Childhood anger management

The Pediatric Insider

© 2012 Roy Benaroch, MD

Christy posted: “My seven year old son has been having trouble managing his anger. He is typically a very laid back child with a great temperament. However, when something does upset him he will usually lash out — hit, kick walls, slam doors, throws items, yells and screams, and will take it out on everyone and everything around him. It is a tornado effect. When this happens, we calmly and firmly tell him to stop the negative behavior and we then send him to his room to let him calm down. Unfortunately, things usually get worse when we talk with him. After a series of fits, tears, etc., he will come back to apologize but won’t let us discuss things. He will just say ‘Can we please forget it?’ or ‘Can we not talk about it?’ I feel that we need to discuss things with him so he understands his behavior and so it doesn’t happen again. However, he always wants to sweep everything under the rug. I would love any advice you have that could help calm him down before he gets to that ‘anger’ point. Any advice?”

Anger and frustration are emotions we all have sometimes, and they’re feelings that many of us could do a better job managing. They’re especially difficult for children to handle, because they haven’t yet developed mature communication skills and the ability of modulate emotions—when they’re mad, they’re MAD with a capital ‘M’! Many adults, unfortunately, haven’t really learned to manage anger very well, either. So I’m glad you’re trying to help your son learn to cope with this better. Lessons learned well now will help him for the rest of his life.

First, keep in mind that the goal isn’t to tell him not to get angry, or make anger itself something “bad” or something that needs to be punished. Getting angry, that’s OK. What you’re trying to do is teach him how to get angry in a good way.

You’ll want to make sure that the adults in your son’s life are managing their own anger well. Adults serve as models, and if you or Dad are yelling and screaming, that’s what your children are going to learn. Children will learn far more from what you do than from what you say.

Talking about anger management is important—but many parents do it at the wrong time. Once your child has “lost it”, you’re not going to be able to have a meaningful or useful discussion. Send him off to his room to cool, and don’t follow him, and don’t raise your voice. At the height of a tantrum, you’re not going to teach anyone anything. Right afterwards is still not a good time for a big discussion. He’ll still be overwrought, and embarrassed, and he’s going to feel picked on if you start up the lecture as soon as he’s calmed down. Instead, you should wait until a few hours later, or even the next day, to bring up the explosion. “Wow,” you might say. “You were really upset. Maybe there was a better way you could have handled that, do you think? Rather than screaming and throwing that toy, what would have been a better way?” Try to get the right answers out of your child, without saying them yourself. Make sure he hears positive reinforcement, too:

Child: “I shouldn’t have hit my sister.”

Wrong response from parent: “Yeah! But you still always do it! What’s wrong with you?”

Better response: “That’s right, I knew that deep down you knew that already. What would be a better thing to do next time?”

Child: “I should have just taken some deep breaths, or just walked away.”

Wrong response from parent: “Why don’t you ever do that? You always make it a fight!”

Better response: “That’s exactly right. I know it’s hard to remember to do the right thing when you’re mad. I’m proud that we could talk about this now, and I know you’re going to try to do better next time.”

Sometimes, indirect teaching works best. Children can find “the big talk” kind of scary and intimidating—that’s when you sit ‘em down, and tell ‘em what’s expected of them. Instead (or in addition), try some indirect teaching by putting on a puppet show, where the characters get angry at each other, and handle it well (or maybe one character can be “the good guy” who teachers another character how to not freak out.) You could get your own child to be the voice of a puppet himself. Indirect teaching can also occur by discussing people you see together, or making up stories together, or painting a scene. The idea is that by talking about how other people feel and how other people learn, your child can learn himself—but without the direct baggage of thinking about himself as the person who is the disappointment.

Make sure that you’re teaching your child what he ought to do, not just what he shouldn’t do. You shouldn’t just say “Don’t hit, don’t scream, don’t yell, don’t throw …” without giving him some ideas about what he can do when he gets angry. Some good ideas:

• Take deep breaths (sometimes a very-specific number helps, like “14.” There’s a magic in counting.)
• Go to your room and scream into your pillow.
• Flip your mattress over (this is surprisingly difficult for a child to do, and—bonus!—you’ll get your mattresses rotated!)
• Punch a (safe) punching bag.

Most importantly, recognize that a child’s own temperament isn’t something that can easily change. Learning to handle anger in a mature way isn’t a weekend project. For many people, it takes years to learn this skill. There will be good days and bad days, and some setbacks too. Remember to continue to model how you want your children to act, and provide plenty of specific positive reinforcement when your child makes even a few baby steps in the right direction. If you’re feeling discouraged, or you don’t feel that you and your child are making headway, ask your pediatrician for a referral to a family therapist or another counselor with experience in anger management in children.

To diagnose an ear infection, you have to look at the eardrum

The Pediatric Insider

© 2012 Roy Benaroch, MD

“I can just tell he has an ear infection! Can’t you just call in an antibiotic?”

I don’t want kids to suffer, and I don’t want kids having to go to an ER or busy after-hours place on the weekend. (In Atlanta, parents have a great after-hours alternative—kids can see a real pediatrician after hours!) Why not just call in weekend antibiotics without seeing the child? If a parent thinks their toddler has an ear infection, how likely is it that they’re right?

Researchers in Finland tried to find out. In a 2010 study, they reported their findings based on 469 children over a 2 year period who were brought to a clinic because of parental concerns of a possible ear infection. The children were all aged 6 – 35 months. Prior to their exams, parents recorded the degree of ear pain, irritability, crying, restless sleep, fevers, and many other symptoms. Examinations were performed with state-of-the-art equipment, and videos of the ear exams were reviewed by an ENT specialist to confirm the diagnoses.

It turned out that none of the symptoms could reliably differentiate children with ear infections from children whose ears were normal. Not pain, not height of fever, not how the children were acting. Parents who reported these symptoms were just as likely to have  a child with or without a real ear infection. Ear rubbing was actually more common in kids who did not have an ear infection.

The only reliable way to tell if a child has an ear infection is to look at the eardrum. Even then, it’s not always easy. Sometimes there’s wax, and sometimes, even for me, children squirm and yell. Unless you get a good exam, there is just no way to know. And it is important to know, before you start antibiotics– if you’re going to use antibiotics at all. Since many ear infections will improve without antibiotics, unless a child seems really miserable it’s often best to wait a few days, especially if it’s a weekend. An ear infection that got better on its own didn’t need to see the doctor, anyway!

So: if your child seems to have an ear infection on the weekend, do things to help him feel better. A gentle heating pad or a dose of ibuprofen or acetaminophen will provide quick relief. Emergency, weekend care is really only needed if your child remains miserable even after pain medication. Starting antibiotics without a sure diagnosis is like flipping a coin—you may be doing more harm than good.

Letters to the editor

The Pediatric Insider

© 2012 Roy Benaroch, MD

I get a fair amount of email and comments on the blog—some are great, and some are just plain weird. Feel free to add comments to any post on this blog, or you can send me a private message through a webform. Either way, I read everything. If I don’t respond, it’s entirely my fault.

Here’s some recent posts worth sharing. They’re all genuine, I promise. First, a short post from someone named “Giubbotti” on the About this site page:

Wanted great article with your blog page, it truly gives me a look during this issue.

Thanks Giubbotti! I think!

Sac Hermes posted this gem:

 In reality such as your web sites particulars! Without any doubt a wonderful provide of information that is very useful. Carry on to offer posting that i’m planning to move reading through through! Take care.

 More kudos from someone who posted with a URL rather than a name:

 This is some thing which i dont usually do, but what the hell i loved your post so i desire to say thank you. You’ve got gotten a loyal reader.

Finally, one last comment, a short post by “Canada Goose”, or maybe it should have been “Canada Gander”:

 I’m a website crazed man or woman and i desire to read through great blog site for instance you.

 Couldn’t have said it better myself, Mr. or Mrs. Goose!

Why patients wait

The Pediatric Insider

© 2012 Roy Benaroch, MD

I hate it, too. I hate waiting for doctors. And I honestly don’t like to keep my patients waiting for me. My practice has a nifty electronic records system that shows me—at a glance that’s hard to ignore—just how long patients have been waiting. I don’t like keeping you waiting for me any more than you and your kids like sitting there yourselves.

So why all the wait?

There are a bunch of reasons, some of which will come across as lame excuses. Still, this is the honest, inside truth here. Believe it or not. I can’t speak for every other doctor, but I can tell you why you’ll sometimes wait before seeing me. These are the top reasons:

Sometimes a patient earlier in the morning came in late themselves. If you show up 15 minutes late, or 30 minutes late, I can’t get that time back. I very well may have been pacing around, pestering my nurses, with nothing to do. And every single patient after you is going to pay for that wasted time, because your appointment started late. In my office, we’ll ask you to reschedule if you’re over about 20 minutes late—but many of you say, that’s OK, we’ll wait. OK for you, maybe, but is it OK for the everyone after you? Time, once gone, cannot be brought back.

Sometimes a patient has a more-complex problem that just takes more time than could possibly be allotted. I have no idea what to expect in a room, and sometimes the most important health issue isn’t even mentioned until I think the encounter is already over, and I’ve got my hand on the doorknob. If that’s when you mention that your boyfriend is hitting your child, or that your teenager is doing drugs, I’m going to sit myself back down again and spend as long as I need with you. That does mean that other people will have to wait, but sometimes that’s still the right thing to do. For those of you who’ve waited because someone ahead of you needed extra time, I apologize: but I also promise that when it’s you who needs the extra time, I will be there for you.

Sometimes there really are emergencies. I know, it’s not like I’m running an ER, but sometimes genuinely very sick kids come in, or sometimes I’m needed on the phone to sort out a complex problem that just can’t wait. The problems can’t wait, but the families in the rooms end up paying the price. Again: sorry. Again: I’ll do the same for you, if you’re the one who needs me to drop everything for your child.

So what can parents do to avoid a wait?

Try to choose a doctor and practice that isn’t always behind. If you have to wait every time, it may be time to switch practices. That being said, if you never ever have to wait, either your doctor has no patients or is the kind of person who watches the clock and doesn’t let any encounters last longer than a set time. That’s not so good, either.

Make appointments 1^st thing in the AM, or 1^st thing after lunch. That avoids your having to pay the cumulative price for whatever happened in the appointments before yours.

Try to help your doctor stay on time. Arrive to your appointments on time, and try to focus the visit on your child’s main concerns. If you have questions about siblings, by all means ask them—by making a separate appointment for the sibling.

I don’t think I’m the worst doc in town for keeping families waiting, but I’m probably not the most on-time guy either. The bottom line for me is that I’d rather do a good, thorough job than watch the clock. For those of you I’ve kept waiting over the years, I do apologize. Hopefully, in the long run, waiting for me was worth it.

Lead poisoning: How long to worry?

The Pediatric Insider

© 2012 Roy Benaroch, MD

This is a question I answered on the WebMD parenting community, edited, expanded, and obfuscated for your enjoyment here!

“My 3 year-old daughter was diagnosed with lead poisoning a little over a year ago. Her initial lead level was 33. The previous residents of our home didn’t follow regulations when they changed the windows, filling the yard with lead. She hasn’t had any symptoms, and her levels are within safe levels at this point, but I haven’t been able to find much information for parents after children are diagnosed with lead poisoning. What is her prognosis? She seems fine now, but how long do I need to worry?”
I’d like to give you a clear, unequivocal answer. But unfortunately, there’s no way to predict for sure whether your daughter is likely to have problems from this level of lead exposure.

Lead can cause symptoms both from acute exposure to high levels, and also from chronic, low-level exposures. Children with acute lead intoxication can have irritability or sluggishness, plus GI symptoms like vomiting or constipation. More common, though, are prolonged, lower-level exposures that may not have any obvious symptoms at first. In the long run, children (including not-yet-born babies) exposed to even relatively low levels of lead can have behavior and learning problems.

Unfortunately, it’s difficult to know exactly what the cut-off for safe exposure is, or if an individual child with a mildly raised lead level is likely to have problems. The effects of lead poisoning depend on many things other than the lead level. Different people have different susceptibility to the effects of lead (that’s probably genetically determined.) Certain other health conditions, like iron deficiency, seem to have an additive effect on lead poisoning. Effects also depend on how long the level was elevated—the longer a child is exposed to lead in the environment, the worse it can be. Earlier exposures seem to cause more problems than exposures in later childhood.

The best treatment for lead exposure is the prevention of exposure by limiting the lead in our environment. Lead paint has been banned in The United States and most other countries since the 1970s, but might still be found in layers of older paint in homes. During renovation, old layers of paint can be chipped off or turned into dust that can contaminate a home. Lead paint also occasionally is found in toys produced overseas, and lead contamination has been found in herbal and other medical products. Some hobbies (like stained glass and ceramics) and occupations involve exposure to lead in solder and glazes. Leaded gasoline had been a significant source of environmental lead exposures until it was phased on in the 1990s; however, lead is still used as an additive in some aviation fuels.

Going back to the original question, there is a very good possibility that a lead level of 33 will lead to no permanent harm whatsoever, but no one can predict that at age 3. Certainly we know that there are no severe or marked problems– that would be noticed  already. Subtle issues can’t be ruled out at this age, so continued watchfulness is still needed at least until the child is well into the school years.

What the heck are percentiles, anyway?

The Pediatric Insider

© 2011 Roy Benaroch, MD

In pediatrics, our patients are growing targets. There’s no “best” weight or “correct” blood pressure—there’s averages and ranges that depend on things like a child’s age and sex. Since there’s no way we could possibly memorize all of the normals at every age, we rely on “percentiles.”

Talking in percentiles doesn’t always make sense to parents. I blame number grades in school, where the closer to 100% your child gets, the better the grade. “I scored a 97!” is great. Having a BMI (body mass index) percentile of 97%– that’s not so great.

A percentile is a way of comparing your child to kids of similar age and sex. If your son’s height percentile is 40%, that means he’d be number 40 in a line of boys of his exact age if they were lined up in height order. A percentile at or near 50% is about average, and anything between about 25-75 percentile is close enough to be considered average.

In most areas of health, average equals good. It’s the outliers, the ones with the highest blood pressure or the lowest blood counts, that we worry about.

Percentiles are especially useful when we look at growth and weight. Most children grow along about the same percentile range from age 2 through puberty—so if after two the percentile is changing much, something might be going wrong with growth (before two, there is a lot of percentile shifting as children move towards their expected growth pattern.)

A person’s overall “chubbiness” is usually expressed numerically as a BMI, or body mass index. In adults, a BMI of 25 is usually considered overweight; over 30 is obese. In kids, we rely on the BMI percentile—over 85% is overweight, over 95% is obese. From year to year, the BMI number will change, but the percentile should not vary very much.

Another thing about percentiles: in the middle of the pack, a very small change in a number will lead to an exaggerated change the percentile number that really isn’t very meaningful. For instance, a  9 year old boy who weighs 79 pounds is at the 50^th percentile. If he gains 3 pounds, that takes him to the 60^th percentile. But a change from 85 percentile to 95 percentile in the same boy would mean he’s gained 15 extra pounds. Percentile changes in the 25-75^th percentile range usually don’t mean there’s been a big change in absolute numbers, but percentile changes of only a few points way at the top of bottom of the percentile range can mean a big shift has occurred.

If you’re concerned about your child’s growth or weight, ask your pediatrician to review the growth chart and show you how the percentiles have trended over the years. For most kids, a nice stable percentile curve means that their overall health is good—even if the percentile isn’t right the middle. But a child who’s percentile is very far from average (especially those with BMIs higher than 85-95 percentile), may have significant health risks that ought to be addressed.

Depression in the family

The Pediatric Insider

© 2011 Roy Benaroch, MD

Beth posted, “As someone who has battled clinical depression since childhood, and whose husband has many of the same issues, I’m very curious about the risks my children face in this area. How much more likely are they to suffer from depression?”

Depression, as well as other mental illnesses, do run in families. The population risk of major depression—that is, the risk that someone will have depression at least once during their life—is probably about 5-10%. Add in the risk of an anxiety disorder, and you’ve probably got a lifetime risk in the 10-15% range. With one parent with problems with anxiety or depression, the risk for their children is about doubled, to 20-30%; with both parents, it’s somewhat higher than that (I couldn’t find an exact number.) So you’re right to be concerned about the risk in your kids.

We do know that there is more than genetics at work, though. Depression and anxiety are also influenced by environmental factors, including early childhood trauma, and exposure to parents and other loved ones with mental illness. If you and your husband are being successfully treated for depression,  it should reduce your own children’s risk—because they’re being raised by parents without symptoms (or with reduced symptoms) of mental illness.

The diagnosis of depression and anxiety disorders in children may be more difficult because kids do not necessarily have the same symptoms. While adults have anhedonia (lack of joy), children will more typically have irritability or chronic unexplained pain, trouble sleeping, or trouble with peers and in school.

If you’re worried about symptoms of mental illness in your kids, please bring them to your pediatrician. Be open about your own history of these problems. That can help the doctor come up with the best diagnosis. Though your kids are at elevated risk, that’s not to say that they’ll definitely—or even probably—have problems like these.

MD vs DO

The Pediatric Insider

© 2011 Roy Benaroch, MD

Shannon posted, “After having to part with our beloved pediatrician :0) to find one in our new home state, we’ve been feverishly researching the field of pediatricians. In particular, we’ve come across one in a practice that we are considering who is a pediatric DO not MD. They provided us with a sheet saying what a DO is but it was not a side by side comparison as to the difference between the two so we’re a little confused. What is a DO and what are your thoughts on their qualifications with regards to an MD?”

DO stands for “Doctor of Osteopathy”, which is different from the MD’s “Medical Doctor” degree. However, the difference is mostly historical. For the most part, in the United States physicians with either degree have very similar training, and are equally qualified.

The term osteopathy was invented by an American politician and doctor (an “MD”), Andrew Taylor Still, in 1874. He felt that the human body possessed inherent mechanisms to prevent injury and disease, and that these mechanisms could be relied on to heal the body during times of illness. Osteopathic physicians, based on Dr. Still’s teachings, were meant to provide therapy that helped enhance and unlock a body’s own healing power.

However, modern osteopathic medical schools, while continuing to teach a philosophy of mind, body, and health integration, also teach the same anatomy, physiology, and pathology taught at schools that train MDs. Indeed, almost all graduates of DO schools go on to residency programs alongside MDs, pursuing the same post-graduate training. They give prescribe the same medicines, do the same surgery, and for the most part give medical advice and perform medical services in a manner identical to that of MDs. Though some integrate osteopathic manual therapies (manipulation) into their practice, many do not.

So: I have no misgivings about taking your child to a person with a DO degree rather than an MD. In either case, your pediatrician should have completed a pediatric residency program, and ought to be a “Fellow” of the American Academy of Pediatrics (that’s the FAAP after our names). Beyond that, look for someone who listens, cares, and loves your children. With free parking, a friendly staff, and (ideally) monkeys painted on the exam room walls. That’s far more important than the name of the medical or osteopathic school on the diploma!

Is he ready for kindergarten?

The Pediatric Insider

© 2011 Roy Benaroch, MD

Lydia wrote: “I live in a state with a December 1st cut-off and both of my kids have fall birthdays. We started the oldest when he was four and have never questioned our decision, but my younger son’s birthday is in late November, so he’d be four for the first 3 months of the school year. The kindergarten classes have over 25 kids and the district is starting full-day kindergarten for the first time next year. Are most four year olds ready for full-day kindergarten or for such large classes?”

I think most four year olds are ready for this kind of experience, if the classes are organized and supportive and well-run. With tight budgets, though, parents need to ensure that there are adequate resources for a strong kindergarten experience, no matter what the age of their children.

I’ve written kindergarten readiness on this blog before, and also recently on WebMD. My feeling has always been to allow most kids (boys and girls) to advance and proceed as recommended by the guidelines of the local school—that is, to follow “the usual track”—unless there’s a specific academic or emotional issue that’s holding your child back. Schools that indulge parents only for being “squeaky wheels” are not doing children or society any favors by allowing a handful of older children to stay back and mix with younger kids.

There is a downside to holding kids back. Some will get bored, and some will end up pushing around the smaller, younger kids. Children surrounded by same-age peers are more likely to pick up new, more mature skills than children who are with kids younger than they are. As held-back children age, they may feel especially awkward going through pubertal changes in fifth grade, long before most of their classmates will.

That being said, there certainly are some kids who should be held back. Some children, whenever their birthdays, may not be emotionally or academically ready to proceed forward. The best people to make this judgment are people from the local school, who know what the kids in their classes are like, and know what kinds of expectations there will be. Parents also need to keep in mind that not all kindergartens (or pre-Ks) are the same—a child may not quite be ready for “The Aristotle Scholars Academy,” but could do great in the “Learning Together Preschool” across the street. There isn’t one set of requirements that applies to all schools.

Parents know their kids best, and local teachers and administrators know their schools best. They should work together to help choose the best placement for children entering school.

Thanks, I’m back now

I’ve been running reruns for November, so I could concentrate on working on a new writing project: young adult fiction! My first book is done, and I’m publishing it chapter-by-chapter for free at my new fiction blog, Benawrite.com. Please click on over there and check out the first few chapters. If you want, you can also visit the Benawrite Facebook Page– and while you’re there, feel free to click “like”.

But now, it’s time to get back to medicine. I’m going to try to catch up on backlogged topic suggestions first– so if you’ve sent in a suggestion and you’ve been waiting, it will (probably) be answered soon!