A Few Thoughts on Civility

There has been a lot of talk about civility recently because of events in the news and it reminded me of this string of incidents.

My parents have a sign in their front yard which says “No matter where you are from, we’re glad you’re our neighbor.” This same sentence is repeated in both Spanish and Arabic.

Shortly after the 2016 election, my then 79 year old father was out in the yard. He had had several recent hospitalizations for heart problems so his activities were limited. While he was in the yard, a man approached him and began yelling at him about the sign. My father responded to him with the word “friend” and was abruptly told that they were not friends. He then tried to explain his view that all people are made in the image of God and have intrinsic value and tried to discuss some of the reasons people come here from other countries but he kept being angrily interrupted.

At another encounter several weeks later, this same man told my father that “his kind” (elderly Mennonites with yard signs?) were not welcome here and would be run out of the country. My father responded that he hoped they could talk more and eventually become friends. Most recently at another chance meeting, the other man greeted him by saying “Hi friend” and they were able to have a civil discussion.

In discussing it later, my father said he did not consider the other man to be an enemy, just someone with whom he disagreed. But he also stated that even if he was an enemy, it did not matter because Jesus instructed us to love our enemies.

This kind of love does not mean warm, fuzzy feelings. The Apostle Paul defined love this way: “Love is patient, love is kind. It does not envy, it does not boast, it is not proud. It does not dishonor others, it is not self-seeking, it is not easily angered, it keeps no record of wrongs. Love does not delight in evil but rejoices with the truth. It always protects, always trusts, always hopes, always perseveres.”

Imagine a world in which we all took that approach with each other. Sounds nice, doesn’t it? Sounds like a world in which an octogenarian could enjoy his lawn in peace.

I think civility is one of those things which is more caught than taught. Good or bad, I often see reflections of myself in our children. Leaders have a duty to model civility to their followers. Parents have a responsibility to model it for their children. And we all need to be aware of what those around us may be catching from us.

Warning Signs of Eating Disorders

It is always good to get constructive feedback from patients and their families. A parent of a patient recently let me know that more public information regarding the signs of potential eating disorders would be helpful. There are several different types of eating disorders and it is a complex topic. This is therefore not meant to be an exhaustive discussion of eating disorders but rather some general information regarding potential warning signs.

Eating disorders were previously felt to be mostly isolated to Caucasians in western countries but are now more prevalent in other regions and diverse ethnic groups. They are potentially life-threatening and are more likely to occur in women and girls. Certain personality traits such as perfectionism, anxiety, and behavioral inflexibility may increase one’s risk for developing an eating disorder.

Warning signs include:

·         Excessive dieting and exercise

·         Inducing vomiting after eating or taking laxatives. It may not be obvious that someone is making themselves vomit so be aware of this possibility if someone routinely heads to the bathroom right after eating.

·         Distorted body image – the assertion that one is overweight even when they are thin

·         Strictly counting calories

·         Obsession with food. Some people with eating disorders will spend a lot of time preparing food for others without eating it themselves.

·         Strictly limiting intake of foods or certain types of foods

·         Weight loss

·         Binge eating

·         Dental erosion from stomach acids from frequent vomiting

·         Loss of menstrual periods

Not everyone who exhibits one of these signs has an eating disorder. For example, some people would consider training for marathons to be “excessive exercise” and sometimes competitive athletes will stop menstruating during their season of play. But if you see any of these signs, it is worth noting and mentioning to your child’s physician.

Treatment can be difficult and involves both medical monitoring as well as addressing psychological factors. Treatment is also likely to be easier and more effective if the eating disorder is caught early so be proactive in mentioning concerns to your child’s doctor if you see any of the signs above.

 

 

Do you need to worry about mumps?

With the reporting of some cases of mumps close-by recently, we have been receiving inquiries about the need for an extra dose of the vaccine as well as other questions about how people should protect themselves.

Mumps is a viral illness which causes symptoms including low-grade fever, headache, body aches, swelling and inflammation of the parotid glands (salivary glands located close to the ears) and orchitis (inflammation of the testicles). The virus is spread from person to person through respiratory secretions and saliva.

A vaccine for mumps was first introduced in 1967 and now children are routinely vaccinated against mumps with a dose of the vaccine at 12-15 months and a second dose at 4-6 years. With this approach, the incidence of mumps has decreased by 99% as compared to the pre-vaccine era.

Over time, the immunity acquired from the vaccine decreases. Folks who were immunized years ago still have a lower chance of getting mumps and tend to get less severe symptoms if they do become infected. But the more time has elapsed since one was immunized, the more susceptible they are to acquiring the disease, if exposed.

During outbreaks, giving a third dose of the MMR (measles, mumps, rubella) vaccine to potentially exposed and susceptible individuals has been shown to decrease the number of persons who become infected. This is currently being advised for most students at James Madison University due to the number of cases that have been seen there recently. A third dose is not recommended routinely for people who are not part of an institution or community where there is an outbreak.

If you have questions or are not sure if you should be getting a third dose of the vaccine, contact your healthcare provider.

Why does Johnny use bad words?

As I was sitting at a public event recently listening to the folks behind me dropping F-bombs left and right, I began thinking about how we got into a situation as a society where it is just normal to hear this type of thing. Maybe it has always been this way and I was just clueless and am now turning into a grumpy old man but the things I occasionally hear in public now would have at least elicited appalled glares in the world in which I grew up.

Sometimes parents will ask me about how to address their young child’s foul language. It seems pretty obvious that children don’t invent these words on their own. They are simply repeating what they have heard. I am a firm believer that the behavior we model for children is far more influential than what we tell them to do or not to do. Children will mimic what they hear from the adults around them, the media they consume, etc.

How can you explain to children that they should not call others names when adults in positions of authority engage in name-calling and insulting others? How can you convince them not to use expletives when they are commonplace in the movies they watch or when the evening news involves having to spell words with asterisks in the place of some letters to report a story?

I am a UVA alumnus and fan but loved when Virginia Tech men’s basketball coach Buzz Williams grabbed the microphone at the scorer’s table during a recent game and told a person or group in the student section to “stop cussing.”

I do not think children should be raised in a bubble and then dumped into the world as adults. But there is a difference between being immersed in a world of vulgarity and incivility and knowing that that world exists but having a different one modeled for you.

So be the kind of person you want your children to be. Model civility and respect. Don’t hide the world from them but guide them through it. Be honest, answer their questions. But do it on their level. You can probably tell a five year old that it is a bad word that we don’t use and leave it at that. For an older child you may have to explain what the word means and that there are more acceptable words to use instead.

There are no easy rules to follow and every child is different. So this really involves knowing your child and listening to him so that when these situations arise, you have a baseline understanding to start the discussion. And if you get it right every time, let me know because you will be the first parent in history to do so.

Varicella Variations

One of the striking changes that has occurred during my career is the almost total disappearance of chicken pox in the United States. When I started out, chicken pox was commonplace, almost like seeing someone with strep throat. And it was not unusual for us to have children in the hospital with complications of chicken pox. But now that we routinely vaccinate children for it, I had not seen a case for years until I was in Zambia in July.

I was in a makeshift clinic in a mud brick building and a child was brought in by his mother for a rash which was the classic “dew drop on a rose petal” of chicken pox. He was not particularly ill and everything else was normal and I discussed with his mother through the interpreter what to expect as the illness ran its course.

It was not until they were gone that I realized the Zambians I was working with were surprised (appalled?) at my nonchalance. In their context, without routine vaccination, chicken pox remains a formidable foe. Because many folks lack easy access to clean water, they are more likely to see skin lesions which have become secondarily infected with bacteria. And due to limited transportation and access to medical care, the secondary infections can become severe before they come to medical attention.

So they typically treat aggressively with a combination of an antiviral called acyclovir and antibiotics such as dicloxacillin to prevent secondary skin infections. While this type of treatment would seem excessive in our context, it was a good reminder that chicken pox is not always a benign disease. Prior to the introduction of the vaccine, about 100 children died of chicken pox complications in the United States each year.

When an illness becomes a sort of historical footnote, it is easy to forget the misery it caused in the past, even if you saw some of that misery first-hand 25 years ago. And remaining pockets of diphtheria, polio and measles remind us that without continued vigilance, these diseases could jump out of history right back into our present.

HPV Confusion

I am all for parents making informed decisions about their children’s healthcare and not just being passive bystanders. The key to that is that they need to have accurate information on which to base their decisions.

One subject on which there seems to be a lot of confusion is the HPV vaccine. This vaccine was introduced in 2006 to decrease the risk of contracting the Human Papilloma Virus which can lead to cancer of the cervix, penis, and mouth. One of the early concerns was that by giving young people a vaccine against a sexually-transmitted disease, this would give them license to have sex. This reasoning never made sense to me. I doubt that when young people are contemplating having sex they spend much time considering the risk of cervical dysplasia years in the future. A study in the journal Pediatrics in 2012 found no increase in sexual activity in teens who had had the vaccine when compared to those who did not.

More recently, the concern has been about side effects of the vaccine. Parents sometimes cite “horror stories” they have heard but they often cannot remember exactly what they heard. They often just have a vague unease about the vaccine. In other situations, parents have concerns about specific side effects. When these arise, I have tried to trace their concerns to the original incident in question. When I have done this, I have either run into a dead end because there does not appear to be any actual evidence to support the concern or have found that the circumstances of the alleged side effect were very different from the headlines that end up on the internet.

One concern that has been raised was that the vaccine could cause premature ovarian failure in young women. Premature ovarian failure is when the ovaries stop functioning at an early age, essentially menopause happening at the wrong time. A parent gave me something they had printed from the internet about this. I investigated it as far as I could go and didn’t find anything concerning. In case I was missing something, I asked around and no other physicians I talked to were aware of any evidence of this. Because gynecologists would be the ones likely to hear if there was an increase in this problem in young women since the vaccine went into use, I contacted several gynecologists I know and they also were unaware of any evidence to support this link.

Prior to the introduction of the vaccine, the incidence of premature ovarian failure was reported to be around one in ten thousand women by age 20 and one in a thousand women by age 30. In the first nine years after the vaccine was introduced, six cases were reported in girls who had received the vaccine. During that time around 170 million doses of the vaccine had been given which means the rate was lower than the rate reported prior to the introduction of the vaccine.

Prior to licensure of the HPV vaccine, its safety was studied in 30,000 persons over seven years with no significant adverse effects noted.  Since licensing, more than a million more patients have been studied. In the past seven years, our practice has given almost 9000 doses of HPV vaccine with no significant side effects.

As physicians, we have all taken the Hippocratic Oath which states in part, primum non nocere, “First, do harm.” While we are humans who make mistakes, we would never do anything which we thought would harm a patient. If you have concerns about the vaccine, by all means have that discussion with your child’s doctor. You may even reach a different conclusion than the doctor. Just make sure the decisions being made are based on accurate information.

Three Easy Steps to Make Your Child Behave (or not)

Discipline and behavior issues are a frequent topic of conversation in our office. There are many discipline techniques that are available for children of different ages and in different situations – timeouts, loss of privileges, natural consequences, etc. But none of these approaches will magically make a child behave.

I occasionally will hear parents say something along the lines of “He is too big for me to make him listen.” Hopefully our parental authority is not based on superior physical strength because I would have lost that battle starting about seven or eight years ago. I want my children to listen to me because they respect me, not because they are afraid of me. And now that they are older, I don’t want them to just listen to me. I want them to do the right thing because that is who they have become, something they have internalized.

If a child listens only out of fear, what will they do when that fear is no longer operative? We all have situations in which we could probably get away with doing things we should not. Hopefully we have some internal motivation to do the right thing when the external controls are not present.

I think the internal motivation to behave in appropriate ways starts with modeling of appropriate behavior by the adults in a child’s life and by having relationships with those adults which are based on love and mutual respect. A child is much more likely to listen to an adult who he knows cares about him and wants what is best for him.

Imagine two different children contemplating a forbidden activity. One thinks “I shouldn’t do this because if I get caught I will get whipped.” The other thinks “I shouldn’t do this because this is the type of thing my mother has warned me about and she is generally right about these things.” Which thought process is more likely to produce desirable behaviors in the long run?

I am not talking about just letting kids do whatever. Clear, consistent limits are important and those limits need to be consistently enforced. But they need to be enforced in a way that helps the child to learn and does not demean him as a person.

I have not always done a great job of applying these principles myself but I think I did get better at it over time with successive children (sorry Zach). And clearly not all children react the same. Sometimes parents parent well and the behavior outcomes are not what they had hoped for.

I don’t think there is a magic “just do this” approach to parenting that will make everything turn out well. But I think spending time with your children and showing them that you love them is a good start.