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Notes from Hong Kong: Healthcare Systems and Child development

By Dr. Arthur Lavin

Readers of Real Answers will know that we have family in Hong Kong, our son and daughter-in-law live there, and we visit about once a year.  During these precious days together when we all get to be together, we have the honor and deep pleasure of spending time with their children, our grandchildren.

In past posts, I have written about what sort of things our first grandchild has inspired me to think about when it comes to newborns, or 1 or 2 year olds.  Now she is three years and 9 months old.  And, this trip we are thrilled to be visiting on the occasion of the birth of their new daughter, our second grandchild.  As always, our grandchildren have provided so many hours of amazing time spent so closely together, and have inspired many thoughts.

The cost of health care in Hong Kong

Let me start with some logistical notes about medical care in Hong Kong.  Like every country on the planet that has a modern economy, it is affordable.   Our newest grandchild generated some bills, the care is not entirely free, but when you hear the numbers I bet you will consider it more affordable than here.  Our son and his wife pay taxes, like we all do, at a rate that is less than what we pay here in Ohio and the US.  Their taxes cover the cost of their health care, so they don’t have to buy any health care insurance, not any, not at all.  This means they pay no health care premiums.  When they use medical care, there are no co-pays, deductibles or co-insurance.   Nine months of prenatal care, including all indicated ultrasounds, OB visits, OB tests, and the cost of delivery, including a 3 day stay in the hospital, doctors’ fees, everything, generated a bill to the family of far less than $100.  That’s right, less than one hundred dollars for it all!

This did not include the costs the hospital charged for care of our newest member of the family.  The baby had a question requiring a few days of observation, and so had to be observed in the NICU for 2-3 days.  Fortunately there were no health issues, she is a spectacularly healthy baby girl.  But she did stay in a NICU for 2-3 days, and so the family was burdened with paying for their share of that care, including all the time in the NICU, doctors’ fees, lab tests.  Their total share of that total bill was $6, that’s right six dollars, total!!

Let me just say, we are out of our minds allowing the madness we call a health care industry to continue the way it does here.  The crazy game of wildly expensive health insurance policies with all the hidden fees, and ultimately, very expensive bills, is unique to the United States.  And beyond being a needless and  bad idea, it actually costs lives by making health care in the US some sort of crazy expensive madness, placing needed medical care out of reach for millions of our fellow Americans.

It should be clear that the NICU is not paid $6, they get enough money to run the place, several thousands, but the family is only out $6.   The government finds out how much it costs to run the NICU, tells the tax department, that cost is spread across the nation, and families do not end up paying that much more in taxes than we do, to live in a world with no health insurers, and truly affordable care, which as far as I can see, is excellent.  Infant mortality in Hong Kong is 1.5 and in the US 5.85 per 1,000 births, so babies are even healthier there than here, for all sorts of reasons.  But the point is having cheaper health care does not make health worse.

The concluding observation on health care logistics is that we can have vastly more affordable health care in the United States.  For the madness to end, and for our country to do what every nation in the world that can, requires really one step- for us all to decide that is how we want it to be.

Some Preliminary Thoughts

As in past posts on observing my grandchildren, I am confronted with something I see in all the children we are honored to see in our office- there is a certain depth of humanity we see in every child, really at every age.

A great deal has been published on the development of the human mind.  Clearly there is much to talk about in this field.  A newborn infant simply does not have all the abilities of a 50 year old adult.  Easy examples include the fact that newborns cannot walk, and they cannot talk.   Make a list of everything you can do, a newborn can do almost nothing on that list that requires a cerebral cortex.   Yes, they breathe, they eat, they pee and poop, they sleep, but none of that requires the work of the higher centers of the cerebral cortex.

As children develop, we in the field often talk about developmental steps, which can be a series of skills that are not present at birth, that from time to time appear in the developing child.  These acquired or emerging skills are frequently lumped into categories we deem related.  For example, sitting, walking, running, climbing all involve the legs, really assembly of the whole head, trunk, and limbs, so all these new skills are called gross motor skills.

There are four major categories of skill sets that emerge in development:  gross motor (as noted just now), fine motor (use of the hands), speech and language (talking, listening, reading, writing), and social.  Each of these sets of skills require incomprehensibly complex mechanisms to make happen.  Of these four enormously complex sets of achievements, the one we know the least about is social cognition, the ability of our own mind to reasonably determine what someone else is thinking, at least enough to hold a conversation, guess their attitude on important items, negotiate, and/or play.

All developmental theories include a set of guesses about what and how babies are thinking and how that changes as they get older.  In many instances, the most amazing observations have been made about how the young mind thinks differently about the world than our adult minds.  These observations are compelling, including the variable abilities to make abstract theories based on a series of observations.

But whenever I have time with young infants in the office, and again, while spending time with our newly born granddaughter, I continue to be amazed by how little we know.   To put it more positively, it is amazing how thoughtful we all are, right from the very first moments.  And how to measure the depth of that thinking and learning?   Meeting our new granddaughter made the point dramatically, the human mind is an astounding phenomenon, right from the very beginning of life.

This basic point was very strongly affirmed during our time together this trip.

Meeting a New Person

As with all the various ages and stages of growing up, the newborn phase is unique.  It is the only stage, barring disabilities, disease, or declines later in life, during which there is no speech.  It is an era of life in which the physical demands feel like they dominate.  Newborns eat and sleep, poop and pee, and grow.

Remarkably, the first hour of life is the most dangerous, because the change from being in utero to being in air is the biggest change we ever experience in our lives.  But after the first hour, we have the start of the healthiest part of our life, when despite looking frail and tiny, all our cells, organs, systems are brand new, in the best shape possible.   The newborn period is also the time of the most rapid growth in your whole life.  Typically children ages 4 to puberty grow about 2-2½ inches a year.  A newborn achieves rates of about 12 inches a year during the first weeks of life, a rate not sustained for a year, but for several weeks.  Still the rate of 12 inches a year is phenomenal, and dwarfs the later growth spurt, seen in adolescence, when parents and family gush over their teenager growing 4-6 inches in a year.

Our new daughter-in-law and granddaughter very, very thankfully came through the transition of delivery well.   Again, what a transformation delivery is.  It is routine in the sense that all of us were born, but is remains a truly extraordinary metamorphosis, inspires wonder, and should inspire all of us to be grateful to the mothers who give birth to us and everyone we know.

Another mystery is the time of birth.  Unless the time is set by a scheduled C-section, and only if delivery does not happen before that point, no one knows when their baby will be born.  And so it was especially exciting for us to be able to be present the day of birth.  We got to meet this new person, Rebecca Jane!  Now for the rest of our lives together, we can say we met Rebecca in the first days of her life.

Holding Rebecca during the first two weeks of her life was a wonder and treat.  As noted above, she ate and slept, pooped and peed.   But she also spent long stretches of time looking around, and watching her watch was incredible.   We returned to Cleveland when she was a bit over two weeks old, but even in those few days we saw transformation already taking place.   Her gaze was more intense, more steady, more purposeful.

And with that gaze came that sense I spoke of earlier of even the newest newborn being thoughtful.  What exactly does that mean?  No one knows, because no newborn will ever be able to tell us and no adult will ever be able to consciously remember that time.   Anyone who spends time with a newborn will see them stare forward, but look in any direction they look, and you will find it very heard to guess what they are thinking.  If they are looking at a wall, do they know what a wall is, and if not, what do they think when they stare at one?  And, if they have no idea what they are looking at, what are they thinking when they spend long periods of time looking so intently at something they do not comprehend?

We are not very close to having answers to any of these questions, but when I hold Rebecca and spend time watching her connect with the world, I can feel that connection which is deep and very real.   Every day or so of our time together, we would see that connection palpably grow and intensify.

Rebecca may not be able to walk or talk, but her gaze reminds us that she does do something we all do too, think.  Again, no one knows what Rebecca is thinking, or even for sure if she is thinking.  But I get the feeling that she really is.  And over the first few days together, that sense only deepened.  She became increasingly interactive, with facial expressions to go along with her gazes, often seeming to suggest that she was feeling something connected to a thought.

The more we spent time together, the more it seemed the case that she was thinking, and that her thinking was very similar to ours.  In the sense that just as we scan the world to recognize patterns, to know if we have seen this scene before, to contemplate what we have to do should we come across something new, so does Rebecca, so do newborns.

If this is so, then the chasm between the newborn and the adult mind is at least partly made up of numbers of encounters, and not so much about whether the mind can think.  As we learn more, our minds can do more, but underneath it all is the notion that the mind is built to understand events.

Taking even a closer look at Rebecca, we saw depth of thinking.  It is not just a glance or quick look that her eyes, ears, and body do, it is concentrated engagement, the real sense of the word learning.

How exciting to see this happen right as life begins after being born.

We will see Rebecca again this summer when the family gets together again, how remarkable her progress will be in just those 3 or so months!

Of course, mention needs to be made about the intensity of physical demands this phase of life presents.  No need for me to mention this to anyone caring for their newborn, so I mention it in the spirit of appreciation.  Not only is this one of the most dependent phases of life, but it is constant.  The fact that growing is at its maximum in the first weeks of life means that eating is too.  You can’t grow at the rate of 8-12 inches a year or more for the first weeks of life without eating a ton of food a day.  That can come up to the level of us eating as much as 50,000 calories a day, that’s right 50,000!!  You can’t eat that much without eating all the time, and this is what newborns do.  And, given the widespread practice of breastfeeding, this means the mother is facing extremely high demand for care, feeding every few hours, many, many times a day.  Then add on diaper changes, rocking, it is a time of physical intensity like no other during the healthy times of life.

Putting this all together, we leave Hong Kong totally in love with Rebecca, thrilled to see her emerge, in wonder at how her mind is learning and growing, and with hopes her parents get some sleep.  And I leave with a once again renewed respect and wonder for what all parents do to bring children into the world and care for them as they begin life.

From Three to Four

We also had the amazing pleasure of spending time with our oldest grandchild, Evie, who turns 4 in July.

We have watched Evie grow up from the first days too, so on this visit we had the opportunity to see what it was like to be a 3 year old.  As with all the ages, it is not really possible to go back in time and truly experience what it is like to be a young child again.  Not any more possible than it is to really know what it is like to be anyone else.  But our wonderful time together did allow me to ponder some aspects of being 3.

The first thought has to do with the explosion in the function in our minds that takes place around 15-19 months old, what I have referred to in earlier posts as the explosion of consciousness.  At birth, we are aware, on some level, that we are hungry, or cold, or want to poop or pee, or be held.  But we are not aware of the fact that whatever is happening now can change, does not have to be this way, can be chosen to be altered.  And so, at Rebecca’s age, at birth, we are conscious of various states, but we do not have consciousness that allows us to consciously alter our situation.  No 6 month old is fed bananas and cries demanding sweet potatoes instead.

Around 15 months of age all healthy children have largely mastered the ability to understand conversational words spoken to them in their native language.  This is a monumental achievement, and I believe, is necessary for the explosion in consciousness that always follows this moment within a few months.   Armed with language, the mind can now imagine in more clear detail how it likes or dislikes each moment, what it doesn’t like, what it desires, whether a change needs to be made.

A sure sign of emerging consciousness, and signs can appear even before a year of age, is the appearance of the word “No.”   That word cannot occur to a newborn, but it does to essentially every healthy human being by age 18 months.  With the appearance of the word no comes a lifetime of consciousness, of conscious awareness of our every moment and a range of decisions on how to respond.

Once this new power explodes on the scene, there is much turmoil.  The mind is often overwhelmed with the awareness of so many choices:  what food do I like, how much do I want to be held, what activities do I most want to do?  The result for nearly every child is some time with the mind frozen in the frenzy of choice, stuck, otherwise known as a tantrum.

This was the situation when we last visited Evie, when she was 2.   That struggle with awareness actually never goes away.  All of us, all adults, struggle with our awareness of choices to be made, as long as we live and our minds are capable of normal thinking.  But the experience of consciousness does change.

The 1½ , 2, or 2½ tends to react to consciousness with a very broad brush.  They know when they don’t like a situation, but haven’t yet honed a clear sense of what they want instead.  They can complain more than solve.   It is the 18 month old who howls when given Cheerios, while the parents stand helpless to know what it is they do want.   By age 3, the emotions around wants and dislikes remain very strong, but the child has a much better idea what they want.  Opposition to dislikes remains intense, but more and more, the child is starting to come to a negotiation with a pretty clear idea of what they want.   And so it was with Evie.   She knew so much more about what she wanted.  Conversations were clearly developing, conversations very familiar to her parents and herself, about all sorts of preferences such as food, clothing, and music.

A preview:  over time, the honing of what one wants and does not want allows for the emotions to calm.  By age 4-6, many children will have worked out their preferences with their parents’ preferences, and at the same time, the heat of their emotions will have cooled dramatically.  But that is for later.

One more observation Evie inspired during this trip goes back to what was written about Rebecca’s mind so intently engaged in learning.  So it is with Evie.  As noted above, I think if a mind is healthy, it is learning, it doesn’t matter the age.  Sure, what is learned varies widely over ages, but learning itself seems constant.  For Evie, now that she is fully conversant, we are getting more and more an idea of what her conscious mind is thinking about, she tells us, and what she tells us makes it clear she is learning all the time.  All parents of young children will likely agree that they feel a tremendous relief  when their young child goes to sleep.  Part of that tremendous relief has to do with the fact that the extraordinary intensity of their child’s young mind learning, takes a break.  Make no mistake, their minds are still working very hard, but it is all internal processing during sleep, the interaction of their mind to the world has taken a break, and so we too take that break.  You can almost feel that around young kids, the intensity of their minds at work, always engaged, always learning.

It is with this perspective that we look at a problem with many theories of development.

Most theories of development spend quite a bit of time trying to quantify just how clever our minds are at various ages.  One approach to thinking about how children’s minds develop concentrates on how abstract our thinking can be.  An example of not being abstract would be rolling a ball a child is staring at behind our back, if the child acts like the ball has entirely disappeared from all existence, that suggests they have attained very little abstract thinking at all.  If they go looking for the ball behind your back, that is called object permanence, it makes us think the child knows the ball is still around, even if you hide it.  There are all sorts of types of abstract thinking.  All examples involve our mind thinking about something that is not immediately and physically obvious.   The progress towards higher and higher levels of abstract thinking likely never ends.  As we get older, the concept of wisdom, of putting together pieces of experience and knowledge into deeper understanding, is clearly another example of abstract reasoning, and a sort of abstract thinking that improves as long as we live.

But almost all theories of child development start with the assumption that at the start of thinking, infants have no ability to think abstractly.  All their thoughts are about situations immediately visible, audible, smellable, touchable, sensed.   Many developmental theories call this sort of thinking concrete.

Piaget, the great French pioneer in the field of child development (d. 1980), established a theory of how our minds develop that still serves as the foundation of our understanding of this process.  In his four stages of development of thinking, he claims that a child’s mind does not achieve the ability to use logic to solve problems, view the world around them as if it is outside themselves, or plan for the future until 11 years old and up.   These are examples of abstract thinking which makes sense- logic, seeing the world from another’s viewpoint, and planning all have nothing to do with immediate experiences of seeing, touching, hearing.  They are, indeed, abstract.

So the question to ponder is this:  why do so many young children, even as young as 2 or 3, make statements that seem to surprise adults about the depth of their thinking, of their ability to develop abstract thought?   Evie gave us a number of examples during our last visit when we were 2, but now at age 3, they abound.  Sometimes it is a bit of wit, or some amazing amount of irony, or simply being able to connect a few thoughts, but whatever the moment, we all stop in wonder and are amazed that 3 year olds can think at this level.   We also experienced this with our own children, and I have seen it with many 3 year olds in the office.

Moments when 2 and 3 years old exhibit clearly abstract thought processing are always highly entertaining for parents and adults who are with the children.  There is always a bit of wonderful shock, one has to turn one’s head and look at the young child, and wonder- just how is their mind working?  How much more like us, fully grown adults, is this mind, really?   Of course, the answer is that in so may ways, no one can skip steps.  A 3 year old is not able to function fully at the level of thinking of a 21 year old.  But the differences, I believe, are not absolute.  Spending time with children over the years, and last month for an intense 3 weeks together with Evie, demonstrates that there are levels of complexity, true abstract thinking, that truly are present, no doubt, way, way before age 11, even at age 2, perhaps even younger.

Given these observations, how to make sense of just how does the mind develop after birth?  It clearly does develop, it is working differently at age 21 than age 1.  But does it go from no ability to all abilities, or is it more complex than this sort of progression?

Over the years, I become more and more convinced we don’t really know how our minds, the human mind, develops.  I don’t think it starts from primitive and goes to complex.  I think it starts off with full complexity, it’s the levels of achievement that change, not the complexity.   This may be why we see glimpses of full minds at work, even at the start of life, and see extraordinary, truly abstract feats of wit and thinking in young toddlers, nearly a decade before the theorists say they can.

BOTTOM LINES

  1. We had an extraordinary visit with family, and so thrilled to welcome another grandchild to the world, and so grateful everyone is fine.
  2. We had a great time spending time with, playing with, talking with, our two granddaughters.  Some observations they inspired are above.
  3. Once again, I am inspired to see how vibrant, exciting, inventive, funny, and human our minds are, right from the start of life, and how rich humanity is at its deepest roots.
  4. And, we continue to be so honored that you trust us with the care of your children and allow us to share in the wonder of their emerging development.

To your health,
Dr. Arthur Lavin

 

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