Last year, the Florida State legislature attempted to gag pediatricians from discussing gun safety with families. That law, referred to as the docs n’ Glocks Law, was overturned by a Federal Judge this past September after strong rallying by the American Academy of Pediatrics and the Brady Center to Prevent Gun Violence.

Judge Marcia Cooke’s ruling was a huge victory for gun safety education and for pediatricians. Her ruling validated what pediatricians in Florida, and every other state in our Nation, have been attempting to explain for a very long time: this issue isn’t about gun ownership but about gun safety.

The recent  tragic death of a Texas 8th grader, Jaime Gonzalez, is a grim and very real reminder of how serious events can become when any type of gun is involved.  According to reports, police could not discern that the gun was a pellet gun and the events unfolded in a way that forced them to act so that the school student body and staff would be safe. That’s their job. Playing Monday morning quarterback isn’t going to change the event. However, we can prevent future events by recognizing that we need to do better in providing gun safety educations in our schools, for parents in their homes and for pediatricians in their offices.

For some reason, gun safety education is one of those topics that everyone agrees is important, including pediatricians, yet no one takes enough time to truly do justice to when they have a family, or group of students, in front of them. With kids still bringing guns to school, we have to stop assuming that someone else is providing that important talk and step up.

Parents need to have the talk with their kids, whether they own a gun or not.

Schools need to have gun safety education in their health and safety courses and in their Open Circle times.

And, pediatricians need to fit it into their busy office visits.

We should be having it at home with our kids.

Communities and schools can think outside the box and post information and links to resource on websites and in newsletters. Drama classes could organize skits. Art classes could make posters. Both of these avenues have been very successful with other hard to discuss topics such as drug and alcohol use and abuse and high tech issues.

As long as you do more today than you did yesterday, the students in your community will more safe tomorrow and the likelihood of another school gun incident will go dramatically down.

This is a New Year’s Resolution we can do something about – and we owe it to the Jaime Gonzalez’s family to do just that.

New study says child abuse is underreported by primary care providers: MyFoxBOSTON.com

Child abuse is one of the most difficult issues we face as pediatricians and in society. A new study out this month by Boston University School of Medicine sheds some light on one of the most important issues in helping children who have been abused: a pediatrician’s ability to report.

Bob Sege, MD, the study’s lead author, and I talked appeared on Fox 25′s Morning Show yesterday to make sense of not just the study but the bigger issue:

New study says child abuse is underreported by primary care providers: MyFoxBOSTON.com

The anniversary of 9/11 is still a few days away but very much on my mind lately. Perhaps it’s the fact that it’s been an entire decade since that surreal day. Perhaps it’s because of all the media coverage triggering memories that still invoke raw emotions. Or, perhaps it’s because my kids are now old enough to talk about 9/11 but to truly understand’s its impact.

In my daughters’ high school, the social studies department is devoting a great deal of time to 9/11. Each class is reading the same essay but to varying degrees and depths depending on their grade. So, as a Freshman, my 14 year old is just reading the first part and talking about 9/11 in a broad way. My 17 year old, though, is emerged with much more detail, which is what you’d expect in a Junior social studies class.

Talking to my kids as they process their assignments, they are at very different places. A decade ago they were only 4 and 7 years old. At the time, our youngest daughter had no idea what was going on even when she over heard snipits at home or at preschool. Our 7 year old, though, picked up on a bit more. As a first grader, she understood the concept of “good vs. Evil” but if it didn’t impact her directly, she didn’t become uprooted. At the time, she would ask about a few details she heard about at school or for some clarification of the few details we told her but that was it. Ten years later, she admits she doesn’t remember much about 9/11 or what we told her but just knew that something “bad” had occurred.

Being very different kids, they process information like this very differently. My oldest needs facts and always has. My youngest needs reassurance of stability and safety, and always has. So, as my husband and I comtemplate how to explain our reactions to 9/11 a decade ago, we are very much cogniscent of who they are as people and what they need.

That’s actually the key to successfully talking about any hard to discuss topic, actually. That and making sure their immediate worlds are not too derailed by the introspection and reflection an anniversary such as 9/11 can produce.

One of their assignments for preparing for the 9/11 anniversary is to talk to us and other adults they know about what 9/11/2001 was like for us – what we remember. While I’d love to forget that day, I have to admit it’s etched in my mind permanently, the way profound events seem to have way of doing.

I was working in a clinic outside of Boston back then and had just started my day when one of the medical assistants ran down the hall screaming “we’re under attack!” I’ll never forget the expression on her face, or those of all my colleagues as we stood around a TV in the conference room in silent disbelief at what we were witnessing.

We spent a great deal of that day watching the news and trying to track down friends and relatives. We learned later that day that a friend of my husband’s from high school had died in one of the towers. He was a firefighter.

It was hard to not feel overwhelmed about how to reassure our children. The tough part a decade ago was that we were relying on instincts to guide us as we had little credible information to truly explain what had transpired. Today, while the thought of the events are still unsettling, we have had the passage of time to provide some relief to this open wound and to help us make sense of some of the details. We also have the knowledge that the most notorious of the terrorists have been captured and killed.

If the last decade has taught us nothing else it’s that we are incredibly resilient as a nation and that our kids are more resilient than we often want to admit.  Where they differ is in how they process the information and react to it. Some kids will want to get into a huge amount of detail while others will want much less and may not want to talk about it at all. Some will feel incredibly empathy for the events and others appear virtually unphased.  The key is in tailoring your approach to talking about 9/11 to your kids’ needs and temperament.

Once the anniversary of 9/11 comes and goes, you’ll likely find that your kids handled it all better than you. Through their eyes, perhaps we can start to recognize that we are ok – and our resilience and need to persevere are what will always set our world back on the right axis.

If you are interested in resources to help you talk to your kids, here are a few:

American Academy of Pediatrics: talking to kids about terrorism 

Remembering What’s Hard to Understand

Talking to Kids about tough world events

Over the last decade we’ve had to face far too many of tough world events from terrorism to natural disasters, such as Hurricane Katrina or the tsunami in Japan. It’s always the same pattern:  in the blink of an eye, we are transported from our relatively happy lives to an uncertain fog as we grapple with whatever event had just occurred.

I recall vividly one such event a few years back after my husband returned from a trip to London. Just by the expression on his face I knew to hit the off switch on the TV but missed the airing of the news of the event by seconds. Our ten year old daughter had already heard that there were explosions in London in the same area that my husband had just been to. “Was it as bad as 9/11? Do you think they’ll catch the bad guys this time?”

Good questions with difficult answers. These events shatter not only our feeling of security in the world but our hopes for our children’s futures. Luckily, children are not small adults and their lack of life experience actually protects them in many ways from all the concerns we focus on when we hear that about a tragic event. Children of all ages really only need reassurance about the integrity of their own worlds, their own safety, and the safety of those they know and love. They still have that wonderful leap that everything will turn out fine – especially if we, their parents, tell them that it will

Dr. Paula Rauch, Director of the Child Psychiatry Consultation Service at Massachusetts General Hospital, emphasizes the need to not only find out what the child has heard and to clarify the details of the event but to emphasize the rarity of these events in the big picture of the world. This is true for tough world event such as terrorism as well as natural events such as earthquakes and tsumamis.

For example, to answer my daughter’s questions about whether the bad guys would get caught, Dr. Rauch suggested an answer such as “It’s a good question. I can’t be sure, but I hope so. I know there will be a lot of smart people looking for them….There will always be a small number of “bad” people in the world and luckily a much bigger number of caring ones. A surprise thing could happen, but it is really, really rare.”

For natural disasters, it’s important to emphasize similar message around safety. Kids need to know that people are looking out for the people directly involved in the incident as well as people elsewhere. In addition, we need to be good listeners ourselves to find out if our kids have any specific questions about the disaster that may be weighing heavily on their minds. If we don’t listen openly, we’ll never know what information to offer.

The age of your children is your best guide for how to comment on any difficult event. Small children, preschoolers and kindergarteners, should be told little about tragic world events. The fantasy world of small children and their lack of understanding about space and time make it difficult for them to grasp what has occurred. For this age group, you may need to let them know that something scary happened far away from home but that everyone they know is safe.

As children get older, what you tell them will of course become more detailed. For all children, including teenagers, discussions need to be simple. Media exposure should be monitored closely at this age. Many experts feel that a parent should be present if a child is going to see a traumatic image in any media forum. This is sound advice for all of us to follow.

Helping a child see what is really in their control can be very reassuring. Notes Dr. Rauch, “a parent could say…my approach as a grown up is to pay attention to the safety things I can do that protect us from things that happen more often. Look both ways crossing the street. Wear a bike helmet. Know your important phone numbers if you need to call parents…The adage “Think Globally. Act Locally” is a good way to think about safety”. In the case of any disaster, hotlines are usually set up where people can contribute funds or good to help those in need. Kids respond well to helping other kids so mobilizing them into a call to action around one of these hotlines can help them feel less powerless. Save The Children is one group that kids of school age and older can relate to for any event involving children.  They already have a donation center set up for the victims of the Japan tsunami. If your kids want to help, check it out.

Clearly the more personal the event is for a family the more difficult it will be for a child. Consult your pediatrician or a child psychiatrist if you have concerns about any world event’s impact on your child. The earlier you address these issues, the easier it will be to help your child.

Preserving the rhythm of our children’s lives is ultimately what will reassure them that the world as they know it is still ok. A friend of mine said it best at a concert band rehearsal a couple years ago:

“The world may be unraveling as we speak but at least we have something civilized to look forward to and do each week”.

So, embrace what is important to you and keep on doing it.

(First published 2009; updated 2011)

“I am hereby officially tendering my resignation as an adult. I have decided I would like to accept the responsibilities of an 8 year old again.  I want to go to McDonald’s and think that it’s a 4 star restaurant.  I want to think M&M’s are better than money because you can eat them.  I want to return to a time when life was simple.  When all you knew were colors, …, and nursery rhymes, but that didn’t bother you because you didn’t know what you didn’t know and you didn’t care. All you knew was to be happy because you were blissfully unaware of all the things that should make you worried or upset.  I want to think the world is fair. That everyone is honest and good.  I want to believe that anything is possible….I want to be… overly excited by the little things again.  … I want to believe in the power of smiles, hugs, a kind word, truth, justice peace, dreams, …, and making angels in the snow….I am officially resigning from adulthood.  And if you want to discuss this further, you’ll have to catch me first, cause… Tag! You’re it.”

My daughter’s teacher circulated this to the parents when she was in second grade. The teacher received it from a friend via email and the author is unknown.  But, what a smart person this author must be!  Thankfully, children are not small adults and their self-centered view of the world  protects them from the emotional turmoil we all feel during a horrible disaster, regardless of the nature of the event. Not only is that the way it should be but what we must all work hard at preserving.

So, should you even tell your child about current events? Absolutely.  But, keep it simple and age appropriate.  Small children, preschoolers and kindergarteners, really should not be told about anything so horrific as the shuttle exploding or the possibility of war with Iraq – both are far too terrifying for a small child.  For this age group, you may need to let them know that something scary occurred in the world but that everyone they know is safe and that they are safe.

As children get older, what you tell them will of course become more detailed.  For all children, including teenagers, its important that you keep your discussions simple and that you don’t overexpose them to the media.  Many experts feel that if a child is going to see a traumatic image, a parent should be present and this is sound advice for all of us to follow.

Keep in mind that in the case of horrific, tragic events, the absolute truth may be too overwhelming for a young child.  Most developmental experts advocate downplaying these catastrophic events when talking to children.  Instead of focusing on the details of the event, redirect  the conversation to focus on their safety and security.

Imagine that you are playing ball with your child – but the ball is a world that just experienced something bad.  You look at the ball and see the event, remember past events, and think ahead to what may happen next – and then become a bit anxious.  When our children look at the ball, they see the event,  want to know that those they love are fine,  whether soccer is still happening that day, and wonder what they will do tomorrow with their friends.

My advice for the future: try playing ball like your kids do for a bit – not only will it help you keep recent and future events in perspective but will help your children play longer by their rules and not ours.

One of the situations I found most challenging working in emergency rooms and urgent care settings was when a teen came in for “medical clearance”. This phrase is code for “a teen in an emotional crisis who may need be having a major psychiatric issue…or not.” My job was look into any possible medical issues of the mood changes and then to call the on-call psychiatric crisis team in for the remainder of the evaluation, if needed…which was the majority of the time.

I recall one 17 year old teenager who had threatened to commit suicide earlier that day.  I remember being struck by two observations: how sad she appeared and how “normal” her family was by all standards. They were basically like any of our neighbors.

Talking to this particular teenager, I learned she had great success in school, sports and music and appeared to have a very loving and supportive family. Yet, she never felt happy…ever. Her parents described her to me as a “serious” teenager and very busy, burning the candle at both ends and feeling enormous pressure about the college application process.

That particular day, she decided the world would be better off without her and it frightened her so much she told one of her high school teachers.  After the initial shock of the moment, her parents and teachers were able to look back and notice small clues that were missed by this teens outward success that lead to that day. Thankfully, they knew to bring her in for a crisis evaluation and the team on-call agreed she was clinically depressed and needed in-patient care. Finding that care was a different story with the usual bed crunch we have in the child psychiatry world but at least in this case we had a family on board with care and a teen wanting help. These situations don’t always occur this way.

What makes teen depression so challenging is teens are moody and can have off days. So, how do we decide if our teen is “clinically” depressed or just going through a short term rough patch, perhaps due to t a friendship issue or issue with a boyfriend or girl friend, or simply having a bad day?

Keep in mind that most teens, despite their reputation as a group, do listen to adults and follow the rules. Remember, a busy teen is a happy teen most of the time. What we have to look for is a flip-flopping of emotions where the teen’s mood shifts from being mostly cooperative and happy to mostly not so cooperative and unhappy. In other words, instead of the teen melodrama being the exception and fleeting, it becomes more persistent and prevailing and lasts at least 2 weeks, if not more. That’s the point we have to pause and get our teen evaluated.

www.aboutourkids.org has a list of screening questions that can help you decide whether you may need to seek professional help for your child. Keep in mind that a “screening” test picks up kids who MIGHT have a problem – kids you want to have someone else look at – but it may not mean that there is a HUGE problem.

1. Does your child feel sad, blue, or tearful?
2. Is your child often angry or picks fights at school or at home?
3. Does your child no longer care about favorite activities?
4. Has your child lost or gained a lot of weight?
5. Does your child have trouble sleeping or sleeps too much?
6. Does your child have trouble sitting still or appears very slowed down?
7. Does your child always look tired or is “too tired to play”?
8. Does your child feel hopeless or tell you, “I’m no good?”
9. Does your child have trouble concentrating or making small decisions?
10. Does your child talk about how life is not worth living, death, or suicide?
11. Have you noticed these symptoms have been present for almost every day for a 2 week period?
12. Do these problems get in the way of activities at home, in school, or with friends?

If your teen is clinically depressed, you will have a large peak to climb – but don’t let that deter you. There will be peaks and valleys as you help your teen battle this beast but keep the ultimate peak, the gold ring in mind to keep you focused: the smile on your child’s face that you’ve likely not seen in all too long a time.

Q)
Dear Dr. Gwenn:

My daughter is 3 ½ years old. I just spent the last year raising her alone while my husband was in Korea. Since we are a military family, our lives change every so often when it has to. Lately our daughter takes up to 3 hours to go to sleep, we have left her by herself and we have to take her back into her room at least 6 times. We’ve tried reading stories in her bed and staying in her room until she falls asleep. On occasion, she has lain in our bed for hours before falling asleep.

During the evening struggles, she often throws fits and kicks and screams. I need help!!! This is affecting my marriage and now I have become one of those mothers that I didn’t want to become with a spoiled child. Please help!!!

Thank you,
Rebecca

A)
Dear Rebecca:

Please know you are not alone in your frustration – we’ve all been there with toddler struggles but you have the additional burden of having a husband who is only intermittently in the picture due to his military obligations. This is not small challenge for so many families today.

Toddlers become easily disrupted when their schedule and sense of security change, and in today’s world deployment of a parent is one of the biggest stressors facing families and kids.

Deployment and separation are very difficult on a family and it is not uncommon for couples and kids to feel enormous stress even on the welcome and happy occassion of a home coming.
The military often has excellent family services which I’d encourage you to explore since part of this situation is an adjustment for all of you to your husband’s tour of duty and his return. I found some very useful resources online that may help you at least start to understand your child’s view of her Daddy’s comings and goings. She is old enough that she may also have some fears about his job. Here are some links that may help you out:

Militarybaby.com: helping a preschooler when daddy is deployed.

Talking to my friends whose husbands have been in the Armed Services, I learned that there are many services available to military families. From what I understand, all military families are connected to a FRG – family readiness group. Those groups form the foundation for support groups, play groups, etc. That group would be a good starting point for you. There really is power in knowing you are not alone.

You could also talk to your husband’s command’s wife who is often in charge of help out the spouses. My friends who have had husbands in the army tell me that different units have different levels of cohesiveness but all these services do exist in one form or another. Finally, keep in mind that all posts have medical units with therapist. From what you described, I’d start there while you are pulling together more social supports.

In the mean time, you and your husband should try and be consistent with your daughter and present a united front. She may be toying with limits now that two parents are actively involved. While I understand how frustrating it must be for your husband to have to deal with a child so out of control, help him see this through her eyes and he may feel less helpless. He’s likely feeling a bit guilty and that is not an easy feeling. This will get better but will take a bit of work from all of you, a great deal of patience and understanding, and some support and help from the outside.

Dr. Gwenn

Many children are lucky – they live with at least one of their natural parents. But, what if a child can’t live with mom or dad? What if circumstances dictate that a child must be removed from the home to live with relatives, friends or a foster parent? If you are having trouble creating a mental image or even coming up with the words, you need to read “Finding The Right Spot” by Janice Levy. It fills just the right spots of this challenging topic in just the right way for kids and adults.

This book tells a heart-felt, simple story of a little girl separated by her mom and now living with a foster mother, a woman she calls “Aunt Dane”. While “Finding the Right Spot” deals with a foster situation due to drug abuse, it could easily apply to any child separted from parents for any reason because the emotional issues are the same.

“Finding the Right Spot” fills a void in the child health literature for children and adults. The benefits of the book for adults caring for children caring for children separated from their parents are enormous by helping the caregivers see and understand the experience of the child better. And, for the child, they’ll feel less alone knowing their experience is not too different from those of other kids separated from their parents. That peer connection is very powerful for kids.

For me, the best part of “Finding the Right Spot” is to show how the love of a patient caregiver can help a child heal when wounded by the frailty of parents facing insurmountable hurdles in their own lives. If there ever was a calling card for why we need more support for social services, “Finding the Right Spot” is it. It takes a special person to be a “Aunt Dane”. This books gives a voice to those people and the many children they care for, regardless of reason.

My Final 2cents:  

Disney movies have a wonderful way of providing something for everyone but are sometimes criticized for content that may be too overwhelming for children – parents dying, natural disasters, and sickness in a friend or loved one. I was particularly sensitive to these very issues when my children were younger and would simply fast-forward through “questionable” scenes. Eventually my kids started insisting on watching movies without interruptions regardless of content. What’s interesting is my kids did fine with the movies we felt were “too intense” but had a tough time with movies we assumed would be more low-keyed. For example, in Bambi, my oldest daughter figured out at age 5 that Bambi’s mother was now gone but told us that Bambi would be ok because his daddy and Flower were around to help. In contrast, when my youngest daughter was 3 she cried uncontrollably in Elmo in Grouchland because Elmo’s favorite blanket was lost. She had a much loved blanket at the time called “kiki” which she still has. The parallel to her life was just too intense for her whereas my older daughter was more able to process a tough topic because her life was not at all like Bambi’s – her mom and dad were right there watching the movie with her.

We could not have predicted these reactions if we tried – they were completely opposite of what we anticipated. And, according to child psychiatry experts, my daughter’s reactions were not only predictable but essential for their development. According to Paula Rauch, MD, Director of Massachusetts General Hospital’s Parenting At a Challenging Time (PACT) Program, (www.mgh.harvard.edu/cancer/cancer_ptsupportedu_pact.htm ) “rather than “protecting” children from loss related content, think of them as opportunities. It is not protective to exclude children from the reality that people get sick, and people and animals die. When parents do “protect” their child, they ensure that a child’s first experience with loss will be more overwhelming. Having a pet die, hearing about a friend’s parent dying, going to a family member’s funeral are sad experiences but they are also opportunities to talk about feelings and observations and hear a child’s questions. When the experiences are less overwhelming than a close family member’s death, the parents are likely to be most emotionally available to hear a child’s full experience and a child to feel safe enough to really talk about the loss and the ceremonies associated with it or the treatment that was involved.”

Additionally, Dr. Rauch encouraged families to consider the PACT’s “lessons learned” to help guide them through challenging conversations with children on illness and death. While originally designed for use by cancer patient’s and families, these tips are applicable to most other situations that put stress on a family and on children such as divorce, natural disasters, terrorism and war.
Euphemisms lead to confusion.
Name the illness, e.g. “Breast Cancer,” not “lump” or “boo-boo”. Facilitate honest communication.

The worst way to hear news is to overhear it.
Describe what is happening and what to expect.

Welcome all questions.
Learn the settings that work best for each child, e.g. in the car, at the kitchen table while a parent is cooking, at bedtime etc.

Figure out what the real question is.
“What got you wondering about …?” The real question is often easier to answer than the imagined one.

Questions do not always require immediate answers.
“That is such a good question. I’ll need to think about it, or discuss with my (doctor, nurse, social worker) and get back to you.”

Children shouldn’t worry alone.
“Bring what you hear back home to us for accuracy”. Sometimes people say unhelpful things with the kindest intentions.

Review your child’s support system.
Assign tasks, or appoint a person for each child.
Keep the channels of communication open with key caregivers.

Maintain the child’s usual schedule.
Try to preserve some time for kids to be kids.

Keep a pulse on each child’s experience.
Find reflective times to check in about hearing too much/too little. “What is it like having …”

Respect a child’s wish not to talk.
Non-talkers need “News Bulletins”. There is information that the child needs to hear, but may not want to discuss.

Bring support people for hospital visits.
Adjust visit lengths to the comfort of the child.

Learning to handle bitter life moments is essential for savoring and appreciating the sweet. Disney’s use of humor and grace to portray the more fragile and difficult aspects of life provides us with a blueprint for managing difficult aspects of our own lives. So, next time you feel the urge to fast forward through a “tough” scene in a show, sit on the remote, hand out tissue, and allow your family to experience the moment together. As often as art imitates life, life will eventually imitate art – someday that experience will help all of you enormously.