In my travels since as a parent and a pediatrician, I’ve come to see that my son’s pre-sleep actions were a variation on a phenomena called headbanging, that causes amusement, curiosity, or frank worry on the part of parents. Can it cause injury? (almost never) What causes it? (good question) What should one do? (read on!)

Headbanging is startlingly common–occurring in up to 1 in 5 healthy infants and toddlers at some point– and is considered a normal habit behavior in healthy children.  Habits like headbanging are known in psychiatric circles as repetitive movement disorders, and they may be described as  behaviors that range from innocuous and quirky, to annoying, and on occasion, causing injury.  Most habits are the stuff that drives grandparents crazy: throat clearing, nailbiting, and teethgrinding. And, then there’s the headbangers.

Headbanging  appears in children after six months of age. It occurs in boys three times more often than in girls.  The textbook case usually goes something like this: Parents may notice that their infants or toddlers tendency to gently wap their head in a facedown position onto a pillow, mattress or blanket as they drift off to sleep. The frequency of these movements can be pretty brisk, occurring about once a second, and can last up to 10-15 minutes until a child falls asleep. In lesser cases, children thump their head or pull on their hair as sleep takes them. Headbanging diminishes and disappears in about 97% of children by their third birthday.  In older kids, who may tap the headboard or wall as they go through these motions, it can make quite a racket.

In children with known neurological issues, developmental delay, autism, hearing or visual impairments, and for children who are institutionalized or neglected, headbanging can be much more prevalent, and may be associated with other repetitive behaviors, such as rocking, or humming. And, some of these kids may continue to headbang into their adolescence and beyond.

No, not that kind of headbanging...

What is going on here?

For all those children who headbang, the exact source of the drive of the behavior is not entirely understood. There appears to be something about the gentle, repeating movement that allows the child to relax and organize themselves for sleep, much in the same way perhaps, that a sucking on a binky does for a newborn. Headbanging in children with neurodevelopmental issues, it may provide a source of dealing with overstimulation, or boredom and loneliness.

From a primary care provider’s perspective, I’ll consider each case individually, with an eye to each child’s medical and developmental history followed by a thorough exam. For children without neurologic or developmental concerns, getting a sense of how long a child has been headbanging is important (minutes? weeks? months?), and helps discern if something painful is afoot, such as a bump to the noggin, ear infection or discomfort from teething.  What’s more, it is helpful to establish that these behaviors only occur when going to sleep, and do not carry over into the daytime, and/or occur with movements of other extremities (tapping of the feet, or tics of facial muscles).

In older children, banging one’s head on the floor during a meltdown can be a supreme means of  getting parental attentions.  For parents who encounter episodes of headthumping during tantrums, the best approach is to minimize attention to the outburst.  Make sure a child is safe, but retreat to a distance. Responding repeatedly may actually reinforce the behavior. While headbanging may cause bruises, bumps, calluses, and the occasional scrape, severe injuries are blessedly rare in the vast majority of children.

And what to do? Parents understandably ask if any special preparations should be made for their child when they bang their head at bedtime.  In short, not much past common sense is the best approach. For infants and toddlers, I do not recommend putting bumpers or extra pillows in the child’s crib. There isn’t much danger to begin with, they’re not terribly effective, and the soft objects may pose a hazard to a little one in their bedspace.   For older children, it may be preferable to have the bed moved away from the wall, to avoid the noisy tattoo of head-on-wall.  Otherwise, checking that the bed or crib is secure should do the trick.  All that, and, it’s probably a good idea to tell the grandparents or babysitter so they don’t have a cow when the bedtime rituals begin.

It is absolutely appropriate to see a child’s health care provider if:

• the behavior is causing stress in the household
• there is any difficulty with breathing(such as pronounced snoring or gasping for breath),
• there are concerns for seizures, unrecognized developmental delays, or a risk of injury
• Or, if people are worried.

If warranted, a consultation with a psychiatrist, neurologist, or developmental pediatrician would be just the ticket.

Perhaps, as your charges sleep in their cribs or their beds, there’ll be a half-Bullwinkle,  or someone tip-tapping Night Night in Morse Code. Following the rhythm and the ritual, sleep will come. For most families, headbanging is a funky but benign interlude in their child’s journey. May this lessen your worry. Sweet dreams.

Photo 1 by Alessandro Zangrilli at http://commons.wikimedia.org/wiki/File:A_child_sleeping.jpg

Photo 2 by Lilly M at http://upload.wikimedia.org/wikipedia/commons/9/96/Metalmania_2008_Vader_Maurycy_Mauser_Stefanowicz_01.jpg

Cartoon below by me.

“Daddy is not well. I’m taking his temature. I’m the doctor.”

Ordinarily I would take the opportunity – rare as they are — to slip out of the room and go reply to email or read a book. But this time it’s different. My daughter is barely three and she’s playing doctor!

“Isn’t she a little young for this?” I ask my husband, with obvious pride.

He takes the key out of his mouth and replies: “She must have seen it on television.”

Patiently my daughter sticks the key back down his throat. Then she piles books, a doll and puzzle pieces on his belly.

“Voodoo medicine,” my husband lisps through the key.

“Isn’t this kind of great that she wants to play doctor?” I prod.

“Being a doctor isn’t what it used to be,” he says.

Undaunted, I hop in bed beside him and announce that I’m not feeling very well either. Visions of my daughter in scrubs, looking smart like Ellen Pompeo on Grey’s Anatomy, pop into my head.

Flash forward: I’m tan and wrinkled by a sunlit pool playing bridge with my old lady friends.

“Did I mention that my daughter found a cure for cancer?” I ask.

“A million times,” my friend Kim replies. “Now play your card.”

Back on the bed, my daughter feels my forehead. “Hot,” she says.

My husband hands her the key. “Take mommy’s temperature,” he says. She sticks the key in my mouth. “No, it’s not all the way in,” he says. She jams it in further, the metal cracking against my teeth. Painful, but we all need to make sacrifices.

“Great bedside manner,” my husband jokes, as he slips out of bed and runs off to check a cycling race on his computer. I remain still as my daughter piles on the books and the doll and the puzzle pieces.

It’s getting annoying, though, sucking on a key and so I pull it out and ask her to read it. “No,” she says and jams it in again. “Mommy is sick.”

A month later my daughter gets a doctor’s kit for Christmas from her Uncle Simon. (He tells me he had me in mind, more than her. Am I so transparent?)

She barely looks at it and I don’t push it. I don’t want to scare her off.

Then early one Saturday morning shortly after Christmas we’re sitting by our still decorated tree (I can never bear to take it down). My daughter tells me that I don’t look too good and makes me lie on the couch. I quickly comply.

She looks into her kit, slightly confused. She’s seen a medicine bottle before and so pulls it out. After that, she’s lost. She doesn’t know what to do with the tools. I catch her glancing at the Lego set and so tell her I’ll be the doctor to show her how it works.  She gets comfortable on the couch, neatly spreading her princess gown around her.

I try to find my pulse, thinking that ought to interest her. Sadly, I can’t find it and she’s close to jumping up. I open her kit and use the plastic stethoscope and then check her blood pressure, putting the little cuff around her arm and pumping the small balloon. I look into her ears and knock on her knees with the other tools. I’ve no clue what to do with the tweezers and so use them to squeeze her fingers. She’s really getting into it and so I tell her it’s her turn to be the doctor and try to get on the couch. She won’t budge.

“I’m not feeling well,” I say. “If only there were a doctor…”

“I’m not the doctor,” she says. “You’re doctor mommy. I’m the beautiful princess.”

Image by Sweet Caroline Design & Photo

I’ve consumed scads of biographies over the years, but I could always manage to put them down long enough to grab a snack.  The Jobs book has me bound in a headlock, and until this morning I was puzzled by my attraction to this particular life. My list of favorite topics includes the American and French revolutions, but certainly not the technological one. No geek am I.  Yet something is compelling me to rifle through this book in search of something elusive. Meaning? A moral? A warning?  This morning, after a phone call from my son during which I bombarded him with Jobs anecdotes, the epiphany came. I am not reading the Jobs biography from the point of view of an interested observer of human nature, or a curious wannabe, or a jealous competitor, or simply a voracious reader.  For some reason, I am reading this book from the vantage point of motherhood.

Perhaps because my sons are all of an age when they are seeking their professional niches in the world, I am particularly attuned to the story of one man’s journey to the top of the heap.  The more I read the more questions arise…questions I fear no biographer will tackle.

Walter Isaacson, Jobs’ biographer, asserts that he was asked by Jobs to write the book because the man at Apple’s core wanted his children to see into his.  Jobs took no issue with Isaacson’s warning that in the interest of full disclosure he would have to paint an unflattering portrait of his subject as friend, colleague, employer, and father.  As I wade deeper into this man’s life, I become more surprised by this. Most of us want to shield our children from the evil inclinations that lurk within us.  It seems Jobs almost dares his kids to enter his dark side.

When Jobs’ mothers, both biological and adoptive, read the book, will they be proud?   The man’s genius is legendary, but so are his narcissism and aloofness.  Can a parent burst with pride over a son’s monumental accomplishments while simultaneously being ashamed of him for putting miles of emotional distance between himself and others, including his own children?  Does one overwhelming emotion cancel out the other?

If building an empire demands total self-absorption, do we rob our children of their fiefdom by teaching them to care about others?If we push our children to excel academically and then professionally, do we sacrifice time they could have spent learning to be empathetic?

Of course, the answer is balance. Good parents try to establish a healthy self-esteem in their children without giving them the false impression that they are the center of the universe.  At the same time, we encourage our progeny to set goals, work hard, and ignore the naysayers who tell them they can’t succeed.

Balance is key for most people, but Steve Jobs was not like most people. The question remains, could Jobs have created Apple and changed the world if he hadn’t demanded perfection (often to the point of boorishness) from the mere mortals who served him?  Could he have found the time to be an emperor if he had accepted responsibility for the child he fathered at 23?

By all reports including his own, Jobs’ adoptive parents were lovely and loving people. If ever a subject was fodder for the nature/nurture debate, Steve Jobs is it.  Like his father, he was a perfectionist.  Like his graduate student biological parents, he was extremely intelligent. But the bare feet, the failure to bathe regularly, the freedom with which he insulted people and their work, the rude behavior in restaurants?  He may have brought all that to the table himself.

I’d love my children to be visionaries.  It would be wonderful to have a child who changed the world. But if my child had to be Steve Jobs to be Steve Jobs, I think I’d say never mind.

Croup.  Here it comes. Oh, that stop-you-in-your tracks cough makes it that most anomatopoeic of illnesses.

Variously described as barking, brassy, or seal-like, the cough of croup and its accompanying noises are most frequently heard–at a great distance–during the late fall and early winter.  Almost always, parents are understandably distressed by croup and seek urgent or emergency care for their charges when they get it. Questions abound: what causes it ? (you might be surprised) have treatments gotten better? (kinda, sorta) And, is it true that a walk outside on a cold night for a croupy kiddo could fix troublesome symptoms? (read on and find out)….

The name “croup” is apt, and is a centuries-old contraction of the words croak and whoop. (Interestingly, and quite of another subject, croup is also the term for the hindquarters of a quadriped–which happily has no clinical significance here).  Croup affects the youngest set, ages 6 months to 3 years, most often. However, it does occur occasionally in children up to school age and older.  Parents typically describe a few days of mild cough and cold symptoms, with unremarkable runny nose, sore throat, and perhaps a hoarse cry or voice at the start. However, it is when the infection attacks the upper airway on the second or third night (always at night for some reason) of illness in these children that things get exciting.

Croup’s medical aliases– laryngotracheitis or laryngotracheobronchitis –reflect the zip code of a child’s airway affected  by the viral infection and inflammation.  Parainfluenza virus most often is the culprit here, causing about 80% of cases in kids. The other 20% of viral bad guys causing croup are an infamous lot, including RSV, adenovirus, rhinovirus (the common cold), and influenza (aka the flu).  Irritation and swelling of the airway above and below the vocal cords begins as that sore throat or raspy voice, and may progress to that sea-lion’s cough, and perhaps it’s pal, stridor.

Stridor is the hallmark of a more dramatic case of croup, and is caused by noisy turbulence in breathing through a narrow, inflamed airway. Stridor creates a harsh, musical sound, reminiscent of a squeaky wooden drawer being pulled from a jammed position.  When taken in combination with the croupy cough, things can get quite symphonic and can seem pretty freaky. Fortunately, the vast majority of croup cases are mild, and stridor may be absent altogether. Parents can be reassured if their child is coughing noisily, but acts playfully, smiles, and can be consoled easily. All that, no stridor? Mild croup.

In moderate or severe cases of croup, stridor may be audible during inspiration and exhalation. As cases become more serious, kids may appear to work harder to breathe, seem cranky and uncomfortable, and show puckering (retracting) between the spaces of their ribs.

Parents will note that stridor often becomes more pronounced (and thus be more distressing) when children breathe more quickly. For this reason, finding ways to keep kids calm (comfort, hugs, and reassuring whispers) during bad croup flares is always a good idea.  Medications like acetaminophen (Tylenol) or ibuprofen (Motrin) may help in fever control and for throat discomfort. Steaming up the bathroom with a hot shower may offer some temporary relief.

What’s more, there may be something to this clinical pearl:  bundling up and going outside in the winter chill and breathing that cold air for a few minutes may soothe and improve a child’s airway inflammation.  ER docs I have worked with insist they have seen multiple cases of kids hacking and barking at home, only to appear much better by the time they reach the hospital after travelling through a December night.

For any family member or caretaker who suspects a case of croup is progressing past the noisy cough stage towards some degree of respiratory distress–or if they are just worried–a STAT checkin with their child’s primary care doc is called for, so to speak.  If circumstances allow, and if a child seems more bothered than sick, a phone call may suffice. Having that child within earshot of the clinician on the line to hear some coughing/barking may help clinch the diagnosis and allow for appropriate triage: manage at home? come in tomorrow? go right to the ER?

Treatment for croup has evolved a fair amount in the last twenty years. Some parents today may remember in their childhood that hospitals used to have ‘croup tents’, filled with misty water vapor.  These were a mainstay of therapy for croup dating back to the 19th century. However, research by the late 90s proved these devices were not terribly effective for more severe symptoms, and placing children in the plastic-shrouded cribs may have done more to make them anxious and their stridor worse.

In the office or ER, clinicians can usually assess a child quickly and make the croup diagnosis by taking the history and performing an exam.  First order of business: determine the severity of the disease. Steroid medications are the first line treatment for children with advancing symptoms of discomfort or distress for croup, and may even be given in milder cases to head off badness.  These medications may be administered orally or by injection, and work to reduce the viral inflammation and swelling of the airway.  For many, this may do the trick and will work well combined with the comfort and care measures described above.  For a few, a checkback and even a second steroid treatment the next day may be recommended.

Children who have more extreme symptoms of cough, stridor, may be given aerosolized treatments of epinephrine. This is dramatic, potent stuff—typically given in an emergency room versus a doctor’s office–and can work in minutes to open things up.  Heliox (a blend of oxygen and helium used by scuba divers for deep dives, among other things) has been used for children who have been unresponsive to epinephrine, and tends to be reserved for children admitted to hospital. Fortunately, the effectiveness of these treatments have contributed to faster recoveries and lower rates of hospital admissions for croup over the last decade. That’s nothing to cough at.

Before we wrap up, an important question to consider: Can you get croup again? About 5% of children can have a recurrent episode of croup. Most of these will be another, unfortunate viral illness.  Note: a second bout will place a patient on watch to be sure nothing else is going on. Clinician and family may consider if something else is afoot. So-called spasmodic croup, for example, includes a subset of kids who have precipitous bouts of stridor and barking cough absent fever and signs of illness. In short, they customarily awake from sleep in full croupy splendor with little warning. These kids, and others may have other causes at work, including unrecognized allergy, acid reflux disease, or anatomical issues that trigger brassy coughs and noisy breathing.  For these children, imaging or the use of special scopes to look at the airway by a specialist may be warranted.

So, my wishes for the best of luck for all of you with a super crouper, the illness with a bark that bites.

photo by jaQinthebox84

diagram link at   http://commons.wikimedia.org/wiki/File:Throat_Diagram.svg

Cartoon below by me.

What a day!  I went to the protest at Old Main directly after the board of trustees announcement in hopes that it would turn into something productive. It became clear fairly quickly that that wasn’t going to happen. We followed the crowd to Beaver Canyon and I was holding out some hope that integrity or respect or something like that would lead to cooler heads prevailing, but it wasn’t to be. I was okay with the WE ARE – PENN STATE chants, but I had to stay silent for the ones about Paterno or the Trustees – I just don’t know what side I’m on anymore. I guess I’m just on my school’s side, rather than some individual or group of individuals. We left as soon as the first light post went down – I felt absolutely sick seeing the news vans parked up the street and knowing how this was going to make my school look in the media today.
I’ve always known there were a lot of stupid assholes at this school. I see them every day at the gym or at the HUB and I wonder for a second how they got in here, and then I move on with my life. Unfortunately, our reputation as a school is judged on the actions of the worst of us, not the best of us, and that’s just a harsh reality. There were at least 15,000 kids out there and I would say 90% of them were either trying to be productive or just trying to watch, but that isn’t what gets played on the news reels.

Everyone here at Penn State is pissed off, and part of that is because we can barely keep track of what we’re supposed to be pissed off about anymore. I heard a few things yesterday that confirmed that this is going to get MUCH MUCH worse before it gets better. Thinking that only five people knew about this and covered it up was fairly naive-it looks like many more knew or at least suspected and failed to act.

I’m praying (why not, tried everything else) that this new rumor about Ssandusky running some kind of pedophile ring is false. The media has jumped on every rumor and speculation so far and turned it into their version of the truth, and it’s been a sickening process to watch unfold.  All they’ve done is sensationalize everything having to do with Paterno and the administration while ignoring the real villain (Sandusky) and the real victims (the kids, who seem like a tragic footnote at this point).  I cannot ever see myself working in journalism after this.

Please forward this to anyone wondering what it feels like at State at the moment, or wondering why the media is showing a bunch of assholes in PSU sweatshirts flipping a news van. Those kids are not Penn State, and hopefully sometime soon we will be able to separate the 90% of students who acted with integrity from the 10% who ruined it for everyone else. No one I know went to Old Main just to protest about Joe Paterno. It’s much more complicated than that.

We went to protest the handling of the situation by the administration, the gutless way Graham Spanier tried to save his job by throwing a local icon under the bus, the way the media has put the victims in the back seat to sell ad time, and the fact that something this monstrous could happen right under our noses and no one lifted a finger to stop it.

For years I have wondered what it is that will ignite the next generation of college students. Our country has been engaged in two wars for more than a decade.  Eighteen-year-old children have been killed or scarred for life both physically and emotionally while our fortunate coeds play beer pong.  Granted, there is no draft to call them to action, but still…

Then there’s the economy. There are conflicting reports about how Occupy Wall Street began. The Canadian anti-capitalist magazine, Adbusters, credits itself with sparking the idea, but according to Mother Jones Magazine, the protest against the 1% began when a group of artists, activists, writers and organizers gathered on the fourth floor of 16 Beaver Street, an artist’s space near Wall Street, to talk about changing the world.  In either case, the impetus for the massive protest did not begin in a college or university setting.

But this week, we finally learned what college kids deem significant enough to riot about.  Football.  The riots on Penn State’s campus in support of Joe Paturno were a disgrace. Thousands of students displayed outrage that “JoePa” would not be allowed to coach one more game on his way to a record.  Are our hearts supposed to bleed for those poor coachless babies?  Are you kidding me?  We’re talking about rape and sodomy here.

Paul Howard, a 24-year-old student told The New York Times, “Of course we’re going to riot. What do they expect when they tell us at 10 pm that they fired our football coach?”

I’m sure he didn’t mean me when he asked what “they” would expect, because I would expect Penn State students to feel disappointed that a man trusted to work with young people failed to alert authorities when very young people were victimized by his assistant. I would expect them to feel shame that their school was stained by the horrific reports coming from Jerry Sandusky’s victims, and by the fact that their head coach could have made a courageous and morally appropriate move and chose not to.

You have to wonder what would have happened if a Dean had been fired for not reporting that one of the English teachers had sexually abused children.  I don’t think I’m going out on a limb by suggesting the whole ordeal would have been inconsequential to the students at worst, and at best the outrage would have been directed at the Dean and not at the administration that released him from his duties. But this is football.

Tonight the students have decided to hold a candlelight vigil to show solidarity with the victims and their families.  It’s a nice gesture, though a tardy one.  After all the unfavorable press coverage the students’ received, it’s no wonder they decided to do the right thing.

My son is in college. I sent him there for academics, but also to mature as a person by taking the code of morality we tried to teach him at home, and applying it in real life situations. I would have been appalled had he been one of the rioters that night.

An argument can be made that there are 44,000 students at Penn State so obviously most of them did not riot.  But that fact doesn’t cancel out the fact that thousands, not hundreds, but thousands of students did.  I hope they someday lasso that energy and direct it in support of something good.

Airlines have cut costs dramatically and so it’s not just that harried attendants are uncooperative, but that they literally don’t have the extra milk. The little they have goes to full-fare paying customers in the better seats.

Anyone who has flown recently with children knows the stories. Because we live overseas, our trips are often across the Atlantic and so particularly long and painful. There are the baggage inspectors who chat up each other instead of unfolding a stroller. (I know it’s not their job, but it’s callous to watch a mom struggle on her own). The flight attendant who wouldn’t help me find a seat by my toddler after the booking agent failed to do so, as well as the desk crew. And then there’s the flight attendant who refused to warm up a bowl of vegetable mash. She told me the airline provided a meal. My daughter was one.

Yet for all of these encounters with rude flight staff, I have many more examples of airline employees and other passengers going out of their way to make travelling with a young child so much easier.

The Delta pilot who carried my bag to my seat, so that I could carry my daughter. On a Lufthansa flight, an attendant insisted on taking my daughter on rounds, even though at two my daughter clearly wasn’t helping. Then there was the Southwest Airlines desk attendant who quietly mentioned the one extra seat on the flight and suggested I put my child (who hadn’t paid) in it.

More often though, it’s fellow passengers who have helped out the most. On one transatlantic flight, a middle-aged couple took turns walking my daughter up and down the aisles. At one point, they took her to their seats and played with her while I napped. They had a grown daughter, they said, but no grandkids. They missed the days when their daughter was young. I required no explanation whatsoever. My only regret was that I failed to get their names and address to send a note. If you’re reading this, kind couple who looked after my kid, “Thank you!”

Another long-haul trip last summer was supposed to stop in Atlanta first. With winds big enough to upend a plane, we were rerouted to Birmingham where the winds were pretty much the same. Three attempts to land failed as the captain pulled up the plane in the final seconds. We were jerked all over the place and I have no doubt everyone aboard that plane was praying. Everyone except my daughter. She was too busy throwing up.

I saw the look on her face seconds before it happened. I had time to grab an air sickness bag. The problem: there wasn’t one. Apparently cost cuts on passenger amenities spare nothing. There wasn’t a single bag in our row. My daughter vomited everywhere, on herself, her chair, the floor, my handbag.

I remained calm enough and started to clean up the mess. But it was the guy next to me who deserves a merit badge for life for good citizenship in the air. He rallied our fellow passengers to send over their air sickness bags. Fortunately the airline had stocked some. Then he got me towels, despite my protests that he remain seated as the plane was still badly shaking. He helped clean up the mess. And most important, he kept me calm and even made me laugh.

All I remember is that he was a building developer from South Florida who in the economic downturn had gone back to building engineering work. I think his name was Steve. Thank you Steve, if that is your name, and thanks also to the Delta pilot (yes, the same pilot who carried my bag), for getting us all on the ground alive.

Image by Aonghus Flynn

I’m covering this topic on the occasion of the opening of NIDA’s National Drug Facts Week  to raise awareness — for teens and the adults in their lives — of something about which there are a lot of myths: prescription drug abuse, including ADHD meds.

Not too long ago, a patient of mine, an 18-year old named Martin, came back from college break for a checkup. He is an enterprising fellow, and I was glad to see he had settled in nicely for his first semester at college. However, he became upset when he reported that his roommate had found his ADHD medication, and had convinced him and his friends to take two or three pills each to stay up and study through the night just before midterms. This was a kid who’d been taking prescription medications responsibly since 9^th grade  and had always been careful to follow the correct dosages.

“Does this mean I’m addicted?” he asked sincerely, before adding, “Is taking these meds for fun really that dangerous?” Good kid. Tough questions.

As a pediatrician, you can bet that nearly every day I’m asked about treatment and medications for attention deficit/hyperactivity disorder (ADHD), such as stimulants Ritalin (aka methylphenidate) and Adderall (or amphetamine salts).  Do no harm, right?

After alcohol, marijuana, and tobacco, prescription medications are the next most commonly abused drugs by adolescents. This happens more than you might think. Upwards of one in five high schoolers reported using prescription meds for nonmedical purposes.  In cases like Martin’s, where prescription  medications are used for purposes for which they were not intended.  Ritalin or Adderall are often readily available drugs of abuse.

The Good?

Stimulant medications boost the effects of neurotransmitters in the brain such as dopamine and norepinephrine and allow more distractible and hyperactive folks to concentrate and focus. When used to treat a medical condition such as ADHD, the goal of the health care provider is to prescribe the lowest dose of stimulant for the best effect, then adjust meds until a desired degree of attention improvement or impulse control is achieved.

The Bad.

In the medicine universe, stimulants are potent stuff. Adolescent and adult users can take them in pill form, or crush them for snorting (ick), or inject them (yikes).  Higher doses of stimulants can derange the normal actions of neurotransmitters like the aforementioned dopamine, producing a euphoric-like high. Stimulant highs can be bewitching to those who seek them, heightening the risk of addiction. Ironically and rather cruelly, these medications decrease responses to normal dopamine, and require abusers to use more of the drug to get high over time.

The Ugly!

Taking stimulants at higher doses, or in combination with over-the-counter medications or anti-depressants gets scary quickly. Short-term reactions to high dose stimulants can include potentially dangerous changes in heart rhythms, heart attacks, stroke, or seizures. Any of these can lead to devastating injury or death. Some users may become dangerously hostile or paranoid and pose a threat to themselves or others. Longer term, chronic abusers of stimulants may experience drug withdrawal symptoms with severe disorders of mood, declines in academic performance, depression, thoughts of suicide, and engaging in illicit or high risk behaviors to feed their drug craving. It ain’t pretty.

Like many adolescents and adults, Martin perceived a prescription medication as being a less risky prospect than a street drug.  Prescription drugs, omnipresent in so many medicine cabinets and dorm rooms, render them familiar and less scary.  Further, Martin fell under the spell cast by his roommate about the performance-enhancing aspect of “a little extra” Adderall. Other kids may take stimulants, or other prescription drugs to self-medicate (to relax or feel better), or out of curiosity (everyone else is doing it).

How do we prevent or respond to instances when family members, friends (or for that matter, patients in clinic) are considering or actively abusing prescription drugs? For starters, everyone benefits by including prescription medications on the agenda of any discussion about substance abuse. Stimulant medications, pain killers, and other prescription drugs should also be recognized for their potential for benefit for treating medical conditions when done right.

Research has continued to demonstrate that parents often share with their teens the perception that prescription medications are less risky, or that their kids would not engage in their misuse. It ain’t necessarily so. Martin was not the first teen I’d met with such a story, nor will he be the last. I have encountered more than a few instances where a relative poaches a child’s prescription for their own use or profit. Sad, but true. Potential prescription drugs of abuse–including pain-killers, stimulants, or other psychiatric meds–should be kept in secure places and supplies monitored no matter who they are for.

Likewise, it continues to be the responsibility of health care providers like myself to ensure that prescribed stimulants are being used correctly, for the right reason. These medicines are considered ‘controlled substances,’ and so may only be given out in limited amounts to any one person for specific amounts of time. As in any medical concern, we consider each case individually and consider the need to review drug use if an individual or family appears to be refilling a prescription too quickly, or ‘losing’ their pills once too often.

And so, back to Martin. Does this one time dalliance render him an addict? Unlikely, I told him, but his action did put him at risk–and could do so again. He pondered this while I reviewed how the abuse of prescription stimulants could pose a real threat to his well being, or that of his friends. He had a lot to think about.

Before we left, we refilled his Adderall medication. We’ve met a few times since. (And, for the record, he’s made his refills on time!) Martin reports he’s declined other offers from friends to have another “ADHD Pill Party.”  And, for good measure, he keeps his own pills in a safe place.

And so we all do well to remember: the prescription drugs in our everyday medicine cabinets can help those for whom they are meant when used correctly.  And we all must pay attention to this key fact:  their abuse happens, and can lead to dangerous, or tragic results.

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For more information on the misuse of prescription drugs or other questions on youth and adolescent substance abuse see the following links:

Great resource for teens: The Sara Bellum blog : http://teens.drugabuse.gov/blog/

NIDA’s National Drug Facts Week:  http://teens.drugabuse.gov/index.php

Referrals to treatment programs: 1-800-662-HELP (a confidential hotline), or www.findtreatment. samhsa.gov

Roommate trouble is not big news on college campuses.  By the fourth week of school, housing offices traditionally see their fair share of disgruntled freshman requesting, sometimes demanding roommate switches. Often these switches are made with little ado. But the university housing office had little sympathy for Beth.  Beth and Bryce had chosen to room with each other in very much the same way singles choose to meet through match.com or eharmony or jdate.

Many colleges now allow incoming students to select their own roommates by filling out extensive online questionnaires.  In advance of living with someone, freshmen can now learn prospective roommates’ tastes in music, film, and television. They can find out about religious practices, study habits, politics, fashion preferences, allergies, eating habits and more. When I went to school I was able to choose a nonsmoker.

I’m all for the convenience of the Internet, but really?   Why bother leaving home to go to college if you’re going to live with someone who is exactly the same as the kids from your own neighborhood?   Save the money and commute to a nearby school.

This is what I told my youngest son when I insisted he allow his school to randomly select a roommate for him.  He could have roomed with any one of his seven high school friends who had been admitted to the school.  But I explained that the value of a college education is not simply to be found nestled in the pages of a textbook or spewed from the lips of an esteemed professor.  It is also to be gained by living among a diverse group of thinkers and people with lifestyles quite different from your own.  An anatomy teacher can show you where the tibia is, and this information will help you get along in a medical environment. But a bad roommate can teach you patience, negotiation skills, and communication tactics that will help you immeasurably in the big, diverse world that awaits you outside the protective walls of academia.

My freshman roommate was a mercurial theater major. I had declared a major in speech pathology. I needed a quiet place to memorize the anatomy of the vocal tract. She needed a place to emote. Somehow we managed to accommodate each other.

I was raised in a suburban Jewish neighborhood in upstate New York.  On paper, I have absolutely nothing in common with my dear friend Sylvia, a Lithuanian Lutheran from Valparaiso, Indiana, except for a mutual love of deep- dish pizza.  Nevertheless, we have loved each other since the day we met in college more than three decades ago.

During sorority rush, my soon-to-be best friend Leslie, who had been raised in Kansas, asked me if I had ever seen a cow.  I responded by asking her why she wasn’t in braids and gingham, and whether or not a house had ever fallen on anyone she knew. We enjoyed a good laugh, and have been laughing and crying together for 38 years.

My son listened to my stories, and was assigned three roommates whose interests were widely divergent from his.  The three young men were able to create a living environment based on mutual respect, and Zack has thanked me for helping him broaden his horizons.

On its website, eCampustours.com lists the seven most important qualities to look for when choosing a college roommate. They are: trustworthiness, respectfulness, willingness to cooperate, friendliness, patience, compatibility, and communication skills.  Do people actually reply “no” when asked if they are trustworthy?  Do they admit to being unfriendly or impatient?  I’m willing to bet the lying cheating Bryce didn’t reveal her dark side on her roommate questionnaire.

Chemistry between humans is not the science it is between elements and mixtures.  If it were, there would be no serial match.com daters.  We would all get it right the first time.  Kids who seek out those most like themselves are denying themselves the beauty and surprise of a friendship forged through mutual experience rather than mutual upbringing or interests.

Far more important is the impact this will have on society at large. Aren’t we, as a nation, divisive enough?   Turn on any news station and you see an assortment of cantankerous middle-aged louts pontificating to people just like them.  This is not going to change for the better if college freshman are randomly assigned roommates as used to be the case.  But, if our young people in great numbers seek to “live with same,” if they are not encouraged to meet and get along with a diverse student population, I’m afraid things could get frighteningly worse.

Oh, me achin' knees! classic painful bump just under the knee in OSD

“Osgood-Schlatter disease?” the athletic teen asked me, turning pale, “What is that, some sort of cancer? Is it something I’m going to have for the rest of my life?”

Alas, medicine is full of conditions named for their long-dead discoverers. Some of them sound misleadingly but downright jolly–e.g. Chvostek’s sign (a term for the lockjaw of tetany). Others sound obscure, like McBurney’s point (the point on the lower right abdomen known for tenderness during appendicitis). And then there’s Osgood-Schlatter.  It has enough syllables to sound life-ending, or perhaps describing some sort of Bavarian side dish. No, on both counts.

Rather, Osgood Schlatter disease (OSD) is the most common cause of knee pain in adolescents. In one survey, Osgood Schlatter was found in about 1 in 5 teen athletes (versus less than in 5% of a comparable group of non-athletic kids). Oh, and it isn’t cancer either.

Most often, the stories go a little something like this: An eighth grade basketball player comes into my office about 8 weeks into the season. He complains it feels like some little leprechaun has run up and bashed upon upon his knees with a ball peen hammer at the end of every practice or game. And, wouldn’t you know it? Our hero walks without a limp, but has telltale swelling on the upper aspects of both shin bones that are tender to the touch. These areas ache when he goes down stairs, squats, or kneels. The pain comes and goes, in general, but is usually always worse after a workout.  For the few severely affected kids, the pain may render them unable to play.

The area of interest

Fortunately for my panicked patient in clinic that day, and for the vast majority of those I see with it, OSD causes a mild to moderate amount of discomfort, and responds well to proper treatment and a tincture of time.  What is it, exactly? Take a knee, I’ll explain.

The growing knee of early adolescence is a busy place. Roll up your pant legs and play along as I go. Osgood Schlatter disease can be explained by age, growth, and teen lifestyle. As the old song says, the knee bone (aka, patella) is connected to the shinbone (or tibia). The  workhorse muscle of the thigh, the quadriceps, slings across the kneecap and inserts onto the upper aspect of the tibia via the patellar tendon. For a girl aged 8-12, or for boys around 12-15, the upper aspect of the shinbone where the patellar tendon anchors is a growth plate, and is especially vulnerable to stress and inflammation.

And here we have the setup. Middle school and high school athletes who have rapid periods of growth, and frequently, who engage in high impact sports with prolonged sessions of running and jumping are those who are most vulnerable to developing Osgood Schlatter discomfort.

Over time, tension placed on the patellar ligament by growing bones and the increased stress of athletics can cause microtrauma to the insertion point of the patellar tendon at the bump under the knee, called the tibial tubercle.  In some cases, the cycle of injury and re-healed bone can lead to prominent little goose eggs (see photo above) on one or both of these areas (about 3/4 of all cases are one-sided) that hurt when doctors or parents poke them.

For the treating primary care provider, Osgood Schlatter disease tops our list of diagnoses when we have a so-called classic case, such as a tennis, basketball player, or runner of cross country with sore, bumpy knees. However, before we ever rush to a conclusion, it remains a part of our job to go over parts of each story, and consider and eliminate other possibilities.

Consider: Hip pain can be referred to the knee, oddly enough, and it is key to ensure there is no problem with that big joint, or any other muscles, bones or tendons (anyone for jumper’s knee?). A clinician will perform a leg and knee exam, looking for suspicious rashes, swelling, fluid in the joint, tenderness or limits in strength or movement. To assist in this process, parents or teens who may suspect they have a case of OSD, should be clear about the timing of the onset of pain, triggers for its recurrence, and activities or positions that offer relief of any symptoms.  Most often, a good history combined with a physical exam clinches the diagnosis.

Most teens with Osgood Schlatter disease may continue their sports activity with proper care and treatment. Indeed, whether I meet kids with OSD who’ve undertaken a sport to address their obesity issues or to perform at the elite level, my approach is to keep them playing and to minimize downtime. Kids and parents should discuss with the child’s primary care provider if they would benefit from patellar tendon straps or knee pads.

Customarily, applying ice to painful shins post-workout for 20 min every 2-3 hours after  a workout can suppress swelling and inflammation. Pain relievers, such as Ibuprofen or other non-steroidal anti-inflammatory medications, may take the edge off the owie, but do not tend to shorten the overall course of the problem. Some teens may benefit from some certain stretches to promote quadricep and hamstring flexibility. For those so inclined, acupuncture may also help with pain and inflammation. Happily, the prognosis is excellent for over 90% of kids with Osgood Schlatter disease, and the knee pain typically resolves within a year or when their growth spurts ends–whichever comes first.

For those who encounter more profound pain or disruption of their performance, a respite from play (up to a couple of months!) may be recommended.  For tougher cases, I’d recommend a consultation with a specialist in orthopedics or sports medicine.

So, the next time a 14 year old talks about a leprechaun whacking his knees with hammer after practice, take heed! You need not believe in the wee people part, to be sure, but knee pain? growing kid? athlete? Consider if you might have a case of Osgood Schlatter disease…and getting it checked out for good measure.

Photo #1 by Berg/Worzala,from this nice article; Photo 2 by bonecareatrbjcc

Cartoon below by me.

More Faster Pediatrics:

Sweating It: Understanding Kids, Armpits, and Body Odor

Sunblocked? Keeping Kids Safer in the Sun