Adolescent and Young Adult Health

The War and Us

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 31 Aug 2010 22:23:00 +0000

Because my son, Nick, is in The Basic School of the USMarines in Quantico Virginia, I have found myself reading books about the war that I would not even have stopped to look at until recently.

First, I read War by Sebastian Junger who is the wonderful writer many of us admire from his book The Perfect Storm. In War, Junger chronicles a storm of a different sort as he shows us what it is like to be stationed for months at a forlorn outpost in Afghanistan with a small platoon of bored, lonely and confused soldiers. This is a story of the agony of waiting, of sitting out their tour of duty in a devastated and uncertain area.

The next book I read is The Good Soldiers by David Finkel that recounts his eight months in Iraq while embedded with soldiers during the surge. A reviewer on Amazon.com summed it up this way, better than I ever could:

It's not easy to read. It's not fun. It always seems like the audience wants these types of books to be either blatantly anti-any-war polemics, or rah-rah, wave-the-flag screeds. Iraq was neither of those places. It wasn't anything other than the worst place on earth, with a lot of bad things happening, and everybody telling a lot of funny stories while they were hoping to get home okay. Nobody really remembers or considers the soldiers who had to go out there, into that fight. They think they do, but they don't. This book will help you understand; oh, will it ever.

I can only tell you that my personal reaction to these Up-Close-And-Personal accounts went deeper than just the read. Yesterday when I boarded a plane to fly home after vacation, I saw a very young soldier in army camouflage seated in the bulkhead seat in first class. Some spirit possessed me to lean over to him as I passed and say "thank you for whatever you do." As he smiled at me and thanked me in return, I recognized some person in myself that I was not familiar with until this summer. That's a person who used to think there was some pathological weakness about a US soldier, especially someone who would have been to Vietnam. As the soldiers in these two books show, these warriors are our very own boys and girls-- brave, adventurous, fit, idealistic, damaged, funny, talented, and scared.

I wish I could believe that the current drawdown and return of our troops meant the end of something. I fear it will be just a new phase, maybe even more removed from our daily lives, even more inaccessible to our understanding. Bravo to Junger and Finkel for exposing the harrowing, disconcerting and unsettling inner workings of this war in writing that is gripping and has the ability to change us.

Lessons from the Garden for Parents

noreply@blogger.com (Ann Engelland, M.D.) — Mon, 23 Aug 2010 11:43:00 +0000

Back in the Spring I bought those familiar little spindly plants in a four-pack at the local nursery imagining that I would enjoy a few meals of sophisticated sauteed zucchini blossoms stuffed with goat cheese.
But now three months later, my plants are almost waist high, the leaves as big as a t-shirt and the blossoms usually forgotten under a jungle. What lies beneath is a zoo of zucchini that are proliferating out of control. Just when I think I have corralled them and harvested them and sent them on their way to be pickles, fritters, frittattas, parmesans, breads, grilled side dishes, and ultimately compost, I take one more gander and there hiding below me is one more. Bigger than the last ones, or more deformed, or even in the shape of conjoined twins, or slightly orange, or completely rotten and falling apart. How come I missed this one or that? How did it grow to be this way right under my watchful eye? All I did was plant and wait. And here is a gaggle of ZOOKS!

Had I pruned more, harvested more blossoms, pinched back the foliage, been more watchful, applied more discipline, would it have made a difference? Would it have produced a different crop of perfectly shaped, predictable, tasteless, uniform and dullard veggies for me?

You get the idea, anyway. We plant, we sow, we harvest, we marvel. At the uniqueness, the humor, the variety, the troubles, the stealth, the versatility, and the inexplicable offspring that result from our love and labor.

On Your Marks, Get Breakfast, Go!

noreply@blogger.com (Ann Engelland, M.D.) — Sat, 21 Aug 2010 12:59:00 +0000

Looking for a great way to start the day once school begins? Everyone knows that breakfast is key. Nonetheless, when I see students in the mornings for sports physicals, or when I talk with patients in my office, I am struck by how frequently they confess to never eating breakfast.

I am seldom accused of being a helicopter parent and strongly believe in kids' independence and self reliance, but I think parents can and should go a long way to making breakfast happen in the morning. It can be as simple as a bowl of cereal, but there are many other quick, fun, delicious ways to start the day. Since I drive my kids to school, I frequently pack a small picnic basket (it's literally a small basket) with foil-wrapped warm goodies, a water bottle of milk or hot chocolate, and napkins.

Although it does require a bit of extra time on mom's part, the rewards are huge, and the effort is well worth it. Here I share with you my recipe for breakfast bread which comes to mind right now because I have some monster zucchini in my garden that need a destination. Breakfast bread can be made on the weekend and can last the whole week (in theory anyway--you'll see, it's a real hit.) It is highly nutritious, easy to slice and can be supplemented with butter, jam, nut butter or cheese. My group tends to like it just plain.

Breakfast Bread Recipe

Makes two 8-inch or three 6-inch loaves
Ingredients:

5 eggs
1 cup oil (safflower or canola)
1 TB fresh lemon juice
2 tsp vanilla
3 cups flour (half whole wheat, half white)
1 ½ cups sugar
2 TB cinnamon
2 tsp baking powder
2 tsp baking soda
1 tsp salt
2 ½ cups grated veggies (zucchini, carrot, squash, apple, in any combinations)
½ cup chopped walnuts (better if roasted before adding)
¼ cup raisins (better if soaked in OJ or even water)

Method:
Prepare loaf pans: spray with oil and coat with demerara (coarse) sugar. Pat to empty. (This gives the breads a sweet, crunchy crust that also acts to keep the bread moist.)
Preheat oven to 350.
In large mixing bowl, beat eggs, oil, lemon and vanilla until foamy.
In separate bowl, sift flour, sugar, cinnamon, baking powder, soda and salt. Mix in veggies, nuts and raisins. Gradually add egg mixture, beating until smooth, but not over-beating. Pour batter into pans. Sprinkle cinnamon and coarse sugar on top of batter.
Bake about one hour until tester just comes out clean. Cool a bit, then invert carefully, and continue cooling.
May be wrapped in foil and kept in refrigerator or sliced and frozen.

Watch here for more breakfast options. Soon it will be a happy habit!
image credit

Guys Get a Turn at STD Prevention Too

noreply@blogger.com (Ann Engelland, M.D.) — Thu, 19 Aug 2010 11:18:00 +0000

HPV or Gardisil is now approved for boys and men. Over the past 6 years we have been vaccinating girls and women, and now boys and men can be on an equal footing with this virus. It is now recommended for boys and men ages 9-26.

HPV, or human papilloma virus is a ubiquitous virus, easily contracted through intimate contact or touching that does not necessarily involve intercourse. "Outercourse" and oral sex are easy ways to pass HPV among partners, friends, friends with benefits, etc. You get the picture.

We know that over three quarters of people have been exposed to HPV by the time they are sexually active for a short period of time. We also know that most types of HPV in most people can be disposed of by our amazing immune systems. However, there are certain sub types of HPV which we know can wreak havoc and are not so easily gotten rid of. The most frightening consequences of these infections are genital warts and cervical cancer.

Genital warts are not pretty. I chose not to display images of them but you can see some pretty nasty pictures of them here. People might remember from health class that genital warts can be contracted by skin to skin contact outside of the areas protected by condoms. Hence the advantage of the HPV vaccine.

Downsides to this vaccine? It is expensive as these things go;but my brief investigation has taught me that most insurance companies are covering it. They know how much treating one case of genital warts can cost and they are only measuring the financial costs, not the emotional and psychological ones ("You gave me WHAT?"). In addition to cost, immunization involves three shots over a six month period and truth is they hurt a bit. But hey, nothing compared to having a wart burned off the private parts.

Ask your doctor about HPV vaccine. Or contact my office.

Money and Mental Illness: how much does it matter?

noreply@blogger.com (Ann Engelland, M.D.) — Thu, 12 Aug 2010 14:30:00 +0000

Today Lisa Belkin published an article in the New York Times which profiles some of the life of Millicent Monks, the grand niece of Andrew Carnegie. Monks has just written a book called "Songs of Three Islands, a Story of Mental Illness in an Iconic American Family" and Belkin's interview with Monks is a poignant story of a woman's attempt to explain her history and her legacy to herself.

As interesting as the interview (and probably as interesting as the book itself) is the conversation on Ms Belkin's blog, where readers (including myself) are weighing in with personal anecdotes and reactions to this story. Many, of course, are noting that the disabled Monks/Carnegie clan can hole up on beautiful, remote and private islands and have round the clock caregivers if they need and want them. Such options for daily care are not available to many and in our current dysfunctional health care system, it is difficult for many even to get the therapy or medications that they need for proper diagnosis or to keep their illness in check.

However, it is worth noting that much of the misery of family members in this situation arises from the reluctance to seek treatment, the aggression, the hostility, and the loss of motivation that is inherent to some mental illness itself, particularly borderline personality disorder which appears to have afflicted some of Monks' family. No amount of mothering, management or even money will dissolve these enduring difficulties. No amount of self-flagellation or questioning will really help the strong, healthy survivors in the family to carry on.

But understanding mental illness and genetics can sometimes help create the cushion that is necessary to protect oneself. The efforts of Monks and Belkin might serve to encourage more of us to explore the family tree and grow in our knowledge and compassion.

Puberty Hits the News!

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 10 Aug 2010 16:09:00 +0000

First graders with breasts? Third graders just mastering their multiplication tables also managing menstruation? Anecdotal reports from school nurses and my experience as a district physician have been calling attention for a while to what appears to be the earlier onset of puberty in early elementary years, especially among overweight girls.

So what is going on? A study reviewed all over the news yesterday but published in the American Academy of Pediatrics journal Pediatrics, showed that in fact the onset of puberty for Hispanic and black girls is not much earlier than reported in 1997 but that for white girls the onset does appear to be dropping to age 7 or 8. The reasons for earlier development are not clear. Pudgy girls appear to develop signs of breast development earlier, but in a 2009 Danish study girls were developing earlier whether overweight (measured as BMI) was a factor or not.

Researchers are postulating and concerned that some other factor in our environment, such as the chemicals in many of the ubiquitous plastics, may be disrupting the natural endocrine systems of our young girls. Further studies will need to be done to determine how this might actually happen and whether it is true in early bloomers.

In the mean time, what should we do?

As the lead author of the Pediatrics study, Dr. Frank Biro, suggested in an interview with the Los Angeles Times "...for younger children and the tweens, they should probably live a little bit greener. People could eat together as families — not avoiding fast food, but minimizing it to once a week — and families could engage in regular physical activity." Managing weight, living "green" and keeping the family meal might all serve to protect us from the risks of overweight, bad chemicals, and stress.

It's amazing how frequently it comes down to this simple bit of advice, best encapsulated by Michael Polan: "Eat real food, not too much, mostly plants." And I think I would add that we should avoid drinking, eating, and microwaving out of plastic containers until we have more information.

image credit: Google images

Workshop for Middle School Girls on Relationships

noreply@blogger.com (Ann Engelland, M.D.) — Wed, 04 Aug 2010 18:13:00 +0000

Queen Bees, Wannabees, Bullies, Friends, Best Friends Forever!
As our youngest teens and tweens head to middle school, some of them need tips, advice and coaching on handling the new and strong social relationship challenges that will meet them.

To help with the transition we are announcing a three part series of workshops for middle school girls, grades 6-8. The groups will be led by Jenifer McLaughlin,a social worker with vast experience leading groups in schools who is now sharing my new office in White Plains.

The series looks like this:

Tuesday August 31, 5:30pm:
Transitioning (fitting-in versus being yourself)

Tuesday, September 14, 5:30pm
Understanding peer relationships(why do kids act that way sometimes?)

Tuesday, September 21, 5:30pm
Navigating Social Media (Getting the most out of Facebook and the Internet)
Girls may choose to attend one or all three sessions. Each session will cost $10, last one hour, and be held at the office in White Plains. Small healthy snacks will be available.
Please RSVP to 698-5544 or email engellandoffice@aol.com

image from www.wondercomments.com

Book Review: Girls on the Edge

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 27 Jul 2010 16:34:00 +0000

From time to time it is valuable for me to browse the aisles of the library or bookstore to see what is new on the "parenting" shelves. Girls on the Edge:the four factors driving the new crisis for girls by Leonard Sax, is a fresh look at some of the problems I see in my office every day. Sax who is a family physician and a psychologist singles out four issues that he believes contribute to what he sees as an epidemic of angst and an ill-defined sense of self among US girls. These four are:

confusion over sexual identity or how girls are confusing sexuality with premature sexualization
the cyberbubble or how excessive social networking replaces real friendships
obsessions or how the pusuit of thinness, a fit body, or other notions of perfection lead to disaster
environmental toxins or how chemicals in our midst may be contributing to early puberty and sexualization.

To me this is a waste basket of current hot-button issues, and the book moves quickly from interesting and helpful observations to unproven speculation. One strong aspect of the book is Sax's discussion of the impoverished souls and spiritual lives of many teenage girls. This is a common theme among the prolific evangelical Christian writers for parents, but it is interesting to see Sax handle similar issues from a more ecumenical perspective. He discusses the "anorexia of the soul" of many of the driven, over-achieving, stressed and fragile girls he describes.

I would give this book a Bminus, but would say it is worth a quick read (from the library) and may galvanize parents to be more and more aware of the cultural pitfalls that await teenage young women.

"Meet my Sister, Ana Rexia"

noreply@blogger.com (Ann Engelland, M.D.) — Wed, 21 Jul 2010 21:06:00 +0000

In Spring and Summer it sometimes feels to those of us in adolescent medicine as if patients with anorexia, bulimia and other eating disorders simply come out of the woodwork. These patients are enormously consuming of time, energy, effort and empathy, not to mention their parents' funds. Many of them take months if not years to recover and during this time their parents are often forced to focus on the patient to the exclusion of themselves and their other children.

In the Journal of Adolescent Health this Spring, four clinicians from Toronto Sick Children's Hospital conducted a survey to evaluate the experiences of the siblings of twenty siblings of adolescents with an eating disorder (AED). Following are quotations from their interviews with these 10-18 year old siblings that illustrate some of the key themes they discovered. Anyone who has lived with a friend, child or sibling with ED will recognize the issues:

the struggle to understand:

"Yeah it's like, when people are saying 'what is wrong with those people;why don't they just control it', you feel kind of defensive but you're thinking the same thing."

acute awareness of ED behaviors and thoughts:

"I hear (people saying)'I'm fat' a lot more than I used to and I hear 'I need to go on a diet'...a lot more."

challenges in understanding non-eating-related obsessive behavior:

"When she is ready to go to school, she would tap the pencil on the table. When she's brushing her teeth she has to touch the tap. Once I tried to stop her from doing this and she said, 'no I have to do it.'....Why do they do those things?"

increase in family conflicts and arguments:

"My parents fight if she doesn't eat and she doesn't want to eat. So it's kind of weird because all you hear is yelling and stuff just because she's not eating."

compassion and concern for the AED:

"...you can't not think about it. How can you not think about it when someone who you love is just suffering?"

overwhelming sense of responsibility for the AED:

"...I blamed myself for that. I don't know, I just thought 'what did I say?' or 'what did I do that made her feel she wasn't good enough?...Maybe I should not have said, 'those pants are too small."

pervasiveness of the ED in all aspects of the siblings' life:

"sure it does affect the way I see myself and it does affect the way I see the world; the way I see my sister, our relationship; how we used to talk and how we used to laugh. We don't do that as much anymore."

The conflicts, pathos and compassion in these comments is often forgotten in the intensive programs organized around the AED. As with any sibling of a chronically ill patient or of a special needs child, their special concerns need to be elicited expressly since they are often left out or left home while the parents and patients' needs are addressed. What this study shows is that these collaterally affected siblings could be some of the strongest allies in the therapeutic team. But it's clear that we need to specifically address their own needs too.

photo credit: www.hypericum.wordpress.com

Extreme Sport/Extreme Heat

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 20 Jul 2010 02:03:00 +0000

These days you hear bits of advice everywhere about staying hydrated and exercising in this hot and humid environment. So here is a bit of advice I solicited from my son, Justin Merolla, who completed the New York City Triathlon yesterday.

For those who don't know, a triathlon means the athletes complete a 1,500-meter swim(in the Hudson River), a 40-kilometer bicycle ride and a 10-kilometer run, ending in Central Park, all executed as quickly as possible, moving from one event to the next in a seamless, organized way.

The photo at the left is Justin running in the New York City triathlon exactly one year ago when it was 97 degrees at 11 am! Yesterday was barely different. So from someone who knows and has trained extensively and intensively are some words of advice on hydration. This advice holds especially for endurance athletes but any tennis, football, soccer or field hockey player who is training now (or later in August when this weather is even more common) should listen up:

there IS such a thing as drinking too much water-hyponatremia (or a low concentration of sodium in the blood can be potentially lethal).
hydrating properly does not only mean 'drinking water' - it also means replacing salt lost through sweat (sodium and potassium). One way to tell if you sweat a lot of salt is simply to compare the taste of your sweat to the taste of tears. Hmmm (hard to do).
cold drinks are better - most of the calories burned during exercise go towards body temp regulation, especially in July!!! Drinking cold drinks will bring down the core temperature faster and preserve internal body fluids which otherwise would be lost in sweat, the body's cooling mechanism.
hydrate to prevent dehydration - which is self explanatory, but by the time you feel thirsty, you're already in trouble
you sweat more than you think - you can lose up to 1 liter of sweat per hour during exercise.

Any coach, trainer, player or parent who thinks it's ok to overdress (eg in football gear) and decrease the ability to cool by sweating should be advised of his or her error. When sweating profusely an electrolyte drink such as Gatorade is the way to go.

The human body can adapt to incredibly harsh conditions. But there is no substitute for training, nutrition, focus and willpower. And then those shoes from JackRabbit in New York!

Please send up three cheers for Justin's accomplishment!

A Doctor Takes a Look at Bad Kids

noreply@blogger.com (Ann Engelland, M.D.) — Wed, 14 Jul 2010 21:53:00 +0000

Ghetto parenting? Ouch.

Apparently the Chicago Sun-Times writer Mary Mitchell who is African American has caught some flak for her recent article about poor parenting. “Ghetto Parenting Dooms Kids: Deck Stacked Against Those Who Were Raised in the Streets" describes horribly poor parenting such as leaving kids with neighbors so that you can go hang out on the street or cursing at or around kids, or brawling with your spouse. These behaviors are obviously not limited to the African American or the urban/ghetto community and for this perceived assumption, Mitchell has had some serious feedback and scorn. It makes common sense to most of us that this kind of parenting is likely to lead to unleashed kids with school troubles and ultimate failure.

I am intrigued that in the New York Times this week, Dr Richard Friedman wrote about good parenting that results-in spite of best efforts- in offspring who behave as "bad seeds." His article poignantly tells of his professional experience with a family whose son just turned out "badly" in spite of what seemed to be "good enough" parenting and a loving environment.

Even though Friedman's article is encouraging and expiating for the thousands of families who are pained by the antisocial, disruptive or even criminal behavior of family members, Mitchell's nearly simultaneous article reminds us of the balance of nature and nurture. In the end we must be humbled by our childrens' success as much as by their misfortune or mistakes. How we adapt, how we carry on, and how we keep our balance without punishing ourselves or renouncing our ongoing responsibilities to ourselves, our partners, and our other children is what really matters in the end.

photo credit: http://www.independent.co.uk/multimedia/archive/00147/pg-14-teenagers-ala_147614s.jpg

Shame on them!

noreply@blogger.com (Ann Engelland, M.D.) — Mon, 12 Jul 2010 20:18:00 +0000

Just when I was thinking about which subject to blog on this afternoon I got a call from a patient. She is twenty and after a year of severe anxiety attacks and many ER and office visits, she has been stable and working at a well known sandwich chain.

She called me because her health insurance is terminating since she is no longer working "full time." "How many hours are you working?" I asked. Turns out she is working thirty eight hours a week, and they won't let their employees work any more because "Guess What?" They would be obligated to pay health insurance!

My anemic suggestion to my patient was to try to see if she can be covered under our state health insurance plan since she is not 21 yet. I'm not optimistic. It seems to me that when corporations want to hold on to money that they should be spending for the welfare of their employees (in the case of my patient) or their clients (in the case of insurance companies) they do a really good job of not paying out.

There ought to be a law. Laws are needed when people and their companies don't do what is right on their own. It's no wonder young adults can't move out of their parents' homes. They simply cannot afford it. Shame on someone.

The End of Men?

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 06 Jul 2010 22:53:00 +0000

In this summer's issue of The Atlantic Hannah Rosin makes the case that we are close upon a major change in the roles women and men play in our world. Armed with facts such as "according to the Bureau of Labor Statistics, women now hold 51.4 percent of managerial and professional jobs--up from 26.1 percent in 1980...and (women) make up 54 percent of all accountants and hold about half of all banking and insurance jobs" she describes a "role reversal" that is troubling even to a feminist from the 70's.

There is a change afoot that Rosin argues is primarily a fundamental shift in the economy. She notes that more mens' jobs have been lost during this recession. Traditional male jobs--construction, manufacturing, and finance are slipping away. Rosin argues that women have better communication, multi-tasking and team working skills. These are all skills that are prized now in the era of Internet transactions and rapid global information exchange and business.

Unfortunately she paints a gloomy picture of women ruling the world and the home, leaving incompetent, lazy, unmotivated men in their dust. As the mother of young men and the doctor to many young men and women, I have absorbed Rosin's ideas and pledge to look with renewed commitment at ways we can bring the boys, young men, and men along on this journey. Maybe women are temporarily better suited to the challenges of our new world but let us continue to believe that this pendulum shift of power and influence will eventually bring all of us to a happier middle ground for all.

Who is this brave young woman?

noreply@blogger.com (Ann Engelland, M.D.) — Mon, 28 Jun 2010 19:59:00 +0000

Meet Constance McMillen, an 18 year old from Fulton, Mississippi who has made headlines all over the country because she fought back. After she announced that she wanted to attend her high school prom with her girlfriend--and wear a tux to boot--the school cancelled the prom. The ACLU got involved and Constance pretty much became a pariah in her small town.

But she is a heroine to a wider world which includes Mayor Bloomberg who marched with her in the Gay Pride Parade in New York City this weekend and Ellen Degeneres who awarded her a $30,000 scholarship for college and to President Obama who hosted her at the White House.

To listen to her during interviews is to marvel at her poise and her grace. Her message is simple; it is wrong to discriminate in this way.

For great photos of the riotous, uproarious and joyous Gay Pride Parade in New York City click here. Constance's presence at this annual tradition just goes to show that the struggle is not over for many.

photo credit

Teen Smokers: Can You Really Quit?

noreply@blogger.com (Ann Engelland, M.D.) — Wed, 23 Jun 2010 18:27:00 +0000

How quickly does a young teen smoker become dependent or "addicted?" It turns out very quickly. In a new article in the respected journal Pediatrics by Doubeni and colleagues from Massachusetts a remarkable study shows that even monthly puffs can quickly lead to a risk of developing dependency.

The researchers followed over a thousand sixth graders in 6 Massachusetts schools with three confidential interviews per year for four years. Of note is that of 1246 sixth graders, 370 had inhaled from a cigarette at least once.

Dependence follows a pretty typical course and begins, sometimes after the very first cigarette. The sequence is as follows: a strong desire for a cigarette followed by a sense of dis-ease when cigarettes are not available (called "withdrawal") and then followed by a sense of being "addicted" and unable to control use. As the symptoms intensify, the frequency of use accelerates in order to satisfy the cravings and treat the increasing withdrawal (feeling irritable, restless, anxious, and having difficulty concentrating). This feeds a vicious cycle of tolerance (a hallmark of addiction where needs are only met with increasing doses of the drug) and more symptoms of addiction.

What this study shows is that even relatively infrequent and intermittent use of tobacco can promote symptoms of dependence very quickly in young people. Parents, teachers, doctors and students need to know this and begin to recognize the early symptoms of dependence and encourage stopping even the most casual nicotine exposure.

photo credit: http://news.bbc.com

Guns or Roses?

noreply@blogger.com (Ann Engelland, M.D.) — Fri, 18 Jun 2010 11:26:00 +0000

Maybe it was wrong to forbid him to play with guns. At the time it seemed like the right thing to do, like not hitting or spanking the way my own parents were raised. Sure I was a byproduct of growing up through the sixties, although I was only a flower child til the flowers in my hair wilted.

Of course I realized it was futile when he started telling stories out loud to himself at the age of two that were audibly peppered with explosions and pops and all manner of violent imaginations. And then when he chewed his ginger cookie into an unmistakable pistol it should really have been clear.

But I stuck to my guns. No guns, not even the historic model of a bayonet from Williamsburg.

And he grew into the gentlest of sons, attentive to his younger sisters, adoring and admiring of his brothers. Able to strike up a conversation with anyone, empathize and actually go help tsunami, hurricane, and earthquake victims around the world.

So how strange to flash forward to this week when my 26 year old son was commissioned as a second lieutenant in the US Marine Corps at a small ceremony in a lush, flowery corner of Central Park. How odd to see him walk that particular way, stiff and serious, poured smartly into the dress blues and the impeccable white pants. I briefly thought of pretending it was Halloween but couldn't. This was his moment, the culmination of years of wishing, convincing me, and training for this moment.

However much it makes sense that this ragged environmentalist has become a counter-insurgency advocate; however much I admire his physical and intellectual accomplishment, it's still hard to hand over the first born to a power greater than us and worry that the bravado or incompetence or marksmanship of someone else could some day take him out.

For now, worry trumps pride, but I'm trying.

photo credit

Hosting an After Prom Party? Listen up

noreply@blogger.com (Ann Engelland, M.D.) — Fri, 11 Jun 2010 13:15:00 +0000

My dental hygienist loves to talk. Maybe that is part of the job description, but I don't think she usually expects the patient to burst out laughing from her stories and leave the floss dangling.

Yesterday she told me about a friend of her son who is a cadet at West Point. The friend's mom generously hosted a Memorial Day party at her house for some of his friends. She didn't really know that the entire baseball team would arrive for a sleepover and pool party. When she decided to go to bed she made rounds of the party and discovered at least one cadet who had had too much to drink. Wisely, she told one of the friends: "Listen to me, I am holding you responsible for this young man. I do not want to find a body in the pool in the morning." The response? The well trained, "Yes, Maam." I don't think a salute was included.

When she got up early the next morning to a very quiet house, of course the first thing she did was go check the pool . She found the sleeping cadet she had spotted the night before upright in a lounger sitting poolside and duck taped to the chair.

Classic novels to better understand your teen

noreply@blogger.com (Ann Engelland, M.D.) — Wed, 02 Jun 2010 18:42:00 +0000

Parents of boys are no strangers to the commonly reported facts that boys are not as engaged as their sisters in school, that girls' admissions to selective Manhattan nursery schools outstrip boys, and that there are more women than men graduating from most colleges and universities. Along comes a novel way to approach understanding teens, and boys in particular.

David Reinstein, LCSW, recently reported on a list of books for parents of teens to read in order to better understand adolescents. What makes this list refreshing is that it is a list of NOVELS, not How-To Parent guides. "Ten Best Books of Fiction for Parents of Teens to Read" is a brief review of ten classic stories. Except for one, they are all about boys. Here is the list, minus his instructive annotations.

1.Lord of the Flies, by William Golding (1954)
2.Huckleberry Finn, by Mark Twain (1855)
3.The Catcher in the Rye, by J.D. ASalinger (1951)
4.1984, by George Orwell (1949)
5. Invisible Man, by Ralph Ellison (1952)
6. Animal Farm, by George Orwell (1946)
7.The Naked and the Dead, by Norman Mailer (1948)
8.On the Road, by Jack Kerouac (1957)
9. The Adventures of Augie March, by Saul Bellow (1953)
10. The Call of the Wild by Jack London (1903)

I would say this is a Guys' List of Classic tales. I wonder about two aspects of it:
What would the list look like if we wanted to teach boys compassion, patience, tolerance and humility? Or do these stories do just that?
And,
What would the list look like if we wanted to teach girls about physicality, bravery, adventure and spirit?

It's always a good idea to reach out to the experiences of others to understand our children. The notion of reading novels to plumb their psyches is nothing new to an English teacher but it's a wonderful notion for parents.

Let me know if you have other books to add to such a list. Who knows? Maybe it's the start of a book club.

Just a bump on the head?

noreply@blogger.com (Ann Engelland, M.D.) — Mon, 24 May 2010 14:04:00 +0000

My heroine from last week is a fourteen year old soccer player from Virginia who sustained a concussion--one we would have previously considered "mild"- five weeks ago. Sarah Rainey told the congressional committee that has previously seen the NFL and a host of medical experts testify: "I sometimes now have to use a calculator to do simple arithmetic." She made it painfully clear that head injuries might appear insignificant ("dings" in old parlance) but that the seriousness and consequences of such an injury might be quite subtle and interior to the patient.

After relatively minor head injury, difficulties with math are legion, not to mention emotional instability, memory dysfunction, and slow processing speed. Some teens will describe that their minds feel as if they are on dial-up instead of DSL. Hard to get through an SAT with that sort of problem. Because these symptoms are so subjective and depend on the student reporting them, the entire diagnosis can be missed. Add to that the pressure to get back to the game from coaches, teammates, parents and friends, and it becomes even harder to protect concussed brains.

One thing Sarah Rainey boldly spoke about on May 20 was the notion that sitting out a game or two will be enough. Before the august panel she argued about the Centers for Disease Control's

concussion slogan 'It's better to miss one game than a whole season.' She went on to say according to the New York Times report of the hearing: "I understand their intent, but I think they minimize the seriousness of concussions by making it sound like you just need to take a game off and then you'll be good to go."

Having seen a number of patients in the last few months who have truly been sidelined by concussions with marked behavioral, academic and medical consequences, I can only hope that these public reports will help to educate our coaches, parents and students about the subtle and important nature of this issue.

Watch Sarah Rainey here as she recently testified before congress about her experience with a concussion. Here on Youtube

Predictors of Internet Addiction

noreply@blogger.com (Ann Engelland, M.D.) — Mon, 17 May 2010 18:38:00 +0000

Seems the problem of internet overuse and addiction is a global one. A recent prospective study in Taiwan published in the Archives of Pediatric and Adolescent Medicine in 2009 showed that two characteristics could predict the seventh graders who would become addicted to the internet when screened two years later. These characteristics are Attention Deficit Hyperactivity Disorder (ADHD) and hostility.

As described in Pediatric News, internet addiction is characterized by a "preoccupation, uncontrolled impulses, more usage than intended, tolerance, withdrawal, impairment of control, excessive time and effort devoted to the Internet, and impairment of decision-making ability.

The researchers, working under Dr Chih-Hung Ko, followed over 2000 seventh graders in order to determine that ADHD was the strongest predictor of Internet addiction among girls and that hostile boys (defined by the Buss-Durkee Hostility Inventory--DO NOT TRY THIS AT HOME!) were more likely than others to develop the addiction.

Dr Ko hypothesizes that kids with ADHD can master fast-paced internet games readily and their success at this is "addictive" as their brains release dopamine during the intense online activity. Hostile boys, on the other hand, may allow themselves to express their otherwise anti-social behavior and aggression in a relatively safe way by gaming on the internet

My concern as an adolescent physician is that the ADHD and hostility may lead to more harmful consequences when the online activities go beyond games to involve social networking sites. Impulsive teens with ADHD may "go places" they shouldn't or say things that are dangerous or harmful when they hit "Send" prematurely. Hostile teens may in turn find solace on any number of websites that encourage and nurture the kind of anger that we have all seen turn into treacherous life threatening pursuits or even terrorism

On a more creative and optimistic note, I hope that game designers will work with mental health professionals and use this information to create therapeutic games and activities to treat these hurting kids.

image from www.crenk.com

How Stress CAN Make You Sick

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 11 May 2010 16:33:00 +0000

A lot of really cool information is coming out of a variety of sources that I think will help explain and prove phenomena that we have observed for a very long time. Take for instance the idea that traumatic events (The Four D's:death, divorce, debt, and disease) or War experiences, for that matter, can leave long term effects including an increased likelihood of illness following any of these traumas. Generations have known this to be so--"Don't get so upset, you'll make yourself sick" I used to hear. Now research from the Columbia University School of Public Health has come up with scientific explanations for why this is so.

Dr Sandro Galea and colleagues at Columbia were able to correlate Post Traumatic Stress Disorder (PTSD) with measurable changes in the genetic regulation of the immune system. Through a process of demethylation, cetain areas of the DNA that affect the immune system were found to be compromised in PTSD patients. Demethylation may cause genes to be unregulated and in this case, it may make a person more prone to disease. These findings were reported in the Proceedings of the National Academy of Sciences and are described on Scienceblog.

This is fascinating research because it begins to clearly link mental processes (PTSD) with those that have been traditionally considered physical (bodily illness). The lines are increasingly blurred between these two phenomena as we learn more about neuroscience and are able to quantify heretofore mysterious brain phenomena. It also helps to explain why some conditions-addiction, eating disorders, self-destructive behaviors, to name a few are really "wired" in the system at the level of the genes. As we continue to understand these connections better, diagnosis, treatment and prevention will improve. But perhaps most of all we will achieve a higher level of understanding of and compassion for conditions that we have deemed "all in our heads."

Painters, Plumbers, Roofers, Doctors

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 04 May 2010 16:54:00 +0000

For months I have been bothered each time I hear the radio ad for Angie's List, an online review mechanism for all sorts of local "service providers." I have struggled to understand what it is that perturbs me about being grouped together with technicians of this sort when I consider what I do as an adolescent doctor something very different and more complicated to judge than the results of a repair to a leaky roof or faucet.

Well today, I got some experience to help me sort it out. For a few days my bathroom hot water faucet has simply not let any water out. All the other faucets work fine so I figured it had to be some odd sort of blockage...maybe the kind they could have used in the pipes of the oil rig in the Gulf coast. Anyway, I couldn't see where the problem might be so I called my local plumber. Within minutes of looking he found a kink in a metal tube high up under the faucet. What happened next?

He told me to take down the name of the manufacturer and go on line, order the part and call him back once I had it. Sure I would order the wrong thing and making a quick calculation as to what my own time is worth compared to a plumber, I told him I really couldn't do that, that I considered it his job. "That's sort of like a doctor telling you to go order your heart valve and then they can schedule surgery." He just looked at me, relented and then told me he would take care of it, probably making his own calculation about how much he could charge for this.

But he went on to explain that he doesn't normally do parts any more. Since the advent and rise of the "big box stores" plumbers no longer are the experts on this or make any money when they deal in anything but repairs.

OK, so that's where we had a meeting of the minds. He's got Home Depot and other megastores; I've got Aetna and other insurance companies. We are both diminished in our ability to do the right thing and the whole thing with respect to our customers and patients. Nevertheless, I remain hopeful that with the wink of an eye and a please and a thank you and maybe an extra charge here or there, we can preserve the dignity of our mutual professions. Maybe Angie is on to something afterall.

I won't go quietly

noreply@blogger.com (Ann Engelland, M.D.) — Tue, 27 Apr 2010 14:18:00 +0000

For over twenty years my parents have lived in Southern Arizona. That's right, in the part of the country that is in the news now because of the new state legislation aimed at pruning immigrants from its midst.

A frequent day trip from my parents' retirement community is to an artsy enclave called Tubac which is about 20 miles away and smack between their home and the Mexican border. Artists have started bemoaning the fact that their business is way down in no small part because of the border patrol posts that create traffic backups as uniformed Homeland Security agents with very dark glasses lean over the drivers' side and check out the passengers.

When they see two tamish white chicks like my Mom and myself, they never ask for any sort of papers and wave us on. I always rail to my mom as she pulls away, threatening to speak Spanish and see what they would do. "How," I always ask, "would they know I'm not Mexican? Since when does my driver's license say anything about my nationality even if they asked for it? They are the worst kind of racial profilers." And on and on. She responds: "Oh, I don't know. Can't we just have a nice outing together?" They make me angry; they could ruin our day.

Now, I am tempted to boycott the road blocks. There are back dusty roads around their posts, I am sure of it. Rattle snakes be damned. Actually, it makes me want to boycott the whole damn state whose Governor Brewer is pandering to the reactionary forces of the state and taking immigration law into its own hands. Of course, they already have a pretty good track record on this in Arizona with sheriffs who proudly display their hatred, racism and fear-mongering on television.

Speaking of reality television and Arizona, a frontpage story today in the New York Times, entitled "Boozy, Bawdy Reality TV, With a Few Wrinkles", tells us about the middle aged "sassy" retirees of Phoenix Arizona who share their meaningless antics, drinking and even their hernia repair operations with the world. All in all, it's not a pretty picture for the state.

In today's New York Times, Linda Greenhouse has an idea. She writes:

Everyone remembers the wartime Danish king who drove through Copenhagen wearing a Star of David in support of his Jewish subjects. It’s an apocryphal story, actually, but an inspiring one. Let the good people of Arizona — and anyone passing through — walk the streets of Tucson and Phoenix wearing buttons that say: I Could Be Illegal.

I'd love one of those buttons. And maybe I will just go down to Tubac, buy some cowboy art and return speaking Spanish. "Ola, que tal, senor?" That's my kind of sass.

The Pill Turns Fifty

noreply@blogger.com (Ann Engelland, M.D.) — Mon, 26 Apr 2010 17:26:00 +0000

June 2010 marks the fiftieth anniversary of the birth control pill. At the time of my own adolescence, I had no idea that it had just come on the scene. Like women's lib, drinking at age 18 and conscientious objection, we took this for granted as part of growing up. As a practitioner I prescribe it every day; as often as not it's for a problem that is not directly related to contraception. Many people are still surprised at the multi-tasking the Pill can do in a woman's body.

In reviewing the history of the pill I ran across a 2000 New Yorker article by Malcolm Gladwell about the first days of the pill and in particular the story of Dr John Rock's attempts to make the new birth control pill as acceptable as possible to the leaders of his own Catholic church. Rock worked hard to present the Pill as a "natural" method of birth control to rival the more acceptable "rhythm" method (meaning timing intercourse with the menstrual cycle to try to avoid the days surrounding ovulation). Not only did he try to sell the idea that birth control pills promote the "natural" safe times of the month, but the classic 28 day cycle was created with the pills to mimic what they thought were the "natural" cycles of most women. Another remarkable aspect of the pill was the packaging:it was first marketed in the now familiar plastic round compact in order to pass as a makeup container in a woman's pocketbook, a natural for most women.

Since this time, a great deal of anthropological and endocrine research has shown that the 400 or so menstrual periods that a modern woman gets between her first one and her menopause are mostly a result of modern lifestyle. Before the twentieth century it would be more likely for a woman to have only about one hundred periods with the difference being accounted for by more period-free pregnancies and lactation. Experts wonder what the effects of so much exposure to female hormones, albeit "natural" ones, might be.

In the meantime, we celebrate the gains that oral contraceptives have afforded women and the way in which many of the modern hormone-related afflictions of modern life (acne, heavy or irregular periods, menstrual cramps, polycystic ovaries, and endometriosis) can be managed with this little middle-aged pill.

We have learned a lot about the Pill in the past few decades.

Thank you, Michelle Obama (and Oprah, too)

noreply@blogger.com (Ann Engelland, M.D.) — Wed, 14 Apr 2010 10:25:00 +0000

First Lady Michelle Obama's bilateral High Five on the front page of the New York Times this morning will draw you into the picture of pig-tailed Haitian children greeting her during a surprise visit to Port au Prince yesterday. But take a look at her furrowed brow, and you can only imagine what is going through her mind. I think it might be a mix of sorrow and admiration and a desperate wish to help in some way.

My first response when I heard she had decided to visit Haiti was "it's about time." I have wanted to see Barack's face on the front page of the paper walking in boots among the rubble. Ever since my visit in January I have wanted him to go there to lend support to the Haitian people. I have wondered why he has not gone personally to this amazing country where slaves overthrew their French oppressors only to go on to oppress their own for generations that have followed. Maybe the security concerns extend to a fear that the man would be swamped and exalted as a new savior for the Haitian people.

In any case, if there is one thing Michelle (and Jill Biden, too, by the way) can do it is to provide a photo op, even without stylish clothes, to remind us all that the plight of Haitians is still very much alive. With time, the needs are evolving and the call is more sophisticated and sometimes harder to negotiate as described yesterday in the New York Times article about the dancer/amputee who is a pawn in an international struggle over goodwill.

One more person has been keeping Haiti on the front burner. That is Oprah who is sponsoring a Mother's Day walk in New York City to help a number of charities, including Partners in Health, my Haitian favorite. I plan to be there.

Thanks, Ladies!