided upon.
  • Doctors shouldn’t be involved.  Consulted for their expertise, but I’d prefer regular people like me to make decisions for me.
    The hospital should assign somebody, or a small group of people, to look out for me during my whole stay.  That way, this person or group would get to know my case and have a consistent approach.

Here’s how most hospitals handle this, by the way.  They make up a rule.  Sometimes their Ethics Committee makes up a rule, sometimes some other group or executive.  Then everybody follows the rule.  As far as I know (granted, not that far) nobody actually asks potential patients.  That’s you.  DO THE SURVEY!  It’s short. 

For the record, I don’t know the answer to this problem.  This is one of the scenarios, by the way, that seem complex and subtle to my adult-medicine colleagues.  Yet every child is this patient—not able to give consent, not able to designate somebody.  We think of children as part of a package, which includes a family or caretaking adult.  What happens when only the child part of the package shows up?  Please help me figure this out and DO THE SURVEY.

The photo above, from my collection, is by Helen Levitt from 1942.  I think it’s really funny, and is thus appropriate as therapeutic relief for this blog post.

January 26, 2010

The Funny Story: Loose Lips Sink Ships

In my last post, I told about going over to the home of a baby getting treatment for jaundice, just to make sure the phototherapy device was being used right and answer any questions the parents might have.  It’s called a ‘bili blanket’ and gives off an otherworldly glow.

Warmly invited to stay for dinner, an extra place was set for me next to the baby’s grandmother.  She’s 78 and had come a long way to see the new baby.  Each of us told funny stories of our own childhoods.  Sometimes they weren’t really stories from our direct memory, but stories we remember that our parents told about us as babies.  These gradually became part of our personal folklore.  When the stories are outrageous enough or dramatic enough, they enter into our family folklore.

It was told by my parents many times that we were on a family car trip at about the time of my mother’s birthday, when I was 2 or maybe 3.  We were on a car ferry, I don’t remember exactly—maybe it was Maine to Nova Scotia, or something in that general region.  We had a little birthday celebration for my mom.  I don’t remember (nor was it told as part of the story) what her gifts were, just that my dad and my older sister both had things to give her.  No one had included me in this process, and I was giftless.  So after a couple of moments of losing track of me in the ship’s bar/restaurant, I show up with a gift.  Looking very pleased and with a big smile, I hand my mother a lovely black leather purse.  I expected immediate surprise, gratitude, and compliments on my resourcefulness in acquiring such an elegant gift while on a ferry without a store at night somewhere in the Bay of Fundy.  Did I mention I was around 2?  You can imagine what happened instead.  My mother looked aghast and said, Where did you get this?  Show me right now!  And I couldn’t figure out what I did wrong.  Well, the ship wasn’t that big and the open seating in the restaurant area was limited, so it didn’t take long to find a woman looking for her purse.  She was gracious to my parents who were so apologetic to her.  My mother still tells this story as cute and endearing but it makes me cringe.
Here’s what Doris had to tell. 

    “I have a funny story too.”  We all listened.  “I killed my sister.  I was just a baby but I killed her just the same.”  We were still kind of chuckling from the last story.  The baby’s mother turned to her husband and said that he had never told him that his mother had a sister.  He stopped smiling and told her to just listen to the story.  “I was a fraternal twin.  I was just two and a half pounds but she was over five pounds.  Apparently there wasn’t quite enough room in there, inside our mother, and I was stepping on her umbilical cord until I killed her.  She was dead when she was born.  But not me!”  Doris smiled broadly.

“These were the days before ultrasound,” I pointed out.  “How did your mom know this?” 
“I don’t know,” said Doris.  “Maybe the doctor told her.”  She looked around at the suddenly quiet table.  “Oh, it’s a funny story.  Besides, I found out it just couldn’t be true.  When I was old enough to find out for myself, I learned that fraternal twins (you know, the non-identical kind) are born from separate sacs.  So there was no way my foot could have been on her umbilical cord.”
“How did you feel about the story when you learned that?”
“I don’t know.  Maybe it wasn’t that nice of my mother to have been telling this joke all those years.  Sort of at my expense."
“If it were true,” I suggested, “it wouldn’t be that funny.  If it wasn’t true, it wouldn’t be funny either.  Why have you thought it was a funny story all these years later?"
“Because she always said it was a funny story.  She would tell it at parties and say ‘Let me tell you all the funniest story...about how little Doris killed her sister!’  Then she would laugh and so would everyone else.”

What do you think of this story?  Do you remember the first time you brought a date to Thanksgiving dinner at your family’s home?  Why was it necessary for your parent to tell everyone about the time you crashed the car or had a Playboy under your bed or were hauled in by the police for something?  Maybe it was the time you had a bathroom accident at a particularly humiliating moment?

I have several opinions about this phenomenon, which seems to be fairly common.  They are subtle, desperate attempts by parents to re-assert their dominance over the child, who is now an independent teen or adult.  They are just what their own parents did to them.  They are stories that the parent feels are genuinely cute or funny. 

The last point really makes me mad.  Nearly always, as the story gets repeated year after year, holiday after holiday, the child victim has made their opinion of it really clear.  Maybe with crying with embarrassment, maybe storming off away from the table (‘oh don’t be such a baby’), maybe tantrums, maybe one of the times you told your parents that you hate them.  Somehow, they never got any of these messages, and the story becomes family truth.  No one listened to the child.

Dr. Wolffe’s Rule Number 1:  Listen to your child.

When the baby is new, it’s OK at some superficial level to joke with your friends and family about the common experiences of parenthood:  the baby’s gas and various effluvia, the time you fell asleep with her in your arms and she slid with a thud onto the floor.  But I say this is OK only on a superficial level because I worry about the laxity parents allow themselves.  You think you’ll know when the baby is old enough to have feelings hurt by your words?  You think you will know the moment when you are really angry at her but will hold back because she will remember what you are about to say for the rest of her life and use what you say to describe you in one phrase to a room full of strangers?

Dr. Wolffe’s Rule Number 2:  Be kind.

Kindness isn’t always saying yes.  But if you want to get to Doris’s age and still have your children speaking to you, you need to be kind to them now.  Today. 

Doris, from my brief meeting with her, is a terrifically smart, independent woman who emerged apparently quite well from an abusive marriage.  But she didn’t really see that the story wasn’t funny and said so much about her parents.  I’m not worried about her.

These posters are from World War II, during which the phrase Loose Lips Sink Ships was in common parlance.  The idea was that you never knew who could overhear and in what way something could be turned against us.  Parents should have this in mind.  That joke they tell at junior’s expense could cost them the ability to know their own grandchildren.  Is it worth it?

January 22, 2010


As I’ve admitted before, I’m a worrier.  So when I first saw Martha in the delivery room, I thought she would require a little extra vigilance.  She was red.  Not in the ethnic-slur sense, of course.  But from head to toe, she was a lot redder than most babies.  I worried that she had too many extra red blood cells.  This could be a sign of a problem or it could be a sign of difficulties she had during gestation that her prenatal screening didn’t pick up.  And no matter what the cause, these extra red blood cells break down into bilirubin, which causes jaundice.

Jaundice happens to half or more of all newborns.  (This brings up an interesting question about the definition of ‘normal.’  Surely being jaundiced isn’t normal.  But if the majority of babies get jaundice, isn’t your jaundiced baby normal?  Is your non-jaundiced baby abnormal?)  Sure enough, by the time the baby was 3 days old, her bilirubin level had risen high enough to require a little intervention, in the form of a glowing pad that the parents need to keep next to the baby’s skin.  This helps her body dispose of the bilirubin. 
And I’m a worrier.  So I go over to their house on the first evening they were using this device, to check on the baby and to be sure they were using the gizmo correctly.

I came just as they were sitting down to dinner.  This was a little awkward socially, I admit, but my concern was genuine.  They set another place at the table.

The biggest change in the design of hospitals, and of industrial buildings of all kinds, came about from 3 sequential inventions.  First, electric generation and transmission.  This made the second invention, the elevator, possible.  It became a lot easier to build high and transport sick people without using stairs.  And then air conditioning.  Air_conditioners on roof2 These 3 things were in wide use by the 1950’s.  Prior to this, however, and for many centuries, hospitals were built at the top of the local hill.  There were several practical reasons for this.  The sick were kept away from town.  There was generally good through-ventilation, from big windows facing different directions.  This was important because, in the days before the idea that germs caused disease, the breeze would disperse the contagious miasmas that carried sickness.  And the drainage, often infectious, was good.  Though many or most women gave birth at home, a lot of newborns, especially the sick ones, had stays in the maternity ward.  The babies were often put together (we’ve all seen this in old movies--an expectant father looking through a viewing window trying to find his own in a cluster of newborns).  Long before modern medicine, it was noticed that the babies near the aisle were generally more jaundiced than the babies near the windows.  If where you live was developed before 1900, as in New England (or old England for that matter), think about where the old hospital building was or is.  On a hill, right?

The explanation for this had to wait until the 20th century.  Hemoglobin is the molecule in our red blood cells that carries life-sustaining oxygen everywhere we need it.  When the red blood cells that carry the hemoglobin (they are red from the iron in them) are damaged or worn out, the hemoglobin breaks down.  When we get a bruise, it starts as red or black.  This is from the actual blood under the skin.  The blood cells break down quickly, however, so the ‘black and blue’ stage usually only lasts days.  The hemoglobin content of these cells breaks down into bilirubin, a bright yellow pigment.  This can last for many weeks.  Bilirubin is oily and dissolves easily into fatty tissue, such as skin, fat, and brain.  Because it doesn’t mix well with watery liquids (like blood) it’s stuck in the skin.  Sunlight provides just enough extra energy to shake up the bilirubin molecule and make it a little more soluble in blood.  When this happens, some of the bilirubin leaves the skin, gets taken by the blood to the liver where it is processed and disposed of along with the baby’s other creative output.  It’s why baby poop is yellow.  phototherapy1 If the baby needs phototherapy, it’s often safer and more dependable to get the baby under lights that are specifically engineered to be effective and safe.

Since more than half of babies have some jaundice, it’s usually benign.  It usually peaks at about day 3 or so, and gradually declines.  Unless where you live is tropical, it’s hard to get your baby’s skin a lot of sun exposure without letting them get too cold.  And you definitely don’t want a sunburned baby!

There are some good reasons, however, to be vigilant about it.  Many kinds of problems, from innocent to serious, can cause accelerated break-down of those red blood cells.  So the jaundice might be sign that something’s wrong.  And though jaundice is usually benign, and goes away by itself without consequence, it can be very serious at very high levels (a rare event) because it settles in brain tissue.  So jaundice is something I worry about.

Incidentally, as we sat at dinner all the adults told funny stories about our own childhoods and wacky things our parents said to us.  One of those stories will be coming up.

January 19, 2010

Hurting Mommy

I’m a worrier.  I worry about the patients I see and their families.  It comes with the job, I guess.  After all, part or much of a doctor’s job is to see people when they are sick or otherwise out of sorts, and try and make it better.  Make them better.  Maybe fix something that’s broken.  So I suppose it’s natural enough to worry about the things I can’t or don’t know how to fix.

Almost a year ago, I wrote about a toddler who couldn’t stop hitting mommy.  I could frame the situation in a logical way, since a new baby had just joined the family.  I thought that helping the mother see my interpretation of what was going on would relieve her of her feeling of failure as a parent, and it would give us a logical path for intervention.  It did on both counts.  I suggested that she spend extra time with the older sibling, on a rigidly scheduled basis so that the child could come to depend on the attention, rather than feel she had to fight for it.  It was insightful and helpful, and it worked.

I reviewed that post before starting this one.  At the bottom, in a smaller font, I provided a hedge against anybody thinking that I claimed having a magic formula to child behavior that works with everybody.  I’m glad to say that despite being one of the go-to people around here for difficult kids, I’ve only seen a very few who really seemed to like being difficult.

Albert came to the office today with his mother, to say goodbye.  He’s 30-months now, and he’s big for his age.  A year ago, when his mother first brought him, she cried easily.  She asked me how to manage him without hitting him.  I listened carefully to the situation she described.  Having recently moved here from out of state, she was isolated without friends or relatives.  She joined various parent/child groups.  Everyone was very nice, she said, but her little boy was so aggressive with the other children that the other parents didn’t want to get together with her.  She was alone with him all day, every day.  His father worked long hours at the new job, and came home late.  He had grown up in another country, in another culture, and didn’t think there was a problem.  Whenever he played with Albert, the child was always happy and active.  He told his wife explicitly that if there were a problem, it must be her, since Albert was just fine when he was with his dad.  Today, at 2 ½, I’m not really sure how much dad has been with him alone.  I have never met the man.

(OK, there’s obviously more than a child behavior issue here.  One of the many advantages of the conventional method of providing medical services (like at my own doctor:  6 minutes after 50 minutes of waiting; I get to ask maybe one question before the guy is out the door heading for the next patient; nothing is explained; often no exam of any kind takes place; I’m not sure he knows my name) is that the doctor can remain completely unconnected to the patient.  Time, or the lack of it, is a great insulator between people.  I spent hours with this mother and child over the last year.  She did better, she felt better.  I just couldn’t fix the structural issues of her life.  But I worried about her.)

My exam rooms have toys in them.  I have heard about—no, I have also seen—pediatric offices that don’t have toys in the rooms.  While it’s certainly less to keep clean, it seems to send a message.  Albert was getting bored quickly as his mom and I talked.  For just such occasions, I have a small inventory of double-secret toys, which often will engage even a finicky kid’s interest.  As any good magician will tell you, the patter is more important than it appears.  I make a show of reluctantly taking out my special and treasured toys.  Today it was a battery-driven hamster in a plastic ball.  Nicely designed, the ball’s relationship with the driving wheels of the hamster were asymmetric enough to redirect the device if it ran in to an obstacle.  In this way, it would keep going unpredictably until the batteries ran out (yes, I use rechargeables).

Another stroke of Dr. Wolffe magic!  Albert was completely enthralled for...maybe a couple of minutes.
When kids his age get bored, they ask for something, they whine about stuff, they interrupt.  Albert picked up the little gizmo and threw it to the floor as hard as he could.  The plastic sphere, which is designed to come apart in order to turn the hamster on and off, came apart.  I picked up the separated (not broken) sphere to put it back together for him.  Angrily, he tried to pull it out of my hands.  Hold on, I said, I’m trying to put it together.  He looked really mad and then, as hard as he could, hit his mother. 

This was new, even to me.  “Don’t hit your mother!” I said in my most serious voice.  He kept trying to strike her, but she deflected his blows.  He smoothly moved his head to her leg and started to bite her.  “NO!”  I said and physically lifted him to the other side of the small room and placed him on the floor.  He looked at me coldly, nearly expressionless.  He turned to his mother and started crying, sort of.  He needs your comfort, I told her, and she went to pick him up.  He started hitting her again.  “You can’t allow him to hit you.  Or hit anybody,” I said.  We started to talk about hitting.  He went to the little container of stuffed animals and one by one took them out and threw them at his mother’s head.

I need to stop this story, since I know his mom will read it and I don’t want to hurt her feelings.  She’s a smart, warm person who is not incompetent as a parent.  I respect her and like her.  My extensive experience with difficult children reinforces my reluctance to walk a day in her shoes.

Does it tell you something that the child hit mom when he was frustrated with me?  Most kids, even at this age, are socialized enough to keep their most egregious behavior out of the view of strangers.  I don’t believe he could think that hitting his mother was acceptable, and certainly not in front of me.  That he felt completely at ease about it is kind of chilling.  This was not about attention, not about having to share a parent with a new baby sibling.  He had certainly come to take mom for granted, since he knew she was going to be there with him no matter what he did.  But it bothers me that he kept pushing the envelope in this difficult, aggressive direction.  I worry that it’s not a typical instinct.

For his mother, I think there are guidelines that generally apply:
  • Be the grown-up.
  • If you let your child hurt you, you are permitting him to hurt others.
  • Is this what you want your kid to be?  (The nonsense that pop psychology projected onto bullies for decades was that they suffered as much as the victims, and had low self-esteem.  That is and has always been crap.  In fact, the latest research on bullies confirms what I thought when I was in elementary school (and medical school)—they are happy, and have high self-esteem. ) 

At Albert’s age, the key to extinguishing a problem behavior is immediate disengagement and feedback.  Don’t punish him—he won’t remember the transgression and will simply interpret your punishment as arbitrary and mean on your part.  This can lead to an escalating problem.  A dramatic NO! or brief sentence will do.  No hitting! or No kicking!  Then remove the child from the activity.  If they do it again, remove again with the same brief message.  Don’t interact with the child or engage in conversation, don’t lecture the kid.  It’s not supposed to be fun.  But as soon as the tide turns, you need to be there, as ever, with open arms.  Every child can learn to get mom’s attention in a better way.

Ironically enough, I think that part of parenthood is loving our children despite the many little ways they hurt us, whether intentionally or not. 

Albert and his family are moving away, close to his mom’s family.  I really hope that she will get a lot more support and help.  But I’m a worrier, and I will worry about her.  I hope she stays in touch.

January 15, 2010

Monsters: Part 3

The Monster Whisperer

In Monsters:  Part 2, my medical colleague, a very smart adult physician whose office is across the hall from mine, burst in and asked for a urgent medical consultation, assuming I had expertise beyond his own.  He asked me what he can tell his distraught patient to help her get rid of her child's witches.

I didn’t think her child was afraid of the fact that there are witches. She’s not afraid of their power to do things by magic.  She’s not afraid of their malicious motives or the scary way they look or dress or of their scary henchpeople or flying monkeys.  I thought that gentle questioning of the child, while never doubting her belief in witches, would probably reveal that she’s afraid they will come into her room when she’s asleep, and work their bad intentions there.  (I would use this opportunity to point out that it is the child’s concrete thinking that doesn’t usually consider that a witch with magic powers could cast an evil spell from afar, without warning.  In Snow White, why couldn't the evil queen just wave a wand over in her palace, and do her mischief from there?  Despite her apparent powers, she had to get Snow White to take a physical bite of a tangible apple.)  As in Monsters:  Part 1, with the child so afraid of a toilet monster, this child was keenly aware of when she was most corporeally vulnerable.

How can we help?  If we tell them that their belief system is sheer nonsense, we alienate them and make them feel worse.  If we sympathize with them and agree that witches are a constant threat, they might continue to trust us, yet their fear is reinforced and we have confirmed that there is a dangerous broomstick-riding predator somewhere above us just waiting for the right opportunity to strike.  Keep watching the skies!

Our problem is that the child's fear is magical, but we are limited by our physical reality.  Or are we?

  • If her specific fear is of a witch entering her room, she might benefit from a meticulous bedtime ritual of closing and locking her windows at bedtime.  If it’s hot and her window must stay open, how about getting a special witch screen that fits the opening?  The openings in a window screen are very small and no witch could fit through.  Or maybe witches can’t fit through those window safety bars that you are going to install to protect your child. (Maybe you should be doing that anyway.)
  • Consider a special witch treatment or repellent that is not toxic once dry but is especially specific and new to the child.  My favorite for witches and related hazards is witch hazel, a pre-19th-century remedy for many things with a distinctive smell.  Because it is not in widespread use these days, it might not be easy to find.  But it sounds like a logical product.  So an exhaustive hunt for it with the child in tow will have that much more of a chance of effective pest extermination.  As you go from pharmacy to pharmacy, don’t look on the shelf!  Since the child can’t read, it is not helpful when you tell her that you looked and there’s no witch hazel there.  How can the child be confident of that?  Make a point of asking a manager—always with the child right there—if they carry witch hazel and if not, where you might be able to get it.   Maybe it can be used to seal the joints around the windows and doors.

These aren’t tricks.  I will repeat that lying to your child is never, ever a good idea.  Are these lies?  Is my approach dishonest?  Yes, in spirit it is dishonest, because you don’t, in fact, believe in witches or in the monster du jour.  But these anxieties and beliefs are a normal developmental phase.  I often discuss concrete thinking and the ways a parent has to anticipate and deal with a concrete thinker.  I have also discussed in previous posts the gradual development of abstract thinking as a mark of adulthood.  The kind of thinking that gives rise to this kind of childhood anxiety is called magical thinking.

With magical thinking, there does need to be some sort of a link between observations or events, but it doesn’t have to be rational from the point of view of an adult.  Let’s say your child takes a bath every day just about the time that daddy gets home from work.  One night, dad has to work late.  At bedtime, your child snuggles with you and asks to take a bath.  This seems odd to you, but slow iterative questions determine that he believes that if he takes a bath, daddy will come home.

So my empathic approach, as always, directs our technique to take its cue from the child.  This brings up...

5.  Dr. Wolffe’s Thinking Rule:
Concrete thinkers need concrete actions.  Magical thinkers need magical actions. 

There is no intervention for supernatural issues except for supernatural interventions.  If you wanted to help someone suffering from demonic possession, would you call a surgeon?  Of course not.  You’d look for an exorcist.  How do we accomplish this for the supernatural conflicts experienced by young children, when we might not be experts in the field—and probably can’t easily find an expert.  Think about it...who is an expert on toilet monsters or witches? Maybe we all have enough knowledge for the job we need to do.

All of us, by the way, are a soup of all kinds of thinking.  My bank just changed the way ATM deposits are done.  I asked a bank officer about this, and she helpfully showed me how to drop the deposit into the night deposit slot.  I told her I’d rather change banks—it was intolerable for me to drop an envelope of checks or cash into a blind slot without any sort of record or receipt.  It wasn’t that I didn’t trust them, it was just my need for concrete security.  (Ronald Reagan said, "Trust but verify.")  Now that the holidays are over, do you feel comfortable telling your kid all you really know about Santa Claus?  And what do you do when you are cornered by somebody at a social gathering who insists on convincing you that every English word of the Bible is the literal word of God, despite your knowledge of it being compiled by a committee in London at the turn of the 17th century?  I have met plenty of scientists who follow a religion.  Does understanding the universe convince us that there is no God or that there must be a God?  Whichever we believe, no amount of moot-court argument will change a person’s faith in their belief system.

I’m not lying when I tell preschoolers that I can see an elephant in their ears.  It makes them laugh.  Even if I say I see a dinosaur or a crocodile, they still, mostly, laugh.  They aren’t worried about it because they know, within their magical belief system, that the only elephants that could be in their ears would have to be very tiny ones and they wouldn’t hurt.  Maybe they just acknowledge the elephant I see the same way they would play along with one of their younger peers, and are being indulgent with me because I’m obviously not as mature as they are.  That, indeed, is rational insight.

January 12, 2010

Monsters: Part 2

The doctor from the office across the hall from me burst into my office. “Do you have a minute?” he asked when he saw me walking between exam rooms. He’s a very nice, very smart physician who treats adults. When he’s in the office, he wears a long, starched white exam coat.

“I have a very distraught woman in my office. She hasn’t slept in 3 days.” I felt bad for the woman, but the expression on my face must have conveyed my curiosity about how, exactly, he thought I might help. “She’s in the office right now waiting for me.” I suspect I must have looked increasingly unhelpful with this new urgency. “Can you tell me, really quickly, how you get rid of witches?”

One evening in the early 1980's, I was having dinner in New York's Theater District at a lovely restaurant named Barbetta.  Margaret Hamilton, pictured above (not, however, as she appeared that evening in the restaurant), came in with a couple of companions and was seated at the next table.  I wanted to tell her how great I thought she was, but it felt awkward to interrupt her dinner, and I didn't.  It didn't seem like anybody else in the restaurant noticed her.  It isn't well known that she started her working life as a kindergarten teacher, and was known to be particularly good with children.  She once was a guest on Mr. Rogers' Neighborhood, and explained that she wasn't really a witch.  She just played one as an actress. If children were frightened by this character, would her appeal help?

He explained that the woman’s 5-year-old daughter had been unable to sleep for 2 or 3 nights since a play date with a friend. When I asked, he didn’t have a lot of the important details. He didn’t know if they had watched a video intended for an older sibling, or seen a TV show, or just been told a scary story by somebody. My approach, as usual, is from an empathic direction, in which the child guides the response.
In this blog, I don’t usually discuss religion. I think parenting is about universal truths about children and childhood that transcend most cultural and religious variations. Think about religion, in your personal experience. Has anyone ever tried to convert you? Have you ever tried to point out the rational inconsistencies in your own or somebody else’s religion? Generally, this is an unproductive tactic. When someone sees the Virgin Mary in a reflection from the glass of an office building, often a flock of believers come to the miraculous spot. Yet plenty of others either can’t pick out the particular shape or just don’t think it’s a supernatural event. Whatever your religious beliefs, I can suggest certain things that you either believe or you don’t. For these matters of faith, it’s hard to imagine even the most cogent and scientifically-supported argument will dissuade you from your belief. I could be writing, for example, about UFOs. Some people believe that the US government has aliens (unclear if they might be considered legal or illegal aliens) in top-secret storage hidden in Area 51. This is the reason, I suspect, that new religions have such a hard time catching on. You have to convince people that their cherished belief system is wrong, and then convince them that yours is right. How well do you think it would work if you said something along the lines of Your religion is ridiculous. There’s no such thing as a god like the one you believe in? It doesn’t work with adults. Being dismissive of someone’s beliefs is not an effective way to get them to give up those beliefs. We all know this, and it’s why the socially adept among us try not to get into discussions about religious belief at friendly dinner parties.

If this approach wouldn’t work with you, why would you think it would work with a child?

In Monsters: Part 1, I described a child who believed that monsters lived in toilets, and were a serious threat to her safety. Her fear, however bizarre and irrational it appeared to be, was having a material impact on her quality of life. Modern life just doesn’t go as smoothly when you're afraid to use a toilet. Though this was genuinely frightening to her, she started to cry after her mother told her that her monsters did not exist and that she was immature for thinking so. She was hurt that her mother didn’t believe her. She felt bad that her mother didn’t think of her as a big girl. And she felt isolated and abandoned and especially scared now that her mom, basically, told her that as far as the monster threat went, she was on her own. Can you imagine abandoning a preschooler?  Imagine how it feels to her.  That’s why my solution wasn’t attempting to dismiss the potency of her fear. The solution did not require her to give up her belief. Instead, it empowers her to overcome the anxiety-provoking aspects of this fear.

I knew the doctor across the hall didn’t have answers to many of my questions. So I gave him some general guidelines for the distraught mother.

1.  Don’t discount her fear.  This gives her messages you aren’t trying to give.  To her, it appears that either you don’t care about her suffering, or you are unable to help her, or maybe you just aren’t listening.  When you tell your terrified child that there’s no such thing as monsters or witches, you do not silence these demons.  You simply drive them underground*. Often, these children will open up to me about these threats in private, but not in the presence of the unsupportive parent.

2.  Find out concrete things about the problem, and what it is that she is actually afraid of.  This knowledge about the fear is what will give you the tools to help her manage it. Most kids, for example, are not particularly anxious about the existence of ghosts or aliens or monsters of any particular kind.  They accept these as a part of the natural world.

Why is it that kids aren’t afraid of dinosaurs?  When they go to the Natural History museum and see the giant skeletons, it’s clear they understand that these things were really big.  They see the teeth, maybe they ask a guide about it and are told that yes, they could eat a child in one bite.  The gentlest little angels wear pajamas with depictions of Tyrannosaurs in particularly aggressive and threatening poses.  So why no nightmares about this, when they know the script so well?

It’s because dinosaurs aren’t part of their belief system.  Go ahead and ask a 5-year-old.  They won’t tell you about von Baer’s theory about the recapitulation of phylogeny by ontogeny, and they won’t know Lyell from Lamarck, but before they can read they know the word extinct.

* In 1895, H.G. Wells published his story The Time Machine in which creatures called Morlocks lived underground.  There they keep the machinery working that supports the care-free life of the surface-dwellers.  In exchange for providing this labor, the people that live in the sunshine regularly march off to feed themselves to the CHUDS.

January 8, 2010

Monsters: Part 1

IMG_3117-sophia looking down 12-15-09 Jane was brought to the office because she didn't want to go to school.  Her mother said that she liked first grade, and so I was immediately worried. 

Was something bad happening to her at school?  Were her classmates being mean to her or making fun of her?  Was there a bully making her life miserable?  Her mother said she asked all these questions, but Jane denied all of them.  Her mother added that in the last week or so, Jane has had a couple of minor 'accidents' and now brings an extra pair of underpants to school, just in case.

I knew what this was, right away.  It was the mean 5th or 6th graders in the bathroom, hanging out and using bad language.  They could be brutal on the littler kids, so much so that the younger children are afraid to go in.  After a while, the inevitable happens.

But that wasn't the only possibility.  She could have an infection somewhere in her urinary tract.  The irritation of the bladder lining often makes holding capacity limited.  Among the other things, especially among girls, is something occasionally called giggle incontinence.  Do I have to spell out exactly what this is?

I asked mom to let me speak to Jane alone for a moment.  I was sure it was the older kids in the bathroom.  Jane admitted that she didn't use the bathrooms at school.  Gently, I asked if it was because of the other kids in the bathroom.  She said it wasn't.  Of course, I couldn’t be certain this was completely accurate.  So after several other uninformative questions and answers, I asked her again, and rephrased the question.  “Are you afraid of going to the bathroom at school?”  I asked.  She nodded.  “But it’s not because of other people in the bathroom?”  She nodded again.  Gradually, we narrowed it down.  She was afraid of the toilets.  Huh?

All of my presupposed diagnoses were wrong.  Someone creative had invented something entirely new since the time that I had attended elementary school.  The Toilet Monster.

The Toilet Monster would--unpredictably and only occasionally--emerge from the toilet at one of our most vulnerable moments.  Without warning, some accounts say that the unwitting victim is devoured completely and disappears without a trace.  Other versions have the monster lingering to inflict painful bites on our most confusing parts.  Always, it would attack without warning of any kind.  Jane reluctantly recounted the sad but completely true, she swore, tale of a kindergarten student from 2 years ago who went into the toilet stall and nobody ever saw her ever again even her mom and her dad.

She wasn’t sure but it might be in the toilet at home also.  Only after being asked, her mother thoughtfully recalled that now that I mention it, she hasn’t seen Jane use the bathroom at home in 2 days.  She assumed she was going extra at school.  In fact, she was holding it in until it overflowed.

After hearing about this, with me as witness, Jane’s mother told her that it was ridiculous and there were no such things as monsters and nothing can live in a toilet. Stuff in the toilet goes down to the sewer and not back up, ever.  Big girls, she said, don’t believe in monsters.

Jane started to cry.

I make a point of speaking directly to the child as much as possible during doctor visits.  This, I believe, empowers the child and enhances rapport with the doctor.  This situation in the meeting I have described, however, is a notable exception.  Jane was looking at me and sobbing.  I didn’t make eye contact with her, but looked straight at her mother and used the adult authoritative and expert voice I might use when giving a lecture at the University, or when explaining how to use some sort of serious medicine.  “What about Blue?” I asked the mother.

“Blue?  What do you mean?”  The poor woman was completely ignorant about Blue.  She was also in the dark, of course, about the fact I was making this up as I went along.  Her face showed  blank confusion.  Jane stopped crying, looked interested.

Obviously, they needed me to share more of my years of training and considerable expertise.  “Sure,” I continued, “everybody knows what toilet monsters do.  But I’m surprised no one explained what they are afraid of.”  Turning to Jane, “Did they?”  She shook her head.  “Everybody knows that toilet monsters are afraid of the color blue.”  Jane looked incredulous.  Her mother couldn’t see where I was going.  “I’m going to write a prescription and I want you to take it to the drugstore as soon as you leave here and I think that will help with this problem.”  Jane was starting to look relieved just as her mother was looking more confused.

I used a real prescription, which might be a violation of section 409(b) paragraph 11 of DEA regulations.  I wrote:  Toilet bowl insert--the kind that makes the water turn blue--for every toilet at home.   I wrote for 5 refills.  On the line for a second prescription, I wrote for blue food coloring (washable) in a small bottle with an eyedropper.  I explained to the patient that just one drop in a toilet bowl prior to using will repel toilet monsters and prevent their attacks.  blue-toilet-bowl-mumbai-lands-end-306x459It was very strong medicine!  Just one drop is all you need!  Adverse side effects could include blue hands, blue splotches on clothes.

About a week later, I called Jane’s mother.  The incontinence problem appeared to have resolved completely.

Jane, ever helpful, boasted of her newly-acquired knowledge of the species to her classmates.  They were very impressed with her expertise and her mother’s and her doctor’s trust in sending her to school with bottle of strong medicine.  She showed them how she uses the medicine, and shared it with them when they needed it.  Even some of the boys!

January 5, 2010

Looks Like an Attention Problem: Part 2

leventon Like many kids brought to me because of an attention problem, Franklin turned out to be a more complex case.

I found out about his depression.  Not by being so empathic.  I found out because I took the time to ask him.  There were several important reasons for treating his depression first, before the ADHD that had been obvious to him and to me.  Depression pervades every aspect of life.  Until it’s gone, or at least improved, he wasn’t going to have the motivation needed to stay compliant with medication or new organization techniques.  And there was no point in trying to help him improve his school work if his suicidal thinking made school seem unimportant to him.  Through these and other mechanisms, depression itself reduces attention span, interferes with restful sleep, and weakens our most important supportive relationships.  Of course, I was deeply concerned about his safety above all. 

Dr. Wolffe’s Rule #11:  The Parent Unawareness Rule
Just because parents don’t know about it, doesn’t mean it’s not important to the child.

This rule applies to many of the hidden corners of every child’s life.  The bullying at school that will only get worse if a parent is told.  Maybe it’s the teacher who just doesn’t like you and singles you out.  Maybe it’s the coach who makes everyone else laugh at you.  Maybe it’s the popular girl who thinks you’re pathetic for even trying to speak to her.

In Franklin’s case, this is a serious rule.  Just because his parents were unaware of the severity—or maybe even the existence—of his depression, didn’t mean that it wasn’t the dominant issue in this child’s life at the moment.  This was clear when we first talked about it by the relief in his voice and on his face.  Somebody else—me—finally knew.  He was relieved when I told him I wanted to treat him for depression and that the treatment might help.  He was relieved, too, when I told him I wanted to tell his mother.

That was more than 2 months ago.  Since then, his depression has lifted, and he’s getting along better with everyone. 

I started him on a conventional stimulant medication designed for ADHD.  It made him feel sick and feel like his thinking was slowed, somehow.  I reduced the dose, but it still gave him stomach aches.

There are good things and bad things about the enormous number of psychopharmacological choices for a physician to make when treating common problems like ADHD (at least 13 or so different medications) or depression (at least 30).  With so many different available medications, there’s a good chance that one or several of them might work well for a patient without too many side effects.  On the other hand, with so many choices, it sometimes takes a lot of patience and trial-and-error to find the best fit for any particular person.  So if we try a medication for a chronic problem, and it doesn’t work, there’s still a reasonable chance that something else will work.  But if each medication requires at least a week or two or three, going through 20 medications could result in a year of suffering both from the original problem and a series of unwanted side effects.

I changed the medicine Franklin was on, and prescribed the lowest dose that is manufactured.  I prescribed exactly 2 pills.  If they didn’t upset his stomach or cause anything else, I’d write another prescription for 2 pills at the next-higher dose.  Franklin was willing to stick with it because of the dramatic change he saw from the effective treatment of his depression.  With this very cautious approach, we found something that helped his ADHD.  His mother seemed surprised when she told me that he went from all Fs to all As in 2 weeks.  He made up all the delinquent or missing assignments for every course.  This case, clearly, is a success.

But there’s something that I can’t treat, medicate, or fix.  In the previous post about Franklin, I noted that at our first meeting his mother said that his various problems weren’t in the family.  His two younger brothers were academic and athletic stars, she told me, and never caused problems at home.  Franklin heard her tell me this.  I watched him look defeated.  His mother didn’t see it, since she was talking to me.

Though his mother, an obviously very bright and caring person, was relieved and pleased by the improvement in her son’s depression, I’m not sure how much she shared with Franklin that she was happy he felt better.  When they returned to discuss the ADHD treatment, his mom continued to focus on his school failure.  At the most recent visit, it was clear that for her, a key criterion of successful treatment was the improvement in his grades.

It made me a little sad for Franklin that his parents openly compared him unfavorably to his younger siblings.  How did this make him feel about himself?  How did it make him feel about his parents?  How did it make his siblings feel about him?  And how did this make him feel about school?  These feelings probably contributed to his depression.  And it made me a little sad to think that he has been living in a crisis of hopelessness for at least a couple of years and the problem only got the attention it deserved because his grades were low.  Thank goodness he didn’t do anything really desperate.

Regular readers know that I don't think school grades are unimportant.  It's certainly true that those who excel at schoolwork can have certain doors open to them.  And when parents convey the message that school isn't important, children don't think it's important either.  But keep in mind that school performance is a measure of school performance, and doesn't say much about who that child really is.  So please don't let the school's opinion influence your opinion of your child.  The kid will thank you for it.

I don’t think this glass is half empty.  Eight weeks or so ago, I met a suicidal teenager failing all his courses.  Now he’s doing great, feeling great, and he’s back in the embrace of his parents.  Certainly, that’s success in my line of work.

But I still keep in mind Rule #11.

The photograph at top was taken by Alexander Leventon, and is from my collection.  It was probably taken prior to 1921 but it was printed, most likely, in the early 1920s after he had moved to the United States.  He was concertmaster of the Rochester Philharmonic from 1923 to 1944.