Take N.O.T.E. - A Tool for Parents

Two of our favorite organizations - The American Academy of Pediatrics (AAP) and Understood - have teamed up to create a tool for parents to help them recognize when and how their children may be having learning difficulties and the steps to take to help them.

 

Take N.O.T.E. breaks learning issues down into four steps:

NOTICE is the first step, with subject by subject guidance on how a parent can be certain there’s something going on with their child that’s out of the ordinary. Areas of concern need not be academic and include:

• Reading and writing
• Math
• Focus and organization
• Self-control and hyperactivity
• Frustration, stress, and anxiety
• Developmental milestones

OBSERVING comes next. Once parents notice a problem, the program guides parents in how they can learn how to find and keep track of patterns in their child’s behavior with downloadable observation tools.

The third step of the process is TALKING. The program includes tips and conversation starters for parents to use when talking with those who know their child best, like teachers, aides, and other caregivers, as well as talking to their child about what they are observing.

The final step is to ENGAGE, helping parents figure out  how and when to connect with experts like pediatricians and school specialists, who can help you figure out if your child might have a learning and thinking difference.

The Understood site includes links to helpful articles and videos designed to illustrate the issues in  each of the steps involved. So far, so good, since Understood is known for its helpful information for parents. But Take N.O.T.E. goes further, and that's where its partnership with the AAP comes in. The AAP urges pediatricians to be familiar with the steps in the Take N.O.T.E. program and shares links to information from Understood. Furthermore, it offers guidance to its members on how to discuss learning and developmental issues with families, including suggestions to start with open-ended questions, asking for details, and getting more information. 

Dr. Yellin serves as one of Understood's "Experts" and is a resource for numerous pediatricians who seek to refer their patients for a better understanding of their learning, behavioral, and related difficulties. Parents and professionals are welcome to contact our office for more information.

First Stop: Your Pediatrician

Our colleagues at the American Academy of Pediatrics (AAP) just released an extensive report aimed at informing their members of their important role in recognizing and helping to treat many problems that relate to learning and development,. Starting in infancy, long before a child is first enrolled in school, it is the pediatrician who often can spot a problem that can be addressed early to improve a child's chances of success in school. Screening for vision and hearing deficits, lags in motor and language development, and psycho-social family issues can all lead to interventions that can improve a child's chances of succeeding in school and in life.

As children reach school age, even before parents turn to their school system for help with learning or behavior issues, a child's pediatrician can pick up on a wide array of conditions -- genetic, neurological, medical, emotional -- that can have a wide ranging affect on how a child functions in and outside of school. While the AAP article is aimed at pediatricians, to guide them in their role in diagnosing issues that can get in the way of school success, it is also important that parents understand how their child's pediatrician can be an important first stop when things are not going well developmentally or academically.

There is a concept in medicine called "differential diagnosis" that plays an important role in helping to understand what is going on when children struggle. Pediatricians are trained to apply this concept when dealing with their patients and it is at the core of what we do here at The Yellin Center. As Dr. Yellin (a pediatrician and a member of the AAP) explains, you can use the analogy of a child with a cough. Before treating the cough, it is crucial to understand why the child is coughing. Does he have an upper respiratory infection, a bone stuck in his throat, asthma, or pneumonia? Only by looking for the cause of a problem can an effective solution be applied. Many learning or school problems require this same approach; only by looking deeply and ruling out many of the problems pediatricians are trained to consider can families begin to help their child get the help he or she needs.

Pediatricians are also excellent sources of referrals. They will be able to suggest educational evaluators (and many of our families are sent to us by their pediatrician for an evaluation for suspected learning or attention difficulties), or send a child to have their vision or hearing explored in depth, or recommend a therapist or other professional if there are signs of serious emotional or family difficulties. Parents should use their child's pediatrician, and the expertise and experience he or she offers, as an important resource when children are struggling in school.

Photo: Alex Proimos/Flickr Creative Commons

Toys for Young Children

Any parent who has watched their toddler play with a box, or a wooden spoon and saucepan, can attest to the joy to be found in simple items. This feeling contrasts with the concern many parents feel as they watch their school-aged child stare into a screen as they spend far too long playing a game or passively watching a video . It's no surprise, then, that the American Academy of Pediatrics has recently released a reminder of the importance -- and joys -- of simple play in the development of children.

This Clinical Report, Selecting Appropriate Toys for Young Children in the Digital Era, was designed to guide pediatricians in speaking with parents, but contains important research findings and recommendations that parents will find helpful as well. The authors of the Report include Dr. Alan L. Mendelsohn, FAAP, who, like Dr. Yellin, is a member of the Department of Pediatrics, Division of Developmental-Behavioral Pediatrics, at New York University School of Medicine.

The report notes the importance of imaginative play, problem solving, and physical activity and especially supports the use of "guided play", where children use toys as part of an interaction with their caregiver. This can build social skills and language in a way that solitary play cannot.

Among other topics covered are the need to limit screen time. The Report notes, "there is presently no evidence to suggest that possible benefits of interactive media match those of active, creative, hands-on, and pretend play with more traditional toys."  The Report also discusses the need for toy safety, what to look for in toys for children with disabilities, and the importance of using books for pretend play. Especially in this season of gift giving, this Report is something parents should read, while incorporating its suggestions into their purchases and play with their children.

The Importance of Early Hearing and Vision Screening

Almost every student we see here at The Yellin Center is given a vision and hearing screening. These are not meant to take the place of in-depth testing by ophthalmologists, optometrists, or audiologists, but are an important part of checking for anything that could interfere with a student's learning and school success. Children who can't see the blackboard clearly, who find text in books to be blurry, or who have difficulty hearing instructions from their teachers or classroom discussion, are at a disadvantage when it comes to learning. Most of the time, the students pass these screenings with flying colors -- but sometimes we note difficulties that warrant further investigation.

Our colleagues at the American Academy of Pediatrics (AAP) note that screening for hearing loss should begin very early in infancy,  not later than the first month of life. Infants who do not pass this initial screening should have a comprehensive audiological examination not later than at three months of age. And interventions should begin by age six months, from appropriate professionals with expertise in hearing loss and deafness in infants and young children. Even infants who pass the initial screening should have the development of their communication skills evaluated at their well-baby visits starting by two months of age.

The importance of early screening for hearing issues was noted in a recent New York Times article by long-time health writer Jane Brody, who looked at the amazing technological advances in recent years that have enabled most children born with hearing loss to hear, speak, and learn together with children without hearing difficulties, albeit with extensive speech and language training and lots of hard work. The article notes that a new documentary, "The Listening Project"demonstrates the impact of technology, specifically cochlear implants, on the hearing impaired. The trailer for this film is quite compelling to watch.

Vision screening also should begin in infancy. The AAP guidelines note:

• All babies should have their eyes checked for infections, defects, cataracts, or glaucoma before leaving the hospital. This is especially true for premature babies, babies who were given oxygen for an extended period, and babies with multiple medical problems. Another group warranting special consideration are babies with family histories of vision difficulties.
• By six months of age - As part of each well-child visit, eye health, vision development, and alignment of the eyes should be checked.
• Starting at about one year - Photo screening devices can be used to start detecting potential eyes problems.
• At 3-4 years - Eyes and vision should be checked for any abnormalities that may cause problems with later development.
• At five years and older - Vision in each eye should be checked separately every year. If a problem is found during routine eye exams, a child should see a pediatric ophthalmologist.

Targeting Environmental Risks to Children

Parents of children with learning and other challenges often wonder if environmental factors could have caused or been a factor in their child's difficulties. As noted in a recent issue of Pediatrics, this question was behind the 2015 founding of Project TENDR (Targeting Environmental Neuro-Developmental Risks) by scientists, physicians, other health professionals, and advocates. Project TENDR's mission is to raise awareness of the risk from toxic chemicals to the development of brain-based disorders in children, including intellectual and learning disabilities, autism, and ADHD.

In July 2016, TENDR issued a Consensus Statement, intended to be a Call to Action ...

"to reduce exposures to toxic chemicals that can contribute to the prevalence of neurodevelopmental disabilities in America’s children. The TENDR authors agree that widespread exposures to toxic chemicals in our air, water, food, soil, and consumer products can increase the risks for cognitive, behavioral, or social impairment, as well as specific neurodevelopmental disorders such as autism and attention deficit hyperactivity disorder (ADHD) (Di Renzo et al. 2015; Gore et al. 2015; Lanphear 2015; Council on Environmental Health 2011). This preventable threat results from a failure of our industrial and consumer markets and regulatory systems to protect the developing brain from toxic chemicals. To lower children’s risks for developing neurodevelopmental disorders, policies and actions are urgently needed to eliminate or significantly reduce exposures to these chemicals. Further, if we are to protect children, we must overhaul how government agencies and business assess risks to human health from chemical exposures, how chemicals in commerce are regulated, and how scientific evidence informs decision making by government and the private sector."

The Consensus Statement coincided with the June 2016 signing of amendments to the Toxic Substances Control Act (TSCA), the Nation’s primary chemicals management law, but the authors of the Consensus Statement note that this legislation, while "an important step," provides "too little action at too slow a pace."

The Consensus Statement sets out frightening information about the vulnerability of developing fetuses and children to environmental toxins. So what can parents do to avoid exposing their children to these poisons?

The American Academy of Pediatrics (AAP) Healthy Children initiative has a comprehensive list of steps parents can take to reduce the exposure of their children to pesticides, including links to information about organic foods. The AAP site has similar helpful information about numerous other risks, such as lead and mosquito spraying. Scroll through the list of topics to find those you want to review and take the recommended actions to reduce the risks to your family.

New AAP Media Guidelines and Family Media Use Tool

Our colleagues at the American Academy of Pediatrics recently updated their policy guidelines regarding screen time for children, looking separately at young children up to five years of age and at older children and teens.

The backbone of their polices for children of all ages, as it has been in the past, is that parents should make sure that screen time does not displace other activities that are critical to healthy development. In other words, families should balance a light diet of media time with physical activity, hands-on exploration, and face-to-face interactions. The AAP policy notes that digital media can provide older children with new ways to acquire information and ideas and with increased opportunities for social contact and information about health and life style. For older children, who generally use digital media without constant parental supervision, risks include negative health effects on weight and sleep; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. 

The AAP continues to recommend no screen time for children under 18 months of age, except for video-chatting (FaceTime or Skype with relatives). Children from eighteen months up to two years old can begin to watch some high-quality programming, as long as a caregiver is present to enhance their understanding of the media and make the experience interactive. The AAP cautions that just because media is advertised as "educational" does not mean that it offers real benefits to children. Between the ages of two and five, children can watch up to one hour but, again, caregivers should be present and engaged. Screen time is used most effectively when caregivers can relate the information on the screen to the world around them, highlighting the interactive nature of the experience. Once a child hits six years old, parents should be consistent in the limits they place on screen time. Most importantly, as noted above, screen time should not replace the more critical activities of childhood, including sleep and active play. 

The AAP also suggests creating media-free zones at home (e.g., no media in the bedroom) as well as media-free times, such as dinner or car trips. As children get older, caregivers should continue to discuss their online presence, including safety and what it means to be a upright online citizen. The policy for older children urges parents to discourage entertainment media during homework time and to make sure that teens don't sleep with their phones, tablets, or computers in their bedroom. Finally, for children of all ages, parents should model responsible use of media, limiting their own use and remaining "present" during family time.

What’s new this year is the Family Media Use Tool. This online tool allows family members to work together to decide how media is going to play a role in their home. It provides customizable options for media-free zones and times, as well as how screen time is going to be used by each family member. For example, toddlers may be designated as co-viewers only, meaning they only engage in screen time as a joint activity. Older children may be designated as allowed to use social media and watch age-appropriate shows, but not visit new websites without permission. Older teens may be able to have freer use of the internet, but limits on where they can use their screen devices, so that parents can keep an eye on what they are viewing. The tool also allows families to choose some suggestions for what they can do instead of screen time, including joining a team sport or playing board games. The media use plan includes tips for online citizenship as well as reminders for kids to keep their eyes off the screen while engaging in conversation. The plan is printable and can easily be made into a contract or star chart for helping children learn how to be knowledgeable and conscientious consumers of media.

AAP Encourages Minors to Participate in Medical Decisions

Our colleagues at the American Academy of Pediatrics (AAP) recently released an updated policy statement about informed consent for medical procedures. This update, the first since 1995, was also the subject of an explanatory article in The New York Times. The AAP policy goes into great detail regarding not just parental informed consent, but also assent by minors. Legally, all patients must be provided with enough information about medical conditions and procedures in order for them to agree to undergo any treatments. Children, however, are under the care of their parents, who are the ones providing the consent. That’s where assent comes into play. Even though children (anyone under 18) can’t legally make their own medical decisions, it’s still considered best practice to explain as much as possible to them in age-appropriate language, and to allow their voice to be heard in the decision-making process.

We’ve always taken student participation very seriously here at The Yellin Center, and we’re thrilled to know that the medical community is continuing to advocate for including children and teens in the decision-making process. Allowing children and teens the opportunity to become actively engaged in the conversation about their healthcare allows them to practice these decision-making skills safely for later on, with the understanding that parents and doctors ultimately (and legally) have the final say. Even more importantly, the AAP notes that letting kids and teens “in the loop” – helping them understand everything that’s going on – can promote empowerment and compliance with treatment.

Even though this policy statement was released by medical professionals, the sentiment translates well right down to the classroom level, and it’s something many teachers are starting to embrace. When kids understand why they’re being asked to do certain tasks, or learn certain concepts, they can develop an appreciation for their time in school. Similarly, many students can benefit from knowledge of how all brains work differently and what strategies might help them learn best, just like a doctor may explain to a child why she has to get her tetanus booster. It could make that shot a little less painful, and that classroom activity a little more worthwhile, from the child’s perspective.

Teen Diet Recommendations Have Lost Some Weight

Our colleagues at The American Academy of Pediatrics (AAP) have some updated recommendations for promoting healthy eating habits in adolescents. Based on a review of studies looking at adolescent obesity and eating disorders, the recommendations include that family discussions focus not on weight loss but rather on generally healthy behaviors, such as exercising and eating nutritious foods. Research suggests that parents’ comments about their own weight or that of their teenage children, even if encouraging, tend to be counterproductive. Such comments actually increase the likelihood of the adolescents gaining an unhealthy amount of weight or developing eating disorders. The AAP report also notes that dieting tends not to work, with efforts to restrict caloric intake leading to binge eating and, ultimately, weight gain.

With the prevalence of obesity and eating disorders having increased in the past few decades, efforts geared toward their prevention are as important as ever. Both types of conditions are associated with medical complications as well as psychosocial challenges, i.e., certainly counter to our goal of having happy, healthy students who are optimally available for learning. Parents with the best intentions, who may be inclined to encourage their teens to lose weight, may be wise to heed the AAP advice and shift focus from the numbers on the scale.

photo credit: Greg O'Connell via flickr cc

ADHD Treatments for Young Children - A New Study

A new study just released by the Centers for Disease Control and Prevention (CDC) finds that while more than 75% of young children (ages 2-5) with attention-deficit/hyperactivity disorder (ADHD) are prescribed medication, only about half receive behavior therapy* to address their attention difficulties.

 

This preference for medicating young children runs counter to the clinical guidelines established by the American Academy of Pediatrics, which in 2011 recommended:

"For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based … behavior therapy as the first line of treatment and may prescribe [medication] if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child's function."

The AAP guidelines go on to caution that, “…in areas where evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment.” The AAP noted that even students whose attention difficulties do not rise to the diagnostic criteria of ADHD may benefit from a behavioral approach to their attention issues.

The CDC study observed that approximately 6.4 million U.S. children ages 4-17 years had a diagnosis of ADHD in 2011-12, which was an increase of 42% increase compared to 2003. The study used insurance claims for psychological services (which includes behavior therapy) and ADHD medication from both Medicaid and private insurance to determine the frequency with which each approach was utilized. 

The CDC reported that the strength of evidence for behavior therapy exceeds that for ADHD medications. It noted that behavior therapy might require more time to impact child behavior and might require more resources but that the impact lasts longer relative to ADHD medication and does not have the side effects associated with these medications. Most of these side effects are minor but they are experienced by approximately 30% of children aged 3–5 years who take ADHD medications and more than 10 % of the children in this group stopped medication treatment because of such side effects.

Here at The Yellin Center we always recommend behavioral strategies for school and home when dealing with attention issues. When appropriate, we can also provide consultation and ongoing prescription management for medications, but we strongly believe that medication should only be considered in the context of a student's overall educational plan, and never thought of as a "quick fix" for school difficulties.

*Behavior therapy in this context includes any psychological interventions that are designed to change problem behaviors, including ADHD symptoms, by modifying the physical or social contexts in which the behavior occurs and can be delivered to the child by a therapist, teacher, parent, or other provider.

Keeping Guns Away from Children

Twice this past week, students in New York City public schools have brought loaded guns to school. The New York Times notes that these two incidents - one involving a 15-year-old student at an "early college" high school with a strong academic reputation, and one involving an 11-year-old elementary school student -- were two of four times this year where guns were seized in New York City schools. Last year, The Times reported, there were nine such episodes. These latest incidents resulted in the arrest of the 15-year-old and the arrest of the gun-owner grandfather of the 11-year-old.

As far back as 2011, we blogged about efforts by pediatricians to address gun safety by asking parents whether there is a gun in their home as a first step to beginning a conversation about ways to keep that gun away from children. We followed up in later blogs to discuss efforts to block even this basic step towards gun safety and can now report that the Florida ban on asking about guns in the home was upheld by the 11th Circuit Court of Appeals. A look at this decision in The Miami Herald lays out the history of this law.

Let's pause for a moment to make it clear that we are not taking a stand on gun ownership. The issue of keeping guns out of our schools and out of the hands of kids is something else entirely.

Notably, neither of the schools in this week's events had metal detectors, which are common in many New York City public high schools and elsewhere. A report last September by WNYC noted that approximately 90,000 New York City public school students go through a scanning process each day. But there are real issues with metal detectors.  The likelihood of having to go through a scanner varies by borough, as well as by the racial and ethnic make-up of the student body. As the WNYC report noted, "getting scanned before school every day can mean earlier wake ups, long waits and lots of hassle." Having experienced scanning while visiting schools, your blogger can report that it is much like going through airport security every day. And while metal detectors and scanners may keep guns outside school buildings, they don't keep guns out of kids' hands elsewhere.

So, what can parents do to help make their children safer, in school and out? Our colleagues at The American Academy of Pediatrics have some common sense information and talking points about guns and kids that addresses families that have guns -- and those that don't. It includes statistics on how having a gun in the home affects family safety and questions to ask other parents before your child visits their home. It's worth reading.

photo credit: Ken via flickr cc

Lag in Putting Sleep Research into Practice

A recent editorial in The Brown University Child and Adolescent Behavior Letter expresses frustration with the lengthy time gap between important scientific discoveries and the implementation of these discoveries in everyday practice.

Dr. Gregory Fritz notes that the lag between research findings and changes in practice and behavior is often cited to be 17 years on the average, but that the disconnect is particularly egregious when it comes to what researchers know about the importance of sleep for adolescents and the actual amount of sleep that teenagers get. He refers to a 2014 Policy Statement from the American Academy of Pediatrics as evidence that the need for sleep is well-accepted in the pediatric community. The AAP Policy Statement and Dr. Fritz both point to early school start times as a major factor in sleep deprivation. We have written about this issue many times; in fact so often that it is impossible to include links to all relevant posts. Searching "sleep" in the list of blog topics will enable readers to locate all our posts on this subject.

Research has demonstrated that the tendency for teens to stay up later is part of the changes in the level of the hormone melatonin that occur during puberty and continue through adolescence. When teens are able to compensate for this change by sleeping later in the morning, things tend to balance out. But, when teens have an early start time at school and they must get up before they have had the full amount of sleep needed for maximum functioning, their daytime function is impaired. Dr. Fritz notes that, "sleep-deprived adolescents tend to get lower grades and report higher rates of depressive symptoms," compared to those who get the optimal amount of sleep - close to nine hours. Particularly concerning is that there is a correlation between sleep deprived teens and auto accidents. When you consider that teens are inexperienced drivers, and you add in the impairment caused by drowsy driving, this is frightening.

Dr. Fritz laments the failure of adults to take the available data seriously and to take steps to change the start times of school for teens. It may take some logistical maneuvering, but failure to make this a national priority is creating a generation of drowsy, inattentive- and possibly endangered - teens.

photo credit :D Sharon Pruitt @ flickrcc

Use of "Touch Screen Devices" by Toddlers

The  American Academy of Pediatrics (AAP) has long cautioned parents to limit media exposure of young children and updated their recommendations as recently as 2013.

A new study on this subject from a team led by Dr. Ruth Milanaik, an attending developmental and behavioral physician at the Cohen Children’s Medical Center of New York on Long Island, New York, looked at the very youngest children -- infants and toddlers up to age three -- to examine what the researchers called "touchscreen device usage" or TDU, to see how use of or exposure to such devices as smart phones and iPads impacts children's development.

Dr. Milanaik noted that the study was prompted, in part, by the observation that the "number one toy" that parents gave their children to play with at a newborn follow-up clinic was a smartphone. In an article on the study in Forbes, she noted that parents were substituting smart phones for books and other baby toys and stated, "Many parents did not seem to bring any other distraction for their children except the touch screen devices.”

The study found that the majority of parents questioned believed that TDU had educational benefits. However, developmental scores showed no significant difference between children who had access to such devices and those who did not. Furthermore, children who played non-educational games (such as Angry Birds or Fruit Ninja) on touchscreen devices had lower receptive & expressive language scores compared to children who engaged in other types of TDU. The authors caution that it is possible that children with slower language development may prefer playing non-educational games and that it would be inappropriate to conclude that lower scores in language were caused by TDU.

Dr. Paul Yellin commented,  "Dr. Millanaik’s quote may get to the heart of the matter. It may not be the devices per se, but rather the fact that they are used instead of reading or speaking to children. This is consistent with recent research demonstrating the importance of exposure to language in the early years."

August Health Observances

Two month-long reminders about children's health take place in August, both intended to coincide with the start of the school year.

National Immunization Awareness Month

First, this month marks the annual National Immunization Awareness Month, and the American Academy of Pediatrics (AAP) reminds parents that "August is an ideal time to make sure everyone is up-to-date on vaccines before heading back to school and to plan ahead to receive flu vaccines." The AAP notes that some parents have concerns or questions about immunizations, and their website includes information on every aspect of immunization from school vaccination requirements in all 50 states to vaccine safety. They recognize the importance of getting accurate information about immunizations and note that the "AAP Immunization Web site was assessed by the World Health Organization (WHO) and passed their credibility and good information criteria."

Children's Vision and Learning Month

Ano Lobb

August is also Children’s Vision and Learning Month. As the New Jersey Society of Optometric Physicians states, "Children with undiagnosed, untreated vision problems ... can experience trouble focusing between a book or electronic device and the blackboard, or controlling or coordinating eye movements. In today’s digital classroom, a student must see well to not only keep up but to excel." We could not agree more -- and it is because of these important connections between eyesight and learning that vision screening is a routine component of a comprehensive educational evaluation at The Yellin Center. Further, we believe that regular exams with a pediatric ophthalmologist (a medical doctor who specializes in the eye issues of children) should be a part of your child's medical care.


Here's to a healthy start of school for all!

Better Quality TV Programming Can Improve Behavior of Young Children

We've noted before that researchers have found that what children watch on television can impact their behavior. For example, the ability of a group of four-year-olds to maintain attention, control behavior, and solve problems was severely compromised after just nine minutes of watching a fast-paced cartoon.

Now, new findings just published in the journal Pediatrics note the results of a randomized controlled study of 565 three to five year-old preschoolers where researchers "developed and tested an approach in which preschool-aged children’s viewing habits were altered such that they substituted high quality educational programs for violence laden ones."

The study used parent education as the key to reducing the children's exposure to violent television and other media. Participating families received home visits, newsletters, and telephone calls that provided information on the benefits of educational programs, how to use blocking features on televisions to keep children from accessing violent programs, and recommended channels selected from those available to that specific family. In addition, families received DVDs with clips of "positive" programming, designed to capture the interest of parents and children and encourage them to seek out such programs. There was no effort made to curtail the amount of screen time, just the quality of programs to which the children were exposed.

The researchers found a significant increase in high quality viewing in the families that were encouraged to focus on educational programs, as well as a move away from violent viewing. Notably, there were also significant changes in "social and emotional competence," a result that was particularly strong in boys from low income households. The changes in viewing habits and resulting positive impacts continued for the months of post study follow up.

The study authors note, "Although television is frequently implicated as a cause of many problems in children, our research indicates that it may also be part of the solution. Future research to perhaps further enhance media choices particularly for older children and potentially with an emphasis on low income boys is needed."

Photo: CC by Sarah Reid

Parent Resources from Pediatricians

We were recently reminded of the many resources for parents available through our colleagues at the American Academy of Pediatrics (AAP). While many of the features of the main AAP website are only available to pediatrician members, there is no such restriction on the AAP sponsored website HealthyChildren.org.

The Healthy Children website, which is available in both English and Spanish language versions,  features information for parents on each stage of child development, in a section called "Ages and Stages". It also has timely information on current issues, such as flu prevention and treatment and winter safety tips. There are links to new research findings and a "find a pediatrician" feature.

We were also pleased to see the website information available in a new free app for iPads and iPhones as well as android phones. A web based magazine, also titled Healthy Children, seems excellent but has not been updated since it was launched in the fall of 2012.

The Crucial Role of Recess

The American Academy of Pediatrics (AAP) has just issued a Policy Statement, reaffirming what researchers have noted for years -- that recess plays a crucial role in the well-being of children and that cutting recess time in an effort to devote more of the school day to academics is a short-sighted practice, which can deprive students of significant physical, social, and academic benefits.

The Statement, issued by the AAP Council on School Health notes that recess is different from physical education, which it describes as an "academic discipline", and stresses the need for unstructured playtime. The Statement notes that  students are able to perform better on cognitive tasks after a period away from the  classroom, and that what matters most is that students get a break from academics, not what they do during this break or even how long the break lasts.

Social benefits to recess include building skills such as cooperation, negotiation, sharing, and problem solving. There are physical benefits, as well, even for those students who are not particularly active on the playground; they are still moving more than they would at their desks. The AAP notes that while there is much discussion about structured play time and playground safety, too much supervision and structure can impede spontaneous play and creativity. They note that while supervision is important, there needs to be a balance so that recess is really a time for play. They also note that while students traditionally have recess time after lunch, that there is merit to the "recess before lunch" movement. When students get to play before their lunch period they take more time to eat, waste less food, and their behavior is improved both at mealtime and after lunch. 

Court Bars Limits on Physician Gun Counseling

Unless you spent your summer in an isolated locale with no news broadcasts, newspapers, or internet (is there such a place anymore?) you know that this has been a summer punctuated by devastating, deadly gun violence. So we were particularly pleased to see an article in the August issue of AAP News noting that U.S. District Court Judge Marcia G. Cooke has ruled that a 2011 Florida law which restricted pediatricians from asking about whether there are firearms in a home is unconstitutional. Judge Cooke has issued a permanent injunction which blocks enforcement of this law.

We had previously written about our concerns with this legislation, noting that it was intended to counter an initiative on the part of the American Academy of Pediatrics (AAP) and others to make sure that families were aware of the need to keep guns away from children and to counsel patients and families on the need to store guns safely. As we noted in our prior blog on this topic, this was not an effort to limit gun ownership, only to improve safety.

The judge's ruling followed a lawsuit brought by the Florida branches of the AAP, the American Academy of Family Physicians, and the American College of Physicians, as well as several individual physicians. The plaintiffs argued that the law limited their right to free speech under the First Amendment because it did not allow them to exchange information about gun safety with their patients. The judge agreed and also noted that the law prevented patients from hearing preventive health information from their doctors.

There are several other states in which similar legislation to the Florida law has been proposed, but not yet enacted. We hope that the ruling in Florida gives those in other states pause before they push ahead with limiting the rights of physicians to try to keep their patients safe.

Photo: flguardian2 / Creative Commons

August is National Immunization Awareness Month

Although New York City's public schools don't begin classes until September 6 this year, many schools across the country have already opened. It's a good time to make sure your child's immunizations are up to date, especially since August is National Immunization Awareness Month.

The American Academy of Pediatrics has a section on their website directed at parents that looks at what immunizations are needed for different age groups and considers questions parents may have about the safety of vaccinations.

All 50 states require that students be immunized and will not permit children without immunizations to attend school, although there are exemptions available for medical and religious reasons (which vary from state to state). Check out the requirements in your state for immunizations and speak with your child's pediatrician to make sure that your child also receives non-mandatory vaccines, such as a flu shot, when appropriate.

The Centers for Disease Control has created a list of childhood diseases that can be prevented by vaccination. Parents who question why their child needs to be vaccinated should find this important reading.

Photo: AKZOphoto / Creative Commons

AAP Updates Guidelines for Diagnosis and Treatment of ADHD

The American Academy of Pediatrics recently released new guidelines for the diagnosis and treatment of ADHD (Attention Deficit Hyperactivity Disorder). These are intended to update and integrate two separate sets of guidelines for the diagnosis and treatment of attention difficulties which date to 2000 and 2001, respectively.

The new guidelines still rely upon the definition of ADHD that appears in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. We have not been big fans of relying solely on this approach to diagnosis, which involves counting symptoms of inattention, hyperactivity, and impulsivity and then looking to see if these symptoms have been present for a number of months in more than one setting (such as both in school and at home). While this approach can be very helpful, we don't think it goes far enough towards truly understanding how attention impacts behavior and learning.

We have always preferred to look at attention from a different, more functional perspective, which considers three primary areas -- mental energy controls, processing controls, and production controls. Within each functional area, we break down areas of strength and weakness, so that we consider a broad array of skills and competencies.

When we look at mental energy controls, we consider not just attentional consistency, but also alertness, mental work stamina, and sleep/arousal balance. We sometimes discuss these factors in terms of whether an individual has sufficient cognitive "fuel" to power their tasks.

When we look at the processing controls of attention, we examine such areas as saliency determination, processing depth, focus on detail, cognitive activation, focal maintenance, and satisfaction levels. These considerations can be viewed as the camera lens that a student will bring to his or her work. Does it focus at the right depth for the task at hand?

We examine production controls by reviewing an array of skills which include previewing, facilitation, pacing, self-monitoring, and inhibition. These are the "output" skills that impact academic performance and classroom behavior.

As a practical matter, we believe that looking at functions is a more helpful approach than just counting symptoms, and the new AAP guidelines do seem to move in that direction. For example, they urge that physicians look at other causes for the symptoms commonly attributed to ADHD, such as learning, emotional, and physical conditions. They also note that special consideration needs to be given to both young children and teens, and they expand the age range in which attention problems should be considered to ages 4-18 (from ages 6-11). The new guidelines also acknowledge advances in medication for attention problems and offer guidelines for physicians as to the best initial approaches for children of varying age groups.

Protecting Children from Gun Violence

Our colleagues at the American Academy of Pediatrics (AAP) have been working for years to ensure the safety of children in countless ways -- by advocating for such fundamental safety issues as automobile car seats, bike helmets, prevention of sports injuries, and avoiding dog bites -- just to name a few issues. Now, they and the pediatricians and family physicians who care for children, are under fire (pun intentional!) from the State of Florida, for promoting gun safety.

Let's be very clear about what is going on here. There is no action proposed by the AAP or its gun safety partners to limit gun ownership. There is a strong move to have parents ASK if there is a gun present in a home where their children play. Think about it. Even if you can control what goes on in your own home, what about your child's friend down the street? Might there be a gun in that household? And, if so, is it properly secured so that it is impossible for children to find it, and use it? Wouldn't you want someone offering advice on that issue to other parents?

The Florida House of Representatives and Senate have both passed a bill that would prohibit physicians from asking parents about whether there are guns in their homes, if that could in any way be considered "harassment." The question, when asked by a pediatrician or family physician, can open the topic of gun safety and allow the doctor to counsel the parent about what is needed to make sure that their own and other people's children are kept safe. Proponents of the bill, which is expected to be signed shortly by Governor Rick Scott, believe it is needed to prohibit doctors from recording which of their patients own guns and from refusing to accept patients into their practices who won't discuss gun safety issues. The numerous opponents of the law, including the AAP and Pax, which partners with the AAP to raise awareness of gun safety concerns, point to limits on a physician's judgment, freedom of speech issues, and the appalling number of children injured or killed by playing with guns found in their home or another house at which they play.

The statistics are staggering. According to research from the last decade compiled by PAX:

• Nearly 1.7 million children, under the age of 18, live in homes with firearms that are both loaded and unlocked in the United States
• Over 40% of American households with children have guns
• 8 children and teens were killed by firearms every day in 2006

We are deeply concerned about this effort to keep doctors from doing their primary job -- keeping our children safe.