Transition Issues -- A Definition

Pretty much every week, I’m in an airplane.  At this point, I have flown so often that nearly everything is routine about it.  Those of us who board earlier in the process are already sitting as the rest of the passengers walk on.  Nearly everybody is using this time to talk on their cellphone, text messages, or do something technological until the plane takes off, when all electronics must be shut off.  So it was not unusual that the guy across the aisle from me was chatting breezily on his blackberry phone in a foreign language as the plane filled up.  I heard the big door shut and sealed by the flight attendant, who announced that all electronics must be turned off.  They walked up and down the aisle.  Politely, they reminded a few of the passengers that they had to finish using their laptops or phones.  The big jet was being backed out of the gate.  One of them tapped him on the shoulder and gestured, with a smile, to his phone.  He nodded his head in cooperation as he continued to talk on the phone.  The plane started to taxi to the runway.  Both flight attendants approached the man and told him verbally that he must shut off the phone.  He kept talking but nodded his understanding.  They walked away, as the plane got closer to the end of the runway.  The plane stopped.  Both pilot and co-pilot, in uniform, emerged from the cockpit and came to the man.  He saw them, smiled and held up his index finger, as if to say ‘I’ll be with you in  a minute.’  One of the officers said, “In 15 seconds we will have you removed from this aircraft by Federal marshalls.  You will be taken to Federal detention.  You are committing a crime and will have a criminal record.”  The man, showing an unexpected facility with languages, seemed suddenly to understand English.  He abruptly said into the phone, “I gotta go,” and turned off the device.

Ask any parent about getting their child to turn off the video mid-story and wash their hands for dinner.  Sometimes they wish they had a couple of Federal marshalls to call.

This is the first essay of several on transition issues, techniques, and objects.  I hope some readers find these ideas helpful.

Transitions are the times of overlap between what we are doing and what we are doing next. 

This is my own definition, so it doesn’t appear just this way in parenting books.  But I think it applies throughout our lives.  In babies, it could be transition between being awake and being asleep, or maybe between being held and being put down into the crib.  For preschoolers, it might be the transition between one activity and another, say coloring vs. playing with blocks.  In school, there are transitions between classroom work and lunch, lunch and active play, then back to class.  By high school, it may be all about just getting off the phone.

Being able to navigate successful transitions is a life skill.  Our frequent flyer, for example, nearly spent a night in jail.  There’s an important balance to be struck between being bad at this and being too good at it.

Many children are brought to me for evaluation of what is thought to be an attention problem.  (Because I do this very carefully, I often find other issues. )  Other children are brought in for behavioral advice because every transition results in a tantrum.

Being able to pay attention is also a key life skill.  It enables us to listen to a story, to follow crucial directions, and to fall in love.  Even if it didn’t help us get through school, it would be important in establishing human relationships and stalking prey on the savannah.

But it’s also important, and little studied I think, to be able to break off our attention when appropriate.  Otherwise, we might end up on the No-Fly List.

There’s something about certain activities, I believe, that interferes with the normal balance of transition controls in the brain for certain children.  For some, video games tap into something very primal.  There aren’t many activities that a child can do for so many hours that they ignore bodily functions.  There’s a clue about autistic spectrum disorders here, by the way.  Some children with ASDs will continue to do a repetitive activity until they fall asleep exhausted, or are distracted or stopped by somebody.  Maybe it’s making a sound, maybe it’s not so benign.  Decades ago, some of these were assigned the unfortunate categorization of self-stimulatory behaviors. 

Max was brought to me because his mother didn’t know what to do.  In kindergarten, he did fine with the class activities and didn’t get in trouble.  In school, he could transition between circle games and coloring and learning to write his name just as well as everybody else in the class.  He was not a behavior problem.  At home, however, it was a different story.  No matter what he was doing--playing with blocks, playing with his robot people, or looking through picture books of trucks--his mother couldn’t pull him away.  She’d plead with him to come to dinner, bargain with him to get into the bath, but he always said words that were the equivalent of holding up an index finger as if to say, ‘I’ll be with you in a minute.’  When she was more assertive, a long and unpleasant tantrum exploded.

Max was not, in my professional opinion, developmentally abnormal, attention-challenged, or emotionally unstable.

It was hard for him to give up a fun activity.  Because of his normal developmental stage, it was almost impossible for him to envision himself in a future situation, even if that future was only 15 or 30 minutes away.  So even when his next activity would be even more fun, he could never appreciate it.  So there was never an incentive to stop what he was doing and move on.

For the record, he was brought to me with his mother complaining that he was constipated.  It was only after I asked lots of questions that the whole story emerged.  He focused so intensely on whatever he was doing that he never wanted to stop, even for brief bathroom breaks.  After a while of ignoring the feeling that he had to go, he no longer felt that he had to go.  This led to a spiral of holding it in until it turned to concrete.

The first step would be helping him get to a less intensely-focused state, in which he'd be less and less invested in his current activity and more ready for the next.  I suggested a gentle reminder at 20-minutes.  Mom could tap him on the shoulder and let him know that a change was coming.  As expected, he would nod his head or indicate he understood but otherwise show no indication that he would comply.  Then again at 10-minutes, but this time with a little more discussion.  At 4 or 5 minutes, he should be told to shut off the video.  He won't, but he also won't be surprised when it happens.  Maybe he won't like the transition, but at least he'll be prepared for it.

Too Many Clean Diapers

As devices go, babies are pretty basic. They eat. They sleep. They poop.

New parents give so much, so fully. Shouldn't they expect something in return? So maybe it's natural that some parents ascribe to the baby's material productivity some kind of assessment of their parenting prowess.

Ellen was about 4 weeks old when her parents brought her in. They were generous enough to let me hold her and play with her while they told me why they were in my office. She hadn’t pooped in 4 days. Last week, she went 3 days, then several times a day for a few days, and now nothing for 4 days in a row. I was kind of listening to them, but I was having a lot of fun making Ellen smile, which she did easily. I asked them if she was this happy at home. She was happy, ate well, didn’t throw up, slept well, and was nursing like a champ. Her weight gain was perfect.

I told them what I knew at the time. Breastfed babies have unpredictable stooling patterns. Medically, I wouldn’t diagnose her as constipated unless she went at least 5 days. They were pretty amazed by this, and though they didn’t seem worried, I got the impression they weren’t fully satisfied, either.

There were many things that could be done to help the process along. An old remedy is to add sugar syrup (Karo syrup) to a baby’s bottle. Another is to sneak in a little pear juice. Taking advantage of the baby’s autonomic nervous system, a little direct anal stimulation will usually provide an effective reminder (that's why they usually go after getting their temperature taken).

They called me the following day, at 5 days. I tried to be reassuring.

They called me on the morning of day 6 to report that nothing productive had occurred. I called one of the very smart specialists in pediatric gastroenterology at Children’s Hospital Oakland. The specialist chuckled a little and said that he’s seen healthy breastfed babies go a long time.

I didn’t hear from them the next day, so I called to ask about the blessed event. I got a surprising response.

On the insistence of the baby’s grandmother, they reported being fortunate to get an urgent appointment with the grandmother’s chiropractor. He diagnosed the problem as a misalignment of the baby’s coccyx. In an additionally fortunate stroke, he was confident he could realign the baby’s lowermost spine to alleviate this problem. In order to reach the coccyx, which is deeply protected in the center of the pelvis, he put on a glove and pressed directly on the baby’s anal and perianal area.

Sure enough, said the parents, the baby went within an hour. They were told, however, that this alignment procedure was only temporary and the baby had a tendency to sacro-coccygeal subluxation. For this chronic problem, they would have to return once or twice a week for the foreseeable future. Each visit was $100.

They continued to see me for scheduled check-ups. Every few days, Ellen got a realignment. They never again had a problem with constipation.


The astute reader will notice that in the uppermost photograph of the felt-and-velcro skeleton which hangs in my office, a creative anatomist placed the pelvis and thorax upside-down. The sacrum and coccyx are oriented correctly, however. By giving medical experts of varying ages the opportunity to share their expertise, I have access to a valuable consulting resource. It could be argued that the implementation of a 21st-century perspective requires a voice born in the 21st-century. The occasional redesign of the human form is a small price to pay for this cutting-edge knowledge, especially from someone who has just learned to walk.


For the neuroanatomicially curious, the nerves controlling sphincter muscles and thus pooping emerge from the cauda equina tail of the spinal cord at the S3 and S4 segments of the sacrum, above the coccyx. For this reason, one could live life with a subluxed, broken, deformed, or absent coccyx and poop like a champion. There are champions for this, aren't there? I'm not much of a sports fan so I don't know for sure.

Please see my post on Swine Flu, UPDATED 5/5/09