The Empathic Pediatrician

Media Ratings and Materialism

2011-11-09T19:08:00.000-08:00

A recent study I read in one of my medical journals surveyed parents about media ratings. Not surprisingly, parents said that they liked the idea of a rating system to help them decide if certain content was acceptable for their children. The list of content they wanted notification about was extensive. It included all the usual suspects: bad language, everything even remotely suggestive of sex, private parts, and so on. The list of rated content included romantic situations, innuendo of every kind, violence seen and implied, derogatory terms, putdowns that kids say to each other (e.g. 'butthead'), and much more. The length and extent of the list shows the lack of consensus about what parents think is important. What is it that parents don't think is important?

But that's not the topic of this post. Embedded in the study publication was this item, which received no other discussion by the authors:

"Of all content types included in the survey, only 1 was not rated as extremely important or very important by the majority of parents: materialism or things that promote materialistic attitudes."

I report this from Berkeley California. In Berkeley, a nuclear-free zone, the sprawling Whole Foods market across from my office is filled with shoppers loading their fair-trade renewable-resource unbleached hemp-fiber shopping bags, filled with out-of-season organic produce flown in from New Zealand, into the back of the Range Rovers required to ensure the safety of their unvaccinated kids when driven by the au pair every morning a few hundred yards to the private Waldorf preschool.

I'm not in favor of unfiltered access by children to everything an adult or even teenage mind can imagine or put on the internet, in a game, or available some other way.

But materialism gets a free pass? Nearly all media produced with a child audience in mind is marketing. It is hard to find content, even content I love, without this. I think Monsters Inc. is one of the best movies ever made. But Pixar (and Pixar/Disney) has clearly taken a lesson from George Lucas, and licensed their trademarked characters widely. If I could afford them, I would have Monsters Inc Band-Aids in the office. It isn't unusual for your kids to see products in the store or owned by their friends and beg for them or ask to see the movie or TV show.

What about the materialism, not considered a problem by most parents, apparently, of so many of the television shows available on networks watched by preteens? Not limited to product placement, this materialism equates success with wealth, big houses, fancy cars, and so on.

I'm not a monk. I like nice things, fancy restaurants, and so on. I sometimes make purchasing decisions that in retrospect seem impulsive. But at this point in my life, I no longer believe these things constitute success.

I’m appalled that the parents surveyed identified depictions of materialism as unworthy of rating. They want to know if their kids will hear the word 'butthead,' but don't care that nearly all of the live action shows on Nickelodeon have characters whose goal is to achieve something financial or monetarily valuable, and they get general peer approval for it. For me, I would like to know if my kids are spending their screen time, no matter how strictly limited, watching infomercials for getting rich in the 'cash flow business.'

For what I suppose is the same reason parents don't focus on the aspect of media content, however, there is very little actual research done on this issue. So we don't really know how powerful this message is. But if it's like so many other subtle media messages, it gets a direct pipeline into the kid's brain.

Still, just like those other media messages, the real way to combat unwanted influences has been repeatedly shown to be modeling at home and not by media ratings. If the parents aren't confirming these media messages, they generally won't stick. So it's great to tell your kids they aren't allowed to eat snack food, but they see you on the sofa with a big bag of potato chips, you will need to do a better sales job. I guess I don't have to mention that all the lectures you received as a child (think back now) about the way you were supposed to act, the things you were required to do or forbidden from doing, just didn't take when you had the freedom to ignore these rules. While it's normal to push the envelope at certain developmental stages, we are most strongly influenced by what we witness our parents doing with our own eyes.

If you don't want your kids to use bad language, don't use it. For everything else, ask yourself 'What would I want my child to do?'

Breastfeeding Sucks

2011-10-19T19:55:00.001-07:00

Self-deception is always a problem. With me, it usually rears its ugly head in the thought that I don’t really need to count just this one little piece of chocolate.

So I can't claim to be shocked when I observe it in others. I think it's a normal human trait.

But it has been a consistent and disturbing fact over my career that mothers are given information which is simply and obviously wrong. I don't know it for a fact, but I suspect the problem is well-intentioned propaganda.

I admit that I can justly be accused, in an ad hominem argument against me, of being mammarily-challenged. But that doesn't make it right.

My job, naturally enough, has brought me in contact with hundreds and hundreds of mothers and babies over the years. Even mothers who have nursed many children say that at the beginning, it's quite painful. Later on, when the baby is months old, they still say that almost always the initial latch causes a flash of pain. (Once this latch pain is over, however, it's usually painless.)

It bothers me that the vocal, even militant, advocates for breastfeeding have so downplayed the discomfort associated with normal breastfeeding that they might be hurting their own cause.

I don't know for sure, but I suspect the authors of breastfeeding books and others resolutely claim that nursing is painless because they don't want mothers to be scared of trying it. My guess is that they have wanted to give mothers, especially first time mothers, the idea that nursing is a blissful satori-like state in which your earth-mother womanhood will reach some sort of ultimate fulfillment.

What I hear in my office, from every Gaia-aspirant, is very different. The initiation of breastfeeding—even for mothers who have nursed many previous babies—is painful. Let's face it: nipples are a reasonably sensitive part of your body, and they are generally not conditioned to this use. Many times a day. Sure, babies generally aren't born with teeth. But they can, as the expression goes, suck the chrome off a trailer hitch. As if that's not enough, saliva is a digestive juice. It might not be as irritating as stomach acid, but leave any skin wet with saliva and it will get irritated within hours. (By the way, this is an important reason that toddlers using pacifiers often have a rash around their mouths.)

I have not seen a baby whose mother has not noted this pain. Clearly, it's normal. I don't think knowing about this pain would make a new mother avoid breastfeeding. She just had a baby! I think she can handle it.

Since I try to promote nursing, I've been frustrated by the mistaken expectation of new mothers that the process is supposed to be painless. They often get the feeling that they must be doing something wrong, or there's something wrong with them, or there's something wrong with their baby. Again and again, I have to tell them that the baby and their breasts are doing just fine, and what they are experiencing is normal. I give them lots of suggestions for things they can try that might help. And I am unhesitant to send them to a lactation consultant.

I suspect that some postpartum depression is worsened by this feeling of helplessness and inadequacy, that there's something fundamental wrong with themselves, or their bodies. Their expectations for motherhood were so high, that this normal deviation from those expectations can't be anything but disappointing. So I wonder if breastfeeding advocates have made it sound so effortless that many mothers switch to formula right away. Some have told me that they think there's something wrong with them, and being good mothers, they want to be sure their baby is getting enough. By formula feeding at the most painful time--often when the baby is 2-5 days old--they never produce enough to get the system working effectively. They are afraid that they aren't able to produce enough, and sure enough, they can't. This confirms their self-doubt. But it's just something else for them to feel bad about.

I think it would be much more helpful to tell women openly what they should realistically expect. At least they will be prepared and reassured that what they are going through is normal.

Pharmacogenetics and Race in the Medical Record

2011-09-02T20:10:00.001-07:00

There’s a discussion on a physician site I subscribe to about whether ‘Race’ should be included in the general demographics information of electronic medical records. Here’s the reason it should. Now that we are every so slowly receding from the political correctness of the last couple of decades of the 20th century, medical researchers are finding out that there are differences in both disease risk and care for certain groups of people. We’ve know for years that your child’s chances of certain genetic conditions were different based on your and your reproductive-partner’s genetic background. Everyone has known that children of Ashkenazi Jewish heritage (more or less of Eastern European background) were at higher risk for a terrible genetic disease called Tay-Sachs. Dark-skinned people of African descent were at higher risk of sickle-cell disease; white kids of cystic fibrosis. Finally, in the last decade or so, researchers have found the freedom to study some important medical problems, and they have found out important things. Here’s a good summary of some findings in the growing field of pharmacogenetics, which looks for differences in the response to different medications.

Racial differences in response to cardiovascular medication. [It’s pretty readable for non-doctors.]

It has been found, generally speaking and for example, that there’s a difference in response to a common blood anti-clotting medicine in Black, White, Hispanic, Asian people. This could be really important to know. Though not a cardiologist, I have the impression that treatment guidelines have incorporated some of these findings, and you might get a different dose or medication depending on your ethnicity.

Have I sold you on this?

We have always known that different people respond differently to a given medication or dose. Sometimes doctors have to try different formulations or doses to get the therapeutic response that will help the patient. Clearly, there’s something about the way that patient is metabolizing the therapy that is special. Presumably, it’s genetic. Note—it might not be. Grapefruit and grapefruit juice, for example, is a very potent inhibitor of (and this is common knowledge) the CYP3A4 form of the P450 enzyme. A lot of drugs get digested by this enzyme. Blood pressure drugs, heart rhythm drugs, cholesterol drugs, sleeping pills, anxiety drugs, antidepressants, antihistamines, some birth-control pills, some immune-suppressant drugs and some anti-HIV drugs. Chances are really good that you or someone you love is taking a medication affected by grapefruit, especially by grapefruit juice. Organic or not. Did the people studying these drug-responses ask their subjects about grapefruit juice intake? I don’t know.

I’m bothered by the idea of having an ‘Ethnicity’ in your child’s medical chart.

So far, a lot of the research in this emerging field of Pharmacogenetics (also Pharmacogenomics) isn’t. It’s really PharmacoRacialist research. There’s painfully little genetics and lots of studies of ‘racial groups.’

I’m not trying to be politically correct here. I wouldn’t doubt that epidemiologic research done in a remote Chinese village is probably representative of a relatively limited genetic pool. True genetic research in the U.S. has depended for decades on relatively closed and technically inbred communities among the Amish. One of the reasons behind the excellent and expert genetics professionals in Utah is precisely the multigenerational stability and consanguineous inbreeding available for research. Genetics research looks for a link between subjects. A lot of this current research has only an ‘ethnic’ label as the common link.

Partly, it’s the government’s fault. Seriously. The Census is probably the most important way our tax dollars get divided. And, perhaps with good intentions, the government wants to know about the ‘racial’ makeup of this country.

As far as I can tell, this is the latest official information from the Office of Management and Budget, which manages the Census.

US Census Directive 15

Everything is going to be bases on the census, and the racial distinctions are sociopolitical, no longer genetic or medically-based in any way. If you think certain groups need to be kept track of, write your congressperson.

From a medical ethics point of view, there is clearly emerging data suggesting that different treatments or approaches might be optimal for those with different genetic ancestries. These distinctions are unlikely to overlap much with meaningless Census distinctions, such as 'Hispanic' (which, after years of debate, has apparently been changed to “Hispanic or Latino.” The 'Asian or Pacific Islander' category will be separated into two categories -- "Asian" and "Native Hawaiian or Other Pacific Islander." Hey, at least the islanders live on islands for pete's sake, at one point in the 19th-century genetically isolated in the Darwin-in-the-Galapagos sense. My Korean and Chinese families don't think they are Japanese. What about Filipinos or Indonesians where different islands can mean different origins.

I have a family with 2 Chinese grandparents on one side and 2 grandparents from Portugal on the other. They recently immigrated here from Brazil--what are they? What are their 2 adorable kids?Are they Latino because Portuguese is a Romance Language? Hispanic because they are from South America? Asian because the kids have those sort-of-Asian eyes?

There’s an easy reality check. Ask the Spanish-speaking people you know. Believe me (and the US Census), they are all around you. When I lived in Utah, which I considered to be the least ethnically-diverse place I had ever lived, we had a medical clinic that was pretty much 90% Spanish-speaking. These families lived right there among, well, you know who, in Salt Lake City. Here’s what I have noticed. Ecuadorians hang out, mostly, with their fellow Ecuadorians. They may have travelled through Mexico to get here, and they speak the same language (to me). When a friend from Venezuela went out with me in Boston many years ago, he could tell immediately that people we met were speaking with accents from Peru or Guatemala or Cuba. I’ll say he could tell if people came from Puerto Rico, but he said that he couldn’t understand much since they spoke so fast and dropped so many syllables. He sometimes complained that he was too impatient to wait for a Colombian to finish the sentence. He could tell when they started speaking—but not by how they looked. It was a revelation to me when I attended the wedding of a distant relative in Paris. Also there were relatives from Nice (on the Mediterranean coast of France). My relatives said it was impossible to talk to them because “…they speak with such a heavy Southern accent.” It took me a while to figure this out. It was hard for me to reconcile Hercule Poirot and The Dukes of Hazzard.

[Tasteful? Professional? Oh come on, what did you really expect?]

I think this is an ethics discussion because even with demonstrable medical distinctions, how does the working doctor categorize the folks sitting in the exam room, and their variegated offspring? Do we wing it on skin pigment (I all shades of dark kids and light kids from curiously mixed parents).

My personal opinion is that the idea of race is a sad vestigial construct without helpful meaning. Here's what I might need to know: have any of the child's relatives had sickle-cell disease? Cystic Fibrosis? Hemophilia? It wouldn't help me to have a place on the chart for 'ethnicity.' But in the Social History section of my computerized charting program, I will note if a child is adopted and from where. I will note there if there are medically-relevant familial risk factors.

And what about those medical distinctions I noted above that ‘everyone has known for years?’ Even if this were true for one very long historical era, until World Wars and intercontinental migration, it isn’t very true here in California. When I first moved here from Utah in 1999, I made a comment to one of the hematologists at the local children’s hospital about not seeing much sickle-cell disease in Utah. She said she had a clinic full of white kids with sickle-cell, and I felt as ignorant as I was. Here in California, every baby is screened for sickle-cell at birth (since 1990). Everyone has known, since 1885, at least, that Mongolian Spots (benign bruise-like markings often appearing on the lower back of babies) were much more common in Asian children. This was first noted, as a fact, by Dr. Erwin Bälz [I couldn’t make this stuff up!], the German-trained personal physician to the Meiji Emperor. It was only around 100 years later that these were found to be correlated with skin pigment—the more pigment you had, the greater the chances of a mongolian spot. But they are harder to spot in babies with very dark skin. So they were noticed more in babies of Asian descent who had more pigment that Laplanders but less than equatorial Africans. Ira Gershwin said it best: It ain’t necessarily so.

It turns out that the whole ‘ethnic’ idea is largely confounded by genetics. It’s certainly true that my ancestry is tough to follow prior to immigration from southern Russia. Nobody kept track of peasants and who they mated with. Still, there are lots on great kings who have kids with serving wenches. And from there, it’s all down hill straight to me. Which leads to this: I’m descended from Charlemagne. Yes, that Charlemagne. Perhaps less likely an ancestor for you if your family recently came from Africa or Asia. Your folks came from Africa in the 19th-century? We can both attend the Charlemagne family reunion. Just arrived? Maybe not Charlemagne, but definitely Nerertiti. Just like me. Read this article from The Atlantic Magazine. It will likely affect your view on race forever. You can’t judge a book by its cover.

Because I don't think racial labels are generally helpful, I also believe that they are a potential problem. I wouldn't want my calling a patient 'white' when they are 1/16 Native American to interfere with their self-description. This may have legal implications, perhaps for Federal contracts or programs. Will it help them or hurt one of my patients in gaining a scholarship to define their race in a certain way, especially if whatever institution looks to their physician or medical record for verification? If I don’t think I, a fairly observant physician, can tell what race you are by looking at you, I certainly don’t have confidence that—even with training—college students working for the summer can categorize your ethnogenetic heritage when they come to your door to help with the census and try to give you a careful look in the hallway outside your apartment door by the dangling blinking buzzing insufficient fluorescent light that you’ve been bugging the cheapskate landlord to fix for months.

Back to Birth Weight

2011-05-11T21:09:00.000-07:00

I just received a comment on a blog post. The post was called, “Newborn Won’t Gain Weight.” The comment from Joey, 5/17/2011, said, "What if the child is now 1 month old and still 5oz shy from birth weight? My niece is in the hospital right now. Her parents aren't the brightest and I'm worried. Thanks for writing about this by the way! "

I'm so grateful that you have found this blog interesting. It isn't meant to give medical advice of any kind, ever.

In this true story, I was seeing the baby every few days at first, but as the inadequate weight gain continued, I was seeing the baby every single day. I was worried about the baby! It's normal for babies to lose weight for the first few days. But they should start gaining weight within about a week or so. Babies who are born bigger tend to lose more weight at first, so it might take them a little longer to regain their birth weight.

Pediatricians often use, as a rule of thumb for this initial weight loss, about 10% as a guide. If a term baby of average weight, say 7 1/2 pounds (about 3400g), loses anything less than 10%, we usually don't worry too much about it. For this average baby, that would be about 12 ounces (about 340g).

We also have a rough guide for weight gain. On average, once newborns start gaining weight, we expect them to gain about 1 ounce a day (~30g). This slows down, of course, as the months go by.

Let's do the math. If our 7 1/2 pound baby lost 10% of her weight by the time she was 5 days old, she would weigh 6 pounds, 12 ounces. She lost 12 ounces. It would be reasonable to guess that it might take 12 days (at a rate of weight-gain of 1 ounce a day) for her to regain that weight. But she only started gaining weight on her 6th day, so she'd be back to her birth weight around day 18. That's about 2 1/2 weeks old. I'm usually pretty satisfied with anything in the 2-3 week range.

Let's do it again for a bigger baby, say 9 pounds (~4100g). Weight loss of 10% would bring the baby down to about 8 pounds 1.5 ounces. If this baby gained an ounce a day, the baby wouldn't be back to its birth weight until closer to 3 weeks of age.

Babies who are born smaller, lighter, or prematurely don't have so much extra, and the 10% rule-of-thumb really doesn't apply. Remember that the baby is not just getting food but also fluid in each feeding. If there's a delay getting breast milk or formula, that's always going to be concerning.

The blog post you commented on was an example of how I manage this as a physician, in the unusual practice I have created. If a baby who wasn't gaining weight was brought to urgent care or to a doctor for the first time, it would be understandable if that doctor, alarmed by the poor weight gain, felt compelled to get some tests to make sure the baby wasn't sick in some way. It would also be reasonable to discourage breastfeeding, at least for the moment, and encourage formula use. Maybe the baby would be admitted to the hospital for intravenous fluids. None of these interventions would be wrong or bad care.

I wanted, as much as possible, to avoid these. I wanted to support and facilitate successful breastfeeding as much as possible. But the baby's health and safety are always, in every case, the most important things I care about. I have one thing that the urgent care or emergency room physician does not have: continuity. I have the power to ask the parent to bring the baby back the next day, and the day after that. I will see the baby on Saturday and Sunday and July 4th, and so on. I can give parents instructions about what to look for, and if they observe these symptoms or have new concerns, they should call me right away. When they do call, I answer the phone and I know the story, I know them, I know their baby. This concept of continuity of care is extremely valuable because I'm less likely to miss a condition that evolves over time. It saves a lot of money, because I'm not sending every child who's sick in the evening to the ER. And I'm not treating every patient for the first time. I can and do order tests and x-rays, when they're needed. I send kids to the ER sometimes.

But I can see this mother every single day, weigh the baby, try first one idea and if that doesn't work, try another. I can find out how the mother is doing emotionally and physically, how much pain she's in and how tired she is. I can find a way to get that baby on the right track.

There's a nice epilog to the story. We did feed the baby formula, but only for a few days. As the baby put on a little weight from the formula, he got a little stronger with his nursing on the breast, and was less famished when he nursed. Mom's body responded well, and they soon didn't need the formula at all. They successfully nursed for more than a year.

As I pointed out in the original post, formula isn't poison. It's an important tool we have available if we need it.

Hothouse, Part 3

2010-08-20T04:17:00.000-07:00

My strategy was simple but subtle. I was there in Amy's house, sitting at the foot of her bed in the sauna-like bedroom. I was worried about her, and I needed to help. I wanted to uncover each concern, shine daylight on the dark corners where the unknown and the irrationally-feared thrive.

So I reviewed the baby’s weight history (normal) and recent weight gain (great). The baby wasn’t getting nutrition, not even fluid, from any other source. So that must mean that Amy’s breasts are doing a great and normal job at keeping him healthy and thriving. There’s no evidence of any kind that her body will either suddenly or gradually stop providing the milk it has already proven that it can provide. She understood the logic, but didn’t have a lot of confidence for the future. She asked what would happen if, despite her excellent track record, she just failed to make enough or any.

What indeed, I asked her back. I guided her through this unlikely scenario the way we should plan a fire exit in our homes. First, would she know? She didn’t have confidence that she would, so I asked her how she would find out. She correctly figured that the baby would be hungry. Since her baby was neurologically normal, and since hunger is one of our most primitive and basic drives, the baby would surely let her know if he weren’t getting enough.

She wasn’t debating with me, but my answers gave her the freedom to ask the frightening questions without being judged harshly. What if the baby was crying and she couldn’t tell if it was from hunger and it really was but she didn’t know? OK, how long would you let the baby cry before calling me? She didn’t know exactly, but it was a lot less than a day. She agreed that her healthy baby could go a few hours without eating and still do well. If the baby really were crying inconsolably, I would always want to be called and usually want to see the baby in person. This is all pretty standard stuff, I think. As we went back and forth on this precise topic, however, I happened upon the answer she needed. I hadn’t understood exactly what would break through this until I hit upon it after trying other answers. 3 hours. That was the key, as it turned out. She was glad to get the reassurance, glad to get my commitment to be there if needed, confident in my professional skills and judgment. What she didn’t have was the confidence to trust her own common sense and innate ability to see when the baby has crossed over from fussy to worrisome. She needed an unambiguous border she could look for. If the baby crosses it, she knows exactly what to do. I could see the relief on her face when I said 3 hours. Any time, day or night, for any reason. Hunger, illness, bad weather, it just didn’t matter. If you try everything you know and the baby is crying for 3 hours, call me.

That wasn’t the only breakthrough. Like many new mothers I see, she was anxious about her continued ability to nurse successfully, even though she had been doing it perfectly. There are sometimes reasons that women have to stop, but they aren’t common. Usually, with some support and expert advice, breastfeeding problems can be overcome. But how, she wondered, does she really know that? She has already taken her body places it has never gone. Sure, my experience is optimistic, but that’s based on other women, other babies. This, I admitted, was an excellent point. I don’t push formula, but this is its perfect role. How do we know if 911 will answer when we call? Still, we teach even kids this number. That can of formula can usually sit on the shelf of a kitchen cabinet for a year. It can wait like a silent guardian, hidden behind the stuff you actually use. Nobody but you and your doctor need to know it was ever there. A can might feed a baby for several days or a week, depending on how big they are. But even if never touched until you throw it away when discovering it as you pack up to move, it is working its magic as an effective contingency plan. Depending on the disfavor in which formula is held, it might not be plan B or even C. But the one day when you decide to leave the baby with your mom for a few hours, but a truck got stuck under an overpass and there’s no way to get off the freeway and people are stopped and getting out of their cars, that can will be there.

Next, and I’ve made this point about bicycle helmets, protecting the baby might be a necessity but the safe and thriving baby is nowhere good without you. So taking care of yourself is crucial for the baby’s life and happiness. No, that doesn’t mean I think you should give in to the urge, ever since you heard of that big storm in the Gulf of Alaska, to have a neoprene Snugli custom made so that you'll be prepared when you get the text that Mavericks is up—way up—and you want to show the world how gnarly you really can be. Once the baby’s needs are met, we need to find a way to fold them into our lives in some functional way, or perhaps fold our lives into theirs. For Amy, this meant getting out of bed, out of the sweatpants and into regular attire and footwear. Another subtle advantage of housecalls, I made this suggestion to help her, not hurt her feelings. Perhaps doctors don't usually make fashion tips, but this was an essential precursor to the final note of this post.

This last is important because it facilitates the next important suggestion I made. She needed to take a walk. I strongly urged her to go for a walk with the baby in a stroller every day, without exception. Every part of this idea has a reason behind it. The feedback I've received has been so consistently good about it that it seems inexplicable for it never being mentioned in my training or textbooks.

The walk allows the new mother to get some exercise. Since this is often after spending at least a few days in bed, even previously fit mothers should take it easy at first. And for goodness sake, check with your OB who may have information about your stitches that I just don't. Studies have clearly shown that even a couple of days in bed decrease our fitness level. Together with some blood loss, you need to get back on your feet. Studies have also consistently shown that exercise improves our mood. People who get some exercise every day tend to sleep better, and some important functions of their body seem to work better. These include breathing and digestion.

The walk allows the mother to get some daylight. Amy hadn't left her bedroom much since leaving the hospital. Her planning for the baby had been so good, in fact, that her room had a changing table and baby supplies, a crib, swing, and so on. I noted this as her mood gradually lifted, and inquired when she planned to start using empty tissue boxes as slippers as Howard Hughes apparently did when he sealed himself in the penthouse of a casino he owned. Just because she was suffering didn't mean I couldn't make fun of her. Daylight, too, has been demonstrated to lift the mood and help regulate sleep.

Daylight is also helpful for the baby. It is directly therapeutic for jaundice, which baby Henry didn't have. But the baby had been living in a dark cave for 9 months. It needs daylight exposure (not direct sun, just daylight) to establish a day/night pattern. It also needs daylight to help provide vitamin D, which is activated by sunlight.

I specified using a stroller for several reasons. The jostling of the stroller is a natural pacifier, which many babies find soothing. Slings of many kinds can be great when doing many activities, especially in places with a lot of other people around, such as supermarkets. But the stroller takes the weight off. There's no extra weight on your back, no extra weight on your hips and knees and ankles. That will make the walk just a little easier, and make you able to walk a little bit longer than you might be able to with a sling or backpack carrier. It also gives you the luxury of stopping. If the baby's asleep, you could stop at a park bench. The stroller also moves the baby away from your body. This seems counterintuitive, since I certainly want you to hold and love your baby pretty much constantly. But it brings up the timing issue.

Take the daily walk at the baby's fussiest time. If your baby is consistently fussy in the late afternoon, say between 4:00 and 7:00PM, that's the time to go out. There aren't too many things more frustrating than trying and failing to comfort a fussy baby. It makes us feel helpless and doubt our ability to parent. But if the baby's basic needs are being met, and we know he'll be fussy in the late afternoon, that's the time he'll benefit from the calming effect of that walk in the stroller. If it's his fussiest time, he won't be right in your face, reminding you of your shortcomings as a parent. That, after all, is what adolescence is for.

Hothouse, Postpartum—Part 2

2010-08-17T04:54:00.000-07:00

Like every new mother, or maybe at least the good ones, Amy said she was worried if her baby was getting enough. Henry was a week old, and I walked her through my iterative procedure to determine if he was getting what he needed. He was gaining weight appropriately. He was having lots of wet diapers. He was satisfied after nursing, and could be heard swallowing voraciously at every feeding. This was apparently an adequate response until she asked me if I thought he’d be alive in 6 months.

I wasn’t going even to try and finesse this over the phone. I stopped at the supermarket, picked up a small portion of hot macaroni and cheese along with a little bit of cut-up watermelon, and drove directly to her house. Intentionally, I did not ask if it was a convenient time for a visit. I didn’t care if it was convenient—it was necessary.

Her mother was there to open the door. Though it was just a few minutes ago when we were on the phone, her mother had arrived in the meantime. I thought that was lucky and we introduced ourselves. I asked where Amy was, and her mother directed me upstairs. I was carrying the old-fashioned housecall bag that I kept in the car, but I didn’t think I would need to examine the baby.

Henry was a term baby, and healthy. Amy had been doing a good job keeping up with the demands of initiating breastfeeding, and her general concerns were common, reasonable, and could be comfortably answered with rational reassurance.

I walked up the stairs to the master bedroom, where Amy was in bed, holding the baby. It’s was a nice big room, with big windows that looked out onto a garden. The windows were closed. I asked how she was and she said she was OK. The baby was OK, too. It was nice of me to come over, but it wasn’t really necessary. I told her that I had brought over a little watermelon, which has a lot of water in it. It was July, after all. I also brought over some macaroni and cheese—though I had this before and the store where I bought it usually makes it quite bland. It was a good way to raise your blood sugar if you haven’t been eating right.

She admitted that she hadn’t really been eating right. She was in bed, I noted, and it was about 5:30 in the afternoon. She said she hadn’t been out of bed much, either. I didn’t mention it, but I didn’t really understand why her mother was downstairs and she and the baby were upstairs. It’s hard to know what the right approach is to get a channel of communication open. I’m usually very good and very intuitive at this with children, but I’m not as skilled with adults. I decided that for the moment, I’d let my actions speak for themselves: I was there. I didn’t tell her to call if something happened, I actually showed up. I believe that sometimes that is exactly what’s needed.

So I didn’t immediately confront her about what she said. “Do you think it’s warm in here?” I asked. It felt like a sauna to me, though I’m biased by my weight. I was self-conscious about the beads of sweat I knew were appearing on my bald scalp. In my little doctor bag, there was an infrared thermometer. It read 95° [35°C].

Amy said, “Oh god yes. I like it cool and so does my husband. But it has to be warm for the baby, right?”

“Is the baby cold?” I asked. He looked comfortable enough in her arms, wrapped in a blanket and wearing a hat.

“How can I tell?” she asked. I asked if the baby’s hands or feet were cool or purple. She had to unwrap him to look, and they weren’t. But, she noticed, his back was sweaty. I put down the doctor bag. I asked if it had been this temperature in the room for the 4 days since the baby was brought home from the hospital. It had been, she said, because they wanted it to be comfortable for the baby.

I walked to the windows and opened them. “What are you doing?” she asked.

“I’m making the room temperature compatible with life for non-reptiles.” I explained that if having a newborn baby in the room was not enough of a cause of sleep deprivation, being uncomfortable would suffice as well.

Her thought was reasonable, even right in a way. Babies do have more difficulty maintaining their body temperature and need to be kept warm enough, especially if undressed. But they are warm-blooded, at least in some general Linnaean sense. They will maintain their body temperature with appropriate energy resources and insulation. I coached her on this point as I undressed the baby and took off his hat. I suggested a couple of thin layers, that were easy to add or remove as needed. That kind of management is less practical for adults, so it was important to keep the environment comfortable for her and her husband. The baby could be dressed as needed. She liked this idea.

Maybe to my sophisticated readers this will seem simplistic, but I don’t think it is. Again and again I find that housecalls can be profoundly helpful, often in unexpected ways. In this case, Amy did indeed have some postpartum depression. We are dealing with that, hopefully, in helpful ways. But the housecall accomplished several important things.

She knows, in a convincing way, that I will actually come to her house if needed. She’s not in this by herself.
I know what she’s got, I’m concerned about it but not frightened away.

She has my permission to be comfortable. This is so important. It’s crucial, of course, that the baby gets what he needs to thrive. But those needs are pretty basic. Once the baby’s needs are met, the next priority is finding a way to make the new world order work for the parents in some practical way. Amy was doing a good job with the needs of the baby. She was ignoring her own. I wanted her to know that getting some relief in the misery of the mother is good for the baby, too.

After making the ambient temperature low enough to assuage my concern that the buttons on my shirt might melt and leave permanent scars seared into my chest, I had several other suggestions for her. That’s next.

Hothouse, Postpartum—Part 1

2010-08-14T05:47:00.000-07:00

I arrived at Amy’s house just a few minutes after hanging up the phone. I brought my house-call bag with me out of the car, but I didn’t think I would need much to examine Henry, who was about a week old. He had been full-term, and was doing everything right.

Before the baby, Amy was a working professional, very smart and with a good sense of humor. This is often an important coping skill. It can also be an important tool for parents who bring their children to me. I often have to remind them that: ‘Just because you are sick or in pain doesn’t mean I can’t make fun of you.’ It’s a coping mechanism for me too, of course. I try to help parents see the humor or absurdity in themselves and what their kids do. But, I suppose like all humor, it doesn’t play to every audience. The families who appreciate my point of view know that when needed I can slip quickly into the role of a serious doctor. Sometimes it’s hard for me to tell what’s needed. Being happy is often infectious, so staying upbeat can bring somebody up. But being unrealistically optimistic can make a depressed person doubt your sincerity and simply not trust that you understand how they are seeing the world.

The phone conversation with Amy started in a typical way. She had some concerns about breastfeeding, especially wondering if the baby was getting enough. This was the most common question that new mothers asked, and I explained that we can be reassured if the baby is gaining weight and having lots of wet diapers. If he’s growing and peeing, and not sneaking out for snacks when she’s not watching, he must be getting it from her. That was the ‘gold-standard’ for determining breastfeeding success. She bought that reasoning.

But when she asked the real question, which she tried to hide in the words of an innocent question, alarms developed over my years of experience started ringing. She asked if I thought she’d still be breastfeeding in 6 months. And added, quietly, “if he’s still…here.”

Though nobody wants to bring it up, every parent has dark fears. I think we all do about people we love and depend upon. The inconceivable loss looms, we all know, above us too distant to see clearly. But we know it’s always there, hidden in tragic news stories that happen to other people. We’d all be in trouble, however, if we fixated on this instead of going about our daily tasks. A couple came to interview me to see if they wanted me as their doctor. They had just moved from Florida with their baby, and I was making pleasant conversation. I asked why they moved. They said they had stayed through a couple of hurricanes last year. That was enough, they said. They had a child now, so they moved here to the Bay Area so they didn’t have to cope with the constant threat of a natural disaster. I told them I would be happy to have them in my practice.

The dark thoughts are there, lurking deep in the background. We might know how fragile babies are, but good parents shove these concerns to a back burner while they focus on feeding the kid and making sure they don’t run out of diapers.

It’s natural to wonder if the baby is getting enough. It’s natural, even, to worry about it. If the baby isn’t getting enough, he might not gain weight well. He might even lose weight. He might—heaven forfend—have to get formula. Most parents who have these concerns are genuinely worried. They might or might not realize that these concerns are sometimes out of proportion to the actual risk to the baby.

I tell parents that they should never tell a child who’s getting a shot that it won’t hurt. Shots do hurt, at least a little. A smart child will immediately reach the correct conclusion that either you didn’t know that shots hurt or that you knew and lied about it. Either way, you’ve lost credibility. Sadly, you’ve also lost the credibility to comfort the child afterward. In this way, I do not try to hide or gloss-over my concern for a baby that doesn’t gain weight as expected. I try to take a measured and reasonably algorithmic approach, however. It doesn’t scare me, and I have a lot of experience and knowledge. If one thing doesn’t work, we’ll try another. I will not give up. When I’m concerned, I tell the parents and then do something about it. Having a plan, indeed a whole decision-tree of analytical approach to uncertain events, can be a crucial tool in the management of complex problems and the anxiety these provoke.

But I knew, and she knew, that Henry was gaining weight just as expected. The nursing was going well. As described in the last post, she had not expected the appearance of her breasts to change. I felt bad that I hadn’t expected this either—at least not overnight. I had not warned her of this possibility. At first, I thought she was concerned if her baby was getting enough, so I reassured her about that. Then it appeared her concern was that her breasts no longer seemed to appear full, and she was worried that this might be a sign of a problem with her milk supply. I reassured her about this, too. One by one, I asked her about her concerns, and one by one I dealt with them in the best way I could figure. Seriously, thoughtfully, and, I hoped, kindly. On the phone, I thought I was getting her past this buzzing cloud of anxiety. I didn’t expect her to ask if the baby was going to survive. For that, there was no answer on the phone.

I know about the dark places. But I can’t make them go away. If they are prominent in the moment to moment thoughts we need to have to get through our daily tasks, they interfere with doing what we need to do. They sometimes interfere with what our children need. They always interfere with what we need.

I didn’t ask what she meant when she asked if I thought the baby would still be there in 6 months. I just got her address and told her I’d be there in a few minutes. I didn’t ask her permission. I didn’t ask if it was a convenient time, or if there was somebody else she could call. This was not a time to be afraid to step up to the plate. I stopped briefly in the supermarket across the street. I bought a small serving of macaroni and cheese (usually quite bland at the place near my office) and a small amount of freshly cut-up watermelon. I went to her house. That’s coming up in Part 2.

Boob Job 2—Breastfeeding in the Real World

2010-08-11T05:34:00.000-07:00

In the last post, I mentioned getting a call from Amy, a first-time mother. She’s nice, very intelligent, very well educated. She has a good sense of humor and a nice husband. When they took baby Henry home a few days ago, he looked great. He was losing weight, as expected.

Usually, babies are born with a store of extra fluid. For the first day or so, it’s not unusual for them to sleep nearly all the time. They aren’t hungry yet, and a lot of their energy is taken up just keeping their body temperature stable. Sometimes a new mom is worried by this.

Some breastfeeding books—and advisors—convey the idea that a newborn baby is completely driven to nurse from the moment of the first breath. It’s true that babies have rooting and sucking reflexes when they are born, and that they can nurse if it’s available. It’s unfortunate that some new mothers get the expectation that their newborn will nurse immediately and often during that first day. Though exhausted by giving birth, some first-time mothers just can’t put the baby down. Having pestered Santa for 9 months about that big toy they’ve been wanting, they finally see it under the tree. Now that it’s open, they don’t even want to go to sleep and miss precious playtime with it. The baby has also usually had a pretty exhausting first day. It’s not unusual for a baby to sleep 22 of the first 24 hours. So I hear a lot of concern and disappointment when I’m told that every time the baby is put to breast, he falls asleep.

The problem with unrealistic expectations about nursing, of course, isn’t that they will result in a less-healthy baby. They will, however, cause the mother to question the viability of her plan to nurse, and question her body’s capability to make milk. I put this squarely on the culture of breastfeeding, at least in the community I’m in. The books make it sound easy, painless, and problem-free. This, as I’ve said, is counterproductive.

It’s been a revelation for me to see the peer pressure at work in my community. That clique of mean ‘popular’ girls in high school has morphed, at least here in Berkeley, into the competitive breastfeeding league. They are the women who see a mother in the park and through warm smiles tell about nursing their baby blissfully and without problems. Until high-school. They won’t fail to tell horror stories about the ground-glass and petrochemicals in baby formula, the hormone-like bisphenols in baby bottles that are so potent that you might as well start saving now for the kid’s gender-reassignment surgery. Not that there’s anything wrong with that.

As if these pressures aren’t enough, new mothers have a lot to cope with. Their lives have been turned upside-down, their careers are, at best, in limbo, their relationships have changed, they aren’t getting enough sleep, their breasts have changed, their privates have changed, and they have—did I mention this?—a baby.

I’m prepared for breastfeeding questions and problems.

Amy said that she had a couple of questions. She said she was worried that something was going wrong with nursing. Over the prior few days, as expected, her breasts gradually would become engorged, and she had been producing milk. She knew it because she would leak milk. When Henry nursed, she could hear him swallowing, and some milk would leak out of his mouth when he was done. I told her that was great. But this morning, when she awoke, her breasts seemed different. They seemed both to be kind of deflated, flatter. Not painful or red. Henry seemed completely satisfied when he nursed, and was audibly swallowing as ever. She was still leaking. I found this all pretty reassuring, and told her so. I asked if she had ever seen a nature-show on TV or a National Geographic article that showed women who nursed their babies but don’t have bras in their culture. They just aren’t, I pointed out, perky. There’s a reason, after all, that Frederick’s is ‘of Hollywood’ and not, for example, ‘of Manaus.’ Appearance and functionality are simply not linked.

It’s worth mentioning that for most of their lives, women get strong messages about their appearance. Men do too, of course, and I speculate that the pervasive influence of visual media has tended to increase the appearance-pressure on boys and men. Still, women are bombarded. In deep and subtle ways, these appearance pressures are all about cultural beliefs concerning attractiveness and ability to find and retain a mate. Sometimes, as I create a dialog with mothers, they are concerned about the ways in which their bodies change. It’s natural enough to think about this. I wondered if this was the basis of her concern.

She said she was concerned that the baby wasn’t getting enough. This was the most common concern of new moms who breastfeed. I’ll point out again that though the words are about infant nutrition, the meaning is all about anxiety.

I asked her to relate the entire day up to the time of her call. She didn’t understand where I was going with this, but went along with my questions. Every thing she said she did—even getting out of bed—was coupled with a question from me. “Did the baby have a wet diaper? Did you change him?” By the time she got to our phone call, about 4:30 in the afternoon, she had changed at least 8 wet diapers, most of which had a little bit of soft yellow poop. It was a revelation to her that he went through that many diapers. It’s a normal amount. I asked what else she fed the baby. She was confused by this question and a little shocked. Nothing else, of course. How about her husband? Did he take the baby to a drive-through window for a bacon double-cheeseburger? Of course not. So if the baby is having about a dozen wet diapers a day, he must be getting plenty of fluid from someplace. If it’s not the all-you-can-drink fountain dispenser at a fast-food restaurant, it must be from her. She embraced this reassurance.

I also made the following offer. She could bring the baby to the office every single day and use our baby scale to weigh the baby. The scale doesn’t lie, doesn’t give exaggerated reassurance. If the baby is gaining weight appropriately, she’ll see it for herself. If not, I’ll be right there to make whatever changes are needed. I will not let her baby, or her, fail.

As an aside, I strongly discourage anybody from getting a baby scale in their home. It is not useful in feeding management for healthy babies. It is both a material manifestation of psychopathological anxiety and a prop that enables and exacerbates that anxiety. It doesn’t help the baby. By the way, I have recently been hearing about new parents who are advised to take their baby’s temperature daily or several times a day. Even if it weren’t ironic, I would really advise most of these parents, too, to chill.

Each of these reassurances seemed to help. I felt like I was helping her. She asked me, “Do you think I’ll still be nursing in 6 months? I mean, you know, if he’s still…here.”

I said, “Give me your street address. I’ll be right over.” I got in my car and was there in moments. That’s the next post.

Boob Job—Breastfeeding in the Real World

2010-08-08T13:06:00.000-07:00

When Amy called, she sounded fine. She’s in her early 30’s and just had her first child, a great and healthy baby named Henry. The baby was about a week old.

In pediatric training, I wasn’t taught much about the mechanics of breastfeeding. Sure, I was taught that it was a good thing. I was taught to encourage it. But how the process happens, how the machinery in the breast works or doesn’t, and what some of the key practical issues might be was all unexplained. Luckily, I used to work with a fabulous nurse-practitioner, who is also a lactation consultant. She taught me a ton, and I have learned more since. So I’m no longer afraid of dealing with nursing issues head-on.

Before she left the hospital with the baby, I had told Amy what to expect, in general terms. I told her that most women who are mothers for the first time don’t usually make a lot of milk for the first few days, maybe more. But in order to get the factory going, she needed to keep putting the baby to her breasts. It’s nature’s way to have the baby get hungrier over those first few days. The baby gets hungrier, sucks harder, sleeps less and wants to nurse more. This results in more stimulation, causing more hormone release from the brain, causing milk production. As the milk starts coming, the baby gets some positive feedback from nursing, leading to a completely Pavlovian conditioning system, which leads to the baby wanting to nurse more, leading to more stimulation, leading to more production, and the next thing you know, you’re getting a bill for college tuition.

Nearly always, I’d give new parents this speech or something close. I started doing this because again and again I have had to reassure new parents that it was completely normal to have a 2-day-old baby who wants to eat but mom has nothing to give. Colostrum, the early secretion of a breast, is very healthy for the baby but not very filling. Though I haven’t found this written about much, it’s just this anxiety which seems to have coincided with abandonment of breastfeeding in patients I saw years ago. The parents would care so much about the baby that they would draw a premature conclusion that their ability to lactate successfully had failed in some way, and start giving the baby formula. Formula isn’t poison, no matter what you’ve heard. Sometimes, it’s necessary and I recommend it. But once a baby starts eating from a bottle, they learn that this is the way to eat. It’s much more work for a baby to extract milk from a breast, and takes much more coordination of breathing, and sucking pressure. So even after there’s a decent milk supply, the baby will nurse briefly and then complain, preferring the bottle. They are saying that even though they like home-cooking, they’d rather go to the drive-through window and get fast food.

Honestly, I think that taking the time to explain what to expect has resulted in very few breastfeeding failures. I’m very grateful, as well, for being in a community in which lactation consultants are available and can be enormously helpful. Though I have a lot of the same knowledge, and am completely comfortable around nursing babies, I’m still a little awkward when it comes to judgmental assessments (‘wow, now that’s an inverted nipple’) and manual intervention (‘OK, push your breast this way, squeeze here, and massage your nipple like this’).

It may be counterintuitive, but I think one of the smartest things that I do with breastfeeding promotion is give the parents some formula. Hospitals used to give formula samples, provided by the manufacturers, to all the parents of new babies. I’m against this. It sends the wrong message, and some hospitals have stopped doing it.

It’s different when I do it. I give the parents a small amount. Sometimes I have premixed little bottles in packages of 4. I like giving those. Sometimes I have cans, and that’s OK if it’s all I have available. I get these from the same manufacturers as the hospitals. This isn’t formula to feed the baby, though the manufacturers would certainly like me to promote it as such. It’s an anxiety-relief apparatus, which works at many levels.

First, by coming from me, I am implicitly granting permission for the mother to use it if needed. If she decided she needed it, it would be OK. I’d tell her that she should just keep it in the kitchen cabinet, just to have it on hand. I tell parents that I don’t expect it will be necessary.

I’m not much of a back-country camper. The whole idea of a bivouac is unappealing to me. But I know plenty of people who love the outdoors and the idea of following a Road Not Taken. Oddly enough, they still take along a cell phone. Just in case. Just because you don't anticipate a problem doesn't mean that you shouldn't have a contingency plan. Maybe it's the cell phone, maybe that wacky silver emergency blanket. Just having it along can give you the sense of security you need to go someplace that otherwise would be too scary to go.

Second, it’s a message that I won’t let their baby fail, and neither will they. When a new baby comes home with a first-time parent, our insular society has precious little support to offer. Other cultures, and our own of 150 years ago, provided a multi-generational household. Several generations of women would be there waiting with a deep repository of knowledge and experience in nursing and babies. If your milk didn’t come in easily, there was other milk available that would get the baby through those first few days. My experience was that many or most of the women who turned to formula could, in fact, nurse successfully. What they could not do was wait. At some point, their anxiety about feeding the baby crossed the high threshold of their desire to breastfeed. They wanted to make it work, but they couldn’t stand another moment of knowing the baby wasn’t going to get anything to eat. This wasn’t bad parenting, it was good and loving instinct.

I wrote a blog post about The Telephone Paradox. The more I gave my home phone number to patients, the fewer calls I got. None of my physician colleagues believe it. I found that when patients knew and really believed that they could contact me at any time, they were empowered. If the kid had a fever, they wouldn’t call immediately. They’d try some fever medicine, knowing that if it didn’t work, they could call later. Usually, it did work, so no call. The parent was made to feel that they had the power to try what their common sense suggested, and that I was there if it didn’t work out as hoped.

So that formula in the kitchen cabinet usually sits unused until it’s past the expiration date. The new mom is empowered by it. Maybe she can get through just one more night with a hungry baby, maybe just a few more hours even. If she needs it, it’s there. But for now, she’ll keep putting the baby on the breast, doing what she needs to do to get that machine started.

I asked Amy if the baby was all right. She said that the baby was fine, but she had a couple of questions. They didn’t go where I thought they would, but that’s the next post.

Mystery Diagnosis—Mom’s Wrist

2010-08-03T04:22:00.000-07:00

More than a year ago, I wrote about a little-known entity that I have sometimes diagnosed in a mother who is complaining about wrist pain. Called Nursemaid’s Wrist, it is hard to find online or even in many medical textbooks. It has nothing whatever to do with Nursemaid’s Elbow, which is something that kids can get. Nursemaid’s Wrist is a pain in the wrist that adults, usually mothers or those who care for infants, get from repetitively stooping to pick up a baby.

It’s easy, of course, to underestimate the weight of a baby. The average birth weight these days is over 7 pounds, and by the time the baby is 4 months old, it might be double that. If the baby were a bowling ball—professional bowler weight—it would seem quite heavy. A 4-month-old weighs about the same as a 2-gallon container of water. It’s easy to see how someone lifting and moving that kind of weight can get sore. But they are moving that object with considerably more care than they might a plastic jug of water or a bowling ball. The muscle tension required for fine movement control while holding on to a heavy weight puts an enormous strain on the whole mechanical system. Some muscles of the body seem well designed to handle massive enlargement and strengthening if circumstances required it. Biceps and shoulders, and the muscles of running and leg movement are good examples. Except for a protective covering of skin, they have a good blood supply and can pretty much expand from exercise to whatever size is needed. Though we’ve all seen photos of shockingly-massive bodybuilders, much of the muscle size they have is in these muscle groups. The fact that babies are considerably more adorable than, for example, steel weights, gives us the motivation to keep picking them up. Weightlifters, however, are not looking to build up or enlarge those fine-motor muscles, which are usually invisible even in the most defined physique.

The wrist problem occurs because those fine-control muscles, of the hand and fingers and forearm, are threaded though a remarkable system of lubricated sheaths to keep everything operating smoothly. They are threaded through notches to keep them from tangling or getting caught on angles of our bones and joints, and they slip through guide-channels so that they don’t restrict the range of motion of our joints. With enough repeated exercise, just like lifting a barbell, those little muscles get stronger—and bigger. If they get even a little too big, they start rubbing the inside of the sheath they pass through, they rub against each other, and they don’t slide as easily through their notches. This leads to irritation, inflammation, and pain. Carpal Tunnel Syndrome is the best known of these, but there are others. Treatment is simple, if inconvenient with a baby around. Immobilize the problem area, ice if possible, and anti-inflammatory medicine like ibuprofen.

This leads to the important question of this post. The same question has come up before and probably will again. What, exactly , is my job?

I’ve worked in other practices where the pediatrician’s job is reasonably clear. Since I was paid a fixed salary and the practice was paid a fixed price per visit, there was constant pressure from management or the owner/partners to do as many visits as possible. There was never any kind of incentive, even appreciation, for doing a good job, being thorough, ending a visit without the child screaming and traumatized.

When I started my own practice, I wanted to do things differently. I knew, of course, that the business model of the factory-production design of medical-care delivery was the way a doctor could earn a living. There are some really good reasons that nobody else practices the way I do. Still, I wanted to have the feeling of taking care of kids and dealing with the whole person.

That sounds great, but it is so different from my training and experience that some really confusing issues have come up. In the 8-minute pediatric visit, the doctor has decided that your kid’s upset stomach is from a virus and not appendicitis, tells you to keep up with fluids, and has left. That, to be blunt, is the standard of care. Teasing out the history of stomach aches, the recent weight loss, and a recent history of food refusal could take an hour, especially if the doctor actually tries to ask the child. And what about symptoms in the parents? These could hold an important clue to what could be going on in a child.

Where does my care of the child end and care for the parent begin? All of my insight about postpartum depression stems from my belief that it’s not all about the mother. It’s the mother-baby system that somehow isn’t working optimally. Helping the mother is de facto helping the baby, who is indeed my patient. In the same way, I would strongly urge any parent to wear a bicycle helmet. My patient needs you. Without a head injury.

Which leads to the case at hand. A mother, mid-30’s, was in today with her baby. The baby was fine, but mother was wearing black neoprene wrist supports. I asked what was going on. She said that she had been having wrist pain and went to her doctor, who told her she had carpal tunnel syndrome. Here’s where my role gets confusing. What could she be doing that could give her carpal tunnel syndrome in both wrists at the same time? I didn’t think she was working in a parts-assembly factory or on a computer since the baby was born 3 weeks ago. She wasn’t, she confirmed, and after asking her a few more questions, it was clear that this wasn’t carpal tunnel. Do I tell her her doctor was wrong?

She pointed to where it hurt, which was the same on both left and right. Uh, that’s not where carpal tunnel hurts. It wasn’t where nursemaid’s wrist hurts, either, and that was what I had been thinking. I touched where she said it hurt, and she confirmed a little bit of pain. I asked her to hold her hand bent in a certain way, then I pressed her thumb across her palm. This hurt a little, too. In this position, I pressed on the spot pointed out by the arrow in the picture above. She jumped. This was the Finkelstein Test—I’m not making that up. I know, it sounds like an algebra mid-term from high school. (He published this in the late 19th-century, I think.) Her reaction led me to her diagnosis.

DeQuervain’s Tenosynovitis isn’t something that people assume they have. It occurs mostly in women, mostly in their 30’s and 40’s. It is thought that long before Dr. DeQuervain stuck his name to it more than 100 years ago, it was known as mother’s wrist.

If a little knowledge is a dangerous thing, what about knowing about the Finkelstein Test? I suppose it would be right to say I couldn’t be positive about her diagnosis, but I was pretty sure this is what she had.

Here are some of the issues for me as a physician:

I’m not a doctor for grown-ups. Do I mind my own business even if I think I’ve got a clue—and maybe they don’t?
Do I say something cautious like, ‘Maybe you should get another opinion.’ Isn’t my opinion another opinion?
If I say, ‘Have you looked into DeQuervain’s Tenosynovitis? It going around,’ what is the message I’m really sending?
If I say, ‘I believe you have DeQuervain’s Tenosynovitis,’ what is my next obligation? Do I have to treat it or suggest treatment?
What if I’m wrong?
How much work do I have to do, especially since I can’t get paid for any of it? Officially, the mother is not my patient.

I found some information on DeQuervain’s Tenosynovitis on the internet and printed it out for her. Treatment required a completely different kind of splint, which I also described. I don’t know the name of her doctor and didn’t ask who it was. But I deeply suspect that there were only a couple of reasons that she was still suffering in pain. Either the doctor didn’t know about this unusual diagnosis, or didn’t listen carefully enough to the patient. It was in her description of the the problem, the timing of its onset, and the exact location of the pain that eliminated diagnostic possibilities like carpal tunnel syndrome. I think these are both potential problems: a doctor who doesn’t know or a doctor who doesn’t listen. Nobody can know everything, and this is an unrealistic goal. But it would be great if doctors would spend the time to listen carefully, and then be open about not knowing. When that happens, good doctors hit the books.

As a closing aside, this is an ongoing pattern in Every Patient Tells a Story, a book about unusual diagnoses that I like a lot and reviewed in this blog a while ago. Though the author was kind about it, the first doctor to see these unusual problems often didn’t make a correct diagnosis. But at some point, all the patients described finally saw a professional who wouldn’t give up, even if they didn’t know. They reasoned it out, did what homework was needed, and got to the diagnosis. Of course, they weren’t paid more for this extra work than the doctor who said, because it would take the least time, ‘carpal tunnel syndrome.’

4/3/2011: A commenter asked for suggestions. This blog doesn't give medical advice. Indeed, I don't think it's a great idea to give medical advice without some kind of an examination. Of course, that never prevented my mother from giving medical advice. But I will tell you what I recommended for the mother written about above. Exercise: this problem, like other repetitive-use types of problems requires rest, not exercise. Stretching just to the point where pain starts might be helpful, along with ice on the problem area after it gets used a lot can help with inflammation. As described above, I suggested that the mother get a 'hard' splint, one that will hold her hand and wrist in a fixed, natural position, and will tend to prevent her from holding the baby's weight on the painful muscles and tendons. I told her to get a wrist splint that wrapped around the thumb, and had a rigid (usually slightly bendable aluminum metal) spine on the wrist/palm side to hold her hand in a comfortable but fixed position, even when picking up the baby.

A Baby with Diarrhea

2010-07-30T05:10:00.000-07:00

The mother that called me wasn't in a panic, and that's usually reassuring to me. She told me that her 3-month-old baby had diarrhea for 3 days. At that age, with nursing well-established and generally consistent growth, they can usually weather a brief illness without too much difficulty. But I asked the usual questions. He didn't have fever or a rash. He didn't seem to be in pain, he wasn't unusually irritable. In fact, he was nursing as usual, seemed happy and playful as usual, and was having a lot of wet diapers, as usual. But he was having diarrhea in small amounts a dozen or more times a day. It started 3 days ago, and nobody else in the family was sick. Did they change what he was getting? I wondered if they had started to introduce a baby formula to which he was having some sort of reaction.

"No formula," his mother said. "Except...," she paused here with a giggle. “Well,” she said, “we were in McDonald's and the baby was hungry and he kept looking at us and seemed to be grabbing at our food. So we took a little piece of cheeseburger, kind of mashed it up, and fed it to him. He really liked it! We were careful not to give him a lot though. Everybody knows that kids shouldn’t eat too much fast food.” The diarrhea started the following day.

“Oh,” I said. “Uh…did you give him anything at home?” I had a feeling about what to expect.

“Well, he liked the cheeseburger so much that we wanted to see what else he’d like. We were having spaghetti, so we gave him some of that.”

“Sauce of some sort with that?”

“Of course. Who eats spaghetti plain?” Not 3-month-old babies at their house, for one. Within the last 3 or 4 days, the baby, who had never had solids before, had at least a little bit of cheeseburger, pasta, marinara sauce with meat, mushrooms, at least 2 different kinds of sausage, several breads with and without butter, and just about everything else the parents ate. And, the mother pointed out, “He really liked the ice cream.”

Usually, the first solid food we introduce to babies is rice cereal. Sometimes it's as early as 4 months, sometimes as late as 6 months. Much later than that is still compatible with life, of course, but the nutrition seems to be less complete, the child doesn't learn the skill of eating, and the maturation of the digestive system is delayed. Aside from This Island Berkeley, perhaps, places where nursing is the exclusive source of child nutrition extending well beyond a year are usually places of great deprivation.

The recommendation of starting with rice cereal has some sense behind it. You may know people who have reactions to wheat or just trouble digesting it. But though possible, this is much less likely with rice. It's reasonably inexpensive, and readily available in the supermarket, fortified with iron. It can be mixed with breast milk, formula or water. It cam be put into a bottle or made thick enough to stand on a spoon.
The iron is important. Formula in this country is fortified with iron. Breast milk has little iron, but what it has is especially absorbable to the baby. Even in Red States, babies don't generally get a lot of beef or related high-iron foods until they are walking. As the first year goes by, the store of iron-rich red blood cells inherited from the baby's mother are gradually used up. By 9 months or so, these are all gone, and babies whose diets are low on foie gras don't have a lot of concentrated dietary sources. That's why we test every 9-month-old for iron (hemoglobin level, actually) at their well-child visit.

Here's what happens, as every parent knows. The first time a spoon of cereal goes in their mouths, babies scrunch up their faces and scrape the stuff off their tongue and out of their mouths. Never having had anything like this before, they wonder why you are putting a spoonful of what could be sand in their mouth. It had never occurred to them that food could come in some form other than liquid. They get the idea eventually, of course. This process, often requiring patience and persistence, is important. It's not the nutritional value of the cereal that's so essential. It's the learned skill of manipulating solid food in your mouth to get it to go down the right way without choking. We've all had that horrible sensation, and we've had a lot of practice. For a baby, this is a skill for life. Still, rice cereal is bland and not every baby likes it.

This is a good spot to tell an absolutely true story, which I freely share with many first-time parents who struggle with teaching a baby to eat. In my graduating class at medical school, there were about 100 graduates. Every one of them—with no exceptions—was on solid food. At this point, most of these exhausted and frustrated parents look at me and wonder if they picked the right doctor. Every one of my medical school classmates, I assure them, learned to eat solids at some point between being 4 months old and medical school. Though I couldn’t say exactly when.

I’m happy to report that the baby with diarrhea didn’t have a dreaded infectious gastroenteritis. Or if he did, it just happened to resolve at the same time he stopped getting his meals at a drive-though window. Do you want fries with that?

Technorati Tags: infants,pediatrics,diarrhea,childhood illnesses,child development

Mystery Diagnosis--The Streak

2010-07-27T04:42:00.000-07:00

Sometimes it’s easy to figure our why parents call when they do. If a child is sick, most parents have no problem recognizing this. Most people are empathic enough to sense when a person has difficulty breathing, or is in pain or distress of some sort.

Sometimes, this is a language problem. It’s probably not a great idea to speak loudly about a movie that bombed at the box office while going through airport security. And it always gets my attention when parents tell me that their baby had a hard time breathing last night. True, a complaint like this is one that will usually get a doctor’s attention. But if you take advantage of this too often, the doctor could decide you are just crying wolf, and gradually take your complaints less seriously.

Today, a nice couple came in to the office with their baby. They had been up all night and said that the baby was having trouble breathing. I sat up. Maybe I didn’t really sit up, but instead slouched a little less than I usually do. After several minutes of interrogation-like questioning, it was clear what the baby’s real problem was. He was having trouble breathing…through his nose. This can be a real nuisance for a nursing baby, since they can’t really nurse and breathe at the same time with a stuffy nose. Still, from the doctor’s point of view, it’s a long and reassuring distance from having trouble breathing.

There are also parents who are generally less anxious. I try and fail to contain my surprise when a child is brought to me with severe symptoms that have been going on for a long time. Every doctor has cases like this, some tragic. For pediatricians, a typical example would be asthma. Several times a year a child comes in whose parents say that she’s coughing. For how long, I ask. ‘Maybe a year,’ they say.

I don’t fault these people. If the kid was really in trouble, they would have sought help right away. For some, coming to the doctor is a logistic nightmare consisting of taking time off from work, getting the kid transported, parking expenses, and lots of other incidentals. (As an aside, it’s easier if the kids actually like going to the doctor.) Besides the general pain-in-the-neck quality to doctor visits, there’s a natural inclination—often correct—to believe that medical problems that aren’t too bad will probably get better on their own. Even though I am often sent unusual and difficult cases, many times I have to tell parents that I don’t know what is causing the symptoms they report.

This brings up an extremely important but subtle part of good medical education and experience. Some people believe the smartest doctors can diagnose the most exotic problems. That’s certainly a great and useful skill. But in primary care practice, especially pediatrics (and, I suspect, geriatrics) where the patients often can’t answer your questions, it’s often most important just to be able to tell worrisome or not. So though I didn’t know exactly why the baby was congested, I had no idea why the baby was fussy last night, and I didn’t know if the fussiness would happen again tonight, I was confident that the baby was generally OK and would continue to thrive despite having a stuffy nose.

This ability to assess some kind of worry-worthiness grading system seems to be in all of us. Obviously, some are more anxious than others, and they will grade a threat-level higher than others.

So it’s not bad parenting that led to the call I got about 4:30 this afternoon. A mom called and said that her daughter, 6, had a rash. How long had the rash been there? At least a month. I asked more questions, and they decided to come to the office and let me take a look at it immediately, which I did tonight.

Memory is a funny thing. Sometimes a visual image will stick out like a stone in your shoe. It’s pretty common for people to say that they know they’ve seen something before, but have trouble placing just when or where. And I wish I knew why people can look so familiar but I just can’t come up with a name. This happens to me locally all the time. Someone will stop me in the supermarket, for example, and say, “Hi Dr. Wolffe.” I return the greeting but don’t even recognize the person. Then from another aisle comes grandma with the kids, and I’ll know exactly who they are. I’m so focused on the children when they are here in the office that sometimes the adults look familiar, but without the kids they are sometimes hard to recall.

The mother said that this girl hadn’t been sick, and this developed over some period of time—she wasn’t really sure how long. Maybe it was a week, maybe several weeks. The girl said that it was itchy, but it hadn’t been scratched and she wasn’t scratching it in the office. It was a little flaky, possibly a little red. It didn’t hurt. It had been there for at least a month. It did feel a tiny bit raised, dry. Mostly, though, the impression I got was that it was lighter than the surrounding skin and wound like the Andes from her upper arm to her wrist.

The first level of diagnosis, for me, is figuring out if I have to worry about it. She had it for a month, for goodness sake, and the kid was none the worse. She was happy and playful in my office. I looked the kid over, and she was fine. It’s certainly true that there are diseases that appear to get better and then return. But most of the bad things generally just get worse, or at least don’t get better.

The next question for me is if I know what this is. I didn’t know. But I knew I had seen it before. But where? What was it called? I think that I am a reasonable diagnostician because I have real difficulty putting this aside and catching up with all the work I really have to do. I eliminated the rashes that cause light streaks on the skin, but are there since birth. I crossed off the ones that hurt or itch a lot or come from trauma of some kind. And the ones that are very smooth or very rough or whorled like a cowlick. So the diagnosis gradually came to me, but I hadn’t seen it in so long that I couldn’t be sure. I excused myself from the exam room, and went to the computer in my little office. It wasn't helpful. I went to a reference textbook. I looked up what it was…and I had been, well, close. This was Lichen Striatus, a bizarre thing that preferentially appears in girls (no one knows why), of age 3-6 or so (no one knows why), usually affects a single extremity (no one knows why), and goes away by itself after some weeks to months (no one knows why). No one knows what causes it. It doesn’t seem to do any permanent damage, and generally needs no treatment.

(This is a good example, however, of the incremental information value of an analog book. I was thinking right, and knew what kind of rash it was. My first guess was indeed Lichen Striatus, but I couldn’t remember the right name. I kept thinking, ‘Lichen…something.’ Honestly, I confabulated a last name for this disease. I looked in the index for ‘Lichen Linearis.’ Seriously. There is no such condition, and perhaps if my Latin training had been a little more thorough—or I had paid better attention—I would have realized this. I had unintentionally taken a word from a real but unrelated problem called Lichen Planus Linearis (which I didn’t think this was), and stuck it in the empty spot, like a medical MadLibs game for doctor geeks. I looked it up on the computer—but could not find the misnamed disease. It was only when I went to the textbook and leafed through the index section starting with the word Lichen that a bell really rang for me. Then when I saw the textbook pictures, I knew I was right. This is the difference between going to the library to find a book on the shelf and getting the book, fully scanned, online. Sometimes what is most valuable isn’t what you’re looking for, it’s what’s next to what you’re looking for.)

I forgot to ask the mom why, today, she called to have the child seen. I’d be interested.

Headache in a 5-year-old

2010-07-23T05:57:00.000-07:00

Molly, 5, had an eye problem. It was pretty common, and her eye doctor recommended that she wear a patch on one eye several hours a day. She didn’t mind this, and she and her parents picked out all different designs for the patch that might suit her mood or fashion requirement. Usually, the patch is worn over the stronger eye in order to force the weaker one to get more exercise.

So when her mother told me that she had a headache, my first guess was eyestrain. It's a common cause of headache at almost any age. But still, 5-year-olds don't often complain of headaches.

Her mother was sympathetic. She told her child that she'd get some medicine for her that would help her feel better, and went to the cabinet where they keep the acetaminophen. It was only a few steps away, but Molly started crying. She said that it was still hurting. Mother repeated that she would give her some medicine that would help. Molly said that it wouldn't help. Mother said, calmly, that she thought it would and that after the medicine they would lie down in the bedroom together until she felt better. Molly said that it wouldn't help and that it was going to get worse and it was getting worse right now and she didn't know what was going to happen and that it was still getting worse and medicine isn't going to help and nothing is going to help and she was really scared. Molly was screaming by now, continuing to express her fear and pain. Mom had picked her up, of course, and was doing her best to settle her.
She did the best thing she could think of, and took her into the bedroom. They lay on the bed together, with Molly in her mother's arms. Soon, Molly fell asleep and was better a few hours later when she awoke. When mom told me the rest of the story, I told her I wanted them to come to the office so I could speak to Molly in person.
Fortunately, Molly is smart and talkative and likes me as much as I adore her. She told me that her eyes didn't hurt when this happened. Her mother told me that there really wasn't a family history of migraine.
Though in my training I received a little exposure to migraines, even now this is generally thought to be uncommon in children. I have a feeling that isn't right. I have diagnosed migraine in children as young as 5, and there is often a family history. Their symptoms are usually just like adult symptoms. I wonder if these kids have headaches or stomach aches from even younger ages, but lack the expressive language to tell us. In this way they suffer without relief, and their doctors never get the clues they need to make the diagnosis. I would guess that a toddler with a headache is pretty cranky. So I wonder if some emotional or behavior problems in these younger kids--who knows? maybe babies, too--could be resulting from this kind of invisible problem.

But Molly didn't fit an identifiable migraine syndrome. She didn't have any problem with her brain that I could find.

I asked if she would get headaches when she was outside in the bright sun. Her mom said that she didn't have one when they went to the local county fair the previous weekend. They were outside all day. They went to the petting zoo--but she didn't go in. Her brother, just 2, had no hesitation and had fun with the gentle animals. In fact, the closer she got to the fence around the petting zoo, the more upset she had become. She even was scared to see her brother near the animals. I asked her mother about other things she was afraid of.

The list was long. She was scared of just about any animal that was live, any bug of any kind but especially spiders, snakes, dark places including closets and under the bed. I asked Molly, and she was open with me. She said that she was afraid of being separated from her family, she was afraid that something bad would happen to her mother, to her father, to her brother, to all of them together, and to herself. She was afraid of strange and new places, new foods. She was afraid of snakes.

Now, with a little more insight, I asked her about the headache. She said it had hurt. This time I asked her more about what she was feeling during the headache. She said that she was very afraid that it wasn't going to get better. She was afraid that her mother wasn't going to be able to help her and that would make her mother feel bad and it would be her fault.

It's always concerning to me when a 5-year-old complains of a headache. I think Molly had a headache, and I'm not sure what caused it. But though it's not in my textbooks, this is what a panic attack looks like in a preschooler. When I told her mother this, she was able to think of a couple of other unusual meltdowns that seemed to come out of nowhere. They weren't for the usual reasons, when a parent says that the child can't have ice cream for dinner or has to turn off the television. They weren't about defiance, they were about worry. And each time, her mother felt powerless to stop them. In many ways, these events might look behavioral. They include crying, perhaps screaming, maybe pounding fists or feet.

It's the panic attack that made her reaction spiral out of control. Her mother had the right treatment for a headache. Some acetaminophen, closing her eyes in a dark quiet room. But I had to give them something that could make the panic attack less traumatic for the child—and maybe for the mother, too.

I gave the mother a pair of questionnaires I give to parents to help me evaluate anxiety disorders in children. The responses were convincing.

Though Molly had a clear anxiety disorder, she had some big potential advantages as I considered her treatment options. She was smart, she was verbal, and she wasn't afraid of me. The first two points would enable her to cooperate in her treatment in important ways. The last one would, I hoped, enable her to accept my guidance without her anxiety interfering. I discussed treatment options with her mother. She, too, thought that Molly's particular trust in me was worth exploiting to help her.

Often, with generalized anxiety that includes aspects of the diagnostic subcategories (such as social anxiety disorder, separation anxiety, phobias, and so on) medication is a reasonable approach. But we had these advantages, and her mom and I wanted to try and take advantage of them. We could always revisit a medication option if other approaches didn't work.

I could have sent her to someone really good at Cognitive Behavioral Therapy. In 5-year-olds.
This approach is designed to help patients recognize their dysfunctional thoughts, and manage them in a rational way. Though the technique is well-known in adult psychotherapeutic circles, it's not so well developed for kids. And certainly not with preschoolers.

In the bigger picture, however, the effects of Cognitive Behavioral Therapy, I think, can be thought of in the same general pool with meditation, yoga, prayer, and clinical hypnosis. They all help people (nothing works for everybody—each helps some people) get relief from thoughts and feelings that are painful or harmful.

What her mother decided was to let me try to teach her self-hypnosis.

Technorati Tags: preschoolers,headaches,anxiety,anxiety disorders,pediatrics,self-hypnosis,phobias,panic attacks

Vaccine Refusal and Ethical Issues

2010-07-18T04:15:00.000-07:00

All the families who bring their kids to see me know that, in general I’m a supporter of childhood vaccination. On balance, the risk to your child of a devastating or lethal disease with known and terrible effects seems to dominate the risk of vague eventual possibilities of problems that are either unproven or completely debunked. This post is not about why you should vaccinate your baby. Though you should.

I’m in a pretty privileged position. None of my patients comes to me just because my name was on the list from the insurance company. A parent picked me, researched me, got my name from a friend or coworker. Sometimes, I’m gratified to say, they get my name from a nurse in Labor and Delivery or from one of the lactation consultants or midwives. Some of my most difficult cases come to me on the recommendation of my pediatric colleagues who have practices of their own.

So it’s what is generally called a self-selecting group. They are here because they want to be here. When parents expecting their first baby come to interview me, many don’t know my views on vaccination. Perhaps it’s a result of being located here in Berkeley, but I don't get parents who have heard that vaccines are harmful, and want to learn my professional opinion. I get those who say they want me to be their child's doctor because they have read or heard about me, but have made up their minds about vaccines. I wonder what they really want from me. If they don't want my medical expertise, they why are they coming to me? How can I help them? I hope that I will always provide the best care I can, but I was not trained in and do not know how to provide some reduced level of care.

What prompted this observation is a comment I read on one of the informational websites for physicians. A very smart academic doctor pointed out that when we treat families who refuse vaccinations, we are really being asked to provide substandard care. He argued that if we send these families elsewhere, we have lost the opportunity—perhaps many opportunities—to educate them and help them appreciate the value of this intervention.

It makes sense to engage with these parents. Most of them are extremely well-educated and literate. I would love to give them literature on the subject, cite references, tell them my own horror stories to counter the ones they heard from the internet, the parent group, or in the check-out line at the local organic market. I'd love to tell them that one of the local Montessori schools was closed twice in the last year by the Public Health Department for being a center of major pertussis epidemics. But I get the sense that they are not interested in receiving this information, or perhaps just not from me.

The parents of every child make essential health decisions every day. They manage the diet, activity, and safety of their children. Hopefully, they balance protection with freedom, and find a way to let the child ride a bicycle but still make them wear a helmet. I don’t think I’m the only one who is shocked when driving in a parking lot and a toddler is walking along without holding a grown-up’s hand, while they walk far behind, texting. That’s not OK! I keep my mouth shut when this happens, but I mutter unflattering things as long as my car’s windows and doors are closed.

But I am required, as much by my own standards as those of my state licensing board, to practice at very least at the standard of care. If the kid needs an antibiotic, I prescribe an antibiotic. For this reason, doctors shouldn’t be complacent with the nonvaccinating parents. It seems like a strategy of engagement is a reasonable way to go.

But I'm scared. In the past couple of weeks, I saw in my office a pair of former preemie twins. They are now about 6 and 8 pounds or so, and just got out of the intensive care unit. They are over 2 months old. Having unvaccinated kids in my office would seem to put them at substantial incremental risk. What is my responsibility to them?

That's not the only reason I have problems seeing unvaccinated kids in my practice. I feel so strongly about the importance of a meaningful doctor-patient relationship that I'm unclear about my role in their care. If I prescribe a medication to help your child breathe but you don't give it to your child, and instead use what your homeopath recommends, why did you consult me in the first place? If HIB vaccine could save your baby's life (or brain) but you refuse it, how much trust do you really have in me, my judgment, my training? It's better to bring your child to an advisor you really trust, whose expertise you respect, who can provide the care you really want and value.

I have absolutely accomplished one of the goals I set out for myself when I started this practice. I have patients and families that I know and who respect my guidance. This is probably a logical point at which to note that this doesn’t mean slavish obedience! I expect my own doctors to give me their very best professional advice, and in return I promise them—though this is unspoken—that I will take it seriously and do the best I can. I haven’t always followed what they suggested. Occasionally, I thought they were wrong, or didn’t understand all the aspects to my situation or complaint. Most often I just couldn’t do what they wanted. I couldn’t afford it, couldn’t spare the time, couldn’t make it work for me in some important way. But it has never been because I thought they were stupid, uninformed, or malicious. It wouldn’t say good things about me if I continued to go to a doctor like that.

So if I recommend that you let me painfully inject into your baby something you believe to be poisonous, toxic, or unproven, or if by recommending this your belief is confirmed that I am little more than a meretricious shill for the Big Pharma cabal, why would you want me to see your child?

Sometimes, when the prospective parents are interviewing me but before they storm out of the office, the reason comes out. I’m not really going to be their baby’s doctor. I’m the safety net for the naturopath, homeopath, or chiropractor who will really be managing the baby’s care. Then, if something goes wrong, they can bring the baby to me.

So the first ethical problem I have with treating families that don’t vaccinate is the fundamental nature of their request. They have asked me, with their full consent, to provide substandard care. When asked about this, a physician said that it was like the family refused to use a car seat for the baby. They ask the pediatrician, however earnestly, ‘What’s the best way to hold the baby while driving?’ Not only isn’t there a good way to hold the baby, but it would be unethical to do the research which could tell us if holding one way is 100 times more potential lethal than using a car seat but holding a different way is only 92 times more potentially lethal than using a car seat.

This is a line from a common translation of the Hippocratic Oath: I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. There isn’t much about doing less than my ability because the helpless baby has parents with...issues.

But the second ethical problem is obvious. Though it doesn’t come up in Hippocrates, it’s a central tenet in medical ethics. Autonomy. The patient has the right to make decisions about themselves and their treatments. With children, it’s generally understood that this means that the parents get this autonomy. When exactly this ends, by the way, is unclear. Legally, kids who are 18 acquire most of the medical rights of adults. This is confused, of course, if mom and dad are still paying for the health insurance. And, varying state by state, teenagers of a certain age can ask for and receive contraception or contraception counseling. Sometimes psychological services. Babies...not so much. Our society makes an implicit assumption that a baby’s parents have the best interest of the child at heart. Luckily and almost always, that’s true. The parents who choose not to vaccinate aren’t trying to hurt their baby, they are trying to protect it in the best way they know. Given this complete and unquestionable lack of malice, don’t they deserve the autonomy we all expect?

And one more thing. If a parent came to my office obviously intoxicated, I wouldn't let them drive home. Maybe I’d call a taxi, maybe I’d drive them home or call someone to pick them up. I would intervene in some way to protect them, their child, the community of unsuspecting and unwarned drivers on the road who all agree to follow some shared set of rules that protect them all. I don't know how to resolve this ethical dilemma between their autonomy and my responsibility. When they decide not to vaccinate, it's not like holding the baby without a car seat—it’s loosening the straps a little bit in every baby's car seat. What's my obligation to them?

So I think there’s a third ethical problem: my responsibility as a physician in the community, perhaps as a citizen. It would be wrong to cry out, ‘Fire!’ if there was none. But do I have an obligation to cry out if I see one?

Anxiety—College Boy Problems

2010-07-16T07:31:00.000-07:00

Before I met with Peter, the 21-year old college boy with anxiety, I asked his parents if there was anything they were concerned about. He said, “Well, it would be great if he were a little more outgoing.” I hadn’t seen the boy in a couple of years and didn’t really know him well since he didn’t go to the doctor much. Was he shy?

An hour or so later, with them waiting patiently outside the exam room, I knew he had a full-blown anxiety disorder. Many people have some anxiety in certain situations, like public speaking. Some people have more focused anxiety about specific things, like spiders or heights. Some have anxiety about things that they themselves know intellectually to be fairly harmless to most other people, such as a fear of balloons. Some fears are so unusual that the person is able to talk about them freely, and knows that they are not an issue for everyone else they have ever met, but the fear is quite real to them. Perhaps a great thing about the internet is that it can give this last group of people the ability to connect with the 1 or 2 or 5 other people who share their unusual problem. By example, there is a community, of sorts, for those with a fear of buttons.

He lived at home with his parents. There’s nothing wrong with that, of course. His parents were nice people and nice to him. And they never threatened to kick him out. They probably never would. That’s a nice thing, too.

But he never indicated that there might be advantages to living away from his parents. More than that, he couldn’t fathom why anybody his age would want to move away from home. It wasn’t like he was so emotionally tied to his parents. I had spoken with them, though not about him. They went on vacation, sometimes camping. They went out to the movies sometimes. Most of the time, I learned from Peter, he never wanted to go. I could picture a dysfunctional relationship in which he didn’t want them to leave, but he never objected. He was most comfortable just staying at home. Alone.

He wasn’t psychotic about his anxiety. He didn’t believe (or say he believed) that if he rode the bus then the world would end by a volcano emerging under his suburban town just as a meteor hit the earth causing an rip in the space-time continuum which would provide an attack opportunity for the Monsters from the Id.

Still, I had a bad feeling about where this was heading. Unlike the College Girl I had seen just a day before, he was not tortured by his anxiety. He knew that others weren’t as concerned as he was about many things, but the way he thought was obvious. Every unusual fear was completely reasonable, and he was almost bemused about the mad foolishness he witnessed around him. To him, our riding in vehicles of all kinds appeared like those who walk tightropes over great gorges. He saw that people did it, that they could do it regularly, but you’d have to be positively nuts actually to try it.

This is also how he saw the pursuit of human relationships. This was another big difference with the College Girl. She didn’t have a boyfriend and wanted one. She absolutely did understand why her peers were in or wanted to be in a relationship. She also understood what was keeping her from achieving this goal. She perceived her anxiety as a handicap that she hated, a roadblock she was desperate to overcome and was so far unsuccessful at doing so.

Was he really forthcoming with me? Like every patient, he was entitled to his privacy and owed me no explanation. Some doctors, I know, think that if a patient isn’t open about something, or if a patient fabricates something, then they can’t or shouldn’t help them. It’s certainly an impediment to treatment when a person doesn’t seem to respond to medication that they say they are taking but aren’t. But mostly if patients want me to give them my best advice and they want advice based on some hypothetical situation, that’s what I and they will be stuck with.

Is this denial? Once I saw a child who had been in and out of emergency rooms at least 4 or 5 times over several months. Every time the family went in with him, he had trouble breathing. He was given breathing treatments and medication and sent home to follow up with his primary care physician. They didn’t give him the medication, didn’t make the follow up appointments. They needed a form filled out for school, and the doctor told them that the child had asthma and would benefit from better control of his symptoms. They changed doctors, and came to the practice where I used to work. I told them their child had asthma and would benefit from better control of his symptoms. He went to the ER again, then they asked for their records to be transferred to another practice.

Is it my job to puncture his denial, if it is? Is it my role to judge his life decisions as somehow inadequate, as incompatible with happiness? Is my definition of happiness and success as an adult a reasonable goal? There are societal norms, of course, and he was aware of these. Marriage, family, work, kids, and so on. Certainly here in one of the epicenters of alternative lifestyles, there aren’t a lot of choices that wouldn’t be tolerated. Besides, I lived in Utah for 3 years. In ways that I appreciate more from a distance—topographical, chronological, and metaphorical—some of those people were very much willing to do a lot to live outside of the mainstream. Whether in shallow swamps of consanguine genes or in isolated heavily-armed bunkers waiting for the race-war end-of-times, they were going to do it their way.

Let me be explicit about some of the ethical issues associated with this case.

1. If the patient doesn’t think it’s a problem, is it a problem? Before there were Wall Street executives who didn’t take any responsibility in their congressional testimony, there was a panel of Tobacco CEOs who swore under oath that they didn’t believe that smoking caused health problems. That seemed sleazy and dishonest. But if a patient says that they are just fine with what they are doing, does it matter if they are in denial or are out of touch with reality? Does the doctor have an obligation to do more than educate, inform, and offer help?

2. Is Peter hurting anyone else by his inattention to his anxiety disorder? Sure, his parents had dreams for him that might be difficult to achieve. But who among us has parents who have always thought that we would be exactly who we are now? I am, to be blunt, worried that what appears typical enough at the moment—a college kid living at home while attending a decent and popular local institution—could become more cumbersome as the years go by. Do his parents deserve a life of their own, without their kids? Do their kids owe them the freedom gained by moving the heck out of the house at some point? And the parents aren’t my patient, so should I care what they need?

3. I want to repeat that last part. The parents aren’t my patient. This is an easy issue for some of the patients I see. I have a patient who’s nearly 30 now, severely developmentally delayed. I have autistic kids who are technically autistic adults. It’s an easy issue for them because they have legal guardians and decision-makers. Not Peter—he’s warm and smart and going to college. But in some ways, obviously from these essays, I think of him as having a handicap. It’s not politically-correct, I know, to use that term at all. But there’s something about him, that is with him in every setting, that often interferes with his achievement of some of his own goals. It interferes, in my professional opinion, with his ability to meet some criteria of independent—if not happy, perhaps—adulthood. The Americans with Disabilities Act of 1990 says a covered disability is a physical or mental impairment that substantially limits a major life activity. What, if anything, should I tell his parents? That their kid is sick and needs to have medication spiked into his orange juice? I want to tell them everything. They are his best advocates, they know something isn’t right. He gets along well with them. Shouldn’t they be there to encourage him to seek the help I think he needs? A lot of parents read this, and would probably agree. But what about when you were 20—would you have wanted your doctor calling your parents?

Anxiety--College Boy

2010-07-13T05:42:00.000-07:00

Peter was at college here in Berkeley, and needed a physical exam form filled out for a summer job he had applied for. He came in with his parents. I asked them if they were worried about anything in particular and they said that he had been very healthy. But they wished he'd get out more. Maybe be a little more...outgoing. He looked very relieved when his parents left the room.

"Gosh," I said, "I thought they'd never leave!" He smiled briefly. I asked how college was going, if he had a major.

He said, politely enough, looking at the floor, "It's going OK. Don't have a major." Didn't I recall that he was interested in Economics? "Yes, but I didn't get a good feeling from those people." Meaning, I took it, from those in that department. How about people in other departments? I told him I thought there was a lot to be said about finding a group where you feel like you fit in. "Maybe, but I don't fit in." Still no eye contact.

"You haven't made a lot of new friends?"

"None, really."

"Are you in touch with your friends from high school?"

"I had two friends in high school but they are going to college in Hayward [Cal State]." It is a sad fact of suburban life that the logistics of socialization are often very cumbersome for children. (This is very different from my experience growing up where public transport was great and cheap.) But he was 21, not 14. What about borrowing a car from his parents? "I don't drive."

"Why not? Didn't they have driver education in your high school?"

"Yes but I stopped taking it after the first day. It was just too dangerous." But his mom and dad drove, I pointed out. "But I won't drive with them at night. Anything could happen. No," he added for emphasis, "I definitely don't want to drive."

Most 16-year-olds have, at least in their minds, cut from magazines the photos of the cars they want to have. A car, or access to one, or even without access but having a driving license, meant adulthood, liberation from the control of their parents, freedom. Most American teenagers have much clearer dreams of owning their own car than they have of owning their own home someday. I think that this is less prevalent among those growing up in urban settings. (A wealthy high-school classmate of mine had his own car, but I don't know where he drove it (let alone parked it) and neither I nor most of my other classmates were envious.) But this is California, where having a car or wanting one is or should be considered an essential developmental milestone, like walking or potty training. When he said that he didn't want to learn to drive, whatever alarms were not already ringing for me started to go off. "What about going to Hayward on BART?" [Bay Area Rapid Transit--a not very extensive system, but fast and reasonably comfortable and clean. And ] I knew he lived in a town with a station.

"That goes under the Bay!" he explained as if I has somehow been misinformed about this fact. But it didn't between Berkeley and Hayward.

At some point, I stood up to wash my hands and examine him. I went to put my stethoscope on his chest, but stopped. "Gosh, Peter. Have you been gardening? Working with paint solvents?" His hands were red, very dry-looking and irritated. He denied this but said that he washed his hands a lot. Mine were not so raw, and I typically washed them 20 times a day, sometimes more.

"I know. I'm a bit of a germophobe."

He was attending college locally. So I asked him if BART was uncomfortable for him, why wasn’t it a problem taking the public transit bus to school? He told me that he walked to his college campus, about 3 miles or so from his home. He admitted that not using public transportation was a real barrier to making and sustaining new friendships at college.

Continuing in this line, I was worried about what would come next. As I would ask any patient his age, I asked if he was dating anyone. I assumed that this would be logistically difficult for him, given his transportation constraints. He said he wasn’t in a way that concerned me. Sometimes I get a disappointed response, when the college kid wished they were dating somebody. Sometimes it’s a blissful yes they are. He looked at me at me with an odd expression of confusion. Now I was confused about why he was confused. I asked him to clarify what he was thinking.

He told me that he wasn’t dating and convincingly claimed not to know why people did. Let me be really clear here: I asked about just dating, nothing more intimate. Yes, he knew classmates in high school went on dates or wanted to and talked about it. He knew they did in college. I asked if he knew how his parents met. Like most of us, their relationship started with dating. But he didn’t really see why people did this. There were so many obstacles that he pointed out. Getting together in a certain place and time, which is a key part of the definition of a ‘date,’ is very difficult if one of the people has to be within walking distance of their home. Holding hands seemed unappealing to him, and kissing appeared positively unhygienic. I asked if he would like someday to have a family of his own and a mate. He said that he would but he didn’t know and couldn’t picture what kind of a person that would be or how he would get to there from where he was.

I spent about an hour with him, much of it trying to figure out the level of isolation to which he was willing to subject himself.

I told him he had anxiety. I recommended many things, including trying some medication. I was willing to work with him in any way that I could. He was willing to commit only to think about these choices, or if he wanted to do anything at all. So deeply did he see his perspective as an accurate view of the world that he didn’t see it as a problem in his life. I asked about continuing to live with his parents, and he didn’t see a problem with that, or limiting for school or work to a walking-radius around his parents’ house in Berkeley. Gently, I tried to point out that it might be difficult to meet somebody under these circumstances, but he was blind to this. He didn’t try to reconcile his dream of having a family with his disinterest in looking for somebody with whom to start that family.

Anxiety—College Girl

2010-07-07T22:28:00.000-07:00

Not feeling well for a weekend, getting through a really busy spell in your work, maybe just being exhausted and not getting a good night's sleep. Those are common reasons why people stop their regular daily exercise routine. It's not like they make a decision that the exercise they've been doing isn't a good idea, or even that they hadn't been enjoying it. But somehow the routine is broken. It's really hard to get started again. When you do restart, what came easily when you stopped is really difficult. It will take time to work up to your former level of fitness.

I got unusually tired and wasn't feeling well. My closest friend called and told me she had cancer. Suddenly, the effort that was required to keep this up just didn't seem so important. A series of moving patient encounters, together with a surprising amount of encouragement from readers both locally and around the world combined to get me off my lazy behind. My 2-month sabbatical from this blog, I hope, is over.

Jessica came to my office by herself last week. She was 18 now, and starting college. She’s been seeing me since she was a girl, and though I knew we got along well enough, I never got the feeling that she was entirely comfortable. This visit might be the first time I saw her without her mother. She had always been thin, but my perceptive assistant noted to me that she had lost about 10 pounds since the last time she’d been in the office.

She said that she wanted me to take a look at something on the skin of her leg. It had started as a bump a few weeks ago, about the size, she said, of a ‘mosquito bite.’ Maybe it was a little itchy at first, but she didn’t remember it being very annoying. After some time, she wasn’t exactly sure how long, the bump went away and an area of the surrounding skin on her leg was red. It wasn’t painful or bothersome. Over the last couple of days, the redness has decreased and there was a very small amount of skin peeling. When I asked, she said that it looked like it was getting better. It didn’t hurt, itch, burn, bleed, ooze, or interfere with anything she did or wore. I asked to see it. A little above her knee was an area about the size of a quarter with some faint pinkness and a few skin flakes. I asked if I could touch it, and found that it wasn’t warm, firm, soft, raised, or bumpy. She said that it didn’t hurt when I touched or pressed on it. There were no other such lesions on her. I was not very worried about it, whatever it was originally—and told her so. She should call right away, however, if it didn’t continue to improve a little every day.

I will inject as an aside that I believe the rapport that a patient—even a little kid—has with her doctor can be really important. It is very hard to establish that relationship with 6-minute visits. There are lots of other impediments established by current care standards. If you see a different doctor every time, if the doctor never seems interested in other symptoms you might be living with, if you’re made to feel like just another hot-stamped drop-shipped cog delivered through optimized just-in-time-supply-chain management into the inflexible assembly line of efficient health care designed to achieve least-common-denominator-acceptable outcomes for your particular diagnosis code in order to achieve maximal reimbursement from a 3rd-party-payer at whose toll-free-number you cannot ever reach a human, then you probably won’t really feel relaxed with your doctor. My patients of all ages, I hope, know that’s not how I work.

So when I told her to call right away if it didn’t improve, my hand was not on the doorknob. I didn’t even stand up to go. I simply asked her, “What else hurts?”

“Nothing much,” she said thoughtfully. “I mean, you know, except for the stomach aches.” I resisted the urge to smack myself in the head. Only gradually had I come to realize that bald as I am, a good smack might leave a red mark that could last an afternoon. Somehow, it was not as satisfying to smack myself on, for example, the ankle. I didn’t say or do anything except pay attention. “Sometimes they’re really bad.” With that her eyes filled with tears and so did mine. The exam rooms are stocked with tissues, but only one box. We shared.

She had been having abdominal pain for at least several months. It was very worrisome for her. She was afraid she had an ulcer caused by her anxiety. Anxiety? Forget the mosquito bite—what happened to the abdominal pain?

About an hour later, I had learned that she had a couple of jobs that she couldn’t keep because of her anxiety about many, many things. She had no problem with the academics of college but being in a classroom was a problem and if the classroom were filled with busy, social, chatting, comfortable peers it was an awful experience. She had sought professional help for this, I was relieved to learn. But the medication she was prescribed wasn’t helping her—and she was afraid of bringing this up. I offered to make that call, but she declined for now. She felt hopeless about the anxiety because the medication didn’t work. She said that she was worried that her abdominal pain could be something serious. Right after she said that, she said that it’s her fault because she probably has an ulcer that’s caused by her anxiety.

Here’s what I told her. Neither the anxiety nor the abdominal pain were her fault. This I backed up with a short neurophysiologic explanation of how the amygdala communicating with the prefrontal cortex can give the uncomfortable sensations associated with anxiety. I told her that though it does indeed seem like she has an anxiety disorder, people with anxiety disorders can get just as sick as people without.

I explained the curious history of peptic ulcer disease. For more than 100 years, an entire field of medical knowledge was based on the belief that it was somehow caused by intense or anxious or angry or unstable personalities. Idioms like Type-A Personality entered the daily lexicon largely based on this medical belief. It was all crap. Ulcers are usually caused by a bacterial infection in the stomach, which is typically successfully treated with antibiotics and Pepto-Bismol. (Even happy little kids can get ulcers, by the way, though this is quite unusual.)

I told her that it would be a medical error to assume that her anxiety had been the cause of her symptoms. It didn’t help, of course. But I suggested an alternative way of looking at her pain. Suppose there were some reasonable explanation for the pain and other symptoms that she described. Maybe when the pain was bad, she would become worried about it and if it were something serious. This, I pointed out explicitly, would be just how people without an anxiety disorder would think about it. If the pain continued, a person would be increasingly worried. As the worry increased, their senses would be focused on the pain, observing it carefully for changes. With this concentration, continued pain would be sharply perceived and the worry would just continue in an accelerating spiral. She had not looked at it that way. Besides, I said, I would really like to relieve that pain if I could. She deserved and needed the workup I would do for any young woman with chronic abdominal pain.

I informed her that though she might not have been helped by her treatment so far, there are many other treatments available. None of them works with everybody, but all of them work with some people. There’s at least a dozen medications she hasn’t tried. Has she tried a workbook? She said she had one but she didn’t want to do it because it might not help. She had not seen that she was too anxious to try an anxiety treatment. Maybe yoga, maybe hypnosis, I suggested. She hadn’t thought of those. I didn’t promise to make her better. But I promised I would try and I wouldn’t give up. I don’t know if that will be enough, but it’s all I had to offer. Well, that and calling the shrink. For now, I’m working on the stomach aches.

By complete coincidence I have had a series of patients with anxiety issues. Maybe there were more of them out there than I knew about, and maybe I wasn’t asking enough or the right questions. With teenagers, I screen everyone for depression. I get the feeling that’s not enough. I’ll write more about these young people.

The poster pictured above, stolen from the internet, is from a movie I have not seen. It’s apparently being shown as a double feature with Libidoland, by the same filmmakers. Not sure what to make of that. The tag line for Anxiety Acres is: “When Casey moved Kevin to the country, she hoped he’d find peace and quiet; instead he found new things to worry about: zombies, hitchhikers, and chocolate cake.” Who doesn’t worry about zombies, hitchhikers, and chocolate cake?

Technorati Tags: anxiety,psychology,teenagers,abdominal pain

The Empathic Family Meal

2010-04-27T04:38:00.000-07:00

In the last post, I’ve pointed out that a family meal is a good idea. At least by current research, there seems to be solid evidence that family meals are good things for your kids. When read critically, the research leaves many questions unanswered. Research shows that kids who eat regular family meals have lower rates of obesity. And lower rates of other problems. It could be that kids are less likely to have eating issues if they come from these cartoonishly-structured families. You know, the families where mom is in an apron most of the day at home and dad comes home from work about 5:30. It could also be that families that make an effort to get together and keep in touch with the lives of each family member are more supportive, and this is a key factor in prevention of obesity. Maybe just the fact of having a dependable dinner every night prevents that fast-food or pizza stop on the way home from school.

Since I’m writing this to encourage you to make a family meal part of your daily routine, or part of your weekly routine if you can’t do it daily, you should have an idea what an Empathic Family Meal might look like.

Those that follow my general take on parenting see that I encourage an empathic approach. The authoritarian, Top-Down Management model of parenting—as would be practiced by the family I described above with mom at home wearing an apron and so looking forward to the time her husband will give her permission to leave the bunker and freshen up their survivalist hoard—is not going to get a lot of support here. But because these families don’t move much (it’s just so inconvenient to pack up all the firearms), have stable family structures and menus that are easy to keep track of, they are heavily followed by researchers. That alone might skew some of the conclusions.

It’s both funny and foolish to look back on those family meals from our own childhoods or those we have witnessed. Sometimes they were opportunities for bitter parents to enforce conformity, where having an elbow on the table was an offense deserving of discipline. Children were there to be interrogated about their school or personal lives, and their attempts to keep certain parts of their lives private were never respected. Occasionally, parents who were either sadistic or indifferent would bring up the most humiliating issues at the dinner table. You know this is possible. It has happened to you or your friends. (These parents are the ones who in 30 years will have adult children that don’t talk to them.) So there’s a danger in the power structure of the family meal that I think has been ignored. Absolute power, corrupting as it does, has a nasty tendency to make the people sitting at the head of the table really believe that they are in charge. Like a president-for-life in a small ex-colonial country, they really believe that if they are happy, the family is happy.

Family meals do more than somehow help reduce the chances of obesity and eating disorders. They are a great way of reducing picky eating in younger kids, and getting children to try new--occasionally even green--things. This can be accomplished with an empathic family meal.

Here is the best way I know to get a preschooler to eat vegetables. Give them some guidelines, take them to the market, and leave them in charge. Start with a plan. Maybe your plan is that on Wednesday night, Eric is making dinner. Why would he? Is this just another unrewarded chore that Eric, 5, is supposed to do while you catch up on your emails? Of course not. Eric’s true reward is the one-on-one time he will spend with you. First, you and he will plan a menu. Make the menu suitable for a weeknight family dinner. There are many fine cookbooks with short recipes, if you don’t know some off the top of your head. This dinner, however, does not consist of a phone number and stained paper menu of the ethnic restaurant that delivers. From the menu, make a shopping list. From the shopping list, make a trip to the market. With Eric. This last part is crucial for success. When you call your partner to pick up some broccoli on the way home, you have rescinded Eric’s ownership of the event. He needs to pick it out. However ridiculous it may appear, he makes an important step when he’s at the market with you and picks out one bunch of broccoli over another. In his mind, he has been given authority over what his family will eat. You have trusted him with your sustenance and he has taken up that challenge.

I often encourage new parents to put aside one bottle a day for dad to feed the baby. A baby bottle, I mean. Whatever bottle dad was hoping for is his own business. However sleep-deprived he might be, that intimate time with the baby, giving her what she needs, is profoundly meaningful to new dads. Even though newborns may not smile or laugh, the dads have no problem sensing their baby’s gratitude. It’s a moving and wonderful thing that every mother knows.

I think this wonderful generosity of supporting another’s life through food stars with feeding a baby. It continues through life. There’s a reason humans of all cultures socialize over food.

So picture the parent I saw today with an 18-month old. She complained that he’s “starting to get picky about eating.” She said that she fed him in the kitchen before she and his dad sat down to eat. I asked why they didn’t have him at the table with them. She said that it was just too much trouble because he would keep grabbing their food if they held him, and if he was in his high chair, he would complain about not getting stuff off their plates. Do you see the empathic parenting lesson here? When they give him baby food he’s not interested in, he won’t eat it unless he’s very hungry or it’s one of his favorite foods. We’ve all had this experience. We look in the full refrigerator, the bursting pantry and complain that there’s nothing to eat. That’s us. We’re picky, too.

But we usually will eat if the company is good, and even if the food isn’t just to our taste, we’ll be polite about it because we see how happy it makes others. Babies know this and they feel it. This 18-month-old was telling his mother this in the clearest way he could. Isolating the child isn’t what he wants. If he had a place at the table, it would indeed be a lot messier. But he would love to taste the broccoli off mom’s plate and maybe some of the clam chowder dad was eating. They don’t want to try healthy foods, and they don’t want to try new foods. They want to try your foods. Let them.

The Family Meal

2010-04-23T05:04:00.000-07:00

One of the things that research consistently supports is the value of a family meal. The more often your children sit at the table with you and have a meal together, the better off they are.

When I read some of the early research on this topic, it seemed obvious and biased. When we examine households in which there are two parents, one full-time breadwinner who shows up every night by 6 PM, one full-time homemaker who shops and does child-care and prepares meals, we find certain unsurprising and uninformative things. Relatively low rates of juvenile delinquency, teenage drug use, legal entanglements, and similar social problems. The kids seem to eat healthier, snack less and have a lower rate of obesity.
I was and remain dismissive of this as medically relevant. In so many ways, it’s like surveying people who identify themselves as happy and then announcing that these people have a lower rate of depression than the population in general and a much lower rate of depression than those who have been hospitalized for depression. These mythical households, in which parents live unrealistic lives in unrealistic places with unrealistic children, provide little in the way of helpful insight for those who don’t fit into the constraints of these fantasy family structures. In most places, financial realities have made two incomes essential. Even when it’s not, and perhaps especially when it’s not, the idea that one partner is at home cooking dinner for several hours a day is obsolete. equally unstudied are school and work schedules. Our children, even from the happy and intact families, are busy with their own schedules that include after school sports, tutoring, or jobs. Perhaps because of where I practice, here in Berkeley (but I think this is true most places) it’s tough to make a living from a job you never take home. It’s been hard not to notice, making as many house calls as I do, how often one of the parents isn’t at home. Mostly it’s dad who is still working at 7 or 8 o’clock. But I have often seen kids who are fed and watched and put to bed by dad or grandma since mom won’t get home from work until after the child is asleep.

So I admit that this might seem like a distant dream for many families. But there are a lot of lessons in The Family Meal that go beyond nutrition. Those families from the television-reality of the 1950’s may not have much in common with yours. And it’s no surprise that in these families, teenagers are expected to be home from school before dinner and don’t go out at night. With this level of tight supervision, it is understandably difficult to imagine them getting into trouble. There’s also little opportunity for stopping for a cheeseburger on the way home instead of dinner with the family. No chance for snacking, drinking, or other unhealthy activities.
I have intentionally painted this lifestyle as repressive and restrictive. That’s the way your teenager is likely to see it. After all, their friends get to do these things. And that feeling of imprisonment is a universal one at this developmental stage. They know what they are able to do, and this doesn’t match what their parents are able to allow them to do. But I wouldn’t be doing my job if I advised ignoring some of this research.
I don’t think the research adequately explains why kids with more family meals are less likely to be obese. Maybe the reduced time outside of the house, eating fast food less often is an explanation. Maybe the increased parental supervision contributes something. Maybe it’s something deeper.

Think about the last binge you had—whatever constitutes a binge for you. Did you do it sitting down at a table of people? Maybe kids who would eat particularly badly feel this same social restraint. So if they get a family dinner every night, even if it’s hot dogs and mashed potatoes, and even if they have two helpings, they won’t be having 7 or 8 portions. Even if they could sneak out, the sense of fullness probably will short-circuit the impulse to binge, which happens more often when we miss meals.

Think about the last good dinner you had with someone else, or a group of people. What made it good? The most fabulous chef can’t make food good enough to provide satisfaction and enjoyment from time spent with bickering unfriendly people. Normal family and sibling interactions are not, realistically, going to lead to peaceful supportive conversations at every meal. But the dependability of the meal, day after day—or even week after week—will provide its own important support. Think of it this way. You are on a team. Sometimes it’s competitive, and sometimes you need to work together. Sometimes you will win and sometimes you’ll lose—and some of those times, you feel that you’ve lost very unfairly. But you keep showing up for practice, keep showing up for games. And your coach is always available, whether encouraging you or pointing out your mistakes. I think the family dinner is like this. Sometimes a child will be sulking and quiet, or quick to anger. And nobody should be forced, somehow, to do this. But the dependability of that dinner is crucial. They can invite a friend to join. That may seem easy, but it’s an impossible social step if everyone in the family eats at different times, in different places. So it’s easy for a child to ask a classmate to come over for dinner if your child knows in advance when and where that dinner will take place. If they don’t do this, when will you meet and get to know your child’s friends? This is an easy, natural way to do this important task.

Most important of all, the family meal is the place to show your children that you’re interested in them and their lives, their schoolwork, friends, and news. Please, no interrogations. Don’t go around the table as I have sometimes seen and make each child complete some checklist you have created for them. Tell me one thing that happened in school today or something like that. If the child is always saying that nothing happened and that they have no homework and nothing is new, you need to reach out in a better way. Maybe over the dinner table isn’t the ideal venue for many types of conversation. But when parents repeatedly express interest in their children and the lives of their children, it’s probably a good thing. Maybe it will convince some of those kids that their parents really care about them. Maybe it will help them care about themselves. Maybe it will help a few of them eat healthier.

Satiety and Problems with Obesity Research

2010-04-20T06:11:00.000-07:00

There's plenty of research on obesity. When push comes to shove, however, we already know the answer. When we consume fewer calories than we use, we gain weight and vice versa.

There's much less research on what drives obesity: satiety. This is the feeling of being satisfied that you've had enough. So all the useless research on portion control, what a 4 ounce piece of steak looks like, on how to measure 100 grams of pasta, is of little applicable value. A patient put it perfectly, "I'm just not satisfied with a yogurt for lunch." We don't have a problem with metabolism, with not getting enough exercise, with fast food chains. If we could go to McDonald's and order one single hamburger and leave, we might be happy with the quality, taste, and value of the food. We don't do that for the same reasons we can't push away from the table after our 4 ounces of chicken breast.

For decades, stomach ulcers were thought to be caused by 'Type A' personalities, emotional instability, and so on. A whole medical-industrial industry had been created to get these high-strung, quick-tempered, hotheads to relax. It wasn't true. The ulcers are caused by a bacterial infection that is treatable. What everybody talks about as 'willpower' is a code word for blaming the patient in the same way that people with ulcers were blamed for their own ulcers. I have met people whose iron discipline is helpful in some circumstances; a surprising number of these folks, in my professional opinion, probably could be comfortable placed somewhere on the autistic spectrum. (You've met these people. Their diets aren't generally the only things they are completely rigid about. They often have difficulty imagining or accepting alternative ways of getting even simple tasks accomplished. Does this sound like people with easy-going personalities and excellent social skills?) For most of us, however, I think what we dismissively think of as a lack of willpower is, in fact, representative of deficiencies in our scientific knowledge about satiety. Many of us insist that our metabolisms run differently, and that others we see eating the same meals don't seem to have our difficulty with weight. I strongly suspect that what is unstudied is not differences of metabolic rate (sorry, most studies suggest that it's all about eating more calories than we burn). It's individual differences in satiety that determines if we need that extra piece of pizza.

When I lived in New York, I was taken to a screening of movies recently completed by film-school students, one of whom was the roommate of my girlfriend at the time. It seemed oddly curious to me that all the films had same maudlin themes of dark introspection. No humor, no irony, no twists, no surprises, no action, no sex. The roommate asked me what I thought. After saying that I thought it was really deep (she smiled proudly), I asked what kinds of movies she liked. She bragged, 'I've seen every European film produced in the last year that I could get my hands on.' I named a couple of blockbuster American hit movies and asked if she had seen any of these. 'Why would I?' she scoffed, and went back to a group of her classmates and professors in black turtlenecks.

It's not that the popular movies were better. But the fact that they were popular strongly suggests that there was some universal, shared appeal about them. So while I would never argue that one should eat more Big Macs, we miss something really important by ignoring how popular they are and why so many people really like them. This is the research that hasn't been done yet.

Back to the lousy student films. I would never argue that popular is equivalent to good. But only in figuring out why some things are popular can we find out our universal drives. Why isn't there more research about what makes fast food so good or so popular? Why do we like it so much, why do we eat too much of it, why do we want to get the larger size for just 50 cents more? Maybe there are great lessons to be learned there about the issues that the majority of us face every day in our eating decisions. This, I believe, is an important reason so many struggle with overweight.

This is also a reason why people on stimulant drugs lose weight. It's not that they no longer like cheeseburgers, or that the stimulant speeds up their metabolism. These medications reduce hunger and increase satiety.

Our bodies have no trouble losing weight. It's our brains that can't do it so easily.

So it has saddened me over the years to read so much research concentrating on the body, which was never the problem. Here are titles of 3 research studies in the April 2010 issue of Obesity, a leading medical research journal in this field:

Long-term Successful Weight Loss Improves Vascular Endothelial Function in Severely Obese Individuals
In Central Obesity, Weight Loss Restores Platelet Sensitivity to Nitric Oxide and Prostacyclin
Exercise Training Prevents Regain of Visceral Fat for 1 Year Following Weight Loss

So, based on these studies, weight loss is a good thing for the obese, especially if they start exercising. Imagine being sent a colorful postcard from a paradise-like exotic resort. It says that your friends are having a wonderful time, will probably never leave, and wish you were there. There's no mention about how to get there, how to afford it, or where, exactly, the place is.

With all of the above contributing to a comfortable amount of cynicism about this, I went to a lecture on childhood obesity. The content was an unexpected surprise. They didn't say that we're winning the war, not even winning the battle. But I think they've come up with some reasonable rudimentary tools. That's the next post.

The Committee: Problems with Obesity Researchers

2010-04-16T07:02:00.000-07:00

A couple of years ago, I was on a committee of the American Academy of Pediatrics that focused on child nutrition and problems of overweight. We all agreed there was a problem. Maybe most adults, even those who don't work with children, have seen a generational change.

When I was a child, there was often one kid--if that--who was thought of as fat. I wasn't that child, and that child, at school at least, must have had a tough time. Honestly, I don't remember if there was such a child in the elementary schools I went to. There was a single classmate in grades 7-12, but at the school we shared, it would have been considered rude to make fun of anyone. (Though some were more competitive than others, I don't think anyone would have wanted to appear mean. I never got the impression he was anything but as happy as any of us were as teenagers.)

Things are clearly different now. Not just every school but every class has several overweight children, in every grade. Among these, some are dramatically overweight. Research confirms that though many kids get leaner when they grow into adolescents, many don't really recover from this early obesity.

Given the lack of easy fixes for this problem, and the obviousness of the extent of the problem, it is a hot topic for research. I've been frustrated, however, by the work that's been done and the people who do it.

In general, I think people should go into fields they're interested in. This is not only important for their own happiness and job satisfaction, but also for their motivation and creativity. I was shocked, for example, to have met in my pediatric career more than a handful of people who don't particularly like children. That's OK, I suppose, but it implies a suboptimal career choice for both doctor and patient.

So, in this statistically-unsupported argumentum ad hominem, let me tell you about the people I've met in the obesity-science world. First, who do you think chooses to go into the field? The professor in medical school who lectured on the topic, and has published quite a bit on this topic since, had nothing in common with me. Rail thin, his lectures were, to my sensitive ears, fire-and-brimstone evangelical sermons on people being their own worst enemies, fast or prepared food of any kind being a narcotic-like poison that eats like a parasite at the very fiber of civilized society. He taught, at least this is what I recall, that eating is like smoking, and should be heavily regulated if not banned altogether. He could be seen in the cafeteria eating a salad without any dressing. I didn't sit at his cafeteria table. He actually said, and I remember this vividly, that doctors need to be models for their patients. I interpreted this to mean that doctors who struggle with their weight or smoking or personality flaws are pretty much equivalent to permitting an alcoholic counsel other alcoholics.

Uh, that actually works. In study after study, though by no means always successful, the Alcoholics Anonymous model--in which recovering addicts share their experience and hard-earned wisdom--has been about the most consistently worthwhile intervention. It has been copied for addictive behaviors of many kinds.

But the obesity research establishment hasn't gotten this message. They haven't even opened the mailbox to see that there might be a message waiting. It's because their aren't looking for this or some other message. They think, like that anorexic professor at Yale whose personal diet is uneconomic and unsustainable for even patients with the most driven eating disorders and who thinks that his obsessive neurosis is the only appropriate prescription for the millions of people with whom he has neither anything in common nor empathy, that they really know how to fix the problem.

So the research they do doesn't, ultimately, tell us much that's actually helpful. Studies that show that if you watch TV 6 hours a day you tend to be fatter than those whose varsity sports team practices 3 hours a day after school. The title is usually something like, 'Varsity sports participation is a protective factor for excessive body-mass-index in adolescents.' Or, 'Proportion of daily calories from fruit predicts lean body mass.'

Knowing the abysmal failure rate when doctors tell their patients they need to lose weight, and the worthless nature of this kind of research for any practical purpose except the resumé-building of the authors, I had assumed that the grind of inevitable progress would, by now, have brought us out of this dark cave. So I looked forward to joining this committee, in which I presumed to be kept at the very cutting edge of child obesity research. I wanted to find out what actually works, what has been tried, and what can I tell my patients and their families that will genuinely help them.

The committee met at a lovely upscale restaurant in San Francisco. I was one of 3 men. There were about 40 women on the committee, but not every member came to every meeting. Though their ages spanned from mid 20's to mid 40's, I feel comfortable, since this whole post is about judging books by covers, saying that they all could have been sisters. A pair of waiters came around to take our orders. You know the rest already, I suppose. Salad with no dressing--not even on the side. Fish grilled without butter or oil, no potatoes, no bread, no dessert. Even so, most didn't eat at the table, and just pushed the food around the plate. At the time, I felt humiliated and ashamed, as if they were all staring at me conspiratorially and silently agreeing that He's the reason we're here.

I thought the committee might address pediatric patients who have a nascent weight problem that needs to be addressed for their health. This group, as a subset of the obesity-research elite seeing to affirm their own dysfunctional relationship with food, was really just an excuse for these doctors to get together and affirm each other's neurosis. The consensus was that

McDonald's = Blackwater.

More than one of the members of this committee proudly boasted that she had never, not once, eaten or even been inside a McDonald's.

I'm no apologist for McDonald's. But I think there's deep truth about patient care that these starvation-junkies have missed.

On a personal note, by the third meeting or so, I looked forward to the dinners. I would ask for extra butter on my mashed potatoes, ranch on the salad. At one point, about 25 people indicated that they didn't want dessert. I asked for an extra crème brûlée. It wasn't passive aggressive, it was just aggressive. The committee disbanded when the American Academy of Pediatrics realized, I suppose, that it would be cheaper to pay for these doctors to stand around outside of the restaurant rather than go inside and order food they didn't eat. And that it would not be possible for even less to get accomplished.

Next: what's missing from obesity research.
After that: some hope, or at least some reality, from recent research

Stem Cells for Autism

2010-04-13T05:33:00.000-07:00

Danny is an 8-year old on the very functional part of the autism spectrum. He’s happy, has friends, and is in a mainstream class where his work is on grade level. He’s a success in nearly every important way a parent could want. Still, at his most recent visit, his mom gave me a flyer for a company offering fetal stem-cell transplant as a cure for autism. She asked me to take a look at it (she insisted it was dad’s idea) and let them know what I thought. Having, as I do, such a large number of patients on the autism spectrum has helped me learn a lot about treatments that are available. I hadn’t heard of this one, so I was particularly interested in learning about it.

First, here’s a dependable stock tip. People who really know how to make money in the financial markets never, ever, consider selling or sharing that knowledge. If they knew a sure way of making money through a technical analysis system, computer program, or any other way, why would they have an infomercial?

I took a careful look at the brochure. I looked at the website, looked up the people involved.

Have you heard of stem-cell transplants? Sure you have. I’m no expert in this, but here’s the general idea. A person has a specific disease caused by some cells that aren’t working right. We give them new cells, that have the sense to replace the ones that aren’t working right. In this way, a cure becomes possible. Most cells have a certain function. But stem cells are cells that can take on different functions, depending on what’s needed. It’s a promising idea, but hasn’t really resulting in major cures yet.

So is autism caused by a problem with the way that specific types of cells are working? There’s no evidence for this. No one knows what causes autism. A working treatment for autism would be a shortcut to financial and Nobel prizes.

Have you heard of a cure for autism? No? We all know that autism is a mystery. Among ways to achieve fame and fortune, finding a cure for it isn’t something that would be unnoticed. If you had a for-profit business that had such a cure, would you keep it quiet?

You’d be right again, even if you don’t follow the details of ongoing stem-cell research news, to think that you haven’t heard much about using stem cells for autism. Maybe you’ve heard about researchers trying it with some forms of cancer, and some awful neurological and brain diseases for which there aren’t other good treatments. Though there aren’t other good treatments for autism, nobody knows what causes autism. For this very reason, there’s no reason to think that stem cells will help. I can’t swear that they won’t help, but I also don’t know if seawater will help, or radio waves, or marshmallows.

Oh, did I mention they propose to use stem cells from rabbits? Have you been hearing a lot about transplanting rabbit cells into humans? Me neither.
It might occur to you that this must be an exotic, cutting-edge research facility that is pushing the envelope in xenotransplantation to give hope to the hopeless. Some place like UCSF or Yale. The rabbit cells are ‘manufactured’ in Europe. The transplantation into humans and claim that it will cure autism would result, even there, with lost licenses, criminal charges, and likely jail time. So the company has a courier carry the processed bunny cells to an undisclosed--seriously--site in Asia somewhere. There, an unnamed practitioner of some sort does the actual transplantation. On your child.

I guess by now you must have guessed that this is very expensive, they require payment in cash up front, and that there are no refunds if it doesn’t work. If your previously healthy, though autistic, child gets some sort of side effect, adverse effect or worse from the treatment, there’s nobody to sue, and I couldn’t find an address on the website. The only person you actually meet is the person in Asia. Will they still be there, with that name, when you contact the embassy?

I’m not done. I looked at the brochure I had been given, and read it carefully. There were lots of grammatical errors. This is an ominous sign for me. If I give them the benefit of the doubt, and assume that they just don’t have anyone really fluent in English, that would still make me concerned that if you have a question, if something goes wrong, who in the company can you talk to?

I looked at every page in their website, which was entirely in English, riddled with language errors. There was a photograph of a worker in their manufacturing facility, wearing protective equipment. But no gloves. This tells me that the protective outfit was to protect him or her, not prevent contamination of the product.

Another page in the document bragged about the medical advisors of the company. In most biotech companies, these are very impressive people who have little to do with the company, but lend their names in return for stock or money or both. The company touts their involvement as a way to add scientific credibility to their presentations when trying to raise venture capital. This particular group was different than others I had seen or been involved with. None, zero, were scientists or researchers or physicians in this or related fields. Nobody even claimed that their degree in naturopathic medicine gave them any expertise in stem cells, xenotransplantation, or autism or any of the other diseases their company claimed to treat by this method. One of their board members, with MD and PhD degrees, was quite clear in noting that these degrees were awarded “by thesis.” Think about that. MD degree: pay a fee, write a paper. No anatomy course, no patient contact, no classes of any kind. This is a guy that wants a lot of your money to put rabbit cells inside your child someplace in Asia by somebody you will never see again.

At the center of this company isn’t stem cells, autism, or science. It’s money. So I will finish this post with this note, and I’m embarrassed to mention it. How much do I get paid for spending 5 or 6 hours researching a treatment for your child? I do it because I have to. Would your other practitioner do the same? For the same payment?

This is part of the email I wrote back.

With so many 'alternative' treatments, I usually say that it's OK to try it if it's safe and won't hurt the kid. With this, I am very scared that a courier delivers some product--who knows what, rabbit cells? contamination?--to a practitioner in Asia somewhere who somehow gets it into your unconsenting child, and then everybody walks away after they get paid. You couldn't even sue them if something bad happened, and certainly couldn't get your money back. What about the child? How will he feel--assuming that he did OK with the rabbit cells--if he 'fails' this treatment? Won't he feel like he let you down? Won't he feel like there's something wrong with him in your eyes? Will rabbit cells make that better? So, in this case, I'm going out on a limb. Please don't do this.
Wolffe

This is their procedure:

STEM CELL IMPLANTATION PROCEDURE
1) Patients consult with their respective medical doctors.
2) Doctor writes a brief medical summary or fills up the medical standardised questionnaire. Doctors can also make 1 attachment in "pdf" file or "jpeg" file comprising all relevant medical report if they think are of significant importance.
3) Doctor sent email to:-
4)      ’s professional team analyzes the medical summary and/or medical questionnaire. A prescription of individualised preparation of different type of cells
is made if the patient is found to be an ideal candidate for Fetal Precursor Stem Cell Implantation. Doctor will also be informed of otherwise.
5) Doctor consults with the patient. A decision is made to take or not to take up the fetal stem cell Implantation by patient. Doctor will then email to                  .com upon conformation of consent.
6) Full Payment made to                         (or Minimum: 50%) at least 17 days before carrying out the procedure on the pre-schedule.
7) Proprietary Primary Cell Tissue Culture harvesting commence (time frame of 14 to 17 days preparation)
8) European Human Couriers transport down the cells from Lab/Plant fromVienna airport to different parts of ASIA in special packaging while maintaining the                cells at room temperature
9) Individualised prepared cultured Fetal Precursor Stem Cells should be implanted on patient within 24 hours generally and not exceeding 72 hours from time of completion of culturing in our European Plant
10) Post Fetal Precursor Stem Cell Implantation progress report in 3.5 months to 4 months from Doctor to   coordinating team for evaluations as well as database updating.

This is a list of disease they can cure with this technique:
INDICATIONS FOR STEM CELL THERAPY
Ageing Disease
• Menopause
• Depression
• Impotence and loss of libido
• Memory loss
• Arteriosclerosis
• Impaired liver function
• Osteoarthrosis
• Immune deficiency
Autism
Autoimmune disease
• Scleroderma
• Rheumatoid arthritis
• Dermatomyositis
• Systemic lupus erythematosus
• Polymyositis
• Sjogren syndrome
• Hashimoto’s thyroiditis
• Addison’s disease
• Chronic active hepatitis
• Primary biliary cirrhosis
• Glomerulonephritis
• Good pasture syndrome
• Myasthenia gravis
• Bronchial asthma
• Pemphigus
• Bullous pemphigoid
• Vitiligo
• Atopic dermatitis
• Autoimmune hemolytic anemia
• Autoimmune thrombocytopenic purpura
• Pernicious anemia
• Muscular dystrophy
• Neurofibromatosis
• Tuberous sclerosis
• Cornelia-de-Lange syndrome
• Gaucher disease
• Metachromatic leukodystrophy
• Fabry's disease
• Gangliosidoses
• Refsum disease
• Mitochondrial genetic disease
Genetic and Chromosomal Disorders
• Down Syndrome
• Noonan syndrome
• Turner syndrome
• Wolf syndrome
Hematological Diseases
• Thalassemias
• Sickle cell anemia
• Aplastic anemias
• Hereditary hemolytic anemias
• Thrombocytopenia
• Erythropoiesis disorder
• Primary hemachromatosis
• Werlhof disease
Immune System Disorders
• AIDS
• Chronic fatigue syndrome
• Disorder of non-specific immunity(e.g. defects of natural
killer (N.K) cells)
Kidney Diseases
• Genetic diseases of renal tubules
Cancer Treatment
• Enhanced weakened immune system
Cardiovascular Diseases
• Intractable arrhythmia
• Myocardial infarction
• Congestive heart failure
• Peripheral arterial disease
• Chronic cardiac disorder
• Arteriosclerotic vascular disease
• Migraine
Central Nervous System Diseases
• Neurodegenerative disease
• Parkinson’s disease
• Demyelinisation diseases
• Old/new spinal cord injuries
• Apallic syndrome
• Encephalitis
• Locked-in-syndrome
• Amyotrophic lateral sclerosis
• Friedreich’s ataxia
• Werdnig-Hoffman disease
• Duchenne & Becker muscular dystrophies
• Dementia
Chromosomal Diseases
• Down syndrome
• Noonan syndrome
• Turner syndrome
• Wolf syndrome
Digestive System Diseases
• Atrophic gastritis
• Chronic pancreatitis
• Malabsorption syndrome
• Crohn’s disease
• Ulcerative colitis
• Peptic ulcer
Endocrine Diseases
• Diabetes mellitus
• Vasculopathy
• Adrenocortical hormonal insufficiency
• Premature menopause
• Retarded puberty
• Female infertility
• Imbalance state of autonomous nervous system
• Endometriosis
• Female infertility
• Uterine myomas
• Habitual abortion of adrenal atiology
• Parathyroid insufficiency
• Hypothyroidism
Genetic Diseases
• Wilson's disease
• Nephrotic syndrome
• Glomerular disease
Liver Disease
• Liver cirrhosis
• Chronic hepatitis
• Crigler-Najjar syndrome
• PrimaryBiliary cirrhosis
• Primary Sclerosing Cholangitis
• Hepatorenal syndrome
Locomotor System Disease
• Non-healing fractures
• Osteoarthrosis
• Aseptic necroses
• Chronic osteomyelitis
• Osteogenesis imperfecta
• Achondroplasia
• Marfan syndrome
• Arthrogryposis multiplex
• Chronic osteomyelitis
• Chronic arthritis
• Rheumatoid arthritis
• Osteoporosis
Lung Diseases
• Bronchial asthma
• Pulmonary fibrosis
• Emphysema
Metabolic Diseases
• Atherosclerosis
• Lipoprotein metabolism
• A-β-lipoproteinemia
Neonatal & Perinatal Diseases
• Cerebral palsy
• Inborn errors of metabolism
Skin Diseases
• Psoriasis
• Chronic eczemas
• Deep burns
• Acne vulgaris
• Ulcus cruris
• Various eczemas
• Sarcoid Darier-Roussy
• Hereditary keratosis
• Palmaris et plantaris
• Chronic lichen
• Scleroderma
• Vitiligo
• Frostbite of big toes
• Alopecia areata
Radiation Injuries
e.g Post radiation ulcers

Addendum, April 20, 2010. Just a few days after posting this, and completely by coincidence (as if 60 Minutes coordinates their schedule with mine), a substantial portion of 60 Minutes was devoted to just such a stem-cell scam. The one they investigated had recently treated a child for autism. This is a link to part 1 of the segment. This is a link to part 2 of the segment.

Grandparenting: Basic Guide

2010-04-09T05:41:00.000-07:00

1. When the baby is born, don’t come to stay. It is curious to me that by some mechanism the emergence of an infant from the body of a daughter or daughter-in-law is taken as an open-ended invitation for a sleep-over visit. I won’t be a burden. You won’t even know I’m there. You won’t have to do a thing. I can help with watching the baby, doing laundry, going shopping. You’ll need the help. These are some of their honest well-meaning intentions. The reality is that your body is slowly recovering, you’re in pain just to walk around, you’re incredibly sleep-deprived, you want to focus on the baby so everything else in your life and home have been put on hold. What do you get? Critical, judgmental houseguests.

It’s great, perhaps essential, to have supportive parents or relatives nearby when a baby is born. It can be crucial to have someone trusted to watch the baby while you sleep for a couple of hours. And it is indeed helpful if somebody is willing to do the laundry or some basic shopping. But the stories I hear are often about grandparents who bring their usual daily routine with them, play with the baby when the baby is happy but give you the crying baby. I hear about grandparents who, though they might not say it, still think of you as their child so they expect to be able to direct the baby’s care. After all, they’ve already been there and done that.

So when the baby is new, stay in a hotel. Or at least find a different relative nearby you can stay with.

2. Pay for college. Obviously, if you’re not well-off enough to pay for the kid’s college, you can’t do this. And I’m happy to say that love and support is way more important than money. If you have no money, than it’s even more important to be supportive of your adult children. Now that I got that out of the way, however, money is sometimes where the rubber meets the road. Your children are adults now, with children of their own. They will be concerned about providing for the children and will be worried about this. It’s OK to believe in self-sufficiency and living within one’s means. But complaining about the cost of your yacht maintenance while your kids are struggling is not going to get you whatever sympathy you’re looking for. It’s not an empathic thing to do, and it’s potentially lethal to the relationship you have with those grandkids. So if you can, put money away for college. If you can’t, share with an open hand. Take the grandchildren to Disneyland. If that’s too much, take them to the movies. If you don’t like the way your kids handle money (who’s fault is that?), then do your giving directly to the grandchildren. But sharing what you have in this way takes a serious burden off of your children, and it might materially improve their lives. They will be grateful for it.

3. Watch the children. What do you have that no one else has? Trust. The disturbing stories we hear on the news have made parents more cautious than ever to leave their kids in the care of a stranger. A grandparent is in the unique and privileged position of knowing the parent for his or her whole life. The parents know where you live, know who your friends are, and know how to get hold of you. They may not want you to let their children watch cartoons all afternoon. They may not want you to feed the child chocolate cake and 2 glasses of milk every schoolday afternoon. But they will love that their child loves you. And they will love you for being there to babysit. Generosity with your time will give you the opportunity to bond directly with your grandchildren without their parents filtering your intentions. Hopefully, your children will see this as the valuable gift that it is.

4. Bite your tongue. I have said this several times, but I’ll say it again here. You had your opportunity. You raised your children in the best way you knew at the time, and now they are raising their own. It might look to you that they are needlessly flailing about and trying to re-invent the wheel. You might feel that you could save them a lot of trouble by just telling or showing them the way certain things should be done. If you get asked, then go ahead and be the teacher. But if you aren’t asked, volunteering an opinion could leave you vulnerable. This isn’t picking out a color for the drapes! For better or worse, your adult children have chosen a path to follow with their own children. If your suggestions contradict this, you won’t change anything. But you might give the impression that you think you know better, or that you’re interested in continuing to treat your child as a child. How will this help? Your experience and knowledge are important resources if they are wanted. If not, you are playing with fire.

Empathic Grandparenting

2010-04-06T05:21:00.000-07:00

As I publish more and more about parenting, I’ve been getting a lot more questions about the role of grandparents. Parents, whether biological or foster or adoptive or step or any other kind, have certain reasonably uniform tasks they usually need to accomplish with their children. Survival basics, such as food and shelter, schooling, love and support, and promotion of the child’s general sense of growth and accomplishment as they grow and develop. If there are some hurdles on the way, people ask me about it, and I do my best to give them some ideas on how to manage.

When grandparents are the primary caregivers for the children, and there are many, many families like this, then they are really acting as parents. In this context, parenting advice applies no matter what your title is. I have known fine adults raised by relatives both close and distant, and sometimes by parents who weren’t related to them at all. In all of these situations, I recommend openness about the reasons behind the situation. This openness should be limited to what is developmentally-appropriate for the child, and which protects the child’s sense of self worth. If parents are gone, then they’re gone and there’s no point in giving the child further opportunity for emotional scars by learning that what you say can’t be trusted. It’s hard to imagine a sadder image than a child waiting at the window for the parent who won’t return. So be as honest as you can with them.

An important part of the bargain when we take on the responsibility of being parents is that there are no warranty periods or lease expirations, during which we can trade up to a new model as long as the one we’re returning has only normal wear-and-tear. More needs to be said about what is and is not appropriate, and I’ll try to do that another time.

For most grandparents, however, the primary responsibilities of care for the grandkids falls squarely on the shoulders of your children and their spouses. This is a blissful arrangement in which you get most of the benefits of child indulgence with little of the consequences. Sure, it’s not as good to buy love as it is to get it spontaneously. But--just between us--it’s still love and it feels mighty good when bartered for some new toy or ice-cream before dinner that mommy would throw a fit about but we’ll just keep it as our little secret.

For those who’ve been reading my advice about getting kids to eat right and behave nicely, it might come as a surprise to know that I don’t disapprove of any of the above. Every child deserves to have somebody in this grandparent role, where some of the rules are a little more flexible than at home. I think there’s an important place in every child’s life for a trusted non-parental adult who isn’t spending every waking hour managing the relationship. But that’s not the same as having carte blanche.

With that said, however, we all know that childhood obesity is a big problem. There are many causes, of course, and I have no special cure or treatment. But I have had one insight that I have not seen written about in all the studies I’ve read: grandparents.

There are many reasons that both parents have to work outside the home. Mine did. With most elementary schools still dismissing their students at 3:00 in the afternoon, most working parents have to find some arrangement for the 2-3 hours or more before they get home from work. In my community, this is often a job gladly taken by grandparents. They treasure the opportunity to be with their grandchildren and have such an important role in their lives. They also are happy to help their children by being there when needed.

But when I talk to children who are overweight, I ask them about their diets. It becomes clear that their parents aren’t usually taking them out for fast food, and aren’t letting them eat potato chips instead of dinner. Most parents are reasonably careful about what they feed the kids, so the extra calories aren’t coming on their watch. Again and again, the calories just don’t add up. While it’s true that school lunch is often not nutritionally optimal, it’s usually not a major problem. They usually don’t have the money or transportation to get fast food. But again and again, I hear about the time in the afternoon with grandparents. There’s a lot of school-day afternoons filled with television and very fattening snacks. It’s one thing to be the indulgent grandparent who gets the kids stuff their parents wouldn’t or couldn’t get them. It’s quite another to be contributing to serious and long-lasting health problems for the child. Though I don’t want to be confrontational, I really wonder if these grandparents, who melt at the first hint of a whine, really feel all right with the consequences of that big piece of cake as an after-school snack.

I have often wondered about the mysterious mechanism by which brain functioning seems to change as soon as one’s offspring has offspring of their own. There is a clear difference between being a grandparent and being a parent, and I’m fine with that. But why, besides failing vision, can’t grandparents see that their grandchildren don’t need that extra cookie?

We get our parenting knowledge from several sources. Our own experience as a child is a major source, whether this was good or not. Our perspective on the parenting techniques used by our parents is a very biased one. In general, we love our parents. Perhaps as a result, I have heard people describe as useful some incredibly counterproductive experiences they had as children. Did washing your mouth out with soap stop you from using bad language? Sometime, parents are aware of the mistakes made by their own families, and make a conscious decision to go in another direction. This leaves the parent trying to find a path when they have no landmarks. And, of course, there are all kinds of parenting experts willing to suggest things, perhaps in a book or blog, that the parent hadn’t thought of.

Grandparents, however, have the certainty of their own experience. This can be a pain in the neck for parents who have decided to do some things differently. Just because you raised your kids a certain way, doesn’t mean that’s the only right way to raise them. This is often a major source of friction between adult children and their parents. If you, as a grandparent, value contact with your children and grandchildren, you must respect their point of view.

I guess it should go without saying that there are always exceptions. But it’s a mistake to assume that you are one of these exceptions.

In the next post, I’ll offer some specific guidelines for grandparents.

Quality Time with Launderteam Delta

2010-04-02T05:02:00.000-07:00

In an online forum recently, I was asked by a grandmother why her grandchildren are so poorly behaved with their mother, but are so well behaved with her. She babysits most days while the mother works two jobs.

In my office, another working mother confided in me that her son, 7, was upset about her recent divorce. But her daughter, 5, was simply ‘sour.’ She said the girl was just never nice to her, and she was sadly misguided if she thought that was a way to get her mother’s affection. She was angry at her daughter.

I don’t always get these behavioral issues right. They are always complex, with factors of family and environment, health and finances always complicating the emotional and behavioral problems. This time, I did get it just right, so I thought it might be helpful to see these cases unfold.

Here’s an empathic interpretation. In the first case, I had some important information just from the short statement that the grandmother provided. The fact that the kids were generally well-behaved with the grandmother meant that they didn’t carry their bad behavior with them everywhere they went. That was essential to know so I could be really confident that there wasn’t something about the children that was causing the problem. I had no contact with the mother, so there was no way to know if she was really messing up the relationship with her kids, but I took an educated guess. With her heavy work schedule, she didn’t get to spend time with her kids. They didn’t see this, of course, as her sacrificing for their welfare. They see it as their own sacrifice for no apparent purpose at all. So since they feel the cost but none of the benefit, they aren’t happy about it. Then when mother comes home, they are demanding of her time. She’s exhausted, of course, and maybe protective of what little time she has for herself. The children interpret this as rejection, and get even more unhappy, and actively experiment with their own actions to do what they need to do in order to get the attention from mom that they need to get. With the escalation in difficult behavior, the mother has to escalate her attempts to control the behavior, which ends up in a spiral from skirmish to battle. Everybody gets hurt.

In the second case, the older child has tried to fill some of the role of his absent father. He helps mom around the house, gets his homework done without asking her for anything, watches his sister when asked. The elevation in his status and the affectionate rewards he gets from mom are not missed by the 5-year-old, however. What can she do? It seems that every time she tries to help, either her brother steals the chance from her or her mother complains that now she’ll have to do it over again because it was done wrong. Besides missing her dad, she can’t find a role for herself in this new family unit. So to get the attention of her mother, she needs a burning flare to get her mother’s attention and dynamite to separate her mom from her brother. Flares and dynamite are a combustible combination, and she, too, is left to her own creative devices to find activities so egregiously naughty that they demand the attention of her mother. The mom complained to me, explicitly, that she didn’t even like to spend time with this unpleasant girl.

In both cases, the parent needs to spend more time with the child.

There used to be a myth called ‘quality time.’ Though I haven’t been able to find a clear definition, sometimes it meant time uninterrupted by phone calls or distractions, sometimes it meant time with the kids during which everybody was having a good time, sometimes it meant a massive mutual crying session during which the whole family bared their innermost feelings in a catharsis that typically ended with a lot of awkward embracing.

I think there is such a thing as quality time. Again taking an empathic approach, I think it’s the children who determine if the time is ‘quality’ or not. What are their criteria? Even if they say they want more time to watch TV or play on the computer, time with a parent is what’s really valuable to them. If there’s a mistake that many parents make, it’s making this time arbitrary and unpredictable. Children cannot understand this. They don’t see the complexities of your life and can’t understand the flexible priorities you assign to your own daily tasks. So maybe you don’t take business calls at home…unless it’s your boss and it’s really important. Maybe you go to the gym every evening…unless your friend is visiting from out of town. There’s nothing bad in this kind of flexibility. It’s an essential skill of successful adulthood. Those who don’t have the ability to realign priorities with changing situations are not going to fit in to our every-changing lives. (This rigidity in the face of an obvious change in circumstances can be a sign of autistic-spectrum , or perhaps obsessive-compulsive disorder.)

But that’s not your children. To them, quality is not just time with you, but time they can count on. So here’s how to do it if you’re working all the time and have little time with them.

I had a close friend who used to work in the financial markets here in California. The problem was that he usually left for work around 5:00 am, and he hated missing his preschool-aged kids in the morning. So the family decided to skip the pre-bedtime bath. Instead, the kids would get up with daddy, everybody would take a shower together and then go back to bed when dad left for work. While I presume this did take a little more time than a quick morning shower alone would otherwise have taken, dad could leave for work feeling energized for the day. At first, one of the kids preferred to stay in bed. But when one sibling knew that the other was spending time with dad, even if it seemed like the middle of the night, there was no problem getting up.

So when I was asked about how the mom with two jobs can find ‘quality’ time with her kids, I responded by noting that the time was available, and the ‘quality’ was up to her. The key rule--it’s not a guideline, it’s a rule--is that this is an appointment you must always keep. Your children depend upon it as a sign of their importance to you. It really doesn’t matter what you do together, as long as it’s together. If you’re working long hours, what are the tasks that you have to do anyway? Even if the kids weren’t there? The ones I usually come up with are laundry, shopping for food, housework of specified kinds, maybe some others like walking the dog or even emptying all the wastebaskets and then taking out the trash. These are not chores to be assigned to your child while you catch up on your email or return important phone calls! (It could be a chore under certain circumstances. But if your child is acting up, there’s a 100% chance they need more time with you. So if you’re going to use a task for this time, it has to be something you do together.) Make it a team job.

So for a preschooler, maybe they can sort the light items from the dark ones. They can fold things as you take them from the dryer. They can help you put things away. Tip: don’t assign them tasks to do by themselves. You’re a team. So don’t tell the child to put her brother’s clothes in his closet. That’s a chore, no matter how you try to tell her how much she’s helping you (then it’s a favor). Have her help you carry her brother’s things into his room and then hand you the items as you put them in the closet. Why am I so particular about this? It’s the conversation, of course.

Yes, you’re going to have to put down the bluetooth headset. If a call comes during this important time, say ‘I’m doing some work with my son right now, let me call you back later.’ Once you’ve said it, watch the magic it makes with your son. See how much more enthusiastically he helps you. But you’ve also sent another person an important message--you. Once you have embraced that laundry with your son isn’t a chore for you, it’s quality time with your son, it might not be something you do because if you don’t, no one else will. When you do it with your son, you are doing it because no one else can. You and he are now

Launderteam Delta.

Special headgear or weapons--developed at skunkworks to be indistinguishable by an untrained observer from household terrycloth--might be required.

Every busy parent’s life is filled with these tasks. Many depend on where you live and what your preferences are. Do you wash your car? Do you tend a garden? I acknowledge that often adult tasks we do alone can be fulfilling and relaxing when done alone. And there are some jobs that are downright dangerous when done with a child (mowing the lawn, blowing glass, welding the steel roll bars on your monster truck, etc.) But if you are doing these tasks instead of spending time with your children, can you blame them for acting in ways that are more demanding of your attention?

The next step in this plan is scheduling. When you have made this magical transformation from chore to team activity, you have to stop treating it as a chore to be done reluctantly and squeezed in whenever you can. That may have worked for laundry, but it doesn’t work for time with your kid. They don’t respond to being a low priority on your to-do list. So go shopping with your child for a monthly calendar. (Another team activity!) They can choose puppies or fighter jets or whatever else they like. Then every Thursday night or Saturday morning or how often you think is necessary, write laundry on those days. It doesn’t matter if he can’t read. He will see that word and recognize it for what it is, a contract with mommy or daddy for his personal time. IT’S A CONTRACT. Break it, and there will be consequences.

The Human Rickshaw

2010-03-30T04:06:00.000-07:00

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.

Baby 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.

Sean’s ADHD, Part 4: Sticks and Stones

2010-03-26T05:44:00.000-07:00

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.

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

2010-03-23T04:24:00.000-07:00

Sean is a 1^st-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.

So it is written, so it shall be done.

2010-03-19T04:10:00.000-07:00

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?

The 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.

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 Congress...it 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.

Cultural Sensitivity

2010-03-16T06:14:00.000-07:00

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."

Bad Attitude

2010-03-12T05:44:00.000-08:00

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.

Dancing and Friendship

2010-03-09T04:48:00.000-08:00

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.

Friends

2010-03-05T04:33:00.000-08:00

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 30^th, 40^th, and yes 50^th reunions. Oh, did I mention there was a 60^th 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.

A First-Grade ADHD Story, Part 2

2010-03-02T05:10:00.000-08:00

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.

Stop punishing him in ways that are not effective.
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.
Like the tree branch that bends with the wind, find a way to support his attention. For him, I have invented #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.
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.

A First-Grade ADHD Story

2010-02-26T04:58:00.000-08:00

There was no secret about Sean. when Mr. Dickson took over the first-grade class after the original teacher had to leave for an operation, she had told him a little bit about every student. So he knew what to expect about Sean.

And so did his mother. She telephoned me in tears about 3 weeks after Miss Maclean left and Mr. Dickson took over. Sean was saying he was sick every morning, didn’t want to go to school At the same time, Mr. Dickson had called her about every other day, complaining about Sean’s behavior. He wasn’t getting into fights, wasn’t hurting anything or anybody, but was spending a lot of the time joking with his friends, making silly noises when the teacher’s back was turned, making silly drawings, writing silly notes, and basically just being silly. He is very fidgety, and never sat still on his chair. This was, if anything, getting worse. It was becoming a real management problem for Mr. Dickson in the classroom. During the most recent phone call from him, he suggested that Sean might benefit from ADHD medication and urged an ADHD evaluation, as he put it, ‘ASAP.’

Sean’s mother, perhaps feeling a little defensive, asked Dickson why he thought it might be that for the first half of the school year she had not received a single phone call about her son, but since he took over, she’s had at least 10. Maybe, she suggested, he was not doing something that Maclean had been doing, or wasn’t doing something she used to do.

I asked her some neutral but important questions. Was he doing his assignments? Was he handing them in? How did he do on quizzes? How did he get along with the other students? Did he get in trouble during recess when he was running around outside? Were any of his standardized test scores available? She told me that he was popular and had lots of friends, all his assignments were up to date and he seemed to breeze through his homework, which seems completely unchallenging to him. His standardized test scores put him fully a grade-level ahead of where he was. when mom asked him why he talks in class, and why he gets in trouble, he says that he’s bored.

She told his teacher, Mr. Dickson, that Sean says he’s bored. He responded that there was no way to manage a classroom full of first-graders if some students were off doing stuff on their own. He went on to note that Sean seemed particularly unimpressed by the loss of certain privileges in the classroom. He asked for advice on how to ‘control’ him until he starts taking ADHD medication. This was all quite upsetting for Sean’s mom, so she telephoned me.

I have been Sean’s doctor since he was born. I have been the doctor of Sean’s 3 older siblings since they were born. I have been to his home many times for house calls. His family is intact and loving, but with 3 older siblings, there’s no point in getting too attached to any particular toys or objects--the whole concept of ownership has to be flexible. At home, all the kids play with all the toys. For Sean in particular, who has never been a materialistic kid, this weak attachment to things makes them poor tools for discipline. His parents have mentioned to me that taking away his access to any particular toy just isn’t an effective way for them to get their point across.

Having been the doctor for him and his siblings for many years, and coincidentally having some expertise in ADHD and child behavior, I didn’t hesitate bringing these issues up to his parents when they became obvious in my office some years ago. I asked his mom if she thought he was more active that his 3 siblings. I already knew that he interrupted a lot, couldn’t sit still, seemed always to be in motion. So I don’t think that mom was insulted, exactly, when Dickson brought up ADHD. I had brought it up to her years earlier. But I thought she was right to mention that this wasn’t a problem until the new teacher showed up.

So I thought Sean was a little hyperactive, had some impulse control issues, was often interrupting and talkative. That does indeed sound like ADHD. But he had some important compensatory skills. He was very intelligent, and had excellent reading ability, a good vocabulary, and could speak in a surprisingly articulate way. He was also funny and warm and the only people he had occasional fights with were his siblings. Because of these positive traits, he had friends at school and did well in his schoolwork. Sure, he had an attention-deficit. He had hyperactivity. (That’s ‘ADH’ if you’re keeping track.) But the ‘D’ for disorder didn’t really start until the new teacher started.

As I have written before, this is an essential part of the diagnosis. Just because you might have every other trait associated with ADHD doesn’t mean you need to be on medication for it. If, on the other hand, your life is crumbling, is it because of the ADHD or something else going on in your life? Maybe a new teacher in the middle of the year?

Among the most important skills for a doctor is listening. There was one important person I had not heard from yet.

Sean could not sit still. He made good eye contact when he was speaking to me, but not as good when I was speaking to him. When we were talking, he had no problem staying on his chair. His answers to my questions were completely focused and appropriate. But he was a little fidgety. When I asked him why things were different with Mr. Dickson--something he said that no one else had asked him--he told me. He said that Miss Maclean had let him get up from his chair and go to the back of the room and work on stuff when he got bored. Mr. Dickson not only doesn’t allow that, but enforces infractions of his classroom rules by taking things and privileges away from Sean. According to Sean, this doesn’t make him angry, it just confuses him. He didn’t understand why his teacher would take away stuff that he didn’t really care about. It’s true he joked around a lot in class, and he knows that he’s not supposed to, but class is so boring for him when he often has nothing to do. He usually finished his classwork early and it was hard for him to sit with nothing to do as he waited for the rest of the class to catch up. He got in trouble for getting up out of his seat, for looking for something to keep himself busy. He repeated the definition to me, together with his conclusion. “I don’t like being bored.”

Who does? In the next post, I propose an intervention.

Ethical Dilemma: Do the right thing or keep the patient?

2010-02-23T04:39:00.000-08:00

Robert is one of my troubled teenagers. To him, his parents seem outrageously restrictive and inflexible. No particularly innovative insight is needed to recall the times in ones life when parents seem less like a tugboat, pushing and pulling us ahead, and more like an anchor, holding us behind. He came to me for an ADHD evaluation, in the course of which I noticed his itchiness, and thought he should get some allergy testing.

For most of his 15 years, his family moved every few years as dictated by his father’s diplomatic career. Now stationed here, his European parents have lived all over the world. They had just begun a stay in Thailand when Robert was born. He was scrawny then (as he is now) and became jaundiced. I have written previously about jaundice in a newborn. Though his parents didn’t remember the levels in his blood, they were told that his jaundice was quite serious and that the baby needed a blood transfusion.

The idea behind transfusion for this problem is simple enough. If we take out the blood that’s packed with bilirubin--the natural breakdown product of hemoglobin that can build up in the blood--and replace it with blood without bilirubin, then it’s much less likely that bilirubin will get deposited in the baby’s brain. It’s the treatment of last resort, and his mother was told that it was necessary at the time. This is 15 years ago, remember, and technology has improved since then. Even so, I’m not experienced enough in international medical practices to know the level of vigilance used to screen donated blood in most of the world.

When I proposed doing some blood tests for allergies, given his history of itchiness and runny nose, his mother asked if I could do a test for Hepatitis. She told me about the tranfusion in Thailand, and I added the blood test to the laboratory order form. His test result indicated that he had been immunized against Hepatitis A and B. The test was ambiguous for Hepatitis C. I looked up his specific test result, and the references I looked at said that he should get a follow-up test or two to be sure he didn’t have it. This didn’t seem ominous to me, just something that needed to be done to be thorough.

I called his parents to discuss the tests, and mailed them copies of the test results and a printout of the reference interpretation that indicated the necessity of another test. I tried not to make a big deal out of it--but I was clear about what needed to be done. I asked his mom if she wanted me to mail her another lab form or if she’d pick one up in the office. She said it would have to wait. She explained that it would have to wait until we do another round of allergy or other blood tests.

She asked me not to tell him about the test.

Huh? It’s not like the lab sucked a half-dozen tubes of blood out of his arm without him knowing about it. She told me that he doesn’t know anything about the transfusions, the jaundice. Somehow, she said, it never came up. I was confused--wasn’t he there when I filled out the lab form? Where was he when his mother told me the story about the jaundice? I couldn’t remember. During the long visit, he got up to go to the bathroom. Was that when she told me the story about him as a baby in Thailand? She never told me not to tell him anything, and I just assumed….

I was silent for a long time on the phone, and she asked if I was still there. I do not withhold anything from my teenage patients. Already struggling with trust issues (parents usually try to convince their teenagers that sex is lousy and nobody should think about it), I have found that the only dependable way to establish trust with a teenager is to be 100% open with them all the time. If they want to keep something from their parents, I try to use my best judgment to support them or to explain why I disagree and push them to do the right thing. I am always very clear about the secrets I cannot keep, such as those making me fear for the child’s safety. It doesn’t work the other way around: when I am occasionally asked by a parent to keep something from the teenager, I just say no.

Many times, for example, I have been asked by a parent to test a child for drug use. I tell them that if they want to find out if their kid is using drugs, ask the child directly. Perhaps surprisingly, many teens will be quite honest about it. If they aren’t, the parent might want to try another tactic. But I am the child’s physician, not parole officer. [There are circumstances, most of which occur in emergency rooms, in which a drug test is sometimes done without consent. That’s true for adults, too, by the way.] I have never tested a competent teenager for anything without telling them about it. I felt manipulated by the mother.

I told her that I thought this was a bad idea. If he had hepatitis and she (and I) knew about it, surely she would tell him. She agreed with this but noted that if he didn’t, why should he have to worry about it? There’s usually only a few days between lab test and result, I pointed out. That didn’t seem like a lot of worry.

I looked at it a different way. If he didn’t have the disease, yet found out that we had tested him for it, the trust I had built with him would be gone, and could never be re-established. And the trust of his parents would be a mess. I told his mother that this was a dangerous plan from the point of view of her relationship with her son. She said that he was already unhappy, and didn’t think he could handle the anxiety. That upset me. Many studies on adults clearly show that the paternalistic witholding of bad news is universally counterproductive. Paradoxically, it increases patient anxiety (we tend to fear worse scenarios than the actual bad scenario), and damages the relationship between patient and whoever it is who was supposed to be telling them the truth. Often that’s a doctor, but it might be a family member. So her assumptions about how this bright, sensitive teenager would take the news either way was simply misinformed. Inevitability is the elephant in this room. Even if I don’t tell him, he’s going to find out. Maybe not today, not tomorrow, but someday he will. And when he does, she may lose him over this. Who is she really protecting? His delicate sensibilities or her denial of a lifelong lie that she would now have to confess to her teenager?

Getting to the point, I am ed. If I take it upon myself to tell him, she’ll fire me and the damage to the relationship that his mother fears will come about. If I don’t tell him, I am facilitating this lie and being bullied into doing the wrong thing. And when he does find out, I’ve lost him just the same.

I did my best to convince her to have a heart-to-heart with this nice boy and apologize profusely for her mistake. With the troubled kids I see, they get themselves into this same situation all the time. They don’t do the big project for their least-favorite class, but say they did it, thinking that they will catch up in a few days. Then it’s a week overdue, then a month, then suddenly mom and dad get a call about summer school. Maybe we’ve all been there, maybe there’s a MasterCard with our name on it about which this all seems hauntingly resonant. It’s the human condition, and I was sympathetic to her situation. But I was angry about being pulled into it unawares. I was tricked. How can I trust her in the future? How can her son?

Now what do I do?

Please comment and let me know what you think I should do.

The Coming Wave: ADHD

2010-02-19T05:10:00.000-08:00

Currently, to get an ADHD diagnosis you need more that just a problem paying attention. You also need this problem to be causing problems in your life. I have discussed this many times in the context of many cases. I’ve described a couple of times giving a ‘test’ for ADHD to a lecture hall at UC Berkeley filled with overworked premeds, and how most of them qualified for the diagnosis by that test.

I read an article about planned changes in the criteria for diagnosing ADHD. The article quotes Dr. David Shaffer of Columbia University saying

“We really separated ourselves from the rest of medicine by saying you couldn’t have a disorder unless you were impaired. We all know that there are some people who persist with a very active and unimpaired life even though they have very severe illness.”

He explained that the current way of making the diagnosis was not consistent with the way most other diseases are managed.

He’s right, of course. There are, perhaps, millions of adults in this country with Type 2 adult-onset diabetes. It means that their blood sugar gets abnormally high when they eat sugary things, and simple starches like bread. But for many of these people, they can control their sugars with a disciplined diet, weight-loss, and exercise. Certainly, they still have the disease. No doctor would say they are cured. But they have no symptoms, and get through their daily lives without incident. Another common diagnosis is asthma. You can have it, but have no symptoms for years and only under certain circumstances. And who would claim that someone who is in a wheelchair and clearly cannot walk is therefore somehow ‘impaired.’

Impairment is relative, of course. Some of us can’t reach a high shelf, and others can’t see what’s on it. But human ingenuity being what it is, we mostly can get by despite our inabilities.

I am asked to evaluate many kids with genuine attention problems. If they are intelligent and creative, and perhaps if their focusing problem isn’t too awfully severe, they develop compensatory skills. Maybe they can recall what the teacher was saying even while looking elsewhere. Maybe by making lists of things to do, they keep from falling behind. Maybe by bringing a carton of pencils brought from home and left in class they will never be without one.

This is a picture of the pen that I have carried and used every day for about 3 or 4 years. Pretty nice, huh? I used to lose pens constantly. Then I received a really nice pen as a gift. I didn’t use it for a long time. Since I lost pens all the time, sometimes after a single use, I didn’t want to risk it. Am I absent-minded? A close friend convinced me that life is indeed short, and that I should use the pen. At first, I was obsessive about it. But I use it so often that it didn’t take long for me to stop thinking about it. I have not lost it in years. Am I absent-minded? Maybe those cheap pens just couldn’t afford the writing-utensil-LoJack part of my brain, which was there all along when it was important enough.

Yet I worry a lot about this particular change (not officially coming for a couple of years, I think). I have chronicled many cases of kids who clearly aren’t paying attention like they should.

So what?

I don’t think paying attention matters. Quote me on that.

I have heard parents complain about it, and seen teachers reduce a kid’s grade because of it. If they fidget in their chair, does it matter? As I deconstruct ADHD, it’s not the same as having diabetes or asthma.

As with most of our inner lives, as with our homes, the problems which require fixing are the ones that interact with the outside world. You want to live in a messy, dirty house? I don’t think anybody would care as long as you showed up to work on time and did good work. It may be distracting for the teacher to see a student chronically staring out the window or doodling in her notebook. But the rubber doesn’t hit the road at all if the homework gets handed in on time and well done, if the projects and exams are good.

This is an issue familiar to the Human Resources manager at your company. Good management and good morale are based on clear goals and criteria for success. If you achieve those goals, you should be rewarded. Notwithstanding legal issues, if the manager doesn’t like the way you look or dress or stare out the window, tough luck. Even so, we work and interface with others, so nobody gets a free ride in an office or school setting with general hygiene issues, or being disruptive in some way. That hurts others, thus requiring guidance if not intervention.

In the case of Kyle’s ADHD, I got the impression that the insidious annoyance of a tapping pencil was what pushed his mother to seek out professional help for him. But when it got right down to it, he was doing as well as he was willing to do.

It may be with best intentions that you encourage your child to start work on the big project earlier than the night before. And I would support you if this pattern had an impact on the outcome. But what is it, exactly, that you want? Do you want your child to get good grades? Then decide what you mean by that and let them go after it, always with the offer of help and support and suggestions. If you want your child to stop staring out the window, close the shades.

Here’s what will happen when the impairment criterion is removed: everybody will have ADHD. Everybody normal, that is. [Boy, I don’t use that word much!] Think about who, until about age 15 or so (or maybe 90), is not fidgety and distractible when having to sit still and do repeated tasks without interruption, pay no attention to their friends and classmates who are not so attentive, who focus on the teacher with laser-like intensity and who sit quietly during any pauses. Picture these kids from when you were in school.

Say a parent brought such a child to me, as many have over the years, and told me that they’re doing well in class but eat lunch alone, that they don’t have a best friend, that they aren’t part of a group. Luckily, the same general group of academic experts helped to categorize these kids some years ago as having autistic spectrum disorders. Normal intellect, normal communication ability, but weak in social intuition, inept in social skills, maybe thought of as ‘different’ by their peers. Recall, however, that the creative and technology industries are filled with distractible, interrupting, socially inept people. They are warm, loving, and have sometimes done quite well for themselves.

Maybe you are ‘on the spectrum’, maybe you have an attention deficit. But when this change comes, the number of kids so identified will explode, and we will see a massive hunt for the culprit. Vaccines?

The Knowledgeable and Empowered Parent

2010-02-16T04:18:00.000-08:00

Last night I went over to the home of a couple of my patients to drop something off. The dad greeted me at the door and said that his daughter had something for me. The 7-year-old gave me the picture above. Impressed as I was, I asked her why she chose this subject. “Because we were really sick! You could have made us feel better.” But I didn’t know anything about it. Her parents had never called.

Much of what I write about could be called parenting. Hopefully, the cases I describe are instructive in some way. It’s logical that a first-time parent will learn more new information than a more experienced parent, who have seen and experienced so much.

Indeed, part of my Slow Medicine practice model (described in parts 1, and 2) is taking the time not just to engage with the child but also the parents. I want to make the parents feel like an essential part of the health apparatus applied to their child. In what I call the ‘factory model’ of medical care currently being practiced, patients are nameless widgets whose crucial function is to be passively processed as quickly as possible. Above all, they can’t be allowed to slow the velocity of throughput. I want to take the time to explain things to parents, describe my approach to the problem and what the options are as I see them.

Over time, however, I have discovered an unexpected aspect of this method. Empowered families feel empowered. Strangely, this hadn’t occurred to me right away. I did realize that from the payer’s point of view (the insurance company), it was an absurd and obvious false economy to push patients to be seen as quickly as possible. Though it might cut insurance expenses this month or this quarter, over time each patient would have to come in again and again for their one or several problems. Teaching them to manage their own care better will save both patient and insurer a lot of real money. Keeping patients out of ERs would save even more. This post, however, isn’t about the counterproductive financial incentives of our dysfunctional system, and the ways it doesn’t work. This post is about the system I came up with, and how it does work. I want to be up-front about the economics, however, and get that out of the way. Like every primary-care physician, I am paid per visit. No visit means no pay. It may be true that if you give a man a fish you feed him for a day but if you teach him to fish you feed him for a lifetime. Still, it seems strange to run a fish store with a tuition-free fishing academy.

(As an aside, when I was in Business School a few decades ago, piecework was considered so obsolete and ineffective a model of employee compensation that it wasn’t really covered. I couldn’t have guessed that one day I’d be living the dream.)

In The Telephone Paradox, I note my experience of changing people’s behavior just by answering the phone. Not so much but what I say, but just by picking up. As parents came to believe that they really could reach me directly at any time, nights or holidays, they actually called less. They came to see that since they could always call if the child got worse, they could wait and see for a moment. Given the opportunity, many of those sick children did get better on their own, and so the parent never actually called the doctor.

My practice is populated by a very diverse group of families. Many of the nurses at the nearby hospital bring their children to me, along with many of the physicians. They all know lots of things that I don’t know. As the parents in non-medical fields become more educated and empowered, by me and by their own experience, they too make a lot of their own treatment and diagnostic decisions.

‘This is what I wanted!’ I sometimes have to remind myself. A group of smart, independent-thinking, empowered parents who can handle a lot of routine medical issues.

The problem is, they don’t come to the office. When the children get sick, these parents are rightly self-assured that they can handle it. They were carefully instructed by me about the method and purpose of treatment, and what to watch for. Besides, they know they can call me at any time. I’ll always see their child the same day, even if it’s at night or I have to come to their home.

As it turns out, I’m not sure this is really ideal. I worry about parents being a little too confident, and missing some important aspect of the child’s condition.

I also worry more about missing patterns of illness that I might pick up over time, by seeing when or how often certain symptoms were happening. In the case of Tammy, her horrible rash kept appearing on Mondays, a day after visiting grandma. There are many medical problems that are identified by pattern-matching, and like a pixelated picture, more data produces a clearer image.
Surprisingly often, I see a child in the office with the following dialog.

“It’s nice to see you. How have things been going?”
“Great,” says the parent. “She’s been really healthy.”
“I’m glad to hear it. So what brings you in today?
“Well, she’s been coughing a lot at night.”
“For how many nights?”
“I don’t know exactly. Maybe 4 or 5 months.”

There are important, unspoken—and mostly unstudied—aspects to medical care and the doctor-patient interaction. Her parents may have been right in deciding that they knew how to handle the illness and I wouldn’t have changed anything. But for children (and this is true for many people of all ages), going to the doctor helps to make them feel better. I think it’s one of the reasons that people sometimes complain when the doctor never examined them or listened to their heart, even if they are there for an unrelated problem. I think there’s a real therapeutic value in physical touch and just listening attentively to the patient’s complaint. So although her parents may have been precisely right about the appropriate therapeutic intervention, and maybe I couldn’t have made the child get better sooner. But they didn’t see that maybe I could have made her feel better sooner.

Perhaps this is why doctors and nurses bring their kids to me. I may not know more, but I’m the doctor, and that gives them permission to be mom and dad.

Honesty vs.. Hope: An Ethical Dilemma

2010-02-12T04:11:00.000-08:00

Lupus pilum mutat, non mentem

At our last visit, Franklin spoke to me in private. “Will it get better?” he asked

“Will what get better?”

“My parents.” His parents had recently been suggesting to him that his antidepressant medication cost should come out of his allowance and if he were more like his two younger brothers, star athletes and students, he would be costing them a lot less. He needed to get away from them any way he could. He played X-Box video games. Given his ADHD, this was the perfect escape, and would hold his attention for hours. But this bothered his parents quite a bit. They didn’t feel like they were being responsible parents if they let him play video games for hour after hour. So they decided that he was to play no more than 1 hour.

Most parenting authorities would agree with this restriction, I think. I, too, think that it’s reasonable for parents to restrict the amount of time a kid is playing video games. It’s reasonable to limit the time to 1 hour.

But I know something else: it’s completely arbitrary. Yes, there are studies that show that increased screen time is correlated with obesity, social dysfunction, and other problems. But at what duration do those problems suddenly occur? Nobody knows or has looked at that. Is 15 minutes safe? What about 120 minutes? Because I believe television is a drug, how much of a dose will cause some effect, and what dose will cause trouble? Franklin may not have been familiar with the research in this field, but he know in his gut that the 1-hour limit was arbitrary, and that his parent picked it out of thin air. He also knew that he was unnaturally thin, didn’t snack, got plenty of exercise, and that whatever social problems he had weren’t caused by his screen time. His parents made another mistake. They insisted that he reduce his video game time by hours. They didn’t offer him any alternative ways to spend those hours. He was doing well in his classes, and keeping up with his assignments.

When he spoke to me in private, he told of many little remarks made by his parents. They weren’t directed at him, they weren’t meant to hurt his feelings. They weren’t insults or denigrating. They were, however, part of the family lexicon. He recalled this statements in precise detail, and I don’t doubt him at all. Sometimes they came when a parent was talking on the phone to a friend or relative, sometimes it was a statement between the parents, and sometimes it was something said sotto voce to one of his younger siblings. Franklin heard them all, and he knew what they meant. ‘We can’t go because Franklin….’ ‘Why can’t Franklin be more like you? You never cause us any trouble.’

Families have a jargon all their own. Big companies have this, the military has this. Sometime restaurants do, too: Adam and Eve on a raft famously meant poached eggs on toast. And wreck ‘em was added if you wanted scrambled. When his brothers fought, sometimes one would call the other Franklin; a parent would smirk.

So he asked me one of the hardest questions I have been asked. He asked if it would get better. The easy way out would have been to say one truth, ‘I don’t know.’ I can’t predict the future, so I would have fallen back on that dependable standard. But he wasn’t really asking me for a prediction, such as the dates and times for the coming apocalypse, for example. Just as so many parents do, he was asking my professional opinion. Based on my training and experience, my intelligence and intuition, what did I really think? Would it get better?

This is an ethical problem, too. Do I make him feel better or do I tell him the whole truth as I know it, not just a statement that happens to be an accurate ‘I don’t know?’ When I ask my own doctors if something will get better and they say they don’t know, is this the whole truth?

I knew a more substantial truth than ‘I don’t know.’ I knew from my own life and from the families I have known since childhood, from the families of my parents’ friends in their retirement community. And I knew from the children I have seen grow from babies to high school students. Most parents have told me that their teenagers ‘were the same way’ when they were infants, maybe easily frustrated or easy to comfort, restless or relaxed. In this way, personalities can be surprisingly stable.

In Franklin’s life, I had become about the only person he opened up to. It was a great privilege and he deserved more than facile answers. I told him once that I would always be honest with him. I said, “No, I don’t think it will get much better.” I don’t know if this was what he wanted to hear. If I had sounded upbeat and tried to assure him that it was going to get better, would he have believed me? How long would he give that prediction to unfold if it didn’t get better? I suspect he expected the easy answer, ‘I don’t know.’
Though this was my best professional assessment, rolled into a single No, it wasn’t the whole truth, either. Dealing with some of the most difficult kids, I can say confidently that even when we can’t change the difficult child, we can change how we understand them and deal with them in ways that make those interactions much less frustrating. This increasingly educated and empathic approach often helps a lot in reducing the number and intensity of explosions. In Franklin’s case, I found myself with a type of role reversal. I told him what I often tell parents of particularly problematic kids. Pick your battles carefully. If you know that something will provoke an explosion, then whose fault is it when the inevitable happens? Change your expectations of them, and that will cause you to change your expectations for yourself. Be the grown-up.

I reviewed with him the situations most likely to cause battles. I asked him the same questions I ask parents of difficult children. What was your last fight about? Did you win? If you did, was it worth it? Did the child learn a lesson and now won’t do that ever again? (The answer is always no, by the way.) Do you feel good about it? Does the child feel good about you because of it? I ask the same follow-up questions if they didn’t win the fight. If it wasn’t worth it, if nothing was learned or gained by it, would you like to do it again? If not, then don’t fight about it. It takes two to make an argument. Be the grown-up, be the first to walk away and say you’re sorry. You may lose a fight but gain a child.

In Franklin's case, I counseled him to play the grown-up. I suggested that he try to predict what the battles will be about, and decide carefully if they will be worth it. I'm hoping that just having a plan will empower him and help to stabilize his relationship with his parents.

The Latin proverb at the top of the page means The wolf changes his coat, not his disposition. Readers need only look as far as their own aging parents. Are they very different from when you were a kid? Do they treat you or talk to you so much differently?

Kyle’s ADHD, Part 2

2010-02-09T04:53:00.000-08:00

At our meeting, Kyle was, at first, reserved. He wasn't angry at me, I don't think. Nor at his mom, exactly. But he wasn't happy with her for bringing him or having to have this conversation with a doctor. Clearly, this is something that his mother had brought up with him before and he had made his feelings on it clear to her.

I describe meeting Kyle, 13, in the last post. His mother was frustrated with him for underperforming his capabilities at school. His standardized test scores were generally much higher than his grades. While not in serious trouble, he had a lot of detention last semester for talking in class and lapses of attention. These lapses included failing to hand in some assignments, forgetting work and exams, and not paying attention in class. By all accounts, however, he was generally well liked by students and teachers.

Especially when doing homework, as the effort dragged out, his mother would watch him stare into space, tapping his pencil and leg in complicated rhythms.

She assembled data on his attention issues from teachers, from his father and from herself. She also secured for him some tutoring which focused on organization and study skills.

I clarified my position to him as soon as I asked his mom out of the room. I told him that I would tell him exactly what I thought, and that I would tell him first whatever I was going to tell his mom so that there would be no surprises.

What I learned when she wasn't in the room was apparent in the teacher comments. He didn't pay attention in class like he should, and was often socializing. He admitted not handing in some assignments, saying that he kind of lost track of them, not that he had real difficulty doing them. None of his teachers mentioned the pencil-tapping. He said he never really did that in school, it was just at home during the tedious homework time. He also pointed out that in the last couple of weeks he had been engaged in an after-school program, during which he nearly always finishes his homework. He doesn't socialize so much there because most of the other students aren't in his class or aren't even in his grade. And they want to get their homework done, too. For these reasons, he felt that his problems were largely solved.

As promised, I told him the truth. According to the teacher and parent questionnaires, he met the arithmetic criteria for an ADHD diagnosis. His mother, he and I agreed, would probably like me to say that he had it and needed treatment. But there was no way I was going even to suggest treating him when he didn't think there was a problem. And I didn't want to suggest to his mother that it was necessary if I didn't believe it and that would only increase the amount of conflict between him and his mother.

But I didn't want to lie to his mother, either. So when she returned, I told her that Kyle definitely does have some traits in common with people who have ADHD—as we all do. He meets the numerical criteria according to the questionnaires that were answered about a month earlier. But I explained that many intelligent people with short attention spans and occasionally annoying habits have other skills that help them compensate for these weaknesses. In Kyle’s case, he has now gone a full two weeks without a missing assignment or detention. He’s getting homework done after school, before he gets home. That alone will cure him of most of his school underperformance as well as the dreaded pencil tapping. (Which seemed to bug mom more than anyone else. In the previous post, I included a video of a high-school student whose peers appreciated his talent.)

Yet this was clearly an optimistic scenario given what has been going on earlier in the school year. The compromise I struck with Kyle in private was that he would agree to return in 6 weeks and revisit the issue. If his optimism were justified, he’d still be current with his homework and assignments and not spending time in detention. His grades wouldn’t have been lowered by penalties for missing and late assignments. If somehow things didn’t turn out the way he was anticipating, he might have to admit there’s a problem. His mother appeared pleased with this plan (I haven’t spoken to her in the few days since the visit, however). Kyle seemed OK with it, and I think he knew it was about as good a deal as he was likely to get.

Does he have ADHD? In some ways, yes. Last semester, definitely. But if you have a problem that’s fixable with the diligent use of a day planner and some coaching, do you need medication? Should you get a diagnostic label?

Off the record, just between us (I didn’t tell him or his mom any of this), I have a different take on this. I don’t know if it’s right or not, and I only met this mother twice and the boy only once. I think it’s mostly his age and developmental stage, mentally and physically. I think 7^th and 8^th grades are difficult transition years. The teachers try really hard, but the boys are discovering more interesting distractions. Yes, the obvious. But also new and confusing rules of social standing. (For boys, the only typical constant is sports. Those few boys of nearly any age who are good athletes often have a natural peer group and image among their peers that is reasonably stable.) Kyle was like the majority of boys, perhaps. Searching for a place among his group, finding his people. This is also the age when aspiring to be part of the wrong group can be ominous. But that wasn’t him. The highest priority for him is his friends that will be his companions into adulthood, at least for this part of the journey. Bright as he was, he was still developmentally-stuck in concrete thinking that prevents him from seeing that the homework for 7^th-grade History—that would only take him a half-hour and he should just get done, for goodness sake—will be dust under his feet long before he forgets the beloved friends he got in trouble with. When he told his mother that listening in class just wasn’t that important to him, she was shocked…but he might be right.

Charity, Haiti, and The Teachable Moment

2010-02-05T04:13:00.000-08:00

We all think of ourselves as generous. Obviously, that can’t be right because we definitely think of some people we know as not being generous at all. From their point of view, however, I’ll bet they would say they are very generous (as generous as they feel they can afford to be). People who are more giving, in their view, aren’t more generous, they are simply foolish or misguided. So an empathic perspective is that we each give what we feel we can. We know there are those who give much more of themselves, and those who give much less. I hope most people aren’t too judgmental about this, but I think we all tend to label people when we perceive a mismatch between what some people appear to have and what they appear to give. We are unforgiving of those who seem to have a lot yet give little, and impressed by those who seem to have little yet give a lot.

Research in early child development has rid us of the antiquated idea that all babies are born as a blank slate, equal in capacity but either blessed or limited by their nurturing situations. Let’s face it, some people are really good at math and some people find it really hard. But this skill or weakness isn’t destiny. With some sympathetic tutoring and lots of patience and practice, even the math-phobic can get through high school.

But how can parents teach important things that they themselves were never taught? How can children learn concepts that don’t come in workbooks or sets of DVDs or in listings for tutors?

Empathy isn’t a course you can sign up for. It’s a way of looking at other people and trying to imagine what it would be like to be them. This is a teachable skill. Empathy is a particularly human ability, and those that don’t show much of it are not well liked. We are born with our brain chemistry wired for a particularly great amount of it, or maybe a lesser amount in some people. Some have an intuitive skill and some don’t. I’ve seen this in children: some find it easy to sense a playmate’s feelings, and some seem oblivious. Can we teach it?

Teaching children feelings is much more complex than teaching them behaviors or factual knowledge. Each child is different in how their experiences affect their own feelings. For this reason, talking to them about what they should feel is likely to be fruitless. If they don’t feel sorry for the crying child in the park, your telling them they should will just be confusing, inexplicable, frustrating, or insulting. If they do feel they way you think they should, then your telling them about it is simply unproductive. It’s great to try and help your children get a vocabulary that helps them express their feelings verbally, so talking about feelings is an important exercise to do with your child, whether the feelings are strong or mild.

But how can we get them to see what they don’t? How do we teach them to open their hearts?

Since I suspect we each believe ourselves to be appropriately generous—open handed but not profligate—I also suspect we want to instill these values in our children. As with most behaviors, what we tell our children is mostly irrelevant and what we force them to do largely backfires. So forcing them to give part of their allowance to some charity—no matter how worthy—when we don’t show them our paychecks and how much we are giving, is preying on their arithmetic naivite. What happens when they get to high school and find out that you weren’t giving 20% to the poor, it was more like $20? You will have created yet another reason that you can never undo for them to avoid calling you or visiting when you’re 70. I wonder if, at that age, you’ll be thinking it was worth the money you saved.

To those not naturally inclined, we teach math through gentle encouragement, positive feedback, and practice. And perhaps most effectively, through real-life examples.

The important aspects of life are there every day, all around us in our lives. They might not lend themselves to school books, but they are everywhere. If you want to teach your child something really difficult, like altruism or charity, master the teachable moment.

A teachable moment is defined (by me) as an important event that gets your child’s attention without direction from you. It could be when he comes to you in the park and tells you that a child is crying. It could be when she asks you where Haiti is. Once the teachable moment is brought to you, it’s up to you what to do with it. You can certainly show her where Haiti is on a map. You could look it up online together and map its leading agricultural products by topography. To me, that’s a teachable moment squandered.

She’s asking about Haiti because she hears about it on the news. Maybe she’s seen some pictures. Her words might be asking where it is, but she’s really asking why it’s important, why it’s on TV, why people are talking about it. Tell her—she deserves to know, and will continue to come to you for these important questions.

Here’s what I did. I took some of the ties out of the top shelf in my closet. Over the years, I have received many as gifts that for one reason or another I was never going to wear. I hope I was always gracious about the generosity, but I knew I would never wear them. The Garfield tie above..well, that’s obvious. The Save the Children tie was nice, but not useful as a prop when I examine a preschooler. I sold them on eBay, and designated 100% of the proceeds to go to Medecins Sans Frontières, an amazing group that was already on the ground in Haiti. I donated the ties and the shipping and the fees for listing the items. Anything people paid would go to MSF in Haiti. They sold really well! I’m also selling a camera lens I’ll never use. Haiti needs whatever it will bring more than my closet needs a lens.

When your child asks you about Haiti, tell them that you want to help and ask her if she wants to help, too. What does she have on her shelf or closet that she can give up? She must make her own decision! And she has to see you do it, too. If you’ve never sold anything on eBay, now’s the time. This is a real teachable moment, and it will make a lifetime impression on her to see you take a photo of the stuff and then write the listing. It doesn’t matter if you only get a dollar. The lesson isn’t about how much, it’s about identifying the feelings, then taking action. There aren’t too many more important lessons than working with your child to make the world just a tiny bit better. That’s incredibly empowering for a child, who often feels unable to change the world around her. Besides, we both know how long that stuff has been in your closet.

The Tapping Teenager -- Part 1 of Kyle's ADHD case

2010-02-02T04:47:00.000-08:00

While I nodded, nearly napping, suddenly there came a tapping,
As of someone gently rapping, rapping at my chamber door.

--Edgar Allan Poe, from The Raven

I was asked to give a lecture at the local University about child mental health. It’s a big topic and so I limited it to just a couple of examples that I thought would be interesting to the large class of undergraduates. It was a big course of about 500 students. I gave them a test. Taken from an internet site directed at those adults who think they might have ADHD, it asked, I think, only about 10 questions. Each was generally like this: When you’re tired, do you find yourself reading the same paragraph over and over again? I asked the students to keep track of their score as they answered the questions. According to the directions of the site, I told them that if their score met a certain threshold score, they did, in fact, have ‘adult’ ADHD. When I asked for a show of hands (realizing this was a clear violation of their medical confidentiality), at least 80% of the students achieved the diagnosis.

They didn’t all have ADHD. They were college students—staying up too late, too much coursework, too many deadlines, not enough structure, romantic entanglements, part-time jobs, and so on.

ADHD stands for Attention Deficit Hyperactivity Disorder. In my experience, it’s easy to find and focus on the attention deficit and the hyperactivity. When people are tired and have to do some reading, they will read the same paragraph over and over. It’s how our brains work—or don’t—when we’re tired. When we’re worried about something or depressed about something, we probably don’t have our best listening skills or make our most well-thought-out decisions. So it’s normal for everyone to have an attention deficit in certain situations or at certain times.

For this reason, making the diagnosis of ADHD, for me, isn’t about an attention deficit or hyperactivity. It’s about disorder.

A worried mother called me about her 13-year-old son, Kyle, and wanted me to evaluate him. I suggested that the family come in to talk to me and tell me what prompted this. She said she wanted to come in alone first.

This is a bit of a red flag for me. It often means that this parent feels strongly but another parent doesn’t. Maybe the child in question doesn’t want to be seen about this. If that’s the case, it could be because they don’t realize there is a problem or that they don’t want to help their parent do anything about it. Either way, it’s tough on the doctor, the parent, and the child himself.

She came in and gave me all the appropriate questionnaires and supporting documents—school evaluations, standardized tests, and so on. I took them from her and told her it might take me a week or so to get through them all. But she summarized the problem and her concern. She said that on most school nights he would spend a long time doing homework—sometimes more than 3 hours. He wasn’t really getting that much homework, since he had the opportunity to do most or all of it after school. It bothered her most that whenever she would check on him, he was staring off into space, tapping his pencil on the table. Gradually, she observed him more systematically. She thought that he appeared to be spending a great deal more time tapping his pencil or shaking his leg than on the homework. This must be a problem because who would want to sit there and look around when he could, if he finished his work, doing something fun? To me, it certainly sounded like it could be an attention problem. She said that he had not been doing well in a couple of courses because of assignments not turned in, and that some of his teachers have mentioned to her that they often see him staring into space. The child himself asked her if he might have ADHD. She said that some people could find the constant tapping infuriating.

When I scored the questionnaires, he did meet the minimum score to diagnose ADHD, but just barely. The comments by his teachers were consistent, and repeated again and again that he is casual about homework, prepares poorly, spends a lot of classroom time socializing, and is clearly not paying attention much in class. I made sure to have a prescription pad available when he came in.

He didn’t want to come to see me—or any other doctor—about this. His grades at mid-year were: one C, one A, and a few B’s and B-‘s. This was also a flag for me. Where is the disorder? True, his standardized test results suggested that he should be able to do better than this, but I thought this was pretty good for somebody who chronically got penalized for turning in homework late or who messed up on obviously unstudied quiz material. I asked him about this, and he said that he consistently got A’s on important and bigger exams. He was often graded down for not paying attention in class. As I always do, I asked him questions about depression (he wasn’t), anxiety (wasn’t worried), substance use (didn’t), and why he thought that his mom thought this was such a problem. He didn’t know. During our conversation, he answered all my questions appropriately. He was polite and seemed articulate and bright, though he didn’t volunteer anything not asked about. He said that his parents had hired an ‘organization tutor’ to help him with some study skills. This helped him a lot, he felt, and he was no longer behind on assignments. He believed that whatever the old issues were, they were behind him.

He certainly didn’t think this was a problem or that there was anything wrong with him. That was one of the reasons why he didn’t want to see me. The other reason was that it was Friday night, and he could have been out with his friends.

I told him explicitly that he seemed nice enough, but we both knew how concerned his mother was, and I had to come up with some sort of conclusion acceptable to her. He agreed in principle, and I outlined what I planned to tell her. I cleared with him first everything I planned to say to her.

That will be the post after next.

Worst Possible Scenario Survey

2010-01-29T04:12:00.000-08:00

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.

The Funny Story: Loose Lips Sink Ships

2010-01-26T04:29:00.000-08:00

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?

Jaundice

2010-01-22T05:01:00.000-08:00

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. 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. 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.

Hurting Mommy

2010-01-19T04:52:00.000-08:00

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.