To recap last week’s post: behaviors can be sorted into three categories:
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:
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’.
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:
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.
- Head lice/ Sklice co-pay coupon
- Should you give tylenol before the shots? / vaccine reaction discussion
- Skin fold irritations
- HAND FOOT MOUTH (and butt) VIRUS
- Tips for giving medication
- Strep Throat
- The Poop series: Chapter #1 Baby poop
- Nurse Judy' Blog
- Anaphylaxis/Do you need an epipen?
- Pinworms (ugh)
Friday, September 28, 2018
Posted by Nurse Judy at 9:01 AM
Friday, September 21, 2018
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.
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:
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.
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)
Posted by Nurse Judy at 9:05 AM
Friday, September 14, 2018
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:
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?”
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/
Posted by Nurse Judy at 9:32 AM
Friday, September 7, 2018
Things to know about measles:
Measles, also known as rubeola, is a very contagious respiratory virus.
- This virus is so virulent that ninety percent of unvaccinated people will catch this virus once they are exposed. What is even more alarming is that it can remain on surfaces or even in the air for 2 hours after someone has sneezed or coughed! If someone travels on a plane while they are contagious...that is a potential nightmare. One of the reasons that it spreads so easily is that people are contagious as early as 2-4 days prior to showing any signs of the virus and may remain contagious until the rash is gone, or 4 days after the symptoms are all clear.
- Infected people present with high fever, cough, congestion and red eyes.
- After several days they will also develop a significant rash all over the body.
- If you have a happy child with a rash, my guess would be that it isn’t measles. People with measles will look sick and likely have a high fever. The rash will not be one of the first symptoms.
Complications are frequent. They range from ear infections to pneumonia, encephalitis and/or seizures. 1-2 out of every 1,000 cases are fatal. Take a moment and reflect on what that means. This is a serious illness. This is not one of those illnesses to wish your child would catch in order to get natural immunity.
The routine measles vaccine is combined with mumps and rubella and is referred to as the MMR. The individual components have not been available separately for many years. The first MMR shot is routinely given to patients between 12-15 months and again between 4-6 years. For the second dose we have the option of combining it with the chickenpox vaccine called Varivax. That combo vaccine is called Proquad or MMRV. The MMR vaccine is thought to be 95% effective. The second dose is given just to catch the occasional person who didn't get effective immunity from one dose and bumps the effectiveness up to 99%. It can be given earlier than 4 years, but we aren't too concerned about the timing of the second dose as long as our patients have gotten the first one. The schools just count the doses and don’t mind if the second is given early. If you are traveling to a high risk area, the CDC will suggest getting the second shot early. The 2 shots simply need to be given at least 28 days apart.
Why do we wait so long before giving the first MMR protection to our babies?
Assuming that mom has been fully vaccinated (or less likely has had the actual measles) infants are born with passive immunity to the disease. This immunity starts to wane as they get older and is considered mostly gone by the time the babies are between 12 and 15 months. If a child is vaccinated when they are younger than a year old and still have the maternal protection, the vaccine does not seem to be as effective for long term protection.
The MMR is a live vaccine and it is true that in some rare cases the reaction can be a little rough. Interestingly, most kids are just fine the day of the immunization. Typically the reaction comes along between a 7-21 days after the shot. This reaction may include high fever and rash. This is not thought to be contagious. It usually lasts only a day or so. If your child is allergic to eggs, we are extra cautious when giving the vaccine. Some folks with a significant reaction to eggs may opt to get it at the allergist's office. I have NEVER had any patient have an allergic reaction from the MMR or a serious post vaccination reaction other than about 20% who seem to get the fever the following week.
Before routine use of the measles vaccine, there were about 500,000 cases of measles in the United States each year and about 500 deaths. Measles also led to about 48,000 people being hospitalized and another 1,000 people being left with chronic disability from measles encephalitis. Study after study has shown that there is no link between the MMR and autism,
but there are still some folks reluctant to give their children the vaccination.
In July 2016, SB277 was signed into law. It is now a requirement for all children attending schools in California to have the measles vaccine unless they have a medical contraindication. Since the law passed, I have seen a steep increase in vaccination rates. This law probably has saved lives.
Measles has been in the headlines recently.There have been a few cases here in the Bay Area, but the fact is, this is not considered an true “outbreak”. The CDC defines an outbreak as “a chain of transmission that includes 3 or more cases linked in time and space.” So even though we have had a few small isolated cases, not enough of them are connected to cause a red alert here.
As of August 2018 there have been 124 cases confirmed in 22 states and the District of Columbia. The states that have reported cases to CDC are Arkansas, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, and Washington.
Even a few cases can make parents of young kids nervous. It goes without saying that if you have a young baby in a crowd they are at risk. You never know where the next outbreak will be. We live in a global world and San Francisco, especially is a destination for travelers who are coming from some of the high risk countries. However, at this time, unless there is a health alert, babies should follow the routine schedule and get their first MMR at either the 12 month or 15 month appointment.
Europe is a different story
Due to poor vaccination rates and policies, cases of measles have reached a record high in Europe this year, with more cases recorded in the first six months of 2018 than any other 12-month period this decade, according to the World Health Organization (WHO). Romania (4,317), France (2,488), Greece (2,238) and Italy(1,716) have the highest number of cases and there have been 31 deaths.
We don’t need to cross the ocean to be exposed. On July 24, 2018 The Pan American Health Organization updated their numbers and reported a total of 2,472 confirmed cases of measles from 11 countries in the Americas so far this year. The majority of the 2018 measles cases occurred in Venezuela ( 1,613) and Brazil (1,053), followed by the 124 here in the US that I noted earlier.
PLAN IN ADVANCE!
If you are traveling to a high risk area or there has been a possible measles exposure, the vaccine can be given as early as 6 months. You need to be aware that this early shot can’t be counted on for lasting protection. Your child will still require two shots after the first birthday. Your insurance company also might refuse payment if the shot is given outside of the routine schedule. If that happens, be aware that getting an early, extra dose may be an out of pocket expense.
It takes about 10-14 days to get any significant protection from the first MMR. For instance, getting an MMR for a 7 month old to protect them from a travel situation the same week is not going to do much of anything.
Several years ago when I was working on my very first measles post, one of my adult friends said to me, "We all got measles and survived, what is the big deal?" My response was, "It is true enough that the vast majority of folks who get measles will recover intact and have lifelong immunity. However, one to two kids out of 1,000 will die; many more than that will be permanently harmed. That is too many when we are talking about something that can be prevented. That 1 child out of 1,000 matters."
Posted by Nurse Judy at 9:02 AM