Headache in a 5-year-old

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

Bad Attitude

 

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.