These articles are written by Dr. Sugarman and first appeared in the Rochester City Paper, Family Matters column.
• Can’t Buy Me Love
• Fever Facts
• Thou Shalt Honor
• Toddlers and Toileting
• Tantrums
• Septembers
• Kids on Psychoactive Drugs
• Get Your Head Out Of The Box
• Stranger Danger
• Bugs and Drugs
• Cold Medicines
• Colorful Language
• Eating Together
• Hurting
• Immunizations, Historical Blindness, and Blame
• Kids in Trance
• The Politics of Discipline
• Sex and Drugs!
•
Sleepless in Parenthood
• Sports Injuries
• PARENTING 9/11: Five years and one month later
• Baby Signs of the Times
• Blankies
• Time-In
• Neurobiology and Violence
• “Normal” Behavior
• Don’t Tell Me What To Do
• Ghosts for the Holidays
• What are We Feeding?
• Thank God She’s Annoying
• Dog’s Training
• Allergies
• What’s ADD?
• Truth Telling
Hypnosis and Hypnotherapy for Children and Adolescents
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Can’t Buy Me Love
Laurence I. Sugarman, MD
During Christmas and Chanukah our kids were recipients of desperately desired stuff, gift cards, and various amounts of money. It happens again on birthdays, bar mitzvahs, graduations, and doting relatives’ visits. All this loot raises that difficult parenting question: how do we teach our kids about money? How do we teach them to save, buy, and give, and about how money corrupts?
Once young kids finish swallowing coins and sticking them up their noses, they learn that money is a token we exchange for stuff. First it’s gum balls and candy: magical instant gratification. Young people grow. Small denominations lose value. Nickels become quarters become dollars become twenties. Advertising pervades our kids’ experiences. Money becomes a vehicle for self-gratification, peer identification, and materialism. How do we teach them to value small stuff? How do they learn that there is little real instant gratification in life? How do they learn how good it feels to give charitably? How do they learn that investing in dreams makes them strong?
Money is powerful but it is not power. Gifts and money are not love. Love is in teaching that balance. As your kids grow wanting, ask them: “How are you going to get that?” “How much do you need for that?” “Is it worth more to you than…?” “How would you earn that?” “What did you do with the money you earned for…?” “What do you want your money to do?”
The holiday season is over. Jesus, Moses, Buddha, and Mohammed would say “Give it all away.”
Fever Facts
Laurence I. Sugarman, MD
Fevers cause worry. Parental anxiety about fever stems from both the altered appearance of their febrile child and the mythology of this mis-information age. Parents falsely fear a fever will get high enough to cause seizures and brain damage, believing it must be controlled to keep their child safe.
Fevers are really a natural way of fighting infection, triggered by our immune systems. Our white blood cells release chemicals (pyrogens) that raise our brain’s thermostat. Our body temperature then rises, slowing the growth of bacteria and viruses, speeding up our immune response, and making us tired, conserving energy. There is good evidence that fevers help us get better. Fever’s not a disease. It’s a sign that we are combating infection.
Fevers can’t get high enough to hurt us. Our bodies make chemicals (cryogens) that lower our temperatures when they get too high. Heat stroke (brain damage from high temperature) results from hot environments not fever. Children can have frightening seizures with fever but they don’t cause brain damage and can’t be prevented by medication. Fever-reducing medicines (ibuprofen and acetaminophen) are safe only at the right doses. They are unnecessary unless a child is uncomfortable from fever. There is no benefit, and there is potential danger, in giving both medicines together.
When your child has a fever, call your pediatrician to make certain that you are dealing with the cause rather than the symptom. The fever’s a good thing. The most contagious germ affecting our children is parental anxiety.
Thou Shalt Honor...
Laurence I. Sugarman, MD
I was instructing six year olds in a Sunday school class with a curriculum of Bible stories. We were making clay tablets of the Ten Commandments with etched Hebrew letters. With each new letter we studied the gist of its matching Commandment. The kids ranged from argumentative agitators to docile partisans. There was lots of good disagreement about coveting, stealing and even adultery. We arrived at "Thou shalt honor thy parents." We figured that "honor" meant to "value," "respect," "be polite," "listen," "follow directions." Then, unanimously, from the anarchist to the meek, every child in that class suddenly exclaimed that Commandment was backwards, "They have to honor us first!"
This pronouncement stunned me. First I was offended by the nerve of their uniform rejection of a precept that was literally written in stone. Then I was intimidated by their fresh perspective, allowing them to question such a tenet. When I was their age this never would have occurred to me. How was I cowed into such obedience?
Finally, listening to their dissent, I was inspired by the nascent wisdom of these children. "Of course," I thought. "Why would kids care to learn to listen, be polite, follow directions and value another person without feeling respected first?" To honor our children does not mean to coddle, cater and indulge them. Those behaviors can be dishonorable. But to teach respect we must model it so our children feel its glow. Perhaps the Commandment should read "Earn the honor of thy children."
Toddlers and Toileting
Laurence I. Sugarman, MD
There is no such thing as toilet training. Nobody has ever trained a toilet. Toddlers are trainable, but just barely. Regrettably, they are not equipped with flusher handles so we cannot conveniently control their urination or defecation. Every time we fail to make them use the toilet, they happily prove that they alone dictate when and where they pee and poop. Our controlling efforts only and always delay their inevitable, independent toileting. When we get out of their way, they do beautifully.
After many years of careful instruction by wise and willful toddlers, this is what I have learned to advise parents. When your child resists diaper changes and wants privacy, around 18-24 months, buy a toilet seat or chair for her, then ignore it. Always change diapers in the bathroom (where the toilet lives) without talking or eye-contact. Be boring and considerate. Have no initiative, ever. Never suggest she sit on the toilet.
When she asks for help with the toilet, act stupid and ask for instructions, every time. This must be all her idea. Enforce privacy. Request "Privacy, please," when you use the bathroom. She will want the same. Finally, offer no praise or bribes. Instead, ask, "Are you proud of yourself?" or "Is that what you wanted to do?" This is her success.
That's it: a respectful, child-directed approach. Our children run this project and we want them to. We need to save our energy for more important parenting issues...like their driving.
Tantrums
Laurence I. Sugarman, MD
It must be really tough to be a two year old: surrounded by giant, arbitrary, unpredictable humanoid creatures who don't seem very smart but do know how to run things. When you are two, the world works by magic and should revolve around you. Anything you want ought to appear immediately. Everybody ought to read your mind and follow your commands. No rules ought to apply to you. You know you have superpowers.
But then nothing goes right and you barely know the language. How utterly infuriating. Sometimes you just have to completely loose your composure and scream until you are done.
Two-year-olds don't really think this through, but it helps to use our relatively grown-up minds to imagine how the world looks to them. Then we can understand that tantrums are expressions of frustration from tireless, slightly crazy, explorers in a huge world who have limited abilities to express their feelings. Tantrums are emotional storms that allow toddlers to reboot and keep going.
And the tantrummers watch our reactions. Do tantrums work? Do we respond by giving in? Do we give tantrumming toddlers power? Tantrums start out as expressions of frustration but can become manipulative. Children who are still using tantrums daily by age three to four have a problem. Either they have unusual sensitivities, expressive language problems, or have learned that tantrums work.
We all had tantrums. We learned to stop when we discovered our real superpowers lay in our ability to empathize.
Septembers
Laurence I. Sugarman, MD
Septembers are poignant times in the lives of parents and children. At summer's end we first send our five year olds off to school. They say goodbye to the cocoon of early childhood. Every September they step up to new grades, schools, and independence. Teens fall in love with autumn's renewed friendships. Then, suddenly, they're grown and off to college, travel, work: their lives. Gone. Parents keep letting go a bit more every September. Kids keep pulling away. Every September we learn that endings are new beginnings, once we let go.
Why don't these separations ever go well? Our kindergartners cry or simply run off to their new classroom, forgetting to say good bye. We embarrass our kids at the bus stop. We linger too long or leave too soon at the college dorm. We can't ask our kids to understand what it is like for us to let them go and, try as we may, we can't really know their yearnings to leave. The contrasting pulls of bonding and separation require these moments to be both painful and sweet. There is no graceful middle.
A few weeks ago, friends asked me what it was like to "drop off" my daughter to start college. "Drop off" seemed too passive a phrase. I said, "I did not drop her off. She cut the tether on the catapult she had been stretching back for eighteen years." Off she soared. I can't wait to see where she's headed.
Kids On Psychoactive Drugs
Laurence I. Sugarman, MD
There are more kids on prescribed psychoactive drugs than ever before. Why? Are kids more susceptible to stress nowadays? Do more kids have anxiety, depression, obsessive-compulsive disorder, and attention problems? Is it just that better drugs are available? Are more families demanding prescriptions for these drugs? Do doctors prescribe more easily? Do we, as a society, accept less suffering? Nobody seems to know.
Mark Twain wrote: "It is not what we don't know that's the problem. It is what we know for certain that just ain't so." The promotion of psychoactive medications starts with the myth that attention, anxiety, depression, and obsessive-compulsive disorders are primarily due to altered brain chemistry. If you buy that then it makes perfect sense that the growing variety of these drugs work simply by correcting a "chemical imbalance" in our brains.
Of course this "just ain't so." The fact that psychoactive drugs affect brain chemistry does not mean that a huge range of emotional and thinking impairments are just chemistry problems. They are not. They are complex conditions that have roots in family structure, early emotional experiences, relationships, learning styles, genetics, and more. Psychological suffering is no more chemistry than a headache is a lack of aspirin.
On the other hand, we have never had safer, better-controlled, and more effective prescription psychoactive drugs. They work. While this is great progress, it does not mean that these medications alone provide answers. Like aspirin, they relieve symptoms. But nobody really knows how they work, and their effectiveness must not overshadow more holistic therapies. The most effective treatments of psychological problems are customized blends of psychotherapy, changing habits, insight, family change, and maturation, along with symptomatic relief.
We need to be careful not to confuse pills with skills.
Get Your Head Out Of The Box
Laurence I. Sugarman, MD
My son and I went kayaking yesterday morning. It was overcast, cool, and quiet but for the dipping paddles, bird calls and soft conversation. It occurred to me that my son had no frame of reference for this experience. No commercials. No script. It was not television or a video game. It just was.
There is ongoing debate about how television influences our kids' behavior. Does it promote obesity through inactivity? Do the commercials sway their desires for products? What's wrong with educational television? What about watching and discussing the news with our kids? What about professional sports on television? What is too much screen time? When is it okay for our kids just to "veg out" in front of the tube?
I don't know the answers to any of these questions. There probably aren't any simple ones. But perhaps they are all the wrong questions. The issue is that the imaginative involvement of viewing television and playing video games acts as a powerful filter of life experience. Neuroscience tells us that this repeated exposure deeply affects developing minds, forming a governing frame of reference. Television's products, language, socialization, and story lines restrict creativity more than they stimulate it. The more kids watch television, the more the world seems like television.
So it was particularly satisfying to watch my son remove the filters, finding balance outside of the TV amidst the reeds and water. Our kids inherit our world. They must experience it outside of the box.
Stranger Danger
Laurence I. Sugarman, MD
“Stranger Danger” is a popular saying. We teach it to keep our children safe. It’s easy to remember… and wrong. Are all strangers dangerous? Do safe strangers dress or talk or act like us? Doesn’t “stranger danger” teach racial, economic, and cultural prejudice? Statistically, strangers are safer than people we know.
The US Department of Health and Human Services reports about 900,000 of our nation’s children are abused each year (and abuse is underreported by an estimated 60%). That’s over 100 kids an hour. Every day 4 children are killed by their abusers. About 96% of abusers are family members or care providers. Strangers don’t wound most kids. They are scarred forever by those they trust.
We don’t need our children to be scared of everybody. We need to instill a right to privacy. “Nobody—not Mom, Dad, teachers, doctors, priests, or strangers—is ever allowed to scare, hurt, or embarrass me, or make me keep bad secrets.” Parents can model this by first knocking on children’s doors, respecting children’s modesty, and requesting their own privacy. We invest in our children’s safety by teaching them to introduce themselves and converse respectfully with people they don’t know…yet. Our children can learn to say, “Excuse me, that’s private.”
We all want secure kids, but security won’t come from seeing a world of strangers or being scared of everybody. It derives from self-respect, self-esteem, and the inner strength to refuse personal threats. When our sons and daughters grow up with those qualities, they also value the gift of intimacy.
Bugs and Drugs
Laurence I. Sugarman, MD
Fevers, colds, sore throats, and rashes cause kids to feel bad, lose sleep, miss school, and worry their parents. Their parents worry about how these illnesses are transmitted and the overuse of antibiotics to treat them. There are two myths about these subjects worth clearing up.
Diseases are not contagious, germs are. We all live in teeming colonies of viruses, bacteria, and fungi. Often helpful, these germs sometimes exploit weaknesses in our immune systems and battles ensue. Those battles are what we experience as infectious diseases. Because children have naïve immune systems they have more fights with germs. The resulting ear infection, sore throat, bronchitis, or rash is not contagious. The germs are. What kids do with the germ determines their symptoms. Infectious diseases have more to do with how we deal with the germ than the germ itself.
Antibiotics do not weaken immunity. It is not true that when we use antibiotics to help fight the germs in a child, her body won't learn how to defend itself. Antibiotics simply limit germs' growth. Immune systems do the vital work of destroying germs and cleaning up the infections. Without strong immune defenses, antibiotics do not work.
On the other hand, our immune systems are weakened by stress, sleep deprivation, poor nutrition, and lack of exercise. Teaching kids to wash their hands and to eat, sleep, and exercise well is most of what limiting infectious disease is about.
Cold Medicines
Laurence I. Sugarman, MD
Coughs, sneezes, and honking noses are everywhere as we slog through another “cold and flu” season. Folks will spend a lot of money on over-the-counter medications promising multi-symptom relief. Most do not help. Here is my brief guide to common, non-prescription cold drugs.
Decongestants. There are only two kinds: pseudoephedrine (Sudafed) by mouth and decongestant nasal sprays (like Afrin). Both work by shrinking mucous membranes in your nose, but wear off quickly, leaving your nose even more congested. As stimulants, they raise heart rate and blood pressure, making it hard to sleep. I rarely recommend them. Salt water (saline) nose sprays are better.
Cough Suppressants. There is only one: dextromethorphan, which barely works. It doesn't work well if you have lots of mucus to cough up. It works best if you just have a tickle in your throat. Don't buy it in any form that lasts less than 12 hours. Tea with honey and lemon is about as good.
Expectorants. There is only one of these, too: guafenesin. It is controversial because research shows that drinking lots of fluids is as effective. It is supposed to loosen mucus in sinuses and lung tubes. So does drinking and gargling.
Antihistamines. These include diphenhydramine (Benadryl) and loratidine (Claritin, Alavert). They decrease allergy symptoms. Diphenhyrdramine makes people spacey, sleepy and irritable. Both make mucus thicker and drier, and don't help with colds or influenza.
Fever and Pain Drugs. Acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) work well for fever and pain. Unfortunately, they are often sold with the drugs above in fixed combinations so that you have to buy medicine you don't need.
None of these medicines will change the course of your cold. Often the side effects are worse than the benefits. Buy only single-ingredient medicines and ask your doctor how best to use them. Sleep, fluids, gargling, and saline nose sprays work about as well. If you've eluded a cold so far this winter, keep washing your hands!
Colorful Language
Laurence I. Sugarman, MD
A father used that term in my office recently. His four year old son is learning how language shocks and dismays parents. He uses terms like “poopy head” and “doo doo.” I like this dad’s reference to “colorful language.” He didn’t call it “bad”, “foul,” or “rude.” He values his son’s creative ability to check out what provocative language does.
My friend, Reverend Jim Warnke, says “Oppositional behavior is strength of character pointed in the direction that pisses you off the most.” This son is doing his job. Our kids have to oppose us, test new behaviors, and express their frustration while learning limits. They could act out physically, hurting themselves, others, or valued property. If we say, “Shut up!” they might choose to keep their feelings inside, unexpressed and festering. Given the alternatives, I’ll take colorful language every time.
This father wanted advice. Responding with, “That’s bad language!” or by washing the child’s mouth with soap, serves to increase the power of the child’s defiance, reinforcing it. Meeting defiance with defiance never works. Ignoring the behavior is really hard to do and difficult for the child to understand. Empathy always works. “Boy, you’re mad!” “I know you don’t want to!” “You’re saying silly words, aren’t you?” This kind of response dodges the provocative intent of the language and grabs the feeling behind it, modeling both compassion and better communication.
By the way, when you use colorful language in front of your kids, smile and say, “Whoops. I’m sorry.”
Eating Together
Laurence I. Sugarman, MD
The Cleaver family never actually existed. For those old enough to remember “Leave it to Beaver”, the cast of that early situation comedy seemed a real family, not unrelated TV actors. Ward, June, Wally, and Theodore, the Beaver, played a perfect family. They ate family meals during which key plot issues were raised. Of course, what really happened during “Leave it to Beaver” was hundreds of thousands of American families sat at their folding TV tables, consumed snack food, and didn't talk while they watched a TV pseudo- family share a meal and have a scripted “meaningful conversation.” It was the beginning of the end.
It is increasingly rare for families to share meals. Schedules, homework, sports, meetings, errands, phone calls, and, of course, TV, all compete with communal meals and meaningful conversations. What's more, since none of us ever achieved Cleaver family perfection, we've nearly given up on the family dinner. The well-publicized epidemic of disordered eating among young people in the US has deep roots in the loss of family mealtimes.
We don’t have to eat the same food. It doesn’t have to be at the same time each day. We don't have to be in a good mood. We don't have to have a family meeting. We don't need to resolve key issues in a scripted situation comedy. We really don't have to talk too much. We do need to have a sanctified time during which we share sustenance, pause in the push of every day imperatives, prepare food together, and become a family that nourishes each other for a few moments.
Hurting
Laurence I. Sugarman, MD
Toddlers are determined and tireless social scientists, pushing the frontiers of human relations with their new abilities. At some point in their early lives, they discover that they can hit, bite, pinch, and pull our hair. It is exciting experimentation. The child wonders, “What happens when I do this?” “Is the response dependable?”
Parents react with pain and surprise when their child first begins to intentionally hurt them. “We never taught little Bruno to hurt people. Why is he doing this?” Most of us say, “Ouch! Stop that!” Then we talk and pay more attention to the child, reinforcing the behavior and prompting more hurting. Our responses change with our moods and patience, and increase with repeated injuries. Some parents even hit, bite, and pinch their kids back. While painful to the child, this simply models and reinforces the value of causing pain. The toddler learns, “This is powerful.”
Parental reactions to these experiments begin to shape the meaning of cruel exchanges in each child's life. What do we want to teach our children about the value of intentionally hurting other people? I recommend a simple, consistent response. When your child begins to explore hurting: stop talking, make no eye contact, turn them around and put them down on the floor, away from you, every time, over and over. The unspoken message, repeatedly, is: “Hurting behavior leads to social isolation.” Balancing this with constant attention for their gentleness, we hope our children learn the subtle power of kindness.
Immunizations, Historical Blindness, and Blame
Laurence I. Sugarman, MD
When our children’s grandparents were babies, every neighborhood lost children to infectious diseases now prevented by immunization. There were no routine child health visits. Children played in unsafe places, swam in creeks without adult supervision, and labored in factories. This was a time before Lysol, air fresheners, and reality TV. During that era more than 48,000 people in the US contracted smallpox annually. Each year there were more than 170,000 cases of diphtheria, 16,000 of paralytic polio, and 500,000 of measles.
Times have changed. In 2001, only 2 cases of diphtheria, none of polio, and 116 of measles were reported in the U.S. The only smallpox in the world is in laboratory freezers. Twenty years ago, when I was a resident at Strong Hospital, children were admitted weekly with life-threatening Haemophilus influenza type b meningitis and infections of bones, joints, and blood. Pediatric Department Chairman Dr. David Smith developed a vaccine. Disease due to this germ plummeted 90 percent in a decade.
The infectious scourges of the previous century are nearly extinct. Pediatric focus has shifted to what Dr. Robert Haggerty called the “New Morbidities”: chronic disease, stress-related problems, and learning and developmental disabilities, among others. Prevention and treatment of these conditions seem as overwhelming as those vaccine-preventable diseases did a century ago.
Now parents fear that vaccinations cause these modern diseases. Parents are alarmed by theoretical links blaming immunizations for autism, diabetes, mental retardation, learning disorders, and immune diseases. Rigorous studies of whole populations have thoroughly disproved these associations between childhood immunizations, various, diseases and immunological stress. The fears persist.
What’s the point? Times are still changing. We don't seem to remember that infections now prevented by immunizations used to cause pain, death, and heartbreak. We want to blame modern diseases on the vaccines that prevent the old ones. If we are victimized by this historical blindness in our longing to protect our children, we put them at risk. It is time to move forward and look for more responsible answers.
Incidentally, nothing kills more children than automobile accidents. Fasten your seat belts.
Kids in Trance
Laurence I. Sugarman, MD
They are everywhere: kids playing intensely, absorbed in music, staring into space and daydreaming. It makes a lot of sense. Neuroscience research teaches us that imagining turns on nerve networks, enriching the brain. Children are just booting up the newest models of the world's best computers. They are in the business of learning how their minds and bodies are connected. They naturally use the gift of imagination for fun, fantasy, to set goals for themselves, and to cope with fears and challenges. This is how they learn to control brain-body reflexes in response to stress, pain, and joy. This is why early life traumas and successes powerfully shape who we become.
This also means that young people are hypnotically talented. With careful training, children can apply their concentration and imagination to prevent migraine headaches, control pain during surgical procedures, stop problem habits, and manage chronic diseases like asthma. Research shows that children can direct immune responses, control blood flow, change skin temperature, and regulate other so-called “involuntary” reflexes with self-hypnosis. This is powerful stuff. Not only does it mean that children can have more control when they are sick, but also that they can cope better when well.
Like any other therapeutic skill, hypnosis, and related strategies (biofeedback, relaxation training), ought to be employed by trained, licensed health care professionals as part of a comprehensive treatment plan. On the other hand, those bedtime stories we tell to help our children sleep well are good places to start.
Dr. Sugarman is the Vice-President of the American Board of Medical Hypnosis.
The Politics of Discipline
Laurence I. Sugarman, MD
Only children under five years old should be allowed to vote. With the wisdom of infancy they see hypocrisy clearly. Imagine a panel of toddlers discussing Washington politics, slicing through the spin and extracting the essential questions. They care what we do, not what we say. They set their lifelong priorities by the consistency of our behavior. Albert Schweitzer wrote, “Modeling is not a form of education. Modeling is the only form of education.”
I wonder how much the conduct of leaders and despots reflects their upbringing. What were Saddam Hussein's Mommy and Daddy like? We know who our current President's parents are but not how they parented his toddlerhood, when it mattered. How did the parents of nineteen young men raise them to believe fervently that their highest achievement would be to use airliners full of innocents as bombs?
I often recommend that parents construct questions about a child's misbehavior from the child's point of view. Can I keep eating if I throw food? If I run toward the street do I get to stay outside? What happens if I don't put my toys away? Will you change your mind if I keep crying ... in public? Can I hurt people? How many times do I need to misbehave before you decide to act instead of talk? All of these questions help your child to form an opinion about how you want the world to be.
Our children keep testing our values with their oppositional behavior until they are satisfied with rules and limits enforced with consistent, meaningful consequences. The meal is over. No more outside play today. No toys for now. Crying costs choices. When you hurt people, even by accident, you lose the privilege of social interaction. When we do not provide clear, respectful answers, our children become grownups who keep testing, eventually hurting others.
When next you are tempted to give a child attention for misbehavior or choices they have not earned, ask yourself: How do I want their world to be?
Sex and Drugs!
Laurence I. Sugarman, MD
These words strike fear in the hearts of parents of teenagers. That makes sense. The harsh truth is that teens have high rates of death due to accidents and mental health problems linked to drugs and sex. We can recall our own behavior and attitudes when we were adolescents. We probably remember close calls that drove our parents crazy, not to mention those things we did that they never found out about. We have scars, too. We ought to worry.
Open communication with our teens is the best way to prevent substance abuse and risky sexual behavior. We don’t want to preach to our kids because they’ll turn us off faster than Lawrence Welk. They have to want to talk with us. A teenager in my care explained it all to me. “Why would I talk to them about sex and drugs? They never tell me about what they did when they were my age.” That is the answer and the challenge. Can we muster the courage to confide in our teens about our own early experiences with alcohol, tobacco, marijuana and sexual exploration? Can we tell our kids what we didn't even tell our parents?
Adolescents will talk when parents will share the lessons of their past, model honesty, and be imperfect. It is really hard to do. The odds are that our kids will respond with, “Gee, Dad, I'm doing a lot better than you did.” Then we can say, “I know.”
Sleepless In Parenthood
Laurence I. Sugarman, MD
Most of the world’s children sleep with their families for their first few years. I doubt their parents struggle to get them to sleep. In “developed” societies, we put kids to sleep in cribs early in the first year of life. We want time to ourselves, have stuff to do, or simply want to sleep in our own beds. Besides, we have work the next morning. We don't want to sleep with our kids forever.
Teaching our kids to go to sleep alone in their own beds is problematic. Life is too new and exciting at one, two, and three; imaginations go wild. Worse, bedtime routines involve parents keeping firm limits at a time of day when no one has much patience or stamina ... except kids. So we break every rule of discipline. We threaten. We give in. We read just one more book. We exorcise closet monsters. We leave. We return. We get the cup of water. Eventually, we fall asleep with our kids.
What’s a parent to do? Normal kids eventually crave independence and privacy at night. It gets better no matter what. This doesn't mean that it's futile for parents to set bedtime limits; kids always benefit from rules and structure. It simply means that those routines ought to be practical, negotiated solutions that work. What do both parent and child require to get adequate sleep and privacy?
In the end, the biggest problem with sleeping with your toddler is that you’ll blink, she’ll be fifteen, and you’ll be asking her why she never says “Good night,” anymore. You’ll miss those days when cuddling her to sleep solved all her problems.
Sports Injuries
Laurence I. Sugarman, MD
To prevent sports injuries, growing teens have to learn a balance between pushing themselves too hard and not enough. They are growing and changing, so that balance point is shifting. Then there is the essential problem of being an adolescent: perspective. This next game or tournament always feels like the most important one, worth making an injury worse.
Most adolescents with sprained ankles, stretched ligaments in knees, shoulder tears, stress fractures, broken fingers and clavicles, and concussions are smart, passionate athletes. They are the kind of kid a coach wants on a team... perhaps too much so. They are the teenagers that are angry when told they cannot play until they have healed. Playing hurt does not bother them even though they are not getting paid. They don't understand that when they are hurt, they cannot compete.
Parents and coaches have to advocate for the balance. The keys to preventing sports injuries in our spirited young athletes are stretching, strengthening, and body awareness. Ideally, parents, coaches, trainers, and doctors should work together to help an athlete learn stretching and toning exercises with goals to meet before competition. Strength training should come second because strengthening muscles and tendons tightens them, and lack of flexibility makes us injury-prone. Finally, the athlete needs to learn how to slide, jump, roll, kick, and throw in ways that minimize stress and strain on joints. This kind of body awareness usually comes only with physical rehabilitation after the injury. Helping kids feel smart about sports injury prevention is the ultimate goal.
PARENTING 9/11: Five years and one month later
Laurence I. Sugarman, MD
Events play tricks with our memories. September 11, 2001 does not seem to be five years ago. It still echoes in our lives. We all know what we were doing during that day and can recall it vividly. We know that our lives changed then.
I learned that two airplanes had hit the towers of the World Trade Center just before I entered an examination room for the first “well child visits” of that day. The mother and her two daughters had been waiting for me, shielded from the incredible news. I did not know enough to tell them anything.
Throughout the visit—as the mother asked me questions about her daughters’ behavior, her limit setting, school, nutrition and all the stuff of our lives with our kids—my mind tried to make sense of the information I had just heard. The pilots did this intentionally. It took a lot of planning. It took a kind of courage. It was probably done by inspired young men. How did these boys grow up to believe that this was the best thing they could do? What did their parents do that led them to believe this way? What responsibility do we all share in this? What did this have to do with my daily work with parents and children?
These various thoughts kept troubling me as the awful information accumulated that day. Finally they flowed together into one stream. In some way, all the world’s children are our children. What did we all do to raise these little boys to become young men who chose death for so many as their ideal? How can we prevent children from growing up this way?
It is just over five short years later. There are hundreds of children who lost parents on September 11, 2001…and thousands since, in the aftermath. In every way we can, let’s help them choose life.
Baby Signs of The Times
Emily A. Sugarman, undergraduate student in Speech Pathology, Ithaca College
Laurence I. Sugarman, MD
The books are everywhere: Baby’s First Signs, Baby Fingers, Sign Language for Baby Flash Cards, and (our favorite) The Complete Idiot’s Guide to Baby Sign Language. These are just a few of the hundreds of new titles available to help parents improve their babies’ communication skills. Teaching babies to sign before they can talk is the latest fad to grow out of studies of how babies’ brains develop. This research has also compelled parents to buy flash cards, do “baby-cise,” and make sure their infants listen to Mozart.
Seems like a good idea: help your child’s mind develop with a ready-made formula for success. So what’s the problem? Well, there is no evidence that these products and exercises support development and relationships any better than parents’ own authentic and creative play. Certainly it is good to have guidelines for clever and consistent methods of interacting and encouraging communication with our infants. But baby sign language, flash cards, and “brain-developing toys” also carry an implicit authority that devalues each parent’s unique creativity and intuition about how to best play with her baby. Am I doing it right? Is it wrong to play with my child without following the manual? Am I causing damage by being myself?
Babies will make discoveries and explore relationships by interacting with us no matter what books and toys we buy. That is their full-time job. They don’t learn from toys and techniques as much as they learn from our being ourselves. When parents get down on the rug, read a story, tickle, and laugh with their infants, they are not only bonding and expanding their babies’ minds. They are being playful, intuitive, and unscripted. You just can’t buy that interaction and authenticity. Priceless.
Blankies
Laurence I. Sugarman, MD
Everybody has one. It may be reduced to a worn, smelly scrap of cloth by now. Maybe all that remains is the bunny’s ear. Perhaps you are lucky enough to have the whole, threadbare stuffed animal or most of the blanket, except where the satin binding has been rubbed away by years of soothing. If you are like me, all you have left is a fuzzy, soft, poignant memory of that very personal companion, a cuddly object that was, and still is, more than reality: a Blankie.
I am a pediatrician so Blankies parade through my office all day holding their young owners. Some are candidate Blankies that may not make the cut. Some are clearly established, with seniority. Blankies serve a very powerful purpose. They are the recipient of our first independent relationship apart from Mommy and Daddy, providing security through our earliest, formative separations. They provide us with a familiar sensual texture that conforms to our changing experiences. Our blankies accept our emotions and even our abuse unconditionally. As we grow older, more responsible, and we attempt to believe confidently in the myth of our independence, our Blankies, or simply the memory of them, are our hedges.
At some point we realize the Blankie was only a symbol. We recognize that the abilities that we assigned to our Blankies were really always within us. There is no external magical being who makes it all better. We are it, and that is the problem.
Charles Schulz knew. Charlie Brown accosts Linus who is clasping his habitual transitional object and exclaims, “Well, if you’ve got so much confidence in the world’s getting better how come you hang onto that blanket?” Linus embraces his blanket, places his thumb in his mouth and says, “Touché.”
Time In
Laurence I. Sugarman, MD
It is the fiftieth anniversary of the “time-out.” In 1957, behavioral psychologist Charles Ferster first published his research on “time-out from positive reinforcement” using pigeons.* Since then, “time-out” has become the gold standard for disciplining children…human children. Put the kid in a quiet place then wait for her to calm down. No yelling or spanking. Simply deprive the unruly child of attention. It is supposed to work. So how come it doesn’t always? How do you do it right?
There are lots of time-out questions. How long and where should it be? Should you warn or count first? Should you lecture the child on the way? Should the child apologize later? These were never issues with Ferster’s pigeons. Fifty years of research has not helped us.
It is hard to find the right answers because these are the wrong questions. Ferster’s work with pigeons was not about the “time out,” but what the time out was from: “time-in.” Time-in is about catching your child being good and giving them unexpected recognition. With kids, time-in can be brief and nonverbal: a short back rub, a hug, a high-five, a meaningful smile. More involved time-in activities include uninterruptible periods reading together, playing a game, walking or cycling, cooking and having a snack. Mostly, time-in is about providing a rich, consistently positive atmosphere in which kids know they are not in trouble.
Most kids cooperate most of the time and that behavior goes mostly unnoticed. When there is a lot of time-in, time-outs are easy. They are an abrupt break in the action; a short, silent, impassive removal from warm acceptance. They can be pretty informal. Kids get it and the details become unimportant.
So celebrate Ferster’s pigeons with lots of time-in for children. Give yourself some, too.
*Ferster CB. Withdrawal of positive reinforcement as punishment. Science, 1957; 126:509.
Neurobiology and Violence
Laurence I. Sugarman, MD
The aftermath from the injuries and murders at Virginia Tech is waning. The gunshots’ echoes still jangle our nerves, just beyond our consciousness. As the event slips out of our awareness, we settle back into the reality of daily violence on our streets. It is not debatable that one cost of our individualistic, independent, private and self-determined culture is that our rate of violent death exceeds most other developed nations. We kill each other more. The cost is too high. It has to change.
Transforming that reality is not simply about the politics of poverty, hopelessness and the availability of weapons. It starts with our children. Research in the biology of brain development demonstrates that persistent witnessing or experiencing of violent behavior, bullying, or prejudice fundamentally and irretrievably affects the wiring of children’s brains early in their life. The alienating stress of trauma affects the growth of specific parts of the child’s brain in such a way that young people become less capable of adapting, empathizing and forming meaningful reciprocal attachments with others. Kids who learn violence have little choice but to become violent.
What’s a parent to do? How can we immunize our children against the endemic contagion of brutality in our communities? Once again, the answer is in the neurobiology of development. Secure, trusting, and empathetic adults, who will hold their children back, listen to them and set firm rules counter the whithering effects of trauma on children’s brains. It is not about shielding our kids from the reality of intentional hurts, but providing them a warm nest from which to understand it, then experience kindness.
Ghandi asked us to “be the change you wish to see in the world.” Our children’s minds are where the world starts.
“Normal” Behavior
Laurence I. Sugarman, MD
As a pediatrician who specializes in behavioral problems, parents ask me regularly if their child is acting normally. Posing this question takes courage. Parents risk finding out the answer is “no.” They risk finding out that they could be better parents. They often start by minimizing the problem, saying, “I suppose this is normal behavior but…” I usually start my response with, “‘Normal’ is the biggest problem we deal with.”
It is normal for our kids to challenge us. In fact, their challenging behavior is their best way to explore the rules of engagement. There is abundant, sound advice available from your doctor and other resources about setting limits and being consistent about your kids’ testing behavior. But what should you do when your child’s sensitivity, anger, withdrawal or fear keeps you up at night? What happens when your intuition tells you to worry?
One of my mentors taught me that parents’ concerns about their child’s behavior are always significant. This doesn’t mean that the behavioral problem is really abnormal. It means that doctors should always act on parent’s worries. Worry is contagious and kids catch it.
When your son’s or daughter’s fears, aggression, play or moods concern you, do not accept reassurance that it is normal. Request a careful assessment, more information to understand your child and a plan of behavior management from your pediatrician. There are standardized scales that professionals use to separate abnormal from normal behavior during childhood development. Your child’s doctor ought to have these or refer you to a professional who does. Get professional advice about how to change your own behavior to help your child. Most importantly have a follow up plan with your doctor to monitor changes.
While most kids’ worrisome behaviors improve with age, it is also true that they can be the first indicators of more significant problems. One of my other mentors says, “I have never helped anyone with a problem that was too small.”
Don’t Tell Me What to Do
Laurence I. Sugarman, MD
Nobody likes to be told what to do. Even people whose business it is to follow orders look for breaks. As our babies morph into independent toddlers and realize the power of thinking for themselves, they become experts at opposing orders. We say, “Come here!” “Put that down!” “Eat your food!” “Go to bed!” and they run away, throw the toy, spit out the food and stay awake. In my office, parents ask me about these behaviors all day. Many have asked me to put my response in writing. So, here it goes.
There is a simple formula that can be recalled with the acronym ERA, for empathy, rule-statement and action. It works this way:
- Empathy. Empathy is how we engage other’s feelings. Emotions come before cooperation so we have to empathize first. Besides, empathy is disarming. Empathy always starts with the phrase, “I know you are…” then follows with a feeling like, “hungry,” “angry,” “upset,” “not the slightest bit tired.” When we are upset with our kids, it is good self-discipline to start with empathy.
- Rule-statement. Kids have a deep sense of democracy. They want rules to apply to everybody. Rule-statement says that we are all governed by the same rules. The statement must be impersonal and pervasive or our kids take it personally. Time is always a good rule-starter: “It’s dinner time,” “bed time” and “time to go.” Rule-statement includes the phrases you want your kid to have stuck in their brains forever: “We don’t hurt people.” Sometimes it is hard to know the rules we want to apply. That’s what our kids make us figure out.
- Action. This is the most important part. We don’t tell the child what they are going to do. They, after all, are entirely responsible for their own behavior (and we want them to be). We tell them what we are about to do to them. We, after all, are responsible for our own behavior. “So I am going to… turn off the TV and put you to bed” “…take that toy away from you.” “… take the food away.” “…put you in the car.” No threats allowed. Just do it.
There is a simple, clear message within this formula: I care about your feelings and we all follow rules and I am going to act with authority in away that affects you…unless you quickly come up with an acceptable alternative. This formula works pretty well on our kids. Unfortunately, if we are successful, our kids eventually use it on us.
Ghosts for the Holidays
Laurence I. Sugarman, MD
Now I don’t want to put a damper on the holidays. Folks are particularly sensitive about traditions and memories at this time of year. Maybe it has always been so, even when we gathered in clans in dark pagan dwellings, praying for a rebirth of the sun at the cold solstice. Even before we organized our faith traditions we humans huddled together at this dim time of year and realized we were all we had. We tried to find meaning in our bonds to each other.
But our families come apart. Divorces, remarriages, blendings, sad memories, and broken hearts become more poignant now as we make plans for family gatherings. The old divisions open like cracks that break across the ice. Out come the ghosts of holidays past.
I think about this stuff because I take care of a lot of kids with injured, sometimes healing families. These kids are in the business of creating their childhood memories about this time of year. Decisions get made about how much time to spend at Dad’s and Mom’s, about feelings of loyalty, about who to include, or not. These decisions affect our kids. They even hurt. Our kids are watching us. How warmly we soften our sharp divisions, join again despite old hurts, forgive, and love will provide the fabric for our children’s early holiday memories.
No. I don’t intend to put a damper on the holidays, as we huddle here in the dark. I mean to make sure our children know that the traditions and memories are warm and cozy. Friendly ghosts.
What Are We Feeding?
Laurence I. Sugarman, MD
I had the pleasure of meeting with a wonderful, insightful, intelligent seventeen-year-old woman who came to my office for weight loss counseling. She weighed 345 pounds. She said that her lifelong obesity made her feel that she had been born into debt and had been unable to pay it off.
We know have a nationwide obesity epidemic. According to the American Obesity Association, the prevalence of obesity in our children has quadrupled to nearly 16% in the last 25 years. We are always searching for the causes of our kids’ corpulence in the excesses: too much fast food, TV, video games, snacks, genetics, laziness. All of these forms of overindulgence contribute to obesity in our children and none of them are the cause.
Food is more than fuel. From breast milk to birthday cakes food is also a powerful form of emotional attachment. We use food to express love and approval to our children, to distract them, as way to share pleasure with them and sometimes to assuage our parental guilt. Meanwhile, portion sizes in restaurants increase and we deserve a break today to get away from the inescapable reality that when we eat more calories than we use, we get fat.
The cause of childhood obesity is simple. Early on, we teach our kids to disconnect their hunger from caloric needs and attach it to their emotional needs. They learn to overeat because it feels good. The problem is feeling good is never good enough. The key to treating obesity is to learn what it is we are feeding with all of these extra calories, then to find healthier ways to nourish it. Prevention is better: as our kids learn how to feed themselves, let’s love them for knowing when they are full.
Thank God She’s Annoying
Laurence I. Sugarman, MD
The pressure to be an ideal parent is enormous. We work so hard to get everything right. We read the parenting books and magazines and watch critically, making mental notes, as others raise their kids. We won’t admit it but we cannot help imagining that our children will inherit our failings and their tantrums, now, will lead to a future life of crime. It is not that we don’t know how to ignore the small stuff. It is that we are too close. With our kids, none of the stuff seems small. Everything is big.
Wouldn’t it be great if we could know that they will turn out all right? Then we would relax our parenting posture, lose some of our incessant worry and simply express faith in their abilities and strengths. After all, their strength is the big stuff. Unfortunately we can’t know. Wait! What would happen if we just acted like they’ll be okay? Could we just enjoy their frustrations and misbehavior, knowing that they are growing and learning from them somehow, in their own way? If we magically found that balance between vigilance and faith, we would sure be more poised and less reactive with our kids.
A mother and father were in my pediatric office the other day with their two youngest daughters. The older of the two has a difficult, profound and unexplained developmental disability. They know that she is not going to be okay. We were concerned that her baby sister may be developing similar traits. At this one-year-old visit, the baby showed so much physical, social and language ability that we were all completely reassured. Now she’s frustrated and having tantrums. As she had one in the office, her mother, with relief and pride, exclaimed, “Thank God she’s annoying.” Yet another gift in a small package.
Dog’s Training
Laurence I. Sugarman, MD
As a boy I was deathly afraid of dogs. On the way home from school each day, I would turn onto our street, pause for a deep breath, then run as fast as I could past the dogs chained in their yards. They barked ferociously as I dashed past. I was terrified. I have no recollection of how this phobia started but I know when it ended. One afternoon an elderly neighbor stopped my running and told me to stand straight, breathe slowly, and calmly approach his leashed collie. That big dog did not eat me. She smiled and wiggled and wagged. I smiled back. Our family had a succession of three dogs after that: Bagel, Jenny, and Tabasco. They taught me a lot.
Dogs can be great for kids and their families if we let them. They teach the value of consistent, quiet praise. They instruct us in the simple, soft language of cuddling. They ask us to gather the courage to face our fear of them, and then they lick us in congratulation. They make us know the right commands, use them dependably, and praise effusively. More than that, dogs train us to pay attention to our posture. They attend exquisitely to our intent. They ask, with their eyebrows and tails—their posture—“Did you really mean that?” They summon our authenticity and will love us unconditionally for it.
The way dogs train us to be ourselves has always made me wonder how much they really know. Maybe they are shaggy Zen masters. In “Thomas Edison’s Shaggy Dog,” Kurt Vonnegut speculates that dogs are our masters. I mean, who cleans up after whom?
Allergies
Laurence I. Sugarman, MD
An idyllic painting hangs on the wall across from my desk. Towards a distant cottage a stone path meanders through a meadow abloom with vivid wildflowers. To someone with allergies at this time of year, the painting is offensive. It makes their eyes water, their nose stuffy, their throat scratchy, and everything itchy. It’s allergy season.
Why we have evolved these hyperactive immune responses we call allergies? A leading theory is that our environments are too germ-free. Our immune systems don’t have enough to do so they become hypersensitive and over-reactive. When an offending substance triggers them, vigilant (mast) cells release a barrage of chemicals that make tissues swell and itch. The triggers can be anything organic: molds, plants, foods, animals and insects, medicines and perfumes. Depending on our genetics, age, and exposure, we can develop hives, puffy eyes, stuffed noses, coughing, wheezing, diarrhea and even, rarely, circulatory shock. Allergies are disabling.
How do we manage? It would be great if we could avoid all exposures to allergic stuff, but it’s impossible. Our immune systems find allergens. Most people take drugs like Benadryl and Claritin. These have side effects and don’t relieve all the symptoms. It gets expensive. Singulair, nasal sprays, eye drops, allergy tests and shots alter our immune response but usually fall short of complete relief. So does acupuncture and a variety of homeopathic and herbal products.
Allergies are a health problem that has evolved as we have changed our environment. There are no easy solutions, just a lot of very busy allergists and therapies that don’t work too well.
Intriguing evidence suggests that our minds can regulate the intensity of our immune responses. Hypnosis, expectation and suggestion can increase or decrease allergic activity. The prospect of mindful self-regulation presents a promising direction for future allergy therapy.
Meanwhile, I will avoid the painting on my wall.
What’s ADD?
Laurence I. Sugarman, MD
ADD/H is among the top five chronic conditions of young people in the US. Nearly one in ten school-aged children has ADD. In 2003, 4.4 million US kids were diagnosed with AD/HD by a healthcare professional. Two and one-half million were taking medicine for it. With these numbers you would think that we would know what it is. If anybody tells you they really understand Attention-Deficit/Hyperactivity Disorder (AD/HD or ADD or ADD/H, so far), smile and walk away.
There is no consensus about what combination of nature and nurture results in ADD/H. It is likely to be different for everybody who has it, whatever “it” is. Despite abundant behavioral scales, questionnaires and tests, the “diagnosis” of AD/HD ultimately rests upon subjective impressions of a child’s degree of impaired attention and impulse control, no matter how we rearrange its initials.
There are reasons to make ADD/H seem more solid than it is. Symptomatic medicines help a lot of kids with these disabilities, so we tend to believe kids who benefit from these drugs are similar. That’s like believing everyone who uses Tylenol is the same. We like the security of naming things. Insurance companies and school systems demand coded labels to spend money on services and medicine. Pharmaceutical companies target their drugs to a specific condition. Researchers need to lump people together to study them. Among healthcare professionals it is common usage to say that a child “is ADHD.” But our kids are not their labels.
When we accept the easy characterization of ADD as a defined “thing” treated with a medicine, we avoid the complexity of each child’s growing mind in a changing environment. Far more than medicine goes into helping young people overcome obstacles. When we reduce the fix to a label and a pill, we reduce our responsibilities.
Truth Telling
Laurence I. Sugarman, MD
It’s a basic philosophical problem. We base our actions on a reality that is subjective, created by our perceptions. For young children this leads to conflicts between their internal, magical world of imagination and our rational one. Kids believe that they can make their imagined realities come true. “Blue Bear ate the cookies, not me!” “My toys play with me.” It takes years for kids to reconcile these conflicts. As with all behaviors, kids keep testing these boundaries: to learn what lies are and how they work…or don’t.
Parents often ask me about what to do as their kids start lying. Should we demand, “Don’t lie!” Should we wash their mouths out with soap? Should we put them in time out? Should we indulge them and let them embellish their stories? The challenge for parents is to help kids learn to buy our reality, our version of “The Truth”, without losing hold of the creative power of their imaginations.
The answer is trust. I advise parents not to accuse their kids of lying, but simply to tell them, “I don’t believe you,” then act accordingly. Wait for the kid to figure out a face-saving way to be honest with themselves, then us. At issue is the young person learning to find their own truth to develop a trusting relationship. They need to run up against their parents’ integrity and meaningful representation of the rational world. Of course we continue to nurture our kids’ creativity…and always tell them the truth.
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