pediatrics

Literacy in the Time of Coronavirus

Texas is returning to normalcy as restrictions are being eased from the COVID-19 pandemic. Children are still out of school and it remains to be seen when they will return to the classroom environment. The combination of idle time, travel restrictions, and social distancing practices present a significant challenge to parents with restless children at home – as well as an excellent opportunity to promote reading. Pediatricians should use each well-child visit right now to encourage parents to take time to read with their children.

The Council on Early Childhood found approximately two-thirds of children in the United States fail to develop reading proficiency by third grade.1 Reading proficiency by third grade is an important predictor of high school graduation rates, as those who cannot read by that mark are four times more likely to later drop out of high school.1-2 Early reading deficiencies can lead to a lifetime of economic consequences. The Program for International Assessment of Adult Competencies (PIAAC), in a 2016 survey, suggested roughly 1 in 5 U.S. adults do not have basic literary proficiency.3 Low levels of adult literacy and educational level are associated with less economic opportunity, poor health outcomes, and social dependency.1,4

The promotion of reading skills can start in infancy. Parents can read aloud to infants to encourage language development and model reading behavior.1 As infants age, they begin to mimic their parents by turning the pages of books. With picture books toddlers can make inferences from the images before they can read the words on the page. Gradually and with training they may begin to recognize letters and eventually words. Ideally, pediatricians would like our patients to be familiar with the alphabet and recognize their name prior to starting kindergarten. For older children and teenagers, quarantine can be an opportunity to expand their literary horizons. By reading popular novels, classic literature, or books from high school reading lists, students can improve their literacy.

Many resources are available to help parents promote reading. Reach Out and Read Texas has a partnership with many pediatric clinics to provide children with a book at each visit from 6 months to 5 years; their website (see link below) also includes expected reading milestones by age. The Dallas Public Library has Tumble books available for children grades K-12 (see link below) online and additional books are available with a library card (free with proof of residence). Google Play Books has free children’s books available online which are playable on iOS devices.

Donovan Berens, MD

Works Referenced:

  1. High PC, Klass P, Council on Early Childhood. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Pediatrics. 2014 August; vol 134 (2): 404-409
  2. Hernandez D. Double Jeopardy: How Third-Grade Reading Skills and Poverty Influence High School Graduation. Annie E. Casey Foundation. 2011 April. https://files.eric.ed.gov/fulltext/ED518818.pdf Date accessed 5/01/2020
  3. Mamedova S, Pawlowski E. Adult Literacy in the United States. National Center for Education Statistics Data Point, U.S. Department of Education. 2019 July. https://nces.ed.gov/pubs2019/2019179.pdf. Date accessed: 5/02/2020
  4. Torpey E. Education pays. Career Outlook, U.S. Bureau of Labor Statistics. 2019 February. https://www.bls.gov/careeroutlook/2019/data-on-display/education_pays.htm?view_full. Date accessed 5/02/2020.

Additional Resources:

https://reachoutandreadtexas.org/index.aspx

https://dallaslibrary2.org/services/ebooks/

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“What’s the Tea?” Current Recommendations on Media Use in the Pediatric Population

With the increasing use of technology in modern society, children have more access than ever to media and screens. Thus, the amount of time children spend playing video-games (who has heard of Fortnite?), on Snapchat, #Instagram, or TikTok, among others, has flourished, and this has become a hot topic amongst parents and pediatricians alike. For pediatricians, this shift towards a growing digital landscape is a moving target – society’s understanding of the impacts of social media and video games, particularly those of violent nature, is constantly shifting, and affecting how physicians address children’s medical needs. Pediatricians should be cognizant of this changing environment to best assess their patients’ electronic footprints and help guide recommendations.

Video games have been around since the 1950s, but they have become a growing force in the community particularly since the 1990s. With this rise came the concurrent increased exposure to “virtual violence”; while previously the exposure primarily occurred through platforms such as television, the exposure increased dramatically with the proliferation of computers and handheld consoles for video games. Discussions regarding the benefits and detriments of these violence-containing media have been polarizing, particularly regarding  short- and long-term behaviors, medical implications, and psychological effects.

Meta-analyses (2014, 2017) suggested that exposure to violent video games can pose a possible risk factor for aggressive behavior. Other studies found that addiction or depression may be sequelae from video-gaming, violence-containing or otherwise. Nevertheless, other studies have suggested some positive aspects of gaming. The 2014 meta-analysis also suggested that violent video games may also provide prosocial benefits and cooperative play that could foster cooperative behavior and empathy. Additional studies have been performed to evaluate the benefits of video games, with some suggesting improved spatial skills, improved efficiency with attention allocation, emotion-regulation tricks called “re-appraisal”, and “prosocial” and helpful behaviors.

Unfortunately, we lack enough data fully delineating causal effects from video games, and violence-exposing media at this time. Needless to say, this clears very little up. Are social media, video games, and violence-containing media good or bad? Should we let our children partake in these activities, or not? This is difficult to assess, and frankly, not useful to delineate the black and white of video games and social media, particularly in the rapidly changing technological environment.

What may be practical for families to do when raising their children in this technology-ubiquitous world is to follow 2016 American Academy of Pediatrics (AAP) official recommendations from three policy statements, published in Pediatrics® 2016, for media use in children: 

  • Avoid screen media for children younger than 18 months – if a parent chooses to continue with media, they should choose “high-quality programming” and interact with their child during the use.
  • Limit screen time to 1 hour in children ages 2-5 years old. Interactions and “co-viewing” media can help children interpret what they are seeing as well as form bonds with the adults they interact with
  • Find a balance of screen time with limits for children 6 years and older – emphasize the importance of healthy sleeping patterns, physical activity, and other healthful behaviors. Families should consider using the Family Media Use Plan tool with HealthyChildren.org, linked here: https://www.healthychildren.org/English/media/Pages/default.asp​x
  • Have pre-determined media-free time together, as well as media-free locations
  • Continue to discuss the benefits and detriments regarding online media use and safe, appropriate media behaviors with children

Additional considerations that families should keep in mind include: 

  • Role-modeling media use for children in the whole family, not just the children
  • Avoiding technology use to regularly distract or soothe children
  • Understand that it is acceptable for older children and teens to be online; finding that balance between appropriate amounts, which foster typical teen development, and too much; this requires communication, trust, and frequent re-evaluation
  • Continue to encourage appropriate behaviors both on and off-line
  • Be mindful of red flags with a child’s online behavior; mistakes will be made, but be more cautious with behaviors such as bullying, sexting, or self-harming images
  • Provide education about privacy and online dangers (such as predators, sexting)

What can pediatricians and other providers do when faced with counseling regarding media use for their families in which media plays a large role in a child’s life? Suggestions from the AAP include:

  • Consistent discussion about the quantity, as well as quality, of children’s media consumption
  • Continue to encourage mindful screen-time, including co-viewing and co-playing
  • Recommend that parents screen what children are watching, particularly those younger than 6 years, and avoid virtual violence – children younger than 6 years are found to have difficulty delineating the fantasy of video-games from reality
  • Consider partaking in advocacy, and maintaining discussions with policy-makers or legislators. Minimal legislative action exists to decrease violence exposure in the media, and no single governing body monitors the content and ratings of games. Pediatricians can advocate for limiting access to violence-containing media for minors, as well as encourage increased creation of “child-positive” forms of media. 

Many questions still exist regarding both the short- and long-term impacts of exposure to violence in the media and video games. Parents and pediatricians alike require frequent reassessment to keep up with the changes in the interactive digital world. Constant discussions with children are recommended to continue to encourage safe and appropriate media use and video-gaming as they navigate through the vast realm of technology. Frequent re-consideration is critical as the landscape continues to evolve. 

Lori Xu, MD

References:

“American Academy of Pediatrics Announces New Recommendations for Children’s Media Use.” AAP.org, American Academy of Pediatrics, 21 Oct. 2016, http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Announces-New-Recommendations-for-Childrens-Media-Use.aspx.

“Children and Media Tips from the American Academy of Pediatrics.” AAP.org, American Academy of Pediatrics, 1 May 2018, http://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Children-and-Media-Tips.aspx.

Council On Communications And Media. “Media and Young Minds.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2591.

Council On Communications And Media. “Media Use in School-Aged Children and Adolescents.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2592.

Council On Communications And Media. “Virtual Violence.” Pediatrics, American Academy of Pediatrics, 1 Aug. 2016, pediatrics.aappublications.org/content/138/2/e20161298.

Coyne, Sarah M., et al. “Violent Video Games, Externalizing Behavior, and Prosocial Behavior: A Five-Year Longitudinal Study during Adolescence.” Developmental Psychology, vol. 54, no. 10, Oct. 2018, pp. 1868–1880., doi:10.1037/dev0000574.

Ferguson, Christopher J., and John C. K. Wang. “Aggressive Video Games Are Not a Risk Factor for Future Aggression in Youth: A Longitudinal Study.” Journal of Youth and Adolescence, vol. 48, no. 8, 4 Aug. 2019, pp. 1439–1451., doi:10.1007/s10964-019-01069-0.

Granic, Isabela, et al. “The Benefits of Playing Video Games.” American Psychologist, vol. 69, no. 1, Jan. 2014, pp. 66–78., doi:10.1037/a0034857.

History.com Editors. “Video Game History.” History.com, A&E Television Networks, 1 Sept. 2017, http://www.history.com/topics/inventions/history-of-video-games.

Hutchinson, Jeffrey W. “How to Advise Parents When Kids Can’t Put Video Game Controller Down.” AAP News, American Academy of Pediatrics, 21 Feb. 2019, https://www.aappublications.org/news/2019/02/21/masteringmedia022119

Prescott, Anna T., et al. “Metaanalysis of the Relationship between Violent Video Game Play and Physical Aggression over Time.” Proceedings of the National Academy of Sciences, vol. 115, no. 40, 1 Oct. 2018, pp. 9882–9888., doi:10.1073/pnas.1611617114.

Radesky, Jenny, et al. “Children and Adolescents and Digital Media.” American Academy of Pediatrics, American Academy of Pediatrics, 1 Nov. 2016, pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593.

“Video Gaming Can Lead to Mental Health Problems.” AAP.org, American Academy of Pediatrics, 17 Jan. 2011, http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Video-Gaming-Can-Lead-to-Mental-Health-Problems.aspx.

“Virtual Violence Impacts Children on Multiple Levels.” AAP.org, American Academy of Pediatrics, 18 July 2016, http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Virtual-Violence-Impacts-Children-on-Multiple-Levels.aspx.

Mistreatment of Immigrant Children at the Southern Border

It was a little over a year ago when I first heard about the child separations happening at the U.S.-Mexico border. I had recently had my own son and it gave me a visceral feeling of horror imagining someone taking him away from me, not knowing where he was going, when I would see him again, or who would take care of him. I read a story of a 4-month-old taken from his mother as I held my own infant of a similar age. I imagined what kind of fear would drive me to make a dangerous journey with a newborn and beg for safety in a foreign country.  Children continue to be separated from their parents and caregivers. They are kept in conditions unfit for anyone, and especially damaging for children. We need to speak out against the treatment of migrant children that is occurring and demand more humane solutions.

Whether unaccompanied or as part of a family unit, when children present for asylum, they are brought first through a Customs and Border Protection facility where by law, they are not to be detained for more than 72 hours (Linton et al., 2017). However, some children and families are being held for much longer (Linton et al., 2017). There are small, unwashed and underfed children taking care of younger, filthy toddlers without proper sanitation available, like clean diapers (Raff, 2019). Studies have shown negative physical and emotional symptoms among detained children under any circumstance (Linton et al., 2017), then their source of resilience might be stolen away- their caregivers. Even a short time in detention can have damaging psychological effects (Linton et al., 2017). Interviewed parents have described regressive behavior in their children after detention along with increased aggression and self-injurious behavior (Linton et. al 2019). They might come with parents or they may come with extended family members hoping to join their parents already in the U.S. (Linton et al., 2017). In 2016, “Family Case Management” was terminated, a short-lived program that was 99% effective in having these families in court, even by ICE’s own statements (Singer, 2019). The former program cost taxpayers about $38 a day, while the current system costs hundreds per day (Singer, 2019).  

Children are dying. They are dying. They are kept in ‘prison-like conditions’ (Linton et al., 2017) and in the last year, at least 7 children have died in immigration custody after almost a decade of no deaths (Acevedo, 2019). Dr. Dolly Lucio Sevier, a pediatrician who visited a Customs and Border Protection facility in McAllen Texas, one of the facilities where immigrants are not to be held for longer than 72 hours. She met a baby whose uncle was forced to feed him for days from an unwashed bottle (Raff, 2019). She met a teenage mom whose baby was wrapped in diapers and plastic because they refused to give her clean clothes for her infant. This facility is known as the hielera, or ice box (Raff, 2019). This mom was trying desperately to keep her baby warm when she had nothing but concrete and mylar blankets (Raff, 2019). Dr. Sevier saw unmistakable signs of mental trauma and illness. The children had not been allowed access to soap, toothbrushes, clean clothes; and many had been in the facility weeks. They smelled, were malnourished, dehydrated, and most had at least a respiratory infection. The baby who had been drinking from a dirty bottle was fevered and ill (Raff, 2019).

Exposure to the ‘prison-like’ conditions present in the immigration facilities causes high levels of stress (Linton et al., 2017). It has been well documented that toxic stress will have lasting effects on the health of these children, even if they manage to somehow get past the mental effects of their trauma. They will be at higher risk for heart disease, cancer, diabetes, etc (Garner et al., 2015). Their present health and their future health are being destroyed in one fell swoop. The recognition and reduction of toxic stress in children should be a priority for all pediatricians (Garner et al., 2015), and should be part of a routine evaluation for the care of immigrant children (Linton et al., 2017).

The American Academy of Pediatrics  issued a policy statement about the detention of immigrant children. The policy outlines many concerns and recommendations including that separating a parent or primary caregiver from their children should never occur unless there is a concern for the safety of the child (Linton et al., 2017). Practices in the CBP processing centers are inconsistent with AAP recommendations for the care of children, and therefore children should not be subjected to them. Community-based case management should be implemented for the children and their families (Linton et al., 2017). Children should receive timely and comprehensive medical care.  “Treat all immigrant children and families seeking safe haven who are taken into US immigration custody with dignity and respect to protect their health and well-being” (Linton et al., 2017). 

It is easy to feel helpless and overwhelmed. I urge you to not become complacent. Write your own opinion. Write your congressional representatives. Donate to the Annunciation House, which helps to house some immigrants. You can also give to RACIES (Refugee and Immigrant Center for Education and legal Services) or to the Human Rights Initiative of North Texas, both of which seek to help immigrants gain asylum and legal status, among other services. I encourage my fellow physicians to look for immigrants among our patients. Recognize the trauma they have been subjected to. Practice trauma-informed care and do your best to refer to services that can help.

Marie Varnet, MD

My son and I protesting the treatment of immigrant children in Dallas, Tx

Acevedo, Nicole. “Why Are Migrant Children Dying in U.S. Custody?” NBCNews.com, NBCUniversal News Group, 30 May 2019, http://www.nbcnews.com/news/latino/why-are-migrant-children-dying-u-s-custody-n1010316.

Garner, Andrew S., et al. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.” Pediatrics, American Academy of Pediatrics, 1 Jan. 2012, pediatrics.aappublications.org/content/129/1/e224.short.

Linton, Julie M., et al. “Detention of Immigrant Children.” Pediatrics, American Academy of Pediatrics, 1 May 2017, pediatrics.aappublications.org/content/139/5/e20170483#xref-ref-10-1.

Raff, Jeremy. “What a Pediatrician Saw Inside a Border Patrol Warehouse.” The Atlantic, Atlantic Media Company, 4 July 2019, http://www.theatlantic.com/politics/archive/2019/07/border-patrols-oversight-sick-migrant-children/593224/.

Singer, Audrey. “Immigration: Alternatives to Detention (ATD) Programs.” Congressional Research Service, 2019, fas.org/sgp/crs/homesec/R45804.pdf.

Autism is diagnosed starting at age 2. But what can we do before then?

In recent years, autism has been at the forefront of many discussions in pediatrics. Its prevalence has increased from 1 in 150 children to 1 in 59 over the last 20 years according to the CDC[i]and this is likely due in large part to our ever-growing knowledge of the condition and efforts promoting early diagnosis. Research thus far has shown that early diagnosis and intervention have been instrumental in generating positive outcomes. But how early can we start “therapy” for autism when it can’t even be diagnosed until 24 months of age? We now have research to show that pediatricians should be encouraging parents to consistently talk to their young children even if they aren’t getting any responses back.[ii]

A recent study published in the journal Autism Research delved a bit deeper into the concept of early intervention.[iii]Dr. Meghan Swanson conducted a study looking at 96 infants, 60 of whom had an older sibling with autism. Such a design was necessary given the age restriction on diagnosis and that younger siblings of children with autism have a 20% chance of having autism as well. This statistic was proven true as 14 of those 60 subjects were later diagnosed with autism at 24 months (23%). Dr. Swanson’s method was to monitor 2 full days of audio in the child’s home via LENA audio software- one day when the child was 9 months old and again at 15 months. The LENA software counts number of words as well as “conversation turns,” meaning when one person speaks and another responds. The content of what is said is not evaluated. The subjects’ language skills were then later assessed at 24 months. 

As mentioned, 14 of the subjects were ultimately diagnosed with autism and were placed in the “high-familial-risk who have ASD” group. The remaining subjects were divided into 2 groups: 1) those with older siblings affected by autism but who did not have autism themselves (high-familial-risk who did not have ASD, n=46) and 2) low-familial-risk who exhibited typical development (n=36). The conclusions of the study were two-fold. First and most important, a richer home language environment with higher numbers of adult words and conversational turns correlated to better language development for ALL study groups. Second, higher parent education levels corresponded to richer home language environment. 

As these results show, the benefit from caregiver interaction particularly in the realm of reciprocal spoken language is not restricted to typically developing children. Pediatricians should advise parents to enhance their child’s development from birth by speaking to them regardless of whether they are able to respond appropriately or at all. To be clear, autism is not a diagnosis that is caused by parenting style. The diagnosis will be present or not regardless of parental intervention. However, this study shows that frequent and early communication from birth can improve language development even in children with autism. Additionally, there are centers available that can provide more directed therapies for children struggling with language, social skills, and other developmental milestones. Life Skills Autism Academy is opening its flagship location in Plano, Texas where children 18 months to 5 years can receive personalized one-on-one therapy and assistance in developing an appropriate Individualized Education Plan (IEP) and advocating for the child in the school system.[iv]

Pediatricians can share this knowledge to help all their infant patients improve language development and kickstart their learning with the goal of success in school and beyond. 

Rachel Tonnis, MD

[i]https://www.cdc.gov/ncbddd/autism/data.html 

[ii]https://utdallas.edu/news/research/autism-language-skills-study-2019/

[iii]Swanson, Meghan R. “Early language exposure supports later language skills in infants with and without autism.” Wiley Online Library. Dallas, TX. 1 Sep. 2019. https://onlinelibrary.wiley.com/doi/abs/10.1002/aur.2163.

[iv]https://www.dallasnews.com/business/health-care/2019/08/29/life-skills-autism-academy-opening-in-plano-plans-to-provide-one-on-one-therapy/

Mental Health Screenings in Adolescent Care

The first week of October every year is designated as Mental Health Awareness Week in the United States – a pattern established by our Congress in 1990 to recognize the efforts of the National Alliance on Mental Illness (NAMI, www.nami.org) and increase awareness about mental health conditions. As we close out the end of Mental Health Awareness Week, I would like to focus on an important topic that sometimes ends up being overlooked or rushed through at a primary care visit: mental health screenings in the adolescent population.

According to results derived from a recent National Comorbidity Survey Replication, nearly 50% of all mental health conditions in the United States begin by age 14. Per data from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA), suicide is currently the second leading cause of death in adolescents; 18% of high school students nationwide reported having seriously considered attempting suicide (females > males), and at least 9% had attempted suicide one or more times. Identifying a possible mental health diagnosis early in life — such as depression, anxiety disorders, ADHD, eating disorders, or PTSD — can help save many individuals from life-altering consequences.

The American Academy of Pediatrics (AAP) recommends annual mental health screenings for adolescents starting at age 12. While state Medicaid provisions in Texas previously only allowed for one mental health screening, total, to be billed between the ages of 12 and 18 as part of an annual well-child exam, recent Texas legislation passed on September 1, 2017 (HB 1600) now allows Medicaid reimbursement for up to once-a-year mental health screenings with well-child exams from the ages of 12-18, which is an important step in the right direction.

Texas, however, is currently in the midst of a mental health workforce shortage, especially in child and adolescent psychiatry. Although legislative efforts to address this shortage within the state are in progress, it renders the pediatrician or primary care doctor’s duty to address mental health within adolescent well-child visits absolutely imperative at this moment.

Screening questions/tools that can be used in an adolescent primary care mental health screening can include, but are not limited to:

  • HEADDDSS Assessment:
    • Home – living situation, safety in the home, relationships with family
    • Education/Environment – address any learning/attention difficulties, friends and social circle, school and online bullying, social media (mis)use
    • Activities – hobbies, extracurriculars, jobs
    • Diet – include screening for disordered eating behaviors
    • Drugs:
      • Substance Use Screening Tool: CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)
    • Depression/Suicidality:
      • Screening Tools: PHQ-2 (initial screen) + the more detailed PHQ-9
    • Sexual Activity/Sexuality/Sexual Abuse
  • Anxiety Screening Tool: SCARED (Screen for Child Anxiety-Related Emotional Disorders)
  • Trauma Screening Tool: CATS (Child-Adolescent Trauma Screen)
  • Pediatric Symptom Checklists (PSCs)

*Note: Mental health screenings for adolescents under Texas Medicaid must utilize at least 1 of the screening tools approved by Texas Health Steps, which includes the PSCs, the CRAFFT, and the PHQ-9.

For additional mental health information for patients, such as finding the closest behavioral health treatment centers, an excellent resource is the national SAMHSA website at https://www.samhsa.gov/treatment/index.aspx.

Anita Verma, MD

References:
American Academy of Child and Adolescent Psychiatry. (2013). Child and Adolescent Psychiatry Workforce Crisis: Solutions to Improve Early Intervention and Access to Care. https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap_workforce_crisis_201305.pdf
American Academy of Pediatrics. (2017). Recommendations for Preventative Pediatric Health Care. Bright Futures, 4th Ed. https://www.aap.org/en‐us/documents/periodicity_schedule.pdf
Centers for Disease Control and Prevention. (2016). Children’s Mental Health Report. CDC Features: Life Stages and Populations. https://www.cdc.gov/features/childrensmentalhealth/
Centers for Disease Control and Prevention. (2016). 1991-2015 High School Youth Risk Behavior Survey data. http://nccd.cdc.gov/YouthOnline/App/Default.aspx
Department of Health and Human Services, Office of Adolescent Health: Adolescent Mental Health Fact Sheets. https://www.hhs.gov/ash/oah/facts-and-stats/national-and-state-data-sheets/adolescent-mental-health-fact-sheets/texas/index.html
HB 1600: Relating to certain mental health screenings under the Texas Health Steps program. http://www.capitol.state.tx.us/BillLookup/Text.aspx?LegSess=85R&Bill=HB1600
Kessler R.C., et al. (2005). Lifetime Prevalence and Age of Onset Distributions of DSM‐IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6): 593‐602. https://www.ncbi.nlm.nih.gov/pubmed/15939837
Testimony of Pritesh Gandhi, MD, MPH, to the Texas House of Representatives Public Health Committee, in support of HB 1600, March 2017. Submitted on behalf of the Texas Pediatric Society, Texas Medical Association, and Texas Academy of Family Physicians. https://txpeds.org/sites/txpeds.org/files/documents/house-ph-hb1600-3-14-17.pdf