Stealing in younger children

Recently a mother brought concerns of her young school age child repeatedly stealing from family and school.  This is actually not too uncommon–teachers report about 5% of kids <10 years being caught taking from others.  There are lots of reasons for it to occur in otherwise well adjusted young ones–attention (my patient has a new sibling), anger if the offender judges some other who they think is rewarded unjustly or disproportionately, misplaced show of bravery to fit into a peer group, or as a way to impress and perhaps offer a gift to a desired friend.  Take note–it can even occur if your child mimics behavior that they witness in parents who might engage in something that people often view as small and innocuous like helping oneself to office supplies or keeping hotel towels and the like.

How should one react if confronted with an older toddler or young school age child who steals?  First, don’t panic or overreact.  Remember–children at this age have only limited impulse control and are not able to project out consequences too far beyond that moment.  Yelling, lecturing, and especially hitting (as almost always) are more typically counterproductive.  Be sure to discipline in a private one on one setting to avoid humiliating your child.  It is certainly proper to express great disappointment and also to require them to perform household chores as penance.  Explain this by saying that if he wishes to buy or own things of value then he needs to work for it.  Remove privileges like TV or video devices until all work is completed satisfactorily.  It can be good to do this work together and if able to praise his effort and performance since, as stated, sometimes these behaviors are manifestations of feelings of neglect or inadequacy.  Usually it is helpful to make your child return the stolen object and apologize.  This can even apply if objects are taken from stores or businesses however be cautious here as not all establishments will necessarily be forgiving even of these younger kids including with a first offense.

If you are concerned that these behaviors may be repeated try the following: make a written inventory of all of your child’s possessions and review it with her.  Explain that she is not allowed to own anything else beyond that list unless she has asked your permission first.  It will not be an acceptable explanation  that she “found” it or it was “given” to her unless she cleared it with you beforehand.  This can take some of the ambiguity out of these occurrences.

If these behaviors are repetitive, associated with poor or deteriorating school performance, or associated with any violence towards self, others, animals, or property it could indicate a more serious problem and should be brought to my attention. So give me a call.

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A few thoughts on DWI

I wish to make a brief comment about the deadly incident in Times Square last week.  All were horrified by the violence committed by an individual captured and charged with that awful crime( I refuse to publicize the alleged perpetrator’s name and give him even small satisfaction of notoriety).  So many people felt a somewhat understandable sense of relief when it was determined that there was no apparent link to any extremist terrorism.  It was “only” DWI.

Who are we kidding?  Of course all are concerned and fearful of the risk of terrorist violence in our society.  However, in reality, from 2004-13 there have been a total of 80 Americans killed in such incidents–36 on US soil.  Tragic, sickening, no doubt.  But for comparison, in 2014 alone there were 9967 Americans killed in drunk driving incidents; this is 28 people/day and one every 53 minutes.  19% of children 0-14 killed in auto accidents (total 209 that year) involved alcohol impaired drivers and over 1/2 who died riding in cars were operated by an impaired driver.  There are approximately 1.1 million DWI arrests yearly.

Other shocking statistics regarding DWI can be found here.

So let’s get real.  Our society has made major strides in DWI over the past generation or so but the above demonstrates that it is still a much greater public health problem in comparison to terrorism.

Obviously its extremely complex to address, but here are just a few simple policies that we as a society could adopt to help better control this terrible scourge:

• Raise the alcohol tax–the American Journal of Public Health estimates that doubling the tax would reduce DWI mortality by 35%.  Many pundits argue generally about raising taxes with the claim that “if you tax something you will have less of it.”  It is mostly an arguable point at best .  But less DWI?  Sign me up.
• Reduce the number of alcohol retail outlets.  The American Journal of Preventive Medicine reports that fewer liquor stores results in less alcohol related mayhem.  There is a “Goldilocks” effect here–too much or too few are both problematic.  But stricter licensing standards would likely be helpful.
• Studies from the RAND Corporation strongly suggest that outlawing the purchase of liquor by people convicted of alcohol related crimes would cut into these numbers quite dramatically.  The program could be implemented with special bracelets and/or breathalyzers to monitor compliance.
• RAND also found that state controlled–as opposed to privately operated–liquor stores are much safer and more protective against alcohol related criminal activity.

I believe that these are sensible and nonpartisan initiatives that all concerned citizens could support.  I encourage everyone to consider these policies and to encourage your elected representatives to advocate on their behalf.  Our society and especially our children will very likely be safer and healthier for your efforts.

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Baseball Arm Injuries

So we spent some time talking about warm weather and girls’ knees.  Let’s give equal time now to boy’s arms–pitchers’ injuries generally.  This is a huge topic, easily filling a textbook or weekend lecture series.  Let’s summarize some risk factors identified by researchers from the American Sports Medicine Institute.  These can guide us to develop safer training/competition schedules.

Firstly, a negative–number and age of breaking balls thrown had little positive correlation with injury.  Injured vs non-injured pitchers all threw on average 60% fastballs, 15%change ups, and 25% breaking balls.  There was also no difference in injured vs non-injured in relief appearances or for those who stayed in the game at another position after being relieved.

The 2 groups differed in size, with the injured group tending to be, on average, 4 cm taller and 5 kg heavier.  This may reflect the bigger boys throwing harder or having somewhat different mechanics.

The injured group threw more warm ups.  Possibly this may reflect a tendency of boys who are already “at risk” taking more time–and more throws–to “get loose.”

The injured group, not surprisingly, used ice and anti-inflammatories like ibuprofen more often and in greater amounts.  Again, this suggests boys with already stressed arms, and tells us a lot about  the folly of “playing through the pain” in kids.

9-14 year olds who lift weights had greater injury risk, possibly due to the strain on skeletally immature bones and joints in younger boys.  Probably best to avoid this until the boy has enough beard to shave somewhat regularly.

Competition issues are the big ones.  Injured pitchers competed at least 8 months/year  (5x risk of surgery) compared to boys pitching 5.5 months/year.  The Institute recommends refrain from all throwing activities(not all sports) for minimum 3 months/year.  Inured pitchers threw 6 innings/game and 88 pitches (2.8x risk of surgery) compared to non-injured at 4 innings, 66 pitches.  One study demonstrated a clear risk of a specific overuse shoulder injury with >100 pitches/week.  Velocity played a role–injuries were more frequent at 88 mph compared to 85 mph.  “Arm fatigue” is key.  67% of injured pitchers admitted to throwing with a “tired arm”–52% regularly– with 36x greater risk of needing surgery.  The non-injured group numbers were 42% and 11% respectively.  I’m sorry, but “toughing it out” in this age group is just crazy.

Finally “showcase” competitions caused greater risk of pitcher injury.  Injured players participated in an average of 4 of these events compared to just one in the non-injured group.  Showcases tend to be held in the off season when boys are not at peak conditioning and places added physical(and MENTAL) strain on young pitchers.  I recommend limiting the number of times boys participate here (if they cannot be avoided entirely) and closely monitor when throwing in this type of competition.

As always, I end by urging parents and coaches to remember the priorities for all youth sports: firstly–have fun and make friends; secondly–fitness, competition, and learning valuable lessons like persistence and commitment; and lastly–win games and glory.  College scholarships, should they occur, are icing on the cake.  Making the majors??–go buy a lottery ticket.

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ACL injuries in girls

As we move to warmer weather we can now really begin to enjoy the outdoors, which means lots of youth sports.  I say great–but I also will take a moment to discuss concerns about the absolute epidemic of anterior cruciate ligament (ACL) injuries in adolescent female athletes.  Over the past generation we’ve seen increasingly frequent ACL injuries by up to 900% due largely to the explosive growth of girls sports since Title IX; anywhere from 20,000-80,000 occurrences yearly.  Soccer, basketball, and gymnastics cause the most injuries; girls are up to 8x greater risk compared to boys.

Some background: the ACL is inside the knee and keeps the tibia (shin) from sliding forward relative to the femur (thigh) during ambulation.  >70% of injuries result from no contact with other players but rather from some sudden, awkward movement.  One example: a girl plants her right foot with extended knee and then tries to quickly cut right.  With sudden deceleration her weight is back with leg straightened moving under her upper body as her torso turns right and out and her thigh rotates inward(counterclockwise) and POP!! (there is often a loud snap that everyone close to the injured girl will hear when the tear occurs).  This is a common mechanism of injury.

There are many physiologic factors contributing to girls’ ACL risks:

• Hormones–testosterone surge in boys makes for greater muscle development allowing boys to control movement more with muscle strength; girls tend to rely more on bones and ligaments.
• Menstruation-the ACL actually gets slightly longer and more lax mid-cycle creating greater risk
• Neuromuscular factors–quadriceps (front thigh):hamstring (back thigh) muscle strength ratio is greater in girls compared to boys.  This puts greater strain on the ACL.  Girls also tend to have one leg stronger than the other compared to boys more symmetrically distributed leg strength which creates more problems in the weaker leg.
• Girls tend to run and land relatively flat footed.  Boys are up on their forefoot more which is a better shock absorber.
• Girls have relatively less core body strength.
• Wider pelvis makes for more uneven landing

Note that for both boys and girls being overweight increases risk.

There are many steps we can take to avoid ACL tears.  Proper fitting quality footwear for their sport is a nice start.  Core strengthening is key–lots of sit-ups and planks.  Neuromuscular training is a very important component.  Here is an excellent program.  A variation on that program is demonstrated here.  So besides dribbling, passing, shooting and SCORING, make these exercises a regular part of your daughter’s training routine, especially off and pre-season.

Chance of ACL injury does not at all mean that your daughter should shrink from enthusiastic participation and aggressive competition.  Like all risk it must be balanced by advantages and can largely be controlled by proper lifestyle.  Sports will help make her more confident, stronger, healthier and so often happier.  And most importantly–IT’S FUN!!  So get out there and play.

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Drug addiction–medicine disposal

Most of us have become aware of the terrible scourge of drug abuse that grips our nation.  Here in Ocean County, heroin kills one person every 48 hours.  Statewide we have seen a 214% increase in drug use since 2010 with approximately 128,000 New Jerseyans struggling with addiction at last count.  As a community, Toms River ranks 8th statewide in the rate of heroin addiction and overall Ocean County ranks 2nd in that sad list with 157 heroin deaths in 2015.

The problem is not just heroin, of course, but also prescriptions pain killers as well–including frequently used drugs like oxycontin, hydrocodone, and fentanyl(note–available as a dermal patch).  Many may have these drugs in their medicine cabinets left over from ailments like dental work, back pains, or surgical procedures.

What can we do with these medications when the problem is resolved but there are pills left over?  It’s NOT as simple as one might think.  The risks here are obvious–adolescents are impulsive and can be foolish: parents should never be too confident and should NEVER take anything for granted here.  And we must note that other youngsters visit and that just adds another variable to that safety equation:

• Do NOT discard medicines in the trash
• Be careful about flushing medications down the toilet
• Best to discard at a reputable center
• When in doubt, check with your pharmacist
• When disposing pill bottles, be sure to scratch off all identifying information
• Do not crush pills, but you can break them into halves or quarter
• If you are going to discard pills, mix them with undesirable substances like dirt, kitty litter, or coffee grounds and discard in trash in sealed plastic bags

One last suggestion:  ask me about keeping a prescription  for naloxone (narcan)–available as a nasal spray–for your home.  Naloxone is an absolute antidote for opioids, is easy and VERY safe to administer.  Because “you never can tell,”

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Probiotics

Probiotics can often be a good natural remedy for simple–if annoying– gastrointestinal complaints.  They are defined as ” live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.” These products have been tried in a variety of situations.  The medical literature is actually quite extensive but, at the same time, conclusions are rather spotty.  Nevertheless I think they are useful in the right setting and, in particular, (“naturally”) I favor their use over most medicines in many instances.

Historically, probiotics have been among the top 3 non-vitamin, non-mineral supplements given to children ages 4-17.  They seem to be most helpful in 2 clinical situations: acute gastroenteritis (AGE) and in the prevention of post-antibiotic diarrhea.  For these conditions the data is quite strong.  For instance, in the latter, probiotic use in one study of over 3,000 children showed a 52% reduction in the risk of diarrhea.  The efficacy of the treatment seems most tied to 2 things.  Firstly is the organism used and the second parameter is the dose of treatment.  The most extensively studied organisms–and those with the best “track record” –are Lactobacillus rhamnosus GG and Saccharomyces boulardii.  For both, 5 billion CFU (“colony forming units”) once or twice daily for 2-4 days seems to be enough to be helpful.  Both of these treatments are available as commercial products in either chewable or packet form and can be purchased in pharmacies or health food stores (I do not list brand names of products in my blog posts).

People have also tried probiotics for a number of other medical conditions like community acquired infections, colic, eczema, and even more severe medical problems like Clostridium dificile (“C dif”) infections and inflammatory bowel diseases like Crohn’s or ulcerative colitis.  Here there is considerably less evidence to support their use so I do not recommend that you rely on probiotics for those problems.  Additionally, many brands of yogurt are touted as a useful source of probiotics.  However, recent studies have not shown significant benefit of yogurt as a probiotic in any of the above medical conditions.  Food experts postulate that there probably aren’t enough “CFU” organisms in yogurt to be effective.

Lastly, we should recall that this treatment utilizes living organisms.  Therefore, use in infants or immunocompromised children–those with HIV, cancer, or receiving other immunosuppressive treatments or with other immune compromised conditions–is not recommended and could even be quite dangerous.

Much of the above information is summarized from a very useful article I found in a professional journal “Infectious Diseases in Children” written by Edward Bell, PharmD at Drake University, Des Moines, Iowa.  So a “shout out” to Dr. Bell for his help here.

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Novel Psychoactive Substances

Many conscientious parents are aware of the terrible scourge of drug addiction that grips many in our nation and in particular locally here in Ocean County.  I wish t0 make you all aware of another danger that exists somewhat under the radar–“novel psychoactive substances” (NPS).  These products are usually not specifically illegal to sell or possess in the US but have various intoxicating effects.  Needless to say, as they are not meant for human consumption they can also often cause serious harm.

There are basically 4 categories of NPS:

• Stimulants–drugs similar in action to cocaine, amphetamines, and MDMA(“ecstasy”).  The most commonly used agent here is mephredone which is sold in the US as a garden fertilizer.  Street names are drone, M-CAT, white magic, or meow-meow.  Taken orally (“bombing”) snorted, injected, even anally.  Toxic effects include agitation, psychosis, hypertension or even heart attack, elevated body temperature, seizures.  If mixed with certain standard prescription or OTC drugs can also cause potentially life threatening serotonin syndrome.
• Cannabinoids–marijuana like substances.  There are a variety of “herbal essence” products that are often used in vape devices.  Brand names include K-2, Spice, Black Mamba, Bliss, Bombay Blue, Genie, Zohai.  Side effects include sleepiness confusion, excessive sweating.  Rarely can cause cardiac toxicity(hypertension or heart attack) kidney, lung, or neurologic damage( seizure or stroke).
• Hallucinogens–there are 2 classes:

1. Dissociative–the primary agent is methoxetamine (“mexxy”) It is not specifically illegal in NJ and can be purchased online.  It produces a sensation of weightlessness and “out of body” experience.  Side effects include nausea and vomiting, cramping, cardiovascular problems.  Injury and death from accidents caused by impulsive or careless behavior is not uncommon.
2. Psychedelics–LSD like effects.  Most common example is NBOMe.  This class os substance is currently on a “temporary” Class I status so cannot legally be obtained in the US.

 

• Depressants–also 2 classes

1. benzodiazepine like–common agents are diclazepam or flubromazepam.  They also are available online.  They cause confusion, somnolence.  These drugs’ effects last longer than commonly used variants like valium or xanax–sometimes > 1 day.
2. Opioids–morphine or heroine like effects of calm, sleepiness but can progress to coma, respiratory depression.  They do respond to antidote naloxone (“narcan”).  Common agents AH-7921 was made Class I illegal as of May 2016, however MT-45 is a lower level variant which is still available legally online in the US.  While nominally somewhat milder, it can be deadly if combined with alcohol or other drugs with sedating effects.

My advise to concerned parents, of course, is vigilance.  Pay attention to your teen’s social environment.  Monitor computer and smart phone use.  Be very aware of online purchases (if you permit them) and if you do not recognize a product purchased or in their possession be sure to look into it very carefully.

And, certainly, call me with questions, and thanks for following.