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.

A Mistake

“Experience is the name everyone gives to their mistakes.” Oscar Wilde, from Lady Windermere's Fan, 1892


Yes, I know. Everyone makes mistakes. Every parent makes mistakes, nearly all of them invisible to a child. To a child, what we do has to be right just because we're doing it. Parenting books are filled with sure-fire techniques to get your kid to do everything from eating something besides white food to success in college. But those authors haven't met your children. Sometimes the best thing to do just isn't that clear.

Doctors make mistakes, too. In my particular line of work, I'm relieved to report, failure isn't usually associated with a really bad outcome--you know what I mean. Still, I look upon my job as making children feel better and making their lives better. I work hard at it and do my best.

Three days ago, a favorite patient came to the office with his mother. He had acquired a splinter in one of the worst places to get one, the center of the palm of his hand. It's a bad place for several practical reasons, not for elaborate medical reasons. The skin on our hands is quite thick, not quite as thick as the soles of the feet, but very thick. Unlike the soles of our feet, however, our palms are covered with sensitive nerves for feeling things. Our palms have a flexibility that makes it difficult for us to flatten our palms completely. And once we start grasping things as babies, we never stop, so the muscles of our grasp are very strong. Lastly, the palm is fully visible to the motivated child.

He had been healthy and was playful with me when they first came into the office. He was glad to show me the splinter. It was clearly visible, only about 2 or 3 mm long. But it was in an awkward position, as if it had been put straight in and then broken off at the surface. Because of this foreshortening, it was difficult to see a way to expose the deepest part of the splinter without digging a deep hole in the center of his hand. The nearest part, however, was close to the surface, and should be an easy grab with my sharpest surgical-quality tweezers. Because of the thickness of the skin in the palm, I thought I could get it on the first try without hurting him.

After about 20 minutes of the most upsetting screams possible, as this child stared at me, wearing a headlamp, using needle-sharp instruments on him, I gave up in a sweat. I had to try a different way.

I prescribed some numbing cream for him, and asked his mother to bring him back with the cream, for me to apply. The next day, I put the cream on, covered it, then wrapped his whole hand in an elastic bandage so he wouldn’t mess with the cream. He was happy to play with the office toys for about an hour. He didn’t mind the unwrapping, or cleaning off the cream. But the screaming started as soon as the tools came near him.

Granted, these are some fairly scary-looking tools. Everything was shiny and needle-sharp. We had a reasonable control ratio. (I have defined this invented term—I wonder if it’ll catch on—as the ratio of adults to the age of the child, in years. In this case, the ratio was a usually-effective 1.0: there were 3 fully grown adults to a single 3-year-old child. The 3 adults didn’t have a chance of restraining this warm and affectionate child. I though it might be helpful to use the numbness provided by the cream to allow a small injection of local anesthetic, to really be sure he wouldn’t feel anything.

I won’t keep you guessing. That didn't work, and the 3 of us never got his hand still enough even to get a good look. I never took out the splinter. Luckily, I haven’t been exaggerating about the patient’s mellow personality, and though he was absolutely impossible to restrain for even 20 or 30 seconds so I could get the thing out, he was immediately forgiving, both of me and his mother.

First, some information about splinters. Usually, they have to come out. By definition, they are little irregular slivers of something, torn or broken off of something else. Broken or torn edges are rough, though you might need a microscope to see that. These rough edges can be packed with bacteria that can cause nasty infections. It’s a sign that you absolutely must get the thing out if it becomes swollen and red and painful to touch. It’s a particularly bad sign if this red/swelling/pain develops just a few hours after getting the splinter in the first place. If that happens, either get it out yourself, or if you can’t, get to an ER. In this case, there was no redness after a day when I first saw it. There was still no redness the following day. No swelling. It hurt him a little to press right on it, but not too bad.

So this was my mistake. Honestly, I don’t think it’s a mistake I make very often. I think of myself as a minimalist, using the least possible intervention that will have the best result for the child. It just looked so easy, no big deal, right there near the surface...all it would take was a few seconds of him holding still. But that’s a common error in judgement. I focused on what would be reasonable medically for all kinds of rational reasons. That wasn't an empathic approach. What was in the best interest of the child? How did he look at this issue? He certainly didn’t see it as a problem that needed what appeared to be an inappropriately serious response.

He was right. Though most splinters need to come out, what happens if they don’t? If small enough, the body’s immune system can literally digest them, and make them disappear. Sometimes, the skin will push them out over time. And sometimes the body can wall them off with scar tissue, and they are with us forever. After a really long (maybe an hour) bath, the top layers of skin on his palm might be soft enough to come off with a vigorous drying, and that might take care of it.

His mother certainly thought it needed to come out, and I did too, at the time.

It's important to try and see things from the child's perspective. It's something I consciously try to do with all my medical encounters. This time, however, not so much.

Being sensitive to the child's viewpoint is really important--but that's not the same as letting that viewpoint dictate what has to happen. Part of the price we pay for having the privileges of being grown-ups is that sometimes we have to make tough, unpleasant decisions. Just because your children would like to play on the freeway doesn't mean you should let them!

If the splinter had been infected, it would be out.