Intangibles.

I was trying to explain something important to my son Louis the other day.  See, Louis is kind of a know-it-all, especially about sports.  He’s 13 years-old, has a memory like a vice grip, reads everything and knows all the data and stats you could imagine.  But as much as he knows ABOUT sports, he hasn’t actually PLAYED much.  So I think when guys like him debate me into statistical oblivion over some “who’s the best blankety blank ever” topic, I feel pretty secure talking about the “feel” for the game or that “intangible” winning attitude, even if my memory for stats and names and stuff like that isn’t so good.

So what I was trying to explain was that Tim Tebow, this college quarterback coming up in the draft, is going to be a great quarterback in the NFL despite what Louis and all the sports pundits say about him.  See a lot of people believe Tebow has some “mechanical” faults with his football throwing motion and footwork that won’t translate well from the college game to the pros.  But I think he’s just a winner, pure and simple, and if it ain’t broke, don’t fix it.  He’ll be a star.

Anyway, I’m trying to make my point about Tebow having great intangibles and being a winner when I thought of an analogy to illustrate my point.  “Remember that movie we rented, long ago, Chariots of Fire?  Where that gold medalist distance runner had that awkward running style but in the middle of a race his mouth would open and his head would tilt back and he’d become so possessed by the spirit of the Lord that his body would push above and beyond toward victory?” 

So I’m reminding him about this movie and I’m talking to him about intangibles and faith and spirit when I notice he’s got that trying-to-recall-something look, and as I’m about to make my final point his eyes suddenly clear, he gets this quizzical expression and says, “Wait.  I don’t get it.  Wasn’t that movie called Blazing Saddles?”

“Uhhh… actually yes, Louis, that WAS the movie we rented, Blazing Saddles, I saw Chariots of Fire with your brother.  So, what’s mom got for dinner tonight anyway?”

Burn Your Sins Boys!

Although a lot of people expect their doctor to figure out what’s wrong with them by doing a physical examination, in reality doctors figure most of it out by listening; simply listening to what the patient says.  That’s why we ask so many questions… well, unless you’re a dermatologist I suppose, in which case you just walk in, look at the patient’s skin, and ask the patient to be quiet.  But for the rest of us doctorly-types it’s mostly about what you patients tell us.  And although I love using electronic medical records and a variety of digital resources, I am certain that no technology will ever replace listening as the most important skill needed for making a correct diagnosis.

We call this question and answer part of the doctor visit “taking a history.”  It’s an art form really, to do it right, and a fun challenge that usually leads to me understanding what is wrong with the patient, or helps the patient and parent realize what is going on.  And sometime a careful history yields quite unexptected results.

Like this… A second grader was brought in by his father this week.  Dad was worried his boy might have a throat infection or asthma.  The boy’s school sent him home the other day noting that the child developed trouble breathing while coughing a lot, then he turned very red in the face.  The father informed me that it is “a Lutheran school where they apparently burn incense,” but that’s all he knew about the incident, and all the school told him.  Well that didn’t sound right, I mean I knew this kid all his life and he’d never shown even a hint of asthma, so I asked a few more questions and here’s what the young sinner told me;  “We were in first period, at chapel, and you know that place where the priest stands, that’s where the teacher was and we all had to write down a bunch of times what we shouldn’t be doing in class, then he took all the papers and put them into a can and then he lit the can on fire with a flame, and all this smoke came out and everyone in the front row started choking and coughing, and I turned all red so they made me leave and called my dad.” 

I wrote a prescription out immediately: One pea-shooter, use as necessary, avoid eyes.

Save the stump

Did I tell you this one yet?  About the belly button?  It’s been so long since I posted I’ve forgotten.

There have been a lot of scrumptuous little newborns in the office lately.  I love newborns; they’re quick and easy to examine, usually perfectly healthy and they bring their parents who are almost always gratifyingly eager to hear what I have to say; they smell nice and look cute and most of all remind me of my chihuahua, which I absolutely adore and treat like a baby.  In fact, when I watch parents fawning over their little babies it occurs to me that that is what I look and feel like when I’m with my little  pooch.  I just love this dog.

My real kids are teenagers and we all know there’s nothing too cute about our species at that stage of life.  So I hadn’t had that “new baby” feeling for quite some time.  Most of you know I keep reptiles as pets.  Lots of snakes in my home, lizards and tortoises too.  But they’re more cool than cuddly. 

We found this little dog a couple years ago; a stray, on the street, skinny and cold and beat up.  I walked in the door with this pitiful little creature on Thanksgiving morning and I’m not kidding, the first thing my wife said was, “Can we keep him?”  And after a reasonable search for his prior owner, we did, named him Pavo (which is “Turkey” in Spanish), and I tell you… if I would have known how much happiness a little brown dog would give my wife I’d have found one years ago!

Well, me too.  It’s like having a baby, all the good things about having a baby I mean, and it stays that way.  I got all those nice warm-baby-in -the-house fuzzies every day now.  I could go on and on about him, about his playfulness, his reliably eager greeting every time I come home from work, some of the silly things he does… but I know that’s a bore… and I’m off track…

Something about belly buttons…   So I walk into an exam room to find another young couple and their newborn, first child, and right off the bat mom tells me that the baby’s umbilical cord stump – that leathery thing that hangs from the belly button on newborns until it withers and falls off – had indeed fallen off the day prior. 

I was reminded of another couple, from Bosnia or Turkey or somewhere I can’t exactly recall, who jumped out of their seats to stop me after I removed their baby’s cord stump and moved toward the trash with it.  “Wait!  We need that!” they blurted.  “Really?” I asked, handing it to the father who carefully wrapped it in tissue, “What for?”

The father explained that in his culture it is customary for hopeful parents to retain the umbilical cord stump and deposit it somewhere they want their child to follow.  Like if they aspire for their child to attend a fine university, they secretly bury the stump somewhere on campus at Harvard or some other school like that.  Or if they want her to be a world traveler they might toss it into the ocean or something.

Interesting right?  I hear stuff like that all the time in my practice, we get such incredible ethnic diversity amongst our patients.

Anyway, I’m telling this little story to the young new parents the other day and the mother is kind of getting into it; “Hey that’s really neat, I like that, what did you do with it honey?” she asks her husband.  And with a sheepish look and apprehension in his voice he answers with impeccable comedic timing, “I threw it in the garbage.”

I should have seen that coming.  Oops.  Not sure where that will lead, but no point speculating.  I’m sure she’ll do fine.

Knowing

I hadn’t laughed this hard during an office visit in a long time…  A young, contemporary woman from Russia , first-time mother, brought her baby in recently with an ear infection.  Now you all know how I explain things in detail and tell you what to watch for and when to return and so forth and so on… I see your eyes glazing over.  Anyway, I’m almost through my standard ear infection speech and out of the blue she interrupts with, “What about fish and onions?”

Then, “What? Why are you laughing at me?”

Okay, maybe you had to be there to get the comic effect right, but when I regained my composure and asked her to explain her startlingly out of place comment, I figured she would tell me that when she was ill as a child in Russia, her mother would grind fish and onions then spread the paste on her chest or something.  But no, she was just wondering if and when she could feed the baby fish and onions.

It’s fish that has me going today, and about knowing.  Some years ago the committee on allergy and immunology from the American Academy of Pediatrics (AAP) recommended that parents delay the introduction of certain foods, like fish and shellfish, into their child’s diet.  Food allergy reactions had become so common that our experts were looking for some way to reduce the risk, and considered that maybe the earlier a person was exposed to the provocative proteins, the more likely they were to react to them later.

Although many of us pediatricians questioned this policy vigorously, believing there was insufficient data to make such a recommendation, when the AAP makes a recommendation it’s more like a decree, especially for something associated with life-threatening possibilities like food allergies.  I mean you can’t really go against the flow on that one, too risky, even if you don’t believe it is correct.  You just don’t know.  Consequently we all started telling parents to delay introduction of foods like peanuts, fish, eggs and so forth.  As it turned out, a few years later the same experts looked again at the data and realized that delaying introduction of provocative foods didn’t change the statistics at all; kids were still turning allergic, big time, so they withdrew the recommendation and went back to square one.

Sometimes you just don’t really know, not for certain anyway.  And it works both ways.

For example, the “Back to Sleep” campaign.  Some of you may not realize that until recently generations of babies in this country were always put to bed on their tummies facing down, not on their backs like now.  Over a decade ago the AAP committee on Sudden Infant Death Syndrome (SIDS) decided that since parents in nearly every other large country put their babies to sleep on their backs facing up, and all those places had substantially lower rates of crib death than we did, American parents should start putting their babies to sleep on their backs too.  Well, big controversy!  Strong feelings expressed on both sides, with many doctors squarely against alterting an established cultural practice based on absolutely no understanding of the cause of SIDS.  But they did it anyway, and amazingly within a couple years the rate of SIDS in the USA had dropped remarkably.  Thousands of lives saved, thanks to a hunch.  (We still don’t know why, but it sure did work out well!)

This comes up all the time in medicine, both as broad guidelines and with day to day decisions in the office.  Sometimes you just have to lay out the facts and make a decision based upon reason and experience, even if you’re not totally certain.  That’s actually the easy part.  The hard part is knowing what you don’t know.  Doctors who get that part are the doctors you want taking care of you.

I’ll give you a notorious example from pediatric history.  Most of you know about jaundice in newborn babies, when the skin turns yellow due to a buildup of a natural substance called bilirubin.  Some jaundice is quite normal, but if it gets out of control it can be harmful.  We can measure the level of bilirubin and use that level to decide how aggressively to treat the condition.  So here’s a scary fact; when I finished training in the early-1990′s, if a baby developed a bili level of 20, we would bring the baby back into the hospital and essentially exchange all of its blood for banked blood!  That’s right, a complete transfusion.  Can you imagine?

Then a smart doctor got to thinking about this situation, researched it thoroughly and found out that there was no evidence underlying the practice of transfusing babies with bili levels of 20 or above.  It was just a doctorly practice that kind of got handed down over the years and nobody questioned it until he did.  He titled his paper, “Vigintiphobia,” from the latin, meaning “fear of the number 20.”  Suffice to say we’ve become a lot smarter about newborn jaundice since then.  (No that wasn’t me.  I’m still trying to figure out where belly-button lint comes from.)

That’s really the key; knowing what you don’t know, or more accurately stated; respecting what you don’t know.

Life-lessons come when you least expect them right?  Back in medical school as I prepared for graduation and the next level of training, I was interviewing for pediatric residency at various institutions.  One day I arrived to a little office hidden deep within a big old university building.  The space was filled with hundreds of books, floor to ceiling, piled everywhere.  A professorial physician emerged from behind stacks on his desk and I remarked about the impressive number of books he had.

Although I was there to be interviewed that doctor dispensed a little casual wisdom.  He replied, “If you learn nothing else in the coming years as you prepare to treat patients, remember this; for every medical library we have, ten more libraries could be filled with what we don’t know about the health and the human body.”

And I never forgot it.  

I meet with expectant parents often, and they ask me all sorts of questions trying to decide if I’m the right pediatrician for their baby.  “Do you support breastfeeding?”  “Are you cautious about antibiotic usage?”  “Do you have weekend office hours?”  But they never know to ask the most important question; “What do you do when you don’t know the answer?”

And the response would be, “I realize I don’t know and work hard to find the answer.”  That’s the kind of doctor my patients deserve.

So…. anybody have any ideas about that lint?

XYZ

While waiting for my tire repair at the bike shop recently an eager salesperson approached and said with enthusiasm, “How about a test ride!”  She stood proudly over a device that looked more like a sculpture than a bicycle.  “On that?” I asked.  “What is it?”  The frame was slender and elliptical, the tires so narrow they’d slip into any grate, and the pedals… well, there were no pedals actually, just little clips for little clippy bike shoes.  I lifted the entire unit up with my pinkie, it weighed much less than my Chihuahua, and had a price tag beyond what I paid for my kid’s braces.  I appeared skeptical and answered, “I’m kind of old-school.”  Undaunted, she pointed to a row of gleaming new bikes with lower but still exorbitant prices and said, “Old school? No problem, those are all made of steel.”

“Listen,” I started scornfully, “see that bike over there, the one with the squishy seat, actual pedals and milk crate strapped to the rear, that’s my bike, and it does everything I want a bike to do, which is get me from here to there, and burn me a few calories on the way.”

I mean that’s the point right?  The harder I pedal the more I sweat, the more I sweat the better I feel, the better I feel the more donuts I eat and donuts make me very happy.  It’s a simple equation really.

But there are drawbacks.  I’ve been biking to work lately.  I get up early and ride to the gym each morning, do some work-out stuff (more donuts), hurriedly change into my backpack-wrinkly clothes and dash to the office.  One morning last week I saw about a dozen patients before noon, and during my final encounter the father of the patient informs me that my fly was open.  Did you catch the part about this being my LAST encounter of the morning?  HELLOOOO!  Couldn’t someone have clued me in earlier?  How embarrassing!

Okay, so you’re wondering how I make the leap to pediatrics and parenting right?  Well I’ll tell you.  On the morning in question I was rushing and everything was crammed into my locker at the gym, I put on whatever I dug out first and bingo, the zipper got overlooked because I was out of sequence.  I was out of my routine.

See… it’s all about routine.

There are few things more important to success in parenting than consistency and routine.  From early on parents get a lot of mileage from this simple principle.  For example, I always suggest that parents of infants develop an organized and directive approach to their interactions with their baby.  As young as two months babies are capable of learning from their parents repetitive behaviors, like putting them down to sleep in the same place, with the same blanket, singing the same song, at the same time and in the same relationship to feedings, and doing the same with feedings, and nursing, etc.  Parents who behave in this organized manner are likely to have infants who do likewise, with predictable nap, bed and feeding times, readiness for weaning and so forth later in infancy.  And we all know how helpful it is to have babies and toddlers with predictable schedules.

The power of routine in parenting works at all ages, from preschoolers agreeably obeying the limits their parents set on television time to older kids arriving at the table hungry and more likely to eat because snacks are always restricted in anticipation of a consistent dinner time.

And vice versa, as parents who do not behave toward their kids in an organized, predictable manner are more likely to have children who behave in disorganized, unpredictable ways, i.e. without routines, making independent sleep and bedtime, family meals, homework and so forth more challenging than they could otherwise be.  I’m not pontificating here, believe me, I’ve already made the mistakes with my kids, and it was my zipper after all that needed examining.

One of my favorite guidelines for parents is “do now what you plan to do later, and don’t do now what you’ll have to change later on.”   Develop favorable  routines with your kids, you’ll never regret it.

But speaking of dressing, I’m reminded of the day I went to sign Louis up for kindergarten.  He had long before learned to dress himself and insisted on doing so without our assistance, so there were days he’d go to preschool dressed very oddly, wearing backwards shirts or extra hats!  The questionnaire was focused on development and school readiness of course, and one question asked, “Does your child dress him/herself?”  So I wrote my answer, “Yes.  So don’t blame us.”

Look, up in the sky, it’s….

According to many parents my name is invoked in a variety of circumstances at home.  For example, many fathers advise their preschoolers that “if you don’t eat your broccoli I’m going to take you to Dr. Sagan!”  Not uncommonly a child will tell their parent an office visit is needed, like the little girl who, while sitting in the bathtub looked between her legs and exclaimed, “Uh oh mommy, there’s a hole there, better go see Dr. Sagan!”  And of course I am often referred to in the heat of battle, “I’m not brushing my teeth and I don’t CARE what Dr. Sagan says!”

But today a mom told me one I really liked.  She said I’m quite the celebrity in their home.  She has three young kids, I’ve known them all since birth, and as she pointed to them in turn she said, “This one is Superman, this one dresses like Spiderman, and this one runs around with them shouting ‘I’m Dr. SAGAN!!!’”

I’m working on my superhero uniform now… could use some ideas for the insignia across my chest.

Summertime, and the giving is easy…

Swedish Covenant Hospital, like every business and community hospital, is struggling during the recession.  But instead of simply cutting costs on all fronts, our CEO insists that Swedish Covenant will weather this financial storm through growth and service.  That way, when the economic storm is winding down, we’ll be better off in every way, and so will our patients.

That impressed me.  Similarly, on a family level, and from a parenting perspective, this is a good time to let our kids know that despite the pinch we’re feeling, it is still important to be unselfish and caring, and if possible to help those less fortunate.  As our president says, it’s a difficult but teachable opportunity, a worthy life-lesson for our kids, who may someday say that “even when my parents were struggling they managed to help others whenever possible.”

And on a family level, times are really tough.  

A bunch of my patients’ parents have lost jobs this year.  I had a mom tell me last week that she’s “got a bit of seniority, but they’re letting more of us go and if I lose my job it’ll be the food lines for my kids!”  I got a father in my practice who sells the world’s most expensive sports cars to the most wealthy local families; He may be closing his doors for good soon.

So many sad and frightening real-life stories.  Most of us work real hard and the recession has hit almost everyone.  A little positive, optimistic spin won’t hurt, and I really feel this falls into the “modeling behavior” category as parents.

Our children see us cutting back, cancelling trips, dining out less often, shopping less, maybe they sense our worry or hear their parents discussing or arguing over finances.  I want my kids to hear about the situation in words and concepts they understand, and to know that while there is real fear and good reason for it, amidst the fear there is hope, and despite the fear there is still room for giving, still room for service.

So, we look for ways to serve, and here’s an easy one for you, real simple…

For every response to this blog one can of food will be donated by Swedish Covenant Hospital to the North Park Friendship Center, a nonprofit dedicated to alleviating hunger and poverty in this area.

C’mon now, I see all the visits this blog is getting… give that Reply button a click, click it to give.  Thanks.

Don’t Hover

A friend shared this story about his kids; One day, his 3 year old son came running into the room all flustered, whining about his 18 month old sister. “Daaaaaaad, tell Jenny to stop playing with my choking hazards!” Can you tell my buddy is a pediatrician?

My favorite childhood toy was an Erector Set. This was building kit that came in a red metal box full of hardware; screws, nuts, clips, metal pieces of all shapes, little motors, chains, pulleys and stuff. You could build about anything with it. Erector Sets were fantastic, albeit with more choking hazards, laceration and electrocution risks in one box than you’ll find in a modern toy store. I bought a vintage Erector Set at a garage sale a while ago; my son got some use out of it. He still has both eyes.

I had other favorites, like the Chemistry Set. Man, there must have been thirty little plastic bottles of chemical powders and solvents with beakers and even a burner. We would try to mix them up so they would boil or fizzle or blow up all the time!

How about Creepy Crawlers? Anyone remember those? This was a kit with tubes of colored goo that you would squirt into metal molds of insects, and cook in a little hot plate. Sure! We’d burn ourselves all the time, and probably croak if we would eat one of the rubbery little creations.

Somehow we managed to survive. We’d make holes in our jeans with our wood burning sets, have lots of near-misses with the Lawn Jarts, and inevitably burn our fingers with Mom’s iron while melting Crayola shavings in wax paper. Our parents were rarely supervising. To the contrary, in preparation for the Pinewood Derby at Cub Scouts my Dad simply handed me a wood carving set. Later I got mad at him for not helping, NOT because my car was so blood stained or because I had to wear so many bandages, but because I never figured out how to get the wheels on good, they fell off and I lost the race!

I guess I just figured I cut myself, it was my mistake, it was my problem. Obviously I was raised in the era before the personal injury lawyers became so… so… prevalent.

Now I don’t mean to suggest that my parents’ generation did it right. But somehow I became a pretty careful parent, and when I talk with parents about safety, which we do at each checkup, I try hard to help them walk that line between being cautious and fearful.

For example, I always urge parents of toddlers and preschoolers to keep their distance at the playground. You know, avoid being that hovering parent one step behind your child. The goal shouldn’t be to keep them from falling, but to let them learn that falling happens and you can still get up and try again. I urge them to watch carefully, to keep her from getting too high and redirect when he’s heading for the big kids on the swings and so forth. At that age learning from an occasional head boink or sore bum is worthwhile.

But it’s clear that thinking “safety first” just doesn’t come naturally to some parents. I have heard and seen so many examples over the years. One time, a father told me his two year old stuffed something into the toilet and while he was complaining how much the plumber cost, I was thinking, “It could have been a toxic ingestion, a fall down the stairs or a burn, and how did the child get from the ground floor to the second level without anyone knowing?”

I have some simple rules for age appropriate discussion with parents about safety, and I suggest parents consider these “rules” as ideal behaviors. After all, we all make mistakes, and I still shudder when thinking of some of mine. Anyway, here are some of the more common issues that come up:

Infant Falls
One of the most common urgent phone calls I get is, “The baby fell off the father’s chest when he fell asleep on the couch!” First, new parents need to realize that they are probably more tired than usual with a newborn waking them up each night, and fatigue impairs judgment. So be extra careful while carrying your baby on stairs, and when resting with the baby unsecured. Also, while we don’t expect infants to start rolling until 4-6 months of age, they are very capable of arching, writhing and thrusting themselves off any surface much earlier. Always have them secured or under hand when on top of any elevated surface.

Burns
The two most common ways I’ve seen patients get burned are when they get underfoot in the kitchen or when they yank at something you are holding, like a cup of tea. There are two little pearls of practical parenting I like to mention in the office. First, “do now what you plan to do later, and don’t do now what you don’t want to undo later.” So, while we all looked cute playing drums on the pots and pans in front of the kitchen cabinets, it’s really a safer policy to not teach your toddler that the kitchen floor is a play area. Another little bit of advice is to think about child safety in developmental terms. For example, between about six and nine months babies get real good at seeing, reaching, grabbing and pulling. So keep that in mind when you’re holding your child in one arm, have the phone tucked into your neck and are holding a cup of coffee in the free hand. Reach, grab and pull! Ouch!

Foreign Body Ingestions
Another way to think developmental safety involves ingestions, or swallowing things you shouldn’t. For late infants and toddlers, “Everything goes in the mouth” is what it amounts to, right? So ideally a parent would always know where their child is and what’s in the child’s hands. Sounds simple, but many parents don’t think this way. That’s why the “childproofing” concept has value. For example, when your child is starting to crawl or walk, it never hurts to take a moment on your hands and knees and look around the rooms from their perspective. You’ll be surprised what you might find between the couch cushions, or under the frill of the carpet edge! Coins, popcorn kernels, I even knew a boy who got lint stuck in his windpipe and had to have it removed!

Choking on Food
Talk about a downer topic during a happy doctor visit checkup! But having been through some disastrous cases of choking early in my career, I feel it very important to remind parents about choking risk with food. I have some simple rules, and I know I’m going to catch a bunch of you on this one… First, ALL EATING AND ALL DRINKING SHOULD OCCUR SEATED WITH AN ADULT PRESENT. (Told you.) Second, YOU MUST ALWAYS KNOW WHAT IS IN YOUR CHILD’S MOUTH. All the food choking incidents I have dealt with over the years occurred during meals, when the parents did not realize how many fries or how much bread the child had stuffed in there! The near miss choking events occurred when parents let their children play actively with candy in their mouths. I don’t think preschoolers should have hard candy, period, but if they do, seated with an adult present. And for meal time, place portions of food thoughtfully on the plate and watch carefully, so you’ll never have a scare.

See, nobody likes talking about that kind of thing, but I hope you see it’s important, and once you start focusing on safety you’ll probably be a little frightened watching how other parents behave in playgrounds and restaurants and such, I know I am!

Okay, one little story relating to personal injury lawyers…

I was called for jury duty a few years ago, and the case involved some poor guy who stepped into a pothole and broke his ankle. So he’s suing the city, and I’m in the pool of potential jurors. I’m thinking “How do I get out of this without telling a lie?” The plaintiff’s attorney was a young guy, not too sharp, and at one point he puts a question to the potential jurors as a group, “Would you be able to find in favor of my client, award him money, by applying the rule of law, even if you didn’t agree with the law?” Juror number 1? “Yes” Juror number 2? “Yes.” Number 3? “Yes” until he gets to number 10, me, and I saw my chance! So I answer kind of iffy. And he pauses, “Doctor, you seem hesitant?” “Well,” I started, “I would be able to follow the judge’s directions to the letter of the law, but I have to say, I think people ought to take responsibility for their actions.”

Suddenly Juror number 8, a little soft-spoken elderly lady raises her hand and nearly jumps out of her seat shouting, “Me too!”

Boys and Girls

When I was an impressionable college student back in the 80′s I learned that boys and girls were the same.  No really!  First, realize that feminism was rampant in Madison, on the streets, in the classrooms, and the party-line held that there was no nature, only nurture, meaning that parents made girls into girls by dressing them in pink and giving them dolls to play with, and vice versa with boys, you know, toy soldiers and trucks and stuff.  I bought that nonsense too, until of course I became a pediatrician and parent, and realized most boys can’t help but rip the heads of f of dolls, turn ANYTHING into a gun, and don’t care whether you dressed them in pink, blue or gender neutral green.

My uncle was telling me a story from back then.  Seems he got into a little politically incorrect trouble talking about ‘boys being boys” with someone at the office, so he asked his wife, who was a pretty sharp family therapist, about the differences between boys and girls.  Now they had two young school-aged boys, and she answered, “You want to know the difference, watch them go to the bus sometime.”  So the next morning watching from the front porch he notes the girls walking in little groups directly to the bus stop, where they wait patiently, chatting.  But when his boys hit the sidewalk, one finds a stick and starts whipping it around like a sword, the other picks up a handful of pebbles to toss at the trees, and after a bit of wrestling and further meandering, they dash to the bustop only after the bus is heard coming down the street.  He walked inside, picked up his briefcase, and said to his wife, “I get it.”

For those of you who bring your kids to me, you know I always finish our checkup visits with a little “what to expect before the next visit” talk.  It’s always a little heads-up about behavior, the next “stage” so to speak, and I try to manage your expectations a little bit to help you avoid surprises or disappointments, frustrations, etc.  Pediatricians call this “anticipatory guidance,” and you may have noticed my comments start to get pretty gender specific around 18 months of age.  That’s because you really start to see the differences in behavior between most boys and most girls around then.

In fact, it often seems there are few things I can teach an experienced parent, but when I have one in the office who’s only raised girls and is soon to experience a darling son’s startling  metamorphosis into a toddler boy (yikes!), I have loads to say, like “forget about getting anything done around the house for the next couple years.”  I mean there’s a reason why parents of toddler/preschool girls seem so calm compared to parents of boys, who appear so frazzled!  Likewise I try to soften the blow for the mother who is about to have her sweet little girl start averting eyes and give mom silent treatments, or let a frustrated father know that even though his big boy repeats the same infraction every single day no matter how many times he’s told no, it’s “normal,” that every day his son wakes up a toddler boy, and every day Dad wakes up the parent of a toddler boy, and we do it all again.  “My daughter was never like that, he just doesn’t seem to get it!”

So what do I have?  Two boys, and I’ve always been a little thankful for that, because they’re easier.  I mean, they tend to wear it on their sleeves so to speak, you know what your dealing with, emotionally for the most part.  I always found little girls harder to read.  Maybe its different for mothers, kind of vice versa.  In any case it seems many of the fundamental differences between boys and girls simply evolve over time, for we all know men and women really do seem to come from different planets.

But THAT’s another story…

Thinking like a child.

I observed an interesting and timely interaction in the office last week.  A mom and I were speaking about discipline strategies while she held her 18 month old son in her arms.  As we talked the boy started patting her on the cheek trying to get her attention, and after she repeatedly brushed his hand away from her face he finally whacked her and quickly bit her in the shoulder!  She yelped!  After composing herself she turned to him, took hold of his hand, looked him in the eye and softly stroking his hand against her cheek said soothingly, “No hitting honey, be gentle, see, no hitting, be gentle with mommy.”

Sound familiar?

So which would be your response?

a) The way she did it, because it teaches important life lessons about aggression and consideration.

b) Sit him down, take his hand and give it a good slap while saying, “NO HITTING!”

d) Put him down on the floor, tell him sharply ”no hitting,” and ignore him for a minute or so.

Well I don’t know about you, but I’m voting for the last one.  He’s 18 months old, ready to misinterpret the hand-slap as “I hit, you hit harder, but I still get your attention,” and at this irrational age he’s not likely to imbibe the life lessons.  In fact, all he knows is he did something that got mom’s attention and a dramatic reaction to biting that was worth the effort!  So while this mom thought she was teaching him to be gentle, from his perspective she effectively told him, “See, if you hit or bite me you get my attention, and I say something sweet sounding to you, look at you lovingly, touch you gently, so keep doing it, Okay?”  So putting him down with a stern negative rebuke, then ignoring him effectively says, “If you hit me, I will not hold you close for a while, and you won’t like that,” without saying it since he wouldn’t understand the words yet.  It’s like a toddler version of a solid time-out.

Of course, avoiding and redirecting would have been the better solution in the first place, but not always possible, and the point is that it’s helpful for parents to think like their child when considering discipline strategies, because it’s very easy to send the wrong message if you think like an adult.

There was a hilarious clip on America’s Funniest Videos a while back.  A toddler in full face-down-fist-pounding-feet-kicking-screaming tantrum mode was on the floor, her father standing over her.  The mother was holding the camera around the corner, and gave Dad a signal.  As the child shrieked the father quietly walked to the next room, then realizing she was alone on the floor she stopped her tantrum cold, spotted her father, walked quietly to him then fell to the floor and resumed her tantrum without missing a beat!

Which illustrates that most tantrums your child throws are somewhat manipulative.  In young kids I think of tantrums as the child’s way of asking, “How do I get what I want?  Let’s try this!”  And as they get older, if parents tend to respond to the tantrum they’re kind of thinking, “This works often enough, I’ll try it again.”

So many frustrated parents I’ve known through the years had to learn this the hard way.  Those toddler years set the tone.  It’s wise to get going on this style of parenting and discipline early-on.  Another way to think of it is to avoid reinforcing the behaviors you don’t want to encourage.  Since the primary reinforcement your toddler wants is your attention, make sure you don’t give it for behaviors you hope to discourage.  Your lack of attention is saying more than anything you could actually say, emphatically stating, “THAT behavior will NOT get the attention you seek!”

Which is why it is always recommended to simply walk away from a tantruming child.

An older-child illustration that occurs commonly is belly aches.  Statistically, “abdominal pain” is one of the most frequent presenting complaints in pediatric practice, and certainly the complaint that most often occurs without an actual “pathology” as cause.  Of course there are plenty of cases with “real” diagnoses like constipation, urinary tract infections, acid reflux and so forth, so I ask a lot of questions to see if the answers point me in a direction.  But when all those answers are “no” and it turns out the child never complains around anyone but the mother, doesn’t miss school or activities due to discomfort, hasn’t lost appetite and so forth, it’s pretty likely that the reason for the complaint is attention-seeking.

And in most of those cases when I ask the right questions I learn that there is a newborn in the home, or a father with a job that takes him away from the home a lot, or simply a sense that the child is having a little trouble with the independence the parents are encouraging.  Think like a child.

So in the end, although a lot of parents seem to have trouble “thinking like a child,” it’s not hard if you think of it as a parental responsibility.  Isn’t it our responsibility to let our kids know what behaviors are acceptable or not?  Sure!  That’s all it is really, one of our jobs as parents.

Now I’m trying to figure out if this works for spouses.  I’m sure my wife would agree, and suggest I title this “Acting like a child!”