Seven Questions Your Health Care Provider Should Ask Your Teen

Although the average doctor face-time is somewhere around 6-7 minutes with a pediatrician these days, it might actually be possible for the most dedicated among them to squeeze in a few potentially life-saving questions.  Here are seven such queries that help educate and elucidate around issues of relationships, risk, romance and sexuality.

ONE: Who do you hang out with? Tell me about your friend group. (gently opening with relationships and friends...)

TWO: On the spectrum of gay to straight or somewhere between, where would you say you are now?(...recognizing that this is a spectrum and a fluid status....)

THREE: Have you ever had an unwanted sexual experience? Have you ever had a sexual experience you regretted?(.....letting the teen know that the doctor cares and that this is a safe place if and when he/she is ready to talk about it....)

FOUR: Have you had skin-to-skin contact below the waist with another person? That's skin-to-skin contact below the waist with any body parts.  Think about that. (...avoiding altogether the concept of "sex" and getting at risky behaviours and a "spectrum" of sexual activity....)

FIVE: Would you say that your romantic relationships or dates have been respectful? How about safe from STD and pregnancy worries?(...allowing for some evaluation of relationships and permission to discuss concerns about STDs,  contraception,  power imbalances, abusive situations or unhappiness....)

SIX: How do you really feel about condoms? Do you know how to use them?(...recognizing that almost no one prefers them but hey! let's be real...what are the alternatives?)

SEVEN: (for boys): Do you know how to do a testicular self exam?(...healthy bodies are sexy and testicular cancer is a young man's disease)

On a given day I can imagine re-prioritizing these questions or adding others.  But these seven are openers to many dialogues.  It should go without saying that these conversations with teens need to happen in a private setting, without parents present, with the reassurance of confidentiality made explicit and with clothes on.  For all parties, including parents in the waiting room, the benefit of these conversations is enormous and gratifying: healthier, savvier kids; reassured parents; and practitioners who know they have done their job well.
image from blog.timesunion.com via Googleimages.com

Parents Reluctant to Vaccinate Kids against HPV?

As one of the medical providers at Barnard College, I am asked every day by students to be tested for STD's.  When I ask them what tests in particular they have in mind, they often answer "all of them."

We, like most clinicians in this kind of clinic only screen for HIV, chlamydia and gonorrhea. And that is not "all" of the STDs. As a followup question I often inquire whether the student has had the three HPV, often called by its brand name, Gardisil, vaccine.  I have been shocked in the year I have been working there by how often students are not aware if they got the vaccine; do not know what HPV is or say that their parents "didn't want them" to get it. Then I launch into my little speech about how they can make their own decisions now and we have a tutorial on HPV.

Now a new study just released in the prestigious journal Pediatrics sheds some light on this situation.  It shows that over half of parents of teens are not vaccinating their teens against Human Papillomavirus or HPV. And the share of unvaccinated teens has increased even though they are making this decision against the medical advice from their own medical providers.

The three most common reasons for not vaccinating against HPV were:

• my child is not sexually active
• the vaccine is not needed or not necessary
• safety concerns/side effects

These reasons linger and in fact increased over the study period from 2008 to 2010 in spite of scientific, medical and public health advice to the contrary.

So what is HPV vaccine and what do most clinicians who see teens and young adults say about it?

• HPV is the most common sexually transmitted disease.
• HPV is ubiquitous and easily transmitted even with non-intercourse sexual activities (read "oral sex")
• By age 18 over 70% of sexually active adolescents have already acquired HPV
• Their are over 100 sub types of HPV
• Most healthy people will clear HPV from their system through natural immune mechanisms
• BUT, four of the 100 subtypes do not clear spontaneously.
• These four subtypes cause cervical cancer, head and neck cancers, and genital warts
• Men and women, young men and women, and girls and boys are all equally susceptible to infection with HPV
• The HPV vaccine was designed to protect agains the four nasty subtypes of the virus that cause most of the lasting and disfiguring diseases (warts and cancers)
• The vaccine is recommended for boys and girls ages 12 and up
• Finally, the vaccine is exceptionally safe and effective
• PS: it requires a series of three shots and it hurts a bit more than the average immunization.

It is my belief that the marketers from Merck should have called this vaccine "the first shot we have to protect against cancer. " The mistake was in connecting the vaccine with sex, teens and heaven forbid, teen sexuality. This was the cue for Michelle Bachman to get on board with those who talk about the "ravages" of HPV vaccine.  

The denial mechanisms that parents need to stay sane as they dare to think about their teens becoming sexually active in a dangerous world have held them back from making smart decisions about this shot.    We don't' wait until our kids step on a rusty nail to get a tetanus shot.  We shouldn't wait until they are infected or have abnormal Pap smears to give them the HPV shot. Besides it would be too late by then.

Call for an appointment today if your children have not had the vaccine.  At least listen to what experts have to say.  And remember when the eighteen year old comes in to see me in college and is ready to make her own decision--having done some reading, research and chatting with friends, it is often too late for the vaccine to work.

image from news.emory.edu

Talking Teen Sexuality with Parents

I have a date with the Mamaroneck PTA.

"Are you sure you want to talk about that?"
"Can you make it funny?"

And then came the understated undercurrent of advice to make it appropriate for parents of middle schoolers, kids with disabilities and special needs, and moms and dads of high school students, some of whom are about ready to go off to college.

You might watch HBO's Girls.  But you might also think that cannot be your daughter who is having unprotected sex, poking Qtips in her ears and getting sexually transmitted diseases and pregnant.  Even though the demographic of the show is precisely the white middle class, highly educated metropolitan cohort that many of Mamaroneck's students go on to inhabit,  it still is not your daughter.

So here is a preview of what I will be discussing at the PTA/SEPTA meeting on April 29:

• What's new in Contraception?
• STDs: diagnosis, prevalence and prevention
• LGBTQ in our families
• Promoting health relationships for young people
• Tips on raising sexually healthy children
• and---because even though you might think you can talk about "everything" with your children, you (or they) probably won't--the final topic of the evening is:
• Seven questions your pediatrician/provider should be asking your teen girl and boy

You will go away empowered to understand the culture that is not just on TV, to arm yourself with information and to advocate for your children so that they have the kind of medical care they and you deserve in order to prepare them for the terrain they walk today and will traverse tomorrow.

image by dailymail.co.uk from Google images

Moments of Repair

In my effort to return to blogging and posting about teens and young adults and their myriad issues beyond head injury and concussion,  I am publishing the second installment of a wonderfully elegant piece on communicating with our teenage children.




This article which I am re-naming "Moments of Repair" because I think it is such a lovely thought for all of us to hold onto even when dealing with our adult peers was written by a colleague of mine, the clinical psychologist Kenneth Barish.  Dr Barish is Clinical Associate Professor of Psychology, Weill Medical College, Cornell University. He is the author of Pride and Joy: A Guide to Understanding Your Child’s Emotions and Solving Family Problems (Oxford University Press, 2012).  Dr Barish and I have shared experiences over the years with families and kids and his advice is always helpful. He is in private practice in Westchester County, New York.

*********************************************************************************

When parents are often angry and critical of their children, children, in turn, become angry and argumentative, stubborn and defiant. Argument begets argument.  When we argue frequently with our children, children become good at arguing.

Here are some additional recommendations that have been helpful to many families in beginning to turn around vicious cycles of criticism, argument, and defiance:

·      Set aside time, every day, to listen to your child’s concerns.

When we are angry or critical of our children, it is almost always because we have lost patience with them. But we cannot listen patiently - or listen well - when we are tired or hurried; when we are burdened or preoccupied; when we are trying to get things done; or when, at that moment, we are just too angry.  Our children, in healthy development, should come to understand this.

·      Initiate repair.

In every family, especially when we are anxious and frustrated, parents will become critical and may say hurtful things to their children. At these times, it is important for us to take the lead and begin to repair these hurtful interactions.

In these moments, make a deliberate effort to set aside criticism and judgment as long as you can. Acknowledge your child’s or adolescent’s disappointments, frustrations, and hurt feelings, and every small gesture she makes toward cooperation and compromise.  The following advice is important enough to say again:  Tell her what is right about what she is saying or doing before you tell her what she is doing wrong.

Children learn invaluable lessons from moments of repair.  They learn that, although it is not always easy, moments of anger and misunderstanding are moments, and they can be repaired. This may be the most important lesson we can teach our children, the lesson that is most vital to their emotional health.  Disappointments are disappointments.  Bad feelings are not forever.

·      When you need to criticize, criticize thoughtfully and gently.

Children make mistakes.  So do we. Try to be gentle and tolerant in your response to their mistakes, and apologize for your own.  If you are willing to acknowledge your mistakes, your teenagers will more willingly acknowledge theirs.

·      Express appreciation.

Criticism - and the resentment it creates - although necessary in small doses, is a toxin.  Appreciation is the antidote for resentment.

Appreciation is a little bit like oxygen. We can survive with less than optimal oxygen, but we do not survive well.  We suffer symptoms - some visible, others insidious. It is the same with appreciation. Without enough appreciation, we begin to suffer vague symptoms - especially diminished enthusiasm - although we may not know what is causing them. Without this psychological oxygen, our minds begin to divert resources and energy, resources that should be used to pursue interests and joy, into self-protective attitudes - defensiveness and demands. 

Appreciate every effort on the part of your child at cooperation and concern for others.  Simple, genuine expressions of appreciation are often remarkably helpful in softening a child’s intransigence and opening her to collaboration in solving problems.  If we say “thank you” to them, they will more often say “thank you” to us.

·      Give Them Time

In talking with children about any difficult problem, do not insist on an immediate response. Even minor criticisms evoke defensiveness in most children; a defensive wall quickly comes up. Children (and perhaps, especially adolescents) need time to think about, and eventually accept, our instruction and advice. When you bring up a problem, place the problem before your child, ask her to think about it, and then plan a discussion for the following day. You can always end with, “Let’s talk about this again tomorrow.”

 image from nwdentalclinic.blogspot.com 

via Google images

Kobe Bryant on Concussions and Rest

It’s one thing when a state law or a policy that comes down from above says that resting is the best treatment for concussion.  But it’s another when a star player like Kobe Bryant has something to say about it.

Commenting in the LA Times and re-quoted on Slamonline.com, Bryant said of his teammate, Paul Gasol who missed five games due to a concussion:

“I was a little angry with him the other day because he’s coming to practice and coming to the games,’ Bryant said. ‘Stay home. Cut all the lights off. Just rest. Let your brain rest. But he wants to be around [the team]. That’s the type of teammate he is.”

What Bryant is recognizing is that healing from a concussion requires athletes, especially at the NBA level to do something that often runs counter to who they are.  That’s to withdraw from the limelight, the locker room, the home territory with the friends and teammates and be quiet and REST.

According to the basketball blog site TrueHoops, the NBA has gotten serious about concussion management.  Even though the degree and frequency of hits may not be what we see in the NFL, they are implementing a multistep protocol to keep players safe in the short and, maybe most importantly, the long run.  Under the guidance of Dr Jeffrey Kutcher, the program is taking hold.  Kutcher is quoted on Slamonline as saying:  “the policies need to reflect the fact that it’s a team effort to diagnose concussions and look out for injuries, because the injured athletes oftentimes don’t know they're injured.”

 It does seem surprising that we have very little to offer injured players other than vigilance—no medication, no shots (meaning vaccinations), no therapy of any kind.  But as Bryant says: ‘It just takes time. There’s nothing you can do really to expedite it. It’s not a muscle. You can’t massage it. There’s nothing you can do. You just rest.’”

image from hiphopnews24-7.com via Google images

Madeline Uretsky

I have begun to join the interesting community on social networking sites that follows concussions and brain injury. Shortly after launching my twitter account (@concussionguide) I heard from ConcussionMom who is Jamie Stelman Uretsky from Massachusetts. She told me about her daughter, Madeline and wrote this:

“In October, she was the speaker at the 10th annual Brian Injury Association Walk in Boston, and last week, she was a speaker at the Pediatric Brain Injury Conference in Marlborough, MA. She will also be featured in an article for Bay State Parenting Magazine in January. This injury has certainly changed her life, and she intends to have some good come of it for others, so she's become an activist for students with concussions. She truly wants to make a difference.”

Here is Madeline’s story in her own words written for ManagingConcussions.com, the website for my book:

"My name is Madeline Uretsky, and I am a high school student/athlete; I play soccer, ice hockey, and track, am an active member in my school/class, an honor roll student, and a very positive person. In a matter of seconds, all of this changed for me. You never think it’s going to happen to you. 

I sustained a mild concussion in May 2011 when I hit my head on a car door. It was my second concussion on October 13, 2011, that has changed my life. While playing in my high school soccer game, I was tripped from behind, fell on my forehead, snapped my neck back, and hit my forehead again. I knew something was wrong immediately, but I had no idea how serious it would be.

I spent the first 3 months of my concussion lying in bed at home, in a dark room, and on complete brain rest. This brain rest meant that I could not watch TV, use a computer, phone, draw, text, read anything, do any sort of homework or exercise. In other words, I could just sleep and lie in bed.

At this time, my symptoms were numerous and very high on the symptoms scale at the doctor. I had excruciating headaches as well as very sharp pains all over my head, severe whiplash, disorientation, memory loss, extreme fatigue, dizziness, balance problems, trouble following a conversation, ringing in my ears, and I could not tolerate any bright colors, light, or noise of any kind. My sleep at night was erratic and filled with nightmares.

For the first 3 months I went to my pediatrician weekly, and my neurosurgeon monthly, for a symptom evaluation. On a scale of 0-6, I had almost all 5’s and 6’s during those three months of brain rest; I could not believe how awful I felt. I started going weekly to a massage therapist who practices a type of acupressure that helps brain injured patients. I liked going because it was a way to relax myself, even though it was painful. I continue to go on an as needed basis, and also do many other kinds of alternative therapies that have been helpful.

As these weeks turned into months, it became apparent that there was no end in sight for me. I was isolated from my friends and my school, yet I felt so awful that I accepted that there was just nothing I could do about it, except rest, and wait it out. I had visitors, on a limited basis, but I did not even feel well enough to enjoy myself. I was unable to engage in any kind of conversation, and I would randomly fall asleep. There were times that I could not even remember that I had visitors.

I missed almost my entire sophomore year and I am still not cleared for physical activity other than walking. I did catch up with my schoolwork and now I am on a full schedule at school but with accommodations such as extended time on tests. I still have many of my symptoms, but they are less severe. Focusing, processing new information, multi tasking, and comprehending orally are some of the issues I currently have. I am doing much better than I was a year ago, but brain injuries are a work in progress.

I have been lucky to have a great support system of family, friends, and my medical team. Brain injuries can be very isolating and lonely, and I want to use my experience to help others, and let them know they are not alone. Things do get better over time."

Image attached from Bostonglobe.com via Google Images.

Lack of ZZZs May Increase Injury in Teen Athletes

Teens always seem tired, except maybe on Saturday night. As parents of adolescents, we’ve all been there. We encourage them to get sleep to be at their best: to get good grades, be sharp in school and at work, to stay awake and alert playing in goal and even to act polite at the dinner table.

But there may be something more important that comes from enough sleep. That’s an immunization against injury.  A recent study from Connecticut shows that athletes who slept “at least 8 hours per night were 68% less likely to be injured, compared with athletes who slept less. Interestingly, the level of sports participation, commitment in terms of hours of training and practice, number of sports, private coaching or an attitude of “having fun in sports” did NOT correlate with increased injuries. The study was reported in the November 2012 issue of Infectious Diseases in Children. (www.healio.com/pediatrics).

No mention was made of types of injuries but we can be sure that head injury and concussion figure in this data. It’s startling to me when I review ImPACT tests on athletes at school, whether baseline tests or post-injury tests, how often students report 4-5 hours of sleep the night before. So in addition to making them prone to bad moods, inattention and trouble learning, we now can point out that lack of sleep may well have contributed to the injury itself.

All this seems logical to parents who are perennially concerned about teens’ lack of sleep. But this might not be so evident to coaches, certified athletic trainers and athletic directors. Of course, “policing” or encouraging good sleep habits starts at home. But sometimes a student will hear the advice with a more open mind from a mentor on the team.

Image from theylta.com