March 30, 2010

The Human Rickshaw

As babies get to the second-half of their first year (around 6 months onward), most will no longer need to feed several times during the night. Their stomachs are generally big enough to hold enough to keep them more or less through the night. The stomach of a newborn can only hold an ounce or two, and few foods are as quickly absorbed and digested as breast milk. So even after a good nursing session, the newborn baby is often hungry again in a couple of hours. They awaken hungry and should, of course, be fed all they want.

But these older babies have also experienced the miracle of positive feedback: when they were younger and cried, mommy miraculously fed them and held them close, spoke to them and comforted them. So even though the need for nutrition during the night is decreased or eliminated, the power of those comforting sensations is as great as ever. So The Human Pacify-ee did improve, but he didn’t extinguish his frequent awakenings through the night, every couple of hours or so.

When the Pacifier recently returned to the office with him, I assumed it was for the same problem. I asked her if she had followed some of my suggestions. She said she did some but not others. She thought his frequent awakenings had improved a lot, but she just couldn’t take the last couple of steps. ’It’s not a problem for me,’ she kept on saying.. She had to choose a spot she felt comfortable with, of course. But I would not let her say it doesn’t work if she gives up on it. And though she might be able to tolerate this at this age, how will it be when the child is 3 and she’s back in my office complaining that the child is coming into her bedroom and bed every night and preventing her from getting any sleep.

I told her that it was OK with me, of course, for her to choose what she is and is not comfortable with doing.

walker pulldownBaby walkers were a big hit several years ago. Babies adore them, so parents are enthusiastic too. Gradually, however, Emergency Rooms across the country started to see the injuries they caused, some of them really serious. A walker gives a baby who can’t walk the ability to move themselves wherever they want to go.

But they don’t see obstructions or problems ahead of their path. The really bad injuries tended to be of two types. 1. Stairs. Once the walker rolled over that top step, it would tumble. Once the walker tips over, the baby’s body and legs are protected, and the full impact lands on the most exposed part of the baby: the head. 2. Pulldown. As every puppy knows, there’s a lot of interesting and delicious things on tabletops that they just can't see. The baby who can’t walk now has the walker to get them over to the side of the table or the side of the stove or ironing board. The walker keeps them upright in a position they are not developmentally capable of doing on their own. With both of these new capabilities, they can finally indulge their curiosity to see what happens when they pull on the handle of that brightly-colored pot on the stove they are standing right next to.

Babies are genuine explorers. They want to see the edge of the world, perhaps just around the corner. So, since The Human Pacifier was told in no uncertain terms by me that there would be no walker in their house, she finds herself metamorphosed, like a reluctant chrysalis, into The Human Rickshaw. When I pointed this out to her, she pointed out that this was a particularly luxurious rickshaw: it served only one customer, and had The Human Pacifier on-call at all times to meet the whims of its master.

The Human Rickshaw explained to me that she knew she was summoned by a brief grunting cry and a quick movement of two arms thrust vertically into the air, as if clearing up any ambiguity about a contested goal. If not picked up within the appropriate pickup-time window, the rickshaw passenger lodges a formal complaint to management. When I pointed out this pattern to The Rickshaw, of which she had been wholly unaware, she said she wasn’t worried about it because, ‘It’s not a problem for me.’ Though happy that it was not a problem for her, I probed further into the everyday activities at home. It turns out that this PhD scientist had swapped roles with the subject of the experiment.

In responding to my frequent suggestion that parents be the grown-up, there are several definitions of adulthood. This baby wasn’t paying the rent, buying the food, changing his own diapers. But he was firmly calling the shots with mommy in most important ways--the ways that affected mommy’s life in a problematic way.

This is not naughty behavior! There is no discipline, no punishment, no consequences that should ever be used in a baby this age. Though his behavior is inconvenient, perhaps a pain in the neck, where did he learn it? How did he choose it?

For all children who are no longer newborns, there is only one Holy Grail, only one irresistible drug. That is a parent’s attention. They will experiment with every kind of behavior that comes to mind. Sometimes this includes biting, hitting, pinching, screaming in ways that, if continued, could cripple our domestic glass-making industry. This child was a prodigy at this developmentally-normal task. But he needed an adult as his mother. Someone who could turn away instead of dutifully lowering the arms of the rickshaw yet again, and silently hoping that the baby’s destination would leave her somewhere near the office of the backache clinic.

March 26, 2010

Sean’s ADHD, Part 4: Sticks and Stones

In my many posts about ADHD, and many other kinds of behavior issues as well, I have described cases in which a lot of the things a kid did looked just like the kind of things that a kid with ADHD would do. (It is for this reason, I suspect, that so many kids get diagnosed with ADHD and get prescribed medication.) Sometimes another doctor will send the child to me because they have ‘failed’ treatment with standard ADHD medication. Careful, patient, and thorough investigation often shows me that the child’s attention problem is actually caused by unappreciated anxiety, unseen depression, itchy skin or itchy eyes, a vision or hearing problem, or a bully.

Some aspects of attention are driven from within us. In order to accomplish any task, we have to shut out sensory inputs from the world. There are many medical studies that show fairly conclusively that multitasking is a simple delusion. We don’t really focus on driving and talking on the phone and sipping our coffee all at the same time. We actually do them in sequence, one after another. Because we’re not spending a visible amount of time on one before moving on to another, the sequence is invisible and it gives the illusion of simultaneous action. In every waking moment, we multitask in the same way. We walk and talk, we look where we’re going, we keep our pants from falling down. (When people get impaired in some way, they stumble.)

In Sean’s case, I thought he clearly had some attention and hyperactivity issues. He will have to learn to restrain some of his impulses in certain situations--such as a classroom. He also needs to be respectful of teachers, even if they aren’t the best. But when I asked him about bullies, he denied this problem. Now I realize that I hadn’t considered the possibility that the bully could be his teacher.

His mom asked him if what the other parent wrote in the email was true. He confirmed all of it.

Even without physical violence, this is abuse. Sean didn’t know or understand that a teacher could be wrong, or could do something wrong. So when Mr. Dickson called him a ‘rotten child,’ he didn’t take it as an insult. He understood it to be a professional assessment, like a B+ grade, or advice that he needed to practice his arithmetic. Since he now understood himself to be a rotten child, he realized that this new identity afforded him a freedom from behavior boundaries that he had not had before.

The rhyme about sticks and stones is simply a lie. It is irresponsible to teach it to your child as a defense. It is curious to me that parents will teach this to their children as if they believed it to be true. Given, part of being an adult is knowing when not to respond to hostility or an insult, when to simply keep your feelings to yourself, when to appear noncommittal when you really do have strong feelings. Most people, maybe everyone, has lost friends, relationships, jobs and many other important things because of words. Believe as we do in freedom of speech, there is no freedom from feeling hurt by speech. If your son struggles in school, and a sibling called him stupid, what would you do? Would you teach him about sticks and stones? Is that doing your job? I’ll come back to this.

When a teacher, and especially a parent, gives a negative assessment of the way a child is, a scar is made.

There are 2 important points here. If your kid messes up, you don’t have to go through some self-effacing nonsense--just tell them how it is. It’s OK to tell them they are wrong, that they must never play with daddy’s drafting equipment, that they are not allowed into the street without holding a grown-up’s hand. You must never tell them that they are stupid, unattractive, incompetent, or that they speak funny. Never tell them that they are rotten kids—save this one for your toast at their weddings. Never even hint that you wish they weren’t born, or wish they were more like one of their siblings or cousins.

In a work environment, there’s a big difference between hearing an assessment that you need to improve the way you organize the files and hearing that you are disorganized. One is a skill you need to improve, and can try to improve. The other is a label that is permanently attached to you.

The second point is how you deal with the bullies in your child’s life.

In the movies, the caring father teaches the child boxing or martial arts, so that when threatened, the on-screen David can beat up a schoolyard Goliath, humiliating him or her and inducing a catharsis in the ticket-buyer powerful enough to provoke tears. While I have often admired the positive impact on a child when they study martial arts, for example, real life never, ever has worked like this even once. If there’s a child threatening your kid, physically or emotionally, are you going to sign the kid up for lessons? How many years will that take? And then when the bully gets the desired reaction, and your kid finally explodes with the righteous justice of any number of action movies, who will be suspended from school? What will the lesson be about fairness and right and wrong? When the bully is an authority figure, who does the child have who could compete with that? Who is more powerful than a teacher or a school principal who tells your kid that he is some kind of delinquent? Only you can fill this role.

It could indeed make the child’s school life more uncomfortable if you intervene on your child’s behalf. But that child will be with you long after this school term is a bad memory. Step up to the plate on the child’s side, and they will remember it for decades. If you don’t, they will remember just as long. Don’t measure your success by whether the child gets a new teacher, or is being sent to the principal’s office. Your success is in your relationship with your children, who have acquired the secure knowledge that you’re always there for them, you’re always going to stand by them against the bullies of the world.

March 23, 2010

Sean’s ADHD? Part 3: Dark Times in 1st Grade

one room schoolhouse classroom
Sean is a 1st-grader who is bright and active and distractible. He’s also funny and talkative. Consistently finishing his classroom work before the rest of the class, he has been viewed as a behavior problem by his teacher. Even in my office, he is more fidgety than most kids his age. But I couldn’t get around the fact that for the first half of the term, he had a different teacher, with whom he never got in trouble. He didn’t sit quietly, exactly. The previous teacher gave him stuff to do to keep him occupied instead of bored. So even though I thought he might indeed have ADHD, I wasn’t ready to medicate him before figuring out why this became a problem as soon as the new teacher, Mr. Dickson, took over.

I re-evaluated Sean and he was just as before: fidgety, happy, talkative. But he never left the chair during a long discussion, and to each of my questions he responded with a full and articulate answer. As promised in Sean’s ADHD Part 2, I wrote a letter to the teacher. Here’s what I wrote:

Dear Mr. Dickson:

Sean’s parents asked me to evaluate their son, and to write you about some of my assessment. He’s a great kid and I enjoyed the time I spent with him.

As you know, Sean has been struggling somewhat in school. His distractibility, talking out of turn, and occasional disrespect have been issues for him. 

There’s no question that he’s an active child, with some of the motor traits of hyperactivity. He is also a bright child, who clearly understands and retains a lot of the academic material presented to him. It’s important to note that he is not uninterested in school work, and is curious and motivated to learn new things.

He has been disrespectful and sometimes even disobedient. Even so, he absolutely does not meet any of the diagnostic criteria for any disorder characterized by oppositionality, defiance, or conduct problems.

Though his hyperkineticism is longstanding, this has not caused problems for him until a recent change in his classroom situation. Thus even though he might be hyperactive when compared to most children his age, this hyperactivity does not mean that he has ADHD requiring medical treatment. In cases such as his, a behavioral approach will often result in the best outcome.

Sean has said that he is sometimes bored in class. He should be taken at his word. He is not very responsive to negative consequences, so these are of marginal value and might serve to frustrate him. A more effective approach would be to channel his energy in productive ways. If he’s done with his class work, for example, he should be able to access a ‘Bored Bag’ containing 4-5 quiet activities that he can do alone. It would be helpful if he chooses these activities from many choices given to him. 

From what Sean has told me, these might include:
  • Some extra or more advanced math problems;
  • Headphones and a recorded book;
  • Coloring;
  • Books.
It is essential that he be able to access these materials without permission, so he doesn’t interrupt you or the class. Ideally, he would also have the freedom to get out of his seat and walk quietly over to another spot, where he could work on some other task. I think he will be relieved to have this freedom.
These recommendations do not imply that he should be allowed to be disrespectful of teachers or disruptive to the class. Before starting this with him, you and his parents should meet with Sean and come up with a set of written rules. They don’t need to be extensive, but they need to be written. They should be simple and specific. For example, ‘you must not have a bad attitude’ is vague and difficult for a child his age to understand. ‘No talking during class,’ is something more likely to be understood. Taking away, as punishment, access to this Bored Bag or to recess—during which he gets to redirect some of that excess motor energy—would be particularly counterproductive. Those are the things that will keep him focused and motivated in the classroom. Try to enlist his help. If he’s fidgety and wanting to get out of his chair, there is no enforcement mechanism that will stop this. He doesn’t do it by choice and it not easy for him to control. Making a rule about him sitting still is setting him up to fail. If this is an issue, ask him to get up and do something helpful, then praise him for it. In this way, he will feel appreciated and not trapped.

There are certain things that ADHD medication can and cannot do. It can help some children sustain their attention, but it won’t do this if they have finished their work and are required to sit still with nothing to do. Indeed, none of us can do that.

Sean is a warm and kind child with a good sense of humor. He needs our help to plan what to do when he’s ‘bored’ and he needs the tools to work with that plan.

Please feel free to call me with your questions.

Only a day or two after mailing the letter, I received a forwarded email from Sean’s mother. She was active in the school, and received this note from a parent of one of Sean’s classmates.

Hello everyone,
I am sending this message because my son has reported to me some very disturbing comments that have been made to some of our children in the classroom.  I have not had an opportunity to speak with Mr. Dickson directly nor have I had the chance to inform the principal of this report because I was just made aware of this tonight. However, if these statements were directed to my child I would be very concerned! 

My son has reported to me that he (Mr. Dickson) told one child (Alice) that kids who talk too much in another country have their "tongues cut out". He said he told the child this because she was talking.    He also reported to me that he told one of the girls to sit her "fat butt" on the chair today when she was attempting to pick up her papers and color pencils off the ground.  He also told me that he often refers to two other boys (directly) as "rotten children" (Sean and Michael).  I am totally shocked that this man would speak to our kids like this!

I do not believe that this is a constructive way to reprimand children but it is a sure way to make them develop low self-esteem.

I am certainly not sending my child to school to be verbally abused by an adult.  I will be at the school bright and early Monday to speak with the principal about this.  The last thing we need is someone belittling our children.  Please speak with your children to confirm this. 

It is our responsibility to make sure that our children receive a good education in an environment that is conducive for them.

Suddenly, the pieces of this story started to fit together really well. More in the next post.

March 19, 2010

So it is written, so it shall be done.


Can you read this?  Even if you can't, do you know--more or less--what it says?  Do you know what it is that the guy in the picture is holding? Have you ever wondered why an omnipotent god needed to write them down like 10 crib notes for a marginally dishonest weak student on the sweaty palms of his disobedient chosen people?

declaration_of_independenceThe item pictured is the Declaration of Independence, which formed the United States in 1776. The history of the United States as a country certainly begins with independence from its colonial power. I don’t think most people would argue that independence is important for a sovereign state. Philadelphia is about 3500 miles (5700 km) from London. Surely most people in the colonies (at least those affected by this document) could go about their business without interference from London and frequently did. So why did they need to write it down?  I suspect that there was already some independence.  The real power of the document is in the word Declaration.

Even today, most governments don’t appreciate it when their citizens decide they no longer want to cooperate with the existing management structure. There would be consequences. So why would they sign their names? Even in the pre-internet era, avatars were often used. Voltaire, for example. Lewis Carroll was another. As it turns out, there were indeed serious consequences. Several of the signers of the declaration were sought by the British, treated harshly, then killed or otherwise punished. So why didn’t Benjamin Franklin use a name like Silence Dogood, Anthony Afterwit, or Richard Saunders (the poor Richard of Poor Richard’s Almanack)?

The document says that ‘We hold these truths to be self-evident....’ If they are truths, why did they need to write them down? If they are self-evident, why waste the effort writing down the obvious?
A group of well-educated wealthy guys getting together at the pub and agreeing that ‘there ought to be a law’ is not the same as writing it down. And then signing it.

tara cropped
This is a picture of one of the most precious things I own. A girl named Tara spent at least 20 minutes meticulously writing it for me. I asked her what it meant, and she said, ‘I love you.’ (I loved her, too.)

Tara, the Continental must be obvious where I’m going with this, right?

Why did Ben Franklin and Thomas Jefferson and Button Gwinnett for that matter feel that they had to make a written list of self-evident truths? Maybe because they weren’t so clearly evident to everybody. Maybe to eliminate ambiguity about what exactly those truths were. Maybe to make it really clear how they look at things and what they perceive as self-evident. Maybe because they already knew that not everyone agreed with the truths and evident-ness of the list they made.

How do you teach manners? Do you explain why some things are regarded as impolite at the dinner table or do you say, ‘Don’t put your elbows on the table!’ One is education, the other is a command. What do you want your children to be, automata following your whims and instructions or polite young people? Do you want to be proud of them for their manners or for the unhesitant way they follow your orders? Think hard about the answer. Either way, they won’t put their elbows on the table. Either way, you will beam with accomplishment when company is over and they all say what polite children you have and what a wonderful job you did raising them.

It’s reasonably easy to raise the obedient child. There’s lots of punishment involved, lots of arbitrary instructions that reinforce your dominance both physically and emotionally. Feel free to find a website that helps with this.

Most of my readers and pretty much all of my patients don’t identify with this kind of parenting. The difference between this drill-sergeant parent and an empathic parent sometimes, simply enough, is writing it down.

Even Tara, a sweet foster child with several kinds of developmental delays and just 3 years old, understood how much it meant to write it down. She understood that long after that visit was over, that day was over, I could have this paper and touch it and hear her voice and remember her. It couldn’t be changed. King George III, whatever his issues, was experienced at politics. He had plenty of opponents, foreign and domestic. But once it was on paper, there was no going back. He had to understand that the undersigned did indeed risk their property, their fortunes, and their lives.

What are you willing to write down? What are you willing to punish your child for? Let me put it another way. Are you willing to punish your child for something you aren’t willing to write down? Is it ever OK to put elbows on a table? Or is it just when the Bishop is over for dinner?

This post is yet another comment on discipline, and I don’t want to make it difficult to apply. Here’s one rule that's pretty easy for me: No Hitting. This is an easy one, because it’s unambiguous, applies pretty much all the time and everywhere and with everyone, and is a specific action that the child can correct or control. Thus, it does not violate Dr. Wolffe’s Rule #16, the Action Rule.  Write the rule down on your list of house rules. If your child hits somebody, there should be a warning and if it continues, a consequence. It’s not negotiable, ever. It’s a rule.

This is just how concrete thinkers understand rules, and we should take advantage of it. We squander this opportunity by saying to the hitting child again and again, ‘Stop doing that, please’ or ‘if you keep hitting there will be no TV on Sunday.’ When the unmentioned consequence comes, the child doesn’t remember the infraction, so nothing is learned except how arbitrarily mean the parent can be. You perceive this feeling, and since you don’t want your kid to think of you that way, you let the child negotiate down to a promise they won’t do it again. But this, too, is inconsistent with concrete thinking and isn’t worth the paper it’s not written on.

Ideally, you and your child should sit down with all household members and come up with a reasonably short list of rules. 30 is way too many, and 3 is not enough (because they probably aren’t specific enough). Rules like ‘Be Good’ or ‘Don’t have a Bad Attitude at the Dinner Table’ are foolish and violate Dr. Wolffe’s Rule #15, the Definition Rule. Keep it simple and enjoy the results. No Hitting. No Biting. No Swiping other people’s stuff. And then—this is the tricky part—write them down. Make a copy. Keep the copy, tape the other copy to a wall where everyone can see it.

Dr. Wolffe’s Rule #17:  The Writing Rule.  Write it down.  Children are not surprised by consequences for violating written rules.  Even if they can’t read, the writing process helps them to know what’s expected.  The fact that it’s posted on the wall tells them that you will stick to these rules, too.  And they apply equally to all the siblings, and are not enforced as you see fit.

And remember Dr. Wolffe’s Rule #2, which violates everything said above. Be Kind.

March 16, 2010

Cultural Sensitivity

linkage tree-2

A delightful couple, pregnant with their first child, came to the office to interview me, to help them decide if I was the right pediatrician for their baby. We had a lovely chat and I felt that I was doing well. At the very end, they asked a question. “Do you have many Asian patients? Do you find you have to ask questions a different way with them or that you have to take a different approach?“ I took these questions as an inquiry about my level of cultural sensitivity. I had a long answer. For the record, though, these people looked by their facial features to be of Asian ancestry; the last name appeared to be of Japanese origin.

“It’s the Bay Area, “ I replied. “What are the odds?“ They agreed it was pretty likely that I had some Asian patients. This was the beginning of my reply.

I told them I took care of a group of about 8 or 10 families from Mongolia. They all live near each other because only a couple of them speak any English at all, and the language barrier is substantial. Taking care of them has sometimes been a challenge. there are no patient-education materials available in Mongolian. AT&T has available translators via telephone in dozens and dozens of languages, but Mongolian is not among them. I called UNICEF at the United Nations in New York. They did send people to Mongolia, but they had no patient information. Same story when I contacted the World Health Organization in Geneva, Switzerland. At one point I had a polite exchange of emails with the Minister of Health in Ulan Bator, Mongolia. He or the person composing the emails under his direction and signing his name, had good English-Language skills. His office had no written materials on child health in Mongolian. These families are Asian. Am I culturally sensitive with them? Probably not. Since communication is so difficult, we need every extemporaneous sign language technique we can come up with just to convey information.  So cultural sensitivity is not helped by a language barrier. I take care of these Asian patients, but do I take care of them differently? Yes, I suppose so, but it’s not because of a cultural divide.

I’m reminded of a classmate in medical school. When he was 14, his parents and he joined many others on a small boat headed blindly from Vietnam out into the South China Sea. Obviously they made it, and he’s now a fine surgeon. What should I know to deal with his family in a Vietnamese-friendly way? Are Koreans different?  What about Malaysians of Chinese descent?

When I was in business, there were no courses that were required, but everyone knew that Japanese investors and businessmen expected certain salesmanship behaviors when they were entertained in New York. In Japan, a completely different set of rules applied. It wasn’t called cultural awareness, it was called good business. In Hong Kong, it was often thought best not to mention that you’d just had a successful series of meetings in Tokyo.

So what was this nice couple asking me? If I had other patients who, by their visible bodily characteristics, appeared to be of Asian descent? Nearly half the human race is of Asian descent. Were they asking if I treated my patients of Japanese descent as if they were Japanese? I don’t know. How many generations of their family have been born in the United States?

I take care of a nice family, for example, with a hyphenated last name. They are all American citizens. They say that they are Brazilian. When their kids were born, I encouraged the parents to speak only Portuguese to them at home. The mother’s ancestors were from Portugal. She looks like a European might. The father’s ancestors were Chinese. He looks Asian. The kids are…adorable. Is this an Asian family? I don’t think even the father’s parents speak much Chinese, back in Brazil. How Asian to you have to be to qualify for a checkbox of ethnic identity? How Asian to you have to look?

No institution with which I have been associated over the last 20 years or so has failed to offer--actually require, I think--a course of some sort in cultural sensitivity. As demanded, I have wasted valuable hours in these courses. In one, the head of a fabulous Spanish-language health clinic gave a presentation on cultural awareness doctors should have to the Latino community. Assuming that language wasn’t a barrier, what could I do with that? Ask a proud Ecuadorian if they identify more with Mexicans than with Americans? Ask someone from Spain if they relate better to a Dominican than a Californian? Will I learn about the distinctions of all those who speak Spanish in a short course or lecture on cultural sensitivity?

I have a family from Yemen. Devout Muslims, they appreciate that I never extend my hand to the mother. I try to be respectful and to the point. I don’t even close the exam-room door when I see their kids and the father isn’t with them.

I think that doctors--people in general--look fake when they try to be someone they’re not. I also think that doctors can be particularly culturally insensitive. But I think it’s cynical political correctness to require learning cultural sensitivity. What they really need to learn is just sensitivity.

If physicians are going to be culturally sensitive, they must first spend enough time with the patient to listen. Maybe they can take a course on reading body language and eye contact, tone of voice or listening skills. Maybe they can learn to interrupt just a little bit less. This would go a really long way towards sensitivity to what a patient really needs. I don't think it's helpful to put on an air of paternalistic cosmopolitanism—like an anachronistic white man's burden—that says to patients that overeducated well-to-do Americans can feel inappropriately self-confident about learning in an hour what patients have taken a lifetime to master.

It's nice if you and your auto mechanic grew up in the same neighborhood. But it's a lot nicer if you find a mechanic who treats you well, listens to your complaint, and actually fixes your car. Which one would you choose?  The one that shares your background/language/heritage or the one who listens to you, does a great job, and doesn't rip you off?

Medical management (and this applies equally to corporate management) shows astounding hubris to impose an unsupported belief that patients will perceive as a better experience a visit with a doctor who has memorized a few facts about your grandparents' country of origin. Whether the patient is from Mongolia or Malaysia, Brazil or Burundi, I don't pretend to be something I'm not. If doctors could spend more time, could simply have more empathy, listen to their patients and think about what it's like to live a day in their shoes, cultural sensitivity would just be sensitivity.

The photograph from my collection is by Keith Carter and is titled, "George Washington."

March 12, 2010

Bad Attitude

bad attitude label2 
I don’t remember the first time I was told I had a bad attitude. I asked around, and it turns out that everyone I asked had been told at some point in their lives that they, too, had a bad attitude. This suggests an epidemiological question. Is a bad attitude like a common childhood disease, which everybody has had at some point in their lives, or is this a case of ‘selection bias’ in which I happen to choose to be surrounded by those who either have or have had a bad attitude? I guess if there were some sort of test for it, perhaps there might be an answer to that question. I don’t think I was ever fired from a job for having a bad attitude, but certainly being told this in a declarative way, as if it were a clinical observation made with the wisdom of specialized training and experience, didn’t help me feel closer to my manager or employer. Now self-employed (I guess that answers the question if I ended up staying in that job those jobs.) 

What is a bad attitude? I suspect it is often an expression used as a surrogate for questioning the authority of somebody who thinks that they have authority over you. Does it mean that you are subversive, fomenting revolution? Does it mean that you simply don’t follow directions? I think I have an idea.

Many of the children that I see note that they have been disciplined, kicked out of school, put into detention, or brought to me with the intention of a parent that they be medicated in some way, because of their bad attitude.

I searched Yahoo for “bad attitude.” It returned 7,360,000 results. I liked that it came up with dozens and dozens of t-shirts. Some said simply, ‘bad attitude.’ Apparently, this self-identification is meant for those who would like others to use this trait as a means of identifying them. As in my epidemiological problem stated above, it’s unclear if they mean for others to simply stay away or if they would like to help like-minded folks seek them out. One said that ‘A bad attitude was a terrible thing to waste.’ This implies that it is valuable. ‘A little bad attitude makes for a lot of great hockey.’ Not much of a sports fan, I found this deeply insightful. There were also a lot of posters and coffee mugs. I can’t help but draw some inferences by the preponderance of cats pictured on so many product offerings with a ‘bad attitude’ caption. I have always associated indifference with cats, but essentially they are, after all, predators.

In April of 2009, I published an essay about a disease called pinkeye. I have a 2000-page pediatric textbook in which the index at the back is several hundred pages long. Pinkeye does not appear in the index or in the book. Though accepted as common knowledge, pinkeye is not a disease as understood by medical science. It is a symptom, literally a pink eye, which has attached to it whatever definition a school official feels certain about. It isn’t treatable by me without the crucial diagnostic information to establish a medical cause of this single symptom.

It is a deep truth that no one in the history of attitude ever believes that their own attitude is bad and somehow in need of adjustment. The person making the claim that someone has a bad attitude is assigning a label. Do you like being labeled? We all like the good ones, but the bad ones don’t come off. So permanent are these labels that people remember them their whole lives. I bet you can think of adults you know who have said that they were told they had a great talent...when they were 6.

On my very first day of residency, I was scheduled to attend a welcome meeting in the Pediatric Conference Room. No room number was given, just the time. I was nervous and arrived an hour early. I asked the person at the entrance desk to the hospital where this conference room was. I sat in the empty room and waited. No one ever showed up, so I eventually called the residency office and they told me it was in the other building, where there was a different room with the same name. I ran over there, and arrived sweating and breathless. Without missing a beat, the leader of this meeting said, “You’re expected to show up on time. Lateness is irresponsible and won’t be tolerated.” Luckily, I had the real-life experience to keep my mouth shut and just sit down. (Did he have a bad attitude? Oh my yes. There’s something about doctors with Porsches that says so much.)

What I’m getting at is the label that we can’t wash off. How many hundreds of times can I be early before he decides that I don’t have a problem with lateness? In 3 years I was late to that one meeting. Three years of being early to everything was not enough.

How many times can a bullied child do anything to remove the names that he has been called? Several times a year I have to recommend to a parent to take their child out of school and send the child elsewhere. It’s the only way to wash that child of the names that hurt them so deeply. What happens when the names are assigned by a teacher? That doesn’t go away by switching classes. Sometimes not even switching schools. I have had children go to private school, boarding school, or home school because a single teacher at a single school decided that the child had a bad attitude. They told the other teachers, they told the principal.
If you hear that your child has a bad attitude, the person saying it is a bully. If you are saying it, say it really slowly. Your child with not ever forget any syllable of that label. Go ahead, seal the deal. Call them lazy, ugly, ditzy.

How about stupid?

You didn’t see that dark turn coming? Rather than looking back in amusement, think hard about how you felt when you were told you had a bad attitude. Angry. Maybe defiant, distrustful, vengeful. Or maybe you were depressed, hopeless. Labeling somebody is mean work. When it is done to a child, it is bullying.

When a parent does it to a child, there is no more self-fulfilling an act. The child feels bad that you don’t like something about them. They don’t know what, exactly, because you haven’t told them. You don’t like something they can’t change. How would you—how did you—react? You would be angry, defiant, vengeful, depressed and hopeless. Would this statement of definition about who your parent thought you were make you somehow change for the better? Would you suddenly become optimistic, cooperative, trying twice as hard?

I do indeed see children who are oppositional, defiant, antisocial, and constant conduct problems. They don’t have bad attitudes. They do bad things.

There are 2 distinct lessons here, and these will come up again and again as I discuss discipline in detail.
First, being disciplined for being the way you are is just the same as discrimination. If your child is disorganized and forgetful, for example, no amount of any kind of discipline is going to help. I wrote a series about Claire, who was always called ‘ditzy’ or ‘spacey.’ She believed it about herself. Once her anxiety was diagnosed and treated, she wasn’t that way anymore. Only time will tell if she will overcome the label. Negative labels of any kind are mean. Don’t use them ever, or the throw-away line you said once that your child perceives as your true feelings will crush you when they move—or run—away.

Dr. Wolffe’s Rule 15: The Action Rule. Only discipline a child for actions they are able to correct. Would you discipline your child for having trouble reading or speaking? What if they couldn’t walk? You will lose them just as surely if you discipline them for not liking olives or Aunt Harriet’s meatloaf.

Second, disciplining a child for something you cannot specifically define is abuse. The child perceives it as abuse. Let me be more specific. Picture a parent, just home from an unpleasant day. Tired, angry at the boss who said they had a bad attitude, that parent says something mean to the innocent child at home, maybe to the spouse, too. (Substitute ‘does something’ for ‘says something’ if you need to.) The expression of negative feelings in ways that hurt others is simply abusive. The abused see this as arbitrary and unpredictable. As a result, there’s no good way to protect against it. That leads to very bad and long-lasting feelings.

Dr. Wolffe’s Rule 16: The Definition Rule. Never discipline a child for something you cannot define explicitly. Never for an attitude, a way of walking, a tone of voice. Never for being angry with you. If you want your kid to control her emotions, show her how you control yours.

I saw one of those nanny shows on TV in which the parents were encouraged to give a child a ‘time-out’ because of a bad attitude. I nearly threw up. How can the child fix that? How can the child know what they did wrong? The kid will remember the punishment, but how can he wash the label off?

Here’s what actually happened on video: the parent asked the child to help, the child said, ‘No!’, then the parent asked again, nicely, and the child said something along the lines of ‘I’m not going to and you can’t make me!’ The child received a warning, ‘Because you have a bad attitude.’ Then, time-out. I don’t have a problem with the consequence, and I don’t think that was an appropriate way for a kindergartener to speak to his mom. But the consequence must be attached unambiguously with a specific correctable action in order for the child to learn from it. In this case, all the child learned was that punishment comes when mom is angry. That’s pretty darn close to abuse.

Remember Dr. Wolffe’s Rule #2: Be Kind.

March 9, 2010

Dancing and Friendship

carter waltz 

George’s father brought him to me because he was worried. He remembered middle school, and the close friends he made and kept through most of high school. Though both he and his friends moved on and in different directions, he knew how essential they were as catalysts for him to become independent of his parents.

George, 13, didn’t have a best friend. He didn’t have a group of friends that his father knew about. He was smart, courteous, respectful of people and things. He usually had a book with him. His father was also concerned that George might inevitably become known as a nerd.

I admit that I have not seen genetic research investigating whether nerdiness can be inherited. I predict that at some point, there will be a nature vs. nurture debate about it among academic intelligentsia. Among nerds. The issue of nerdism is not the topic of this post, but I would politely point out that George’s father just happened to be the only computer engineer in his working class family.

George’s father was also concerned that his child might have an autistic-spectrum disorder, and wanted a professional opinion.

When I spoke to George, I asked questions I usually ask of teenagers. I asked about depression, suicidality, substance use. There were no surprises in the answers to my usual screening questions. He was a happy, thoughtful kid without any worrisome activities. He agreed that he really didn’t have any friends. The claimed this didn’t bother him. He didn’t say that people didn’t like him, he didn’t complain about having no one to play with. He said he was content the way things were.

How do you get your 2-year old to taste new foods, when she doesn’t want anything that isn’t the right shade of white even on her plate? As far as she is concerned, there isn’t a problem growing to retirement age on milk, macaroni and cheese (made one very specific way only), plain white rice, and cookies. Some years ago, I read a research study that asked how many times you have to put a new food in front of a 2-year-old before she will spontaneously try it. On average, 30. That’s just an average, of course. Some were more adventurous and some took a lot longer than 30 times. One single, lonely, french-cut string bean every night. Seven nights a week for a month. And then she takes a reluctant nibble. And then she says she doesn’t like it.

Be the parent. You know what your child does not know. Maybe George is satisfied with his friendships as they are. Maybe he’s not depressed about it, lonely, isolated. Maybe he’s not suffering from a personality disorder or autistic-spectrum disorder. Maybe he just doesn’t know how helpful and rewarding a good friendship can be. He doesn’t know that it can be crucial to have somebody who completely agrees that the history teacher mumbles and that parents can be unbearably unreasonable. He doesn’t know that eventually his classmates will notice that he carries a book around.

Social skills are an old-fashioned dance. A few of our children need no coaching. They will ask somebody to dance and get out there in front of everyone making a perfect fool of themselves. The rest of us look on critically about the way they look or move, and secretly envious that they are willing to do it. We feel helpless and alone. We want this skill, but feel humiliated to admit we lack it. We don’t even know where to go to learn it. We do not believe it can be learned, and feel like it is a deep personality flaw. Because we believe it can’t be learned, any attempt appears to us as doomed to failure. So we don’t try. We hang out with a group of our pals and make fun of the kids actually having fun.

You now know that this isn’t a flawless oracle predicting our futures. After all, somewhere along the way you became a parent. Professionally speaking, that usually requires help. (Though we have the technology….)

I told George’s dad that I thought he was on a spectrum, but it wasn’t the Autistic Spectrum. Some people, especially starting around middle school, are particularly self-conscious about the possibility of social failure and rejection. We might not be able to teach them to love to dance. We can, however, teach them some dance steps. We can also be there to catch them when they fall.

I made some specific suggestions. If George wasn’t into sports—he wasn’t—he should sign up for an after-school program. He should be given a list of choices. In this local area, there are many choices that aren’t too costly. In his case, there were library programs and science and computer classes. There were also programs in which students like George can tutor other students in certain subjects. This can be really helpful for good students who get their homework done before they get home, and spend the rest of the day and evening playing video games or on the computer. In some schools, there’s still a chess club or a debate team. I suggested finding a program requiring some cooperative activity, where participants have to work together to make something or learn something. The group is the way to find others of about the same age with a common interest.

The next suggestion was to host one or several group gatherings. Don’t miss this opportunity to show those kids where George lives, the stuff he has in his room, the video games he plays. Remember, they are all nervously making fun of the popular kids on the dance floor. They don’t have enough perspective to realize that none of them know how to dance. Be the parent. As everyone shows up, keep a little log book of names, addresses and phone numbers—George won’t think of this. Don’t supervise, disappear into the background. But only after the pizza arrives.

The photograph is from my collection and is by Keith Carter.  It's called Waltz.

March 5, 2010



I received the following message from the faceless internet: Are you the wolf nadoolman who went to p.s. 189 in manhattan?.I know you can't possibly remember me. My name is sonja and I sat behind you in mrs. Lowe's class. [First grade.] We were taking a test and you didn't have a no. 2 pencil. I had an extra one and you asked me what I wanted for it. I was fascinated with the word encyclopedia so the next day you brought me in volume 1 of your encyclopedia! I had it for years and have often told people this story!  Of course I remembered her.

My father, by all accounts, was naughty. He grew up in a relatively rural area, and his family didn’t have much. Among the stories he told--or, rather, confessed to--was the one in which he led and coaxed a nearby goat away from the neighbor’s field and into the school building, up the stairs, and onto the roof of the school. It turns out that goats are not that easy to move once their acrophobia makes them so terrified that they resist moving altogether. His mother, as he put it, let him have it. There were about 15 or so people in his high school graduating class.

He was a good student and a smart man. But he never talked about his grades or the tests he aced or failed (I have no idea which). He never spoke about the book report he didn’t hand in on time, never told stories about the textbook he had to skim because he didn’t get the reading done before the test.

He spoke about the goat. And the windows he broke: some accidentally, some not so accidentally.

These are the stories he told, and the ones he and his schoolmates laughed about at their 30th, 40th, and yes 50th reunions. Oh, did I mention there was a 60th reunion? By then, of course, some classmates had passed away. For his entire life, he continued to socialize with these friends and his friends from his military service.
What do you remember from elementary school? OK, maybe it wasn’t an entirely rosy picture. There was the bully, the humiliating bathroom accident in kindergarten, the time the teacher made you read aloud in class and you weren’t good at reading aloud. I will grant that you might still remember those events, which left some scars. But you probably don’t remember the map of the united States that took so much work, the pages and pages of vocabulary words and arithmetic problems. The paragraph you had to write about George Washington.

What about middle school? Do you remember the homework assignments, the final exams, the problem you got only partial credit for though you deserved full credit for and how unfair it felt? High school?

Homework is important. It’s how we learn. It’s how unfamiliar material becomes familiar, gets to sound right in our heads, becomes comfortable knowledge. We may use every day what we learned in those pages of arithmetic problems. But it’s not what we remember.

It’s the friends.

Friends are our pathfinders to the world outside of our families. Though we don’t plan to be, we are their pathfinders, too. To outsiders, especially in the school years, it looks like our friendships are very superficial relationships. Whether in cooperative sandbox play like digging a tunnel from both sides at one time or a swordfight using rolled newspaper as weapons, or co-hosting a tea party for dolls and stuffed bears, these are important social experiences. Some important learning skills are obvious. Learning to listen to the other person, to incorporate their ideas into our plan, and compromising are just a few aspects of social play that can be key factors for success or failure in adulthood.

Sometimes parents mistakenly equate social play with sports or other ultrastructured group activities. They aren’t the same. While physical activity is important, and organized sports or theater can be essential for some kids, I think learning to play with others is a lesson itself, not obviously reinforced automatically in the context of competition and trophies. I wonder about the influence of professional sports, in which players are teammates only as long as their contract term. Star players want to help their team win, but only if they get the exposure and opportunity to enhance the next round of negotiations, during which their team loyalty is explicitly for sale. Is it so different, by the way, for star ballet dancers or actresses?

It’s the friends. Are you still in touch with friends from these school years? Maybe from preschool? Even if you’re not in touch with them, I bet you remember them.

We all remember these early friendships, and the ones we may have lost along the way. Why is that? The answer, I believe, is hidden in the way we keep and categorize our friends. Most of us keep our friends in organized containers. There’s the friends from glee club, friends from our mom’s group. Maybe the soldiers we trained with--and they might be in a different group from those we served with. The friends from church and friends from karate. The friends from tie-dye class and the friends from detention. The friends our parents seemed to like more than us and the friends they used to forbid us to see.

Friendships are not generic. Empathic parents see beyond the playdate and try to understand the importance of friends in the lives of their children.

The lives of infants are constrained by their physical needs. Food, shelter, and the need to induce sleep deprivation and emotional lability in those who love them. As they become more capable of exploring the world, they manage their curiosity through good-natured spelunking in the cabinet where you keep your cleaning products, and originate science experiments involving figuring out how to open grandma’s pills.
How do they get to see the world outside our family constraints? How did you? As we get to school age and older, our friends, from each of the compartments in which we keep them, show us what they know. They show us the places they discovered and the insights they have had. They show us paths we didn’t know were there.

Friends are important for your children, especially once they get to school age. Mess with this at your own risk!

The photograph is from my collection and is by Helen Levitt, 1942.

March 2, 2010

A First-Grade ADHD Story, Part 2

write100times When parents ask me about ‘discipline’ they are generally thinking of ‘punishment.’ Though they might feel very uncomfortable with the concept, they associate a child’s naughty behavior with a supposed need to have the child associate their impulsive or destructive actions with some kind of negative consequence. The way I see it, this is very close to an eye for an eye metaphor of proportional response. If your kindergartener is jumping on the bed, that would presumably require a different consequence than if you found him at a pool table in a bar having just lost your next mortgage payment to a particularly unkempt-looking group of motorcycle enthusiasts with tattoos that seem somehow less decorative than meant to convey some kind of threatening message.

My patient Sean, a bright first-grader who is bored and distractible in class, is a thorn in his teacher’s side. He’s not difficult, exactly. He’s polite and helpful and isn’t a problem student. But every time the teacher turns his back, giggling erupts and it usually seems centered on Sean. His homework is usually 100% and he does well on both in-class tests and standardized tests. But the teacher doesn’t know how to punish him. Every time he takes away a thing or a privilege, it just doesn’t seem to matter to Sean.

Sean’s mother knows this, of course. In their crowded house with Sean and his 3 older siblings, the kids have learned that becoming too attached to specific things like toys is a setup for frustration and disappointment as ownership gets vague very quickly amongst the children.

There are children, just as there are adults, who are particularly attached to specific things. In helping a child establish a sleep ritual, for example, I often recommend finding a transition object--like a teddy bear or doll--which can provide some comfort and help the child relax. I bring this up at this time because it is one of the deep errors parents sometimes make when they are angry. If you must punish your child, temporarily take something away. Never take away the one thing that gives them comfort. When you do that, you leave them helpless against the world, which at that moment is you.

Just like many parents struggling with discipline, Sean’s teacher was blinded by the fog of action and consequence. Here’s a medical example. A person in an emergency room says that they have chest pain. Should they get some pain killer? The right answer is that it depends. The first thing we try to do is find the cause of the pain or problem and deal directly with that.

Parents (and teachers) often try a discipline method that doesn’t appear to work. The kid either ignores the discipline, or it doesn’t have any impact on the behavior they want to change. Under these circumstances, it’s a mistake to do more of what’s not working. In my line of work, if I try some sort of medication or treatment and it’s not helping, should I just give more of it? Maybe I should change the treatment.

Sean’s teacher tried taking stuff away from Sean, but Sean wasn’t attached to material things and this didn’t work. So his teacher took more stuff away. This just appeared as wacky to Sean, who was amused by his bare desk. His teacher felt that he had no other options but to place more and more restrictions on the child. These didn’t really control his talking in class. Without even a piece of paper or pencil at his desk, Sean had nothing to do except talk with his classmates. This appeared to Mr. Dickson as overtly defiant, requiring ever more intensive punishments and restrictions.

I haven’t spoken directly to the teacher, but it certainly seems that it was much easier for the teacher to escalate the situation than it was to try and figure out why it was happening.

I’m not proposing that you even try to do some kind of forensic psychological analysis when one of your kids smacks the other. A simple NO HITTING! will do. But if it keeps happening, it is absolutely your responsibility to figure out why. Besides, it will only increase your frustration with the child and the child’s frustration with you when you keep pouring on more of whatever it is that isn’t helpful.

What about ADHD medication? It might help some of Sean’s symptoms of distractibility and impulsiveness, as well as what looks to be a short attention span. But I just couldn’t get past the idea that he was doing great until this teacher showed up, and suddenly he needs psychoactive medication. As my readers know, I have no philosophical problem with trying to help a child with medication, if it’s appropriate. But if Sean’s ADHD was well managed by non-pharmaceutical intervention, maybe we should try that first.

So I came up with the following plan, for his mother to review with the teacher.
  1. Stop punishing him in ways that are not effective.
  2. If he says he’s bored, and his rapid and excellent schoolwork suggests he might be bored, and he’s acting like a kid who’s bored, consider the possibility that he is, in fact, bored.
  3. Like the tree branch that bends with the wind, find a way to support his attention. For him, I have invented #4.
  4. The Bored Bag
    a. Let Sean pick out not one but at least 3 or 4 or 5 projects that can be worked on quietly and by himself. Give him plenty of choices.
    b. He can work on these without permission.
    c. When he is bored, he can get materials out of his Bored Bag and work on them by himself.
    d. Avoid projects with many pieces or requiring power tools.
    e. Some choices could be reading or drawing something or looking something up or writing about something or working on problems that the rest of the class doesn’t get to do yet.
  5. Sean’s doctor will write a letter stating, pretty much, the above. I will write that I have evaluated him, and suggest that in his particular case, the best remedy for his distractibility is likely to be distraction. Hopefully, the Bored Bag will allow this to occur without disrupting the class.