Updated: How to have safer schools

Note: I have updated this previous post to reflect

today's tragic events on the Virginia Tech campus.

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We are all - yet again - heartsick and bewildered. We collectively grieve this senseless and cruel lose of life at Virignia Tech, and seek somehow to find meaning and consolation in its aftermath. Inevitably, we wonder what this means about the safety of our children in our schools - now college campuses must sadly be included in the conversation - and what we should now do to make our schools safe from such acts. In response to similar past horrors, the pundits have suggested:

• More metal detectors.
• More security guards in the school.
• Faster police responses.
• More security cameras.
• Better surveillance and monitoring of visitors.
• Teaching kids how to behave when under siege and confronted by someone with a gun.
• Teaching less hatred of women in our society (of all the explanations of this kind of tragedy, I thought this the most boneheaded: that some homicidal manaics are reflecting misogynist America's hatred of women, and not what it clearly invariably is: the deranged act of a mentally ill, pathetic nut job from Hell).

All of these have a certain logic and appeal, I suppose. Events like this make us desperate for solutions. But, as I'm sure you can see, all are flawed (not to mention costly), e.g., most of these measures (like metal detectors and cameras and quicker police response). For example, most won't stop maniacs intent on mayhem; they'll just have less time and more inconvenience to commit their heinous acts.

The question is: How much do you want to invest in these measures? And how much fear of the school environment do you want to instill in your kids?

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Are schools safe?
Horrific events like this aside (and now the name "Viginia Tech" is affixed to this infamous and dispiriting list), the inside of a school remains statistically the safest place outside of home for your child to be. Less than 1% of all child fatalities, for example, occur en route to school, in school, or at a school event. The drive home or just hanging out on the street with friends are a lot more dangerous.

The headlines and 24/7 media coverage to come will serve to convince us that schools are far more dangerous than they really are. That's why very rare but dramatic events often lead to ill-conceived policies and misspent resources. True, even less than 1% is too much, but how much should we spend on measures like these which are of dubious efficacy, especially when dangers to children's well-being are much greater in other (but less publicized) areas?

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Dr. P's opinion:
It's easy enough to be critical of others' imperfect suggestions on how to try to manage a really difficult dilemma, so I feel the need to step up to the plate. What is my proposal on how to make safer schools? It's this:

The common denominator of all these events is the perpetrators' mental illness.

The shortage of child mental health services and treatment and research in this country represents, in my opinion, a critical public health danger. Additionally, parents (and pediatricians) are often unaware of or insensitive to young children's mental health challenges, tend to downplay their existence and their significance, and feel a social stigma in seeking a mental health professional.

And the complicated logistics of being working parents often subvert the best intentions. Even if willing, it can be hard to schlep a child to a mental health provider during or after school, once or twice a week, for many years - which is what most significantly disturbed kids need.

So, I'd invest in putting mental health providers in our schools. That way, troubled children who desperately need mental health evaluations and treatment can easily access them in the very setting in which they already spend a good chunk of their day.

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Now, I'm not so naiive as to suggest that early interventions by child mental health professionals are always successful in nipping in the bud incipient mental health problems. But I know sometimes they can. Is it possible that appropriate early diagnosis and counseling and appropriate medications might - just might - have changed the horrible life trajectories of some of these crazy headline-makers (and many more less dramatic folks) into less pathological, more socially-productive outcomes?

Let's put the necessary resources into the goal of placing a school psychologist / social worker / psychiatrist in every elementary and high school. Sure, it would be costly and, sure, it's not the solution. There is no the solution. But don't make the perfect the enemy of the good. I think my proposal could provide a much-needed boost in tackling the mental health issues that plague so many children and lead to so much human suffering.

Message Board Discussion: Safety Shattered: Shootings at VA Tech
Related Topics:

• Millions May Have Rage Disorder
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Technorati Tags: virginia tech, campus shooting, shooting

Obesity Report Cards: Worthy Intervention or Needless Interference?

So you open up your 10 year old daughter's report card. It shows good grades in her academic subjects, her behavior is fine, and she gets along well with other kids. And, oh, by the way, "her body mass index (BMI)

is greater than 90% of children her age."
Translation: she's overweight and "eventually could be at risk for serious medical problems which you need to discuss ASAP with her pediatric provider."

This "obesity report card" is becoming more popular as the schools look to intervene on the epidemic of childhood obesity. How would you feel if this happened to you? Would you be angry or grateful for the heads-up?

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For many years, I co-taught a class in the Boston University School of Public Health in which we discussed "the child, the family, and the state." We pondered when the state should trump parental rights and forcibly intervene to assure a child's health and well–being.

I think most of us would agree (although you never know around here) on certain circumstances when this is the case: to protect maltreated kids, to enforce certain mandatory safety measures (like car seats and seat belts), to order the environmental clean-up of unsafe water and toxins (like lead) and other hazards to their safety, to enforce child labor laws...

Fair enough. But what about the child who is significantly overweight? Is that a risk warranting intervention by the state (i.e., the school system) or is there already too much on their plate just teaching the 3 R's?

And if you vote yes, is an "obesity report card" a wise way to go?

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So far, everyone seems to agree that childhood obesity is an important and legitimate issue for pediatric providers to try to tackle. I've addressed this many times (e.g., see my other posts) and no one has objected that it's none of my business.

But what should be the role, if any, of our schools? I first learned about the "obesity report card" in a New York Times article, entitled, "As obesity fight hits schools, many fear a note from the school."* The article went on to note the irony of many of the participating schools having cut out gym and offering students cafeteria meals that look like this:

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Parents' response to this unasked-for information was mixed. Some were shocked and outraged, and felt that their child's weight was not the school's business. Others appreciated the reminder and, given the seriousness of the problem, felt it might make them and others more likely to do something about it.

My view? Not a great idea.

Let me be clear: I do believe schools can and should play a role in combating childhood obesity. It's a national pediatric scourge and a legitimate major worry. But schools need to play to their strengths, that is by educating kids on sound nutritional principles and the value of exercise, by infusing the peer culture at school with the values of a healthy diet and exercise, by teaching a culture of tolerance and sensitivity towards those who are overweight, by offering healthy, low animal fat meals, and by banning soda and junk food vending machines from the premises.

But not by badgering and, by extension, condemning parents about what they almost certainly already know about their child's overweight (hey, that's my job!), which is a complex, hard-to-solve problem for any family (and pediatrician), and rarely one with simple solutions, like informing parents and advising them to simply do the right thing.

The state usually isn't great (in fact, more often than not, it stinks) at changing family behaviors and values - especially with a challenge so culturally ingrained and emotionally charged as feeding relationships and values within a family. The obesity report card is a case where I think their efforts are likely to prove useless, and could even do some harm with its laudable, but heavy-handed attempt to solve a tough problem.

Your thoughts?

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*Article cited
As Obesity Fight Hits Cafeteria, Many Fear a Note From School

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Technorati Tags: childhood obesity, New York Times, nutrition, diet

Pain-free pediatrics

When I was a lad, my Uncle Max was my dentist. (Uncle Max was a no-nonsense guy. His family-famous perspective on life was, "You fill a few, you pull a few, and the years go by.")

Uncle Max was a great dentist, but he was heavy of thumb and relentless of drill. He had no thought, nor offer, of anesthesia -- local or otherwise. Throughout my childhood I grimly endured his filling every dental cavity known to man. I remember walking up the stairs to his 2nd floor office, seeing a large stain on the wall, and thinking, "The next time I see this stain, it'll all be over." But, between now and then - Hell.

Having known no other manner of dental care, when I got older and moved away I was stunned to see the care and sophistication some dentists took to minimize pain. Now, of course, my first question about a possible new dentist is: how good is s/he at pain-free dental care?

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Turns out that many pediatricians were (and are) just like Uncle Max, with nary a thought of mitigating the pain of common procedures (like immunizations, stitches, circumcisions, post operative pain, etc.).

A relatively new movement -- called "pain free pediatrics" at my home hospital * -- is acquiring sophistication and momentum. Using some well-established (and some not-so-well-established) techniques to diminish the experience of pain, the screaming of kids in our emergency room and offices has markedly decreased.

(FYI: One intriguing study suggested that babies who were denied anesthesia for their circumcision in the newborn period showed more distress with later painful procedures, such as immunizations at 2 and 4 months, than did those who had analgesia. The theory is that the early intense stress response to the unrelieved pain during circumcision somehow got physiologically ingrained and then resurfaced in all its intensity when the experience of pain recurred.)

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Here are some of the things a pediatrician can do to make the experience less painful:

In the newborn period pain is lessened by:

• A taste of glucose water or being fed.
• Experiencing skin-to-skin contact with the mother during the painful procedure.
• Local anesthesia (dorsal penile block or anesthetic cream) for circumcisions.
  

The pain of immunizations can be lessened by:

• Sugar water or milk during the procedure.
• Using an anesthetic ointment or cream (like "EMLA") or a "vapo-coolant" (a blast of cool spray which temporarily numbs the area) prior to the shot.
• Distracting the infant/child with an exciting display or by having him blow bubbles or a pinwheel.
• Having a reassuring parental presence (most important, in my view) to distract, to soothe, and to comfort.

Your emergency room should be well versed in conscious sedation (medications which keep one awake but only dimly aware of the pain) which, in experienced hands, goes a long way to minimizing the psychic trauma of various procedures.

Inpatient facilities can provide anything from aromatherapy to pet therapy to, in one hospital, allowing the child to ride his tricycle to the operating room, to the use of patient-controlled analgesia (PCA) with a computerized pump for post-operative pain.

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How do your pediatric practice, your ER, and your inpatient facility stack up? Ask! Are we talking Uncle Max redux here, or have they joined the "pain-free pediatrics" movement?

Final note to parents: I beg of you: please, please, please, do not say to your misbehaving child: "Be good or Dr. __ is going to give you a shot!" Every pediatric provider cringes when s/he hears that invocation of pediatric care as torture chamber. Better to enjoin your pediatric provider to get with the pain-free program and to say to your kids: "Finish that book and I'll take you to Dr. __, who will give you a new one to read."

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*For more on Pain Free Pediatrics:
Boston Medical Pain-Free Pediatrics

For some good resources for you and your pediatric provider:
Pediatric Pain Management Toolbox (HRSA)

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• Include Dads in Kids' Doctor Visits
• WebMD Video: Kids and Needle Anxiety

Technorati Tags: pain-free pediatrics, pediatrics, children, health and wellness, parenting