Summertime = School Physical Time!

Summertime is the time many school aged kids get their annual check ups. In Kansas it is important that high school aged kids do their physicals after May 1st if they want to participate in a school sport. Other kids simply don't need to miss school on their birthday to do a physical. It's also good to avoid our office during sick season if possible. For all these reasons, summer time is a great time to have a well check. So if you haven't scheduled your physical exam yet, it's time to call! Appointments do fill in fast.

Why do healthy kids need to come in? It's recommended that kids have annual screenings for growth, development, injury prevention, and more. Actually there's so much that we are supposed to discuss and do at a well visit that it is impossible to do it all in a standard 20 minute exam. (See Drowning in a Sea of Advice for more.)

To help with this enormous volume of information, we use handouts and our website to share a lot so we can spend time at the visit discussing your other questions. Please take the time to register each of your children on our website so you will get a pre-visit e-mail. This is becoming even more important as we are trying to be your true medical home and provide the best care to every patient with their unique needs.

To register, simply go to www.pediatricpartnerskc.com and click on the "Create an Account" tab at the top of the page and fill in the information. (Note: Firefox seems to be the best browser for our website. If you are using Explorer or Safari and cannot get the site to load properly, try Firefox.)

Once you've registered the first child, it's easy to add family members. See our How To page for details!

By registering each child you will be able to not only receive these informational pre-visit e-mails, but also ask questions to our front office staff or your favorite providers in a confidential password-protected manner, and pay bills online. Everything is confidential and we will never sell your personal information. 

Our pre visit e-mails have age-specific information to consider before your visit. Please take the time to read through it. Each e-mail has a homework section that is especially important. If you do your homework before the visit, you will find the visit to run more smoothly and you will get more out of it.

This summer I am doing a test of sorts. We are including several printables on the pre-visit e-mail to make your office time easier. You can print your patient information sheet if needed (due once/year, usually at the annual checkup, so young children who come more often don't always need these). We are starting a pre-visit questionnaire that will help identify any concerns to address at the visit. I am hopeful that we will be able to cover more of your specific questions if we know you have read the information on the e-mail, so we don't have to repeat all of the standard things. This should allow much better use of time at your visit to address your concerns.

Watch for your pre-visit email and take the time to read it! I hope to see your kids for their well checks soon!

What kids need to be able to do to leave the nest...

photo source: Shutterstock

It's graduation season, which has me thinking of all the ways our kids grow over the years. They're born, then just a few years later they are in kindergarten. In just a blink of the eye they get a locker in middle school. Then high school is over. The world awaits...

Where does the time go?

I have one who will be starting high school next year, and have spent a lot of time reflecting about at all he's learned and what he needs to learn to be successful, independent, healthy and happy.

I have never really thought that school is about learning the actual subjects. It is more about learning how to learn. How to organize. How to be responsible. I have always told my kids I don't care what grade they get as long as they learn what they need to and do their best.

Home life is also a process of learning. We learn how to live healthily and respectfully with others. We learn to take care of ourselves. We learn to be responsible with money. Ideally we learn to argue a point without losing control of our emotions or being hurtful.

In all of this reflection, I came up with a list that I have shared with my kids, and I invite you to share it with yours.

Things you should be able to do independently before leaving home:

Good hygiene habits

• Brush teeth twice daily. Floss once a day. 
• Shower or bathe daily. Wash hair as needed for oil control. 
• Wash hands often. 
• Shave as needed. 
• Flush.
• Brush hair at least daily and get a hair cut regularly. 
• Clip and groom nails regularly, fingers and toes. 
• Use personal hygiene products correctly, including: deodorant, facial acne cleansers, etc. 
• Wear clean clothes and change underclothing daily. 

Healthy habits

• Get adequate sleep to wake fresh and ready for the day. Set an alarm and get up on your own. 
• Eat healthy foods and limit junk food and sodas. Be able to prepare simple healthy meals. 
• Take vitamins daily. 
• Understand common over the counter medicine indications and how much to take.
• Understand why you are taking medications (if you are), how to take them, and what is needed to get more -- is it over the counter or a prescription medicine?
• Know your medical history, including any allergies and chronic health care problems.
• Know how to take care of common injuries until they are healed. 
• Exercise regularly, at least 3 times a week. 
• Develop healthy strategies to handle stress. 

• Journal 
• Prayer or meditation 
• Sketch or other artwork
• Talk to someone openly—don’t hold bad feelings in! 
• Take a long bath 
• Think before speaking 
• Deep breathing 
• Laugh 
• Exercise 
• Schedule down time 
• Think about the problem from different points of view 
• Break big projects into small parts to be able to complete in parts 
• List the good things going on and be positive 
• Avoid overscheduling
• Learn to say "no"

• Enjoy social interactions as well as alone time. 
• Exercise the brain by doing puzzles or reading.

Things to learn

• How to cook a healthy, balanced meal. 
• How to grocery shop on a budget to incorporate nutritional balance.
• How to properly clean dishes and tidy up the kitchen after eating.
• How to balance a check book, make a budget, and pay bills on time.
• How to do easy repairs around the house.
• Understand health insurance plans - how to get them, what they cover, what is excluded.
• Basics of money investment, retirement planning, savings.
• What to do in case of a road side emergency.
• Important numbers (doctor, dentist, insurance, etc).
• How to do laundry.
• How to clean a bathroom, use a vacuum, and dust.
• How to sew basic clothing repairs (buttons, hems, etc).
• How to get help when needed.
• How to apply for a job and build a resume.
• Choose words carefully: they can build someone up or crush someone down. 
• Drugs and alcohol should be treated with respect and used only with good judgment. This judgment should take into consideration laws and safety. Our brain does not fully develop until the early/mid 20s and early use of drugs or alcohol increases the risk of addiction.

Be a good friend and responsible family member

• Be clear with plans: Look at the family calendar when making plans. Get permission from all parents involved; let family know where you will be and when you will be home. 
• Keep a phone available to be able to call when needed. Answer calls/texts from parents! 
• Treat everyone with respect: family, teachers, friends, and strangers. 
• Require that others treat you with respect. 
• Do random acts of kindness occasionally. 
• Volunteer regularly.
• If you feel unsafe, leave the situation. Tell a trusted adult as soon as possible. 
• Do only things you and your parents will be proud of. 

Things to do to show you are getting ready to leave the nest...

• Complete assigned homework and chores without reminders or nagging. 
• Keep your room picked up and clothes off the floor. 
• Hang your towel to allow it to dry between uses. 
• Clear dishes from the table. 
• Clean up after projects or play. Return all things to their proper place after using them. 
• Throw all trash in the trashcan. Recycle things that are recyclable. 
• Responsible use of cell phone, computer, and other electronics. Turn off before bedtime to allow uninterrupted sleep. 
• Spend and save money responsibly. Never spend more than you can afford. Use credit cards wisely.
• Take pride in your work: schoolwork, chores, job, and helping others. Do it to the best of your ability and ask nicely for help as needed. Recognize that work is not always fun, but necessary. Doing tasks with a good attitude will help. 
• Time organization skills: Do not procrastinate until the last minute. Plan ahead and do big projects in small steps. Be prepared with all materials you will need for a project and ask in advance if you need help acquiring items. Use tools (apps, calendar, check lists). 
• Take care of your things. Keep them in proper working order, clean, and put away. 
• Drive responsibly. 
• Accept consequences with grace. 
• Earn trust. 
• Know when to trust and follow others and when to take your own path. Make independent decisions based on your own morals. Have the courage to say "no" if something goes against your beliefs.

Group Teaching With Physicals

Around the country the idea of group physicals has been gaining momentum. A recent article in Everyday Health "Group Appointments With Doctors: When Three Isn't a Crowd" explains it well. Before you get creeped out thinking of the doctor examining everyone in a big room, everyone still gets a private exam. The benefit is getting more detailed information and sharing questions with others in a similar interest group.

There are so many teaching points to discuss at annual well visits that it is impossible to fit them into a typical 15-20 minute appointment. If you're really interested in the recommendations (and I will admit I fall short on addressing every one of these sundry things at standard visits and still won't be able to fit them all into the group visit) they are found on Bright Futures.

A solution many doctors are finding helpful to cover more topics is to do a group teaching session to review all the nutrition, safety, development, and vaccine information, then break into individual rooms for history taking, vitals, vaccines, and exams. This eliminates the repeated advice and instruction for separate patients, allowing more to be discussed with a group of patients and still allow time for individual exams.

The benefits to patients are many:

• More information shared in a comprehensive manner
• Start on time!
• Individual time with the nurse and physician 
• Potential to learn from others in the same age group (from discussion/questions raised)

Since summer walk in clinic tends to be slow and many teens need physicals before school starts, I think the opportunity is presenting itself to have a Saturday morning session. Although it is hard to know exactly how it would pan out, I expect that the entire time will be about an hour (which is about the same time for a standard well visit, but less time waiting). Some kids would check in before the discussion to have their vitals and exam, others would arrive for the session and have the exam afterwards. This would allow everyone to be there less overall time, with more information shared. This venue does NOT allow time to be devoted to other health issues, such as chronic illnesses and prescription refills. People who wish to discuss a laundry list of things will be asked to return for a separate visit to be able to devote appropriate time to issues. (This applies to standard well visits as well since each topic can be given its own importance at a separate visit.)

If your teen(s) (13-18 years) would like to participate in this pilot project, please call the office to get on a list of interested people. Be sure to let staff know any blackout dates you can't attend. I will assess how many people are interested, available dates, and ages of the interested teens to offer a few dates for appropriate ages. If your teen already has an appointment scheduled, my staff can move them to the group visit easily.  At the end of the session you will be asked to complete a survey about the concept and the work flow of the visit.

If this idea works out, I will add other age groups.  I think newborns would especially benefit, because they could follow with the same group as the kids age, allowing them to form bonds with other families and get support for all the concerns of their age group.

Call the office soon if you're interested!

Teen Dating Violence Awareness Month

February is Teen Dating Violence Awareness Month, so it is a great time to learn about this all too common problem.

Teen Dating Violence is a very difficult and complex topic.  Teens might share friends with their abusive partner. Their friends might think the abuser is wonderful, lending to peer pressure to stay together. They typically go to school together, so it is difficult to avoid each other entirely.  Teens might fear trying to leave the relationship safely.  If teens have lived with domestic abuse at home, they might even think the abuse is normal.  The abusive behaviors tend to lower the victim's self esteem, making leaving feel less desirable since they feel no one else will ever care about them and a bad relationship is preferable to being alone.  They often have feelings of love and attachment to the abuser, and hope that behaviors will change.  Online teens can experience cyberbullying even when not with their (ex-) partner. There are often no physical signs, but the emotional scars can last a lifetime. Learning about abuse characteristics can help save someone you love from a dangerous relationship!

Nearly 1 in 10 high school students report being physically hurt by their boyfriend or girlfriend in the previous year.  (CDC 2009 Youth Risk Behavior Survey)

1 in 10 = TEN PERCENT of high school kids in the past year were hit, slapped, or otherwise physically hurt by their date!

The Liz Claiborne Inc.'s Love is Not Abuse 2011 College Dating Violence and Abuse Poll showed that 43% of dating college women have experienced violent and abusive dating behaviors.

That's nearly HALF of college dating women who have been victims!  

I remember as a medical student working ER shifts or in the STD clinic and seeing several college girls come in for suspected sex while drunk (they never called it rape) or after unplanned/undesired sex with a "boyfriend".  They typically just wanted testing for disease, but what they really needed was much more!  They had mixed emotions and were confused about who was at fault.  They had a lot of guilt that really was misplaced (in my opinion).

Though females are more likely to be the victims (1 in 4 women have been assaulted by a partner), 1 in 14 men report being victims.  Regardless of sex, it is likely that abusive relationships are underreported due to the nature of the problem.

We see news stories of abusive relationships but it doesn't always seem real. A new bride murdered.  A teen raped.  A sports figure accused.  Unfortunately we don't even know about most abusive relationships. People suffer silently.  How is a parent to know?  Can a teen see risk factors before becoming involved with a risky personality?

Parents might look for the "type" of teen that they want their child to steer away from, but unfortunately, the abusers are not easily identified.

They typically are very smart, personable, likable people.

They manipulate others.

They gain trust.

They weave deception.


What it might look like: 

The relationship typically starts out well.  A lot of laughs, good times.  If it didn't, people would leave.  Abusers have a power and control cycle that builds over time. They gain a little trust, then test with a little control.

Bit by bit they become more controlling and abusive.  It builds so slowly many people miss the early warning signs and then are so swept by the cycle that it is hard to leave.

Abusers want to know your every move, which at first might even seem flattering, but it is a control tactic. They might chose what you wear or where you go. They monitor your phone calls to see who you talk to.  They isolate you from your friends and even family so you lose your support group.  They put you down so you feel no one else would like you or want you.  They make you feel less of a person and they are "good" to put up with you.

They get jealous (again, flattering on the outset because they "care").  They often apologize for hurting you, but then claim it is your fault that they behave that way. In truth, they blame others for most of their behaviors and only take credit when things make them look good.

What to do?

There are many levels that need to be addressed to prevent and recognize abusive relationships, starting with how we raise our children from infancy and continuing throughout their lives.

Children who are raised in homes with abusive behaviors are much more likely to grow up to be in an abusive relationship.  If your home is not safe make every attempt to make it so.  Stop the cycle!

Abusers often monitor your computer and phone use, so use caution.  

From a safe computer, click here if you are in the KC area.  From a safe phone call 913-262-2868 (phones answered 24/7 confidentially at SafeHome).

We need children to feel loved and secure.  Children who feel unloved might look for love in all the wrong places, trying to please others and end up being taken advantage of.  Love unconditionally!

Kids need defined limits, but an ability to learn and grow into independence with experience.  Being firm and setting boundaries is an important part of being a loving parent.  You are NOT their friend. You don't need to be a friend to be an effective, loving, parent who is well loved and respected.

Kids need help learning to stand up for themselves and to deal with anger and disappointment in a healthy way.  Set an example for this.  Life typically presents many opportunities to model these behavior.  If you have not learned to control your temper, learn.  Ensure enough sleep for everyone at home, as we are all more short tempered when tired. Choose words carefully.  Remain calm.  Of course you can't be a pushover either.  There is a way to stand firm in your position without yelling and losing your temper.  There are many self-help books on this topic and counseling is available.  It is that important!

Kids need to learn to accept responsibility.  Responsibility should grow as kids grow.  They should have appropriate consequences that teach lessons along the way.

Remind teens that they are never to blame if someone forces them to do something sexually they don't want to do. They need to feel open to share this pain with you or another trusted adult so they can get the help and support they need.

Kids need respect.  Do unto others as you would have done unto you. These words of wisdom have passed through the generations, and are needed as much now as they were generations ago.

They should be taught to respect themselves in all they do: eat nutritionally, exercise, get enough sleep, wear helmets, buckle up, stay away from drugs, etc.

They should be taught to respect others: say nice things, don't ask others to do things that might cause them harm, respect their personal space and things, etc.

They should enforce that others treat them with respect. If a friend does not treat them with respect, they can try first to talk with the friend about it if they feel safe doing so. If the friend does not change behaviors, they should leave the friendship. 

How can parents and teens recognize signs of potential abuse?  Use your instincts. If you suspect something is not right, act on your hunch and take action to address issues and leave the relationship early if problem behaviors persist.  Get help from local resources as needed.

Things to watch for with an abusive relationship:

• Relationship moves quickly to "serious"
• Jealousy in the relationship 
• Frequent calls, texts, and other contacts  
• Control issues in the relationship
• Isolation from family and friends
• Mood swings, anxiety, or depression
• Physical signs: bruises, cuts, scrapes, showering immediately when coming home
• Verbal criticisms are overheard: stupid, fat, ugly, no one else would put up with you, etc
• Abused feels guilty and "at fault" and makes excuses for their partner
• Personality changes in the abused
• Drug or alcohol use
• Multiple sexual partners

What are signs of an abusive personality or one who is likely to abuse? Abusers do not look like drug dealing, tattoo covered, pierced people in tattered clothing. They are difficult to recognize on first glance because they tend to be popular, good looking, and personable.  They are often *good at reading people and responding to other's desires, making them seem "perfect" initially.

Traits to watch for in an abuser: 

• One who blames others for all problems
• One who wants to move quickly into a relationship
• One who does not respect personal boundaries
• One who is easily jealous 
• One who is insulting (you're fat, you're stupid, no one else would love you like I do)
• One who has a history of hitting or hurting others
• One who criticizes others
• One who takes little personal responsibility for actions
• One who tries to monopolize your time and life
• One who seems perfect initially (no one's perfect!)
• One who has mood swings or can't manage anger or frustration well
• One who takes big risks and is impulsive
• One who wants to control what you wear, who you are with, and what you do

Where to go for more help:

Be Smart. Be Well

Centers for Disease Control and Prevention

Love Is Not Abuse

National Network to End Domestic Violence

Safe Home

Teen Dating Violence

Chores for kids become chores for parents?

As a parent I see the great value of chores for kids.

• Anyone can learn the satisfication of completing a task, improving self confidence.  
• Young children can improve self care competence such as with bathing and dental hygiene. 
• Older kids can learn money appreciation and management if they are paid and expected to save some and share some of their well-earned money.  Learning to save for a large ticket-item and not spend frivolously is a great life lesson many adults missed.
• Older kids can establish a great attitude about work and learn real-world skills such as laundry, cooking, and cleaning.  
• Kids might even gain self esteem by the positive intrinsic reward of a job well done.  
• They learn responsibility.

The downside?

Chores for the kids often make work on the parents harder.  (Who said parenting is easy?)

Parents must decide what tasks are able to be done by children at various stages of maturity.  There are on-line resources available to help guide parents.  This is one place I disagree with the WebMD list because they say a 10 year old can mow the lawn--not recommended by the AAP until 12 years!

Some good lists: Workingmom.com, Focus on the Family, Chores-Help-Kids

Parents must make sure the chores are completed or set a means of monitoring what is done. Ideally chores would be accomplished without fighting and whining, but how?  Verbal praise and acknowledgment is always a winner.  If parents choose to reward chores with stickers, gifts, or money, there must be a way to track when a task is complete.

Consistency is key in any form of discipline, and this includes the tracking of chores.  The biggest reason chores fail in my house is we (the parents) forget to check the lists to be sure the kids did them.  Having a consequence for not doing the expected chores versus getting a reward for doing the list... behavior experts disagree on these points.

Many behavior experts recommend to not remind kids to do chores.  They feel that the negative consequences of not doing the chores will teach the lesson better than the constant nagging to do the chores.  I have found that without reminders the chores are simply not done, but this does not mean I must always directly remind.  Praising the initiation ("I'm glad you are getting your homework done early tonight!"  "I see you remembered to sort your laundry, that's the hardest part!") is often an effective way to get kids to complete the task.  There is a fine line between nagging the kids to do the expected things and letting the chores slip by without being completed.

Over the years we have had many means of keeping track of chores in my family.

• When the kids were young, we first tried a dry erase board, but that got erased too easily.
• We then found a simple paper chart each week that had lists that could earn stickers. I liked the format because it separated tasks into the general categories below, but we often forgot to mark things off at the end of a busy day, so there was little reinforcement for the kids to do the chores.  The categories of chores:

• Self: included things such as brush teeth, bathe, get dressed 
• Home: included things such as pick up toys in living room
• Room: included things such as pick up room, make bed
• School: included things such as help a friend, homework, pack backpack

• One of my favorites was a system called 10-20-30Go! that friends developed.  It was wonderful because it is based on the kids taking full responsibility for marking down what they did. It is simple and includes a strong family and faith base.  It was one of the longest running systems that worked for us, but as all systems, it also faded in follow through.   A big reason was that we often had activities that interfered with the family meeting night, no matter what night of the week we tried to do it.  (Family meeting nights are still a great thing, but difficult in a busy house!)  We also found that the kids didn't look forward to their allowance, so it was little reinforcement to do the tasks.  They might have been too young at the time.
• Another favorite system of mine due to ease of use, cost (free), and kid -centered responsibility is MyJobChart.  It works well for kids who can use the internet fairly independently.  My kids can log in to their account and mark the chores as they do them, or once a day.  They earn points, which they can choose to share (with pre-determined charities), spend (on items I help pick), or save (for the future!)  I like many features of this system, but it still has periods that my kids forget about it for weeks, then periods that we all remember again.  They still do their chores (or they have no clean clothes the following week... or whatever natural consequence follows the forgotten chore) but they don't always mark them down for credit.

What do you find helps to keep your kids up to date on their chore list?

Concussions in Athletes

Concussions in athletes has been the subject of many headlines over the past couple years.  For as much as we know about concussions, there is still much more we need to learn about head injuries and their healing. While most kids recover from concussions within days to weeks, there are some who suffer for months.  This can disrupt not only sport participation, but also reading, concentration, and the ability to learn.

What we know:

• We know that children's brains are still developing and are more at risk with concussions than mature brains. 
• We know that many athletes attempt to hide symptoms of a concussion so they can continue to play. (Bad idea!)
• After a concussion -- even serious ones that affect the daily activities of a teen -- kids are often eager to return to the game that puts them at risk for another injury.
• Symptoms of a concussion range from mild to severe.

• headache
• nausea or vomiting
• slurred speech 
• dizziness 
• ringing in the ears
• trouble concentrating
• sensitivity to light or noise
• sleep problems
• balance problems
• memory loss  

Treatments:

• There are no specific treatments for concussion.
• Rest is important. This includes not only avoiding activities that increase the risk of another injury, but also brain rest. Some kids need quiet time in bed without lights, sounds, television, computers, or books.
• Headaches can be treated with pain relievers and sometimes migraine medications.
• Memory and thinking problems are treated with rehabilitation and memory devices (like a calendar or planner).  Occasionally stimulants (the medicines used for ADHD) are used temporarily.
• Depression and anxiety should be managed by someone experienced in dealing with post-concussion syndrome.

Return to play is a gradual process, in which the athlete progresses in a step wise manner.  If any symptoms return during the stepwise process, the athlete must stop activities and return to a medical practitioner for evaluation.

Step 1: Light aerobic exercise 5-10 minutes without weight lifting, resistance training or other exercises

Step 2: Moderate aerobic exercise 15-20 minutes of running at moderate intensity without a helmet or other equipment.

Step 3: Non-contact training drills in full uniform. May begin weight lifting and resistance training.

Step 4: Full contact practice.

Step 5: Full game play.

Kansas has a new Concussion Law effective July 1, 2011, that requires the State Board of Education and the Kansas State High School Activities Association to provide information about the risks of head injury to coaches, athletes, and parents and guardians of the school athletes. This information should include the risks of playing or practicing with a concussion.  Under the new law an athlete may not participate in a school sport or practice unless the athlete and the parent/guardian have turned in a signed head injury release form each year.  Any school athlete who is suspected of having a concussion or head injury will immediately be removed from play or practice and will be allowed to return to play only after a health care provider gives medical clearance to return to play.

Athletic trainers are available at many local schools to help identify the athletes at risk of concussion. They will be testing kids with various methods, and at this time there is still a lot of variability in what each school program is doing.  It is best to have baseline testing done BEFORE any brain injuries (ie the start of the season) to compare to testing done after a suspected concussion.

If your child is suspected of having a concussion, bring any available test results (both from before and after injury if possible) to your appointment with a healthcare provider.

Prevention is still the best medicine!

• Wear proper gear at all times.  
• Be sure helmets are in good condition and fit properly. 
• Wear mouth guards at all times.  
• Follow the rules of the game. 
• Sit out if injured.  
• If you suspect someone might have a concussion, speak up!

To read the Kansas State High School Activities Association Recommendations for Compliance with the Kansas School Sports Head Prevention Act and Implementation of the National Federation Sports Playing Rules Related to Concussions, click here.