Safety

Sports: Healthy Competition vs Performance Anxiety

With school back in full swing, kids are joining their friends and classmates in school sports. Sports can be a great way for growing children to develop fine and gross motor skills. However, it can also be an area of stress and pressure to perform. (more…)

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Let’s Talk About Bullying

Bullying Picturehttps://www.istockphoto.com/photo/girl-crying-gm518118234-89841353

It is the first month of school for many of our children out there which can be a very exciting time. For many parents, it means their house is a little quieter in the day and the return to a normal routine. For children it means a new pencils, a fun backpack, seeing their friends every day, and a fresh start. However, this time of year can also lead to anxiety and the fear of not “fitting in”. For some children, it can also mean bullying. It is vital that pediatricians and parents understand what bullying is as well as what to look for and what to do if a child is affected by bullying.

Bullying is an unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. This behavior is typically repeated over time. Bullying encompasses verbal abuse, social abuse, and physical abuse. Verbal abuse is writing or saying cruel things. It includes teasing, name-calling, threats, taunting, and inappropriate sexual comments. Social bullying is when someone hurts someone else’s reputation or relationships. It includes leaving someone out on purpose, spreading rumors about someone, telling other children not to be friends with someone, and embarrassing someone in public. This can include cyberbullying, which can take place through text messaging, social media websites, apps, e-mail, web forums, or multi-player online games. Cyberbullying has the potential to “go viral” and spread very quickly. Physical bullying involves hurting a person’s body or possessions. Both boys and girls can be a bully or be bullied.

The effects of bullying, both of the bullying and the bullied, can have long-term consequences. Kids who are bullied can experience depression and anxiety. These issues may persist into adulthood. They also can have an increased amount of health complaints and decreased academic achievement. In fact, children who are bullied are more likely to miss, skip, or drop out of school. Kids who bully others are more likely to abuse alcohol and other drugs in adolescence and as adults, get into fights, vandalize property, and drop out of school. They are also more likely to partake in early sexual activity, have criminal convictions as adults, and be abusive toward their romantic partners, spouses, or children as adults.

Due to all of these potential negative consequences, it is important for both pediatricians and parents to be able to recognize signs of both being bullied and bullying others. Only 40% of children notify an adult in times of bullying. Therefore, it is important for pediatricians and parents to ask kids about bullying with questions such as, “how are things going at school?” or “is anyone being picked on?”. Since not all children being bullied will exhibit physical signs, it is important for parents to look for many different signs and symptoms. These include unexplainable injuries, lost or destroyed clothing, books, electronics, or jewelry, frequent headaches or stomach aches, and changes in eating habits, like suddenly skipping meals or binge eating.

Other signs of bullying include difficulty sleeping or frequent nightmares, declining grades, loss of interest in schoolwork, or not wanting to go to school, sudden loss of friends or avoidance of social situations, feelings of helplessness or decreased self-esteem, and self-destructive behaviors such as running away from home, harming themselves, or talking about suicide. Signs that children are bullying others includes getting into physical or verbal fights, becoming increasingly aggressive, getting sent to the principal’s office or to detention frequently, having unexplained extra money or new belongings, blaming others for their problems, not accepting responsibility for their actions, and being competitive and worrying about their reputation or popularity.

Even after identifying that a child is being bullied or is a bully themselves, it is hard to know what to do. In the case of a child being bullied, one of the first steps is teaching children how to respond. It is important to teach children to look the bully in the eye, stand tall and stay calm, and to know when to walk away. Also teach your child to have them say firmly things such as “I don’t like what you are doing” or “Please do not talk to me that way”.  This will not be instinctive to most children so it is important to practice these skills so they feel more prepared when the time comes. Parents should also encourage their children to make friends with other children inside and outside of school. This can be done by encouraging children in activities that they are interested such as team sports, music groups, or other social clubs.

Another important thing to teach children is to know how to ask for help. Children should know that being bullied is not their fault and they should reach out to their teacher, school counselor, or school principal. Parents should talk with the school principal if the child is too scared to ask for help or if the child continues to be fearful or affected.  If the results from these conversations are not resulting in action on the school’s part, make a written request to the principal asking for a copy of the school district’s policies on reporting and investigating bullying.  Most school districts have procedures for parents and others to make written reports. Some states require schools to make investigations of reports of bullying. If the local campus is not responsive, make a written request to the school superintendent.

If a child is experiencing cyberbullying only a few actions need to be taken differently. First, don’t threaten to take away the child’s devices as this may seem as a punishment. Instead, if there is online evidence of the bullying, take and save a screenshot in order to report the bullying to the social media platforms in which the abuse happened as well the school or police if appropriate. Otherwise, support the child in the same ways as mentioned above.

It can also be a stressful situation as well if your child is bullying others. It is important to be consistent and set firm limits on a child’s aggressive behavior by using effective, nonphysical discipline such as loss of privileges. Another way to influence your child’s behavior is by being a positive role model and showing children they can communicate what they want without teasing, threatening, or hurting others. In addition to these measures, help children understand how bullying can hurt other children. Communication is also important in these situations and parents should be speaking with the school and other parents in order to try to find practical solutions to the bullying that is occurring.

Chelsea Day, MD

 

References:

American Academy of Pediatrics. Bullying and Cyberbullying. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Bullying-and-Cyberbullying.aspx. August 28th, 2018.

Healthy Children. Bullying: It’s Not Okay. https://www.healthychildr en.org/English/safety-prevention/at-play/Pages/Bullying-Its-Not-Ok.aspx. August 28th, 2018.

Healthy Children. Cyberbullying.https://www.healthychildren.org/English/family-life/Media/Pages/Cyberbullying.aspx. August 28th, 2018.

Stop Bullying. Warning Signs for Bullying. https://www.stopbullying.gov/at-risk/warning-signs/index.html. August 28th, 2018.

Adverse Childhood Experiences

The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.

What is an Adverse Childhood Experience?

ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health [1]. These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) [2].

What is the impact of ACEs?

The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors [2]. Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia [3]. Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion [2].

What can we do to help as pediatricians and as citizens?

The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].

As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are [6]:

  • Food security: Are there times when you don’t have enough food?
  • Income: Do you ever have trouble making ends meet?
  • Housing: Is housing ever a problem for you?
  • Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
  • Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?

All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support [7]. Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.

Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.

https://www.aap.org/en-us/advocacy-and-policy/Pages/Advocacy-and-Policy.aspx

https://www.naeyc.org/resources/blog/support-and-advocate

https://www.cwla.org/our-work/advocacy/

http://childwelfaresparc.org/

 

Benjamin Masserano, MD

 

References

[1] https://developingchild.harvard.edu/science/key-concepts/toxic-stress/

[2] https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

[3] https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

[4] http://pediatrics.aappublications.org/content/pediatrics/early/2011/12/21/peds.2011-2663.full.pdf

[5] http://pediatrics.aappublications.org/content/128/6/e1680

[6] http://pediatrics.aappublications.org/content/120/3/e734

[7] http://www.211.org/

Heat Stroke in High School Football Players: A Lack of Regulation Placing Children at Risk

At the start of every school year, thousands of high school athletes come in excited to hit the field.  Unfortunately, heat related death in high school sports, especially high school football, remains a real risk due to lack of regulations and safeguards in place.  However, these injuries and deaths are entirely preventable by proper practices.  Pediatricians have a duty and an opportunity to protect these athletes from environments and circumstances that put them at increased risk for heat stroke and death.

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Keep Schools Safe: No place for firearms

In 1990, the country took action to decrease the amount of gun violence present in schools across the nation by passing the federal Gun-Free School Zones Act originally part of the Crime Control Act. Now, a pending bill called the Safe Students Act, H.R. 34, proposes repealing prohibition of guns on school campuses and would threaten that protection. As pediatricians committed to improving children’s health and safety, we must help prevent this dangerous bill from becoming a law. (more…)

Is the rising cost of prescription drugs preventing patients from accessing life-saving medication?

Prices of prescription drugs in the United States are among the highest in the world. Most recently, the skyrocketing price of the epinephrine pen, EpiPen, has been the subject of major news headlines. Many have been enraged by the dramatic price increase of the EpiPen ($100 to over $600 in the span of a few years). Unfortunately, the EpiPen is one of many prescription drugs that has been affected by such dramatic inflation. Many fear that the rising cost of life-saving medication will limit access to those who need it. Healthcare providers cannot stand idly as these changes negatively impact patients. We need to have a better understanding of the prescription drug industry so that we can find reasonable solutions for our patients. (more…)

Addressing the violence in the news with children

Children are indirectly exposed to acts of violence and terrorism almost continuously via the media.  News media continually cycles global events onto screens in every household. The stress of witnessing a shooting is no longer limited to the bystanders and civilians caught on the scene, but is spread diffusely across state and national borders to viewers in their homes including children. Pediatricians can help children and their caretakers process these tragedies better.  

Exposure to such news stories can contribute to a stressful environment for the child. In recent years the AAP has focused on ‘toxic stress’ in a child’s life. Toxic stress has been defined as “the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships” (National Council of Science: Excessive stress disrupts the development of brain architecture). A growing body of evidence suggests that ecology and biology interact to effect development, i.e., the ecobiodevelopmental framework. In the case of toxic stress, a stressful ecology inculcates lasting detrimental effects in biology and behavior. It can lead to development of poor coping skills, unhealthy lifestyle choices, chronic cardiovascular diseases and serves to perpetuate health disparities to mention a few.

Opinions vary on the extent and significance of the effect of exposure to news media coverage of acts of terror and violence. Increasingly, after such an incident, many articles emerge suggesting how parents should talk to their children about violence. Unfortunately, many children do not have the “buffering protection afforded by stable, responsive relationships” with their parents. Parents themselves may face a difficult time coming to terms with the same tragedies. This gap can be bridged by the pediatrician, school and public policy.

Pediatricians can routinely screen for toxic stress. The AAP has put forward many helpful resources which advise parents on how to talk to their children regarding media violence, tragedies they may have witnessed, school shootings and disasters. Whenever such news is circulating, pediatricians can ask parents if they have trouble communicating with their children about it, expand on their anticipatory guidance using the pre-existing AAP guidelines and recommend appropriate resources to them.  Further, pediatricians in collaboration with mental health professionals can meet with parent-teacher associations to share how children are able to best process these events.

Schools can engage their own mental health services and counselors to have a discourse with children in an age-appropriate manner. In the absence of adequate resources, these sessions could be done in groups and limited to when the event is local.

Finally, state government officials can improve funding for mental health services for children and implement strategies to incentivize an increase in the mental health professionals catering to the pediatric population. Legislators can formulate guidelines for Social and Emotional Learning (SEL) curriculum for grades K-12 as exist for pre-kindergarten. As of December 2015, free-standing guidelines for Social and Emotional Learning exist only in the states of Illinois, West Virginia and Kansas. Bills proposing training of teachers and principals to address social and emotional development needs of students have been previously introduced in the U.S. House (H.R.850; H.R.497) and the U.S Senate (S.897) in 2015. In the same year, a bill (HB 3289) was also introduced in the Texas Legislature proposing formulation of a local school health advisory committee to address mental health concerns existing in school efforts and to make recommendations to the school district concerning the integration of social and emotional learning into the academic curriculum.

Adopting such a multi-pronged approach will better preserve the childhoods of the current generation and safeguard their adult lives as well.

References:

1.       National Scientific Council. Excessive stress disrupts the development of brain architecture. Journal of Children’s Services. 2014 Jun 10;9(2):143-53. Accessed July 11, 2016. URL: http://developingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Developing_Brain-1.pdf

2.       Shonkoff, J.P.; Garner, A.S. Technical Report: The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012. doi:10.1542/peds.2011-2663

3.       Committee on psychosocial aspects of child and family health, committee on early childhood, adoption, and dependent care, and section on developmental and behavioral pediatrics. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012. doi:10.1542/peds.2011-2662

4.       Busso, D.S.; McLaughlin, K.A.; Sheridan, M.A. Media exposure and sympathetic nervous system reactivity predict PTSD symptoms after the Boston marathon bombings. Depress Anxiety. 2014 July ; 31(7): 551–558. doi:10.1002/da.22282

5.       Marie Leiner, M.; Peinado, J.; Villanos, M.T.M.; Lopez, I.; Uribe, R.; Pathak, I. Mental and emotional health of children exposed to news media of threats and acts of terrorism: the cumulative and pervasive effects. Frontiers in Pediatrics. 2016. doi: 10.3389/fped.2016.00026

6.       Collaborative for Academic, Social and Emotional Learning. Identifying K-12 Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: https://pedsadvocacy.files.wordpress.com/2016/07/a46cb-state-scorecard-summary-table-for-k-12-12-16-15.pdf

7.       Collaborative for Academic, Social and Emotional Learning. Identifying Preschool Standards for SEL in all 50 States. 2015. Accessed July 9, 2016. URL: http://static1.squarespace.com/static/513f79f9e4b05ce7b70e9673/t/55df7c05e4b031d82f728c5d/1440709637809/preschool-table-8-27-15.pdf

8.       Texas Education Agency. Accessed July 9, 2016. URL: http://tea.texas.gov/index2.aspx?id=2147495508

 

Gohar Warraich, M.D.

 

The Dangers of Indoor Tanning

It’s summertime! Many kids are excited that the warmer weather means a few months off school and a change in daily routine. This often includes time at the pool with friends, which can motivate teens to want to look their best. For some, this means having a tan, and many teens will head to the tanning salons to darken their skin and achieve a bronze “summer glow.” However, the use of tanning beds has been associated with deadly forms of skin cancer, and kids and teens are at the highest risk. It is time for pediatricians to encourage lawmakers to create legislation protecting children from these dangers.

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Consciously Supporting Concussion Awareness

In recent years, public interest has increased surrounding concussions/mild traumatic brain injuries (MTBI). This is due in large part to the recent hypothesis that concussive forces from contact sports may be a risk factor for the development of chronic traumatic encephalopathy (CTE), a disease seen most often in former boxers and professional football players.

Research, legislation, and documentaries have sought to better define the incidence and risks of concussions, its relationship to these 2 diseases, and to increase public awareness of this issue. Currently, legislation is pending in both the U.S. House of Representatives and the Senate that has the potential to further achieve these goals by increasing general awareness about concussions and giving parents and youth the ability to make informed decisions about the sports in which they participate. We as pediatricians can advocate for the safety of our patients by contacting our local representatives and asking them to become cosponsors for the “SAFE PLAY Act” (H.R. 829).

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Binge Drinking in Adolescents, a Pediatrician’s Role.

Adolescence is a period of limit testing in which children and young adults are at increased risk of substance abuse. The most frequently used substance by adolescents is alcohol.  Adolescents who drink alcohol have an increased rate of binge drinking compared to adults. Adolescent alcohol abuse is associated with an increased risk of chronic alcohol abuse leading to serious illnesses as adults. Also, alcohol use can be associated with the leading causes of death and serious injury in ages 15 to 24 (unintentional injury, homicide, suicide).

The AAP Committee on Substance Abuse recently released a Clinical Report titled Binge Drinking (http://pediatrics.aappublications.org/content/136/3/e718.full). In the report, binge drinking is defined and characterized, risk factors are discussed, and neurobiology is addressed.  The authors provide screening guidance for pediatricians.   The report explains that at age 9, children start having positive feelings about alcohol and start thinking that alcohol may not be just for adults. This means that ages 9-15 is a critical period for screening and intervention.   The report recommends that pediatricians should screen every patient for alcohol use starting at age 9.

The NIAAA collaborated with the AAP to develop a quick two-question screening tool that varies by the  patient’s age.  The questions focus about asking the patient about their own alcohol usage and their friend’s alcohol usage.

Here is an image summarizing the screening tool:

Screen Shot 2015-09-30 at 4.29.54 PM
In addition to screening patients, pediatricians can support the Sober Truth on Preventing (STOP) Underage Drinking Reauthorization Act (H.R. 1717, S. 728).
This bill will reauthorize an act targeted at reducing underage drinking through research, a highly-visible national media campaign, and grants to public health care providers/community organizations/ and partnerships with higher education institutions.
( https://www.congress.gov/bill/114th-congress/house-bill/1717?q={%22search%22%3A[%22sober+truth%22]}&resultIndex=1 )

What YOU can do:

  • Educate yourself about alcohol use in adolescents and it’s health effects.
  • Screen every patient starting at age 9 for alcohol use; intervene as necessary.
  • Talk to your patients and their parents about alcohol-related risks.
  • Contact your federal representatives and ask them to co-sponsor and support  the Reauthorization of the STOP Act.

 

Sources and Resources:
AAP Clinical Report, Binge Drinking. http://pediatrics.aappublications.org/content/136/3/e718.full
http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuideOrderForm.htm
http://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/underage-drinking
http://www.stopalcoholabuse.gov/Default.aspx
http://www.samhsa.gov/underage-drinking

https://www.congress.gov/bill/114th-congress/house-bill/1717?q=%22search%22%3A%5B%22sober+truth%22%5D&resultIndex=1)

Paul Teran, MD