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

Monsters: Part 3

The Monster Whisperer

In Monsters:  Part 2, my medical colleague, a very smart adult physician whose office is across the hall from mine, burst in and asked for a urgent medical consultation, assuming I had expertise beyond his own.  He asked me what he can tell his distraught patient to help her get rid of her child's witches.

I didn’t think her child was afraid of the fact that there are witches. She’s not afraid of their power to do things by magic.  She’s not afraid of their malicious motives or the scary way they look or dress or of their scary henchpeople or flying monkeys.  I thought that gentle questioning of the child, while never doubting her belief in witches, would probably reveal that she’s afraid they will come into her room when she’s asleep, and work their bad intentions there.  (I would use this opportunity to point out that it is the child’s concrete thinking that doesn’t usually consider that a witch with magic powers could cast an evil spell from afar, without warning.  In Snow White, why couldn't the evil queen just wave a wand over in her palace, and do her mischief from there?  Despite her apparent powers, she had to get Snow White to take a physical bite of a tangible apple.)  As in Monsters:  Part 1, with the child so afraid of a toilet monster, this child was keenly aware of when she was most corporeally vulnerable.

How can we help?  If we tell them that their belief system is sheer nonsense, we alienate them and make them feel worse.  If we sympathize with them and agree that witches are a constant threat, they might continue to trust us, yet their fear is reinforced and we have confirmed that there is a dangerous broomstick-riding predator somewhere above us just waiting for the right opportunity to strike.  Keep watching the skies!

Our problem is that the child's fear is magical, but we are limited by our physical reality.  Or are we?

• If her specific fear is of a witch entering her room, she might benefit from a meticulous bedtime ritual of closing and locking her windows at bedtime.  If it’s hot and her window must stay open, how about getting a special witch screen that fits the opening?  The openings in a window screen are very small and no witch could fit through.  Or maybe witches can’t fit through those window safety bars that you are going to install to protect your child. (Maybe you should be doing that anyway.)

• Consider a special witch treatment or repellent that is not toxic once dry but is especially specific and new to the child.  My favorite for witches and related hazards is witch hazel, a pre-19th-century remedy for many things with a distinctive smell.  Because it is not in widespread use these days, it might not be easy to find.  But it sounds like a logical product.  So an exhaustive hunt for it with the child in tow will have that much more of a chance of effective pest extermination.  As you go from pharmacy to pharmacy, don’t look on the shelf!  Since the child can’t read, it is not helpful when you tell her that you looked and there’s no witch hazel there.  How can the child be confident of that?  Make a point of asking a manager—always with the child right there—if they carry witch hazel and if not, where you might be able to get it.   Maybe it can be used to seal the joints around the windows and doors.

These aren’t tricks.  I will repeat that lying to your child is never, ever a good idea.  Are these lies?  Is my approach dishonest?  Yes, in spirit it is dishonest, because you don’t, in fact, believe in witches or in the monster du jour.  But these anxieties and beliefs are a normal developmental phase.  I often discuss concrete thinking and the ways a parent has to anticipate and deal with a concrete thinker.  I have also discussed in previous posts the gradual development of abstract thinking as a mark of adulthood.  The kind of thinking that gives rise to this kind of childhood anxiety is called magical thinking.

With magical thinking, there does need to be some sort of a link between observations or events, but it doesn’t have to be rational from the point of view of an adult.  Let’s say your child takes a bath every day just about the time that daddy gets home from work.  One night, dad has to work late.  At bedtime, your child snuggles with you and asks to take a bath.  This seems odd to you, but slow iterative questions determine that he believes that if he takes a bath, daddy will come home.

So my empathic approach, as always, directs our technique to take its cue from the child.  This brings up...

5.  Dr. Wolffe’s Thinking Rule:
Concrete thinkers need concrete actions.  Magical thinkers need magical actions. 

There is no intervention for supernatural issues except for supernatural interventions.  If you wanted to help someone suffering from demonic possession, would you call a surgeon?  Of course not.  You’d look for an exorcist.  How do we accomplish this for the supernatural conflicts experienced by young children, when we might not be experts in the field—and probably can’t easily find an expert.  Think about it...who is an expert on toilet monsters or witches? Maybe we all have enough knowledge for the job we need to do.

All of us, by the way, are a soup of all kinds of thinking.  My bank just changed the way ATM deposits are done.  I asked a bank officer about this, and she helpfully showed me how to drop the deposit into the night deposit slot.  I told her I’d rather change banks—it was intolerable for me to drop an envelope of checks or cash into a blind slot without any sort of record or receipt.  It wasn’t that I didn’t trust them, it was just my need for concrete security.  (Ronald Reagan said, "Trust but verify.")  Now that the holidays are over, do you feel comfortable telling your kid all you really know about Santa Claus?  And what do you do when you are cornered by somebody at a social gathering who insists on convincing you that every English word of the Bible is the literal word of God, despite your knowledge of it being compiled by a committee in London at the turn of the 17th century?  I have met plenty of scientists who follow a religion.  Does understanding the universe convince us that there is no God or that there must be a God?  Whichever we believe, no amount of moot-court argument will change a person’s faith in their belief system.

I’m not lying when I tell preschoolers that I can see an elephant in their ears.  It makes them laugh.  Even if I say I see a dinosaur or a crocodile, they still, mostly, laugh.  They aren’t worried about it because they know, within their magical belief system, that the only elephants that could be in their ears would have to be very tiny ones and they wouldn’t hurt.  Maybe they just acknowledge the elephant I see the same way they would play along with one of their younger peers, and are being indulgent with me because I’m obviously not as mature as they are.  That, indeed, is rational insight.

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.

Pinkeye

When I applied to medical school, I kept getting asked the same bunch of interview questions. One of them was what I might do if I didn't become a doctor. My usual response was that I'd like to be a kindergarten teacher. Mostly, I was told that this was not a response they usually heard. The interviewers heard a lot, they told me, of applicants saying that they would become research scientists and selfless public health workers. I, on the other hand, thought it would be fun to play circle games. I got in despite this—or maybe because of it. I have great respect for teachers, and appreciate the work they do.

So when Henry came into my office because of a problem noted by his kindergarten teacher, I took it seriously. His mother said that she was told he had pinkeye, which was well known to be extremely contagious, and he would not be permitted back to school until it was better.

Pink Eye is a disease which can only be diagnosed by kindergarten and preschool teachers. It does not appear in the index of, for example, The Manual of Ocular Diagnosis and Therapy (6th edition).

There are many reasons an eye could be red. Eye infections of all kinds can make an eye red. Though this is often called conjunctivitis, there are many different types of infection that can make an eye look red. Mostly, we get these infections from touching our eyes with our hands. It’s a natural thing to do and trying to keep kids from rubbing their eyes is not a worthwhile or achievable goal. Our tears wash over our eyes continuously, rinsing away bacteria and dust from the air. The tear ducts drain into the nose, which is why people blow their nose when they’re crying.

In babies, these tiny tear ducts can get blocked. They are so small that the twists and turns they take on their way to the nose just don’t allow the free flow of tears. When they back up, the dust particles and dead cells and bacteria will clump up and make for a goopy eye. Usually, a clean moist cloth is all that’s needed to clear away the debris. For any symptoms beyond that, I like to see the baby and make sure. Blocked tear ducts often clear up as the baby gets bigger. If they don’t, a specialist can help.

Allergies are also a reason an eye could be red, but why just one eye? Usually, allergies affect both eyes.

Of course, he could have something in his eye, irritating it and hurting or itching.

Henry had a pink eye, which was crusted with dried stuff. He said it didn’t hurt, didn’t itch. It was a little pink yesterday, and pinker today. When he woke up, it was glued shut. Just his right eye was affected. He wasn’t sick and wasn’t injured.

For his eye infection, he got some drops that didn’t sting and took away the goop and redness within about a day.

Kids his age do all kinds of wacky and unsanitary things. But short of rubbing somebody else’s eyeball, these typical ‘pinkeye’ infections are not more contagious and not more serious than any other minor illness.

I am often asked when a preschooler is not contagious and can return to school. Honestly, I’m not sure I know a preschooler who isn’t contagious. At least with a red eye, I can clear up the teacher’s concern and get the kid back to school.

Please see my urgent post on Swine Flu.

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.