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. 








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The Dark Places

Everybody has dark places that they just don't want to go. Sometimes these places are physical locations that we can't avoid.

Evelyn is 9 and has asthma. Controlling her symptoms has been challenging, not because her asthma is so severe, but because her family is very disorganized. As with most chronic conditions, steady routines of preventive care can help to avoid serious episodes. On one Sunday, she was having particular difficulty, so I went to her home to check on her. She turned out basically to be OK and she and her family just needed some hands-on coaching to remind them when and how to use which medication.

A house call is a powerful tool, neither taught nor mentioned in medical training. I have learned a lot from them, and the information from experiencing a child's home is much more substantial than can be inferred from a brief history provided in an office visit. This is particularly true for chronic disease.

Evelyn was eager to show me her room. Her bed was completely hidden under an army of stuffed animals that covered it entirely. There were many clothes on the floor, some clean and some not. There was no door on her closet. She had a desk, which was cluttered with piles of books. Dust was thick everywhere. It looked like nobody in the family was a good housekeeper. I asked her, hinting at the stuffed animals, where her bed was. She pointed to the bed and added, “But I don't sleep there.”

She slept nearly every night on the sofa in the equally dusty living room. I asked, of course, why.

She was afraid of spiders, she explained, as if I were somehow inexplicably dense and couldn't see the obvious.

Evelyn knew there were cobwebs in the corners of her room, and her fear of spiders prevented her from turning off the light when she was in the room. The usual age for the start of specific phobias was about 7, and she said she'd been very afraid of them for a couple of years. She denied any specific traumatic experience, though.

Fear of spiders is one of the most common phobias, and it seems that this affects girls more frequently than boys. But phobias are very common, and we often are embarrassed by them and don't talk about them—we just plan our activities to avoid confronting them. So often when I diagnose an anxiety disorder, I find that the child has specific phobias they never told anyone about. They know that these phobic feelings are not shared by their friends, and sometimes they aren't even comfortable sharing with their parents. Even if the phobias aren't something that restricts their daily life, the child can feel deeply ashamed of what they know is an abnormal perception. So when I am talking to a child who I think might have an anxiety disorder, I always ask about phobias. And when a parent mentions to me that their child has not one but several phobias, I always will consider anxiety.

The key to her asthma control was getting her a low-dust place to sleep, so I offered to come and clean her room with her. She liked this idea and so did her mom. I told them to buy plastic storage bins big enough for clothes and toys, and asked her mother to sew a curtain-rod-to-floor washable curtain to use instead of a closet door. When I returned about a week later, all but one stuffed animal was in a bin. She was welcome to take all of them out whenever she liked, but she could only sleep with one. All the books went in a bin. The clothes went either into a laundry bag in the now-closed closet, or into a bin if clean. Evelyn herself was to take a damp sweeper/mop and dust her bare floor every day. I had a hidden purpose when I proposed this. Sure, it kept the dust level low in her room, which I hoped would help her asthma control. But it gave her control of the corners of her room. By cleaning them herself every day (they shouldn't get too dirty in just a day), she would be reminded that they are really clean, really empty, with no webs or spiders to lurk in the dark.

There was a lot of sneezing while we were cleaning the little room, but we ended up with a lot of dustable smooth surfaces (the floor, the desk, the lids on the bins) that could be kept clean with minimal effort. Within a few weeks, her asthma was much less of a problem. She was still afraid of spiders, but since she herself (with me there helping and protecting her) had cleaned out those dark corners, she could rest much easier in her own bed. I slept better too.

ADHD: Is ADHD Inherited?

About two weeks ago, a couple expecting their first child asked me an intriguing question as they interviewed me for the opportunity to be their pediatrician. They asked if ADHD was inherited. They were concerned because the father had been diagnosed as a child and took medication for many years. The scientific answer is clear. Yes, there is pretty good evidence that from studies of twins and epidemiologic studies of parents and children that if a parent had been diagnosed with ADHD, there was a much greater chance that the child will have ADHD.

ADHD is widely studied, and there are many things known about it. We know that children diagnosed with ADHD but untreated or ineffectively treated have much more problems in school than those whose ADHD is effectively treated. We know that teenagers with ADHD who are untreated have much higher rates of substance abuse problems than those whose ADHD is treated (yes, treated with speed-like medication). There’s a higher rate of ADHD in children raised in households without a father and in which the mother practices inconsistent, unstructured, discipline.

I started to assemble some of these facts. How would the adult with ADHD, untreated, parent a normal child? I'm guessing that there would be a lot of impulsive decisions, inconsistent discipline, and failed relationships. Growing up in a household with a parent with untreated ADHD is likely to make worse any existing problems in the child. It would make an anxious child more anxious, a depressed child more depressed. If the child had some behavior issues, these will become more of a problem with this kind of unstructured household and impulsive, distracted parenting. So a kid with some mild ADHD symptoms--and most normal kids have some (and most normal college students)--might act out enough to get in trouble at school. The impulsive parent might perceive some of these normal behaviors as impossible to manage. Now that the child is having trouble in school and at home, they might cross the diagnostic threshold and meet the official qualifications for ADHD.

Studies have shown that if you smoke, it's more likely that your children will smoke. Is smoking genetically inherited? Kids naturally follow the model behaviors of their parents, even the behaviors we don't want them to copy. But just maybe, children inherit some subtle feature of brain chemistry which responds powerfully to nicotine. So is smoking inherited? I'm not sure what that means.

Some parents with anxiety can't help but share their fears with their children. Won't this make their kids anxious? If the child has a little bit of anxiety of their own, will this make it worse? Does this mean the child inherited anxiety from the parent?

Is ADHD inherited? By studies that have been done on genetics and brain function, yes. But I suspect it is less often inherited when the affected parent has been effectively treated.

There's a couple of general parenting lessons here. First, you are not your parents. The things they did that didn't work for you as a child probably won't work on your own children. But most importantly, every child needs consistency and structure. The more disorganized and unstructured they are, the more valuable a structured environment and consistent parenting will be for them.



Next Post: Does ADHD exist?

Eight is Enough -- All the king's horses and all the king's men

What do you do when you can't fix what's broken? My patients--and my readers--know that I take a practical approach.

There wasn't any way for me to repair the relationship between his mother and father. Maybe it will work out someday, maybe not. I couldn't force his father to call or visit. Indeed, this is just the way Max saw the situation. His family was broken and couldn't be repaired; his father was gone forever. Nobody ever asked him what he thought about it. This is why when you're 8, what happens seems inevitable.

Max was depressed. He had a lot of the same symptoms of depression that adults get. He was sad, cried sometimes without provocation, had disturbed sleep and eating, lost interest in the things he used to enjoy, and was more distant with his friends. Even so, I was optimistic. He hadn't always been like this, it's just been the last few months. Technically speaking, this was a reactive depression, a problem adjusting to new circumstances. But I couldn't sit back and watch this child suffer while waiting for things to happen—like his father calling, or his parents getting back together. That's the perspective of an 8-year-old.

I could help this child by sharing with him some of my power as a grown up. I also respected him in a way he wasn't used to. Rather than telling him what to do, or talking to his mother with or without him in the room, I suggested some positive actions he could take. First, I gave him permission to call his father, and asked him if he'd be willing to call every Monday, Wednesday, and Friday. He liked this idea and his mom said it was OK with her. I told his mom not to dial and not to remind him. This was completely Max's responsibility and he could do it alone. I made it clear that his dad might not pick up the phone or might be busy, but told him that he should leave a message every time he called. It gradually came to him that this might not bring his dad back. “What if he still doesn't call?” he asked. I told him that he could go shopping for postcards and that a couple of times a week, he would send his dad a postcard with a note on it, or a picture.

I had met his dad several times over the years, and knew this man loved his children. If getting a lonely message from your 8-year-old three times a week didn't melt his heart, I'm not sure I could come up with something better.

But here's the key step: moving the child from passive to active. This is a repeating pattern in my parenting advice. Taking a child, especially at this developmental age, and empowering them to take control of at least part of their lives, to give them tools that can leverage the influence they never knew they had. I knew that I didn't have the power to repair what was broken from the child's perspective—his family. But I did have the ability to fix his sense of helplessness, and push away the inevitability of the world.

I also had the ability to try and relieve the sense of sadness. We'll try a little medication, too.



Coming up: a series of posts on ADHD.

Eight is Enough

When you're eight, the world is full of inevitability. Your parents go someplace, and you are dragged along. Your teacher assigns homework, and it has to be done. It feels like everyone in the world has some kind of authority over you. Don't they know you have your own plans? Your own agenda for things that have to get done? Your own idea of what is most important?

Max came into my office with his mother. He gave me a hug hello but wasn't smiling. His mother told me that he said he wasn't feeling well and wanted to see me. She said that he wanted to stay home from school for the last few days, but couldn't say just what was wrong. She made him go to school, but wanted him to see me on Saturday. I went through the usual review of his symptoms with them, but he denied headaches and stomach aches and everything else. I asked if he had pain in his toes. I asked if he had pain in his feet, ankles, knees, legs, and so on up to his eyes. Finally, I asked, “does your hair hurt?”. This usually causes a pause to think and then a smile. He paused and his eyes started to tear up. His mother started to tear up. I started to tear up.

Luckily, my office is equipped with the latest in medical technology and there were tissues enough for all.

His mother flatly related that his father had moved out several months ago, and had just moved in with somebody else. His father hadn't seen Max for about a month. He stopped calling a few days ago. After saying this, his mother told me that she didn't know what was wrong with Max, that she was worried about him, she asked him what was wrong but that he won't talk to her. She wondered aloud if he would talk to me. She didn't ask either of us, but as she said this, she arose and said that she'd wait outside the room.

“Max,” I said, “do you miss your dad?” He nodded tearfully. “Does it make you sad that you don't see him?” At this point, the perceptive reader sees where this is going and I can't claim it was particularly insightful of me to see it at the time. The fact that his mother seemed genuinely in the dark about it was remarkable. Even though he was eight, I asked screening questions I typically ask dejected teens. Did he think about hurting himself? Did he think about running away? Finally, I asked him if I could tell his mom about what we talked about and about what he said. He said that was OK, and I invited her in.

Though mom was made sad by what I relayed to her, she was relieved that he opened up about it. Max was visibly relieved that mom now knew.

Max's younger sister was acting out a little more in kindergarten, but had not taken it so hard in an obvious way. But 8-year-olds can see the world in a bigger picture, and in this case as something that was broken forever. Preschoolers just want more time with mommy, and it's OK if she's shopping as long as they get to come along. Teenagers get to stay home alone.

Max told me that it made him sad to think that his family isn't the family he had when he was little. He said that he thought he would have that family forever and now it's gone. This made him cry a lot. Again, we took advantage of tissue technology. His perspective is an important one for parents in every situation to be aware of. To him, everything in the grown-up world is fixed for eternity. Until it's not, and then it's shattered. As adults, it's typically from about this age that emerge some of our most troubling memories of the relationship of our parents or the circumstances of our childhoods.

Next Post: Trying to help Max.


The photo from my collection is by Walker Evans and was taken during The Depression.

The Power of Slow Medicine

I discovered the power of slowness even while being rushed to see more patients faster. Luckily, I have a good way with most children, and they aren't usually scared of me. But there's no practical way of examining a child within a minute of walking in the room. Like the rest of us, children get territorial about their personal space, and will be upset if you violate their boundaries. So the key to a cooperative examination is getting the child to invite me to share their space with them. This takes time and patience. I will often use a prop of some sort, such as my tie or a toy or stuffed animal to engage the child and get them to reach out to me. It's a subtle dance which can take more than a few minutes, especially for anxious children. The first part of my definition is literal: slow visits.

Slow visits allow the patient or parent to ask all their questions, to get comfortable with the surroundings. In medicine, there's something known as the 'doorknob question.' The patient is in the room with the doctor, and their visit is finished, and just as the doctor turns the knob to leave the room, the patient asks a really important question like, 'Oh, and doc, should I be worried about this chest pain I keep having?' I think there would be fewer doorknob questions if doctors weren't always reaching for doorknobs. The removal of time pressure in the visit allows the patient to express their anxiety, and gradually open up about important issues. It also allows them to explain complex related problems, like family or financial situations that might have an important impact on whether they will be able to take their medicine or follow the doctor's advice.

The goal would not be simply providing the minimal acceptable level of care. Having an expert doctor who knows who you are is like having a chef who knows how to take advantage of that local seasonal produce. It takes more skill to cook something fresh than to heat something in the microwave. Having uninterrupted access to your physician can keep you from unnecessary treatments and save your insurance company money.

When I see a sick child, I have a luxury that I didn't have when working in a busy clinic. In the clinic, it wasn't clear when or if the parent could bring the child back. So to be safe, we would sometimes prescribe medication on the assumption that the diagnosis would eventually require it. Because my current patients have open access to me, I will often choose not to treat the child at all. I tell the parents to call me right away if the child gets worse. If I don't hear from them, I'll call the next day to check up on the child. Often, my patient will get better on their own and won't need any medication at all. This system only works because when parents call, they talk directly to me. I know the situation and can evaluate the need for treatment at that time. If it were a doctor covering for me, this might be a problem. Either the covering doctor would be extra cautious and prescribe medication or possibly not take it as seriously because they wouldn't know the whole history. If the parent is even more removed from the doctor, by calling a call center, they often can only get a response by selling the person answering the phone on how awfully sick their child is.

About two months ago, I got a call one Sunday from a mother of two preschoolers. Both had fever and seemed to be in pain. I met them at my office, opened the office for them and treated them. I was later told by their insurer that Sunday visits aren't a covered service. The person I spoke to on the phone in the claims department suggested that I do what most practices would do on Sunday--send them to the emergency room. It didn't seem to matter that the ER would be way more expensive, slower, and scarier.

I wonder if slower, more customized, more personal care would end up costing less. I think there might be fewer tests, fewer ER visits, fewer prescriptions, better compliance with the doctor's advice, and a lot more medical problems might be caught early. That could result in better health outcomes, lower cost of care, and more satisfied patients. I suspect there aren't enough doctors who practice this way to do the research to prove it.

I practice slow medicine.

Next Post: Slow Medicine and the Telephone Paradox

The Problem with Picky Eaters

Should we intervene with picky eaters?

This is both a medical and philosophical question. The medical question is easier, so I’ll deal with that first.

If the child’s picky eating has left them without enough vitamin intake (if they ate zero vegetables, for example), they probably should take a vitamin. Luckily, there’s a lot of good-tasting vitamin choices available. For iron deficiency, it’s a little more difficult, because the iron supplements often taste bad. But there’s now orange juice with iron, and vitamins with iron which might help. For kids who don’t have any dairy, there are many calcium-fortified foods and drinks. If the child has a problem with creamy-textured foods, that’s sometimes a problem with fat-soluble vitamins A, E, and D, which are usually found in milk. Most soy milk and rice milk is also fortified with these vitamins. But supplements are available for these too. In short, if there's a medical problem, we'll deal with it medically.

The philosophical question is related to the saying, ‘if it ain’t broke, don’t fix it.’ By the time they’re 2, half of all children are considered picky eaters by their parents. So if this is a pretty typical part of child development, do we need to change it? Should we even try?

Research has suggested some of the answers. It turns out that preschoolers who are very picky eaters were often picky toddlers, and these were picky babies who had difficulty nursing and were often fussy. When they became older children, better able to say what they didn’t like, they often had difficulty describing the hesitation they had with certain foods. But many of these very picky eaters remain very sensitive to certain flavors, textures, and smells. Some also were sensitive to other sensory inputs, such as noises, clothing textures, and temperature of the environment.

When I was in medical school, I had the great good fortune to work in a laboratory that studied taste and smell, run by a brilliant scientist named Linda Bartoshuk. Though I personally focused on some of the curious effects of hot peppers in the mouth, the lab studied many interesting phenomena. When I was there, I learned that what I had been taught about the sense of taste was mostly wrong. Bitter taste, in particular, seemed to be genetically determined. It was often more intense in women of childbearing age, and less intense in girls and older women. It was usually less intense in men. Some people simply could not taste one of the test chemicals, while for others it was intolerably intense. Researchers in the lab photographed tongues (including mine) with a microscope, and meticulously counted the taste buds. It turns out that there’s a wide variation in the number and kinds of taste buds people have. Both this and the variations in what we can taste and how intense that taste is can be related to how certain foods taste to us. Professor Bartoshuk and her former student Valerie Duffy, now a professor at the University of Connecticut, collaborated on a great research study that's important to the way we should probably look at this issue. These scientists looked at how intensely adults experienced bitter taste. Then they tested how much these same adults liked asparagus, kale, and brussels sprouts; they also asked about how many servings of vegetables these people ate. Maybe it's not a surprise that those who had the most unpleasant and intense bitter taste perception ate the fewest vegetables. So it's not because their parents were inept about teaching good eating habits. And not because their parents didn't find the right bribe to use to get them to have one more bite of vegetables. It's because the vegetables just didn't taste good.

I have always been interested in doing this kind of experiment in children, which nobody's done. But there are complex issues when experimenting on kids, and that's why it hasn't happened.

Knowing this influences my approach to this common question. The child may not, in fact, be perceiving as delicious what we perceive as delicious. To them, it might be too intensely flavored, even bitter enough to make them gag or vomit. This might be built into their tongues and brains, and won’t improve with nagging or bribing. In other words, it's not necessarily behavioral—which is why behavioral approaches may not work, and could return unwanted consequences.

We could end up causing lasting harm, leaving them with serious food and eating issues that might result in eating disorders and self-esteem issues when they are older.

It’s an unfortunate coincidence that this issue seems to coincide developmentally with the time that most kids are naturally learning to exert control on their environment and their parents. It will take an intelligent parent to figure out when these typical eating issues leave off and the child’s quest for independence and control take over.

So what is the perceptive parent to do? That's the next post.

Toddler Makes Friends with the Doctor

This was a great day and a great visit.

I had my first visit with a 16-month-old girl today. Her mother interviewed me a week or so ago. When her mother called today, I told her that I was surprised I passed the audition.

I didn't think she'd pick me as she looked for her new pediatrician. My practice is very grounded in practical science, and in general I am reluctant to intervene unless necessary. This is a luxury of good access to the physician and a willingness to see patients whenever they need it. It's a luxury of good follow-up. So I don't routinely give a prescription to every kid with a cold. This parent liked that, but I know she would have preferred a doctor who was ambivalent about vaccination but a cheerleader for something more alternative. It took a lot of humility for her to return to me with her child when it would have been easy to find a practitioner here in Berkeley who could meet every litmus test for alternative medicine. But her daughter had a cough for a few days. When she called, I suggested she bring her daughter in today.

During the interview last week, the girl was exploring the toys I have in the office. They are there for a reason, after all. She was reluctant at first, and didn't know what to make of the balding giant with the tie. It is an anxiety-provoking situation at her age. I saw she was not comfortable, so I took the basket of stuffed animals, turned it over, and let them all fall into a big pile on the floor. I laughed when this happened.

Today it was the first thing she did. She knew just where to go and didn't ask permission. She picked up the fabric basket and dumped out all the stuffed animals. She really laughed. Then she put the basket over her head. For the first 10 minutes or so, I sat on the floor and did silly things with her. When her mom and I were talking, she would sometimes seem bored, so I got up and fetched her a new toy from another room. Her mother looked a little concerned when the floor was covered with toys. I reassured her that this is exactly what will help the child be comfortable.

Eventually, of course, it was time for the exam. As I approached, the child backed away into mom's lap. I kept talking to her in a soft voice. I offered her my stethoscope to handle and check out, just to make sure it was OK and nonthreatening. I picked up a stuffed dinosaur. First I listened to the dinosaur, then her mother's leg, then the dinosaur. Back and forth right in front of her just to show that neither her mother nor the dinosaur minded even one bit. Back and forth she followed the movement as if she were watching a tennis match. Then I made a quick stop on her chest--just for a moment--and then back to the dinosaur. Then a longer pause on her right chest, dinosaur, left chest, dinosaur, right back, dinosaur, left back. I took off the stethoscope and handed it to her. She gave a big smile and put it on her ears. I took out my little otoscope and handed it to her. She knew right away! She put it in her own ears and I held on briefly to give myself a quick view. By this time she was laughing a lot and I as able to use one of those opportunities to get a good look at her throat. I felt her neck and we were done.

That was the first time in her life, her mother said, that she ever had a doctor visit in which she wasn't screaming throughout. Her mother said she'd start screaming when they approached the doctor's building.

I've seen doctors examine children who are screaming. Sometimes that's what has to be done and there's no way around it. But I've never met the 1 to 3-year-old who lets a non-parent adult get right into their space and poke around the way a doctor does. I have sometimes read exam notes that say that a kid's heart sounds were normal or their lungs were normal when the only exam was while the child was terrified and wailing. It takes practice and patience, and both only come when the doctor is willing to take the time to let the child come to him.

Medically, a child's uncooperative demeanor is a potentially serious confounder of physical exam findings. Crucial and subtle observations, such as sounds of the heart and lungs and abdomen, are easily eclipsed by the glare of screaming. Indeed, the gestalt of the child is an essential observation of the skilled examiner (ie does the child look sick?). Is the child in distress from the illness or from the situation? The good doctor needs to know these things and figures out how to get the information needed. It may look like play, but I take it very seriously and work very hard at it.

Just as with adults, some kids are a lot more anxious than others. But just as with adults, it's a lot less stressful to have a doctor you like. I believe that this results in better care. The exams are better, the communication is better. Even the communication between 16-month-old and pediatrician.

The kid had a cold, I thought. No need for medicine, I told the mother. Some home-made nose drops might help with the congestion. Nothing for the cough unless it gets to be a problem. And of course, call me anytime if you're worried or if she's not better in a few days. The only time the child was upset was when she was leaving. Her mom and I agreed to make another playdate soon.



The photograph: photographer Arnold Eagle is most famous for documenting the Lower East Side, a tenement area of New York City. In the 1930's he took a series of photographs he called One Third of a Nation, referring to children living in poverty. He made up a book from the prints of this series, and gave it to his wife as a gift. There are no other copies beyond the one that was in my collection.

Breakthrough with a Two-year-old's anxiety

Some time ago, I looked for but couldn't find the origins of the phrase 'terrible twos.'

I could not find who invented the terrible 2s. I think it's a great year. Finally, they are talking just enough to let you know what they want, sometimes. They are interested in everything and going everywhere. This is often inconvenient, but it's a wonderful thing to see in terms of their development. They often explore and are willing to put themselves in harm's way just for the thrill of your raising your voice and yanking them back to reality. They are busy discovering new techniques to meet their most important goal: getting the parent to play with them.

With that said, however, I got a call last week from a woman whose English was as bad as my Spanish. We had enough overlap to make an appointment. She brought her 2 year old for what she had called a check-up. As soon as they walked in the office, I know that no check up was going to be getting accomplished. They opened the door to the office, walked in, and the child started screaming. Not crying--that happens sometimes with very anxious children--screaming at full capacity as if in pain. The other kids in the office were startled. My medical assistant didn't know what to do. The child took one look at the student who was following me around that day and increased his volume higher.

I ushered out the other patients.

I asked mom to follow me into the room with the sofa. He never left her side, of course. I asked the mom, over his shrieks, if my student could observe and she was gracious about this. I observed the child for about 5 minutes, during which he played with none of the toys that are in all of my exam rooms. He simply stuck to his mother, screaming.

I told the student--something I almost never do--I'm going to need your help. She nodded OK. I told her to avoid all eye contact with the child, no matter what. Then I picked up the large basket of stuffed animals and puppets, and without warning, dumped the entire contents onto the floor in the middle of the room. He stopped, was silent and watched what might happen next. I picked up two hand puppets and told the student to pick up 2 also. She got the cow and the frog. Ignoring the child, she and I played with the puppets, moving their mouths and making animal sounds for at least 10 minutes. He left his mother and came to get a closer look. I took off one of the puppets and gave it to him. Then I sat on the floor and played puppets with him. After a little while, he would smile and laugh with certain puppet actions. I retrieved a Thomas and James train from the other room. He liked these a lot and I sat on the floor with him as we rolled them back and forth between us. I showed him my otoscope, which he liked holding--who doesn't like a flashlight?--so I let him hold it as he looked in my mouth and I in his. I let him play with my stethoscope, then back to Thomas, then back to the stethoscope. I let him listen to some of the stuffed animals. I said it was my turn, even though he didn't understand any English, and he let me listed to his heart and lungs and abdomen.

The whole exam took about 70-80 minutes, most of which was playing with him. When he left the office, he said goodbye and gave me a hug.

His mother told me that he had been very traumatized by the previous place they went for medical care. I'm proud to say that she also said that she had never seen him allow even as much exam as I got and that this represents a major breakthrough for him.

I got that sense as well, I'm glad to say. I grow increasingly convinced that rapport with a child cannot be established in minutes, and this is even more true for difficult children or those who have been hurt in the past. Our medical care delivery paradigm has been optimized for the shortest possible visit, and this will only exacerbate the trauma children (and adults!) experience when they go to the doctor.