"Help! - I'm Out of Control!"

Samantha, a nine-month-old charmer, is frustrated as her mom puts her in the car seat for their ride home from daycare. The baby works herself into such a total tizzy that Mom has to take her out of the seat to soothe her down again.

Mary Lou, a rambunctious toddler, is gleefully opeing and closing the exam room drawers. Dad and I are trying to talk, but I am distracted by the clanging of drawers and fearful that the cabinet's instruments might go flying. Dad doesn't seem bothered by this chaos and continues to chat.

Three-year-old, Jerry, is playing with the basket of toys when I enter the exam room. Mom says, "It's time for your checkup so hop up on the table." The child does not seem to hear his mom and keeps on playing. After her third request, Jerry throws the toy with disgust into the basket and jumps noisily onto the exam table.

Mrs. Franks and her 7-year-old son are here for his check up. As I walk past the boy, he quietly pushes his foot out toward me in a feined effort to trip me up. I dodge his attempts with a little jump to the side. I'm thrown off gaurd by this child's unthoughtful move while his mother giggles.

Scenrio number one is understandable, number two challenging, number three aggravating, and number four is down right worrisome. My colleague, Dr. Barbara Howard of Johns Hopkins University, is fond of explaining that the goal of disciplining children is to help them be happy and successful adults. Most would agree that a child out of control is neither happy nor ultimately successful.

Can young children be taught self-discipline and self-control? I think so. Writings in the Zero to Three Journal highlight efforts parents can make early in a child's life to help their child move toward greater self-control and increased ability to find their way in the world. (http://www.zerotothree.org/site/PageServer?pagename=ter_key_social_selfcontrol&AddInterest=1157)

From birth to 12 months, children's parents can teach them to self comfort. Encouraging a baby to attach to a lovey (e.g., a blanket or teddy bear) can help her find internal means to self comfort. Taking a step-wise approach to comforting a fussy baby may help him demonstrate his own capabilities. (See http://www.hugyourbaby.com/calming.html) Redirecting a 12-month-old whose behavior is unacceptable moves that child to understand on some level that one behavior is acceptable and another is not.

The toddler years give parents ample opportunity to teach self-control. Toddlers are programmed to push a parent's buttons; the trick is not to act like a toddler yourself! Naming feelings ("I see you are mad!" "I can tell you feel really sad." "You are super happy right now.") gives children a feeling vocabulary. This language can be a tool to help a child learn to control, rather than to be controlled by, their feelings. In addition, plafully giving a child the opportunity to practice patience ("Let's see if we can count to five before I give you the cookie!") will help them practice skills of self-control.

Remember that a child's temperament certainly affects how to teach self-control and how easy this process of learning can be (or not!). Jorey always described her toddler as "low-key and easy to hang with!" On the other hand, Rachael's son is described as "full of beans and always on the go!" Rachael discovers early on that helping her son learn self-control will be one of her primary tasks as a mom.

Helping a child find their inner strength as well as to appreciate what it means to be part of a larger family can be a daunting task at times. Family, friends, and professionals may be of help. But your child is your greatest teacher as you come to understand his/her personality and needs. Learning what makes them tick - instead of what ticks you off - is a big step along the path!

Being a Work-at-Home Dad!

"Dad just makes him laugh," Mom reports. And sure enough...the boy bursts out in a big smile when his tall, athletic dad swoops down to pick him up. Mom beams as she watches "her favorite men" enjoy one another. Though born a few weeks early, Noah is now a vigorous, all-ready-for-life nine-month-old!

Noah's situation is especially special. Dad is a work-at-home dad and is the primary daytime caregiver for this energetic, rambunctious fellow. This family is already demonstrating some of the positive impacts of a dad at home with his baby. I savor the energy, love, and joy of being in the same room with this young family.

As Mom, Dad, and I laugh at Noah's funny efforts to get his dad's attention, I'm inspired to share with these parents recent research which looks at the impact of a father's regular, caregiving involovement with his baby.

Work by Dr. Kyle Pruett is especially salient in elucidating this remarkable impact. [http://en.wikipedia.org/wiki/Kyle_Pruett] A ten-year study shows that children who have been cared for primarily by fathers are active, vigorous, robust, and thriving. They function above normal, particularly in areas of problem solving and social adaptation. These kids are attracted to stimulation and are eager to engage with the world around them. They also expect their intense, curious, and sometimes challenging behavior to be tolerated by adults. Earlier studies showed that such babies performed better on developmental tests and were more resilient in the face of stressful life situations.

As expected, Noah cries after his nine-month-old shots. Mom scoops him up with a tender and loving embrace while I hear Dad say, "Oh, big man, be tough. You're ok!" After a hug and a kiss from Mom, Noah reaches out to his dad, who tosses him halfway to the ceiling. Noak cackles with glee. His mom and I can't help but cackle too! [see "Moms and Dads Can Be Really Different!" - blog on January 21, 2008]

A Worried Dad Finds Relief

Howard is the Dad of two-month-old JT and he has lots of questions. As I mentioned in the last two blogs ( Feb.5th and 7th) Howard has many worries as well.

Reseaarch by M Sills, S.Shetterly, et al (http://pediatrics.aappublications.org/cgi/content/full/119/4/e829) confirm that depression in even one parent increases visits to the primary care provider and ER and reduces well-child visits (especially with the older children). When patients are "frequent fliers" as we call them in our practice, consider depresion in either the mother or father.

Now my "rule of three" kicks in. When Howard ask his third question I stop trying to reassure Howard. Instead I say, "I can see you love you baby so much that you want only to do what's best for him." Acknowledging his list of questions as an expression of Dad's love seems to slow down the questions. Howard takes a deep breath, smiles, and admits to being a "bit worried about the baby." Now we are talking about his real worries not the symptoms of his concern.

Dr. T. Berry Brazelton would describe this approach as the Touchpoint's technique of "acknowledge the parent's passion." In this case this acknowledgement opens the door so now we can discuss the difference between everday worries and anxious depression. (It surprises men to learn that research shows that spouses can have hormone changes during their wife's pregnancy and that these changes can contribute to his depression as they do in the woman.)

Howard describes his new job responsibilites and the extra time he now must spend away from home. Research shows that many new fathers worry deeply about the strain on time and money that new parenthood creates.

Next, I set up a specific time to call Howard weekly for the next three weeks and set up a followup visit in a few weeks. Knowing that I will contact he and his wife seems to harness his worries and decrease his calls to me. I suggest he jot down any worries so we can be sure to discuss them at the phone call or visit.

At the following visit I discuss the concept of anxious depression a bit more and ask about Howard's personal and family history of depression. In addition, I ask about alcohol use since this can contribute to or cause depression at any time in a patient's life. Howard promises to go back on his exercise program and cut back on his caffiene. He agrees to accept a little more help from family and friends and he his wife plan a time to go out to dinner on a well-deserved "date night."

Howard's history and symptoms were significant enough to put him on an antidepressant. After three weeks Howard said "I feel like myself again." By JT's four-month-visit Howard, his son, and wife are much better. Howard brags about his son's new trick of rolling over, and laughs when JT swats at Howard's nose. Howard is back, more able to be present with his son and to find joy in these precious moments. Likewise, I'm back on track as their provider. Addressing the cause rather than the symptoms allow me to feel more compassion and be more able to use my skills and knowledge to help these parents be the parents they want to be.

I'm looking for your ideas!

As I mentioned in the February 5, 2008 blog, "Three Strikes and You're Out..." Howard is a challenging parent. "I was really ready to see eight-week-old, JT. In addition to several office visits, I had spoken over the phone to Howard, his Dad, numerous times since the child's birth. I was starting to dread the moment his cell number would appear on my desk. I had it memorized." I confessed my last blog.

Surely many of you have been in a similar situation with a parent. How would you approach this scenario? What would be your goal for further interaction? What would you say? What would you do? Send me a quick email with a little or a big idea! I'd love to hear from you and reflect in a future blog on your (and my) ideas for helping this sturggling Dad (and nurse practitioner!)

"Three strikes and you're OUT"...or "In"...Trouble, that is!

I was really ready to see eight-week-old, JT. In addition to several office visits, I had spoken over the phone to Howard, his Dad, numerous times since the child's birth. I was starting to dread the moment his cell number would appear on my desk. I had it memorized.

J. T. is in for his routine visit and is growing at the 80% in height and the 60% in weight. He cackles once when I palpate his abdomen and looks up at his dad when I listen to his lungs. Though I'm finding this behavior delightful, Howard hardly notices. He looks worried. "Is his head big enough?" "Does it hurt J. T.'s back if he lies on his stomach?" "He always strains his face when he poops. Is that ok?"

Worry seems to be on the job description of most new parents. Each of Howard's questions alone seems resonable; however, this dad has an extraordinarily long list of questions and can't be reassured. He is an attentive father who reads everything about babies on the Internet. He collects ideas from friends and family. He is hypervigilant in his care: getting up several times at night (while the baby sleeps!) to be sure everything is ok, counting every calorie the baby eats, keeping an elaborate diary of the child's sleep, eating, and elimination. Though the data piles up, the questions and worries keep coming. "Anxious attachment," a term used by some professionals, describes the budding relationship between Howard and his baby. Though J. T. is thriving now, babies can eventually sense this anxiousness and over time can look and even act anxious themselves.

Anxious attachment is seen as a form of postpartum depression and can occur in either the mother or the father. This conditiion does not look like classic depression: a "slowed down" parent who becomes teary and sad, has trouble concentrating, appears distracted, and becomes less involved with their baby. Howard is super involved but cannot trust his instincts or learn to read his baby's behavior accurately. When asked, Howard will state that he is "not depressed." "I'm just worried," Howard explains. He, and others like him, need help: frequent contact and support, counselling, and sometimes medication.

When I care for young families I follow the "rule of three." If a parent asks a third question and cannot be reassured, but follows with yet another concern, I start looking for anxious postpartum depression. See the next blog for some strategies to help Howard cope with this situation.