A Happy Little Girl

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Happiness is a gift from within.

I looked up from the menu and saw this young girl standing next to me smiling. Her hair touched the top of a billowing white dress and her black patent leather shoes sparkled.  I cocked my head to the side and said: “Well, hello.” Speechless, she continued to smile. A woman swept over from a distant table and knelt down beside her. “Doctor Barber, I apologize for bothering you but, my daughter saw you come in and asked if she could go over and say hello.”  The next thing I knew she was standing next to your table.  I am so sorry for interrupting your dinner.”  The little girl continued to smile. “She and her sister play doctor and take turns being you.” You are going to be a great doctor someday,” I said to her.  Her smile grew larger. “Come on honey. Let Doctor Barber finish eating.”  She reached up and gave me a hug and skipped back to her table.

Children are born with an ability to live in the moment. Their feelings fueled by love, attention and affection drive their actions. They are able to feel what they want while still controlling what they do.   Attachment fueled by love, attention and affection leads to a sense of happiness, security and satisfaction. For adults this skill and connection is often lost.

The older we become the more our lives are illuminated by responsibility. Schedules and illness shorten our lives. Minutes, hours and days filter out the joy as we become unhealthy and unhappy. This unhappiness fosters the conscious suppression and unconscious repression of desires and feelings.  Life is devoured by rejection, anger, frustration, internal inadequacy and the stress of endless repetition.  One day ends so another can begin.

We must not allow unhappiness to replace positive emotion.  Abundant acts occur daily in each of our lives when we take the time to live in the present moment.

That young girl reminded me of my own power and capability to seek and find happiness no matter where I am or whom I am with.  I realized we have the innate ability to feel good when we take the time to give and receive unconditionally.  This power is within each of us.

Do you choose happiness? The choice is yours.

The Importance of Exercise

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Exercise is an essential component of a healthy lifestyle and leads to good physical health.  There is no single best activity but keeping your exercise routine fresh, exciting and social improves your chance to continue exercising.  Everyone should exercise from infancy through adulthood.

Exercise must always be done in a safe environment. Make sure you drink enough water and always warm up before you begin moderate to strenuous activities. Appropriate flexibility and strength must be present before many activities should be pursued. This includes core strength and an adequate base of muscle, bone, heart and lung strength. Lastly, equipment, pace and duration must always be considered.

The benefits to exercise are both physical and psychological. Physical benefits include improved lean body mass, improved heart and lung function and strong bones and muscles.  Psychological benefits include improved sleep and learning, enhanced self-esteem and a healthier general sense of well-being.  Exercise decreases stress and aides in the restoration of balance to our daily lives.

Exercise is a learned behavior and must be linked to a nutritious diet and adequate sleep and recovery. It must be started at an early age and become part of your daily activities. It must be inexpensive and readily available. It is best to include 60 minutes of a combination of moderate and vigorous exercise in your daily routine.

In recent years physical inactivity has become our standard. This has many causes including our use of automobiles rather than walking or biking, the deep penetration of labor-saving devices into our daily lives and the prevalence of electronic games and other devices that distract and support “sitting” behaviors. Even school schedules have changed with many physical education classes now being cancelled. In many urban areas children are afraid or not allowed to play outside due to safety concerns.

Children under age two years should not watch TV and children from age two to six years should watch less than two hours a day. Older children should keep screen and electronic device time under two to four hours a day. Most teens in the US spend more time with electronic devices than they do sleeping.

For infants the focus should be on developmentally appropriate motor skills. These types of exercise should be lively, consistent and spontaneous. Exercise that is imbedded within tummy time, diaper changing and dressing is best.  Peek-a-Boo , So-Big and Patty Cake are great choices.  Be cautious about the amount of time your infant spends in swings, bouncy chairs and car seats.

For the toddler to pre-school aged child the joy of movement is the focus. Children during these ages need to gain a sense of physical control over their bodies. They become stronger and leaner. They learn about spatial relationships in terms of hand-eye and foot-eye coordination.  They learn how to manipulate more than one object at a time and they develop a sense of stability and rhythm.  Walking, hopping, galloping, skipping, marching, running and obstacle courses are all perfect activities for this age.

As a child enters the school age years between five and ten years there is a transition to activities that have flexible rules and basic instructions.  Teamwork and the integration of motor and cognitive skills become increasingly important.

During the teen years personal interests and socialization opportunities are the focus. Team activities increase and vigorous exercise is common. Some risk-taking behaviors become incorporated into exercise and competition becomes more important. Throughout this period it is important to support in your child the importance of effort rather than outcome.

For more information check out my discussion on WJET.

Transitioning to Solid Foods

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Trust your intuition and always error on the side of moderation. A go slow approach is generally best while always maintaining a relaxed environment during feeding times. Choosing a small initial portion and only adding one new food per week is best.

After age 1 year try to keep milk intake under 24ozs per day. This allows your child to have “room” for other foods. A good approach is to aim for 3 or 4 food groups at every meal. Variety is the spice of life. I would consider yogurt to be part of the milk products administered and would decrease the amount of milk given. Solids should be given prior to or in conjunction with milk or water and avoiding sweetened drinks is always best. Milk and water are the best choices. Eat the fruit not drink the juice. This is also a great time to transition to “sippy” cups and eliminate most of the bottles.

When adding new foods always look for GI symptoms such a diarrhea, gas and vomiting or skin rashes. A reaction may take hours or longer to be evident. You know your child best so you are the best person to challenge your child to a new food exposure. Always wait a few days between new food exposures. Most parents wait until 6 months to add fish, peanuts and egg to a child’s diet. New guidelines suggest exposure between 4 and 6 months is safe and may help prevent dangerous food allergies. Always start with a taste and advance slowly. Be cautious about home prepared spinach, green beans, beets, squash and carrots during the first year of life since these vegetables can contain large amounts of nitrates that can lead to anemia. Peas, corn and sweet potatoes are safe choices for home prepared vegetables. Commercially prepared baby foods test for nitrates and are safe. Although the egg yolk is less allergenic than an egg white there is cross contamination so I generally suggest a small amount of scrambled egg being reasonable rather than straining off and discarding the egg white. I also feel a taste of chocolate is reasonable but remember infants have very sensitive taste and new tastes may need to be acquired slowly.

A well balance breakfast should include carbohydrates, healthy fats and protein. A 60/20/20 ratio is reasonable as is frequent small meals since an infant’s stomach is quite small. Rather than counting calories allow your child to tell you how hungry he or she is. When your child slows down allow the meal to end rather than encouraging all prepared food to be eaten. You know your child has been drinking enough when your child’s urine is clear and copious. Remember that vegetables and fruit contain a large amount of water. Do not fear if your child does not seem to be as thirsty as you would expect.

Bon Appetit!

Magic Erasers

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Have you ever wondered why we find it so difficult to forgive ourselves?

“Did you try a magic eraser?”  I shook my head no but remembered seeing some soft white rectangular blocks in a box autographed with a picture of Mr. Clean. “They are out on the porch with all the cleaning supplies,” my wife answered. Pleased with my success I reached into the box and pulled out two pieces of foam each the size of an ivory soap bar. They were soft and smooth and were made of a material you could use to wrap your grandmother’s china during a cross-country move. “How do you use these?” I asked.  “Just run them under water and squeeze out the water.”  Following her instructions I said to myself, “You have to be kidding.”

I took the first one and began to rub it across a white shelf that had been marked by several years of sliding pots and pans. “There is no way this is going to work,” I said to myself.  With several firm strokes the marks vanished. They did not just soften. They were gone. In disbelief I began to use strokes I had not seen since The Karate Kid movie. Each time the result was the same. Every mark vanished. I moved onto cupboard doors, baseboards, the washer and dryer and a mud sink. Mr. Clean won every time. “These things are unbelievable,” I called to my wife.  I actually became gleeful when I saw that the box was still over half full. “You can even rinse and re-use these things,” I said to her with an ever-growing amazement.  “Does everyone know about these things?” “Pretty much,” she answered.  My eyes searched the room as I successfully deported every scuff and stain I encountered. Not once did I fail.

As parents we all leave scuffs and stains on our children.  As the years pass we search for a Magic Eraser to wipe away our mistakes. We sand, paint and remodel in hope of becoming a better parent and become fatigued, scuffed and stained. Due to these challenges parents are often blinded and lose sight of the passion and joy beneath those scuffs and stains.

Parents search for the right proportions of resourcefulness, self-reliance and teamwork. By blending these traits and patterns within a framework of responsibility parents strive to raise a child who is respectful and cooperative rather than obedient. Learning how to care for oneself and for others separates exploration from entitlement.

Parenting is never easy. Every child-rearing marathon is a race across deep hot sand and many obstacles. Some of these obstacles are self-made and others are not. This marathon causes many to become critics, victims, worriers or perfectionists.  Each of these stains and scuffs distract us from our goal, hides our inner beauty and changes the ways we love and live.

Forgiveness is your magic eraser. It allows you to accept and forgive yourself and others for choices made and lessons learned. Forgiveness provides each of us the opportunity to reach out to our children and parents unburdened by the failure of decisions made to again become fueled by love. The next time you see Mr. Clean and the magic eraser remind yourself your future is not yet written. Your future need not be determined by your past but by how you use your magic eraser called forgiveness.

Obstructive Sleep Apnea

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This disorder is both frequent and serious. Numerous health problems are associated with obstructive sleep apnea syndrome (OSAS) in childhood. It is estimated that 2-3% of children have OSAS and the most common cause is enlarged tonsils and adenoids. When obesity is also present the risk for associated health problems is increased further.

The most common cause of OSAS is airway blockage. The windpipe is restricted or collapses when your child breathes in during inspiration.   Enlarged tonsils and adenoids are often the cause and this obstruction occurs during sleep when there is a decrease in body tone and general awareness.  Symptoms can be mild or severe. Usual symptoms include restless sleep, snoring, noisy breathing apnea, paradoxical chest movements, labored breathing and chest retractions and sweating. Some children complain of frequent waking and nightmares.

If the obstruction is nasal then mouth breathing is often seen. This allows your child to compensate for being unable to breathe through the nose. Other children will hyper extend their neck and assume a nose up sniffing position. This often decreases the snoring noises.  Daytime symptoms can include quality of life issues including mouth breathing, hyperactivity, moodiness, sleepiness, and headaches and learning problems. Moderate obstruction can lead to neurobehavioral, cardiovascular and metabolic consequences. Severe cases can lead to pulmonary hypertension, systemic hypertension, failure to thrive and developmental delay.

OSAS is more commonly seen in children who are overweight and in children with small jaws, muscles weakness, craniofacial syndromes or Down syndrome.

A comprehensive history and physical examination by your pediatrician is the first step to obtain this diagnosis. Your child may also need to see a lung specialist (pulmonologist) or an ear, nose and throat (ENT) physician. Further diagnostic evaluations may be needed including an overnight sleep study (polysomnography) and an evaluation of the upper airways either through direct visualization or through X-rays and other imaging studies.

OSAS treatment depends on the cause. When enlarged tonsils or adenoids are the cause then removal is necessary. This involves an adenoidectomy and/or a tonsillectomy. If other structural or weight issues are present then these issues need to be addressed. When surgery is not helpful then treatment with continuous positive airway pressure (CPAP) is often the option of choice.

If your child has surgery and continues to have symptoms then close follow-up and continued treatment is necessary.

The Importance of Praise

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As parents we worry about praising a child too much or too little. Too much praise and a child might grow up spoiled and unwilling to tackle challenging tasks. Too little and a child grows up insecure, overly independent and absent healthy reciprocal relationships.

Praise encourages your child to explore the world.  It is the natural progression after providing secure attachment for your infant. It engenders a sense of belonging and a sense of purpose in your child’s life. Acts of praise make your child feel worthwhile and loved. It is a powerful reward. Your child wants to please you. Acts of praise show your child she is a good person. It allows her to build her self-confidence and self-worth.

Acts of praise give parents the opportunity to show a child it is the actions we choose rather than the outcomes we achieve which are important. Praise allows a parent to focus on efforts not outcomes. At the same time a parent is able to focus on strengths. By focusing on strengths and not weaknesses your child’s confidence and self-worth increase. Over time, your child will learn how accomplishments are appreciated but actions are treasured.

When praise is given in a fashion that supports feedback rather than criticism your child will learn how statements made from a position of power are prone to be overly personal and lead to feelings of inadequacy, anger and frustration in the child.  Effective praise is directed to events and not the person. In this way praise teaches your child the importance of direction rather than criticism.

Praise also teaches us the importance of authenticity and realistic expectations. Children know when we are being real and when we are not. Praise is one of the ways we learn the importance of being true to ourselves and to others. Another reason it is so important concerns realistic expectations for our child. It is very easy for a busy parent to project onto a child expected behaviors that are not developmentally appropriate. By giving appropriate praise each of us is reminded never to forget the importance of our child’s physical and emotional developmental levels.

Courage

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Are you courageous?

I walked into the exam room as the mother said to me, “She has been waiting for you.” I turned to the mother who was sitting next to a home healthcare nurse. The mother and the nurse were smiling. The nurse turned to the mother. “I don’t think I have ever seen her sit so quietly.” The mother answered, “She loves coming here for her visits.”

I walked over to the young woman sitting in the wheelchair and touched her arm. I had first met her about two decades earlier when I diagnosed her with cerebral palsy. She had limited use of her arms and legs and had difficulty speaking and swallowing yet even as a toddler I remember telling her mother,  “Never let anyone tell you she does not understand every word you say.”

“How are you?” I said looking into her knowing eyes. She shook in her chair and said, “Baby” over and over. Throughout her life this was the only word I had ever heard her say. I sat down next to her. “You look great today.” I said.  I turned to her mother. “How are you feeling?”  “Tired, very tired” she answered.  “She loves coming to see you.”  “Have you been getting enough sleep?” I asked.  She shook her head no. “You have to take care of yourself. We can’t do this without you.”  “I know, I know,” She replied. I returned my attention to her daughter who was smiling widely and still saying, “Baby!”  “I think I need to take you dancing in that wheelchair.”  I said to her as I rolled her chair back slightly. She stiffened her legs and arched her head back. “I think we will be able to do some great spins in that wheelchair.” Everyone smiled as the world disappeared and only the moment remained.

Parents of children with special needs are confronted with unasked-for choices. A child is born who is different from other children. A difference filled with beauty and sadness.  Every parent confronted with such an event must make a series of choices.

The first choice is avoidance. There is no greater pain than the pain felt by your child. All parents seek to protect their children from suffering and lack. This genomic drive is imbedded within the psyche of every parent.  This results in parents willing to risk and give everything, including life, for their child.  This drive encourages a parent to live in a make-believe diorama where horror, pain, suffering and loss are cloaked by avoidance.

Other parents move beyond avoidance and choose to alter or adapt their lives in exchange for opportunities for their child.  Such a gift is given with love and seeds hope in the heart of the parent. Happiness is often found as challenges replace opportunities and actions and deeds replace parental dreams and relationships.

A final choice available to parents is to accept and live in the present rather than the past or the future. By living in the now these parents realize their child came into this world having made a choice. A choice to experience a life chosen with foresight and understanding in exchange for the knowledge and experience it would provide. A life filled with emotional and physical difficulty, suffering and sadness yet overflowing with joy from the words and touch of those they love.

When I touched her arm that day, heard the joy in her voice and saw the love in her mother’s eyes, I remembered what her mother and I had talked about almost two decades earlier.  “Her body did not fail her,” I told her mother. “Her cerebral palsy has freed her to live a life where her acceptance has given each of us the ability to replace fear, anger, anguish and grief with our own acceptance and love.”

When she was an infant I held her in my arms and heard the song of her voice.  I knew but had not yet seen. Now, on this day, two decades wiser, my heart opened as we danced under a shimmering light projected through this child and mother both overflowing with life, love and courage.

Blended Families

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Blending is difficult. Roles and boundaries are easily blurred and even the best intentions can be misread. Challenging “normal” behaviors are often interpreted as being due to being part of a blended family when in fact many of these behaviors are often normal and expected patterns. Children test both parents and stepparents. The reasons for a behavior are often buried deep and due to a confluence of issues relating to attachment and fear of being abandoned.

Common behaviors include temper tantrums, aggressive behavior or avoidance behaviors. Separation and divorce cause anguish for children. These behaviors are often a reflection of a child’s own feelings and his or her own perception of self.

Your best approach is patience and not overreacting. Time is a great healer and showing your love and concern in clear, consistent and concise ways is best. Do not take it personally if a stepchild wishes to keep you at a distance. Stay non-judgmental and be sincere and honest in your interactions. Do not hide your feelings and always be clear that you do not plan to assume the role the child’s biological parent.

The sharing of mutual interests and activities will help build a relationship with your stepchild. Allow time to build the trust each of you will need. By understanding the importance of respect and mutual acceptance you will be laying the foundation for future successful interactions. At all times remember you are married to the parent of the child, and you are not married to the child.

Always be ready for episodic flare-ups of mistrust and doubt. The separation and divorce of parents is difficult for children. When a parent remarries fears of separation and abandonment often resurface. If such issues do not lessen with love and patience then formal counseling may be necessary. The earlier intervention is pursued, the less chance toxic stress will infect the entire family.

Magnets

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What do you attract?

The five year old was silent as the nurse walked into the exam room.  The boy’s head ratcheted sideways with every step while his eyes focused on a tray she carried.  I returned to my note and when I looked up the nurse had finished giving the shot.  The boy’s lips and eyes were tightly shut and a wince was fading from his face. His mother reached over and gave him a hug.  As his eyes and mouth opened she said: “I am so proud of you.” They both smiled.

Most parents wonder whom their child will look up to. Will it be an athlete, a scholar, a friend, a neighbor or a media star? What will happen if that person models negative behavior?  Never ending media bombardment makes it easy for parents to neglect and misjudge their own influence while focusing on the influence of others. 

One of the questions I ask a child when I perform a neurological evaluation is: “If you could spend more time with three people, who would they be?” The most common answers are mom and dad. In these words the near limitless power of parenthood is revealed.  A parent is a child’s most visible and influential role model.

It is easy to understand why a child loves and idolizes a parent who sacrifices everything for them. I have always been surprised, however, by the way young children with detached parents often continue to honor, follow and protect their parents. Children are born with a powerful and blinding desire to seek attachment and love. If medical, social, educational or environmental factors prevent this attachment shame and guilt often result.  It is this desire that empowers every parent with the hidden ability to influence a child’s actions and beliefs. Parents and children become magnets with powers of attraction and repulsion. Your words and actions determine the type and direction of force exerted. The absence of attachment drives a wedge between parent and child and with the passing of time this gap widens silently.

Children are born with a powerful desire to emulate parental behavior.  This desire magnetizes both you and your child. These invisible forces pull you together or push you apart. This force of attraction is strongest in the young child and without proper care this force can change from attachment to avoidance.  Love is repelled and lost.

The next time you consider using coercive parenting techniques towards your child remember you are your child’s ultimate role model.  Threats, anger, hostility and demeaning verbal discipline may stop a behavior briefly but such behaviors do not serve as a model for future healthy behaviors.  Always express your inner love with words and actions your child will never forget.

DSM 5 Changes in Common Pediatric Mental Health Issues

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General Information

Published  5/2013.

Lack of physiologic understanding/ categories are artificial.

DSM 1952/ DSM II 1968/ DSM III 1980/ DSM IV 1994/ DSM IV-TR 2000  (text revision)

American Psychiatric Association

Gold standard for the description of mental illness

Insurers and service providers use it to determine eligibility for services

Last update about 20 years ago.

Goal: improve accuracy of diagnosis

Risk: misdiagnosis/ over diagnosis/ medicalization of normal behavior

Changes: 

  • single axis not multi-axis format
  • Simplify use by clinician
  • Age/ gender/ culture are now considered factors when making a diagnosis
  • Just starting the science of psychiatry (3 sections: introduction/ outline of categorical diagnosis/ conditions that require further research)
  • “Unclear what we know and what we do not know”

 

Notable Changes            

Neurocognitive Disorders: Major neurocognitive disorder (dementia): memory impairment is not essential/ ex. frontotemporal dementia has personality changes early and memory changes later.

Mild neurocognitive disorder: mild cognitive decline beyond normal forgetfulness of aging. 1-2 SD below norm on NC testing.

Intellectual Disabilities:  

  • MR is removed
  • Based on cognitive and adaptive function
  • Mild/ moderate/ severe/ profound are eliminated
  • Specifiers are now used
  • Severity is determined by adaptive functioning not IQ score

 

Autism Spectrum Disorder:     

  • Replaces PDD: AD/ AS/ CDD/ Rett’s syndrome/ PDD(NOS)
  • autistic disorder/ PDD(NOS)/ AS are joined
  • Specifiers: language delay or intellectual disability
  • Primary focus is on strengths and weaknesses
  • Mild/ moderate/ severe are eliminated
  • Defined in terms of level of support required
  • New specifier: ASD is associated with a known medical/ genetic/ environmental factor. (ex: FAS/ Fragile X syndrome/ epilepsy)
  • Benefits: improve diagnosis in girls
  • Unsolved: minority access to services delays diagnosis
  • Dual diagnosis of ADHD and ASD now allowed
  • 2 domains:         
    • deficits in social communication and social interaction
    • RR (restricted repetitive) behaviors, interests and activities

 

Social Communication Disorder               

  • new diagnostic category/ outside of ASD
  • Lack RR behaviors
  • Children with severe ADHD and social skill deficits
  • Allows a new group of patients

 

Somatic Symptom Disorders  

  • Somatoform diagnosis is eliminated: this focused on medically unexplained symptoms.
  • Somatic symptom disorder: medically unexplained is not central to this diagnosis. (lowers the risk of alienating patients by imaginary context)
  • Focus on symptoms lasting longer than 6 months that are associated with disproportionate thoughts, feelings and behaviors such as extreme anxiety.

 

ADHD

  • Reverse of most psychiatric conditions that are defined in adults and modified for use in children.
  • Limits social, academic or occupational functioning
  • At least six symptoms from either or both of two symptom domains: inattention and hyperactivity/ impulsivity.  Over 17 years need only five symptoms.
  • Inattention:  Careless mistakes/ difficulty with sustained attention/ not listen/ not follow instructions/ difficulty organizing/ poor sustained tasks/ loses things/ easily distracted/ forgetful.
  • Hyperactivity and Impulsivity:  Not due to oppositional behavior/ defiance/ hostility or lack of understanding instructions.  Fidgets, squirms or taps/ leaves seat/ runs and climbs when not appropriate/ lack of quiet play/ unable sit still/ talks excessively/ blurts out answers/ difficulty waiting turn/ interrupts or intrudes.
  • Several symptoms must be seen in each setting rather than more than one setting involved as the past criteria.
  • Levels: mild (few symptoms and minor impairment)/ moderate (between mild and severe)/ severe (many symptoms and marked impairment in social or occupational functioning)
  • Age of onset increased to 12 years from age 7 years since some issues with inattention do not manifest until a child is older.
  • 314.00 Predominantly inattentive
  • 314.01 Combined
  • 314.01 Predominantly hyperactive/ impulsive

 

Communication Disorders

  • language disorder: previously called expressive and mixed receptive-expressive language disorders.
  • Speech sound disorder: previously called phonological disorder.
  • Childhood-onset fluency disorder: previously called stuttering

 

Specific Learning Disorder    

  • Includes reading disorder/ mathematics disorder/ disorder of written expression/ learning disorder (NOS).
  • Coded specifiers for the deficit types

Resource: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

Joseph Barber, MD