A glimpse into the world of childhood mental illness

The cut of mental illness can be sharper than any surgeon’s knife. What happens when a child’s emotional turmoil escalates beyond a family’s control? In the newly released book Suicide by Security Blanket, and Other Stories from the Child Psychiatry Emergency Service: What Happens to Children with Acute Mental Illness, Drs. Laura Prager and Abigail Donovan bring us behind the scenes of the Massachusetts General Hospital psychiatric emergency room. Although the discussion can be somewhat technical, the real-life stories are poignant and are fascinating not only for healthcare professionals, but for anyone interested in child mental health.

In this excerpt, a dialogue occurs between Dr. E, a child psychiatrist, and Tommy, a depressed fourth grader who has just tried to strangle himself:

“I hate myself. I want to die.” Tommy’s voice lacked any inflection.

“Why?”

“I’m bad. The world is bad. No one likes me. No one wants me as a friend.”

“No one?”

“I’m a loser. No one wants to be friends with a loser. They all hate me.”

“Why are you a loser?”

“I’m fat. I can’t do anything right. I got in to trouble at school.”

“What happened at school?”

“Nothing.”

“Nothing?”

“I wrote bad stuff.”

“Bad stuff?”

“This one kid farts all the time and I wrote ‘fart’ on his notebook.”

“Then what happened?”

“The teacher made me apologize.”

“That’s it?”

“My parents get mad when I do stuff like that.”

“Were they mad this time?”

“I don’t know. I always get in trouble. No one in my family likes me, either. They won’t care if I’m dead.”

…Tommy’s voice got just a bit louder. “After school, I was really mad. I went down to the playroom and I tried to strangle myself. I didn’t have any rope, so I used my scarf. I also thought about going upstairs and trying to jump out a window.”

Did you hurt yourself when you tied the scarf around your neck?”

“No, I couldn’t get it that tight.”

“Did you think that you could kill yourself that way?”

“If I pulled hard enough.”

“So what happened then?”

“My mother came downstairs and found me.”

“I guess it was lucky that your mother was keeping an eye on you. Do you know why she came down?”

“I don’t know. She took the scarf and called the doctor. Here’s the scarf.” Tommy pushed the sheet away from him. He was wearing maroon hospital PJ’s that were slightly too big for him. Around his neck hung a dirty grey-colored knit scarf that looked as if it might once have been another color, perhaps light blue. It had remnants of fringe hanging from each end. The scarf hung loosely, and the ends tumbled into his lap. As he spoke, Tommy absentmindedly started stroking the tattered fringe on one end.

Dr. E tried to regroup. How could the nurses have let this kid sit in a bay with a scarf around his neck when apparently he had just tried to strangle himself with that very scarf?

“Is this the same scarf?”

“Yes. I just told you that. I had it with me.”

“Is this scarf your security blanket? Do you sleep with it?” Dr. E hoped she didn’t sound quite as incredulous as she felt.

“Well, I don’t take it to school, usually. It usually stays on my bed during the day.” He paused before adding, “I had it with me today. It was in my backpack. It used to be light blue. I’ve had it for as long as I can remember. I think my father gave it to my mother but she didn’t like it.”

“You tried to strangle yourself with the scarf you have held on to forever?”

Tommy was silent.

Dr. E fell silent, too.

Reprinted with permission. Courtesy of Praeger Publishers/ABC-Clio, 2012. Available on Amazon.com

Naline Lai, MD and Julie Kardos, MD
©2012 Two Peds in a Pod®

Beth: a story of life and hope

At this time of the Jewish High Holy Days, Dr. Kardos offers us a glimpse into lessons learned as a doctor in training. This is a true story she wrote years after meeting Beth and until now, had only shared with a few close friends.

Tonight starts Yom Kippur and my two youngest children are asleep in their beds. As my oldest sits in the rocker next to my desk reading the last book in the Lord of the Rings series, my husband relaxes playing a computer adventure game. The Jewish High Holy Days are a time for reflection about the past year. But my mind goes back to a Yom Kippur Eve when I was working as a resident in the Pediatric Intensive Care Unit (PICU) as part of my pediatric training.

Residents work through most holidays, even ones they consider important. This night, I wished I had off, but I consoled myself with knowing that I would be off on Thanksgiving. Luckily I was partnered with Amy, the lead physician in the PICU.

The sickest patient that night was twelve-year-old Beth. She had leukemia and had just started chemotherapy. Because her immune system was weak, Beth was very ill with a bacterial infection in her blood. Despite powerful antibiotics, the infection raised havoc in her body. She developed such difficulty breathing that a tube from a mechanical ventilator was placed down her throat to force air into her lungs. Even the comfort of sleep escaped her. Beth was afraid of what was happening to her body. She refused to accept medicine that could help her sleep because she was so afraid that she would never wake up.

That night, despite her incredibly ill state, she got her period. Usually when a girl’s body is stressed, the body preserves all blood and the periods stop. But hers came, and because her blood cells were so abnormal from a toxic combination of infection, chemotherapy, and leukemia, she began bleeding to death. We transfused her with bag after bag of blood to keep her alive.

In the middle of the night, Beth’s blood pressure suddenly plummeted so we added even more medication. Because my mentor Amy was not certain that Beth would survive the night, we called her family at the hotel near the hospital where they were staying and told them come to Beth’s side. And through it all, Beth refused to sleep. Her eyes always opened in terror whenever we approached her bed. Her face was gray. Her chest rose and fell to the rhythm of the mechanical ventilator, and you could smell the fear all around her.

I stood with Amy just outside Beth’s room as Amy reviewed a checklist for Beth’s care. It went something like: “Ok, we just called blood bank for more blood; we called her family; we called the lab; we called the pharmacy. We are currently attending to all of her problems, we now just have to wait for her body to respond.” She paused,” But you know what?”

“What?” I asked her.

“We need to address her spiritual needs as well. Do we know what religion her family is? They may want a clergy member with them.”

I was startled. In the midst of all the tubes and wires of technology, Amy remembered to summon the human factor in medicine. We looked in her medical chart under “religious preference” and there it was: Jewish.

“Amy,” I said, “of all nights. Tonight is Yom Kippur…the holiest night of the Jewish year.”

I knew that the hospital had a Rabbi “on call” just like they had priests, nuns, ministers, and other spiritual leaders. But that night I was sure that every rabbi in Philadelphia would be at synagogue for Kol Nidre, the declaration chanted at the beginning of the Yom Kippur evening service. We were unlikely to track down a Rabbi.

Despite this, we asked her mother if they wanted us to call a Rabbi for them. She shook her head no. I remember feeling relieved, then guilty that I felt relieved. Amy left to check on another patient. Beth’s mom, dad, and older sister stood together watching Beth. Her sister’s hand lay on her mother’s arm. Her mother’s eyes darted from me to Beth to the mechanical ventilator next to the bed. Beth’s eyes were closed and it was difficult to know if she even knew we were there.

Her family walked out into the hall to talk. Beth at that moment opened her eyes and started tapping on the bed with her foot to get my attention. She couldn’t talk because of the tube down her throat and her hands were taped down with IVs. Yet she reached out with one hand as best she could.

I walked close to her bed so she could touch me and I asked, what is it, Beth?

Her lips formed the words around the breathing tube very deliberately, her body tensing. “Am I going to die?”

All in a split second I am thinking to myself: How do I know/it could very well happen/how can I lie to her/how can I tell her the truth of what I fear could very well happen/how am I going to answer this child?

What I answered was, “Not tonight, Beth.”

She relaxed into her pillow but kept her eyes on mine. I waited to see if she would say anything else, but the effort to ask that one question had exhausted her. I stood, holding her hand, until her family came back into the room. Her eyes followed them to her bed and I left so they could be together.

Beth did survive the night and in fact survived a month in the PICU. She became well enough to be transferred to a regular hospital floor. By this time I was working in a different part of the hospital, but one of the oncologists pointed her out to me.

I don’t know what happened to her in the long term.

So now I tell my oldest child it’s time for him to stop reading and go to sleep, and I walk him to his room to say goodnight. My husband and I decide what time we’ll attend Yom Kippur services tomorrow. Part of me feels joined with Jews everywhere who will also be spending the next day reflecting, praying and celebrating a new year. But mostly, like every year at this time, I remember the sounds and the smells and the fear in the PICU where sickness doesn’t care who your God is or what your intentions are. I remember Amy caring enough to think about a dying child’s family religion, and always, I remember Beth.

Originally posted in fall, 2010

Julie Kardos, MD
© 2012 Two Peds in a Pod ®

Join us at the Bucks County Children’s Museum

bucks county children's museum Wondering about preschool and toddler discipline? sleep? potty training ? emotional well being?

In the Bucks County PA area in October?

We’ll be holding a question and answer session Thursday Oct 11, 10:00am to 10:45 am as part of the first Bucks County Children’s Museum parent outreach series.

The following week on Thursday Oct 18, 10:00am to 10:45am Emergency Department physician Jennifer White, MD, answers the question: When should you take your child to the ER?

Sessions are free for adults. Discounted child price of $5. Children museum members free. Child-friendly arts and crafts provided. Baby sitting not available. To register, call the museum directly at 215-693-1290. The museum is located at 500 Union Square, New Hope, PA.

Series presented in conjunction with Doylestown Hospital, Doylestown, PA and The Bucks County Children’s Museum.

Hope to see you there!

Julie Kardos, MD and Naline Lai, MD

The building blocks of learning

Often parents ask us how to encourage learning in their toddlers. Everyday experiences with parents and toys are more valuable than flashcards or television. To help understand how simple toys enrich toddler development, we bring you an excerpt from occupational therapist Barbara A. Smith’s award winning book From Rattles to Writing, A parent’s guide to Hand skills. We appreciated how the book gives tips on making your own toys, and lists very specific “to dos” to encourage not only fine motor development, but visual motor and sensory processing skills at different ages.

Drs. Lai and Kardos

Why are building blocks one of the most universal and time-honored occupations of young children? For one thing, blocks or other objects that stack (i.e., juice packs, scraps of wood, or rocks) are readily available all over the world. Blocks stack easily because they are flat, and the symmetrical cube shape enables children to align them vertically or horizontally.

Stacking helps to develop the perceptual skills and depth perception required to place one block on top of another and the coordination to release the block at the correct time. Children typically learn to stack two and then three common one-inch blocks between the ages of twelve and eighteen months. These blocks are large enough to be easily grasped yet small enough to be stacked using one hand.

Your child’s arms will grow strong as he steadies his shoulders to place the block in just the right position for stacking. After the blocks fall over, he will learn that mistakes are okay, and it is easy to build another tower, and another, and another. Blocks are basic important learning tools to teach concepts, such as tall and short, counting, and color identification. In fact, they are the “building blocks” that will help your child learn to read and write eventually.

The toy industry has capitalized on our love of blocks and has created magnetic blocks, snap-together blocks, blocks that open up to hold a toy, and blocks with sound effects. However, simple, basic blocks are great. They allow for imagination and creativity in a world where many toys are overly complex and require batteries. Whether homemade or purchased, plastic or wooden, soft or hard, titanium or cloth, your child will enjoy many hours of learning with blocks. Blocks are a must for all children.

Barbara A. Smith, MS, OTR/L

An occupational therapist for over twenty years, Ms. Smith received her master’s degree from Tufts’ Boston School of Occupational Therapy, and went on to receive certifications in sensory integration and hippotherapy. Her website is www.barbarasmithoccupationaltherapist.com. Her book, quoted above, won 2012 National Parenting Publications Award, and can be purchased on Amazon.com.

ABC and zzzz’s on Parent Connections Cable TV

CBCares Do you live in the Central Bucks School District in Pennsylvania? We just got back from filming a segment on sleep and breakfast hints on Parent Connections- running through September.

CBTV community cable
Comcast 28/Verizon 40
7:30 pm on Tuesday, Thursday and Sundays

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

It’s a nailbiter…paronychia infections

finger infection

Ouch! This kid’s index finger has a finger nail infection called a paronychia. Often seen in nail biters and cuticle pickers, this infection occurs in the skin around fingernails. Although most kids are not dexterous enough to bite their toenails, infection can also occur in toes. Bacteria which normally live on skin (Staphylococcus or Streptococcus) find an opportunity to enter the body through openings in broken skin.

The area at the periphery of the nail bed is red, swollen, and painful. At times pus drains from under the nail bed.

Caught early, warm, soapy soaks several times a day may be enough to soften the tense skin and encourage germ-fighting cells to migrate to the infection. After soaking, apply topical antibiotic, such as Bacitracin, to the area. Often the infection improves after 2-3 days of diligent soaking.

Sometimes the infection persists and oral antibiotics are needed to treat the bacteria. In this photo, the redness of the child’s paronychia is spreading beyond the area immediately next to her nail. Besides increased redness, other worrisome signs of worsening infection include red streaks up the affected digit (a sign that the germs are trying to make it up to the heart), increasing pain, or fever. Your child’s pediatrician will make the call after examining your child.

Although I do not keep formal track, I do seem to see more of these infections at the start of the school year when kids at their desks begin to bite or pick their nails and cuticles. To prevent infection, remind your kids to wash their hands. If you have a biter/picker, have her substitute a different habit such as picking at a hair scrunchie or Silly Bandz. A more expensive and time consuming option, which Dr. Lai has seen work—offer a fancy manicure. Kids rarely want to ruin beautifully painted nails by chewing on them.

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

Hellos and good-byes: school 2012

In the office it’s raining school forms. At this time of year, I see many of my patients embarking on their next stage of schooling. Kids I remember starting kindergarten are off to high school. Babies are starting daycare and teens are starting college. For all the parents who have a child entering a new school, whether it’s preschool or college, this letter is for you:

My Child,

As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore.

Tomorrow those toes will step up onto to the bus and carry you away from me. Another step towards independence. Another step to a place where I can protect you less. But I do notice that those toes have feet and legs which are getting stronger. You’re not as wobbly as you used to be. Each time you take a step you seem to go farther and farther.

I trust that you will remember what I’ve taught you. Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow. I also trust that there are other eyes and hearts who will watch and guide you.

But that won’t stop me from worrying about each step you take.

Won’t stop me from holding my breath.

Just like when you first started to walk, I’ll always worry when you falter.

I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands. I just hope that at some point, those independent feet will proudly walk back and stand beside me.

Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus.

Until then,

I hold my breath each time you take a step.

Love,
Mommy

No matter the stage, to smooth your child’s (and your) transition, remember the basic rules of daycare drop-off:

Always convey to your child that the transition is a positive experience. You give your child cues on how to act in any situation. Better to convey optimism than anxiety.
Take your child and place her into the arms of a loving adult- do not leave her alone in the middle of a room.
Do not linger. Prolonging any tears, only prolongs tears. The faster you leave, the faster happiness will start.
It’s ok to go back and spy on them to reassure yourself that they have stopped crying- just don’t let them see you.

For more back-to-school related posts, please be sure to read
How can I motivate my child in school- creating the resilient learner
When children should stay home from school for medical reasons (or listen to our podcast on this subject)
Packing your child’s school lunch: beware of junk food disguised as healthy food
Avoid back strain: what to look for in a school backpack
Wake up, sleepyhead, it’s time for school – how to shift your child’s sleep into a pattern more compatible with school hours

Naline Lai, MD and Julie Kardos, MD
reformatted from original 8/17/09 post
©2012 Two Peds in a Pod®

Sporting a good attitude- an olympian effort

My kids and I cheered as we watched the Olympic swim races together on TV. Having just finished their first summer swim team season, they were especially interested in these events. While we joked about how much faster Olympian swim times were than their own, we also noted that “just like on swim team” at the end of the races, the Olympians shook hands with the swimmers in the adjacent lanes. It got me thinking about sportsmanship.

The adage says, “It’s not whether you win or lose, it’s how you play the game.” But our society puts such heavy emphasis on winning, coming in first, being the best (and thus beating out others) that kids can feel extreme pressure to win. Parents should resist adding to that pressure.

We, as parents, have to accept that our kids can’t always come in first, get the perfect score, or win everything they do. From an early stage, we need to praise our children’s effort, and also teach them to appreciate other kids’ efforts, skills, and accomplishments. We can say to our kids, “Wow, Bobby sure is a fast runner. I bet if you practiced running (or hitting, or catching, or kicking) you could get better too. I’ll help you if you want.” Teach your child that if she wants to improve a skill or test grade, she will have to work at it. Friendly competition that inspires us is a good thing. Kids cheat when they feel too much pressure to win, and fail to understand that there are no “quick fixes.”

When parents (and coaches) fail to model good sportsmanship, kids blame their pitcher when the other team hits, blame their goalie for letting up scores, blame their parents for not buying the most expensive equipment that would have enhanced their performance. At one of my kid’s games, I saw a young athlete punch a child on the winning team during the end-of-game “high five/good game” ritual because he was so angry that his own team lost the game.

Unfortunately, some teen athletes convince themselves that “because everyone does it,” it’s okay to cheat by taking steroids to enhance their performance. Students without a diagnosis of attention deficit hyperactivity disorder cheat by taking their friends’ ADHD medications so they can concentrate longer when studying for exams or completing homework. Even Olympic athletes cheat. Discuss with your children why eight badminton players were disqualified when they attempted to throw their games in order to get a “better” placement in the tournament. Because they cheated, they were given NO place in the tournament.

The 2012 Olympics is a perfect opportunity for parents to point out examples of good sportsmanship to their children. Even the Olympic athletes who cry from disappointment express support for their teammates and gratitude at the opportunity to compete at such a high level. So as we cheer for our own country or for our favorite athletes, let’s also teach our kids to cheer the athletes’ sportsmanship and performance.

Kids should learn to work hard, study hard, do their best all of the time. We hope that as adults they will value themselves and others for having good work ethics and improving their skills. Of course we should teach our kids to “go for the gold.” But we also need to be clear that we still love them even if they never claim a medal.

For tips on fostering sportsmanship in kids, see this post from the Nemours Children’s Health System.

Spotting the rash of ringworm

Although it’s called ringworm, this rash isn’t caused by a worm. In fact, it barely looks like a worm. Otherwise known as tinea corporis, the patch of ringworm is usually a flesh or light-pink colored, slightly scaly oval with raised, red edges.

Caused by a fungus, sometimes the patch is itchy. The same organism also causes athlete’s foot (tinea pedis), jock itch (tinea cruris) and scalp infections (tinea capitis).

Ringworm falls into the mostly-harmless-but-annoying category of skin rashes (cover it up and no one will notice). Your child’s doctor will diagnose the rash by examining your child’s skin. To treat the rash, apply antifungal medication until the rash is gone for at least 48 hours (about two to three weeks duration). Clotrimazole (for example, brand name Lotrimin) is over-the-counter and is applied twice daily. You will find it in the anti-athlete’s foot section.

On the scalp, ringworm causes hair loss where the rash occurs. Treatment is not so straight forward. Ringworm on the scalp requires a prescription oral antifungal medication for several weeks. The fungus on the scalp lives not only on the skin, but also in hair follicles. So, topical antifungals fail to reach the infection.

Ringworm spreads through direct contact. Wrestling teams are often plagued with this infection. Cats may carry ringworm. If your family cat has signs of feline ring worm such as patches of hair loss, take him to the vet for diagnosis.

If your child’s “ringworm” fails to improve after a week of applying antifungal medication, have your child’s doctor examine (or re-examine) the rash. Other diagnoses we keep in mind include eczema and granuloma annulare. If the rash continues to enlarge we consider Lyme disease.

The sooner you start to treat ringworm, the more quickly it resolves. Just remember, “the early bird catches the…” oh never mind.

The dirt on tetanus

fodder for tetanus…don’t get this stuck under your foot

Look at this rusty old anchor atop an old fort. Rust plus dirt equals a perfect breeding ground for tetanus. As my kids scampered between different anchors last week, I quickly calculated in my mind whether their preventative tetanus shots were up to date.

“Getting the tetanus shot” is part of the American societal childhood rite of passage, but most people don’t know much about why their kids are vaccinated. Everyone knows they want to avoid IT, but what is IT? Because it is somewhat rare in the United States, I still remember asking one dad about his child’s family history. I was startled when he erupted onto peals of laughter after he told me the child’s grandfather had died of tetanus. “Why are you laughing?” I said in disbelief.

“You’re right, it’s not funny… It’s just the look on your face is funny,” he said. “Everyone has the same shocked expression when I tell them that he died from tetanus.”

Also known as Lock Jaw, tetanus is an organism which thrives in places with little oxygen. Thus, it tends to live on rusty nails (and anchors!) and deep in dirt. Tetanus secretes a poison which causes muscles to spasm painfully and severely and also causes seizures. Exposed to tetanus, your jaw muscles clench into a sardonic smile which prevents eating – hence the name Lock Jaw. Eventually, the tetanus poison infiltrates the chest muscles that help you breathe, and if you are like nearly 40 percent of cases, you will stop breathing and eventually die.

We have no antidote for the poison of tetanus- but we do have a preventative immunization which causes our bodies to preemptively prepare antibodies as self-defense. At the time of a high risk injury, if needed, doctors will boost your child’s tetanus immunization. If your child is under- immunized, the doctor will also inject your child with tetanus antibodies (tetanus immunoglobulin) to further ensure that your child will not contract this disease.

Because tetanus thrives away from oxygen, it easily multiples in deep wounds contaminated by the germ. The germ surrounds us in soil and also lives in intestines of humans and animals. Since tetanus lives in dirt, the following are considered “high risk” injuries:

-Bites from animals which dig and “eat” dirt such as dogs.

-Deep puncture wounds from dirty, rusty nails.

-Wounds with embedded rocks and gravel.

Be wary of tetanus in wounds possibly contaminated with stool, dirt ,or saliva. In developing countries, there are continued cases of infantile tetanus because poultices of mud are used to take care of the umbilical cord stump of newborns.

For kids, the recommended ages for tetanus shots are at 2 months old, 4 months old, 6 months old, 15-18 months old, 4-6 years old, 11-12 years old, and then every ten years through adulthood. Note, if a high risk wound is sustained, the last shot should be within five years. Thus, a kid around 9 years old may be up-to-date for shots, but because he received a tetanus vaccine at four-years-old (on time) he will still need an immunization at the time of a risky injury. Watch out also if you have a teen. His pediatrician will immunize him at 11-12 years of age, but after 16-17 years old he will need a booster if he sustains a dirty wound.

Nowadays, the tetanus immunization is in the same solution as an immunization against diptheria (a disease that causes a choking-inducing coating at the back of your throat), and usually in the same solution as pertussis (whooping cough). If your doctor gave your child an immunization recently against pertussis, she also received a tetanus immunization.

Kids are expected to get dirty. Enjoy the dirt—just not the tetanus.