Question #9

I always look at it first. Question Number 9: Screen Shot 2019-10-24 at 10.07.46 PM

Sometimes the questions on the Patient Health Questionnaire 9 (PHQ 9)  are completed and ready for me to score before I walk in the room for a teen check up.

Sometimes, the teen is holding it and I gently take it and steal a glance at question #9 as I am saying hello.

Always, I cross my fingers and pray that it says “not at all,” and I exhale a little when it does.

Today, though, I sit on the exam table next to this lanky 15 year old boy, and his answer is not “not at all.”

His answer is “several days.”

My eyes go backwards, up the page, and I am crushed to see that he feels “down depressed and hopeless” nearly every day, that he feels bad about himself, that he is a failure and that he has let himself or his family down more than half days. These are his answers, but my heart hurts as if they were mine.

This child I have watched grow since birth, this child with the energy of an oversized Tigger tells me he feels isolated since starting high school. “My friends have other friends,” he says.  “We don’t have classes or lunch together. It’s like they’ve forgotten me.”

He doesn’t know that many of them have been sitting next to me on this same table saying the same thing in the last few months. He doesn’t know because none of them are talking much to anyone anymore, and even if they were, they wouldn’t talk about this.

We talk about question #9. He tells me that his loneliness makes his thoughts wander toward how people might feel if he ended his life. “Would they even notice?” His eyes well with tears.

So do mine.

I tell him I know this is a hard time for him.
I tell him I think I can help.
I tell him that there is hope, that I truly believe that this loneliness will get better if he will hang in there and that I am planning to hang in there with him.
I ask him if I can partner with him and his mom to come up with a plan to help him get to a better place, and he agrees.

When she joins us in the room, the three of us talk about the options: changing some patterns in his life, counseling, medication. We talk about keeping him safe and what that might require.

I tell him that I am not going to fix it because really, he’s the only one who can truly do that. I tell him I will help him find the tools and that often the most helpful tools have to do with forging stronger relationships and connecting with others.

I ask his mom what she thinks might help.

She tells me that she will check in with him, take walks with him, keep him safe and help him brainstorm ways to reconnect with friends.

“And I have actually been thinking of finding a counselor for myself,” she adds, “so that I can be in a good place to help him.”

I tell her that is the best answer I have ever heard. Like ever. Start with yourself. Always start with yourself.

I say good bye and stand outside the door of the next exam room, afraid to look at the answer to Question #9,

And thanking God for those who had the wisdom to insist that we all begin to ask it routinely.

 

 

*this is not one particular teen. this could be any teen.

 

 

 

 

 

Love. Grace. Wonder.

When you were young, we had some long nights. Bedtime was always the most stressful time of the day. I was always exhausted.
You weren’t.
I wanted a quick bedtime.
You didn’t.
Sleep was definitely not your thing back then.

So I would sing you lullabies.
I think I did it more to calm me down than you.
Now I understand that I was engaging my vagus nerve and parasympathetic nervous system  with those long exhales and phrases.
Then, it just felt right.

There were three songs that were our favorites.

The first was Peter  Paul and Mary’s The Water Is Wide.
One verse went like this:
There is a ship and she sails the sea. She’s loaded deep as deep can be.
But not as deep as the love I’m in.
I know not if I sink or swim.

It was a song about love.

The second was Amazing Grace.
Twas Grace that taught my soul to fear and grace my fears released.
How precious did that grace appear, the hour I first believed.

Grace.

The third was Puff the Magic Dragon—a favorite from my own childhood.
It was about a kid who would play with his imaginary dragon all the time
But then he grew up and stopped and it was a little sad.
You used to play for hours on end with your stuffed animals, creating little worlds and personalities, and I loved watching you do that, and I hoped it would never end.

That was a song about wonder.

Together, we had love, grace, and wonder. Every night.
These were things I prayed you would find in a partner some day.
When you found Charlie, I knew my prayers had been answered.

He loves you fiercely.

He is full of grace. His family is full of grace, and if that’s not enough, he even has a sister named Grace.

He is filled with childlike wonder and fun, and he shares those things with you
…and Obi.Screen Shot 2019-10-06 at 4.15.37 PM

 

 

I will not be singing you lullabies tonight because by now you’ve figured out that I can’t sing.
But I will be wishing both of you a life of love, grace and wonder

Forever.

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Sunflowers and Burrs

I am off today.

Off means:
catching up on emails
answering messages
charting and following up on labs
going to meetings
problem solving with my children
vacuuming
laundry
errands
paying bills
yardwork and weeding
writing notes
scrolling social media
working on a talk
connecting and coordinating

feeling inadequate that I don’t get more done.

But two pairs of eyes stare at me expectantly.
Patiently panting.
Following me relentlessly.
Watching. Waiting. Anticipating.

The walk.

Finally, I give up and I load them in the car and off we go.
We pull into a friend’s fields.
I suddenly realize that the sunflowers are in full bloom,
and this is why I will always have a dog in my life.

I may be spending the rest of the day
hosing off the mud,
picking the burrs out of fur,
failing to cross off more things on my list,


but I will do it having walked among the sunflowers
for a little while this morning.  

Vaccinate on Time

A reporter from Myrtle Beach reached out to me today to ask me about my response to a vaccination issue that had been raised by a parent from his area. I am the Immunization Liaison for the SC Chapter of the American Academy of Pediatrics, a staunch advocate for vaccines, and someone had pointed him in my direction.

Apparently a father had taken his two month old for a well check and was told that if the family didn’t give the child six vaccines (which I assume are the routine recommended ones against tetanus, diphtheria, whooping cough, polio, Hepatitis B, 13 strains of pneumococcus, haemophilus influenza, and rotavirus), he would need to find a new practice. Was that fair?

“Yes,” I replied. “Yes it is. Our office has come to the same decision after years of meetings and discussions and ethical deliberations. We along with many other practices have also decided not to see children whose parents choose not to vaccinate on the recommended schedule. We will see them to discuss the immunization schedule and answer questions, but unless there is a medical reason not to immunize the child, we don’t feel it is safe or fair to expose other families in our practice to those who choose not to help protect  children from preventable illnesses.”

Then I tried to explain what has lead us all, people who have studied for years to care and advocate for all children and families, to a decision to exclude some families from our practices.

I appreciate when parents ask questions and advocate for their children. I really do. I am a skeptic at heart, an advocate like them. I am a parent too. Our children depend on us to ask tough questions and make hard decisions.

They also depend on us to listen to the answers and make the right decisions based on risk assessment, facts, and science.

But increasingly over the years, we have seen parents who are not interested in our recommendations or the information we provide about required and recommended vaccines. They have “done their research” on facebook, referencing a Russian bott post or a nebulous blog or their chiropractor’s concern about the aluminum that is used to enhance the effectiveness of the vaccine (breast milk has more aluminum than vaccines do).

It doesn’t matter what the science says or how much their decisions are opening other families to harm. They have made up their minds not to vaccinate or to vaccinate on a schedule that leaves the child vulnerable to diseases at the time when they most need protection. Breaking up vaccines and prolonging the time it takes to complete the schedule is simply not a good idea.

I am not sure what the reporter will include in his article, but since I’ve been storing up my frustration about this topic for quite some time now, here are some of the highlights that I hope he will include:

  1. Pediatricians across our state have watched with despair as parents increasingly choose to delay or opt out (of vaccinating their children. We see vaccines as the single most important, most miraculous, and most amazing scientific discovery ever, one that has allowed parents to send their children out to play or go to the swimming pool each summer and not worry that the fever they might spike a few days later will be the first signs of polio in their child.
  2. When I was in training in the early 90’s, I was really good at doing spinal taps in little babies because we did them all the time. If an infant came in with a fever and there was no obvious ear infection and he was extremely irritable, a likely cause was H Flu (haemophilus influenza) meningitis. Despite early diagnosis and aggressive treatment, many of these infants went home with hydrocephalus and brain shunts which would then malfunction or get infected off and on for the rest of their shortened lives. They were discharged with early signs of cerebral palsy. They went home with lifelong hearing loss and cognitive disabilities. All that changed in the mid 90’s, though, because by then, all infants had gotten the new H Flu vaccine. Rates of bacterial meningitis plummeted, as did other life threatening infections associated with H flu, and along with it, so did the complications. I don’t miss doing spinal taps on adorable screaming infants whose moms are looking on, terrified from the corner of the room.
  3. In the late 90’s we still routinely saw infants and toddlers with high fevers and blood infections due to several types of pneumococcal bacteria. We routinely did blood work to determine whether a child with fever and no other symptoms might have “bacteremia”–a blood infection that could deposit that nasty bacteria in the baby’s brain, lungs, bones, or ears. But then a vaccine to protect children from many strains of this bacteria burst onto the scene (Prevnar which protects from 13 strains of pneumococcal bacteria), and we rarely see serious complications of pneumococcal infection anymore.
  4. The reporter asked me about religious exemptions. I told him I am not aware of any religions which recommend that their followers put their communities at risk for preventable illnesses, yet in one daycare in a faith community near us, I am aware that 24% of the children are unvaccinated. Vaccines don’t always work perfectly in each individual, but if enough people are vaccinated, an entire community and the individuals within it are much less likely to succumb to an epidemic.
  5. Measles was declared eliminated from the United States in the year 2000.  We now have over 700 cases and counting in 2019, and the year is young. The reporter said
    “but we haven’t had any cases in South Carolina, right?” Not so far in 2019, but there were 6 cases in Spartanburg, SC last fall. The case in Georgetown, SC in 2017 was the first case in SC in 21 years. We can expect those numbers to rise quickly if parents continue to choose not to protect their children and their communities from easily preventable illnesses.
  6. The safety of vaccines is monitored closely. I am old enough to remember the old DTP vaccine which was replaced by a new DTaP (acellular pertussis vaccine) due to an increased risk of seizures with the old vaccine. I remember when rotavirus vaccine was taken off the market soon after its introduction due to concerns of intestinal complications, then reintroduced. I recall giving oral polio vaccine because it was more effective than the shot… until the risk of transmitting attenuated polio virus through the vaccine became greater than the risk of getting wild type polio, so we all switched to giving the killed vaccine. Safety is always the most important consideration when we are administering anything at all to a healthy child.
  7. I don’t miss admitting toddler after toddler with dehydration due to rotavirus. One of the last ones I recall admitting was a 20 month old who had had 40 stool filled diapers well before noon. When she got to the hospital, her mother later told me that her eyes were hollow and her lips were so dry they were curling back and sticking to her gums. “I was so scared,” she told me. Rightly so. In countries where children don’t have easy access to Rotavirus vaccine, they still die routinely from dehydration due to this virus.
  8. I remember the epidemic of pertussis (whooping cough) several years ago in a group of homeschooled children who had not been vaccinated in our area. After observing firsthand how horrible the “100 Day” cough was, many in the group came to our office requesting that their children be vaccinated. I also remember the baby who was counting on our community and those around him to be vaccinated against whooping cough, but his community let him down, and he died of pertussis in the hospital. There is no effective treatment unless it is suspected in the first few days, when it looks like any other routine cold. (Family members should all get a Tdap booster to welcome and new infant into the fold).
  9. There are risks of vaccines, but they are much smaller than the risks of failing to get vaccinated on schedule and getting the disease.
  10. Vaccines do not cause autism. Study after study confirms this. Period.

We appreciate parents who question and advocate and ultimately make the safest decision for their children and their children’s community: vaccinating on time.

Taking a strong stance on vaccinating children according to the evidence-based recommended schedule is one of the most important things pediatric practices can do to protect the lives and health of our nation’s children.

Martha Edwards, MD

Tiny Lights and Tunnels

As I prepare for a talk next week on integrating mental health screenings into primary care visits, I find myself remembering biking through the tunnels of the Via Verde de la Sierra, near Olvera, Spain.

Like many bike trails, the Via Verde was an old train track which had found new purpose as a bike path between the White Cities of Andalusia. The path winds through a series of tunnels.

Most were short. You could see the beginning and the end and you just popped in and right out the other side. Kix4bYrTSOCZcsJTZDnTtA

Some were a little longer and were quite dark, but often some motion sensitive lights would come on as we entered the tunnel.

And then there was one that was long and twisty. We got a little way in and it was completely dark. The motion sensitive lights were either not installed or did not come on. All was black and damp. We were disoriented.

Fortunately, my husband had remembered to charge the batteries for his little bike light in the hotel the night before.

When we suddenly found ourselves in complete darkness, unable to orient ourselves to the ground, the ceiling, the sides, stepping timidly along the uneven ground, feeling along the cool concrete walls, wondering what or who else we might be about to step on or bump into, he pulled out his little tiny bike light, and though his light was small, it was just enough to orient not only all of us, but another couple who had been stumbling along in the dark in the middle of the cave as well.

 

 

He had remembered to charge his batteries.

His light helped orient all of us until the light from the other side was visible.

As you begin 2019, should you suddenly or not so suddenly find yourself in the middle of a dark tunnel, feeling your way along the cool walls, needing help to figure out which  way is up, down, backward, or forward, I hope you can find your tiny light, and that you took time to charge it, or that you are with someone who will share their glow.

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Rescuing Hope

About this time last year, we said goodbye to Lou.

We have adjusted to Life Without Lou, but sometimes it’s a little too quiet. IMG_1063Jazz has always had a co-conspirator, and she misses being part of a larger pack. We knew we wanted to get another dog at some point, and after parking the last child at college this August, it seemed time to consider taking on at least a foster dog, knowing that we have a dismal history of foster failure (you know, where “just two weeks” turns into 8-12 years).

I have two friends who are heavily involved in rescuing dogs–one who works with Project Safe Pet and the other with Humane Society of York County. I knew that the second I told them our requirements (cat friendly, dog friendly, likes to take walks), the options would be limitless, and I was right. Within about a day, we had several amazing options, all of whom needed at least a temporary safe and loving place to stay as they transitioned from a difficult past to the perfect forever home.Screen Shot 2018-10-20 at 9.03.55 AM

But these eyes caught my attention.

Worried eyes.

Hopeful eyes.

It was clear we were headed for failure the first night when, after approximately three minutes of hearing the puppy cry in her crate, my husband said “do you think it would be so bad to let her sleep on the bed?”

(Who is this stranger next to me in the bed and why is there a dog sharing my pillow?).

We’ve had a lot of trouble picking out a name. I liked the idea of calling her Junie B Jones, the heroine of the Barbara Parks series, because I knew she’d be a handful at times, full of well-intentioned but sometimes destructive energy.  But my daughters felt it was too close to “Janie,” my youngest child. Hard to argue that point. We went through hundreds of other options, but none seemed right.

Almost exactly two years ago, I wrote a post about my thoughts as I walked through the woods, full of fear, alarm, disappointment, overwhelming sadness. As I walked the dogs one morning last week, my mind wandered again to all the headlines in the news that week. It seemed my worst fears had evolved into the reality I had feared.

I am usually good at finding things to be hopeful about, but lately I’ve been starting to have trouble.

Hope.

Perhaps that was the name we needed to call her.

When I hear our president mocking a woman who experienced a trauma as a teen, the worst part of which was when the perpetrators laughed while attacking her, then an entire auditorium of people laughing in response.

Come on, Hope.

An earth which is starting to be less forgiving to the ravages we inflict upon her, rolling back policy on coal ash in our waterways, methane, mercury, asbestos, refusing to engage with the rest of the world on working toward solutions.

Children who are seeking refuge from horrors I can’t even begin to contemplate, ripped away from their parents, holocaust-style, at our borders with no identifiable system to reunite them in the future.

Come on, Hope.

A world where two year olds appearing alone in immigration court is a thing.

An administration  trying to do away with protections for insuring people with pre-existing conditions.

People in power, systematically focused on disenfranchising as many minority voters as possible. 

A president who cannot seem to tell the truth. 

Come on Hope.

Parents choosing not to vaccinate their children due to misinformation and ignorance, putting the rest of us at risk and quadrupling the rate of un-immunized children in the US over the last two decades.

Come on Hope.

I walk on and it feels good to be pulled forward by Hope, to see her moving happily  forward, curious to know what’s ahead, ears up, eyes bright.

We get home and begin the tasks of our day. I call her. She comes, settles down by my side, peacefully, calmly, belly up, trusting.

I will walk with Hope. I will sit with Hope. I will advocate with Hope and snuggle with Hope.

It feels good to have Hope.

I think we’ll keep her.

Final draft: Her name is now Dobby. The wrinkled forehead, the expressive ears, her clear desire to lead The Resistance. All Harry Potter/ JK Rowling fans know that Dobby is synonymous with Hope, or perhaps Hope tinged with Worry.

Plus she likes socks.

Please vote.

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Fleeing Florence

We started to worry when we heard that Jane was leaving.

Jane never leaves.

At nearly 85, she’s stared down her share of hurricanes, undaunted. But as Florence approached, Nat’s brother had traveled from Connecticut to her house near the NC coast to help her move all her stuff to a safer area, then drive with her to Richmond, where she would literally wait until the coast was clear.

For those of you who don’t know Jane, this is Jane, circa 2013:

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After I had my first child, Jane came to help care for her while I went back to work for a few weeks to finish my year as Chief Resident before moving to Boston. Not only did she take care of the baby, she dusted, cleaned windows, planted flowers, swept the porch,  took her on long walks, made dinner. One of my friends said “I went by your house today and saw your mother-in-law up on the roof, baby in one hand, hammer in the other, nailing down a shingle.” That was only a slight exaggeration. That is Jane.

So you can see why we raised an eyebrow when we found out Jane was packing up to get away from this hurricane.

Meanwhile, in Rock Hill, we fretted. We had tickets to fly out of the Charlotte, NC airport, for our long-awaited bike trip WHEN? Mid-morning on Friday .

The hurricane was scheduled to hit our area WHEN? Mid-morning on Friday.

“Can’t you cancel your patients on Thursday and leave a day early?” a friend suggested helpfully.

In my brain, that question sounded like this:  “Do you want to cause your scheduler, Tammy, to have a heart attack?”

No. When I already work part time and people are constantly letting me know they can’t get an appointment with me (or sometimes anyone), I can’t cancel a day of patients. I love Tammy. I cause her enough stress already on a daily basis.

We decided to leave on Thursday night after work. There was an 8:00 o’clock flight out, and we could both work a full day, then go straight to the airport. My husband, who could moonlight as a travel agent if he wanted to, got on the computer and the phone and rebooked our flight.

We weren’t here for Hurricane Hugo in 1989, but it remains the stuff of legend in the Charlotte area. No one had imagined the destruction that a hurricane could bring so far from the coast. People described all sorts of chaos, finding porch furniture down the block at the neighbors, windows shattered by flying debris, trees down on houses and cars,  flushing toilets with bathtub water for weeks (or not flushing at all), walking around with candles and flashlights in the dark. KWg87bGyTLKlVroPRYEwEQWith that in mind, we spent Wednesday night redecorating our house, because what living room is complete without a gas grill in the center of it, along with all sorts of wicker porch furniture, outdoor umbrellas, and an outdoor heater thoughtfully placed hither and thither?

 

 

 

The next morning, we carpooled to work. This is only the second time we’ve done this in 20 years of working near each other (and 4 of working in the same building). As we did the first time, we parked here: %hKAvfU9RGOY7QtRuqZsxw

 

 

 

 

(Because here is where you always park when you carpool with a cardiologist whose motto is NOT  “do as I say, not as I do” as mine is,  but “I walk the walk….and walk and walk.”

I briefly considered calling an uber to take me to the entrance of our building.)

We went to work. We saw patients, answered messages, sent in refills, signed orders, reviewed lab results and studies, saw more patients. Then it was time to go.

As the clouds gathered, we jumped in the car and headed to the airport, parked, shuttled in, checked our bags, only to find when we got there that the flight had been delayed. Then it was delayed again. The wind began to pick up a bit.

We worried that if the flight were delayed more, we would not be able to take off.  My husband asked the ticketing lady if we could get on an earlier flight as we checked our luggage. “There’s one boarding now,” she said, and gave us seats on that one. We zoomed through security, rushed to the gate, climbed aboard the plane, and the door closed behind us.  The engines roared. The plane backed up, found its runway and soared into the gathering clouds.

Not only had we escaped the hurricane in the nick of time, we had gained a bonus night in New York City.

Sometimes life calls you to stay and face a storm.

Sometimes you get the hell out.

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Tow Ropes

I stared up at my husband’s face from where I lay on the tile of a hotel bathroom floor in New York City.

“We really can’t go to Spain. I can’t be doing this in Spain.”  March, 2018.

I’d been here before, staring up at faces from the ground. From the pro-shop floor during  tennis lessons in high school, in Europe on a boulevard with friends in the middle of the night, in the Port Au Prince, Haiti airport, on the sidewalk after a talk I gave one spring morning in Charlottesville, from my own bathroom floor in my PJ’s at dawn where we had to call the neighbors to load me in the car to get fluids at the emergency department.  The  episodes are unpredictable and there seems to be no rhyme or reason. They are related to travel. Or not. They are related to hydration. Or not. They occur in the wee hours of the morning. Or not. They come with a dose of vertigo. Or not. One was anxiety-, stupidity-, and stress cardiomyopathy related, but the others were not.

Ultimately we have determined that most episodes seem to be an evil migraine prodrome. They are always followed by several days of an ice-pick-through-one-eye type of headache.

The problem is not so much that I go down, turn pasty white, vomit, and faint, but that I can’t get up.

I knew that if I gave it a few minutes, an  hour, a couple of hours, I’d likely be here still, on these tiny black and white tiles,  vomiting and miserable.

“I think I heard that you can get an IV nurse to come to your room in New York City,” I said.  My husband was the King of Google long before googling things was ever a normal thing to do. It took him less than a minute to confirm that yes indeed, having an IV nurse uber over to your hotel room with a bag or two of resuscitation fluids was on the list of otherwise abnormal but normal things to do in NYC. Apparently, there are enough hung-over people and GI viruses in NYC to support a moderate sized army of traveling IV nurses.

How sad. But how wonderful.

My son and my husband lifted me onto the bed, and within an hour, there was the IV nurse, a halo of glowing light above her head, a 24 gauge needle and 2 liters of normal saline in her rolling suitcase.

I slept the rest of the day away and tried to ignore my raging headache while my son and husband explored the city and found time to get my son a New York Haircut.

Months went by with no more episodes. I dared to start thinking about going to Spain. Two years ago, we had made a plan to accompany friends on this trip in September, after settling our final child in her dorm room in college. But it wasn’t going to be the kind of trip where we traveled around in trains and crowded into unreliable Fiats. No, we were planning to spend most of the trip on bicycles, far from big cities or traveling nurses with IV hydration kits.

fullsizeoutput_64deOur biker friend insisted I’d be fine: “No worries! If you can’t travel with three doctors, who can you travel with? You will have an e-bike. And if your e-bike breaks down, I will bring a rope and tow you up the hills.”  He really could do that, his wife assured me. With no e-bike. The idea that he not only could do that, but would consider doing that is what made me finally commit to the trip.

There are other reasons I shouldn’t be thinking I can bike in the middle of nowhere, up and down hills, in the heat for five days in a row. The first that comes to mind is lingering lower extremity paralysis from a gymnastics injury at age 15. My quadriceps are awesome, but pretty much everything else from the waist down, not so much. Try going up several flights of stairs sometime on your heels, with no assist from those muscles in your calves. Imagine your butt, hamstring, and hip muscles refusing to do their fair share as well, and you get the idea.

What is amazing is not so much that our bodies fall into disrepair or play evil tricks on us from time to time, but that there are people who surround us, pick us up, and help us move forward even when it seems impossible. They offer tow ropes, reassurance, and seem comfortable with the idea that your presence may slow them down immensely. “Come on,” they say. “It will be fun. You will be fine. And if not, it will still all be okay.”

fullsizeoutput_6639That is how I found myself outside a small hotel, in Ronda, Spain, a two thousand year old gleaming white village, standing at the top of a rain-drizzled, cobble stone street, about to try out the bike that I would use for the next week.

I put a leg over the seat and pushed off, teetering a bit, headed down the small hill toward the main street below.  As I approached the bottom, I tried to turn left, while putting on my brakes which responded poorly on slick, wet  cobblestones. The bike spun and went down. I fell hard. I walked the bike back up the hill, bruised and embarrassed, then I got back on.

For the next week, I rode slowly up impossibly steep, long inclines, at full speed down roller-coaster gradient hills, with brakes near-fully engaged down hairpin curvy roads on mountains, past sheep and cows and roosters and barking dogs, on remote roads, through long dark scary tunnels.   I sweated and laughed and mostly kept up.  The battery never gave out on my bike. I never needed towing.  And I never fell again.

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Two Things

Simplify. It’s always my goal, but my tendency is always to complicate. I am an overachiever, always explaining a little more than I need to, checking off more boxes than are required, looking for problems that may not need to be immediately addressed. Hence I run chronically behind.

Seems the longer I practice pediatrics, the more I have to say and the less time I have to say it.

After assessing growth and development and advising parents on how to handle things like symptoms of teething, introducing new foods, potty training, car seats front or back-facing, signs of illness, safe storage of weapons and medications, sunscreen, asthma education, not letting a baby go to bed with a a bottle all night due to risks of cavities and obesity, managing screen time in a pre-teen and so many other important things, I have about two minutes left to impart some parenting wisdom.

Over time, I have come to believe that those two minutes are the most important of every visit. There is so much to say, so much to convey. In two minutes.

I want to share that children who are raised in a house filled with literacy, language, and books are likely to hear 30 million more words by age 3 than those who aren’t.

I want to share that families who sit down to meals routinely increase the odds that their children will attain higher levels of education, decrease their chances of substance abuse, obesity, early intercourse, and odds of ending up in prison.

I want to share that attending to a child’s mental health is just as important as attending to his physical health. Make that more important.

I want to share that discipline should be guided more by positive attention and teaching good habits than reacting strongly to bad behavior. Time ins > Time outs.

I want to share that family walks are a great way to diffuse the stress of the day. They can be done with talking, without talking, at any age, for any distance or length of time. They promote exercise, connection, mindfulness, and are never a waste of time.

I want to share that children are watching parents and will model what they see and hear, what is said, what is done, what is eaten, how others are treated. Everything.

I want to share that bedtime should not be about turning on a TV, turning off the light, and saying good night to a child with a bottle or sippy cup in a crib or bed, but instead should involve an intricate ritual created by each family in which teeth are brushed, fears are discussed, prayers and gratitude are expressed, books are read, and children are snuggled.

I want to share that it’s okay for children to feel happy, angry, sad, anxious, or frustrated, that they should be taught how to name those emotions, sit with them, and learn how to channel them into strong, healthy relationships.

I want to share that sometimes bad things happen to good people, and sometimes good people do bad things. Sometimes these things affect children, affect their growth and development, affect their behavior, can even affect their future mental and physical health.

I want to share that it’s important to acknowledge these things, accept responsibility for them, then learn how to use these hard lessons to strengthen a family going forward.

I want to share that resiliency in children has been studied and that we know that, even when a child’s life is full of challenges, the most important factor to insuring a positive future for that child is having at least one caring adult who is consistently present and offers unconditional love.

How can I cover all this in two minutes?

Two things:

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Every visit.

Every time.

 

 

 

*(or any meal)

 

Or. But. AND.

 

A little over a year ago, I wrote a post for my daughter. It had to do with grammar and more. You can link to it here.  Unlike 17 teachers and children in Parkland, Florida, she will be participating in high school graduation ceremonies in a few short months.

Time for another grammar lesson.

In the last few days as I’ve scrolled through newsfeeds, I’ve found myself noticing the conjunctions.

Or. But. And.

The assumptions involving OR make me angry:

17 students and teachers were assassinated in a high school. Again. People want to find something to blame. It’s a mental health problem OR it’s a gun problem.

It can’t be both?

You can blame the guns for all this heartbreak OR you can blame the people that shoot them.

We can’t blame both?

OR is problematic for me.

 

The BUT sentences fill me with anxiety and confusion:

The murderer was not allowed to carry a backpack at school—too dangerous– then he was not allowed to even go to school, BUT he was allowed to legally purchase a gun.

People suggest arming teachers, putting more armed security guards in schools, using our tax money to pay gun manufacturers for those supplies, BUT we can’t seem to find the money to reimburse teachers for things like Kleenex, school supplies, teaching assistants.

No one would disagree that access to mental health care is a huge problem in our country, BUT we just slashed corporate taxes, gutting our federal budget, insuring that cost effective healthcare will remain out of reach for millions.

 

The ANDs, on the other hand, fill me with hope:

We know that mental illness is often passed on through adverse childhood experiences, ACEs, which change the brain and the DNA, affecting generation after generation. I speak about this locally for the Palmetto Peace Project. My daughter just wrote a big long paper about how ACEs and childhood exposure to toxic stress change a developing brain on the anatomic level, the cellular level,  and the DNA level, hence the generational effects.

As a pediatrician, I see families every day in my office for whom I know this science to be true, especially now that I have begun routinely screening for ACEs using the questionnaire developed by Dr. Nadine Burke Harris and the Center for Youth Wellness.

We know that by investing in children AND families that we can reverse this trend AND promote resiliency through simple, inexpensive things like parent coaching by home visitors AND family dinners AND good sleep routines AND reading with children AND decreasing screen time  (especially violent games) AND making sure every single child has at least one, loving, buffering person in their lives.

 

We can invest in better mental health for families who are struggling in our country

AND invest in simple things that promote lifelong resiliency in children

AND ban assault weapons

AND use technology to do more careful background checks

AND close loopholes for gun sales

AND create guns with childproof locks (like our smartphones)

AND establish policies for ammunitions background checks

AND prevent those with domestic violence charges, stalking behavior, or significant mental health issues from having access to guns.

Polling suggests that our country is not divided on these things.

 

 

My daughter is turning 18 and graduating in a few months.

I hope I have taught her that we can do hard things, individually AND as a country, that life does not have to be filled with ORs and BUTs.

I hope she and her friends know that life can be filled with a series of infinite ANDs.

I hope that she and her friends will cast their 18 year old votes with the ANDs in mind.