Sign Language, Time Outs, Voiding Dysfunction – PediaCast 091

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  • Voiding Dysfunction
  • Sign Language
  • Time Outs
  • View Masters and Drug Reps



Announcer 1: This is PediaCast.

Announcer 2: Bandwidth for PediaCast is provided by Nationwide Children's Hospital. For every
child. For every reason.


Announcer 1: Welcome to PediaCast, a pediatric podcast for parents — the Listener Edition.
And now, direct from Birdhouse Studios, here is your host, Dr. Mike!

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast. It's episode 91, it's another
Listener Edition and this time we're going to do things a little bit differently. I've arranged an
entire show of comments.

So this is not your questions and answers. This is, I'm going to call this episode, "The Listeners
Speak Back" because, you guys had some interesting things to say and I collected a series of
them and then of course since it's my show [laughter], I get the last word.


But there's some good comments, there's some comments with some criticism. You know, we
always like to keep it interesting and we don't shy away from controversy. So I'm going to include
those as well.

Now, in terms of the topics that we'll be covering, one is voiding dysfunction. This has to do with
the child we talked about a few weeks ago who is complaining of vaginal pain. Then we have
some follow up from the mom with what the actual problem was and we'll compare that to the
options that I gave in terms of possibilities.

We had a couple listeners write in about sign language particularly in rural areas or small towns
at any rate and what options are available for learning sign language for your babies. I had an
interesting email regarding time-outs and you'll notice that the way I described the time-out a few
episodes ago and the way that Dr. Hall did a couple episodes ago, were a little bit different.


And I had a listener write in about her ideas on time-out, so I'll discuss all that. And the last one,
View-Masters. You remember View-Masters? You know, the little plastic thing you look in and
you push the lever down.

View-Masters and drug reps, that's all I'm going to say about that one. Before we move on, I do
want to say one thing that's kind of important. It's December 7th and of course this is Pearl
Harbor Day, December 7, 1941, as FDR said a date which we live in infamy and I really think for
me personally Pearl Harbor Day takes on a lot more significance having lived through 9/11.

I mean, you know, it was a surprised attack on home soil, lots of death and destruction and I think
for me and may be for you too, living through 9/11 really helped me understand what Pearl
Harbor must have been like at that time.


You know, before it was just, you know, an event that brought us in the World War II. You read
about it in the history book, but really if you haven't thought about Pearl Harbor in a while or you
don't really remember the details, look it up online. I mean, it just so easy and Wikipedia actually
has a good entry about Pearl Harbor. Wikipedia has its supporters and its detractors but it did
have a pretty interesting outline of the events and pictures and some stories relating to the day.
And I did put a link to that entry in Wikipedia on Pearl Harbor in the show notes. And once you
refresh yourself, share the story of the attack on Pearl Harbor with your kids. See I can bring this
back around and relate it to pediatrics.

So it's not just fluff. Seriously though, it's important that our kids know our country's history if you're
living in America. And one of our jobs as a parent is to teach. Don't let the school system be their
only source of information.


I mean, bring it to life for them and with the internet that's just so much easier to do today than it
was when I was a kid. And also I just want to say a personal thanks to all of the men and women
who are serving at our military for the sacrifice of serving far away from your family and in harm's
way for the sake of our collective freedom.

OK. Don't forget if there's a topic that you would like us to discuss here on PediaCast, all you
have to do is go to and click on the contact link. You can also email or call the voice line at 347-404-KIDS. Let me also remind you that the
information presented in PediaCast is for general educational purposes only.

We do not diagnose medical conditions or formulate treatment plans for specific individuals. So
if you do have a concern about your child's health, call your doctor and arrange a face to face
interview and hands on physical examination.

Also your use of this audio program is subject to the PediaCast Terms of Use Agreement which
you can find at And with all that in mind, we'll be back with your comments right
after a short break.



Dr. Mike Patrick: I would like to remind you that each of our shows, we do stream live now. And
to get the live feed, you just go to in your web browser you're going to need
iTunes or Winamp if you're on a Windows computer.
Although I think if you have iTunes on Windows computer, that will work too. And when it tells you
what program to open the file with you just choose iTunes or Winamp and if you go to Live page
on the website at, there's all the directions there on how to do it.


Now in terms of figuring out what time we're here, it's usually between the 7:00 and 8:00 hour
eastern time. Right now it is 8:09 pm, I'm an hour late on Thursday evening. So you have to
forgive me. I'm going to try to come up with a system that will be a little bit better at letting you
know exactly when we are streaming live.

You know I've tried different ways including– U-stream, we did; Stickam, we did, and I just was
not satisfied with the audio quality but the audio quality with streaming through a Shoutcast
server, this is just fantastic.

So there's no video but we reserved the bandwidth for audio and we get much, much better
program. All right, let's go ahead and get to your comments. Up first is Natalie from Georgia. And
Natalie says, "Hi Dr. Mike, I just thought I'd give you a follow up finally. We went to the urologist at
the end of October and my daughter was diagnosed with voiding dysfunction which was
ultimately causing her bladder and urethra to spasm."


"We were told this is a pretty common condition in children this age. Essentially we have to re-
train our daughter to relax and take her time on the potty. Long story short, it's been over a month
and she's now taking medicine that relieves the spasms.

Getting her diagnosed was an ordeal to say the least but now we have some answers and some
directions, we're hoping for the best. I'm hoping this info will help other parents and prevent
someone from having to go through to the same ordeal we went through with my particular
pediatrician not listening to me, insisting it was body awareness.

Prescribing my child anxiety medicine and referring us to a psychologist, it's been a nightmare.
Thanks again for being such a wonderful source of information for all of us. Keep up the great

OK. Natalie from Georgia, we discussed this back in PediaCast episode number 54 and I do
have a link in the show notes so you can find it pretty easily.


Here though is an excerpt from Natalie's original question, and she said, "In January of this year,
my 3 ½-year-old daughter who turned 4 in May started complaining that her vagina was bothering
her, not hurting, burning, or itching and she described this as a tickling feeling on the inside. This
bothersome feeling exploded to melt-down when having to sit down anywhere including the car

She even had night tear at one point, and I thought she was going to really injure herself. And then
she goes on to say, "We went to her pediatrician, three different times for urine tests, cultures,
and they always came back normal. I was basically told by several different physicians, this is
typical body awareness and potentially triggered by anxiety…. "

OK now, the reason I read that to you again is because then I wanted to tell you what my
discussion was and compared that to what the actual problem ended up being. In my discussion,
I talked about the possibility of urinary tract infection but I said that, that's less likely because of
the fact nobody has been testing for it.


But certainly, when you have a kid with those symptoms, that's the first thing you have to think
about and then we talked a little bit about contact dermatitis from laundry soap and shampoos,
and soaps, and bubble bath such sort of thing.

Contact dermatitis and also urethritis which the urethra which goes from the bladder to the
outside becomes inflamed. And we also talked about labial adhesions as being a potential cost.
But I did not even mention voiding dysfunction. And my point with this, it really illustrates the
importance of face to face exam and history taking, and the limitations of this sort of venue.

Our people ask questions and we provide the answers without examining your kid. Now, I don't
feel quite so bad because your pediatrician did see you in person, did do the history and exam,
and still they didn't get the right answer. But you know, we're all human and honestly, I think it's
important for parents to understand that we base our decisions on what we see over and over
and over again.


And it doesn't mean that's what's wrong with your kid but from the doctor's point of view, you
know it looks like a tomato, it's probably a tomato. You know, and of course it could be an apple
depending on, you know, they're both red, they're both round. But it looks more like a tomato
that's probably what it is.

Now my point with this, because I do have one, is that, it's important for parents to keep, you
know let's say, I don't think this is it. We tried what you said and it's something different. And of
course you did do that, you know, you want to see your doctor three different times, and they
kept, you know, telling you, you know giving you the same story basically and you weren't satisfy,
you want to tell someone else which is appropriate and then you got the diagnosis.

So, I'm sorry it took so long and you had to go through that process. But on the other hand, if you
take — and I'm guessing it the numbers here, but if you took a 100 kids with these same signs
and symptoms probably 95 of them are going to be the things that we talked about — labial
adhesions, much more common would be the contact dermatitis and laundry soaps, and that sort
of thing.


But a couple of them are going to be something different. And you don't want to take all 100 and
put them on medicine like Ditropan, right from the get go. You know, because that's not what
most of the kids have.

And course that sort of diagnosis is tough because there's no simple test that you can do to test
for that. It's more of a diagnosis of exclusion as we say. When nothing else is working, you think
about it, you put them on a bladder relaxant, and if the symptoms go away then you know, that's
what it was.

All right. I do have a real quick talk on voiding dysfunction. Very, very quickly. It's basically
bladders spasms and medicines like Ditropan relaxes the bladder muscle, and the spasms can
cause discomfort. More often you see urgency and what we call enuresis or wetting themselves.

Usually it's, they're trying to get to the bathroom cause all of a sudden there are bladder clamps
down. They feel like they have to go, and they don't quite make it. And then often the bladder
doesn't empty completely because it didn't get stretched out and so it can't then return to its
normal size and cannot push the urine out.


So you do get some residual urine and this can lead to recurrent urinary tract infections in these
kids as well. I do have an information sheet on voiding dysfunction in children courtesy of the
Cleveland clinic and we'll put a link to that in the show notes.

OK, listener number two, this comes from Beth in Arizona.

And Beth says, "Dr. Mike, I really thought today's PediaCast was very informative. We taught
both of our children sign language when they were younger. My son was very verbal, very young,
so we ended up stopping sign language very early since he was communicating with us, but with
my daughter we used sign language much longer.

We taught her ourselves and it really wasn't hard. There is also a great DVD set called signing
time where they use American Sign Language. She liked signing so much that at times she
even been made up her own signs to communicate with us.

Both of my kids learned 'please,' 'thank you,' 'more' and 'all done' then they were saying those
things from day 1 of speaking so we didn't have to teach them those pleasantries. I just wanted to
let you know, you don't have to live in a populated area with signing teachers to teach your kids to


"We did it right at home. My son even taught his sister new words for his science project and he
won first place. Signing has been a great part of our early parenting."

Well Beth, thanks for the feedback on that and look in the show notes folks for link to the
"Signing Times" series of DVDs at Amazon.

And by the way, I'm not an Amazon merchant, I get no kickback if you click the link. I don't know
there's just something not quite right about that. It's a doctor recommending, "oh yeah check this
out." Then you know, I'm collecting five bucks on the side for it. We don't do any of that stuff here,

OK. Listener number three, this is from Taren in Weatherford, Texas. And Taren says, "Hi Dr.
Mike, I just recently started listening to your show and I've really enjoyed it. I finished your
interview on sign language in infants and I just wanted to let you know that coming from a small
town myself, it is gaining popularity and you definitely don't have to be in a large city to find
classes. My 13-month-old son knows a couple of signs. I think he is more limited by my lack of
knowledge in sign language than his ability to do it."


"There's a great show on PBS called "Signing Time, (another example of signing time?), and
there website is I enjoyed watching the show to increase my sign vocabulary
more than my son does, but as my sign vocabulary grows, so does his. I would say his spoken
count is three words and his sign count is two signs, not too bad for an amateur. (Yes, especially
a 13-month-old amateur). Thanks."

Thanks, Taren, for your comments. Look on the show notes, folks, for the link to,
and they actually have a special right now on those "Signing Time" DVDs. The way they put it,
you can mix, match and save by buying three DVDs and save 20%.

Again, no kickbacks here. I did not do a head to head comparison with their price compared to
Amazon. So, I'll let you do to that. Plus that may change by the time you listen to this anyway.

OK, well those were the nice emails, but of course, not one to shrug off controversy, here's a
couple from folks who disagree with me.


The first one is from Suzanna, she didn't say where she was from, but she writes in enough that I
believe it's Vancouver. I know these things when you write in often.

Suzanna says, "Hi Dr. Mike. Sorry I have to disagree with you about the advice you gave for
the stealing trial. (This is from the PediaCast 82, is when we talked about this and of course we'll
put a link to that on the show notes.) Time-out for a child who will literally need a time out to calm
down, it's not a punishment, it's about learning to control themselves to take a breather. You
might set aside them quietly, but obviously holding them down is a way to confrontational to have
the desired effect."

"Wrestling is not very calming. A better strategy for any antisocial behavior like stealing is to
enact logical consequences. Whenever we want to change a child's behavior, we need to think
about why. Why shouldn't we steal? Well, because once a person gets a reputation as a thief,
every time something goes missing, he'll be suspected. When the item is missing, no one gets to
use it. Also no one will want to be his friend. Most importantly trust with his parents is broken."


"It's important to illustrate those consequences to motivate a change in behavior. I think a logical
consequence would be to take one of the child's toys to show him what it feels like to lose
something. Another logical consequence could be that the child has to pay for the replacement
by adding some type of chore or actually losing their allowance that they have one."

"More subtle, and probably more effective, is to show a child has lost trust in general. It might
lose a trust related privilege like playing with something that belongs to the parents or being in
the next room by themselves or they might lose access to other group of objects, the stolen item
was taken from, right? Show them what it looks like when they can't be trusted. I discovered
some Lego pieces in my son's pockets a few times stolen from his out of school care, the first
time he claimed it was a mistake. I gave him the opportunity to simply give it back. I told him that
would be the only time he got that opportunity. When I found Legos in his pocket the second time,
we told his caregiver and he was not allowed to play with Legos for the balance of the week."


"The third time and I'd warned him it would escalate this way, we told the Director and there was
another ban on Lego play. Lots of tears all around, but no more thefts occurred. We since talked
about it and how some key Lego pieces and figures go missing sometimes after new sets are
purchased and how that must mean someone has stolen them."

"We talked about how that means everyone suffers because the sets can't be built anymore. We
talked about how I know he's not the one and that I do trust him again. I don't think this learning
opportunity would have occurred if I held them down on the floor instead. (Ouch! Suzanna.) We've
used this system of escalating logical consequences several times with good results."

All right. I do get the last word here since it's my show, and you want the last word you got to get
your own show. That's how it works. You make some excellent, excellent point, Suzanna. Keep in
mind though that the time-out that I described was not a punishment for stealing and again, just
going back to the show notes listen again to PediaCast 82 and that's where I talked about time-
outs and how to approach those.


But again, the time-out that I described was not punishment for stealing. It was a response to
absolute defiance of the child for not telling where an item was stashed, when his parents knew
he had stolen the item and stashed it, and asked him to go get it.

So if you have a kid who is being extremely defiant and saying "I won't get it for you,… that is the
issue and the longer you allow them to be defiant, you know, the more likely that they're going to
do it because they don't want you to know where it is and so you have to get that taken care of

Now, those who listened to my interview with Dr. Hall a couple days ago realize this. Suzanna is
definitely in his camp on the way do a time-out. Could you reason with the young child to convince
him to tell you or something is stashed, or maybe could you offer reward if he admits that the
object is stashed somewhere and he goes and gets it for you? Well maybe, but would that
encourage future infractions because he thinks, you know, if I want something, I just hide
something and then mom will offer me what I want, you know.


So the positive reinforcement things are not going to really work in that situation. So really all you
have is, can you reason with them to convince them to tell you where it is, and if you can in
a relatively short amount of time, fine, that's great but for most of these kids they're going to be
very defiant and you got to do something about that because otherwise you encourage them to
be defiant in the future when they don't want you to know about something.

Now, could you have retrieved the stashed item and then confront them with it, and use
Suzanna's approach? Sure. And in retrospect for this particular situation, that may actually be the
best approach. But there's also something to be said for training a kid to obey a parent's
command immediately without question especially when they were young, because there may be
a time that, that could actually save their life.


I mean, let's say they're running toward a busy street or there's a fire. I mean there are times that
you want obeying immediately without a question to be a reflex. You know, they're running toward
a busy street and you say, "stop," you want them to stop.

And the part of that is training them to do what you say immediately and without question. That's
where sort of the counting to five comes in. When I approach the kid, kids who hide something
and won't tell where it's located, I mean I see him as a kind of kid who isn't going to stop running
toward a busy street when you tell him to stop.

So, I'll disagree with Dr. Hall and Suzanna and say there is a place for the type of time-out that I
described in episode 82. Again, I won't go to the details of that sort of time out here again. Just to
check out PediaCast 82, if you want to hear the procedure and there's a link to that in the show

My children are well adjusted one is 10 the other is 13. They're good kids, they obey
immediately, may be not so much without question but they do obey immediately. It's not always
been that way, you know we trained them to– Now it's just second nature and reflex for them to
do what we tell them to do.


Even if it's not something that they necessarily agree with. And using the time-out method I
described regularly and consistently got us there. There's no question about that. And I've seen
many other parents use it effectively and with great long term effect.

There's more than one way to raise well-adjusted kids. We have a moral foundation and there's a
time for what Suzanna and Dr. Hall are describing and there's a time for the time-out that I'm
talking about. And, Suzanna, if you still disagree with me, well, we just have to agree or disagree
which is fine.

I mean that's the great thing about living in a free world. You know, we talked about our military
protecting that. We can hold on to our beliefs and disagree because you and I both know there's
plenty of places in the world where disagreements and ideas lead to bad things. You know, like
imprisonment and flogging but that's an issue for another day. OK.

We have one more listener comment. This one comes from Ian. An also Ian did not say where he
was from. Unlike Suzanna, I just don't know.


Ian's comments relate to a couple days ago in my intro. I said that I was complaining about
getting a View-Master in the mail from a drug company.

And Ian says, "Dr. Mike, think about the conjunctivitis View-Master from a different perspective.
You self-described getting tons of materials from drug companies much of which I presume is
quickly filed in the circular cabinet. If you were a drug rep, you job is to increase usage of your
product. That is, you job is to influence doctors' prescribing habits. One of the best means a rep
has for influencing behavior is merely to give their product a place of competitive advantage in
the prescribers' minds. That is to secure the product a place of precedence in mental
accessibility. Recall this person has no ability to control product design or product quality that's
the scientist job. Where the product to be clearly more efficacious or inexpensive than the
competitors the rep can influence prescribing behaviors successfully by arguing the merits."


"However, when the market is competitive and the products do not readily differentiate where the
reps product is actually inferior, the best means of influencing sales may indeed not be the
rational argument; rather it may be to influence non-conscious species wide decision biases.
(OK.) From this very perspective the cost of a Chinese knock-off View-Master may actually be
very, very cheap. If it's an effective– (hopefully it didn't have any may lead in it). If it's ineffective
tool of behavioral influence, it will more than pay for itself. How then does the View-Master serve
this purpose? Well, as said previously enhancing mental accessibility is one of the most effective
means for influencing behavior. Thinking about that, let's review your experience. You noticed the
item because it was distinctive. It was not the common industry food gift for example. It was
surprising, considering your reaction on how your expectation was violated, and it was
emotionally salient in the sentimental sense; in other words, it reminded you of your childhood."


Each of these design details is serving to boot strap the product's memorability by activating
any processing mechanisms evolved orient attention towards an expected events into salient
information. (OK.) Di it work? Obviously you recalled the product's function — conjunctivitis
treatment, can you also recall the brand? (Yeah.) [laughter] If so, the rep has successfully
leveraged nonconscious aspects of you prescription-related decision making. You have
encoded the product name and function such as it is readily accessible in memory.
And I suspect this particular rep will be giving a nice bonus this year. Here she is an evil genius,
and a studious reader of cognitive psychology. Ian."


Ian, Ian, Ian. Was it you? Did you send me that box in the mail with the View-Master in it?.


Ahh! See what us poor docs are up against? I'm telling you it never ends. All right. That wraps up
of this edition of Listener Comments and we'll be back to wrap up the rest of the show, right after
this short break.


All right. Thanks to the Nationwide Children's Hospital for providing the Bandwidth and Vlad over for providing the artwork for the website and feed and of course thanks to all of
you for tuning in whether you're listening to our live stream or listening to it as a podcast, we really
appreciate being here and also appreciate all the comments that you send in to help participate
with the program.


Karen's Pediascribe blog. What's Karen been up to? Well, she did a post called "Tales from the
scales, the wrong direction." We've been so busy, you know, something has to go, you've been
there and for Karen and for me, one of the first thing to do is exercise so we kind of fallen off the
bandwagon and we're kind of headed in the wrong direction weight-wise.

And Karen's talk about in her blog, we'll put a link on the show notes for you. Don't forget reviews
on iTunes, we're trying to hit 200 reviews by the end of the year. I'm not sure it's going to happen.
I think we're up to 157, we're getting in a couple a day.

But in order to get another you know, another 45 or 50, you guys are going to step up to the plate
here. It's all I'm asking for. I mean, I put hours and hours into this show every week and it will take
10 minutes for you to go to iTunes and write a quick review for us. We'd really appreciate it. I'd
like to go into 2008 with 200 reviews under my belt. That would just be fabulous.


And I want to thank — I'm not sure which it is, but there was a family practice doctor who wrote a
review, and he said he was a family practice doctor for 35 years and he still has something to
learn here on PediaCast. He said we're a little wordy and he could do without the advertising, I
understand that, but you know I have to at least– There is the cost to putting something like this
together in terms of bandwidth because you guys are paying anything for it. So we're going to
pay the bills, so the advertising cost will be there and the talking and wordiness part it's because,
I don't know, I think it's because I actually have a personality and a life and I would like to share
with you rather than just being a scientist who reports the facts because that's no fun and you
know, you got to have a little fun in life, you know what I'm saying?

But at least the intro and outro are separated by music. So you know you can always fast forward
through them if you want you know and get to the meat.


All right. Well hope you guys all have a great weekend, and until Monday, this is Dr. Mike, saying
stay safe, stay healthy, and of course stay involved with your kids. So long everybody.


Wait. [laughter]

OK. It's Friday folks. It's been really long week. OK. I hit the wrong button, that's all that was. Let's
try this again. Take care have a good weekend, we'll talk to you on Monday.


I'm still an amateur folks. You got to cut me a little slack.

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