23 February 1997
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physician who knows you and cares about you.
Dr. Warren
Also N.s father and i have been separated for 5 years, and the father doesn't show a whole lot of interest in his son, which is very upsetting to N..
N. has seen a counselor on a regular basis which the sticker reward system was tried, the novelty wore of quickly. We've also tried different rewards and praise is always top on our list, but we seem to fail in each department. I just thought you should know a little more about the situation.
-BR
Dear BR: Your letter clearly demonstrates that when a doctor doesn't have all the information he may draw the wrong conclusions and not give the correct advice. The information I gave you about encopresis is correct, and some of it may still apply to N.. For example, stool withholding may develop in a previously trained child. It may develop for psychological reasons, and while those psychological reasons are being worked on it is still necessary to deal with the physical component of stool withholding and keep the stool soft. And N. is clearly in denial about how these accidents happen and whether he is aware of them.
N.'s problem is obviously not classical stool withholding resulting from constipation and unresolved toilet training issues. Nonetheless, the average 8 year old doesn't usually have 3 to 4 BM's per day even in the toilet. Therefore, it doesn't seem likely that so many BM's are just falling out into his pants unless he has chronic diarrhea from some cause or a neurological problem affecting bowel control (which I assume has already been ruled out). If neither of those are the situation, N. is very likely a stool withholder. Periodic rectal examinations by your pediatrician can help establish if this is true. And it may still be a good idea to see a gastroenterologist since they have more experience with these kinds of problems.
If none of the situations above apply, then there must be times when N. has to put considerable effort into having a BM. Even if a person isn't constipated moving one's bowels usually takes some effort. And this brings up the question of why. If N. is not a stool withholder, has no chronic diarrhea, has no neurological deficit, and at eight years of age chooses to have BM's in his pants, then he is dealing with some serious psychological problems, and until those problems are dealt with, you cannot expect any improvement in the soiling.
It is too much of a coincidence that N.'s soiling began around the time his friend was sexually abused. If he witnessed the abuse that could have been sufficient psychological trauma to cause his problem. Certainly there didn't have to be any signs of abuse for N. to have been abused himself. Even if a child isn't physically injured by sexual abuse so that signs can be found by an examination, deep psychological scars can result. The fact that N.'s father is unavailable only adds to the problem.
N. needs intense psychotherapy. Behavior modification therapy aimed at dealing with the problem is not sufficient. It is time to get to the cause of the problem. If he is not able to make any headway with his therapist, you need to discuss these issues with the therapist. If that doesn't help, you may need to consult another therapist.
Sincerely,
Dr. Warren
What is it?
The neurosurgeon admitted candidly that he never heard of it. Neither has the child's pediatrician. My buddy, the patient's dad, has asked me to do a little research.
Can you help with a layman's explanation of what it is? I'd also be happy with references which I could use to educate myself.
Thank you,
-HN
Dear HN: The first thing anyone needs to understnd about childhood brain tumors is that the location of the tumor is often more important than the type of tumor. This is true because tumors in certain locations can be completely removed whereas tumors in vital areas of the brain cannot. Some tumors may be completely inoperable because of their location, and may cause serious symptoms because of their location as well. Thus, a benign tumor in an inoperable location may be more of a problem than a malignant tumor that can be removed. The complications of the surgery and the resulting neurological deficits are largely affected by the location of the tumor. So the first bit of good news since your friend's son was operated on is that apparently the tumor was operable. Based on the neurosurgeons knowledge of the brain anatomy and the surgery he performed he should be able to tell you a great deal about the prognosis without knowing a great deal about the specific tumor.Gliomas are tumors that arise from the connective tissue of the brain rather than form nerve tissue. They are very variable in terms of rate of growth and degree of malignancy. In fact, two tumors of the same type may not even have the same grade of malignancy. As already explained, the location of the tumor is key in its management.
In doing a search for information you will need to ignore the descriptive terms. The tumor is a GANGLIOGLIOMA. If you go to the NORD home page at http://www.rarediseases.org/ and do a search for ganglioglioma you will be given an opportunity to order free information about gangliogliomas.
Another source of information on the net is Chapter 4: Facts about brain tumors at http://www.btfc.org/english/handbooks/pediatric/pchp4.html. I am quoting from their chapter:
"Gangliogliomas are generally slow growing tumors and may occur anywhere in the brain although the temporal lobe is the most common site. The average age at the time of diagnosis is 12 years. Many children are diagnosed after a long history of seizures that have been difficult to treat. Intellectual and behavioral difficulties may be present. Treatment is usually total removal by surgery."
The following articles may be useful:
VandenBerg, S.R., E.E. May, L.J. Rubinstein, M.M. Herman, E. Perentes, S.A. Vinores,
V.P. Collins and T.S. Park (1987) Desmoplastic supratentorial neuroepithelial tumors of
infancy with divergent differentiation potential ("desmoplastic infantilegangliogliomas").
Report on 11 cases of a distinctive embryonal tumor withfavorable prognosis.
J Neurosurg, 66: 58-71.
VandenBerg, S.R. (1993) Desmoplastic infantile ganglioglioma and desmoplastic cerebral
astrocytoma of infancy. Brain Pathol, 3: 275-281.
I hope this information is useful to you as I have no personal experience dealing with these tumors.
Sincerely,
Dr. Warren
-JG
Dear JG: Not all people who have allergies have or develop asthma, but many asthmatics do have an allergic basis for their asthma. If a child is prone to asthma, chronic exposure to something he is allergic to may precipitate symptoms. If there is a family history of asthma, there is a much greater risk that an allergic child will become asthmatic. So, in answer to your question, it is a legitimate concern that your child could develop asthma from being around the dog to which he is allergic. Even if a child doesn't wheeze immediately on exposure to a specific allergen like dog, the inflammation in his airways from chronic exposure to the dog could result in asthma symptoms at a later time, especially with other asthma triggers such as exercise or upper respiratory infections. But you would need a crystal ball to know what is likely to happen in your specific case, so you have a difficult decision to make.
Sincerely,
Dr. Warren
-HG
Dear HG: The first question we should ask is, "Why is your son stuffy at night, and not during the day?" While cold symptoms may be more disturbing during the night, there is no reason why they should be worse at night or absent during the day. So we have to look at environmental factors. Is he allergic to something in his room? Possibilities for allergy include feather pillows or comforters, dust mites, mold and mildew. Mold and mildew are generally only problems in exceedingly moist environments. As for pillows and comforters, your best bet is to have hypoallergenic ones which are made from synthetics like nylon or foam. Dust mites tend to collect on carpeted surfaces, blinds, and stuffed animals. Allergic children should generally have an uncarpeted room, shades instead of blinds, and NO stuffed animals in bed. Vacuuming does not eliminate dust mites unless you have a special vacuum bag with a micropore filter that will trap the dust mites. A pet sleeping in the bedroom is another potent allergen.Other environmental factors besides allergy include temperature and humidity. If the room is too hot and dry it may be irritating to the mucous membranes and cause nasal stuffiness. During the winter, heating our homes tends to dry the air so it would be helpful to have a humidifier going (assuming you don't have a problem with excess moisture and mold). Saline drops in the nose can also be helpful. Decongestant drops like neosynephrine can be used occasionally, but should never be used regularly because the nasal membrane becomes dependent on them and swells when they are not used.
Finally, you should consult your pediatrician to see if your child should have an allergy evaluation or if he should be seen by an ENT doctor for possible enlarged adenoids which cause nasal obstruction. Children with enlarged adenoids tend to be chronic mouth breathers even during the day.
Sincerely,
Dr. Warren
-J
Dear J: Today's High School students have a wider choice of courses than I did. But in spite of the vast array of electives, a person who hopes to go to a good college and eventually medical school needs to concentrate on the core majors. This means you need 4 years of science, 4 years of math, 4 years of English, 4 years of Social Studies, and 4 years of Language. Although I enjoyed studying French, as a physician practicing in the New York Metropolitan area, I wish I were fluent in Spanish. The more major courses taken as advanced courses, the more attractive you become to a top school. If you take a full curriculum of major subjects your choice of electives won't be crucial. And this will prepare you best for the college curriculum you need for pre-med.Some colleges offer a curriculum specifically designed for pre-med, but you can major in anything and still get into medical school if you do well in school and on your MCATs (Medical College Admissions Test). If you do follow a non-science major in college you will need to take a reasonable number of basic science and math courses to prepare you for medical school. You will need basic Chemistry, Organic Chemistry, Introductory Biology, and a variety of Biology courses. If you hope to do research you should arm yourself with courses in statistics and laboratory research. I can't say I ever used calculus in medical school, but I needed it for the rigorous science curriculum I followed in college.
I really have no knowledge of the current demographics of who gets into medical school. Obviously someone at the top of his class in an Ivy League university has the best chance, but not all of us can attend Ivy League schools. I went to Rensselaer Polytechnic Institute for their strong science program. At the time RPI had a 6 year program with Albany Medical College but I never applied for it since I preferred to have a 4 year college experience and needed to work summers to pay for school. If you do well in any school that has a good reputation and follow a rigorous course of study there you will be a viable candidate for medical school.
Sincerely,
Dr. Warren
-CR
Dear CR: The typical story for roseola is that a young child runs a high fever for 3 to 5 days but is acting fairly well and has no other symptoms. When the fever breaks the rash develops. The rash may be quite brief and rarely lasts more than a day. If your son's rash developed while he still had fever it is highly unlikely that roseola is the correct diagnosis. If your son is still sick with fever roseola isn't a possibility.Roseola is caused by a virus. There is no specific treatment; however, when the rash develops, the illness is over. If your child is still sick or the rash is problematic, he doesn't have roseola. You should certainly have him reevaluated if he seems ill. But may I offer another piece of advice? Emergency room physicians are the tops for treating trauma, poisonings, and life threatening symptoms, but most other childhood illnesses will receive better care in a pediatrician's office.
Sincerely,
Dr. Warren
-Thank You for your time.
-SG
Dear SG: Unfortunately, no method you can think of that stretches your body will make you grow any more or any faster. In fact there is nothing you can do that will increase your growth rate. But chances are, since you are 15, you are still growing. A lot depends on your body development. If your body is fully mature you may be near the end of your growth. On the other hand, if you are in the early part of puberty, your most rapid growth is still coming. If you need more of an explanation of puberty please write back.And by the way, I'm 5'6" tall. I don't think you're so short.
You may inherit the genes for baldness from either parent. Baldness is a sex influenced trait. Women who carry the genes don't go bald unless they have more than one gene for baldness, but men go bald with just one gene for baldness. Since your father is bald, you have at least a 50% chance of being bald. If your father carries two genes for baldness (no way to know if he does), you won't escape it. Even if your mother's father and her grandfathers weren't bald there is still a chance that the women in the family were carrying the gene and it was passed on to your mother. If your mother has any bald brothers that would certainly indicate an increased risk.
Sincerely,
Dr. Warren
After her rage, she remembers what she has done is is very loving, and sorry for her behavior.
We have tried ignoring her, strict discipline, every tacic we can think of. We have tried altering her diet--this has no effect. We have received little direction from our pediatrician on this matter. We also have a 2 year old daughter and another child due in May. She also displays this violent and aggresive behavior toward our youngest child.
I am a stay at home mom, and it is all I can do to get through the day with her.
I will be happy to supply additional information. Any direction you could supply would be greatly appreciated.
Thank you for your time.
Sincerely,
A frazzled Mom
I can see some potential benefits to your child in having a consistent behavioral approach. Trying many different approaches may be confusing and add to your child's frustration because she isn't sure what response to expect from you. Consistency of response from you is extremely important in helping your child come to terms with her own anger. You should not expect to see rapid dramatic improvement from this approach. Her anger may diminish gradually as she learns what to expect from you. You, on the other hand, will feel in more control when you have decided in advance what your response to her will be and become practiced at applying it consistently. You want to remain calm, but firm, and act with a resolve that tells your child that you are in charge. She will feel safer when she knows that you will control her rages. Since her major problem is rage, punishment is not the answer. Time out will allow her to be removed from an emotionally charged situation and regain her composure. You should remove her to her room immediately when she flies into a rage. This is especially true if she strikes out at a younger sibling. Tell her that just like you wouldn't let anybody hurt her because you love her, you won't let anybody, including her, hurt her siblings. Do not yell or discuss. Act but don't react. Discuss later. It might be helpful to consult a psychologist to set up a behavioral program for her.
I am concerned about your description of these violent rages that even come out in sleep. Your little girl may have crossed the line beyond normal difficult childhood behavior. She is upset herself by behavior she can neither control nor understand. When I think of the stories I've heard from teens and young adults who have been treated with medication for chemical imbalances, the most haunting thing that stands out in their stories now that their lives are under control is that they (and their parents) wish that they could go back and reclaim the lost years before they had medication. Their relationships with all the significant people in their lives will remain forever affected by who they were and how they coped with each other before the medication. You should consult a Psychiatrist with your daughter. If he feels that she has a psychiatric disorder he will prescribe appropriate medication.
Sincerely,
Dr. Warren
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