Adolescent and Young Adult Health

Thinly Minted

2012-01-13T09:37:00.000-05:00

This is Taylor. She recently posted a video of herself on YouTube (and it quickly went everywhere, sent to me by many readers, friends and family) decrying the Girl Scouts because the organization failed to notify her and her family of the fact that transgendered girls are allowed to be members of Girls Scout troops. Because of her outrage, she is calling for a boycot of the annual cookie sale.

The ludicrous quality of this girls complaint seems to have registered on her, her family and probably her lawyer since her video has "gone private" as of today, meaning you have missed an opportunity to appreciate it.

I encourage readers to see Lisa Belkin's blogpost today Girls Scout Video: What were her parents thinking? where she lays blame squarely on the parents for raising an intolerant, pugnacious, offensive and "sanctimonious" daughter.

I for one, cannot wait for my neighborhood Brownies to peddle their cookies. I might even buy a box of Samoas which I have always boycotted for their lousy taste.

Helping Fat People

2012-01-10T10:31:00.003-05:00

This is not funny

When I was a rookie fellow in adolescent medicine in the Bronx in the 1980's, I was assigned a new patient, a "morbidly obese" fifteen year old who weighed over 200 pounds at about 5'2". He moved with difficulty and he smelled even from across the room.   My assignment was to engage him in a program of weight management through diet and exercise. He lived close to the hospital so we had weekly appointments.   After a few months of watching his weight increase, I decided to alter my therapeutic goals for him. The purpose for our visits became simply managing his hygiene. He and I bonded and he started to groom himself in a more age appropriate way. I did nothing for his weight.

So now, I wonder if he is still alive, almost 30 years later. I wonder if he suffered a heart attack or stroke, if he has diabetes, if he can walk at all or if he smells bad again.   If he's alive I wonder if he was ever offered surgery to help manage his weight.

Nowadays, this young man would be evaluated for many problems beyond the not insignificant social ostracism he was experiencing.   With a BMI exceeding 35 he would be worked up for metabolic syndrome. Experts disagree on what the components are, but they are some combination of large abdominal girth, elevated triglycerides, blood pressure, and fasting blood sugar. He would also be evaluated for sleep apnea, gallbladder disease, Type II diabetes, thyroid disease and substance abuse.

Current insurance companies might require my patient to undergo six months of medically supervised diet and weight managment. Nowadays, if he continued to gain weight he might be a candidate for weight loss surgery. A recent article in the New York Times profiled a young woman with marginal success after laparoscopic adjustable gastric banding, the simplest and possibly safest of the procedures available to obese teens. Her story underscores the continued efforts required by a multi-disciplinary team to promote the life-long lifestyle changes required to be successful at keeping the weight off.

Many US childrens' hospitals are currently participating in a multi-center study of the efficacy and safety of "lap-band" surgery in adolescents. Here is a quote from the website of the New York-Presbyterian Children's Hospital:

Our investigations evaluate the safety and success rates of laparoscopic adjustable gastric banding surgery in treating adolescents who are obese. There is substantial evidence worldwide that attests to the safety and efficacy of laparoscopic gastric banding, and we are now documenting its role in the adolescent population.

In addition to evaluating the general body changes that occur in the months and years following adjustable gastric banding, we also study the metabolic effects of banding in growing teens. It is our hypothesis that gradual, steady weight loss will not result in nutritional deficiencies, but rather will result in long-term and sustainable weight reduction.

In spite of this progress and the mounting number of success stories, most primary care providers, pediatricians and family medicine doctors, are reluctant to refer patients. Susan Woolford and her colleagues at the University of Michigan studied hundreds of such primary care providers and concluded that "some severely obese adolescents may desire and potentially benefit from bariatric surgery, but referral for the procedure may depend heavily on the attitudes of their primary care physicians."

With one in three US gradeschool children overweight, and epidemic numbers of adults with complications of obesity looming, it behooves all of us to look at all the many ways available to tackle this problem. For some who are beyond a certain BMI, surgery is a life-saving option that deserves exploration.
image from creativeminorityreport.com via Googleimages

Mamaroneck Tigers Hit New Hampshire Primary

2012-01-06T14:47:00.000-05:00

I just heard about an extraordinary opportunity for local Westchester kids from the Mamaroneck High School. Sixty four lucky students are off to the races!

The New Hampshire primary races that is. Under the guidance of the AP Government and Politics teacher, Joe Liberti, they are going to be helping to get out the vote for three days this weekend. Regardless of their own political persuasions or uncertainties, they will stretch their thinking and experience civic duty first hand.

Activities include meeting with the director of field operations for Newt Gingrich and attending a panel discussion sponsored by Politico. Best of all, those of us here at home will be able to share in the adventure because they will be creating a ten minute video of their experience.

As parents, caregivers and educators we are always looking for ways to foster competence, character, contribution, and connection (four of the Seven C's crucial to resilience in our kids and ourselves-best described in Ken Ginsburg's book, A Parent's Guide to Building Resilience in Children and Teens). I am hard pressed to think of a better way to do this. I hope these students will come back with momentum and energy to rally local residents across the community to debate, discuss and ultimately vote.

For a more complete announcement of this and other interesting, progressive educational opportunities at Mamaroneck, click here.

image courtesy of crazyman7.narod.ru via googleimages

New Year's Resolution to Diet?

2011-12-31T16:58:00.001-05:00

With 2012 only hours away, many are scrambling to assemble their resolutions and for millions of us, teens and adults alike, this list includes renewed efforts to improve diet and exercise more. While obesity is a growing international problem, we all know that weight watching can lead to serious health problems, both mental and physical.

Following are a few warning signs that a diet may be misguided or inappropriate:

The desire to lose weight seems more motivated by emotional than health factors. “I’m not popular because I’m fat.” Or “If only I could get rid of my stomach I’d be happy.”
A person signs on to a drastic change in lifestyle. " I’ve decided to become a vegan in 2012.” Not only is a vegan diet (void of all animal products, including cheese and eggs) very difficult to do in a healthy manner, it is usually high in calories and hard to maintain.

You are quite sure that your daughter is at a normal weight and do not think dieting is necessary or safe. If any degree of struggle or disagreement arises between you over this issue, it is best to turn to a professional who can assess the teen’s weight and health status and explore the psychological and emotional motivating factors in order to provide guidance.
You see evidence that your teen, young adult or friend is using caffeine, laxatives, diet pills or is even vomiting to control intake and weight. These are obvious signs of an eating disorder, which can quickly become a chronic and recalcitrant disease. Intervene as soon as possible.
You see a marked increase in concern over fat content of food, accompanied by scrutiny of food labels, avoidance of previously favorite foods, and “fear of fat.”
You note an uncharacteristic and perhaps unsustainable level of physical exercise that accompanies someone's new resolution. In an era when most Americans are not getting enough exercise and spending too much time in front of various screens, there are still many who use excessive exercise as a tool for weight loss and body changes that may not be appropriate.

These concerns apply equally to girls, boys, women and men. The latest issue of Contemporary Pediatrics in fact, discusses "Disordered Eating in Boys," and points out that a desire to gain weight (whether in the form of muscle or bulk) can signal an unhealthy attempt at body modification just as much as a wish to lose weight might.

With respect to this resolution, there is no more apt wish than to "Have a Happy and Healthy New Year."

image from richardwiseman.files.wordpress.com

Home for the Holidays

2011-12-27T16:34:00.000-05:00

Whatever we are asked to call this period of time at the end of December, whether it's religious or festive, in my family we try to make a bow beyond just the secular to both Christmas and Hannukah. However, as the kids get older and the precious time together seems more and more compressed, we spend less and less time with the traditional prayers, stories, and services than we do with the catching up and laughing, making merry, reveling in the special lights, and treasuring moments together.

For a long time, I like many moms before me, have made a ritual of cooking and preparing and creating a vast reception for the hungry appetites I know will land on my doorstep. So over the years, I have worked to accommodate the expanding dietary rules, limitations, limits, and experiments that my growing brood requests. This year I scoured Epicurious.com as well as my shelf of cookbooks for the perfect dishes that would accommodate the vegetarians, the kosher-observant ones, the meat eaters, and the simple gourmets among them. With apologies to the lactose intolerant in the group, the baked Alaska "took the cake" this year with its drama and elegance and in the end, once we got over our disbelief and anxiety, its simplicity.

But no matter how hard I try and no matter how grateful and simply full everyone is, coming home brings certain culinary calls. Among them are the local sandwich shops that generate a debate among sibs over which has the best wraps or cranberry sauce. The homing phenomenon was clear late on Christmas Day when the tired and overfed group decided to honor a Jewish tradition and order Chinese food. From the very busy and stalwart restaurant right around the corner, they ate one of our long time standards: Chinese cold noodles with sesame sauce. One of my adult kids gratefully announced: "The great thing about cold noodles is that they still taste just like they did in sixth grade." Nostalgia strikes again.

No matter how sophisticated their palates might have become through travels and experiences beyond imagining, the tastes, flavors and happy experiences at home mingle and linger a long while in our minds. And that is the blessing of togetherness no matter what's on the menu.

image from zazzle.com via Googleimages

One in three teens and young adults arrested?

2011-12-20T14:29:00.001-05:00

Usually, I can trust the New York Times to report accurately and scientifically about stories and research they pick up in the media. I have not been alone in the past few days in feeling shocked by the article, "Many in US are Arrested by Age 23, Study Finds". They were quoting from a new study reported in the well respected journal Pediatrics that looked at a national sample of adolescents and found that over 30 percent of "23 year-olds had been arrsted for an offense othern than a minor traffic violation."

Upon closer reading of the actual article in Pediatrics we discover that what the study looked at was the "cumulative proportion of youth who self-report having been arrested or taken into custody for illegal or delinquent offenses (excluding arrests for minor traffic violations) from ages 8 to 23 years."

According to WatchingtheGov.com "the study captured arrests for all offenses other than traffic violations, including underage drinking, shoplifting, truancy, robbery, assault and murder. Most teens who are arrested are cited for minor infractions and don’t end up imprisoned."

Lots and lots of kids are in and out of the legal system for offenses related to alcohol and marijuana. Is this the reason for what appear to be high numbers? The data did not separate out information by race or socioeconomic factors. How would it look if we could see it that way? We know that young black men have a much higher chance of being arrested on similar charges than white teens and young adults.

Commentary from the liberal blogoshpere tends to blame the police, the criminal justice system, drug laws, and anti-adolescent bias in our culture. Look at this comment:
"The long term hang up of hair trigger arrests and kangaroo prosecutions is the (sic)we are creating a population of certified losers unable to ever recover. In other words, the cradle-to-prison pipeline is becoming more voluminous. People mired in this apparatus cannot get credit, cannot get employed, cannot get housing, cannot be admitted to practice a profession and are likely encouraged to continue in a life of crime to feed themselves."

For parents and pediatricians there are a number of important ways to think about this data. According to Robert Brame, the lead author of the study and a professor of criminal justice and criminology at the University of North Carolina, "teens who wind up in trouble with the law tend to have early risk factors, such as having a troubled family, childhood behavior problems or difficulty in school." Many of them are also mentally ill or have treatable problems like attention deficit disorder, anxiety and substance use. It's the responsibility of the caregiver and the school to identify these students early on.

But we also know from nationally validated data that a lot of otherwise high functioning kids who star on our athletic teams and go to good colleges end up on the wrong side of the law whether they are caught or have such an encounter on their permanent record. Sometimes it's an issue of Halloween pranks, reckless driving, loud parties, and other "forgivable" things "teens just do," but it often is behavior that the law is managing because parents are not. Communities, clergy, schools, parents and teens can work together to define the extent of kids' risky behavior and respond accordingly. Responses can include programs for those who drink too much, community service for arrests, and other constructive ways of meting out justice.

No teen should be scarred for life, unable to get ahead and without a chance at restitution for behaviors that are commonplace. Nor should communities begin to accept that a criminal record is a right of passage as normal as a bar mitzvah, confirmation or a prom. But I, for one, might be proud of my kid if he or she were arrested at an Occupy demonstration these days.

image from bagnewsnotes.com via Googleimages

What does hockey say about us?

2011-12-12T17:24:00.002-05:00

I was thoroughly mesmerized last week by the three part series in the New York Times by John Branch about the life and death of Derek Boogaard entitled "Punched Out: The Life and Death of a Hockey Enforcer."

First of all, the writing itself brought me to tears as I learned about Boogard's early years and the dedication of his parents that now seems almost pathological. I imagined them driving him in the dead of night across hundreds of miles of Canadian tundra to participate in the national sport that they thought might rescue him from his gargantuan body and his young mind that could not succeed in a classroom as well as it did on the ice.

Then I was stunned by the ferocity and the ghastly descriptions of the brawls and the gladiator-like job of the enforcer, a player whose function is to literally take the gloves off and fight to frighten and intimidate the opponents. Whereas there might be a graceful quality to hockey (one of my sons played high school varsity hockey and I can still hear the scrape and swish of the steel on the ice, but I can also remember the police presence at the games with particular opponents, "just in case.") and the elegance of a well played goal is undeniable, the presence and encouragement of the enforcer turns the game into a spectacle and a brutish game where violence an mayhem are encouraged.

Finally, in the third article in the series I was saddened by the photos of his parents who perhaps thought they were doing the right thing; of his brother who protected and enabled his drug dependency for years; and by the shocking revelations that many of the players who sustain his degree of battering during their short lives are suffering from degenerative brain disease much like the football players we followed in the Fall. So now it's winter and once again we are asked to ponder the morality, yes the morality of this sport that intentionally inflicts damage on young bodies and brains for the sheer enterntainment of it.

Over the past few years as I have had the privilege of seeing athletes with head injuries and have been able to folllow them with sequential visits and Impact tests I have learned that many of these athletes are not playing for the joy of the sport. Very often they are playing to satisfy a parental or family expectation or as a way of compensating for some perceived weakness in some other sphere of their young lives. When they are finally pulled from the rink or the field because of injury many of them will confess to some relief at the drop in the pressure and the loss of fear of injury they experience. As one reader wrote in the Times: "This series should be required reading for parents, coaches and children wherever hockey fever reigns."

For a previous blog post on a youth hockey team in Minnesota that is successfully encouraging more elegant and less dangerous play see this post called "Why I love Minnesota."

image from dialecticmagazine.com

"Dad, can we go out for a drive?"

2011-12-07T14:22:00.000-05:00

If the teen asking this question is a newly minted driver, of course the answer should be "Yes, sure. Where do you want to go?" Drive time is precious for conversation, for teaching and for assessment of the driver's skill. To corroborate this, a new study from Virginia in the December issue of the Journal of Adolescent Health suggests that crash, near-crash, and risky driving is significantly reduced in novice teen drivers when a parent is present.

That might not seem too surprising except that in practice in the real world we often need to remind parents of adolescents that their presence is critical in raising good offspring, whether it's good drivers, students, siblings or responsible drinkers. Most of us accept that risk taking and adolescence go together. But, in an accompanying editorial in the Journal it is pointed out that teens do seem to know how to curtail risky behavior when a grownup is around. So it's no surprise that parents lowered the rates of crashes/near-crashes by 75% and the rates of risky driving (measured by an ingenious on-board computer that recorded g-force, acceleration, gps data, and images of passengers) were lowered by over two thirds with a parental presence.

What is interesting, however, was that the presence of "risky friends" (based on a questionnaire filled out by the teen driver) doubled the likelihood of a crash/near crash or risky driving. As parents can we choose who drives around with our kids? Can we help them avoid the peer pressure of encouraging unsafe or distracted driving practices? Graduated driving programs have mandated the number of non-family member passengers and effectively reduce crashes. But it's not always possible to choose the friends who jump in the car in the high school parking lot once the graduated period has lapsed. But it may be worthwhile reminding one's own "risk-taker" child about the impact of like-minded friends in the car.

The third finding in this study which is a bit surprising is that kids drove in a more risky way when they were alone (allowed in the state of Virginia for new drivers) than when they were with peers of a non-risky sort. This is a small study which would need repeating but gives us pause about unaccompanied young drivers.

What is the lesson? Kids are probably at their absolute best when a parent is around. So if there is any doubt about "road readiness" when Mom or Dad is in the front seat (or in my personal experience if the approval of a responsible older sibling is in question) more practice time should be in order before letting that tether out any further.

Tell the Grandparents You Know About Pertussis

2011-11-30T14:34:00.000-05:00

Here's a heads-up about a subject that pediatricians are more aware of than many internists and other clinicians who care for older kids and adults. Pertussis, or whooping cough, caused by the bacterium Bordetella pertussis, remains a serious cause of illness and even a threat to life to young infants. Although most people have had immunizations against pertussis during childhood, their immunity or ability to fight the infection can wane with age.

It is now recommended that a single dose of Adacel, the vaccine against tetanus which is combined with pertussis (it works better this way) be given to "all adults 65 years of age and older who have or are likely to have contact with an infant aged younger than 12 months." according to the November 2011 Infectious Diseases in Children newsletter. This includes pediatricians who refuse to retire, grandparents who have contact with their childrens' children, and day care workers who may unwittingly expose babies to whooping cough.

In older children and adults, pertussis is usually an annoying and sometimes prolonged illness. But in very young children it can cause pneumonia and even sudden death. If you would like to actually hear the sound of the whoop click here. Here is a quote from my own mother's memoir about having whooping cough during a tornado in South Dakota:

In 1929 when I was one year old, I had whooping cough, and a tornado came to our farm. Since I was very sick (they said I would whoop so much, Pop would hold me upside down to hopefully catch my breath), my folks did not want to take me out into the stormy weather in order to get to "the cave" for shelter.The cave was a storm cellar underground about 50 feet away from the house..... we would seek safety there, even in the middle of the night, when "the weather looked bad". And so, the family descended to the "cellar" under the house itself. I remember none of this, of course, but heard, stories of "The Storm" as I was growing up and we played "house" with the broken dishes and pots and pans in (my grandmother's) grove of trees across the road. These fragments blew out of our house and ended in those trees.
And I feel respect and wonder at how my parents survived after sitting down there in the cellar, hearing the banging of boards and crashing of glass, (and holding a sick baby).

Dramatic, right? Any respiratory distress, even in an adult, can be frightening. Fortunately this degree of disease is preventable. So, if you have friends, relatives, housekeepers, or caregivers who may be in contact with infants who are not yet fully protected through immunizations until about a year of age, encourage them to get the Adacel vaccine to protect themselves (from tetanus and pertussis) but mostly to protect the young ones in their midst.

The end of an era for me

2011-11-21T08:03:00.000-05:00

As 2011 draws to a close so will ten years in private practice. As of January 1, 2012 I will no longer be with BridgeSpan Medicine in White Plains. And I will no longer be practicing primary care for teens and young adults in Westchester.

I will be working as one of the doctors on the multi-disciplinary team of clinicians in the student health center at Barnard College in New York City. I will be available to undergraduates for primary care, consultation and referral. I will work side-by-side with nurse practitioners and mental health providers. And I look forward to participating in mentoring and working with Adolescent Medicine fellows in training.

My current patients have many options. They can continue their primary care at BridgeSpan Medicine with Dr Brooke Balchan and her associates from Westchester Park Pediatrics, Drs. Avvocato, Ross, Wurzel and Eisenberg. And they will be able to access specialty care via a network of fine practitioners throughout the metropolitan area.

In many ways this job is a natural progression for me from being a general pediatrician over 25 years ago when I grew somewhat expert at infants and pre-schoolers as I raised my own tots. As they grew I was lucky enough to immerse myself in the issues of elementary school, special needs children and parenting. Over the past fifteen years, my focus has shifted to adolescents and the concern of raising responsible, content people in our culture and how pursuing those goals can affect their health-and that of their parents. Now as my own children are of college age and beyond, I am called to play a role in the health and well-being of emerging adults. And how thrilling that is. I have long thought a job in college health would be a dream for me, and now is the time.

Of course no decision like this comes lightly. I have struggled for the past decade with the compromises I have had to make with our health care system as it has tried to grow up. But it is a disabled patient with many handicaps and has lost its way. As the mammoth insurance industry, unregulated and driven by bureaucracy and profit, has become the conductor of this cacaphonous symphony, the players have lost their music, lost the tune, and are struggling to play in harmony. I am choosing to move to a smaller quartet, where I can still hear the voices of those next to me and play the classical music of healing that I was trained to deliver.

Many of my patients move in a space in my psyche in much the same way my own children do and I will miss them very much. Parents I have come to know through tears and laughter will also be sorely missed. And my colleagues, especially those in the mental health and education arenas, who have taught me so much about doctoring and caring, will be missed as I carry their lessons forward with me.

image from sapphirelane.com via Google

Dinner Table Conversation about Sex

2011-11-15T18:10:00.001-05:00

Have fun at dinner tonight with your teens and see if they can guess the right answers on the following questions about teenage sex.* All data comes from the recent survey from the Centers for Disease Control and their Vital and Health Statistics Report from October 2011:

*Among females ages 18-24 who had their first sexual experience (here defined as intercourse) before age 20, how many of them really wanted it to happen then? (Answer 41%)

*What percent of boys who had sex before age 20 "really wanted it to happen at the time? (Answer 63%)

This in itself could generate some interesting discussion but if that's not enough to get you to dessert, try these:

*What percent of teen females and males had their first intercourse with someone "they were going steady with?" (Answer for females: 70% and for males: 56%)

*What percent of females ages 15-19 use a form of contraception at first intercourse? (Answer: 78%)

*Is having an older partner at first intercourse associated with a greater or lesser likelihood of using protection at first intercourse? (Answer: lower likelihood) Be sure to talk about pressure from the Big Boys and Girls.

*What percent of females use non-pill hormonal contraception at first intercourse? (Answer: 6%) These methods include vaginal rings, injectable and implantable hormones, and emergency contraception....all worth discussing or looking up)

*What percent of never-married teens (15-19) have had intercourse at least once? (Answer 43%)

These are interesting data and are getting a lot of play in the media. I would point out however, from my reading today of the original document that no questions were asked about non-heterosexual experience and the rather narrow focus on intercourse as an "endpoint" begs the question of what we have discussed elsewhere about the increases in oral sex among both heterosexual and non-heterosexual teens with all the incumbent risks.

*Remind them that you are not fishing around for personal information merely wondering what they think of the data. Right, Mom.

image from blogs.howstuffworks.com via google

What should we do?

2011-11-10T21:37:00.000-05:00

Recently a patient asked me what I thought about the Occupy Wall Street movement. I mumbled something about how I admired the courage to speak out against injustice and inequity but how I worried that their message was being dissipated by a motley group of folks without a clear goal.

I soon realized that was a cop-out. What movement is well formed from its outset? What change is brought about in a tidy fashion? I soon wished I had said something different.

Then at a recent prayer service at my synagogue, Larchmont Temple, I read the following in the siddur, or prayerbook, written by Rabbi Sydney Chayet, a professor of history and a poet:

We oughtn't pray for what we've never known,
and humanity has never known:
unbroken peace,
unmixed blessing.
No.
Better to pray for pity,
for indignation,
discontent,
the will to see and touch,
the power to do good and make new.

What Occupy Wall Street might represent for many is in fact this holy indignation, this drive for improvement and for a more moral and meaningful life. We should be proud and pray for more people like these who are agitated and discontent and are asking us to look for better ways to make our socity anew. Stepping out of our comfort zones and into a place that is uncertain, but certain in its pursuit of justice and fairness, is a healthy thing. I would encourage my patient, my children and my friends to go find out what they have to say and what can be carried back home, to school and to the workplace.

image from salon.com via Googleimages.com

“Dad, what kind of work do you do?”

2011-11-06T17:13:00.000-05:00

As I gather a family history from a new adolescent patient and parents, I usually pause for an entertaining interlude to ask the teenager how old her parents are. Usually she will smile while the parent coyly looks away and the child guesses, often within two or three years of the correct number. After that I inquire about what kind of work her parents do. If mother is a “stay at home mom”, the way in which this is described by her children can be most interesting. Responses have ranged from “she doesn’t do anything” to “she makes sure we are all ok.” Fathers are frequently more complicated and often require a mother’s help to explain.

Recently a sixteen year old answered that her father was in “venture capital” and when I asked what that means to her, she said:”I don’t know.” Nor did the mother know. “We love and respect him,” she said, “but we can’t really explain what he does.” Even when pressed I could not elicit the vocabulary that might explain what his work involves.

So this got me to thinking about Occupy Wall Street, the dissatisfaction so many feel with our “system” and the disillusionment of many youth about their own prospects for success in the current economy and structure of our country. The sense that they have lost control over their destinies leads to the notion that finance and banking are the only means to become truly successful (unless of course they have gifts in the athletic department.) But maybe they don’t even know what bankers and financiers really do all day.

It strikes me that if one cannot share the nature of work with family and talk about the joys, frustrations, pleasures, and pitfalls of one’s job, then there is a badly missed opportunity for teaching our children about making choices and self definition. Not to mention the value to a parent of the intense scrutiny of a smart adolescent who is exploring the world in a moral, political, economic and social sense. As Anderson Cooper calls it: “keeping them honest.”

Here are some questions to start off a discussion* aimed at understanding the world of adult work and the complex decisions that go into choosing a career, seeking and responding to a “calling” and keeping values on track as one prepares for the future:

What is your kind of work called?

What do you actually DO all day?

What do you like about your job?

How did you get started in your work? Why did you choose it? DID you actually choose it?

Do you wish you could do something else? Why don’t you?

What is important to you about your work?

Is it important to make a lot of money?

Do you think the world is a better place because of your work?

What are your hopes for me and my work life?

*clearly these questions are not just for fathers, but can be valuable for any working person, professional or even grandparent

image from easypuppets.com

A Great Way for Students to Give Back: AFYA

2011-10-29T15:35:00.000-04:00

I first heard about AFYA when I returned from Haiti after the earthquake in 2010. Right in our backyard, in Yonkers and run by Danielle Butin, AFYA is an extraordinarily efficient and well organized not-for-profit that collects medical and other supplies from individual, commercial and medical sources and responds to the call for them from around the world. When I first met her, what impressed me most about Danielle

was not only her spirit and energy but the tremendous organization of her vast supplies. I saw row upon row of packed and tidy shelves labelled "Pediatric cardiology" or "Gastroenterology" and an entire room of drugs and pharmaceuticals in properly labelled bins. This doesn't happen by itself. Volunteers are taught to do this and in short order accomplish a small miracle which allows AFYA to continue its work around the world. Please look at their website and consider organizing a group of friends to contribute your community service hours to this wonderful cause:

Calling All School Age Volunteers!

On Saturday, November 12th, AFYA is sponsoring a 16-hour sortathon, where we will celebrate and honor our teenage and young adult volunteers. At the Sortathon, volunteers will sort, inventory and pack supplies for 2-hour segments and contribute enormously to global health. We have a full day of entertainment and amazing, moving speakers lined up.

Start a team or work independently - there will be gifts for all, and prizes as well! We're expecting lots of participation, so register early and make sure to choose your two-hour shift of preference.

Please visit and share our brand new Sortathon website: www.Sortathon.afyafoundation.org
to register and find out the details about this event -- participants will
contribute to the improvement in health for thousands abroad. Registration will require a $25 tax deductible donation.

Please help us to get the word out -- send this sortathon link to everyone you
know!

Thank you!

Readin' Writin' Rithmetic and Relationships

2011-10-26T10:14:00.000-04:00

I am pleased today that my professional organization, Society for Adolescent Health and Medicine, and its president-elect,John Santelli, have come down from what is frequently the organization's ivory tower in the clouds to comment on the sex education program that is going into effect in New York City schools. Along with Arik Marcell, a pediatrician from Johns Hopkins, their op ed piece is a smart and compassionate answer to the October 19 Op-Ed piece entitled "Does Sex-Ed Undermine Parental Rights?"

In that article the authors painted an unsavory picture of young middle schoolers exploring all sorts of "solitary and mutual sex acts" using flash or "risk" cards. This is what they imagine the new NYC Department of Education's requirements will consist of and fear that parents will lose control as "the effect of such lessons is as much to promote a certain sexual ideology among the young as it is to protect their health."

But Santelli and Marcell help us to see this new educational mandate in a different way:

"...public health is built on the twin pillars of scientific understanding and human rights, not ideology.
Children and adolescents are developing human beings, with rights to protection, to health and to education — and sexuality is a normal and vital aspect of human development. Comprehensive sexuality education equips young people with information they need to protect themselves against sexually transmitted infections and unplanned pregnancy and to adopt healthier sexual behaviors."

No matter what the curricula turn out to contain, parents can still have a lock on the values and morality and the when (and maybe the how and with whom) of sexuality in their children. In fact, multiple studies have shown that kids want to know how their parents feel about sex and what their values are. But parents have not done a very good job of it. In another Op-Ed piece today, one of the teenage staff writers for Sex,Etc, one of my favorite publications (cheap, well written by teens, and sharing a diverse and biologically correct view of sexuality in teens) points out that in 2008 while 47% of girls (ages 14-18) "said they had never discussed sex with their parents, only 6% of parents said they had never discussed sex with their children."

It might even turn out that the introduction of the biology and science of human sexuality in our schools may present an invitation to parents to engage in important conversations with their kids. Not unlike proof-reading an English paper or (attempting to) help with math problems, the course in human sexuality can open the dialogue that so many parents and kids all want to be having.

image credit from hispanicallyspeakingnews.com

What they are NOT saying about HPV....

2011-10-17T14:58:00.002-04:00

While the political candidates hurl insults and untruths at each other about all manner of topics, there is something getting lost in the melee. Ever since Gardisil vaccine (to protect against Human Papilloma Virus) was approved for girls, I have been telling sceptical parents that Governor Perry's early and messy endorsement of Gardisil really bollixed it up for those of us on the front lines. What do I mean? In spite of a great track record of safety and efficacy, the HPV vaccine is still not accepted as widely as it should be. This is partly because Perry made it look like one more BigPharma boondoggle. But it's also due to the fear that we will have to discuss SEX when we talk about the shot.

But we must talk about sex. Listen to this:

A new study in the Journal of Clinical Oncology --available here only in abstract (abbreviated) form-- brings the stunning news that HPV is contributing to a growing number of head and neck cancers (tonsils, throat and tongue). It seems that there are two types of oropharyngeal cancers, those caused by tobacco use and those caused by HPV. Between 1984 and 2004 in a study of 6000 patients, HPV-positive cancers increased 225% while HPV-negative oropharynx cancers dropped 50%–most likely because of a reduction in smoking and tobacco use.

Abstinence from intercourse will certainly prevent transmission of HPV to the cervix but what no one is talking about in public is that abstinence and fears of pregnancy and HIV have fostered an explosion in oral sex and other non-intercourse (some call it "outercourse") activities. Of course they look at me funny when I tell my patients that if they are engaging in oral sex (or giving "head") there should be a condom involved. Almost no one actually does that. And so, the HPV is being transmitted to both men and women in growing numbers.

One other problem is that there is as of yet no screening tool to detect early HPV infection or early cancerous cells in the head, neck and oral cavity. For cervical cancer, the Pap smear has been the standard method of early detection and along with HPV vaccine is responsible for dropping incidence of cervical cancer.

"Should the observed declines in cervical cancer and the observed increases in HPV positive oropharyngeal cancers continue into the future," Chaturvedi, the principal investigator on this study, said, (then) "HPV positive oropharyngeal cancers will be the leading HPV associated cancers over the next decade–by around 2020."

What we need is a rational conversation and some quick, good research to determine whether the vaccine actually does prevent these oropharyngeal cancers, as most believe it will. Then we need to continue to press our insurance companies to cover this vaccine for both women and men.

Finally, we need to talk about SEX before it's a conversation about CANCER.

image from halimdeichatmd.tumblr.com via google

My 200th Blog: What does Sponge Bob do to our minds?

2011-10-11T17:03:00.000-04:00

I am celebrating my 200th blogpost with a fresh little article from the October 2011 issue of Pediatrics, "Fast Paced Television and Children's Executive Function." Not exactly about teens but read on.

Researchers at the University of Virginia did a neat little experiment on sixty 4-year-olds---admittedly a small sample but just wait to see the results. What they found is that only a few minutes of certain kinds of television can have a remarkable impact on the childrens' "executive function."

Executive function (EF) is quoted in the article as including "a collection of prefrontal skills underlying goal-directed behavior, including atention, working memory, inhibitory control, problem solving, self-regulation, and delay of gratification."

The kids were randomly assigned to a 9 minute epidose of "fast-paced television" (with scene changes every 11 seconds and almost constant motion on the screen); the same amount of time watching educational television(not specified but I think we mean Sesame Street); or 9 minutes of drawing with crayons and markers on paper. Before the test phase of the research the children were evaluated to show that each group was similar with respect to socio-economic facotrs, television habits and rough measures of attention span. They were then given four tests of executive function (HTKS, backward digit recall, tower of Hanoi, and a test of delayed gratification--all age appropriate and really interesting if you care to take a look at the descriptions of the tests). After the 9 minute TV or drawing test period the kids were re-evaluated and the following graph shows the change between pre- activity (fast-paced tv, educational tv, or drawing) and afterwards:

Essentially what we learn here is that fast paced television can affect these four year olds' minds in a way that slower paced entertainment doesn't. All of the fast-paced TV group scored worse on all of the EF tests that were included in this study. It did not address how long this effect persists or what effect more than nine minutes of watching might have.

In an accompanying editorial in Pediatrics, Dr Dimitri Christakis compares the fast paced television to multi-tasking in older students and adults. Multitasking is the ability to rapidly oscillate between two or more activities, similar perhaps to watching the hyperactive motion on the screen of some shows. He raises the question of what the social and educational implications of this potential deficit in executive function might mean as we move forward.

Is the anxiety and inability to focus (read "poor executive functioning") we see in our teens and young adults related to this fast-paced input? Is it a result of the related multitasking that most of our kids do so "well?"

Stay tuned.

image from sandiego6.com via Google

An Apple from the Teacher

2011-10-06T14:05:00.001-04:00

In my morning haze, I was paging through this morning's New York Times, feeling sad about Steve Jobs when I scanned the lead OpEd piece entitled Where's the Jobs Bill? I was thinking the editors had come out awfully quickly with an oped piece on the genius, only to realize it was another demoralizing plea for Republicans and Democrats to get along with each other. If Steve Jobs were writing a "bill" I think it would be in a beautiful font and it would take the lessons from his own life which he so simply recounted in the now famous Stanford graduation speech in 2004. Some of his words:

Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

Again, you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever. This approach has never let me down, and it has made all the difference in my life.

I didn't see it then, but it turned out that getting fired from Apple was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.

If you know a junior or a senior (high school or college) or a gradutae or even a worried child in kindergarten who might feel overwhelmed and stressed by uncertainty or feeling powerless, share Jobs words with them. Print them out and put them on a card against the salt and pepper shaker on the dinner table tonight. Ponder the wisdom of this man's many gifts to all of us, including his personal philosophy. And try putting the iphones away just for the length of the conversation.

image from frumforum.com via Google

Autism newsletter

2011-10-05T17:31:00.000-04:00

For the family, friend, therapist, teacher or ally of a child, teen, young adult or grown-up with autism spectrum disorder (ASD), Asperger's syndrome or high functioning autism (HFA) the Autism Spectrum News paper is a trove of wonderful information. Almost all of us know someone in our midst who fits into these broadly defined categories. Reading the newsletter is a brilliant way to slip inside the minds and hearts of these people. That's saying something for a segment of our population that is often ignored and misunderstood or worse, bullied and abused.

Just a look at some of the subjects that are covered in the Fall issue:

"Important facts about adult autism employment"

"Do parents and teachers 'get' children with AS/HFA?"

The impact of bullying on individuals with HFA and AS"

"Sensory Processing Difficulties-Dressing for Success"

Even the advertisements are interesting and enlightening:

CUNY's master of arts degree in disability studies
Research centers in New York City, including Mount Sinai's Seaver Autism Center for Research
WJCS family center for community support
and
Prince's sensory delights or "sensory engineered clothing and products" for those kids who scratch and itch and fidget because their neurology is different.

Drama Can Lead to Tragedy

2011-09-26T08:55:00.000-04:00

Thanks to Danah Boyd and Alice Marwick from Microsoft Research who really hit the nail on the head with their article on last week's New York Times oped page entitled "Bullying as True Drama."

In my office not a day goes by without a parent, psychologist, teacher or student referring to "drama." As Boyd and Marwick point out, though, "drama" is frequently a dangerous scrim for something much more real and harmful. Admitting to bullying, whether as a perpetrator or a victim requires "acknowledging oneself as either powerless or abusive."

No adolescent likes to be on either side of this equation. "Many teenagers who are bullied can’t emotionally afford to identify as victims, and young people who bully others rarely see themselves as perpetrators,"say the authors of this article. And they continue:

"Dismissing a conflict that’s really hurting their feelings as drama lets teenagers demonstrate that they don’t care about such petty concerns. They can save face while feeling superior to those tormenting them by dismissing them as desperate for attention. Or, if they’re the instigators, the word drama lets teenagers feel that they’re participating in something innocuous or even funny, rather than having to admit that they’ve hurt someone’s feelings. Drama allows them to distance themselves from painful situations."

Microsoft Research looks like a remarkable international collaboration of social science and technology that covers issues as varied as new speech recognition technology, astronomy, and using data to identify genetic factors in disease. These are the big minds at work on the world's thorniest and most intriguing problems and part of their mission statement is to "examine social media practices through various methodological and theoretical lenses and provide insight into how social media is reconfiguring daily life." It's a thrill that they are using their expertise in a manner that benefits some of the least empowered (and most technically connected) in our society, namely teens.

So next time a student, patient, teacher, parent or even a therapist calls it "drama" think again about what the backstage reality is for the people involved.

image from varyfocal.wordpress.com

Remember Haiti?

2011-09-22T17:19:00.000-04:00

I just received an update from Partners in Healh about the ongoing cholera outbreak in Haiti. Please click on it and read about this disease that is there to stay for the foreseeable future.
Remember PIH in your end of year giving.

Thanks.

LGBTQ Youth: Suicide and Depression

2011-09-20T15:01:00.000-04:00

Youth who identify as LGBTQ (lesbian, gay, bisexual, trans, or queer) are at almost three times higher risk of suicidality compared to "heterosexual" youth.

Let's say that another way: if your child (or one you know or care about) identifies as gay or is attracted to someone of the same sex, he or she is at much higher risk of depression and suicidal thoughts. It turns out that youth who identify as bisexual are at even higher risk. Other behaviors and risks that run in LGBTQ youth (otherwise known as sexual minority youth or SMY) are: substance use, eating disorders, victimization (bullying) and interpersonal violence.

Although clinicians and folks who care for young people have known for some time that the suicide rates among LGBTQ youth are high, this recent study published in theAugust Journal of Adolescent Health looked at 24 previously published studies of depression and suicide in young people to tease out some of this data. They remind us that even in an age when LGBTQ/SMYouth are coming out at younger ages, the risks of doing so remain high. If victimization gives rise to a feeling of hopelessness and if a child's environment is not a validating one, all sorts of behaviors from cutting to substance use and antisocial activities and school failure can be the result.

It doesn't have to be this way.

All youth should be screened at their "physicals" for their "mental" health as well. That should include interviewing them about their sexuality. For LGBTQ youth further queries about harassment, discrimination or lack of validation should be made and providers should be prepared to "provide appropriate care for youth in need."

image from dosomething.org via google.com/images

The Period Tracker Plus

2011-09-15T17:43:00.001-04:00

For many girls it is important to keep track of their periods. For some it's a matter of avoiding a fertile time, for others (older we hope) it's the opposite. For many of my patients who are young and have normally irregular periods they should be aware of the intervals between periods. Of course for anyone having sex without protection or with imperfect protection a tracker can mean the difference between discovering a missed period before it's too late or having some options and choices shut down.

Today a seventeen year old patient showed me "My Days", an app for android phones that allows women and girls to track their periods in as much detail as they might want. It certainly makes it easier on the doctor when she asks: "So when was your last period?" and the young patient whips out her phone to show me this:

The same tool that helps a 14 year old discover how "irregular" she really is will also be perfect for the 30 year old who wants to know when she is most fertile and most likely to conceive. My only concern is that the 14 year old (or anyone for that matter)will interpret those days as the only ones when she should avoid having sex or unprotected sex. In terms of pregnancy prevention and STD avoidance it's not safe to have unprotected sex at any time. Condoms at a minimum, and a second form of contraceptive would be the best bet. All month long.

A Google search of the best apps for keeping track of periods revealed that all of them have ovulation, mostly hitting it rather than avoiding it, as the goal. I have not found a simple app that is appropriate to teenage girls. Other concerns I have with the apps I saw online at this review are that they emphasize PINK and feel ridiculously girly-girl; they hover on PMS, moodiness, and other pre-menstrual symptoms in a way I am not sure is productive; and some of them even have warnings for men to avoid their partners during certain "times of the month."

Come on! Your "fertile window"? Yikes!

Anyone want to work with me on an app for teenagers that is more developmentally appropriate? Kotex are you there? I remember the pamphlet I read from you about periods in the 60's. We can do so much better with technology in our hands.

Bridging a Gap

2011-09-13T17:52:00.002-04:00

I just read Tom Brokaw's book, The Greatest Generation about people born in 1920 who experienced World War II during their twenties. He notes over and over again that this generation was ready to sacrifice education, livelihood, time and family for the country and often gave their lives in the process. The book profiles many famous folks from that time but also some remarkable unsung heroes. One of the best chapters is entitled "Shame" where Brokaw reveals the lives and sacrifices of Japanese-Americans and black and Latino Americans who met with dramatic segregation and hate during the war years.

Have we learned from the mistakes of that great generation?

Over the past week or so, a despicable YouTube video montage that purports to support the notion that Barak Obama is a Muslim was shared by a family member of mine. It struck a cord in my children who have responded with poetic personal anecdotes. As I read The Greatest Generation, I was struck by the possible subtext that in some way the current generation of young people is somehow deficient in patriotism, humility, sense of service and willingness to sacrifice. But my own family has come forward to show that this is not necessarily so. The following email responses (printed with permission) to the video were sent by my family members who decided to jump in the ring to show the global understanding and thoughtful, nuanced way they look at the world in the 21st centruy:

I have heard the call to prayer. I have been a guest in Muslim households. I currently have a Muslim housemate. And i have had Muslim boyfriends! BUt besides all of that, Obama is not Muslim. WAKE UP.

I spent a year hearing the call to prayer too. I fasted during Ramadan (ok, for a day, but still), I ate a ritually slaughtered sheep during eid al adha, donned traditional Muslim dress, visited mosques, learned to speak Arabic, and I still don't eat pork. It doesn't make me a Muslim. More to the point though, being a Muslim wouldn't make me a traitor.

The call to prayer is a beautiful sound - I too heard it every morning in Indonesia, like President Obama, and I am no more Muslim than he. We need more people who appreciate the different cultures that make up this country, and fewer bigots who latch on to every divisive opportunity that presents itself. Inshallah -- God willing.

If the anniversary of 9/11 taught us something maybe it is that it'snot simple or straightforward. Let us all engage in the complex efforts to understand the larger world and nurture the next generation of hope.

image from sethskim.com via Googleimages

Freshman Orientation-Chinese Style

2011-09-07T17:46:00.000-04:00

I am not often accused of hovering over my children. In fact, I generally feel we have done a decent job of raising resilient, independent young adults.

But with my last two headed off to college these past few weeks, I have been hovering more than usual. I have to stop myself from asking what time they will be home or where they are going or asking them to check in too often. And once I dropped the first daughter off at school I was fine with getting pushed out at 6pm after a rushed, but nonetheless teary, goodbye. Fine, that is, for about twenty miles when the flood gates opened up.

So it was particularly amusing for me to see this photo :
"Parents of newly arrived freshmen students sleep on the floor of the Youming Gymnasium at the Central China Normal University on September 3, 2011 in Wuhan, Hubei Province of China. The university opens its gymnasium for the parents who sent their newly enrolled students to the college in the new term. (Photo by Zhou Liangjiu/ChinaFotoPress)

The university set out mats for some 600 parents accompanying freshmen students on their first day of school, local media reported." If you look carefully there are actually two adults on some mats.

Maybe this should serve as a reminder of how we eventually take our children's places and they ours:

image from today.msnbc.msn.com and via Googleimages

HPV (Gardisil) Vaccine and THE TALK

2011-08-30T15:56:00.000-04:00

Do parents get squeamish when they have to bring up HPV vaccine during a checkup for their 12 year old? Yes, it turns out, according to a recent study. Investigators from the Univeristy of North Carolina at Chapel Hill recently presented their work at a national meeting of the Society for Adolescent Health and Medicine.

When it comes to girls, they note that the recommended timing of the vaccine works nicely with the age at which conversation about topics related to sexuality should be happening frequently. Subtle short discussions engaged in with some regularity are better heard than the "talk" which is often awkward for everyone involved. The series of three vaccines over six months allows doctors and other providers to initiate conversation and answer questions about what exactly HPV is. But it also should be an opportunity for providers to model an easy age-appropriate three-way conversation with the young patient and the parent.

As far as boys go, the findings were a bit different and may be enlightening for providers. "Overall," said Abigail Lees, one of the researchers, "parents believed their sons to have a low susceptibility to HPV infection and its outcomes." They figure that this disbelief is driven by the stigmatization and anxiety that people feel with respect to anal cancer ( "my son isn't gay") and oral cancers ("just the thought of so much oral sex makes me uncomfortable"), both conditions associated with HPV. Of course it's not rational but we all know that denial is a powerful thing.

Is it that somehow cervical cancer in females is more "acceptable" even though it is, of course, also sexually transmitted via the HPV virus? The researchers recommend (and are funded by Merck) that "awareness campaigns" focus more on the prevalence of HPV (over 75% of sexually active people are exposed to the virus in its many forms by age 20) and less on the gruesome pictures of lesions and sores that may just backfire on parents and teens alike.

Clearly Gardisil has a PR problem and it's interesting to see how US culture surrounding issues of sexuality continues to appear to be the root roadblock to wider acceptance and immunization rates. Talk early and often to your kids. Keep it simple. Start where they are and don't make assumptions.

image from: noplacelikehome.org

Colleges: First Do No Harm

2011-08-24T08:23:00.000-04:00

Bravo to David Skorton, the president of Cornell University for speaking out against hazing in the fraternity setting in today's New York Times. Full disclosure: my son graduated in 2010 from Cornell and was a fraternity member there. My son also lived through a rash of suicides at Cornell during his senior year (although they were not necessarily fraternity related). It's not random that Dr Skorton is a medical doctor and so lends a more humanistic perspective to the issue.

Even though I usually visited the frat house the "morning after" once cleanup from the Saturday night events had begun, I am sure I joined many parents in their disgust and shock at how their sons could "live that way."

The culture of the frat, whether it is steeped in American tradition or not needs to reform. There are many traditions that we have decided need to be relegated to the history books--slavery, segregated restrooms and classrooms, rape, injustice toward the disabled, and many others. If only more of the egregious activities were revealed, much of what goes on during "pledge" week would go that way as well:

As a physician to teens and young adults, I often hear from my patients or their parents about the ostracism and disappointment that some feel when they have been "rejected" by this wayward culture. As parents we need to send the message that these "clubs" are not necessarily where our children should be. The social "rejection" can be a ticket to a much more meaningful and long-lasting alternative group of friends whose activities are not alcohol or party based. If the group photo of the frat looks like this:

....be sure to ask what goes on after the ties come off.

A mom's adoration of her teenager

2011-08-18T12:02:00.000-04:00

"She's a true beauty, and sometimes I just look at her in awe of all that she is. I'm lucky to have her in my life."
quoted (with permission) from a mom's office questionnaire about her 14 year old daughter.

It's not that often that we hear parents saying really kind things about their children. Often it's about how insolent, quiet, demanding, self-involved, otherwise unconnected or just plain "adolescent" they are. Of course, this interpretation often stems from concerns about one's children or one's parenting. In order to allow parents to express their worries and pride about their kids, I have parents answer a standard questionnaire about my new patients. In addition to family and medical history it gives parents an opportunity to speak their minds.

Perhaps it is because we don't have enough opportunities for our kids to hear how we feel about them that one of the early scenes from the new movie, The Help, is particularly moving. Aibileen, the Mobley family's maid, played by Viola Davis, tells the overweight, forlorn and awkward young Mae Mobley, "You is kind, you is smart, and you is important." This mantra is repeated several times in the film, helping Aibileen imprint on this young child in the absence of her own mother's love or recognition.

Let's start the new school year reminding our children of their treasured qualities. There are so many opportunities to disparage them, whether in our thoughts, to their faces or to others. Let's make the time to say the good things so that these positive messages stick as surely as the negative ones.
image from manzine.org

Don't Fry Your Body in Pre-Season

2011-08-10T17:09:00.000-04:00

Heat-related illness is the most common cause of illness and even death in athletes at this time of year. Korey Stringer was a Minnesota Vikings player who died in August of 2001 from exertional heat stroke.   The Korey Stringer Institute at University of Connecticut is dedicated to the prevention of sudden death in athletes and is supported by Korey Stringer's widow.

There are two basic physiologic processes that contribute to this problem. These are dehydration and hyperthermia:

Dehydration is the process of water loss leading to hypohydration. Usually measured by body mass loss, urine color, urine osmolality, urine specific gravity or via serum osmolality (gold standard).

AND
Hyperthermia is a body temperature elevated above 39°C or 102°F.

And here, from the Korey Stringer website are some other definitions, in descending order of severity:

Exertional Heat Stroke (EHS)- a medical emergency involving life-threatening hyperthermia (rectal temperature > 40°C, 104°F) with concomitant central nervous system dysfunction; treatment involves cooling the body.

Heat Exhaustion- Inability to continue exercise in a hot environment due to cardiovascular insufficiency usually in combination with prolonged heat exposure, cutaneous vasodilation, muscular exertion, and dehydration.

Heat Syncope- A brief fainting episode in the absence of salt, water depletion, fluid loss or
hyperthermia, often subsequent to prolonged standing.

Heat Cramps- Painful spasms of skeletal muscles, usually after exercise in a hot environment.

For some really frightening stories about illness and two recent deaths on the football field check out this blog, Training and Conditioning.

Here are some basic guidelines laid out for athletes by the Korey Stringer Institute:

1. Listen to your body- if you do not feel well, back off (lower your intensity) and seek help if you continue to feel lousy.

2. Hydrate yourself- try to keep your urine color like lemonade and not like apple juice.

3. Listen to your thirst- if you are thirsty, you need fluids.

4. Phase in exercise in the heat- called heat acclimatization, the first 7-10 days should gradually include an incremental increase in intensity, duration, equipment, etc.

5. If your teammate, child, athlete, friend, colleague, look like they are struggling in the heat, seek shade/ice/fluid/rest for the person. If they do not start to do better immediately, call 911.

6. Be sure that an athletic trainer is employed by your high school to take care of the prevention, recognition, and treatment of emergency situations in sport.

7. Be sure to educate coaches and athletes about these tips and the common signs and symptoms of heat illnesses.

8. Realize that your performance will be about 10-15% worse in the heat as compared to cooler climates. Adjust pace, intensity, and effort accordingly.

9. Be sure you are getting enough salt in your diet/sports drinks/sport foods. Sodium assists with the hydration process and you lose a lot in your sweat during intense exercise in the heat.

10. If someone is suffering exertional heat stroke, cool them immediately using cold water immersion, the amount of time hyperthermic (not the temperature obtained) is the key to outcome being life or death.

Most school athletic departments have guidelines that encourage coaches and trainers to pay attention to the Heat index and the Real Feel Temperatures when they are practicing. Of course, they need to remember that the index at noon is very different from what they will feel later inthe afternoon.   Schools should have policies that call for cancelling practice when the Heat Index is over 95 degrees Farhenheit. Here is a website for New York State that charts the correct actions to take based on the Heat Index. And here is a fairly good explanation of the difference betweeen Heat Index (essentially a mix of heat and humidity) and the (Accuweather) Real Feel Index (more complex that takes cloud cover, wind and other factors into account).

Knowing that the country is in the grips of a severe weather system, there is no reason to believe that the temperatures and humidity will vastly improve before pre-season starts. It's a good idea to start acclimatizing by spending time in the heat and humidity and beginning to work out under the hot conditions to get the body accommodated.   Although water is generally good enough to hydrate most athletes, when there is a great deal of sweating, electrolyte containing drinks are going to be much better.

image from beautyangle.com

Mom: Your Brain is Really OK

2011-08-04T09:13:00.002-04:00

The older graduates are coming home, raiding the refrigerator and using the kitchen computer to look for a job (wouldn't want it any other way) and the youngest are sorting through extra-long twin sheets and supply lists while everyone scrounges for the last frozen pizza for a SNACK, and the laundry keeps cranking through the machines (small prayer here to the appliance gods). I am impressed by my own ability to juggle it all while I listen to Adele and run to the grocery store for more milk and juice and go to work.

Funny thing because I was just thinking about how my mind was getting old and I keep losing my keys or my parking spot or forget that I already told the kids that story from my own freshman year. And just in time a book was recommended to me that explains how the middle aged brain can actually do all these things, i.e. forget and accomplish so much. The Secret Life of the Grown-Up Brain:the surprising talents of the middle-aged mind by Barbara Strauch, science and health editor at The New York Times, is a primer on the current psychological and neuroscience research into the ways in which my mind and those of many friends and parents of patients are functioning. Trust me, it's a godsend.

Next time I get reprimanded for re-telling a stupid joke or forgetting a friend's name or the plot of a movie (or that I even saw it before) let me remind people that Strauch says we are better at problem-solving, integrating, social expertise, judging character and situations, multi-tasking (oh yeah!) and wisdom. Used to be that wisdom came with "old age" but it turns out no one really studied healthy middle-aged people so much before. And contrary to decades of "wisdom" it turns out that the brain can make new cells and most importantly, new connections.

So I say, bring it on that middle age stuff. Reading this book I felt empowered to recognize how we have traversed so much life and are really experts in our own little corners. Like the Kali, the multi-limbed Hindu goddess associated with eternal energy and motherhood (and also violence since the world is not so simple), we have many arms and they are all moving, keeping the worlds we inhabit in balance.

Can Me and My Boyfriend Have a Sleepover?

2011-07-26T14:31:00.000-04:00

image from blogs.marinij.com

"Normalizing teenage sex under the family roof opens the way for more responsible sex education."

It turns out that this thoughtful statement is pretty radical in the United States. And that is probably why Amy Schalet's article in the New York Times is one of the top ten most frequently emailed articles today. Although her data is based on a very small (130) and narrow ("all white, middle class and not particularly religious") sample of people, it is provocative for many. It's difficult for most Americans to "normalize" teenage sex when such a loud section of the national discourse looks at sex as "urges" that people cannot manage well, that inevitably end in bad things like pregnancy, STD's and broken hearts. Teen sex is seen by many as something to be tamed, ignored, suppressed or at worst denied.

Some parents sanction a fully open relationship over sexuality and others, whether by tradition, faith, politics, or squeamishness, prefer to be discrete. All parents need to be as clear as possible about their values and the expectation that teens will be safe-emotionally and physically.

Schalet makes the interesting (and for many, counter-intuitive) point that parental involvement in their childrens' emotional and intimate lives allows them more ability to influence and protect. She nicely calls it "control through connection."

However, when I look at teenage sex through a developmental lens, whereby we expect adolescents to become independent, to make mistakes, to take risks and to experiment with lifestyles and relationships (meaning that sometimes they decide to breakup), it might be more difficult for the average teen to traverse these waters if the boyfriend or girlfriend has become part of the family.

Medical Care for Young Adult Men

2011-07-18T15:06:00.000-04:00

A recent article in the Journal of Adolescent Health focussed on the health care access of young adults (19-24). Available in abstract here, it makes a number of points:

insurance matters: "young adults are twice as likely to be uninsured than any other age segment of the population"

males have greater barriers to accessing primary care than females: increasing numbers of young women seek care from their gynecologists rather than primary care providers but clearly young men do not have such an option.

clinical guidelines need to be developed for primary care: other than in the specialties of Ob/Gyn and Adolescent Medicine, there are few guidelines for managing the health of young adults.

young adulthood remains a missed opportunity for preventive interventions: all of the health issues of middle age take root in the younger years (overweight, heart disease, diabetes, bad habits, poor stress management) and anticipatory guidelines should be laid out early.

For young men ages 15-29, two thirds of deaths are accounted for by "unintentional accidents", homicide and suicide. In other words, behavior and mental health are more responsible for losing our young people than infections, cancer, or heart disease. And the behaviors we are talking about here are excessive and dangerous drinking; reckless driving; risky athletic pursuits; untreated anger, depression and anxiety; and unsafe, unhealthy or unethical sexual practices.

How upsetting that young men in our midst get the shortest end of the stick when it comes to health care! In spite of the fact that young adults have higher rates of mortality, more at risk behaviors, and more chronic disease than teens, they have much less access to medical care. Just when young adults start to "think clearly again" after the fog of adolescence they are rudderless when it comes to their health care. A larger proportion of their care is delivered in emergency departments and is not covered by insurance thereby almost ensuring poor follow-up. There are numerous missed opportunities for behavioral counselling on anger management, smoking cessation, prudent alcohol use, safe driving and athletic activities.

We can hope that as more allied professionals (nurses, nurse practitioners, medical assistants) join other providers in caring for this population they will receive the hands-on approach they have been accustomed to with their pediatricians and adolescent medicine providers. In the mean tim, orthopedists, emergency room doctors, urologists, and dermatologists can all pitch in to ask the questions young men need to answer and learn from.

Exergaming: A New Kid Friendly Way to Exercise?

2011-07-13T09:19:00.000-04:00

Kids playing Sportwall

What the heck is "Exergaming"?

According to a new study in the July issue of Archives of Pediatrics and Adolescent Medicine, "exergaming" is "interactive digital exercise that features player movement." Games you may know of this ilk include Dance, Dance, Revolution; LightSpace; Nintendo's Wii, Sportwall; and Xavix to name a few.

Part of me wonders if this encouragement of electronically based indoor activity is the equivalent of the smartboard replacing the black (or white) board, when we all know that kids need to get outside, enjoy nature, and discover their bodies in the big open spaces (see my June 30 blog post
http://www.annengellandmd.com/.)

So I was curious to see the conclusions of this ingenious study conducted with middle school after school programs in Boston, Massachusetts. Most of the games resulted in increases of energy expenditure over the equivalent of walking at 3 miles per hour. The researchers also studied enjoyment of these activities and interestingly discovered that kids with higher BMI values actually got more fun out of them. "Such a result," says an editorial in the same journal, "suggests that exergames may be an attractive mode of activity for overweight and obese adolescents." The authors discuss ways to promote longterm use of the games as a means of exercise since even in this study--with lots of encouragement and followup-- use fell off over time. One suggestion is the idea of using games at home and in group activities in an after school, gym or club setting. Religious groups, scout troups, gyms with teen programs, and even day camps with rainy day activities might be interested in investing in this technology.

Although pediatricians generally want to promote outdoor activities, the authors and editors of this journal article maintain that exergames "can contribute to daily physical activity, their purchase encourages the electronics industry to invest more heavily in innovation and promotion of such games, and they could help keep adolescents fit enough to enjoy doing other forms of physical activity."

In my experience there are very few acceptable activities for the non-athletic overweight adolescent who more than most needs a fun, acceptable and sustainable form of safe exercise. Wouldn't it be great if our schools health programs could team up with athletics to purchase and promote a program that would do just that!

Prescribing exercise

2011-06-30T15:39:00.000-04:00

from the American Trails Organization

As most patients know, doctors are slowly (and often reluctantly) moving over to the mandated electronic medical record systems. Being one of the reluctant ones, I must confess that the great advantage of the EMR is the ability to call in and track prescriptions for patients. I know for instance if a patient is filling a prescription and I can be sure that the prescription is legible and actually received by the correct pharmacy.

So what to do with all those pre-printed prescription pads?

I recently discovered that I can write prescriptions for exercise and patients take the recommendation more seriously. After all, I explain, exercise will often get you healthy as much as an antibiotic or a diet. And we know that it prevents all kinds of diseases and ailments including heart disease, diabetes, cancer and arthritis.

For an overweight person who is not exercising I now recommend my own version of "interval training" which according to the Mayo Clinic simply means this:

It's not as complicated as you might think. Interval training is simply alternating bursts of intense activity with intervals of lighter activity.

Take walking. If you're in good shape, you might incorporate short bursts of jogging into your regular brisk walks. If you're less fit, you might alternate leisurely walking with periods of faster walking. For example, if you're walking outdoors, you could walk faster between certain mailboxes, trees or other landmarks.

I will start with a simple prescription for twenty minutes of walking three times a week. I suggest making the 10-15 minute period in the workout very fast paced or up a hill or set of stairs. How do you know if you are working intensely enough? Simple. Push yourself for those five minutes until you are out of breath and cannot carry on a conversation with an exercise partner. Then spend the last five minutes cooling down.

Benefits:

increased aerobic capacity
mental health benefits
increased ability to keep up
urge to exercise sets in (after 2-3 weeks)
possible weight loss
improved tone

One exercise I love to recommend is that folks take their bikes on the Rails to Trails paths. These are restored railbeds all over the country, including several miles of them in Westchester County where the grade is rarely over 5 degrees and there are seldom cross streets. It is possible to do interval training at a rapid pace just by going faster without the fear of traffic. One of my favorite trails crosses the Croton Reservoir. Out West, the American Parks association is promoting Park Prescriptions, the same idea of exercising but they are marrying this salutary habit to national parks where the trails can be fantastic and fun.

Happy Fourth of July and Happy Trails!

What Would Help You Quit Smoking?

2011-06-23T22:36:00.002-04:00

This week the FDA announced that it would require cigarette manufacturers to display graphic photos of the dark side of smoking tobacco on the top half of all packages.

Now if this:

and this:

aren't grotesque enough, could this possibly have more impact?:

“These labels are frank, honest and powerful depictions of the health risks of smoking, and they will help encourage smokers to quit, and prevent children from smoking,” said Kathleen Sebelius, the secretary of health and human service in a statement at the time of the release of the new policy. Really?

The FDA claims to have done its research and come up with these "scientifically" proven methods of discouraging use. But the problem I see with kids and teens smoking is that many of them never see the pack.   According to Marketplace, a public radio sponsored website, a pack of cigarettes in New York now costs over $10.   That's around the hourly rate for suburban teenage babysitters. So you can imagine that it is unlikely that most smoking kids actually buy a pack. What they do is share and sometimes buy one cigarette at a time from a friend or supplier.

So what could the FDA have imagined as a more likely way to reach smoking youth? They could require manufacturers to actually write on each cigarette paper itself. "Do you really need this cigarette?" "Could you think of another way to spend a dollar?" Or how about a sort of measuring tape printed (in organic harmless ink, of course) that might say: "Stop now and kill this butt."

I'm open to suggestions but the point is that each and every stick needs to be a warning or reminder or encouragement to stop.   Data shows that over 85% of teens who smoke wish they could quit. With all of the research, I wonder how many FDA scientists were hanging around the designated spot at the local high school where kids smoke with impunity and adults seem to turn a blind eye.

Maybe we should ask the kids how to help them quit.     If you know a smoker, try asking him or her. I am not sure the FDA did that.

Graduate, But You Don't Need to Leave!

2011-06-20T08:57:00.001-04:00

Not a day goes by without a blog, email, listserve post, journal article or query in my office about how best to transition older teens and young adults to "adult" medical care. This is especially of concern for patients with special health care needs, or SHCN, the acronym that is currently in vogue. SHCN include medical diagnoses such as diabetes, cystic fibrosis, and congenital heart disease; emotional illnesses such as depression, eating disorders, and anxiety; and developmental disabilities such as autism spectrum disorders, mental retardation and learning differences.

Last week the New York Times published an article by Perri Klass, a Boston pediatrician who frequently writes about current medical topics, called "The Graduation that May Carry Unnecessary Risk" referring to graduation from the pediatrician with nowhere to go and no help in transitioning.

This article is woefully lacking in understanding of what Adolescent Medicine physicians do. As a board certified specialty, adolescent medicine physicians fill exactly the role that Dr Klass is calling for. In her article she gives parenthetical mention to adolescent medicine physicians as managing reproductive concerns but fails to mention that most adolescent medicine physicians are trained to and capable of --and actually enjoy--caring for the special needs of all patients as they age up. This includes primary care, psychological counseling for the patient and the family and communication with the myriad of specialists involved in complex care.

In my practice in White Plains, not only are we committed to this transition (up to age 26) but we are organized physically (with a separate space for teens and young adults) and medically (with board certified care available for all older patients) to respond to this growing need. As the waiting rooms of internists fill with the aging population, young adults--especially those with SHCN, require a comprehensive program that can address all their concerns. We have that, right here.

The most unwanted souvenir from travel abroad

2011-06-12T11:30:00.001-04:00

As a frequent international traveller, I have been giving guidance, advice, immunizations and prescriptions to my patients and families for some time. Because I am a licensed yellow fever vaccine provider I often hear from patients planning trips beyond western Europe.

Now, however, we hear of outbreaks of measles in France and other European countries. This year alone, there have been over 5000 cases of measles in France. Most of these occurred in children who were not vaccinated at all or were inadequately vaccinated against measles. Measles is not a mere nuisance of childhood. It often involves significant illness (that would definitely ruin a vacation), potential for hospitalization and a non-negligeable mortality. Pediatric News (available here with free signup) reports that in January and February of this year there were 28 cases of "import-associated" measles in the US. Patients had either traveled abroad or were exposed to someone who had.

Generally speaking the target group here is infants less than a year of age who have not yet had the recommended vaccine, typically given right after the first birthday. It is now suggested that these infants be vaccinated before a trip abroad (except to Canada and Australia) and then again once they are over 12 months of age. If you have friends or family traveling with young children be sure to remind them to look up the current recommendations and take them to their pediatricians who may not be aware of the current practices given the recent outbreaks overseas.

Most teenagers and young adults have been fully vaccinated against measles. However, a surprising number of patients have not been fully vaccinated against measles often by parental choice. Sometimes this involves a religious exemption to required vaccines. Sometimes there have been concerns about safety of the vaccine (Did it cause autism?) and these concerns have never been addressed and updated since new research has overturned this theory. If I see patients like these who are now over 18 and responsible for their own health I will have a conversation about risk and benefit, especially if they are going abroad. After all, the risk with measles (and other illnesses like pertussis-whooping cough) is not just to the patient herself but to vulnerable people in her midst.

image from bluedeerhealing.com

"Stepping Away"

2011-06-09T21:21:00.000-04:00

Suffering from a broken heart? Missing your classmates already? Worrying about college? a job? Life in general? Feeling in love? Sensing the urge to write poetry? Keeping a journal?

This week's New Yorker magazine treats us to a feature called "Starting Out" that showcases five wonderful short autobiographical pieces by authors who recount or recollect what it's like to be an adolescent or a young adult. When they are supposed to be on the brink of bigger things and moving on or out or up, they are sometimes confused, dejected, rejected and bewildered.

Jennifer Egan in "Archeology" writes about spending a gap year and working as an archeologist for a while to satisfy and dismiss a passion. In less than a page, Junot Diaz writes in "The Money" about understanding his neighborhood and the moral revelation afforded him by a theft. Tea Obreht tells us in "High School Confidential" about the ignominy (and the lessons) in having her written word mocked and disrespected.

"Where I Learned to Read" by Salvatore Scibona is a funny one-pager about a near high school dropout who is turned on to the esoteric and exceptional Great Books program at St John's College, always an intriguing school on the early lists of a few of my children.

Finally, in "Shacks," and in very few choice words, Edward P. Jones conveys the pain of having his letters ignored by his love interest, Sandra. But he also conveys the strong allure of writing when he says: "I don't know what I would have done if I hadn't had it in me to write those letters, those stories, to Sandra." Writing is a tool, he says, that helps to create a little shelter, or shack, that we can inhabit, however briefly.

One of my favorite writers, Jhumpa Lahiri, tells us in "Trading Stories" ( in another section of the magazine) about her own development as a young writer and what the craft did for her:

"...writing is one of the most assertive things a person can do. Fiction is an act of willfulness, a deliberate effort to reconceive, to rearrange, to reconstitute nothing short of reality itself."

There are many situations and emotions that draw us to the keyboard or paper. For teens and young adults, often awash in emotions, life changes, uncertainty and possibility, writing is a way for them to center themselves and to try on or explore intense feelings. In these uncertain economic times, writing can be a life saver and serve a therapeutic purpose. But it might also just be the start of a career.

image from Googleimages. com

A Piece of the Pie

2011-06-03T13:50:00.001-04:00

Don't miss that phrase:
"We Specialize in Pharmaceutical Catering."
More about that in a bit.

My office building is a four story modern one that is essentially all medical offices. A real goldmine for pharmaceutical drug reps. They can park once and do what they do best--peddle their pharmaceuticals to busy doctors and their staff. One might ask how, in these times of shortened and harried office visits does a rep expect to get the attention of the ultimate prescriber.

This was made slightly more difficult by a two year old movement spearheaded by PhRMA, a drug company trade group with an eye to cleaning up their act and not appearing to be bribing doctors. According to a 12/30/2008 article in the New York Times, the pharmaceutical industry "agreed to a voluntary moratorium on the kind of branded goodies --Viagra pens, Zoloft soap dispensers, Lipitor mugs — that were meant to foster good will and, some would say, encourage doctors to prescribe more of the drugs." So the pens are gone. In fact there are doctors who proudly display their pen collections as historic mementos of a time gone by. But there are still plenty of opportunities to influence and cater to doctors.

DR Caren and his Pharmaceutical Pen Collection

And that's where the pizza comes in. Staff lunches for several hundred dollars, including many different types of pizza, salads and drinks are commonplace in offices, unless they are actively forbidden and stopped. There are frequent invitations to free dinners at nice local restaurants with compelling speakers on topics that are not even necessarily related to the drugs the company sells. Some companies make it more subtle than they used to. After all, it defies one's commitment to science and purity to admit that one might be swayed by a fabulous prix fixe menu (of $0) where the fine print at the bottom says "Merck."

Fortunately there is another voice out there. The website NoFreeLunch is dedicated to the principles that I was raised on as a resident at Babies Hospital (part of Columbia Presbyterian) under the often austere chairmanship of Michael Katz, MD who did not allow drug reps in the building. If we heard "GI Rounds" on the overhead PA, it was not so that we could be regaled with "pharmaceutical catering" but to be invited to bring our own lunch and discuss a case of gastrointestinal disease. (I know, I know, doctors can do really gross things while they eat.)

There is ample evidence to suggest that doctors are indeed influenced by these friendly, apparently collegial overtures. But doctors can and do make the pledge not to participate in this insidious enterprise. From No Free Lunch comes this pledge:

"I, __________________, am committed to practicing medicine in the best interest of my patients and on the basis of the best available evidence, rather than on the basis of advertising or promotion.
I therefore pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my practice, teaching, and/or research."

No Free Lunch invites doctors to participate by emailing the pledge to Pledges@nofreelunch.org. Encourage your doctors to do so. I did.

Get Your Head Examined!

2011-05-27T11:38:00.000-04:00

You'd have to be really checked out to have missed the hubbub about concussions, aka "traumatic brain injury" or TBI, that has been in the media over this past year. Now you have an opportunity to protect yourself or your child, to contribute to neuroscience and to make some money. How much fun is all of that for a summer when jobs are scarce and it's going to be hot?

Here is the story. Standards for concussion diagnosis and management are rapidly changing. It is now clear that concussions are much more common than previously recognized and that recovery may take much longer than we knew. Neuroscientists have been working to develop more objective ways to detect the changes in the brain that are associated with head trauma so as to make wise decisions about return to play.

My alma mater, Cornell Medical School, and the Brain Trauma Foundation reached out to me to recruit athletes and people ages 7-80, to study a new method of detecting minimal brain trauma.

Here is what they said (bold type mine):

The Brain Trauma Foundation is investigating a new method of identifying concussions and assessing attention and memory deficits caused by mild Traumatic Brain Injuries in children and adults. We are working with the Department of Defense,
The James McDonnel Foundation, and several leading medical universities to test a newly developed eye tracking device that is able to detect the possible concussions by assessing attention delay in less than 1 minute.

We are looking for children between the ages of 7-17 and adults between 18-55 years who have sustained a previous mild traumatic head injury, along with healthy individuals between the ages of 7-74 who would like to participate as our controls. We are also looking for participants who have been diagnosed with Attention Deficit Disorder. Additional exclusion criteria include no prior neurological diagnoses, no history of substance abuse problems, no major psychiatric disorders, no gross visual or hearing problems, and no pregnant women.

Prior to enrollment, we conduct a 20-30 minute telephone screening to determine eligibility. Testing is conducted at the Citigroup Biomedical Imaging Center on the Weill-Cornell Medical College campus in NYC and usually takes about 4 hours. Our protocol is WCMC IRB-approved and includes interviews, computer tests, paper-and-pencil tests, and an l MRI scan. Participants are compensated $450 for the 4-hour testing session, and those from the control sample are free to use the data we collect as baseline testing for future mTBI’s (ie concussions).

For more detailed information go to the Brain Trauma Foundation and click on research for lots of information. Alternatively you can email Jodi Kanter at jkanter@braintrauma.org. It feels great to be a part of something this important. Please let me know if you participate.

"How external cues make us overeat"

2011-05-19T11:26:00.000-04:00

True confession. Last night I polished off the bottom third of the Edy's coffee ice cream. Was I hungry? No. Was it late? Yes. Am I trying to gain weight? No. Was it pretty lame? yes.

So today the May 2011 Nutrition Action Newsletter cover story called "Under the Influence" intrigued me. What made me do that? Ever mindful of using my own life as a laboratory for making me a better doctor and more empathic toward my patients, I decided to read on.

The article describes research done by Brian Wansink of Cornell University who applies social science, psychology and economics research techniques to demonstrating why and how people eat unintenionally or mindlessly. Sometimes it's just the environmental cues rather than hunger or even an emotional need:

People will actually eat 45% more popcorn at a movie if they have a larger bag (but not more popcorn).
The proximity of a jar of Hershey's kisses on a person's desk can lead to eating almost twice as many in the course of a day than if the jar is just six feet away.
The name of a food (like "Edy's Slow Churned" vs "plain coffee ice cream") can influence the amount of food a person eats and how they enjoy it.
The size of the plate and the type of plate will influence the quantity of food eaten. A stylish plate will contribute to the experience of a brownie much more than if it is served on a napkin.
Eyes are more important than cues from the stomach. In one experiment, people ate 28% more chicken wings if the bones were removed as opposed to building up on the table.
We are all affected by something called the "halo" around foods. In one study people estimated the calorie count of food labelled as "organic" to be 15-20 percent less than if it was not labeled as such.

I love the Nutrition Action Health Letter for a number of reasons. Published by the wonderful Center for Science in the Public Interest, it comes out ten times a year. It's inexpensive, fun to read, full of information, edgy, witty enough, politically left enough to create a stir, and best of all the back page has a column called "Food Porn." Here they expose foods from restaurants or packaged food that is notoriously high in calories, saturated fat, sodium or other harmful ingredients. They also expose the "halo" effect and educate readers while keeping them laughing and giving them great alternatives.

image from www.themoderatevoice.com

Can you afford a $39 Sports Physical?

2011-05-13T23:28:00.000-04:00

For $39 you can buy a manicure-pedicure; a dinner at a local restaurant (without much wine); a movie for four (except on Tuesdays when it's free for Optimum customers); an exercise class for two; or half a tank of gas. CVS' Minute Clinic (is that "minute" as in a sixtieth of an hour or is that "minute" as in very small?) is offering a special on the sports physical for just $39. If you are really so busy or disorganized or unlucky with your insurance or physician, you can take your high school junior to have a ten minute physical at the local CVS. You choose. If you must.

Of course, according to their website, at CVS you will be required to call or otherwise contact your regular pediatrician or other provider to obtain your child's immunization record and health history (Did he have a CT or an MRI back in 1998 when he had that concussion? Do they care? Do I remember?) In exchange for all this information and a few minutes of time (and it seems without even the indignity of having to undress to be examined) they will fill out and stamp and sign all the requisite paperwork. Back to practice you go!

But will they really do what is required of a doctor to verify that a student is safe to participate in sports? Will they know (if you or your independent junior does not tell them) that your son sat out an entire six weeks of basketball practice after his head injury last February? Not if he really, really wants to play lacrosse and decides not to tell them. Even though your pediatrician is fully aware of this. Will they care if he has had unprotected sex, that he has genital warts, but does not have to take his clothes off at the minute clinic?

Probably you get the point already. Our bodies are not like our cars or our pets. It might be worth the discount coupon to have the oil changed at the local QuickLube place on the corner. But are we really ready to treat our children like machines that give up their secrets quickly and reliably? Are we really ready to surrender our therapeutic relationship with someone who really knows our history, about the divorce, about the concussion or the history of asthma to someone who really has no interest in our children's health and welfare?

McDoc might be here to stay but all you have to do is "Just Say NO." Please do.

image from Googleimages.com

Mother's Day

2011-05-07T12:39:00.000-04:00

image from Googleimages.com

Today I received an email with Anna Quindlen's wonderful essay, "All my babies are gone now" from her book, Loud and Clear, published in 2005, but with a timeless message for those of us experiencing the metamorphosis of our babies into teens and young adults. Enjoy and pass it along.

All my babies are gone now. I say this not in sorrow,
but in disbelief.

I take great satisfaction in what I have today: three
almost-adults, two taller than I am, one closing in
fast. Three people who read the same books I do and
have learned not to be afraid of disagreeing with me
in their opinion of them, who sometimes tell vulgar
jokes that make me laugh until I choke and cry, who
need razor blades and shower gel and
privacy, who want to keep their doors closed more than
I like.

Who, miraculously, go to the bathroom, zip up their
jackets and move food from plate to mouth all by
themselves.

Like the trick soap I bought for the bathroom with a
rubber ducky at its center, the baby is buried deep
within each, barely discernible except through the
unreliable haze of the past.

Everything in all the books I once poured over is
finished for me now. Penelope Leach, T. Berry
Brazelton, Dr. Spock. The ones on sibling
rivalry and sleeping through the night and
early-childhood education - all grown obsolete. Along
with Goodnight Moon and Where the Wild Things
Are, they are battered, spotted, well used. But I
suspect that if you flipped the pages dust would rise
like memories. What those books taught me, finally,
and what the women on the playground taught me, and
the well-meaning relations - what they taught me, was
that they couldn't really teach me very much at all.

Raising children is presented at first as a true-false
test, then becomes multiple choice, until finally, far
along, you realize that it is an endless essay.

No one knows anything. One child responds well to
positive reinforcement, another can be managed only
with a stern voice and a timeout. One child is toilet
trained at 3, his sibling at 2.

When my first child was born, parents were told to put
baby to bed on his belly so that he would not choke on
his own spit-up. By the time my
last arrived, babies were put down on their backs
because of research on sudden infant death syndrome.
To a new parent, this ever-shifting
certainty is terrifying, and then soothing.

Eventually you must learn to trust yourself.
Eventually the research will follow. I remember 15
years ago poring over one of Dr. Brazelton's
wonderful books on child development, in which he
describes three different sorts of infants: average,
quiet, and active. I was looking for a sub-quiet
codicil for an 18-month old who did not walk. Was
there something wrong with his fat little legs? Was
there something wrong with his tiny little mind? Was
he developmentally delayed, physically
challenged? Was I insane? Last year he went to China.
Next year he goes to college. He can talk just
fine. He can walk, too.

Every part of raising children is humbling. Believe
me, mistakes were made. They have all been enshrined
in the 'Remember-When-Mom-Did' Hall
of Fame. The outbursts, the temper tantrums, the bad
language - mine, not theirs. The times the baby fell
off the bed. The times I arrived late for preschool
pickup. The nightmare sleepover. The horrible summer
camp. The day when the youngest came
barreling out of the classroom with a 98 on her
geography test, and I responded, 'What did you get
wrong?' (She insisted I include that here.) The time
I ordered food at the McDonald's drive-through speaker
and then drove away without picking it up from the
window. (They all insisted I include that.) I did
not allow them to watch the Simpsons
for the first two seasons. What was I thinking?

But the biggest mistake I made is the one that most
of us make while doing this. I did not live in the
moment enough. This is particularly clear now that t he
moment is gone, captured only in photographs. There
is one picture of the three of them, sitting in the
grass on a quilt in the shadow of the swing set on a
summer day, ages 6, 4 and 1. And I
wish I could remember what we ate, and what we talked
about, and how they sounded, and how they looked when
they slept that night. I wish I
had not been in such a hurry to get on to the next
thing: dinner, bath, book, bed. I wish I had
treasured the doing a little more and the
getting it done a little less.

Even today I'm not sure what worked and what didn't,
what was me and what was simply life. When they were
very small, I suppose I thought
someday they would become who they were because of
what I'd done. Now I
suspect they simply grew into their true selves
because they demanded in a thousand ways that I back
off and let them be. The books said to be
relaxed and I was often tense, matter-of-fact and I
was sometimes over t he top. And look how it all
turned out. I wound up with the three
people I like best in the world, who have done more
than anyone to excavate my essential humanity. That's
what the books never told me.
I was bound and determined to learn from the experts.

It just took me a while to figure out who the experts
were.

---Anna Quindlen

Virginity and the Prom

2011-05-05T10:24:00.000-04:00

This article was published yesterday in my quarterly newsletter but by popular demand I am posting on my website today so that anyone who is not signed up for my newsletter can read it. Thanks for all the interesting reactions to this story from patients and parents alike. And here's to a happy, memorable prom for all those we care about:

If you are a prom-goer, the parent of one, or maybe one of the chaperones -- listen up. After you think and talk about a date, a dress, whether to wear a cummerbund, which friends to share a limo with, which after-party to attend, and what to do about alcohol, remember to think and talk about sex, too.

I once read that 1 in 5 seventeen-year olds plans to have sex for the first time on prom night. Hmmm. Stated another way, twenty percent of prom-goers will lose their virginity on prom night. If we consider that half of US teens do not use condoms at the time of their first intercourse, we are looking at lots of unprotected intercourse. Might as well slip the "morning after pill" into the OJ at the after-prom breakfast. Just kidding.

Most of us know that sex education at home ought to take place over many years and in many different conversations. But maybe prom deserves yet another chat. What are the important messages to share during this conversation?

For a lot of reasons, "loss of virginity" should be a "planned" thing. Not a spontaneous, swept-up-in-the-moment sort of event. Planning actually prevents regret, disease, embarrassment, and unwanted commitments, like pregnancy and babies.

Virginity is not a gift to give away. Nor is it a reward for being asked to the prom. You never "owe" anyone sex or sexual favors. A conversation ahead of time, in the calm of a cool sober moment can set the boundaries before there is a misunderstanding.

What is virginity anyway? It is not an anatomic reality; it is a concept. Teens experiment plenty with fondling, touching, hooking up, playing the bases, "outercourse" or whatever you want to call it before they have intercourse. They incur plenty of risk of herpes, HPV, other STDs and even pregnancy from these activities alone. The physical reality of intercourse is on a continuum with all these other ways of being sexual. Nevertheless, few would argue that intercourse ratchets up the risk - emotional, physical, and psychological.

If you decide that prom night is the night, and you are confident that the person you have chosen is someone you can trust with your body, your emotions and your reputation, then ask yourself one other question: How can I make this experience the best it can be, one that I will not regret for as long as I live?

Buy condoms, whether it's for you or for your partner.
For Girls: buy or ask your doctor for a prescription for Plan B. (Plan B is the morning after pill, available over the counter for anyone over 17 with ID.) If the condom "malfunctions" this is imperative as back-up. If you aren't sure how to use it check here.
Drinking is illegal, of course. If you choose to drink anyway, do not consume more than one drink per hour. Intoxication will take away from the experience in ways you won't even realize. Make the first time a good time, and one to remember, literally. Don't find yourself asking the next day: "Did I really say and do that?"
Take your time with your lover. Don't rush. Enjoy the touch, the pleasure, the joy of being sexual with someone who matters to you. Being a good lover takes practice. Don't be too tough on yourselves if it doesn't seem like the movies.

If you choose abstinence, have you thought through how you will do that? Abstinence may take more advanced planning than sex! What will I say and when? What if he/she/I get carried away? Will "No" mean "No"? Can I withstand the pressure? What if I lose my relationship for refusing? What if someone forces me? Try this: Stand in front of your mirror and try saying "No, I don't want to have sex tonight" or "That's as far as I want to go." Then wipe that smile off your face and practice saying "No" like you really mean it.

Even if you have had intercourse already with this person or someone else, it is perfectly fine to decide that on this particular occasion, you will be abstinent. The choices are yours and belong to no-one else.

To reinforce your choice about abstinence, you should choose not to drink alcohol. Alcohol will lower your inhibitions of course, but it might be putting you at risk of changing your mind, getting swept up in the craziness or making regrettable decisions.

There are other options to consider. If you cannot have "the" conversation with your potential date, then consider going with a friend or a group rather than a "date". Once the party starts large groups of kids who are not looking for sex can have great fun being together.

Let your parents know where you will be and when. Be sure you have an escape plan if things are dangerous or dangerously dull. Always have your cell phone and cab money handy

Remember to put your own feelings first when it comes to sex. Be proud of whatever decision you have made and trust your sober judgment.

PS: It's not just adolescent medicine doctors who think about this stuff. If you don't believe me, check out what the limo drivers have to say here: http://www.limosforproms.com/sex-and-prom-night.htm

Raising Resilient Kids in Seismic Times

2011-04-28T21:51:00.000-04:00

Haitian Teens help build a clinic just three weeks after the earthquake, January 2010

Tonight I gave a lecture at the Mamaroneck High School to a committed group of district-wide parents who came to hear about the budget(not from me--not my forte!) and to listen to some simple guidelines from me about the importance of resilience for raising authentically successful kids. Realizing that success in turbulent and uncertain times is not something that stops at high school or college, we can think about how to raise our children and teens in a way that fosters responsible adulthood.

My lecture is based on the Seven C's of Resilience, a concept endorsed by the American Academy of Pediatrics and promulgated in the work of Doctor Ken Ginsburg, a pediatrician in Philadelphia.

The Seven C's are:
Confidence: it’s not the 90’s message of self-esteem. It’s not about empty praise. How could you ever live up to being compared to Picasso in Kindergarten?

Competence: the real kind. the kind you feel when people notice what you are doing well, really well

Connection: Not about the internet or social media alone. But about the power of stories and generations of friends and family and the Venn diagram of circles of friends.

Character: Living a life of values. Having a strong yardstick of tradition, religion, law, standards, family values, and ethics

Contribution: knowing you matter in this world. Understanding that service to others feels good. One day you might ask for it and then you will know that it actually feels good to help others.

Coping: Learning positive coping strategies for managing day to day and in crisis. This is about modeling what to do and not merely talking about what not to do.

Control: the concept of the "locus of control" and the different parenting styles: authoritarian, authoritative, permissive and disengaged. Instilling a sense of “I can handle this” vs “What I think or do doesn’t matter”

Three books are recommended from this talk:

Ken Ginsburg, MD, A Parent's Guide to Building Resilience in Children and Teens: Giving Your Child Roots and Wings (American Academy of Pediatrics), 2006 and 2011

Richard Weissbourd, The Parents We Mean To Be, 2009

Michael Gurian, Nurture the Nature, 2007

Here is a list of qualities to consider when thinking about the meaning of real success as a person:
kindness, generosity, compassion, creativity; being innovative, full of ingenuity, unafraid, competent, trustworthy, global, and authentic.
Feel free to comment and add more of your own.
Thank you Mamaroneck PTA and SEPTA for this opportunity to reach parents.

Herpes, whether you know it or not. That is the question.

2011-04-27T11:07:00.002-04:00

Since April is STD Awareness month, I thought it important to share a bit of new information about Herpes Simplex infection. Oy.

OK. It looks sort of pretty in this picture but not so much in this or this.

Recent research has shown that even symptom-free people without a known case of herpes to their name can be carrying and transmitting the virus. So even a person who looks like this:

can actually be spreading herpes with kissing or oral sex. This comes from a recent study published in the august journal JAMA.

"Most people, when they shed, do not have any symptoms," study co-author Dr. Christine Johnston, of the University of Washington-Seattle, said. "The people who are symptomatic are really the tip of the iceberg." Aparently about one in six American adults have HSV-2, the most common type of Herpes virus which can affect oral and genital areas.

Johnston and colleagues evaluated herpes simplex virus type 2 shedding in a group of 498 HSV-2 seropositive people. About one in six never had symptoms of their infection. All participants obtained daily self-collected swabs of genital secretions for at least 30 days, regardless of whether they had herpes blisters or not.
Using condoms, taking antiviral drugs, and disclosing the infection to sex partners all have been shown to help cut the transmission rate in half, said Johnston. This study is certain to be quoted all over the media and should raise concerns and awareness among young teens, their parents and health care providers and teachers. In the absence of a vaccine or a more perfect solution, we need to be cautious and teach our kids about the risks and responsibilities of intimacy. Oral sex might not transmit HIV or get you pregnant but WOW can it leave a lasting memento.

Wanna Be a Doctor? How Cool is This?

2011-04-21T09:34:00.000-04:00

Recently, I was examining a teenage girl whom I suspected of having Mono. In order to determine whether she had swollen glands, an enlarged liver or a dangerously enlarged spleen, I checked her abdomen. I started tapping on her abdomen by placing my index and middle fingers of my left hand on her upper tummy and then tapped the two fingers gently with my right index finger. The sound to a physician is unmistakable. There is the hollow sound of the underlying intestines (filled with gas and drum-like) and there is the dullness or hard sound of the underlying solid liver.

"What the heck are you doing?" she asked. So I explained to her about this ancient technique called "percussion" and how without an xray, MRI or a CT scan (terms she was familiar with), I could estimate the size of her organs and whether they were normal.

"That is SO COOL!" she exclaimed. I was thrilled that this simple method could intrigue my young patient so I asked the question I always do when someone shows the least bit of curiosity about medicine: "Did you ever think of being a doctor?"

I told her about Abraham Verghese of Cutting for Stone fame and his wonderful list of simple skills that every physician should have. Called the Stanford 25 , it is a compilation of physical diagnosis maneuvers performed at the patient's bedside with little more than a stethoscope, the four senses (we don't do taste anymore!) and a trained mind. I was happy to see that the examination of the liver is the fourth technique on the list. I first discovered Verghese's mission when I was in Haiti with no technology other than what I brought in my backpack.

The deprivation of working in Haiti isn't necessary to appreciate the value of these fundamental skills. I am reminded every day of how much I enjoy practicing the basics and trying to solve the body's mysteries. Not to mention turning on a student every now and again to the field of medicine.

image from Google images

From High Chairs to High School: 30 Teen Parenting Blogs

2011-04-16T12:09:00.000-04:00

....including yours truly!

I was notified this week that my blog/website has been chosen by Amanda Harris to include in her exciting compilation of online parenting advise givers. Called From High Chairs to High School: 30 Teen Parenting Blogs it features blogs by parents, professionals and teens themselves. It also includes a site for "tweens", not an adorable pronunciation of "twins"-- rather the sometimes awkward age group of 7-12 year olds, especially girls.

I salute Ms Harris for combing through the haystack that is the blogosphere and coming up with some diamonds. I am honored to be a part of the list. Here are a few others she features:

Connect with your teens through pop culture and technology where a recent post lists the top 25 entertainment personalities who Twitter and other important things to know about your child's culture.

Support for Families with Troubled Teens: a good looking blog that appears to support rather than diminish those kids who struggle more.

Denise Witmer's Teen Blog on About.com has long been one of my favorites. It's always good to read the readers' comments here and the site does a good job of cataloguing related articles.

From India comes an intriguing teen-written blog Rants of a Survivor written by teen, Shravan Vijayaprasad, who describes himself as a " random rambler with a mind full of crap and interesting crap at that too!" it gives us a small window into the life and times of an Indian adolescent.

So I am sending a shoutout to any of all my fellow bloggers who never might be sure if anyone is "listening" to our musings. Somehow the message gets out there and into good hands. Thanks, Amanda.

image from Google

Is There Blood in Your Pot?

2011-04-14T13:47:00.001-04:00

Every now and then I need to sit in the parking lot of my office and finish listening to a compelling story on NPR. Today was one of those days. I was listening to Viridiana Rios who according to her Harvard posting "is a PhD candidate in Government and a doctoral fellow in Inequality and Criminal Justice at the Harvard Kennedy School. ...She studies drug trafficking, violence and corruption in Mexico. Currently, she works as an adviser for Mexico's National Security Council Spokesman, Mr. Alejandro Poire, one of the country's most important political figures currently designing Mexico's strategy to combat organized crime."

What drew me in was her passionate description of the interconnection between America's drug habit, including the occasional marijuana user, and the crime, victimization and murder of Mexico's innocent citizens, journalists, politicians, lawyers and fighters for social justice. Caught between the drug-producing countries to its south and the largest consuming country in the world to the north, the Mexican drug lords are financed by our habits and by a continuous supply of weapons to support their nefarious activities.

Rios does not condemn individuals for their personal drug habits. In fact, she seemed to imply today that California's liberalized marijuana laws might actually be a good thing for Mexico since the weed is grown in the US and does not involve illegal trade, transportation, weapons and gangs. But, her plea to consider how each puff might be tainted by the blood, sweat and tears of her countrymen was arresting. It's one more lesson in the globalization that insinuates itself into our lives at the expense of others.

image from charmingchitchat.wordpress.com

Tackling Weight Problems in our Students

2011-04-04T09:25:00.000-04:00

image from experientia.com

It's Spring and this is the time of year when I am asked to see students for mandated periodic physicals and for sports clearance. This is also when I am stunned by the number of overweight children in our schools. Since I have only a few minutes with each student during these marathon sessions, I like to use the time well and will often talk with them about simple ways to make life style changes that can help them get a grip on their expanding torsos. Here are some of the bullets:

1. Always eat breakfast. No excuses. Eat it at home or in the car, bus or while walking to school. If you usually get breakfast at school, make sure to get it as soon as you arrive. Breakfast makes you a smarter, happier and leaner learner. Here is a recipe I love for "breakfast bread" from an earlier blogpost.

2. Eat protein three times a day. The protein portion should be about the size of your palm. Here are some examples:

two scrambled or hard boiled eggs
a hamburger patty
a thin chicken cutlet
Peanut butter on multi-grain bread
Sliced turkey meat
Other sources of protein including beans, cheese, milk, protein bars, tofu, nuts

3. Stop drinking soda even if it’s diet. Drink water instead. Low fat milk once a day is a great source of calcium, protein and fluids.

4. Eat three meals and two snacks a day. At least one meal should be sitting down with family members. Try to eat protein at snack time as well. And don’t forget the water!

5. Exercise for 20 minutes at least three times per week. Make modest, easy goals and you will feel the difference. All kinds of exercise count: walking the dog, walking to school, dancing in your room, raking leaves, riding a bike, even going to the gym if you must!

Pediatricians on board with social media concerns

2011-03-30T09:22:00.002-04:00

Last month's Pediatric News featured a story on pediatricians' perspectives on social media. Parents are increasingly confused and overwhelmed by Twitter, Facebook, texting, Foursquare, etc etc. Many do not know what these terms mean, much less how to access them or understand the safety concerns for their children. Many parents have already given up and it's just the beginning of this revolution.

One Washington-based pediatrician is quoted as saying that the arena of social media is "the world's largest cocktail party." With 74% of kids in grades 7-12 reporting they have a profile on a social networking site such as Facebook, it's one heck of a party out there.

So it's no surprise that pediatricians worry about the short term effects as well as the long term effect on our brains. Dr Susan Greenfield from the Institute for the Future of the Mind at Oxford Martin School, Oxford, England says:

"It's a given that it will affect the brain, because the human brain adapts to whatever environment it's placed in. If you're in an environment as different as the cyberworld is from the real world, I don't think there is any question that we'll adapt to it. The big question is, How will we adapt to it? Is it good or bad? What can we do about it?"

Dr Michael Rich of Boston Children's Center on Media and Child Health hosts a blog called "Ask the Mediatrician" on parental concerns over media and health. "Social media," he says, "fundamentally alter how we interact with other people. There is as much an upside to social media use as there are cautionary tales. Social media can be particularly empowering for kids who are marginalized or minority groups of any kind. It is a wonderful environment for connecting with 'people like me.'"

Closer to home, I have started to work hard on ways to help parents frame these issues in the same way they have evolved rules and mores around driving, alcohol and other high risk behaviors. Working in conjunction with Gerald Stern of WOW Production Services we have developed an efficient, accessible and inexpensive class that parents can attend to bring them quickly up to speed. Sitting at a computer terminal, they sign on to a Facebook page if they don't have one and in under two hours they learn to navigate all the privacy settings and learn to understand the amazing appeal it has for our children. They also begin to understand ways to make social media work for them and their family.

It's truly a WOW/AHA experience. If you and some friends wish to organize such an evening, please contact me or Gerald.

image by Retrevo.com via GoogleImages

A Great Website on Sexuality for Teens

2011-03-26T18:36:00.000-04:00

Through my professional organization SAHM (Society for Adolescent Health and Medicine) I rediscovered a wonderful website today. It's called Scarleteen and can be explored here.

One of the most widely visited websites for people from 15-25, Scarleteen has been recognized by all the big whigs: SIECUS, UNICEF, Planned Parenthood, The Association of Reproductive Health Professionals, Family Health International, Advocates for Youth, the International Association for Adolescent Health, The Boston Women's Health Collective, The Society for the Scientific Study of Sexuality.....to name a few. That means that your parents, teachers, clergy, doctors, and friends will hopefully recognize that this is a really good, reliable safe place to get answers to all those questions that need private, authoritative and comprehensible answers.

To test it out I asked "the website" about a problem that I saw in my office recently. Namely, what to do about the ingrown hairs and irritation that results from shaving pubic hair. After many enlightening paragraphs about the physical risks (low but real) and the nuisance factor (once you start shaving,,,,,) the blog got down to the issue of "who or what is really making you want to remove your pubic hair in the first place?" Here is some of the advice (italics mine):

Just like the hair on our heads, if you want to try shaving it, it's not like you have to commit to doing that from here on out. You can always try it and see how and if it works for you, and how you feel about it. If you find you like it, then you can stick with it for as long as you like. If you find you don't, you can ditch messing with that hair entirely or try something else, like trimming or waxing. I'd just encourage you to make these choices, like any with your appearance, based on what you want and what feels like the most authentic expression of who you are, rather than what someone else wants you to look like or who someone else wants you to be.

Once you or anyone in your family logs on I think you will be tempted to buy their book S.E.X. by Heather Corinna (2007)which covers everything from STIs to sexual orientation, to co-habitation, to clitoris, to penis length, to misogyny, rape, orgasm and more and more. Endorsed by big names in sex ed for teens, I know I want this book on my own bookshelf and will refer patients often for reliable, relatable information.

Support New York's Deaf Students

2011-03-18T22:24:00.000-04:00

Since I moved my practice to White Plains, I have reached out to a few of my neighbors. This has included Whole Foods and The Westchester, but also some of my medical colleagues who line Westchester Avenue. Down the road a piece is The New York School for the Deaf in White Plains, called Fanwood.

When I visited I was enchanted by the small museum they have of various implements and instruments used over the years as hearing aids for hearing impaired people. In addition I was charmed by the beautiful grounds, the lovely people and the enthusiasm of the students and the staff, including the dynamic new executive director, Dr Janet Dickinson.

Here is some information from the website of the NewYork School for the Deaf also known in White Plains as Fanwood:

Chartered in 1817, the New York School for the Deaf is the second oldest school for the deaf in the United States and the oldest in New York State. Originally located in New York City in the Almshouse behind City Hall, the school moved uptown in 1829 to a ten-acre parcel of land between present day Saks’ Fifth Avenue and St. Patrick’s Cathedral.

The school moved again in 1856, after purchasing a 37.5-acre wooded estate on the bank of the Hudson River, near the current location of Columbia Presbyterian Hospital. The school adopted the name of this estate, Fanwood, as its nickname, one that has followed the school to its current location.
In the late 1890s, Fanwood adopted a military curriculum to instill discipline and provide a more structured learning environment for students. The school was the first in the nation to do so and was also the first school for the deaf to form a military band. For the next 50 years, precise military drills in tight formations were a daily occurrence on the Fanwood parade grounds.

After spending 80 years in Upper Manhattan, the school purchased a 77-acre apple farm on Knollwood Road near White Plains in 1934. In 1952, the school dropped its military program and become a coeducational institution again.

Since 1977, Fanwood has practiced a total communication approach to learning – which challenges students to develop their linguistic ability in a number of areas, oral and written English in addition to American Sign Language.

Fanwood has also fully recognized the benefits of using technology to help deaf children function in the world of the hearing. The TTY phones and closed caption TVs of the 1970s have given way to video phones, smart boards and computer learning aids.

In addition, all students are now assigned MacBooks as part of the Apple 1:1 program for use in the classroom and, for high school students, to use at home as well.

2007… School celebrates 190^th year of providing educational services to deaf and hard-of-hearing students
As the New York School for the Deaf approaches its 200^th anniversary, Fanwood will continue to build upon its heritage of combining individualized instruction for students with the latest innovations in education for deaf students.

Click here for a wonderful three minute video of the director and students talking about their school. There are over 185 students there now from many towns, counties and school districts.

BUT NOW THIS amazing history and institution may be threatened by Governor Cuomo's budget plans.

If you take a look here, you will see that the precious status of the NYSD is being threatened as NY State moves to pull back its funding of this and other schools as an approved private school rather than a state funded private school. As I understand it, this proposal would ask local districts to fund the education for their deaf and hearing impaired students since the state funding would be missing. Since we all know local districts themselves are hurting, the fear is that local schools would not be amenable to paying for the special needs of these students and keep them in an integrated, "inclusive" setting.

Many professionals and experts in education for the deaf, including the new director, Dr Janet Dickinson, believe in the value of evaluation and education for deaf students in a specific environment where deaf students are taught strong communication skills in a lively communicative environment, are not a minority and socialize with like students in full view of mentors and role models (older students and faculty) who have similar disabilities, abilities, struggles and achievements.

For a letter to Governor Cuomo from the Fanwood website, take a look here and send it on to Albany to defend this amazing school.

New York Times Photographer Missing in Libya

2011-03-17T07:56:00.002-04:00

Tyler Hicks photo from www.thetravelphotographer.blogspot.com

With all of the overwhelming news and images flowing in from around the globe right now, one might not see that four New York Times journalists are missing in eastern Libya. Included in them is Tyler Hicks, a brilliant and compassionate photographer whose photos from Afghanistan, Iraq, or Haiti can sear into your mind the way a thousand words never could. Hicks marries art, politics, and sociology in a way that imprints humanity on our minds. Let's stay tuned and hope and work for his safety.

Tyler Hicks from flickr.com

Earthquakes and Floods

2011-03-14T22:13:00.003-04:00

As you know I have been in Haiti and I have seen collapsed buildings, amputations and stunned folks. And recently I experienced the devastation of burst pipes that froze on my second floor and soaked my kitchen and living room with hot water for days on end, leaving ceilings collapsed, floors curling and a complete loss.

But when I look at the images from Japan where not only is there collapse but the final force of the tsunami, I am at another loss. I remember when my son, Nick Taranto, went to Banda Ache, Indonesia shortly after the tsunami and described the landscape as if God had taken a spatula and just played with the mud, scraping whatever was in it from side to side, leaving a flattened mess beyond words.

Reach out to the Japanese in your midst. I did that today at the supermarket as I saw a young woman and her two year old waiting to pay. Her English was rudimentary but we exchanged meaning. We both wept gently as she told me she had lost no one and only said "oh, my country."

Do you have sex or plan to?

2011-03-10T07:17:00.021-05:00

If so, then you might want to stand up for Planned Parenthood which is under siege and threat of cutbacks so severe that its very core is at risk. Watch this compelling video and pass it on. Made by students at Wesleyan University, it playfully reminds us that young Americans have sex and think about having sex and need Planned Parenthood:

What the video does not say explicitly is how Planned Parenthood can help everyone:

Women and men who rely on Planned Parenthood for contraception and family planning information -- PP helps avert about 612,000 unintended pregnancies every year.
Teens at risk of getting an STD-as many as 1 in 4 teenage girls already has one.
Teenage girls who are getting pregnant--724,000 do every year.
Women living in states that make it nearly impossible to get a safe and legal abortion.

Whenever I speak to groups of teens, I always take an informal poll to see how many of my young audience has been to Planned Parenthood. The response is always high whether they have accompanied a friend or visited themselves. Kids take it for granted that these competent, confidential and cost-effective services will exist. The way they take public education and garbage collection for granted as well. Let's try to keep it that way but let people know it all depends on our support.

Click here to donate quickly and effectively to Planned Parenthood. Let's stand up for our youth!

Who's afraid of the Internet?

2011-03-01T14:33:00.002-05:00

image from Google.com

If you are over 55, you are in the fastest growing group of Facebook users. As an astute woman was heard to say recently, maybe that's because everyone younger is already on it.

As a parent and doctor who should know about what teens and young adults are up to, I have been making an effort to understand social media and how it impacts our lives. So I was pleased to read Adam Gopnik's article The Information: How the Internet Gets Inside Us in the New Yorker last month. The article is essentially an ingenious book review of a dozen or so books about the joy, threat, fears, possibilities, and dangers of social media and the Internet.

Gopnik divides the plethora of recent books about the phenomenon into three categories (color mine):

...call them the Never-Betters, the Better-Nevers, and the Ever-Wasers. The Never-Betters believe that we’re on the brink of a new utopia, where information will be free and democratic, news will be made from the bottom up, love will reign, and cookies will bake themselves. The Better-Nevers think that we would have been better off if the whole thing had never happened, that the world that is coming to an end is superior to the one that is taking its place, and that, at a minimum, books and magazines create private space for minds in ways that twenty-second bursts of information don’t. The Ever-Wasers insist that at any moment in modernity something like this is going on, and that a new way of organizing data and connecting users is always thrilling to some and chilling to others—that something like this is going on is exactly what makes it a modern moment.

Since the Internet is here to stay, there is not much point in endorsing the concept of going backwards as the Better-Nevers might. And since there is very slim, if any, data to go on about the Never-Betters, it seems right to take some sort of middle ground. Gopnik's dissection of the Ever-Was-ers is the most interesting. He asserts that most forms of media, from the book in the middle ages, to the twentieth century radio and the television and now the Internet have shocked the status quo and made people worry about the corruption of minds and culture. Even the novel was a target of concern in Jane Austen's day. Here is another quote from Gopnik on the current romanticization of the television now that the computer, smartphone and Internet are the current whipping boys:

Now television is the harmless little fireplace over in the corner, where the family gathers to watch “Entourage.” TV isn’t just docile; it’s positively benevolent. This makes you think that what made television so evil back when it was evil was not its essence but its omnipresence. Once it is not everything, it can be merely something. The real demon in the machine is the tirelessness of the user.....an unplugged Sunday is a better idea than turning off the Internet completely, since it demonstrates that we can get along just fine without the screens, if only for a day.

So what is a parent to do? How do we take this information and use it to our advantage as we struggle to raise our children to be healthy, resilient, productive and compassionate human beings. I think we can extend the scary invention metaphor to the automobile and think about the frightening possibilities and the myriad ways we have grown and adjusted to its presence in our world. From headlights, to seatbelts, to airbags, to cruise control and dashboard breathalizers, it's taken a century to learn about the risks and clear benefits of this technology. Ingenious that we are, and unwilling to compromise the clear benefits of automated transportation, we have found our way. And we will find our way with the Internet as well.

Meanwhile, we continue to educate ourselves and parent in the best ways possible, setting limits and offering an authoritative style to our offspring. What we don't need to do is succumb to fear or relinquish all of our parenting skills to the technology. TV dinner anyone?

Let's Do Right by Lindsey Vonn

2011-02-15T15:08:00.001-05:00

It could have been a heart-breaking sort of Valentine's Day for Lindsey Vonn. That's what Alan Schwarz meant to say in his New York Times article entitled "Concussion Protocols Fail Vonn" about her silver medal race in the world championship on Sunday.

Schwarz is a champion himself of safer protocols following head injury and his extraordinary reporting was recently profiled in the New Yorker and on this blog.

The problem is that Vonn was allowed to ski inspite of clear signals from her that she was not ready and was at risk for severe injury and even death if she were to sustain a new head injury. Not to mention that competing at full tilt-even without any injury-- before complete healing will delay complete recovery, sometimes for months. Lindsey was still "foggy" in her practice runs and admits herself that she was not ready to race. But as Schwarz states:

...the United States Ski Team appeared to hit the trifecta of concussion no-no's:they called the injury mild, blindly followed so-called concussion tests, then discounted clear signs that her injury remained."

If an NFL player had been allowed to compete under these circumstances, says Schwarz, "the team (and the league itself) would be roundly flayed for endangering his health--and misleading young athletes about the risks of head injuries."

The lesson here is that anyone in the athlete's midst, starting most importantly with the athlete herself, should be able to trump any protocol, doctor, test or opinion if they believe the athlete is not performing or feeling up to speed. We need to be reminded that even in uber-athletes like Vonn, the brain takes just as much time to recover and can be as unpredictable as in an untrained person. What distinguishes the champion is the ability to perform in spite of sub-par conditions. But that does not make it right.

Sex Ed Online?

2011-02-10T15:09:00.002-05:00

New York magazine's provocative cover story, "Porn and Junior-High Culture" highlights the technologically enhanced exposure of young kids to online pornography. MTV's new series Skins is raising eyebrows about its depiction of underage and teenage actors baring bodies. So I began to wonder about the availability of quality sex education for kids, teens and young adults online.

According to a 16 year old quoted in the New York magazine article:

"You can learn a lot of things about sex. You don't have to use, like your parents sitting down with you and telling you. The Internet's where kids learn it from, most of the time."

So how good is the information out there on the web? I wondered if anyone had ever looked to see what kind of information is available? Along comes a 2010 article in the Journal of Adolescent Health which reviews 177 sexual health websites for quality and accuracy.

Each site was judged based on 15 quality criteria including authors' credentials and affiliations, sources and references, clear dating, disclosure of ownership, clear editorial policies, copyright notices, and internal search engines. Websites were further reviewed for false and inaccurate information. Surprisingly, only 17% of sites had one or more inaccuracies but site quality was not correlated with accuracy. And domain extensions (.com, .gov, .edu, .org) did not seem to affect either the quality of the website or the level of inaccuracies. However, "web sites containing the most technically complex information (contraception, sexually transmitted infections) and controversial topics (abortion, penis size, emergency contraception) contained the most inaccuracies." In other words a site can look legit but have inaccuracies and errors.

The authors pose the question "...what can we do to aid young people in finding quality OSHI (online sexual health information)?" Like all other issues related to nearly infinite web resources, parents, teachers, health care workers and those who care about our kids need to step in and begin to figure out how to endorse and then disseminate quality, accurate, readable and age-appropriate information that is "sexy" enough that kids will get their learning from trusted sources rather than the entertainment industry. Anyone up for creating one with me?

Girl Power:Now More Than Ever!

2011-02-08T14:32:00.000-05:00

I just received the newsletter from Her Honor Mentoring, a wonderful organization that I support. With their permission, I am re-printing here a short essay on the power of girls to help move and change the world. (Color emphasis is mine). Her Honor does this amazing work right in our backyard in Westchester County but that doesn't prevent them from thinking globally. Here it is:

The current unrest in Northern Africa has us thinking, now more than ever, that a meaningful revolution will require a true investment in girls. "Half the Sky - Turning Oppression into Opportunity for Women Worldwide" by Pulitzer Prize winners Nicholas Kristof & Sheryl WuDunn brought this issue to our attention and now Time magazine has echoed these sentiments in their article; "To Fight Poverty . . . Invest in Girls". Here is an excerpt:

"There are countless reasons rescuing girls is the right thing to do. It's also the smart thing to do. Consider the virtuous circle: An extra year of primary school boosts girls' eventual wages by 10% to 20%. An extra year of secondary school adds 15% to 25%. Girls who stay in school for seven or more years typically marry four years later and have two fewer children than girls who drop out. Fewer dependents per worker allows for greater economic growth. And the World Food Programme has found that when girls and women earn income, they reinvest 90% of it in their families. They buy books, medicine, bed nets. For men, that figure is more like 30% to 40%. "Investment in girls' education may well be the highest-return investment available in the developing world," Larry Summers wrote when he was chief economist at the World Bank. Of such cycles are real revolutions born.

The benefits are so obvious, you have to wonder why we haven't paid attention. Less than 2¢ of every development dollar goes to girls — and that is a victory compared with a few years ago, when it was more like half a cent. Roughly 9 of 10 youth programs are aimed at boys. One reason for this is that when it comes to lifting up girls, we don't know as much about how to do it. We have to start by listening to girls, which much of the world is not culturally disposed to do. Development experts say the solutions need to be holistic, providing access to safe spaces, schools and health clinics with programs designed specifically for girls' needs. Success depends on infrastructure, on making fuel and water more available so girls don't have to spend as many as 15 hours a day fetching them. It requires enlisting whole communities — mothers, fathers, teachers, religious leaders — in helping girls realize their potential instead of seeing them as dispensable or, worse, as prey."

Still wary about HPV vaccine for your teens?

2011-02-03T13:53:00.003-05:00

If so, you are not alone. A recent study in Pediatrics which surveyed parents on this topic showed that HPV (Human Papilloma Virus) vaccine (marketed as Gardisil or Cervarix) is the most often refused vaccine in the pediatrician's arsenal against disease. Reasons cited for refusal by parents include belief that there has not been enough research (80% of those refusing); that it "challenges their belief system"(51%); that they believe their children are not at high risk for contracting the STD (59%) and that they do "not believe the vaccine is effective in preventing the disease" (37%).

In my practice I have found that if I take the time to address these concerns with parents and patients, most are convinced of the benefit of the vaccine. It's worth mentioning in my anecdotal experience that most kids are convinced of the value of the shot (probably due to intensive and teen-oriented marketing) but will usually acquiesce to parents' wishes to avoid the needles. A number of my patients with skeptical parents have opted independently to get shots once they reached age 18.

What exactly does the vaccine prevent?

There are over 100 "types" of human papilloma virus. The vaccines prevent over 70% of all cases of cervical cancer and Gardisil in particular also protects against the most common causes of genital warts. In addition to these dread diseases (click here for a photo of the pesky and tenacious genital wart), HPV is now linked to a number of head and neck cancers (due to more oral sex?) and of course can cause months of undue anxiety when Pap smears or biopsies show abnormalities due to HPV infection-even if they are temporary and ultimately vanquished by the body's immune system.

How do we contract HPV?

HPV is contracted through sexual intercourse for sure. But it is also contracted through intimate touching; "third base", oral sex, fingering and other forms of "outercourse" bring risk of infection with them. And let's remember that most teens progress through months to years of these "lower risk" activities (can't get pregnant after all) before engaging in intercourse. Many 13, 14, and 15 year olds are there already even though parents underestimate the likelihood that such activity is going on.

Why vaccinate an 11 or 12 year old?

There is excellent data showing that the earlier we vaccinate the better the immune response. I once heard a pediatrician say "We don't wait for them to step on a rusty nail to give them tetanus vaccine, do we?" Vaccinating with HP, according to Pediatric News, is "not about sexual readiness" rather about the prevention of cancer.

Is it safe?

According to the CDC on this subject, over 32 million doses of Gardisil were ditributed in the US from the time the vaccine was licensed in 2006 until September 2010. The Vaccine Adverse Event Reporting System has investigated all serious event reports and has not found a pattern to suggest the vaccine is causing a serious problem. True confession (that most teens will confirm): The HPV shot DOES hurt a bit more than most vaccines, but it is a brief 60 second ache. This pain may explain a slightly higher than average incidence of post-shot fainting in the doctor's office. Contrary to early YouTube videos, it DOES NOT make people walk backwards!

How long is it good for?

With each passing year since licensure we see strong data that extends the length of time we know the vaccine provides protection. As of now we know it will last at least 7.5 years and most manufacturers and researchers think it will extend far beyond this as it contnues to be studied. By the time the young vaccinees get into young adulthood, we will know whether a booster is necessary (as we have discovered for whooping cough, tetanus, meningitis, polio and many other illnesses).

What about boys?

Boys are the group getting the least extensive coverage in spite of it being approved and recommended for them as of last year. When a parent or a young man asks me "Why should men get it?" I just pause and look at them a little funny and say: "Let's stop and think about where the virus is coming from when girls get it through sexual activity." And if that isn't convincing enough I say: "Would you like to see a picture of penile warts? (see above)" It is worth noting that men having sex with men are at increased risk of warts and penile cancer and should definitely be vaccinated as early as possible.

I fully endorse vaccination against HPV. I am also fully aware that there are political and economic issues surrounding the vaccine. For one, most of the folks who speak about it publically are on the Merck payroll (the sole manufacturer of Gardisil). And the steep price of this immunizaiton raises a moral quandary about whether it is really just a boutique vaccine and much less readily available in the rest of the world. Nonetheless, insurance companies seem to have done their calculus and since they usually err on the side of withholding treatments and are not known for their support of preventive medicine I say we should be grateful for what we have.

Caring for our Anxious Students

2011-01-31T12:37:00.006-05:00

This weekend I attended a Harvard-sponsored conference on Mental Health in our Schools. Here at home we are also responding to what we perceive from the trenches to be rising levels of stress and anxiety among our students. My office, BridgeSpan Medicine in White Plains, is sponsoring a conference on March 11 to bring professionals together.

Click here for the flyer and registration form for "Caring for our Anxious Students." We will be gathering on the expansive Fordham graduate school campus in White Plains to share strategies, resources and information between mental health professionals in the community and those who work in schools. Presentations of and management of anxiety for Grades K-12 will be covered.

Dr Alec Miller from Cognitive and Behavioral Consultants of Westchester will be the keynote speaker, bringing his extensive experience in CBT/DBT to bear on the subject. In addition, dedicated mental health clinicians in the schools will share what they are seeing, what works and what doesn't. Each participant will go away with a trove of resources, including professionals, agencies, clinics, websites, dvd's, and books.

A major goal of the conference is to increase communication and fluidity between disciplines so that we can more readily help our students and in the end make our own work more effective and rewarding.

We hope you will sign up soon. Space is limited. Please bring your experience, expertise and inquiries.

"Caring for our Anxious Students"

"Does Football Have a Future?"

2011-01-27T11:33:00.005-05:00

I didn't ask that question. I continue to beat my drum about concussions, and the sound of the many drumbeats out there is getting louder and harder to ignore. The question is the title of a fascinating, in-depth article in this week's New Yorker by Ben McGrath about America's gladiator sport and the latest on the resulting brain damage.

McGrath intrepidly raises the thorny issues of the socioeconomic aspects of this sport. He says:

"The people most inclined to ask the question 'Would you let your kid play football?' did not play football themselves growing up, because their parents were put off by the sport's brutish culture, regardless of any understanding of brain science....How many of the men on the field in the Super Bowl will be playing with incipient dementia?"

McGrath quotes extensively from and praises the work of Alan Schwarz of the New York Times. A comprehensive list of his recent research and articles can be viewed here. Among other aspects of Schwarz' work, we learn about the likely link between teenage and high school football and later brain damage.

The many coaches, students, athletes, and parents who have wondered over the past few years about the new concussion guidelines and policies that I have helped implement in the Mamaroneck schools all need to read this article. As a teenager noted to me recently--as only a 21st century teen could--The New Yorker articles are very lengthy, but I assure you that if you have anything to do with football it is an engrossing and worthwhile read.

In the mean time, while our schools develop and refine their thinking and policies about concussion management, I encourage all athletes to invest the small fee required for a baseline Impact test (described here) and to be tested if there is any concern that a head injury or significant blow might be strong enough to warrant the new, conservative approach. As a Credentialed ImPACT Consultant, I am one of three providers in Westchester who can test, interpret, educate and counsel athletes and parents on this important issue.

"Hi Mom" from Everest base camp

2011-01-21T12:57:00.003-05:00

Recently I have been thinking about how we can build resilience in our children and taking my lead from Dr Kenneth Ginsburg, a pediatrician in Philadelphia and the author of Building Resilience. Ginsburg talks about the Seven C's of resilient people and how we can foster these qualities in our children. The C's are: Competence, Confidence, Character, Connection, Contribution, Coping and Control. I think Ginsburg is really on to something and in fact have printed these "Seven C's" on the back of my business cards. I've been wondering if these are the qualities that my own young adult children carry with them.

And then came this extraordinary photo from my son, Simon's Facebook page. I had very little contact with him for two weeks while he was on vacation from his teaching job as a Fulbright fellow in Nepal. I knew he was out on icy, cold trails with a colleague, but I had not really been able to imagine what that could be like. Until he called me from about 16,000 feet in the Himalayas and said:"Oh, Mom it's SO BIG."

And now with this photo posted since his--Thank God--safe return to Kathmandu I can see for myself those Ginsburg qualities that he carries inside him. This is the stuff that allows you to think you can do this sort of thing pretty much on your own in a place that is about as foreign as it gets with unspeakable risks and dangers. And rewards. Thanks, Simon, for one in a long string of lessons for me as your Mom.

Momosaurus to Cyberwoman

2011-01-17T17:02:00.001-05:00

From Jezebel, the entertaining website that has its pulse on the culture of American women comes the amusing article titled The Evolution of Moms. From soccer moms to the latest--tiger moms-- this short piece is a witty, tongue in cheek profile of the many faces of Mom in the last twenty years.

And before that? I challenge my readers to invent names for moms of the seventies, sixties, fifties, forties, thirties, twenties, and teens from the twentieth century. Looking forward to your comments.

image from babble.com

Gabby, We Can Do Better.

2011-01-10T15:35:00.000-05:00

Gabby Giffords is a heroine of mine. I have supported her candidacy from afar for some time since Emily's List first introduced me to her years ago. I like the words used to describe her: spunky, tenacious, smart, optimistic, a pioneer, a true friend, and especially a Democrat Arizonans can get behind.

Since Saturday when my distraught brother and mother both called from Arizona to alert me to the news of the shooting, I have been glued to the television and the news. Themes keep repeating themselves: vitriolic politics, right-wing Arizona, the perils of democracy, gun control matters, and of course mental illness. Today, I heard that there is debate in the Obama administration about how to turn this, spin it, twist it all so that it might be massaged to the Democrats' advantage. How, someone mused, could the President keep his health care bill fighting for its life just as Gabby lies in coma fighting for hers in Tucson?

I think the link is clear. The gunman's story is all too familiar. A disgruntled, odd adolescent, expelled from college for bizarre behavior, ranting in cyberspace and elsewhere, buys a military-grade weapon and lets loose. When we briefly put aside our outrage at him, if we can possibly put on our compassionate hats for just a minute, we realize that one way or another the system of health care and mental health treatment failed him. And by failing him and his family, it has jeopardized all of us.

Mental illness, after all, is a health issue. If the Republican congress were to repeal Obama's healthcare legislation as it has threatened, the tiny steps that were put in place to improve access to care will be eroded.

And that could matter for someone like the Arizona gunman. These grave mental illnesses most often present and get diagnosed during late adolescence. Coverage through parents' insurance up to age 26 can help these suffering young adults get the help they need. The certainty that pre-existing conditions-like schizophrenia-will not bar a young person from insurance coverage will go a long ways to supporting these difficult patients. And an attitude and philosophy that moves us all to see illness as bad luck rather than a badge of moral failing will go even further toward creating a more compassionate and safer society that we can be proud to call ours.

Remembering Haiti one year later

2011-01-06T17:48:00.002-05:00

January 12 marks the one year anniversary of the earthquake. Haiti still has no government, no housing for most quake homeless, no clean running water, no public pediatric hospital in Port au Prince, and plenty of other things. But Haiti still somehow seems to carry on with hope.

Partners in Health, the august organization founded bythe pediatrician, Paul Farmer, is sponsoring a commemorative event in Boston and online on January 14, 2011.

The world is moving on to trying to comprehend the devastation of the quake, the reasons for the slow recovery and the extraordinary spirit of the Haitian people in the face of chronic and acute disasters. Having been to Haiti twice this year to help in the disaster and recovery efforts, I can only exhort all those who care to continue to commit themselves to understanding and supporting Haiti in its prolonged time of need. Whether through your house of worship, your school, your government, UNICEF, or from your own heart, please remember.

You can get started at Partners in Health's special site: www.pih.org/jan14. Many different events are listed here as well as links to amazing organizations that are working to rebuild Haiti, including Fonkoze, a microfinance system sponsored by Partners in Health and described by Nicholas Kristof in the January piece entitled Ladders for the Poor in the New York Times.

Thanks from my all Haitian friends who read my blog.
If all my readers could send a word or two of encouragement by commenting on this post, I know they will be grateful for them.

Deployment Burden Hits Home

2011-01-05T15:32:00.004-05:00

"When a parent in the military is deployed, children have an 11% increased risk for requiring mental and behavioral health doctor visits, compared with when the parent is home. This information is the conclusion of a large chart review-type study published in Pediatrics in December, 2010. Frankly I found the number relatively low compared to what I had imagined. Some interesting findings of the study were:

Older children experienced more mental health visits while the parent was deployed than younger kids.
Having a father deployed, as compared to mother carries a thirty percent greater "risk" of mental health visits.
Anxiety, behavioral and stress disorders were the most common diagnoses.

The report in the pediatric literature bears spreading to others who care about and know children. Teachers, family, clergy and friends need to be aware that "the psychosocial burden of war extends beyond the military service members' combat time...perhaps unfolding years after combat exposure," according to Dr Beth Ellen Davis, a retired colonel in the US Army. Resources cited in the 2010 Pediatric News where this study was reviewed include The American Academy of Pediatrics Military Deployment support web site: www.aap.org/sections/unifserv/deployment This features videos and an interactive "youth stress management plan". Other resources include Military One Source and Military Home Front.

A simple acknowledgment of the parents' deployment and a simple "How are you doing with that?" can be an important outreach question. And let's not forget the siblings, cousins, and neighbors who may also be deployed and weighing on young hearts and minds.

I welcome feedback and sharing of experiences from readers who have experienced deployment themselves or have waited at home for a loved one.
image from my-fathersvoice.blogspot.com

Real Food-What to Eat and Why

2010-12-28T14:58:00.001-05:00

I have my new son-in-law to thank for a holiday gift that begs sharing with everyone. Real Food-what to eat and why by Nina Planck, published in 2006, is a gem of a resource for anyone who feels confused or wants to have much clearer guidelines about what to buy and eat and what to leave on the shelf. Endorsed by Michael Pollan for its persuasive and "eye-opening" qualities, Planck takes us back to the days of "real" food. By this she means foods that are old, that we humans have been eating for a long time. And she also means foods that are traditionally prepared "the way we used to eat them." One of Pollan's food rules was to avoid foods your grandmother would not recognize. Planck goes further to endorse local and seasonal fruits and vegetables(goodbye to the perfectly unblemished and insipid winter raspberries from god knows where); whole grains (goodbye to white flour and many of those holiday treats we just downed aplenty);and fats and oils should be unrefined (goodbye to margarine, "I cant' believe it's not butter", trans, hydrogenated etc--welcome home EVOO!). The book is chock full of information, resources, and convincing documentation. We can all challenge ourselves to Planck's lessons that will help us ring in the new year with real, delicious foods to keep us healthy in 2011.

In this same vein, schools can participate in new awareness about healthy eating through Real Food Challenge which carries the same name and adheres to much the same principles.
Bon Appetit!

image from WebMD.com

Why I Love Minnesota

2010-12-22T08:47:00.000-05:00

image from Edmonton.ca

Wanting to read about the UConn women's marvelous basketball victory I leafed through this morning's New York Times sports section only to be drawn to photos of kids playing hockey. Since I have brain injury and sports related concussion on my mind these days I read on. It turns out that some of the Minnesota Youth Leagues--including those in the town where I grew up--have instituted a simple and effective way to minimize injuries and to increase enrollment at the same time.

We have been listening to the NFL grapple with ways to make football safe and school athletic departments are working to lessen the impact of head injury. Now the Hockey Education Program (HEP) from Minnesota shows us how. By simply instituting a system of the "fair play point" which is "an extra point in the standings awarded teams, win or lose, for each game in which they take fewer than a designated number of penalty minutes," they have managed to reduce penalties for hits to the head from 12.4 per 100 games in 2004-05 to only 2 per 100 the following season. In addition, checks from behind which can lead to concussions as well as spinal cord injuries declined by two thirds.

In Quebec where a similar program was implemented in the 1990's they have not only succeeded in documenting reduced injuries but have increased youth registration. I am not surprised since on more than one occasion I have had a despondent boy in my office looking for a way to get out of hockey as he advanced to the older teams where checking and real injury became too threatening.

Coaches to champion teams in Minnesota say they can see that players who have been raised on this new approach to the game play in a more "effective" and elegant as well as safer way. Minnesota players are being recognized as being better players where "lazy penalties and the dumb penalties and the stuff after the whistle" is no longer a distraction from the real sport.

It seems to me that all sports might take a lesson from the Minnesota playbook and realize that we can teach our athletes to do well in their sports without jeopardizing their futures.

College Students and Mental Health

2010-12-21T16:42:00.000-05:00

A story in the New York Times this week highlighted the fact that many students on campus are seeking mental health services and sometimes overwhelming the system. This article touched on some of the reasons that colleges seem to dealing with a great deal of psychological and psychiatric issues in addition to the usual mono, strep throat and exhaustion that are the more mundane problems they see.

Just a year ago the Journal of Adolescent Health published a review article of the research to date about this very subject. Some interesting findings include:

17% of students in a national survey of 26 colleges and universities (the Healthy Minds Study) met the screening criteria for depression.
increases in help-seeking behavior (rather than increases in mental illness) contribute to the perceived rise in mental health problems among college students
there is an increase in severity of problems presenting to student health services. The researchers attribute this to the fact that more students with more severe (and often previously diagnosed and treated) mental health problems are applying to, being accepted at and matriculating in colleges. Increased access during adolescence and improved outcomes with current medications make it more likely that students will be able to function.
In spite of this studies show a high prevalence of untreated mental illness. Only 24% of those diagnosed with depression were receiving treatment.
financial constraints are rarely a barrier to care for college students since at least the first encounters are covered by student health insurance.
Improved faculty, staff and student training will be necessary to steer suffering students toward help and prevent tragedies.

Sometimes, student health and the resources they bring to bear at college are not enough. Many young adult patients come home each year and need to re-group, find treatment, start medication, gain weight or simply make a new start. In New York City, Columbia Presbyterian has an excellent program for college students who have been asked to take or have decided to take a medical/psychiatric leave. Called the Columbia College Student program it is group based and problem oriented, allowing like minded students to have a place where they can learn new skills and support each other during their transition back to health.

Colleges are in a uniquely effective position to detect, diagnose, treat, and refer students for treatment of mental health disorders, many of which emerge during exactly these years of late adolescence. Although there is much work to be done, many innovative programs and initiatives are being studied in hopes of creating a better safety net.

Paying Attention to Attention

2010-12-16T15:17:00.001-05:00

At this time of year when students start streaming back from college for break, I usually have a few who come in to ask for medication for their newly (self-) diagnosed ADHD. What has usually happened is that they have just gone through reading week and final exams and have discovered that the ten bucks they shelled out for their roommate's Adderal did a lot to help them focus and stay up all night to write the final paper in Sociology. Usually these are students who were never prescribed medication before,performed well enough in high school to go to college, often are risk takers or adventure seekers and get insufficient sleep. And rarely do they have ADHD. Frankly, this group is not the one that makes me worry about missing a diagnosis.

A recent article in the New York Times by Dr Perri Klass highlighted the over-use of the ADHD diagnosis and the current trend toward blaming difficulties in focussing on our fast-paced, internet-based culture. She makes passing mention in the article of the "inattentive-type" ADHD student who often passes right under the radar. This is the group of patients and students that concerns me most. These students are more likely to be girls than boys, more likely to have been missed for a long time because they do not cause trouble. They are the "quiet daydreamers, slow, distracted, and forgetful," as described in a recent article in Pediatric News by Dr. Barbara Howard of Johns Hopkins University. The concern with these inattentive-type ADHD patients is that they need a careful evaluation to rule out other causes of their dysfunction. As Dr Howard states, "far and away, the most common missed diagnosis and frequent bedfellow of inattentive-type ADHD is anxiety."

And this is the story that I most frequently uncover in practice when a student approaches me with a request for stimulant medication. There is usually an underlying problem of anxiety, drug use, sleep deprivation, or real life concerns over family matters. Only a careful assessment can uncover whether a student has these issues going on which need sorting through or whether indeed there is a diagnosis of ADHD that has been overlooked. In any case they deserve our attention!

image from newyorkdailynews.com

ImPACT testing now available in my office

2010-12-08T15:05:00.005-05:00

I am now doing my part to protect the heads of athletes in our community. As a Credentialed ImPACT Consultant I can now administer and interpret the test in my office.

ImPACT testing is a quick and easy tool to use in conjunction with careful evaluation and examination of athletes and others who may have sustained a head injury. It is well known from the recent flurry of coverage in the media that concussions are more common and more difficult to manage well than heretofore imagined. I have posted many pieces on this site about the evolution of our thinking on this subject. Just yesterday, Governor Christie announced new legislation in New Jersey that requires all school districts to create a policy to address the issue.

ImPACT is a twenty minute, online test administered and interpreted by a trained professional. In the NHL, NFL, many schools and other sports organizations, it is administered as a baseline during pre-season and then used to help determine when an athlete's visual memory, reaction time and verbal memory have returned to normal following an injury. In many cases this objective information is invaluable in helping to determine when it is safe to return to practice, competition and play.

My adolescent medicine training is particularly helpful in making these decisions. The importance of sports and team membership in building a strong sense of well-being cannot be underestimated. At the same time, it may take an objective professional to keep an eye on long term health and goals. Many complex factors go into this decision: parental concerns, family's tolerance for risk, previous injuries, school policies, objective medical information, school functioning, role on the team, success of the team and pressures from the coach to name a few.

Anyone interested in ImPACT testing through my office can find more information on my website or can call my office. I am happy to consult with students and families even if they are not currently patients in my office. Many insurance plans cover ImPACT testing.

No Child Left Inside: Letting Nature Nurture

2010-12-06T17:23:00.000-05:00

After we talk about excessive online activity and obesity in our young people, let's think about getting our kids back to nature. At the recent annual meeting of the American Academy of Pediatrics the keynote speaker was Richard Louv who makes the case for getting our kids outside. He has coined the phrase "nature deficit disorder" and on his website, Children and Nature, he cites scientific literature and posts oodles of opportunities for kids to get outside, no matter where they live. There is even a downloadable prescription pad for pediatricians to prescribe outdoor play. It says:

Go outside and play in nature.
Limit your “Screen Time” to no more than 60 mins each day.
Read stories about nature.
(Or have someone read them to you.)

Another speaker at the same conference enjoined listeners to help parents have permission to "bring back boredom" to allow kids to daydream and be more creative. Planting seeds, playing in the snow, looking at the sky, listening to the birds, smelling the air: it doesn't have to be very complicated. What seems "boring" will feed the imagination if we allow it to speak.

We are all searching for ways to treat the anxieties that we see in our patients, students and children. Many agree, at least anecdotally, that too much time is spent in sedentary activities. A recent survey by the American Psychological Association on stress noted that "tweens and teens report that they turn to sedentary behaviors to make themselves feel better when they are really worried or stressed, such as listening to music (36 percent of tweens and 66 percent of teens), playing video games (56 percent of tweens and 41 percent of teens) or watching TV (34 percent of tweens and 30 percent of teens)."

Perhaps the panacea lies in the notion of getting kids off the couch and into the outdoors. This may afford them the best chance of avoiding the metaphorical "couch" treatment for their mental health.

image from www.greenloudon.wordpress.com

Staying Connected in a Fast Paced World

2010-12-05T11:19:00.002-05:00

The iConnected Parent by Barbara Hofer and Abigail Sullivan Moore is a new must read for any parent of high school seniors or college age students. And parents with children of any age who want to learn more about contemporary commnication habits may want to take a look as well. The book reveals the blessings and pitfalls of our current electronic connectivity and its impact on young adult development. "iConnected Parents...represent a new era in parenting:a potent new mix of devoted parent, guide, and friend, fluent in speed-dial, Facebook, and the flick of a mouse." They explore the continuous tether that links our kids to us in ways that were not possible when most of us were their age.

Hofer is a professor of psychology at Middlebury who has researched the link between parent-child communication and the development of independence in adolescents and young adults. Moore is a journalist and frequent contributor to the New York Times. In this book they present a compilation of some research and some investigative reporting with many interviews of students, parents, and administrators who have a range of opinions on the issue.

A few highlights:

Families of the college students interviewed communicate one way or another an average of more than 13 times per week.
Parents are intervening in course selection, paper editing, negotiations over grades, and roommate concerns in ways that college administrators find distressing if not illegal and unethical.
The new connectivity between generations can stir some complicated involvement that not all parties find helpful or healthy.
Parents need to be better listeners and not problem solvers. Having easy access to advice with one click may serve to increase anxiety in parents as well as kids.
Dependence on and easy access to Mom and Dad does not foster resilience, patience or self-reliance.
These new relationships are so pervasive now that it may be the start of a new inter-generational norm, heretofore not experienced in American life.

My criticisms of the book include the fact that the research is presented in a thoroughly unscientific and unquantitative way. Not nearly enough thought is given to Facebook and how parents should manage their accounts or interFace with their offspring. Finally, although the subtitle of this book involves the word "college" I wonder about the conncectivity between non-college bound students and their parents. It would also be interesting to know more about the effect of socio-economic and ethnic backgrounds on the issue.

To its credit, this book has one of the best chapters I have read on mental health issues at college. Not surprisingly, the bottom line when a child is struggling in this way is that communication and connection need to go way beyond the one on one parent-child and include key professionals.

Finally, this is a wonderful book for grandparents to read who often feel left out of modern communication but at the same time marvel at their family's connectivity. Having a generational perspective on this can help all of us carefully define what the "new normal" should look like so that everyone benefits in the long run.

image from bbc.co.uk

Vitamin D Craze Bites the Dust

2010-12-01T07:17:00.000-05:00

A word of caution. Whenever a new test, treatment or diagnosis seems to be making the cover stories on the magazines at the grocery store, be wary. With titles like, "the diagnosis your doctor probably doesn't know about", we are led to believe that we need to jump on the bandwagon. Frequently these recommendations have something to do with nutrition.

Yesterday the Institute of Medicine announced that the validity of the recent fad to test and treat for vitamin D deficiency is questionable. It never made sense to me that over 80% of people were allegedly deficient in this vitamin that is nearly ubiquitous in dairy products and can be made in our bodies naturally if we are exposed to sunlight. (Interestingly there is an article in the same New York Times 11/30/10 issue that discusses the deficiency of active outdoor time in our population.)

Several months ago my own physician sent my blood for a Vitamin D level inspite of the fact that I told him I would not take supplements since I spend at least an hour outside five to six times per week. Of course I fell in the 80% of Americans who test low for this particular value. And the test cost over $200. My theory is that we really do not know yet what exactly we are measuring and what its relevance is to actual Vitamin metabolism in our bodies.

This is just one more lesson to all of us, including physicians who order blood work, to be circumspect about recommendations and to wonder whose idea they are, who is benefiting and above all to ask the question: "Where is the data?"

image from jmarbach.com

Special Siblings

2010-11-28T14:03:00.002-05:00

Again, siblings of kids with unusual needs are in the news. Today NPR broadcast "Siblings of Sick Kids Learn a Life Lesson Early" which you can listen to here. This brief report is about the issues that face families where there is a child with a difference. These differences include chronic disease, mental illness, and developmental disabilities.

When young, siblings may feel "caught outside the bubble of the family world" where the medical and social concerns and crises of a sib might "trump regular kid concerns" like birthday parties and sleepovers. Although one might expect kids to sometimes feel neglected or jealous, in the long run research shows that they show a strong capacity for empathy well beyond their years. And this empathy ultimately informs many of their life decisions.

The broadcast showcases a support group at Vanderbilt University that allows teens to come together to share their experiences, concerns and worries with other families and peers. The findings may come as a relief to parents who feel they may have "almost missed (the healthy child's) life," as one mother admits. Those of us in the professions that know and care about such families need to advocate for more attention to the concerns and support for the special qualities of the siblings. Often the next generation of caregivers and professionals come from their ranks.

image via Google from Corbisimages.com

To Eat or Not to Eat:living with anorexia nervosa

2010-11-22T16:10:00.000-05:00

As a physician who frequently sees patients with eating disorders, I am always looking for a better book to help parents learn about ED and pilot them through very destabilizing times. Harriet Brown, a journalism professor, writer, blogger and mother, has written a very personal story.   Brave Girl Eating:a family's struggle with anorexia, follows Brown and her family as they learn about and manage her daughter, Kitty's, anorexia.   Specifically, Brown chronicles her research and the practice of appyling family based treatment (FBT) also known as the Maudsley approach, to managing anorexia.   Although this method requires a great deal of commitment and patience and some seriously impressive parenting skills, it is the only method which really has shown to be successful in treating this terrible disease.

Brown reminds us that anorexia nervosa is a biologically based illness, not simply a willful, bratty misguided attempt to be thin or a failure of otherwise good parents. She deftly describes the theories of this "encapsulated psychosis" and better than in most accounts manages to explain how disordered thinking about food is a result of starvation. As they evolved, prehistoric people who were starving became single minded and frenetic--one might say obsessed-- in their search for food. This phenomenon is often seen in patients with anorexia nervosa who seem to have extraordinary energy and drive for exercise and scholastic pursuits in spite of an obviously wasted body.

Perhaps Brown's greatest contribution is her description of the stress and strain on her husband, their marriage and Kitty's younger sister Emma as the disease takes hold within the family.   Besides the fact that ED runs in families and one has to worry about the impact of living up close and personal to someone who is so "successful" at dieting is the fact that the illness drains energy, time and compassion from the engaged parents. Of course, the "unaffected" siblings are deeply affected by the stress, tension and outright fighting that inevitably goes on in a home rent by anorexia.

More than one parent has come to my office holding onto this book as if it were the guidebook. And in many ways it is. But it is not a hands-on manual and not a substitute for the team of people-doctor, therapist, dietician- who need to be marshalled to care for these patients and families. However, it will help parents seek out and ask questions of providers to ensure buying into a treatment that has a better chance of success than a punitive, psychodynamic approach.   Food is the remedy and "if you do intensive psychotherapy with someone with anorexia, you wind up with an insightful corpse, because without enough glucose the brain can't process or think properly."

TEDx for high school students near you

2010-11-20T18:08:00.002-05:00

Parents worry about what their kids are doing online or in their free time. We hear a lot about the concerns over the internet, social media and the access to strangers online. But, we are just beginning to figure out some of the extraordinary opportunities for growth that all of these new tools can offer.

Now if you've never heard of TED conferences, it's time to learn. TED stands for technology, entertainment and design, and even the AARP website encourages participation. It's for everyone. TED's slogan is "ideas worth sharing" and their website, TED.com, is loaded with over 700 ingenious performances, talks,pitches, patents, and ideas that range all over the encyclopedia of human experience across the globe.

Today I had the singular pleasure of seeing my daughters, Alice and Daphne Taranto, and their friend and creative partner, Zoe Kestan, present their magazine/website/blog/twitter page/facebook phenomenon called FAD at a TED conference sponsored by their school, Horace Mann in Riverdale, NY. FAD magazine stands for FashionArtDesign and is an entirely student run enterprise. They were joined by other hard-working passionate kids who are making extraordinary contributions to culture and making the world a better, richer place.

This TED conference, called TEDx because it is entirely locally run and organized, had five New York City schools participating. The format included the celebrated TED style of short talks, performances and demonstrations, two TEDTalks videos (including JK Rawling from her 2008 Harvard commencement address--perfect on the day after the release of the latest Harry Potter movie); and bias free programming--a stipulation for licensure and use of the TED name.

Other impressive presentations included a student's performance of classical Indian dance followed by an extraordinary video of wheelchair "bound" dancers performing in India where she worked last summer. Four young men presented their latest apps for smartphones of which they have sold over 100, 000 to Apple's App Store online. Another student presented his Zawadi by Youth, a student-run microfinance program which is funding small-scale entrepreneurs in the developing world and teaching NYC students about small business in emerging countries. Closer to home, Chelsea Dale, from Fieldston School, presented her program, On Giants' Shoulders, a mentoring program for privileged high school seniors who mentor weekly through Skype contact with younger students in the East Bronx.

All in all these students were an inspiring mix of passion, hard work, creativity, ingenuity, and risk-taking. Their ability to fearlessly embrace the world at large by wedding technology to compassion is impressive. Let's hope that more schools and teachers like Dr Jeff Weitz at Horace Mann will organize and sponsor these programs and motivate high school students to pursue their passions and learn the value of sharing great ideas and the arduous but rewarding process of going from idea to product.

TED logo from timothyzhu.wordpress.com

Addicted to Indoor Tanning?

2010-11-09T14:09:00.000-05:00

As the days grow longer and colder, many begin to dream of a warm summer day or a Caribbean island inhabited by descendants of pirates or Johnny Depp. And others simply head down the street to the closest tanning center. If you or someone you care about is doing this on a regular basis, you might want to think about why.

In a 2010 collaborative study from SUNY Albany and Memorial Sloan-Kettering Cancer Center, the researchers report the tanning habits and psychological profiles of over 400 students. What they found is notable. Nearly 40% of the 237 students who used indoor tanning met criteria for addiction to the behavior.

Students in this subgroup also reported more use of controlled substances (excluding alcohol). In addition, students who met the criteria for addiction to indoor tanning were twice as likely to have symptoms of anxiety or depression than non-addicted students. This study suggests that students who may have a predilection for addictive behaviors of all kinds are likely to add tanning to the list.

Given the origin of this study at Sloan Kettering it's not surprising that the authors ironic conclusion is that treating an underlying mood or anxiety disorder "may be a necessary step in reducing skin cancer risk among those who frequently tan indoors." Will tanning salons soon be required to add some disclaimer about unstable mental health to the consent form people sign acknowledging their right to cancer?

More Support for our Athletes' Heads!

2010-11-03T07:42:00.001-04:00

The American Academy of Neurology has released a brief position paper on the importance of immediate recognition and management of concussion in athletes. This is a big boost to those of us who are working against a tradition of toughness on the field and getting back in the game, too often with short and long term disastrous consequences. Here is what they said:

The group recommends that all athletes suspected of having a concussion first be removed from participation and then be evaluated by a physician with experience in concussion management. Before being allowed to participate again, athletes must receive clearance from a physician or neurologist. Athletes should not compete if they are still having symptoms of a concussion.

This approach is in keeping with the policy we have implemented in the Mamaroneck School District. Even two years later, we are still working to make this acceptable and accepted by athletes, coaches, parents and physicians in the community. The support of organizations like the AAN along with the NFL will go a long way toward creating acceptance of this conservative and careful approach.

image credit: Google Images

Screening for Depression in Teens

2010-11-01T13:37:00.002-04:00

A study released in the online version of Pediatrics today gives clinicians a readily available tool to screen for depression in adolescents. (At the time of this posting it is not yet available online).

Called the Patient Health Questionnaire-9, or PHQ-9 referring to the nine questions it poses, this tool has been used to screen for depression in adults for some time. Now researchers under the guidance of Dr Laura Richardson at the University of Washington in Seattle have shown its effectiveness in a survey of over 400 teens ages 13-17.

The Questionnaire can be viewed here. Essentially it asks about feelings of sadness, hopelessness, and about appetite, sleep difficulties, and thoughts of hurting oneself. A score of over 11 on the test is highly sensitive for picking up teens with depression.

This is a convenient and useful tool for busy doctors and clinicians to use as a screening device. It should never take the place of a confidential and private conversation to clarify the meaning of the answers, to assess the dangers and to provide support and referral where necessary.

image credit: ox.ac.uk

Homophobia and Cultural Change

2010-10-25T09:55:00.000-04:00

With the passing of my dear friend, Lisa Levi, who at the age of 94 and only days before her death could discuss Woody Allan's newest film, I read of intolerance in our culture and think of her as an example of a woman of great compassion. She was fascinated by the black Jews of Africa, by the homeless, by the mentally ill and by the queer of this world. She would find and celebrate the humanity in anyone.

As I read on a daily basis about the deaths earlier this month of many young gay students, I, of course also must think about how we can bring about change. Watch here the two minute Ellen DeGeneres video where she implores us to stop validating ignorance and intolerance that lead to suffering, suicide and wasted lives. The New York Times magazine this weekend featured a story on the change of culture that led to the cessation of foot binding in China in the nineteenth century, based on a new book "The Honor Code:How Moral Revolutions Happen," by Kwame Appiah. "Change," he notes, (begins) "with a dialogue of mutual respect, free of self-congratulation."

If you are a parent, a friend, a teacher, a clinician or a student begin by observing the language around you;step in when it sounds wrong. Here are a few easily accessible ways to help spread the message and change the language to begin a more civilized dialogue:

The Trevor Project: "The Trevor Project is determined to end suicide among LGBTQ youth by providing life-saving and life-affirming resources including our nationwide, 24/7 crisis intervention lifeline, digital community and advocacy/educational programs that create a safe, supportive and positive environment for everyone."

ItGets BetterProject: "Many LGBT youth can't picture what their lives might be like as openly gay adults. They can't imagine a future for themselves. So let's show them what our lives are like, let's show them what the future may hold in store for them."
Scores of notables (Obama, Ellen, Anderson among them) speak out to teens, often with their own personal stories and help kids see though the difficulties of defining themselves in a culture that does not validate them.

Stories are Good Medicine: a creative website written by a Columbia pediatrician-turned-Young Adult Fiction-author who teaches through story telling. Ultimately it's through relationship with Other that we will learn not just tolerance, but compassion and responsibility for others.

The way Lisa taught us to live.

...and the final story....

2010-10-18T09:41:00.001-04:00

"Ca ne se fait pas….”

“You should not do that.” I heard a firm voice coming from the driver’s seat in the car parked in front of the shoeshine boy whose picture I had just surreptitiously but not silently taken. It was the end of my last day on the street in Port au Prince and I had spent it walking about a mile in the relative calm of early Sunday morning taking photos and talking to people.

What had gotten into me as I walked the last few blocks to the house I had shared for the week? I knew it was the wrong thing to do.

I approached the handsome young driver apologizing in French and told him I would erase the photo (which didn't turn out, but that was beside the point by now) and I did just that so he could see.

I have been struck this week by the general reluctance if not hostility toward foreigners taking photos and so I decided that it was now or never.

I asked him, somewhat naively: “Why not? Why does it bother you so much that I want to take photos.”

“ You should have asked permission.” I agreed that I was wrong. But I persisted with my inquiry.

“Why is it that Haitians do not want their pictures taken?

“Well….” he said with a meaningful pause, “What will you do with those photos?"

I recalled my Haitian friend Rachelle telling me that many people feel “Anderson” and others have made money from the images they “took” from Haiti. I recognized his hurt and anger and I was determined to get to the bottom of it if I could.

“I plan to show them to people to teach and tell them about Haiti.” He was quiet, staring straight ahead, not disengaging, thinking.

So I decided to play my trump card of sorts: “I am a doctor and I came to work in the general hospital.”

I was fully expecting a “big f-ing deal” response as I might have heard elsewhere (eg NYC) but instead he looked at me ever so soulfully and said very quietly: “Bienvenue” or “Welcome”. I put out my hand to shake his through the open window and as we sealed that universal contact tears welled in my eyes as I said “merci” and turned to head home.

A last morning walk in Port au Prince and a final story

2010-10-18T09:35:00.002-04:00

This man was selling sheets with lyrics to popular songs. Everyone on the street seems to have a gig.

This building had housed a school for everything-driving, kindergarten, primary, secondary, languages, nursing. Education is prized in Haiti and of course it matters. Unfortunately for most it costs money.

This elegant building is the broken home of the Universite de Notre Dame, the political science department. No surprise that the bottom right of the gate says "Down with Clinton."

Cherries for sale on Sunday morning

The two preferred candidates' posters together. I looked all week for this shot!

A huge display of new furniture for sale.

More chairs. When we wonder why the rubble hasn't been cleared yet, we have only to look at this scene where we see that people have resumed their lives selling what they make and that it would be impossible to move any of this concrete without heavy equipment (of which I saw very little); it would displace and congest the already crazy streets even further;there is the issue of where to put the rubble; and what should be built in its place. Most importantly, many of these "piles" are shrines where the dead are buried. We have struggled with these issues at the Ground Zero for a long time. So do the Haitians.

A kindergarten on my street. "Garden of the Angels." On Sunday with much less bustle and congestion it was possible to see through the dust and heat to appreciate some of the colors of daily life.

This chicken's feathers exactly matched the owner's shirt! We all had a good laugh about it. Unfortunately I was not in a position to purchase the creature but for once it didn't seem to matter.


This street billboard with the slogan of one of the new political parties says, "Dare to Love Haiti!" I think it sums up a lot about what is required to continue to boost Haiti and get it back on its feet.