Wednesday, March 29, 2017

What Would Dr. Spock Say, and Does Anyone Care?

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I spent over thirteen hours observing a child today. Tomorrow I'll take my notes and a bit of footage I caught with my cell phone [because the behavior was so unusual that it was easier to videotape it than to attempt to describe it with mere words], share everything with my superiors, and, with their help, devise a plan to curb the most disruptive behaviors.  I could probably come up with the plan on my own, but one of the behaviors was so very disturbing to me that I felt that someone with more qualifications and more authority  than I possess should be aware that it is happening. 

For obvious reasons, I should not discuss specific behaviors I observed. For the most part, this child's acts of misbehavior were mild as compared to what I observed on Youtube this weekend.  It's mostly a matter of common sense in terms of what needs to be done about the behaviors as well. Even though the solutions seem obvious to me, I'm willing to cut the parents a bit of slack; a person loses perspective in a big way when his or her child is involved.

One thing that will have to happen is the "time-out" (or whatever you want to call it) concept will have to be cemented into place. It's a very good idea for parents to implement the "time-out" concept when a child is very young -- ideally before the child reaches the age of two. The logistics are much simpler when the child is smaller. The child I observed today is five and is large as five-year-olds go. It seems unlikely that he will comply right away when he is placed in a designated time-out spot. We could be facing a bit of a marathon.

Part of the idea of "time-out" is that the child needs to stay there willingly and not have to be locked or restrained into place. If it's done as it is intended to be done, the child is only there (once he or she has actually remained in place for the required time) for one minute per year of the child's age. It's only intended as a brief time during which a child reflects on his or her behavior. The problem comes when a child has not yet been taught to remain in the designated time-out spot until he or she has been given permission to leave. It may take anywhere from five to two-hundred or more times of placing the child back into the time-out spot before he or she grasps the concept that the parent is not going to give up and that the child has no alternative but to fulfill his or her time-out.  

The teaching of the time-out concept needs to happen before a child reaches school age, as school personnel have limited means of discipline at their disposal. Time-out, by whatever name it is called, is the primary negative consequence employed by teachers, who have every right to assume that a school-aged child with age-appropriate neurological development will comply with a directive to remain in a specific location for a short designated time. Teachers under the best of circumstances are handcuffed when it comes to disciplining students. If teachers cannot even place students in time-out and expect them remain there, schools will have total anarchy, and nothing of substance will be taught or learned.  

Some children are so strong-willed that they may give a parent difficulty during consecutive time-out sessions, though the first time is almost always the worst. If a parent sticks with the plan, the child - if he or she is at least of near-normal intelligence -- will eventually concede. If the child has outlasted the parents in the past, however -- and usually the child has outlasted the parents in situations where behavior consultants are called in to rectify a situation -- a child may resist all the more enthusiastically. It's usually the parents of that child who will want to throw in the towel on time-outs because they "just don't work" with the child. The problem is that the child's parents believe that nothing works in curbing their child's misbehavior because the child has managed to outlast his parents every single time in his life that they have attempted discipline. Almost any consequence if applied consistently will eliminate undesirable behaviors. It's just that it has to be applied until the target behavior ceases.

Some parents think corporal punishment is the most effective of consequences, but, in reality, it's simply the least labor-intensive method of discipline for a parent to employ. Spanking is great  for lazy parents. The lazy parent slaps a child, then his work is over. It takes a lot more of a parent's time and energy to repeatedly re-place a young child into a time-out spot. When the child is a bit older, it impacts a parent far more to have to enforce a grounding or a removal of video game privileges for the duration of the punishment than it does to smack the child. Loss of privileges also causes the child more displeasure in most cases. With a spanking, the kid has to endure a whack or two, then he or she gets to return to business as usual with full privileges. The staying power of a  well-enforced loss of privileges is, in the long run, a far superior deterrent to future acts of misbehavior than is corporal punishment.

A final thing that will have to be addressed with the child I am helping is that unnecessary rules are not helpful to anyone. A child needs not to hurt or endanger himself or anyone else. He needs not to damage property. A child much past the age of two should be able to be able to be taken into public for a reasonable amount of time -- for the sake of argument, the amount of time it takes to consume a meal --  without  the child creating a disturbance of such magnitude that it interferes with the pleasure of others. A child should comply reasonably well with the directives of authority figures. (This is probably another topic for another day, but authority figures need to keep their directives to a minimum.)

Beyond that, rules are probably unnecessary.  Is the child truly harming anyone by cutting his peas before he eats them? I think it's great that he's eating them at all, whether they're cut or whole. Perhaps a boy likes to dig in the dirt with his hands. Must there be a rule against digging with one's hands, or should he wash his hands when he is finished digging in the dirt and then scrub them thoroughly at bath time? Does a child need to remain at the dinner table for a full forty minutes as parents sip an extra glass of wine? Sometimes rules are arbitrary, and sometimes we ask too much of a child. Sometimes we create our own problems.


Monday, March 27, 2017

Supernanny, Walmart Tantrums, and Behavioral Observations



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     I have one more week here before I go to Canada to fulfill my psych rotation. I'm excited to go, but I don't wish to get ahead of myself. I still have one more important week here. For this week I will remain in pediatric neurology. Tomorrow I'll be in the office in addition to meeting with a behavior consultant. The behavior consultant will ensure that I understand the protocol for an extended behavioral observation. 

     The extended behavior observation will happen on Tuesday. It's not a job I will do as a physician -- I'll have underlings of my own to handle such tasks once I'm an actual physician -- but because it will be my responsibility to direct others in doing this task and because I will make decisions as a physician based on the data I will gather in this task, it's best if I actually perform the task myself at least once. I will have additional opportunities to perform this task and other related tasks if I choose to do my externship in the area of pediatric neurology.

     My superiors have warned me that in doing this observation and in the behavioral intervention of which I will be a part later in the week, I will encounter behaviors that I have likely never witnessed before. I was the "bad child" in my family (in part because my parents didn't know about some things my brother did in high school), buy my badness was limited to very minor back-talking, refusal to eat what I was told to eat in a timely manner, and rolling my eyes. Even branching out into the dysfunctional extended family, children very often essentially did as they were told.  The MD supervising me warned me that I would hear words I've possibly never spoken myself uttered by a five-year-old.
The MD is underestimating me, but that is a subject for another day's blog.

     This weekend I watched videos of bratty children shouting obscenities at their mothers and engaging in many other varieties of unacceptable behaviors. My source was YouTube, which made available a selection of videos ranging from Supernanny to random footage shot by spectators while preschoolers hurled epithets and merchandise at their parents, grandparents, and siblings in the aisles of Walmart. I was appalled at the behaviors tolerated by parents and other care-providers.

     When you have a child who routinely kicks, hits, bites, scratches, and spits at his parents and siblings, how did it reach that point? Didn't parents see it coming when the child was younger and perhaps was only hitting?  I acknowledge that civilizing a human being isn't an easy task, but the parent must have done essentially nothing to stop the behavior in some of the cases I viewed. I'm not necessarily advocating the violence of corporal punishment in response to the violence of a child attacking parents or siblings, but I will say that if it were applied consistently at all, even that would be better than doing nothing. In the 1950's or even early 1960's, a TV program such as Supernanny probably couldn't have been filmed in the U.S. because it would have been difficult to find enough families with truly outrageously-behaving children. The footage actually obtained would have bored viewers to sleep. While children of that generation were far from perfect in every way, the prevalence of parent-attacking toddlers simply wasn't to be found at the time. The single biggest reason for this lack of misbehaving children was probably the fear of corporal punishment. 

     Before going any further with a discussion of the merits and drawbacks of corporal punishment, I would like to first interject that corporal punishment is one thing and abuse is quite another. I will not discuss abusive forms of punishment in later paragraphs; if I mention corporal punishment, it would mean a slap or slaps with the open hand that did not leave marks. Anything beyond that is and always was abuse. Abuse was always pejorative in every sense even when it was tolerated by society. Abuse never helped any child in any way. While society permitted some abusive practices in disciplining children in previous generations, that does not make such practices retrospectively non-abusive regardless of when it happened. Beatings that left marks for longer than ten minutes or so were abusive even if the law did not forbid it at the time. Kicks and punches from parents to children always were and always will be abuse.

     I will suggest that the reasonable use of corporal punishment led, for the most part, to children who were generally compliant with adult authority. What corporal punishment failed to accomplish, however, was to teach children anything about self-governance or why it was that they should behave in certain ways. I'm not sure it's a bad thing for a child to know that in a real pinch, a parent has the right to whack him or her. I suspect that knowledge is what kept young children of early generations from physically assaulting their parents in the way that the kids in Supernanny or in the Walmart footage did. The worst bullies on a playground don't hit anyone who will hit them back just as hard, nor do they hit anyone whose big brother will nail them after school. It's a survival concept that nearly everyone grasps. It is preferable that the survival concept eventually be supplemented by higher-level reasoning skills and development of a sense of right and wrong, but for a time, that knowledge serves its purpose.

     So these parents have children who will repeatedly scratch, bite, kick, punch, spit at, pinch, and slap anyone who comes near them in the midst of their meltdowns, and the parents, who have allowed it to evolve to this point, are now clueless as to how to check the behavior. I acknowledge that anything we see on Supernanny has been edited to, in many cases, allow families' dysfunction to be maximized. Still, the produces of Supernanny didn't put words in the childrens' mouths, nor did they use computer simulations to create actions the children did not actually commit. Anything that a child is seen or heard doing or saying, the child actually did say or do. 

     Over the weekend I saw portions and entire episodes of Supernanny featuring close to 100 different families. Of these Supernanny cases, I recall three families with remotely normal dynamics. One of the "normal" families was the family of Wendy Wilson, who is the daughter of Brian Wilson of the Beach Boys and is herself a singer. Ms. Wilson and her husband were a family of four with two toddler sons until they were joined by twins. (I  don't know how old the episode I saw was.) The family was remarkably functional compared to the usual Supernanny clientele. The parents had a few questions about how to get the toddlers into bed more efficiently and about eliminating pacifiers for the toddlers. This episode would have been boring if someone in the family were not a celebrity. They simply had very little in common with the Supernanny regulars. They were all normal and civilized people.

     There were other two episodes I saw in which I perceived the families as being somewhat mainstream. One of these families had a child with Down Syndrome. The parents struggled a bit with the need for different expectations for their special-needs child, which is a very real problem for parents. How does a parent justify to a young child that his older special-needs sibling isn't held to as high a standard as he is? The supernanny convinced the parents that they weren't being unreasonable in their expectations for their neurotypical children and that they weren't being overly lenient in not requiring the same of their child with significant delays due to Down Syndrome. In the other episode in which the family seemed vaguely normal, I couldn't quite discern why this family with  two adorable preschoolers was even considered for Supernanny inclusion.

     One thing that struck me about the cases with children being horribly abusive to their parents was just how much pain it caused the parents to hear their children scream and cry.  Maybe it's because I'm missing the "caring parent" gene, or maybe it's just because I have not yet had children of my own, but if I had children who behaved as horribly as most of the children shown on Supernanny behaved (in fairness, sometimes there was one child in the family with issues while the rest of the children were at least moderately well-behaved), I would not like those children even if they were my own. Does something happen when a person uses his or her own gonads to make a baby that causes the person to like that baby no matter how obnoxious a child he eventually becomes? There was nothing about the cries of those tantruming children that would elicit the slightest degree of sympathy in me. I would probably want to make them unhappy because they had done nothing to deserve even a shred of happiness. Perhaps I'm a bad person and shouldn't become a parent.

     In any event, the kid I observe on Tuesday will need to pull out all sorts of bells and whistles from his arsenal of behaviors if he hopes to impress me with his badness.


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Their parents will sue Walmart for compensation for the head injuries that occur when they fall.



Saturday, March 25, 2017

kids-with-bizarre-non-names-as-given-names-who mysteriously-grow-up-to-be-assholes syndrome

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Next week I get to go into a home of one of our patients, observe him,  devise a plan to help his parents deal with his most challenging behaviors, and spend part of two days helping them to implement it. Someone else from the office will follow up with the family the following week. I haven't met the child yet, but chance are that I'll like him more than I liked the twelve-year-old boy who grabbed my arm on Thursday because I wouldn't fix the broken video game in our waiting room.

I don't need to like the child, though. I need merely to be professional and to have a desire to help him. Teachers and other professionals sometimes beat themselves up over not liking some children in their charge. A person cannot necessarily control whether or not  he or she likes a particular child. A person can control how he or she acts toward the child, though.  It is the professional's duty to treat the child fairly and even to keep in mind that a person's view as to what is fair to the child may be skewed if the person does not like the child. A person has to try harder when working with a child of whom he or she is not particularly fond.

I've reached a conclusion in observing children in the pediatric neurology office and also while watching Supernanny. I decided to watch episodes of Supernanny on Youtube so that the behavior of the real-life child with whom I must work next week will seem less shocking to me by comparison.  The conclusion that I've reached, which is surely a bit of a broad generalization but at the same time, I suspect, something that is generally true, is that people who give their children highly unconventional names, as in made-up names that rarely make it onto lists of actual names (or even if the names do make it onto name lists, make it there only by virtue of a celebrity child having been given the name, which inspired commoners to use the name as well, granting the non-name a place on a list of actual names) more often than not have children who are not inclined to play by society's rules. The reasons for this are probably as varied as the bizarre non-names themselves, but I'm willing to name two of the most common factors in the kids-with-bizarre-non-names-as-given-names-who mysteriously-grow-up-to-be-assholes syndrome: A) Children with bizarre names are angry about having been given bizarre names that are not real names. This is particularly true if they're boys. I suspect that boys are for some reason a bit meaner to other boys who have strange names. Perhaps conformity is a bigger deal among males as well. In general, girls are typically the gender that learns the art of psychological terrorism with amazing ease, but for some reason girls with highly unusual names fare better than boys with odd names. Years of research back this up. B) (and I believe this to be  the dominant factor) Parents who give their children, particularly their sons, names that are not actually names, often view their children as being highly original and therefore often exempt in terms of the expectation of adhering to norms. They want their children to be different, and they often consider their children to be just a bit more special and more entitled than is than the average child. The same force that motivated the parent to give the child a bizarre name that is not an actual name is at work in influencing the parent not to force too much of society's baggage onto his or her child, because the child is, for want of a better word, just too special for such baggage.

Regardless of whether my factors are at work in the non-conformity of a given child, teachers will tell you that the boys named Wild, River, Royalty, Warlord, Champion, Maverick, Innocent, and Touche' (THAT one looks and sounds a bit too much like douche to me) will be children who think they do not have to follow classroom or school rules. It would happen regardless of how the parents felt about the child having such an entitled attitude, but in most cases, the parents have given tacit approval to the child's attitude.

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Friday, March 24, 2017

We're Losing the War on Lousy Parenting

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The mother of the patient with whom I dealt today will soon be airing her grievances to law enforcement personnel and to judges.




I had an interesting afternoon. In our very last appointment, a rather large twelve-year-old boy became mildly distressed that the video game system in the waiting room of the pediatric neurological office to which I am currently assigned was non-operational. That in and of itself is not usual. The game system was already broken when it was brought to the office waiting room. Its sole purpose in the office is to gauge self-control and frustration tolerance issues in pediatric neurology patients. The twelve-year-old male patient apparently had very little self-control or frustration tolerance.

I walked through the waiting room and out the patients' exit to take a jacket to a patient who had left it in an examining room. As I walked back through the waiting room, the boy, who had been trying in vain to get the game system to work, sprang from his seat and grabbed my arm (not hard enough to leave a mark, for the record. "You need to let go of my arm right now!" I told him in a voice that was simultaneously both quiet and the most menacing voice I could manage. The boy's eyes seemed to get bigger as he let go of my arm and backed away from all ninety-five pounds of me. (I weigh ninety-five now if I keep my shoes on.)

Then Mama Bear attempted to come to the kid's rescue. "If you have a problem with anything my son does, you need to take it up with me!" she bellowed, poking herself in the chest for emphasis as though I otherwise would not have known to whom she was referring when she used the pronoun me -- "not with him!" Another parent in the waiting room grabbed her much younger child and moved away from the twelve-year-old. 

I turned to the kid, pointing right at him and deliberately ignoring his mother. "You need to learn to keep your hands to yourself." He tried to hide his roughly 160-pound body behind that of his mother. I then turned my attention to the mother. "You need to teach your kid some manners. You're running out of time."

The receptionist escorted the other mother and child in the waiting room to an exam room. The doctor came out of his office to ask what was going on. The receptionist filled him in. He stepped back into his office, printed something, then stepped into the waiting room. He gave the mother a list of the other pediatric neurologists in the area and told her she would need to find another practitioner for her son.

Monday, March 20, 2017

A One-Night Stand




I'm not really in a relationship. I'm merely pretending to be. A guy in my cohort wants to dissuade his mother from trying to fix him up with the daughter of her new neighbor, so he's having me pose as his fiance during dinner with his mother tonight. He even borrowed an engagement ring from another member of the cohort whose ex-fiance was roughly as underfed as I am, so the ring somewhat fits me.

It's dishonest, but I feel for the guy. He gets one lousy week off this spring, and he doesn't want to spend it trying to ditch the daughter of his mother's new neighbor. As I understand it, his mother is seeing the neighbor, and they both think it would be charming if my cohort mate and the neighbor's daughter  got together. What they don't seem to acknowledge is that, statistically speaking, even if my cohort mate and his mother's neighbor's (or mother's boyfriend's, although that term doesn't seem fitting when both parties are over 55) daughter meet and hit it off well enough to go on a single date,  at least one of these relationships probably won't go the distance. So if one of the two relationships did actually work out and the parties chose to make a legal connection out of it, two other people for whom it didn't work out would occasionally be thrown together, probably uncomfortably. The same is true regardless of which relationship works out.

My cohort mate says his mother has tried to set him up for dates before, and always with disastrous results. The girls that his mother thinks are right for him, he says, are straight out of the Luther League. He's a Scandinavian who was raised Lutheran.  His parents split up when his father, who was the church choir director, had an affair with the pastor's wife. He escaped it all and wants no part in either parent's social scene.

I don't really care if I'm playing a part in someone's deception of someone else. I also am not worried about long-term ramifications of this scenario. It's up to my cohort mate to explain to his mother at graduation next year why the two of us who were engaged are no longer an item. It's really not my problem. I'm merely helping this one time. I don't expect it to become a recurring gig.

Saturday, March 18, 2017

The Oxford Comma







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https://www.nytimes.com/2017/03/16/us/oxford-comma-lawsuit.html?src=recg&_r=0

The preceding address links to a news story involving a contract dispute regarding overtime wages. It appears that the dispute will be resolved in favor of the workers being paid collectively a hefty sum in overtime wages. at the root of the dispute is the absence of an Oxford comma. Had the comma been present, the meaning of the sentence would have been altered. I'm not a huge fan of grammar and English usage pet peeves, but if I were to become one, the place I would start would be in favor of the Oxford comma.

One reason I chose medicine over lae as a course of study is that I did not want to be involved in writing or reading lengthy missives in which the presence or absence of a comma would be the deciding factor. Attention to detail is necessary in the study of medicine as well, but it doesn't seem quite so nit-picky to have to spend so much time going over a CT scan to ensure nothing of importance is missed as it does to pore over every sentence to ensure that all commas are properly placed. 

I'm a fan of the Oxford comma. When it isn't used, at the very least a reader may have to read a sentence twice to ensure it was correctly interpreted. in other cases, the meaning is clearly altered by inclusion or omission of the final comma before a conjunction in a list.  My own preferences notwithstanding, and whether or not anyone else is or isn't a fan of using a comma before the conjunction in a series, if its omission leaves a sentence open to interpretation, is should be used. In the case of this particular corporation, not using it was sloppy writing at the very least, and it appears that the lack of clarification afforded by the non-use of the Oxford comma is going to bite an employer in the bank account. C'est la vie.