Friday, October 19, 2018

Halloween safety and activity guide 2018


Halloween can be such a fun holiday, but as you can imagine, as advice nurses we tend to hear about some of the misfortunes that can along as part of the festivities.

Pumpkins
Carving a pumpkin can be a very fun tradition. Please make sure that your child's level of participation is consistent with their age and ability. Watch out for the sharp implements and make sure you assign your younger child to the safer tasks (young kids can draw on the pumpkin rather than carving.)

Clean up the mess. Pumpkin flesh is slippery and can cause falls and injuries when dropped on the floor. Layer newspaper or old cloths under your carving work space and clean up spills right away so no one slips or trips. Skip the candles, which may cause fires. A burning candle in a pumpkin may become a blazing fire if left unattended. Instead, use a glow stick (available in many colors) or flame-less candle to safely illuminate your jack-o'-lantern.


Choosing a costume
Children are more than twice as likely to be hit by a car on Halloween than on any other day of the year!

Decorate costumes and bags with reflective tape or stickers and, if possible, choose light colors. Have kids use glow sticks or flashlights to help them see and be seen by drivers. Is your dog going along with the trick or treaters? Have them wear a glow in the dark collar!

When selecting a costume make sure it is the right size to prevent trips and falls. Be sure to wear flame-resistant costumes. Remind your child that they need to pay very close attention to their surroundings and avoid walking near any candles or flames, especially if they have loose flowy costumes. If a sword, cane, or stick is a part of the costume, make sure it is not sharp or too long. A child may be easily hurt by these accessories if he or she stumbles or trips.

Make sure that no part of the costume is covering their ears solidly enough that their hearing might be impacted. Since masks can sometimes obstruct a child's vision, try non-toxic face paint and makeup as another option. Face paints have been in the news lately. Some of them have some toxic ingredients like lead. Be familiar with the ingredients before you apply anything to your child’s skin. Always test the makeup in a small area first. Always completely remove it before bedtime to prevent possible skin and eye irritation.

Make sure that your child doesn't have any latex sensitivity before you do too heavy of an exposure. Many masks are made of latex. We actually had a patient who had an allergic reaction to the hair tinsel. You may want to do a test run of the costume and make up a couple of days ahead of time to rule out any allergies.


Trick or treat rules
Children under the age of 12 should not be alone at night without adult supervision. If kids are mature enough to be out without supervision, remind them to stick to familiar areas that are well lit and trick-or-treat in groups. Never go into a strangers house without supervision.

Popular trick-or-treating hours are 5:30 p.m. to 9:30 p.m. so be especially alert for kids during that time if you are out driving.

A good meal prior to parties and trick-or-treating may discourage youngsters from filling up on Halloween treats.

Bring plenty of water along when you go trick or treating. Just trust me on this one.

Make sure that your children know that after trick or treating, the grown up needs to pick through trick or treat bag and toss anything that looks suspicious. There is a warning out in Colorado this year about "pot laced" treats. That could happen here just as easily. Anything that looks like it has been tampered with should get tossed. Some candies are real choking hazards. If you have a younger child in the house, make sure they don't have access to the stash.

If you have a child with nut allergies (I am sure this is NOT your favorite holiday) make sure that they turn over ALL the candy so that you can separate out anything that might cause trouble. My favorite allergist adds another piece of advice. Most of the time nuts may be just one of the ingredients, but as a general rule, kids who are allergic to nuts should also be able to identify the nuts that they are allergic to. If it is peanuts, make sure they know what an actual peanut looks like.

Expecting trick-or-treaters or party guests?
Consider purchasing non-food treats for those who visit your home, such as coloring books, stickers or tattoos. Provide healthier treats for trick-or-treaters such as low-calorie treats and drinks.(Okay, fine...maybe you don't want to be "that" house, but I had to put it on the list.) Be sure walking areas and stairs are well-lit and free of obstacles that could result in falls. Keep candle-lit jack o'lanterns and luminaries away from doorsteps, walkways, landings, and curtains. Place them on sturdy tables, keep them out of the reach of pets and small children, and never leave them unattended.


Now what do we do with all this candy???
Make a plan about how much candy they can eat at one time. It is okay to be a little more liberal than usual for a day or two, but come to an agreement about a reasonable candy intake over the next few weeks. Some dentists and orthodontists have buy back programs, where they will give your child a reward for turning in their candy. Check with your dentist to see if they participate.

Bibi, one of our mom's, doesn't bother with the dentist and has instituted her own buyback program. Her kids can exchange candy for new lego pieces.

You may need to be extra vigilant with teeth brushing this season.

Remember that candy freezes (and some of it is actually better that way; frozen snickers bars, yum!)

My daughter Lauren was about 6 when she caught on that mom and dad were pilfering through her trick or trick bag and stealing all the good stuff. After that she guarded her stash more carefully.

Here are some tips that some wise mamas have added to this post over the years:

"Once Cleo was out of the stroller and walking, we put glow stick bracelets and necklaces on her so we could see her more easily when out and about in crowded spaces in the dark (we do this at things like the Dia de Los Muertos parade, too.) Cliff's sells them in a big 100-stick bulk container. Not terribly eco, but gives a little extra "eyes on" help when navigating the crowds."

My little patient Franny, bent a glow stick in order to activate it and it broke. Some squirted in her mouth. While you do want to avoid unnecessary contact with the insides of a Glow sticks, they are non toxic


Here are some local Halloween activities for the 2018 season.



bayareakidfun Halloween events


Friday, October 12, 2018

Strep throat 2018

Strep throat is a bacterial infection caused by the Group A streptococcus germ.

This illness is most common in people between 5-15 years of age but people of any age can get it. For some reason is is quite unusual for babies under 2 years of age to have it, but there are always exceptions.

Someone with strep throat will usually present with one or more of these symptoms:

  • Sore throat
  • fever
  • body aches
  • headache
  • stomach ache
  • nausea
  • a red sand papery rash all over the body

Strep with the rash may be referred to as Scarlet fever...sounds scary right?? Indeed it used to be. Now that we have antibiotics to treat it with Scarlet Fever is not much more alarming than simple strep.

Get out your little flashlight and do some checking. If you are lucky enough maybe they will actually open their mouth; most of the time the throat will look quite red. You may see red or white patches in the throat or on the palate (the back part of the roof of the mouth.)
The tongue might have red and white patches. This is referred to as strawberry tongue for obvious reasons. Feel around the neck and see if the glands feel swollen. Sniff the breath. Often parents call me and say that is smells like their kids swallowed a 'swamp creature'. The breath smells yucky.

Not everyone has all the symptoms.

Be aware that children under 5 often say that their "mouth" or “neck” hurts, but they are talking about their throat.

Some folks don't even complain about a sore throat and some cases don't present with an elevated temperature.

This week in the office we have had many patients without a sore throat who are testing positive. The chief complaints have been tummy ache and head ache.

It is quite contagious, but it is not uncommon for some family members to have it, while others escape. I would say that in my experience the odds are about 50/50. (The minute someone in your family gets that sore throat I would suggest sucking on a zinc lozenge and some sambucol; maybe you will get lucky.)

The incubation period ranges from 1-5 days but most of the time folks show the first symptoms about 2-3 days after exposure. You can catch it from being in close contact with someone else who has it. If you treat with antibiotics (which is recommended) you are not contagious once you have completed 24 hours of the medication. If you don't treat, you remain contagious and can spread the illness for about 3 weeks.

Given enough time, strep can resolve by itself but the antibiotics absolutely shorten the severity and duration of the illness as well as significantly decrease the risk of complications. Untreated strep throat can lead to complications later on, such as rheumatic fever and heart valve problems.

It is impossible to have real statistics about this. Most folks don't jump into the doctor's office every time they have a sore throat. There are likely millions of untreated cases of strep out there at any given time and of course most of them will have no issues in the future. However, better safe than sorry. If we know you have a case of strep throat, we will strongly advise that you do a course of antibiotics.

Typically the strep throat 'package' does not come along with a lot of congestion. If I am hearing about someone with lots of coughing, clear mucus and sore throat, it is more likely viral.
On the other hand, a sore throat with fever and not a lot of congestion gets my antenna up. I am not kidding when I mention stinky breath. A lot of the parents that I talk to can tell strep from the smell and they are almost always right!

Nausea and tummy aches are quite frequent with strep, but add some diarrhea to the mix and I am no longer as suspicious. Nausea plus loose stools is usually more of a tummy bug of sorts.

We test for strep in the office with a rapid strep test that we find fairly reliable. If the test is negative, but the symptoms are very suspicious for strep, we will send a culture to the lab to double check the result.

Our test is specific for Group A strep. There are different strains of the strep bacteria that can cause various infections.
If the in office test is negative, the lab test may still come back positive with another strain. 

Some folks are carriers. This means that they have a small amount of the bacteria living in their body all of the time and it doesn't make them ill. Those folks may show a very faint positive on the quick test. Some patients also seem way more susceptible to strep than others. I used to get it all the time until I had my tonsils out. That is not an uncommon story. 

If you do end up being treated, it is important that you finish your course of antibiotics. If you are not seeing an improvement within 72 hours of starting the medication, make sure you check in with your doctor. It is rare, but strep can lead to serious complications including abscesses on the tonsils, ear infections as well as kidney problems.

Change your toothbrush 24 hours after starting the antibiotics so that you don't get reinfected!

Symptomatic treatments until the antibiotics kick in include

  • Tylenol or Motrin (we are treating pain, not necessarily fever)
  • Lozenges
  • Tea with honey (no honey for kids until one year old)
  • Check out Manuka honey if you can find it. Not all honey is created equal.
  • Gargling with salt water
  • Popsicle s
  • Cold fruit nectar
  • Having a humidifier running at night.

Friday, October 5, 2018

Colds/coughs/congestion 2018 (symptomatic treatment/when do you need to be seen?)


We are right at the beginning of the cough and cold season. It is useful to have some guidelines to help you figure out when a trip to the doctor's office is indicated. Many times, there is nothing to do but wait it out, so I am including some tips to help you and your child get through the illness as comfortably as possible.

Studies say that most children will have an average of EIGHT colds within the first 18 months of life. Even if we don't have young children, colds and coughs are a common issue for all of us. Most of the time the congestion is caused by a viral syndrome. Allergies and teething* can also be culprits causing you to be congested.

{*Most medical literature disputes whether or not teething is connected to any symptoms, but I still maintain that there surely feels like there is an x in the equation.}

All that mucus is the perfect breeding ground for bacteria, which is why something that starts as a virus can turn into an ear infection, sinus infection, or lower respiratory infection fairly quickly. Be warned, we can see a patient one day with clear lungs and no ear issues, and the very next day they can seem a lot worse and have a raging infection.

When to come in 
If you are dealing with a congested family member, here are the questions to consider:

Do they seem to be having any labored breathing? Babies with labored breathing will look like their little tummies are going in and out more than usual. Respiration will be more rapid (I am more concerned with the lungs than a stuffy nose.) Noisy breathing alone is not a very good indicator as it may be caused by upper airway issues that we aren't too worried about.

  • How is their mood?

  • Do they have a fever?

  • How is the appetite? If your baby is nursing well, that is very reassuring.

  • Are they sleeping well at night?

  • What color is the mucous?

  • How long has this been going on?

If you have any labored breathing, wheezing, a child who is much grumpier or fussier than usual, and/or a fever that is hard to control or has lasted more than 3 days, an office visit is needed. I am also interested in mucus that is getting thicker and greener. Green mucus does not automatically signal a problem. It is just one more clue.

It is okay to play the wait and see game if we have a reasonably consolable child with clear mucus who is eating and sleeping well, whose breathing isn't alarming and who has no significant fever.
Of course if the symptoms show no signs of improvement, please check in with your doctor's office. Many colds and coughs can last between 1 and 2 weeks. Some coughs can really hang on.

If you find that you are having a hard time assessing the respirations, try sticking your ear up to their lungs and see if you can hear anything. If you can hear nice clear air noises, that is great. If you hear whistles or squeaky noises, that may mean the congestion has spread down to the lungs. Using your ear as a stethoscope doesn’t always work; more than half the time you won't be able to hear anything, but once in awhile parents are able to get some important clues from the "ear to chest" evaluation. If your child is old enough to cooperate, have them take a great big deep breath, in and out.

If they are wheezy or have any inflammation in their lungs, that deep breath will often trigger a bit of a coughing fit. If that happens, it is probably worth an office visit.

It is not a bad idea to get an idea of what “normal” looks like. If you are lucky enough to be reading this when your child is healthy, lift up their shirt and watch them breathe for a minute or two. How fast are their normal breaths?

Any baby less than 2 months old is probably worth a visit to the office with their first cold, unless they are eating really well and seem completely happy. It is certainly at least worth a call to the nurse.

Sometimes a big mucus plug may be momentarily blocking an airway, causing a minute of distress that clears with a big cough. If coughing and steam are able to clear things up, it is more likely that it is upper airway congestion.

Management tips
The best way to manage congestion at home is to make sure your little patient is getting plenty of fluids (this will help to keep the mucus thinner.) Breast milk is perfect if you are lucky enough to have it.

With some older kids, cow's milk may not be the best choice because it can increase the amount of mucous (it doesn't impact everyone the same way.) I have plenty of patients who love their milk and taking it away for a couple of days is not a reasonable option. Sometimes thinning it will a bit of extra water is a good compromise.

Steam is great. Hang out in the bathroom when anyone takes a shower. Running a humidifier or vaporizer at night is a good idea. Turn it off during the day and give the room a chance to dry out so that you don't grow mold. Make sure you change the water daily. As long as you follow those rules, I don't have a preference between warm or cool mist.


Keeping the head elevated makes a huge difference. Some of the younger babies will do best napping in their car seats, bouncy seat or swing. Make certain that they are in a safe place. For night time, try a crib wedge or place a towel underneath the mattress to raise it up a bit. Some parents place a book underneath two of the crib legs to get it on a mild slant

You can put saline drops or breast milk into the nose (and then suck it out with a Nose Frida or snot sucker). This is the most natural way to clear the nose. Your baby will no doubt hate this, but if you can manage to do it about ten minutes before a feeding, it may clear the nose up enough to make eating much easier. Do not torture your baby with the nasal irrigation if they are managing just fine.

Some of my parents really like the Oogiebear nose and ear cleaners. These are safe, soft little plastic scoops that allow you to remove stubborn little boogies.

For patients over 6 months of age, ask your doctor about Windbreaker or Pipecleaner. These are Chinese herbs that we use to dry up congestion. Many of our families swear by these. They are sold at the Chinese medicine works on 25th and Noe. For convenience our office tries to also keep it them stock.

Consider acupuncture! One of our neighborhood acupuncturists gets some good results from her treatments for your basic coughs and colds. Her treatment of children often does not use any needles. The Acupuncture Den

Still in the realm of Chinese medicine, there is a new product on the market. Dr. Loo, a local physician, has created a patch to treat the symptoms of congestion. These are safe for any age!
Her website is a work in progress but you can learn all about the products by clicking below. It is possible that we will have some of the patches available for purchase.

For older kids and adults, don't minimize the value of chicken soup! There was a fun study done a few years ago that found that soup drunk out of a mug was actually statistically better than soup out of a bowl.

So, what about the over the counter cough medications? I have been an advice nurse here at Noe Valley pediatrics for a shockingly long time (1988.) For many many years the nurses and docs were pretty quick to prescribe over the counter cough and cold remedies to our patients over 6 months. The rules and recommendations kept changing. First they moved the age to 2 and over, the next thing I knew the age was 6 and over. In my experience, those meds were useful and harmless. It was nice to have an option for the younger patients to help them get over the hump of a nasty cold, but the powers that be are pretty firm that the labels remain for older kids only.

There are some homeopathic remedies out there that are considered completely safe. Chestal and Zarbees are are two of the brands I have had parents give good reports about. Make sure that you don’t give anything honey based to a child under one year of age. The Zarbees does have an infant formula. Boiron came out with something new this year called ColdCalm. This is a homeopathic remedy that comes in a little dropper that can be given to patients as young as 6 months of age.

Here in our office our docs may recommend a dose of Zyrtec or Benadryl at night to help dry the kids up and get them a good night's sleep. Before I would do that, I would want them checked out to make sure the lungs and ears are clear.

For night coughs, without taking anything orally, you might try a bit of  Vicks Vaporub on the feet! Trust me, I scoffed at that as much as anyone, until I asked my patients to test it out and was shocked at how much it seems to help.

Prevention
For parents and big kids I really like Sambucol and zinc lozenges. They may be placebos, but in my case I say " bring it on" because they seem to work. Remember that I work in the germ factory and (knock wood) I manage to avoid many of the things I tend to be exposed to. The second I feel that little tickle in my throat or any tell tale signs of an illness I take a zinc cold therapy lozenge Walgreen's generic taste better and are cheaper) and a Sambucol lozenge twice a day. Ester C is also a good supplement to add.

Another very good thing to do for folks who are old enough is to use a Neti Pot or sinus irrigation. Make sure to use distilled water.
NeilMed has quite a few excellent products to help clear out the nose. For nursing moms, this is my absolute favorite remedy. If you have a deviated septum, this may not work well for you.


Good hand washing is of course essential.

Related posts

Friday, September 28, 2018

Time out variations/behaviors that 'cross the line'


To recap last week’s post: behaviors can be sorted into three categories:

  • Good stuff that we want to encourage
  • Annoying stuff that we want to discourage
  • Actions (usually bad stuff) that require immediate attention or intervention

Last week I wrote about catching kids being good and ignoring the irritating behaviors. (Attention/Parenting Pearls) Several parents sent me requests to address category 3 sooner than later.

Parents and caregivers need to be prepared to deal swiftly with the more challenging behaviors. I am referring to the actions that cross the line. This would include anything that is safety related. It is beneficial for parents to think about these types of things before they happen. Maybe you will be lucky and won’t ever need to be the parent of the biter, but it never hurts to be prepared.

This is a good “what would I do if?” activity for parents.

Let us begin by replacing the concept of punishment with consequence:

If you act a certain way________________the consequence will be__________

Load your arsenal with your sensible consequences ahead of time. Being consistent is essential. All the folks who parent your child need to be on the same page

I like to use sports analogies and in this case let's consider hockey. When a player gets out of line, they are moved to the penalty box for a designated amount of time. When the time is up, they are allowed to return to the ice and all is forgiven.
The player essentially just had a time out. The goal of a time out should be removing the person from a situation that got out of hand. A timeout is not a time for discussion; that comes later.

Here is what makes the time out that I recommend a little different. This ‘chill out session’ can actually happen right on your lap. Find a name for this ‘time out’ period that works for you. Maybe ‘breathing space’. Maybe ‘reset time’. You are a safe place, but stop short of making your cozy lap the goal. This isn’t the time to sing and give a back massage. Some quiet counting and some nice deep breaths are all they should get. This could happen anywhere where you can sit down and hold your child close. You actually likely have a timer in your pocket. Most cell phones have an hourglass app that you can download for free. This period doesn’t need to be long. Some experts suggest that it be a minute per age, but I have a suggestion. Ask your child how long the session should be (this is very effective for some kids and absolutely ludicrous for others.) “You hit your sister. How long do you think we need to reset, 1 minute 2 minutes or 3 minutes?"

We can’t anticipate everything of course, but here are some common behaviors that merit a reaction.

Being physically rough
This gets an immediate version of the ‘time out’ that you have chosen.
(We get calls about biting quite a lot. I frankly don’t know which is worse, being the parent of the biter or the child that got bitten. Both are difficult. Separate the kids immediately. If you have the luxury of 2 adults, one can tend to the victim and the other can sit with the offender. Human bites can get easily infected, so if there is broken skin, they should get checked by a doctor.)

We had a situation once in which Lauren came running and crying. "Alana bit me".

"Alana, Why did you bite your sister?"
"I forgot not to" was the response.
Sometimes we laugh even though it is probably not the correct thing to do.

Once they have been ‘reset’ they need to earn the privilege of close contact with the other person. They can go back to playing nearby but not in touching distance.

“When I trust that no one will get hurt, you can play closer”

If they act out physically to you and you are in a circumstance that allows for it, walk away. Don’t let your child abuse you.
Use your own ‘walking away power’. Go out of the room and close the door for a moment. Make sure you are out of their line of sight.That is generally not the response they are looking for.

Later, find a moment when everyone is calm and talk about what happened. Talking points:

  • You weren’t gentle.
  • What feelings were happening? Mad/ sad/ bored? It is fine if they don’t choose to pick one.
  • What are some other choices that might have been better? Using words/using walking away power/ asking a grown up for help...



Running off
This is a safety issue. I don’t like to see kids on leashes, but we all understand the frustration that must have lead to that decision. Know the rules ahead of time. For instance, we hold hands when we cross the street.

A child who is at risk of running off without listening, has lost the privilege of walking without being held on to. Perhaps they need to be strapped into a stroller until you are in a safe area.

This is a behavior that you need to work on in more controlled situations. Find some parks with gates, so it isn’t actually dangerous if they don’t listen. When you are practicing this, it is probably useful if you have an extra adult on hand, especially if you have more than one child with you. Find an opportunity to play a freeze game, or red light, green light, so that they can learn to stop at your command. Give lots of positive attention when it is merited.

Going to an off limit area. (Think wires, hot stove, climbing inappropriately..) Do some reasonable child proofing in advance to make sure your home is as safe as possible. Blocking access to every wire isn’t usually possible so training a child that there are some places that are off limits is important. Be consistent and move the child away immediately. It might take a dozen times. If they are willfully defiant, I don’t believe in 3 strikes. That implies that they have 2 chances to ignore you. Be clear; “The next time you touch the wire we will need to ‘reset’.


Throwing things
That’s an easy one. Take it away. If they throw something that isn’t sanctioned, they lose it. When everyone is calm, you can decide when they have another chance. Perhaps have something soft and safe that you can offer in its place.
I see a little boy who wants to throw something. Someone could get hurt or something might get damaged. Lets see if you can play with this instead.”


Here is a real life example of a child crossing a line and how it was dealt with:

In my parenting class I tell the story of one of my daughter's friend Anya. She is one of my extra kids. For several years, Anya was working as a nanny. Any family would have felt like they won the lottery to have her helping them raise their kids. Anya took “firm but loving” to heart.

One day, she was at a class with her little 2 year old charge. This was a little dance class at a multi purpose community room. In a corner by the stage there was a pile of martial art equipment. Anya was clear. “Don’t go near that pile”. Her little toddler was feeling a bit defiant that day and went right over like a dare and tried to touch one of the off limit objects. Anya calmly picked her up, removed her from the danger zone and back to the dancing group.

The little toddler went right back over. This repeated several more times. Finally Anya picked her up and this time they left the room completely. Little B was at this point kicking and screaming. “When you are calm we can go back to the dance class, but if you go near that pile we will leave again.” This process took up most of the class time, but I think that for the last several minutes they were able to rejoin the class and finished up happily dancing. B had learned a lesson. (When Anya told me about this, she also mentioned that some of the parents observing all of this commented that it seemed a bit hard on B that she carried her out of the room. Really? I would give her an A+)

Have you ever gotten towed? It’s horrible, but what is worst is that once you have paid the $$$ to collect your car, you find a ticket on the windshield. You are going to be careful in the future that it never happens again.

The Timeouts are the initial tow. Some behaviors now have also earned the ‘ticket.' Try to find a consequence that makes sense. For kids over 3, using tech time as a commodity works well. They start with a daily allotment with opportunities to increase it within reason. Poor behavior docks some of the time away.

Maybe a special outing gets cancelled. “You are not listening when I tell you to stop running. I don’t feel safe going to the park.

DO NOT make the consequence so big that you are not going to stick to it. No TV or play-dates for a month is just silly.
I can't help hearing, "No soup for you!" (That is a Seinfeld reference for any of you too young to know what I am referring to)

Do not let one parent undermine the other. Talk in advance as a team, or wait to pass judgement and come down with the sentence as soon as you are able to come to an agreement.

Here are some parenting tools to use before or after an incident:

  • Look for the triggers. Prevention is preferable to having to deal with something. If you see something about to happen, take some prophylactic step.
  • Are kids starting to bicker? Perhaps it is time to give a snack, distract and/or separate.
  • Tell stories about another child who crossed a line with their behavior.What were some of the consequences?
  • Get out the stuffed animals and do a little playing. Your child is the parent and you are the misbehaving critter.
  • Walking away power is a great choice if anyone is in a situation that is making them feel unsafe. If they are with a friend who gets mad and hits, getting up and leaving is a better choice than hitting back.
  • Taking deep breaths is often a good way to slow down.
  • Share the wisdom with your child that everybody makes mistakes and we can all learn from them.

This post has the most relevance for parents with younger kids. For my patient readers who have older kids and still took the time to read this through, I haven’t forgotten about you. I will do a post dealing with teen consequences sometime soon.

Friday, September 21, 2018

Attention/Parenting Pearl

Attention

Let me start by making a claim that most people, at least subconsciously, appreciate attention. I am not talking about public speaking or being on stage. I am referring to something more basic, like validation or acknowledgment. If you are an attentive reader, some of these concepts will be familiar to you from previous posts.

Think about it; certain tasks are simply drudgery. Cooking dinner for an apathetic family who doesn’t appreciate the effort is not fun at all, but if you were met with a resounding YUM and Thank You (and they actually eat it and ask for seconds) it makes the whole experience more enjoyable

Perhaps even laundry would be fun if someone routinely pointed out how white your whites are (full disclosure, I can turn anything pink and shrink it in the process.)

I remember a young patient who was in for a cough. He slipped sideways on the exam table after a little coughing fit and got a little startled. He was on the verge of bursting into tears. I reacted with a big “look at that! You coughed so hard that it made you fall over!” He grinned at me, sat up..coughed again and purposefully fell over again. I laughed and we had established a pattern.

I don’t know how long we could have kept that up, but I was going to tire of it long before he did. Cough Cough/ Fall over/Look how funny you are……. I stopped reacting. He did it several more times and when he realized I was no longer paying attention to it, he simply stopped. Attention is a powerful tool.

Can you think of some patterns that you have established? The one with my little coughing friend caught on in a moment. Some of the patterns in your life have been ingrained for quite a while and it might take a bit more effort to rewrite the script.

This drive for attention doesn’t fade with age. For most kids (and some adults) attention equals attention, and we often don’t differentiate between positive or negative. Some kids will do their best to elicit a reaction, even if that reaction is yelling.

Assuming you are willing to accept the premise that we can use attention as a means to encourage good behavior and discourage what my kids daycare provider used to call the ‘inconvenient’ behavior, the next step is to consider how to do this.

Let's divide behaviors into 3 categories.

  • Behaviors we like and want to see more of
  • Behaviors we don’t like and we want to see less of
  • Dangerous behaviors that need to be dealt with immediately


Encourage positive behavior
Catch them being good! By no means am I suggesting that every little good deed needs to be showered with praise. Find a balance and use some common sense.

The Nurtured Heart is a well studied approach currently being used by many mental health professionals and therapists. Showing your child plenty of positive energy and attention can promote what they refer to as the ‘inner wealth,’ which is essential for children to build successful relationships. You are not going to spoil them by giving them attention.


Okay, if you have one of those days where the good behavior is nowhere to be found, then catch them trying to be good. A good effort is the first step.

Take picky eaters and meal times. Give positive attention when you have a child who is sitting nicely at the table:

  • I like that you tried something new (even if it is just a bite and they don’t even swallow it)

  • Look at how Max is safely eating. He is chewing and swallowing instead of shoving food in his mouth. That makes me happy.

  • Wow, You are eating nice growing food. Let me feel your muscles.

When they are doing something that you like to see, let them know that you notice. Having them hear you telling someone else that you are proud of something they did counts. It is worth noting that giving attention to another child in the room can be pretty effective.

  • “Look at how Oliver tries new things.” Wait a moment and you might get “Hey look, I am trying it also.” (You can’t count on that; Nurse Heidi says that her younger one would simply give a “good for him, I couldn’t care less")

Keep in mind that you are not simply doing the “good girl” or "good boy" stuff. You are paying attention to the action.

Try to discourage annoying behavior

Nagging or raising your voice in response to an irritating behavior is giving the attention that they crave. The more often we energize these negatives by paying attention to them, the more kids will keep trying to push your buttons. They have figured out how to get a rise out of you and will likely continue to do so as long as it works. Contemplate some situations where you get caught in a nagging cycle. We may be able to affirmatively impact behaviors by being very intentional about what situations we validate or energize. Our goal should be that our kids are getting get more attention for the good behaviors than they do for the annoying ones.

It is hard not to energize these things, but try. We want to make every effort not to fuel the challenging behaviors by giving them too much response. So many kids have realized that they can make parents nuts by NOT eating. Put food on the plate. (Small amounts are better and not as wasteful) If they don’t eat much, don’t fuss. If you like you can make a statement “ I see a little girl who is not eating.” If they toss food or throw a plate, pick it up and simply say, "throwing food means you are finished with this meal". If you think they are actually hungry, you can offer another chance in 10 minutes. Be consistent. It might be 15 times of you taking the food away before they get that you mean business. If they will only eat that one favorite food, have it available with little comment. Remember the attention is given when they are willing to eat something else.

Whining is another issue that can make us all a little nuts. This is the classic example of irritating but not dangerous.Take advantage of the rare miracle when they ask for something without the tone and pounce on it. “I love how you asked for that without whining!!!”

How about interrupting when you are on the phone? See if you can catch them being patient. Have a “test” conversation that lasts 15 seconds (you don’t actually have to have a live person on the other end of the call.) Give your patient child a big high five for not interrupting.

Work on making the “patience interval” longer and longer. “Hey I really like the way you waited until I was off the phone, that makes me happy.” For the interrupting child just hold up your hand; when you are off the phone you can calmly say, “ I am now off the phone, how can I help you".

It is helpful for many kids to be clear about the rules before the phone call. You might want to have a family “team meeting” to problem solve a specific issue. Telephone interrupting is a easy one to work on. Clarify the expectation that they won’t interrupt.
Have a “practice week” that will have rewards for patience and consequences for interrupting. The team can decide in advance what these would be. Tech time is a useful commodity. Start with the basic daily allotment. Rewards add a certain amount of time, and consequences lose time. Have a special word that they can use if they feel that what they have to say is so important that it can’t wait. (for the “I need to poop right now and I can’t unbutton my pants”, it might be worth getting off the call!)

Defining the consequences for certain behaviors ahead of time is important so that if that behavior occurs, your child already knows what the possible responses may be. By doing this, you don’t have to “ignore” your child, but you also don’t have to energize the behavior. When the annoying behavior happens, sometimes it can be as simple as saying “we’ve talked about this before. Let’s calm down first, and then we can remember what our rules are so that we do better with this the next time.”

A dangerous behavior would be one that could get someone injured. That requires an immediate intervention or time out. (I will tackle with that issue for a future post)

Friday, September 14, 2018

The stigma of mental illness



It is suicide prevention awareness week. That makes this an appropriate time to address the stigma of mental illness.
I can’t cure it and I can’t fix society's shortcomings, but just perhaps I can touch the people who read my posts. Sometimes just getting the conversation started can make it less taboo and that is a reasonable first step.

The elephant in the room is Mental Illness.

Here is a startling statistic: According to the World Health Organization, one in four people will be affected by a mental health concern at some point in their life. Either you or someone close to you has dealt with or is currently dealing with this issue. You might not even be fully aware of it! There is often so much reluctance to be open about it.
Parents call me dozens of times a day to talk about physical illness. Sure, if they are calling from work, they might talk in a hushed voice if we are discussing diarrhea or an itchy penis, but there is no shame involved. Okay, perhaps head lice and pinworms have a wee bit of shame (they shouldn’t) but there is generally no stigma associated with physical ailments. I hope you get where I am going with this.

I also get the other calls. These parents are often so tentative as they reach out to share their concerns regarding depression, anxiety, or symptoms related to their child's mood or behavior. When I tell them how often I have these discussions about my teenage patients, most parents are a combination of surprised and somewhat relieved to need feel quite so alone. I am grateful that those who have known me for many years trust me enough to have the harder conversations. How is it that we have managed to suppress the acknowledgement about how common it is?

Think about our bodies. We all deal with a variety of illnesses or discomfort. Many things are mild enough that they don’t impact our daily routine. A mild sniffle probably won’t keep you home from work or school. Some little acute illnesses come and go. Some illnesses are more chronic but can be managed with medication and treatment. Regardless of what is going on, we allow ourselves to talk about it.


Mental illness has some similarities in that it has an extreme spectrum. It can be mild enough that folks can go about their daily life without letting on to the families and co-workers that they are struggling. Some could describe this as ‘managing’, but what an awful burden this places on the person who feels the need to struggle in silence.

Some mental health issues are more chronic. Life is being impacted. These folks need treatment and/or medication. With the correct medication or therapy, many folks are functioning just fine.

Find me someone who never gets anxious and depressed! You likely can’t. We all get a bit out of whack at times. If we are able to talk about it before it overwhelms, that has to have some merit.

There are certain small actions that we can take in our families and circles of friends to try to rid ourselves of the stigma.

Make sure you find the time for the conversations to happen.

With our children, let feelings be okay. ANY FEELINGS.
If someone is crying or feeling sad, don’t diminish it with a simple “ it will be okay, or don’t cry”



As a parent, I know what is is like to watch someone who we love have to deal with this. My daughter Alana suffered from some anxiety when she was in college. Until we figured out what was happening, she had a few difficult years. Alana was having a feeling of chronic “throat tightness.” This lead to the occasional feeling of breathlessness and she would wake her up gasping for air. Sleep deprivation followed. This created a spiral that understandably lead to anxiety.

Fortunately we were able to make the connection that gluten was significantly involved in her symptoms. Alana is a bit unusual in her approach. She widely announced to the world that she was having anxiety issues. Her friends responded. Shockingly high numbers, she hadn’t realized, were in therapy or already on meds. They barraged her with suggestions of various tools that had helped them. Coloring books, tapping, meditation, hypnosis. Some things gave some moments of relief, but in her case the underlying physical cause needed to be dealt with first. A wise friend once said.”You are only as happy as your least happy child”. I find that to be all too true. In the midst of her anxiety waves, I would feel like I had a fist clenched inside my gut.

My daughter is fortunate that she ultimately had something that she has some control over (although she points out that being super allergic to gluten sucks.) She is also a rare person that she never allowed herself to feel isolated or shamed.

After college, Alana went on to work for several years as a counselor and trainer at the SF Suicide Prevention hotline, before getting her Masters in Social Work. After graduating, she worked for several years in a community mental health center with clients of all ages. She acknowledges that as a therapist now, her firsthand experience with anxiety gives her extremely valuable insight.

Here are some tips that she shares:

  • proactively do some psycho-education about emotions. You can do this using games like Uno, where each color represents a different emotion. When you play a red card, you can prompt your child to talk about a time that they felt angry, or explore different coping skills around how to deal with feeling mad. Blue can represent a time that they felt sad. Green, a time where they felt excited, etc…

  • Often times parents are afraid to ask their kids directly if they are feeling suicidal, because they are afraid that it may trigger these thoughts. On the contrary, research demonstrates otherwise - that talking about depression and suicide openly helps individuals feel more supported and more open to explore alternative ways to cope.

The internet is full of some really solid suggestions.



If you are concerned that you are seeing behaviors that are impacting daily life, please be open to therapy. My opinion? Everyone would probably benefit from therapy. Therapy equals tools...who doesn’t need tools? Sometimes you might need to try a few different providers before you find someone who feels like a good fit. Don't give up.

A good therapist can help you identify an issue that might need further treatment. They might advise seeing a psychiatrist to get started on some medication. Medication is not always necessary but in some cases can help achieve the balance that is lacking.

The American society for suicide prevention states:

Although there is no single cause of suicide, one of the risks for suicide is social isolation, and there’s scientific evidence for reducing suicide risk by making sure we connect with one another. We can all play a role through the power of connection by having real conversations about mental health with people in everyday moments – whether it’s with those closest to us, or the coffee barista, parking lot attendant, or the grocery store clerk. It’s also about the connection we each have to the cause, whether you’re a teacher, a physician, a mother, a neighbor, a veteran, or a suicide loss survivor or attempt survivor. We don’t always know who is struggling, but we do know that one conversation could save a life.


I love to take urban walks with my friends. One of my walking partners is my amazing friend DeeDee. Not only does she pick up litter from the sidewalk and stop to ask anyone who is holding a map to see if they need directions, but she always has her antenna up to see if there is someone out there in need of that one conversation or outreached hand. She was moved by the story of a man who survived a suicide attempt from jumping from the Golden Gate Bridge.

This brave man is sharing his story widely in the hope that he can help others. He talks about the day he jumped. He had told himself that if someone had noticed him and said, “Hey, are you okay?” he likely wouldn’t have gone ahead with it, at least that day. Instead, although he was surrounded by many, he felt completely alone. Finally someone spoke to him.

“Hey, can you take our photo?”
He jumped.

Ever since she heard that story, if DeeDee sees someone alone and looking sad, she stops and reaches out.
“Are you okay?”


SF Suicide Hotline 415-781-0500

If you would like to take a class in Youth Mental Health First Aid here is a link: https://www.mentalhealthfirstaid.org/.../course-types/youth/