Summer Slide...

How do you prevent the summer slide at your house?

By Artaxerxes (http://creativecommons.org/licenses/by-sa/3.0), via Wikimedia Commons

No, not a fun water slide.

You know, the one where all the great information and skills your child learned during the school year dwindles and is forgotten in the months of no brain stimulation?

Some ideas that my family's done or that I wish we would have done...

Read

I am a big believer that kids should read every day. I don't care if it is a comic book or a 1000 page novel. As long as it is age appropriate, kids should read.

• You can have them read signs along the road or the map at the zoo. 
• Kids can read below their reading level to work on speed and just enjoy the story. 
• They can read at their level (or one a little challenging) to work on increasing their reading abilities. 
• Visit the library often. 
• Take turns in the evening with the family reading out loud together - like people did before television. This builds family bonds and is an inexpensive fun activity that can become a fun family tradition.
• Ask about what your kids are reading. Can they summarize what they've read? What do they think will happen next? How would they have ended the story differently?
• Gather a group of friends and start a summer book club. Pick a few good books, and meet once a week to talk about them.
• Check out the many places that offer summer reading rewards, such as your local library, bookstore, or school.

Games

Games and puzzles are another great way to build thinking skills.

• Board games can work on colors and counting for young children, and problem solving and strategy building for older kids. They also work on social skills (such as waiting your turn and being a gracious winner or loser). 
• Computer games can be great learning opportunities, despite all the warnings to limit screen time. Too much of anything is not healthy - we need balance in our lives. Monitor screen use for age appropriate activities and limit times, but allow intellectually stimulating games sometimes. Many computer games allow kids to learn from their mistakes and master skills in fun ways.
• Age appropriate puzzles, sudoku, cards, and word games are a great way to learn critical thinking, build vocabulary, and keep math skills sharp. 

Question

• Throughout the day you can ask your kids questions that require thinking before answering. Instead of letting them give just a simple factual answer, ask how they came up with it or how they feel about something. 
• Let them help you pick out meals for the week, taking into consideration the nutritional components of a healthy meal. Ask how they would like the broccoli to be served.
• If they help cook, you can have them convert a recipe to double it for a neighborhood picnic.
• Describe the weather forecast and plans for the day and ask what clothes would be appropriate with that in mind. 
• Ask kids how they feel in response to things that happen throughout the day. 
• Play a game of what if? How would something that happened have turned out if they did or said something differently at any given moment? (One rule: you can't change what others do or say in real life, so you can only change what you would do or say in the game.) Think about the response other people would have had (such as "What could you have said that would have changed the outcome when Billy cut in line at the slide?" Or "What Sally would have said if you said ___ instead?) or ask about what physical events would have changed (such as if they threw the ball to Bob at first base instead of to the pitcher or if they jumped into the cold pool instead of entering slowly).
• Ask if there's another way to do something, since there are usually many options to get to the same place or conclusion. Maybe there's an alternate route to take to the zoo since there's an accident on the road you usually take. (This also works well if they get the wrong answer, such as on a math problem.)

Play and explore

• Outdoor play is amazing for kids and their development. As they climb, roll down hills, build forts, or do whatever, they are working on motor skills.
• Playing with other children helps develop healthy social skills. When kids are always told what to do (school, sports, other scheduled activities) they never learn how to be independent, which can harm them in the long run.
• Play school. Kids love to be the teacher and teach others!
• Visit a museum, zoo, or historical site.

Music and dance

• Kids love to put on shows for friends and family with acting, singing, dancing and playing instruments. This can be impromptu fun or a more organized neighborhood event where they make posters to announce the show and even make tickets to give out. 
• Older kids will love to shoot videos of themselves and share online. Be sure parents review what is posted and it is appropriate for the type of posting (public vs private). 

Create

• Coloring, chalk art, painting, building with blocks or Legos ... so many options!
• Design a "dream" bedroom and show how even small changes can update the room.
• Make a map of your town of all your favorite spots: home, parks, grocery store, the zoo...
• Have kids make up their own game, complete with game pieces and rules.
• Design new outfits from dress up clothes (or actual sewing for older kids) and put on a fashion show for friends and family.
• Build an art gallery over the summer. Make paintings, paper mache, clay models, whatever suits you! Put it all out for display at the end of summer and invite friends and family to see the art!

Volunteer and give to charities

Volunteering not only helps others and makes our world a better place, but it also fosters a humble heart and can help develop skills we might not know we have. It puts us outside our comfort zone sometimes, which builds us into a better person. By focusing on helping others, we become happier.

• Kids, tweens and teens can find many opportunities to volunteer during the summer months. 
• It can be as simple as playing with young neighbors while their parents do yard work or run to the store, help with a neighbor's pet and newspaper while they are out of town, or pick up trash on a family walk. 
• Teens can find volunteer positions in many places. In my community that may be with their church or synagogue, at Deanna Rose Farmstead, hospitals, animal shelters, Harvester's Food Bank, and many more.
• Kids can write letters to soldiers, make blankets for sick or foster kids, pick up trash at a park, plant a tree, make a care package for a soldier, and many more.
• Anyone with long hair can donate hair to kids in need through ChildrenWithHairLoss or WigsForKids.
• If your family wants to financially help a sponsored child in another country, check out Unbound. Your child can help write letters to that child and learn about that child and his/her life from letters received.
• As a family: go through closets and dressers to find clothes, games, books, and toys that are appropriate to give to your favorite charity. To see how charities rank, check out CharityNavigator and CharityWatch.
• For more ideas, check out DoSomething.org.

Science

The internet makes doing science experiments easy! Check out my Pinterest Science board for ideas.

Make a bucket list of things to do and start doing them!

Learning and Behavior Series Part 5: Medications

This is the 5th post in a series of blogs on Learning and Behavior. It will focus on prescription treatments used primarily for ADHD.

There are many parts to the treatment of ADHD including behavior modifications; school accommodations; optimizing nutrition, sleep, and other healthy habits; and supplements -- all covered in previous posts in this series. This one will cover common medications that have been approved or are commonly used for the treatment of ADHD. I am not going to go into how to diagnose ADHD here, but it is of course of utmost importance to have the correct diagnosis before medication is considered.

There are many treatments out there that are not approved for the purpose being used, but if done properly might be a good consideration. Physicians sometimes use treatments that have not been approved for the purpose because they know from experience that it works or they are at a loss from approved treatments failing and they need to try something else.

One example is using a shorter acting form of guanfacine (Tenex) that has not been approved to treat ADHD, but is less expensive than the longer acting form (Intuniv) that is approved for ADHD.

Another common example is the use of albuterol, a medicine that helps breathing with conditions that cause wheezing. It is not approved for use under 2 years of age, but it is commonly used for younger children with difficulty breathing -- and it helps them breathe, which might keep them out of the hospital and off of supplemental oxygen.

I do not think that all non-approved medicines are good or bad. It is a very individual decision of what medicines to use. Discuss with your doctor if a treatment is approved or if they are using something that is not. Although this is relatively common among people who treat children because many drugs have not been tested in children and have been "grandfathered" into use through experiences that show benefit, be sure the provider is not picking something that has no basis or supporting evidence, especially if he or she profits from the treatment.

Be very wary of anyone who promises a cure - if one really existed everyone would use it.

Medications approved to treat ADHD

Medications to treat ADHD fall into the following categories:

• Stimulants

• Methylphenidates (Ritalin©, Focalin©, Concerta©, Daytrana©, Metadate©, Quillivant©) 

• Amphetamines (Adderall©, Vyvanse©, dexedrine) 

• Non-stimulants

• Atomoxetine (Strattera©) 

• Guanfacine (Intuniv©) 

• Clonidine (Kapvay©) 

• Others are used off-label (no FDA approval for the purpose of ADHD treatment): Tenex, Catapres patch, antidepressants, and antipsychotics

When a medication is needed to control symptoms of ADHD, the first line medications are the stimulants unless there are contraindications. Non-stimulant medications are not found to be as effective as stimulants in the majority of children, but they do have a place in the treatment plan for some children. They are sometimes used in addition to stimulants for optimal results. For information on how these medicines, see A Guide to ADHD Medications. It reviews how stimulants act on dopamine and norepinephrine and various time release patterns of different medicines.

Side Effects

Parents usually worry about medication side effects, which is a very legitimate concern. Overall the medicines listed above are very well tolerated. If a child has side effects to one stimulant, they can usually do well on a different class (methylphenidate vs amphetamine). I often hear concerns that parents don't want their kids changing their personalities or becoming "zombies". If the right medicine is used at the appropriate dose, this is usually not a problem. Finding that right medicine and right dose might take some trial and error, but work with your prescriber to get to the right one for your child.

The most commonly observed side effects of stimulants are:

• Decreased appetite – Appetite is often low in the middle of the day and more normal by supper time. Good nutrition is a priority, so encourage kids to eat the healthy "main course" first and leave the dessert out of the lunchbox. Short acting meds improve mid day appetite since they wear off around lunch time. Kids are often very hungry in the evenings when medicines wear off, so encourage healthy foods at that time. I have also seen some kids who have a really hard time off medicine sitting down to eat actually gain weight better on medicine because they can finish the meal.
• Insomnia – Trouble sleeping is common with ADHD, with or without medicines. If it is due to the stimulant medicine, trouble sleeping may be relieved by taking it earlier in the day.
• Increased irritability -- Moodiness is especially common as the medication wears off in the afternoon or evening and in younger children. It makes sense if you consider that all day they are able to focus and think before acting and speaking, but then suddenly their brain can't focus and they act impulsively. Typically kids learn to adjust to the medicine wearing off as they mature. Sometimes just giving kids 30 minutes to themselves and offering a healthy snack can help. Cognitive behavioral therapy can help. 
• Anxiety -- Anxiety does occur with ADHD and might be under-appreciated before the ADHD symptoms are treated. When kids can focus better, they might focus more on things that bother them, increasing anxiety. It is also possible that anxiety is misdiagnosed as ADHD, which is one reason for stimulant medication failure.
• Mild stomach aches or headaches -- Stomach aches and headaches are occasionally noted with stimulant medications. It is my experience that they are most common with a new medication or a change in dose. Because these have many causes, it can be hard to determine if they are really from the medicine or another cause. If they persist with the medicine, it might be needed to change to another.
• Tics - Tics are related to treated and untreated ADHD. People with ADHD are more likely to have tics than the general population. It was once thought that tics were caused by the stimulant medicines, but it is now thought that they happen independent of the medicine, and medicines might even help treat the tics.
• Growth -- Weight gain can be difficult for some kids on stimulant medications due to the appetite suppression on the medicine. Studies have shown a decreased final adult height of about 1-2 cm (1/2 - 1 inch), which most agree is not significant compared to the benefits in self esteem, academics and behavior children gain on stimulants.

Rare side effects of stimulants include hallucinations and heartbeat irregularities

• I have only seen two children who could not tolerate stimulants due to hallucinations, but it is very scary for the family when it happens. Unless there is a significant family history of them, I don't know a way to predict which child is at risk. These are a contraindication for continuing that medication, but another type of stimulant or medication can be considered. 
• Cardiac (heart) problems are overall a rare complication of stimulants and often times are not a contraindication to continuing the stimulant medicine. There is a small increase in blood pressure and heart rate, both of which should be monitored regularly while on treatment and if the treatment is stopped. 

A cardiologist should be considered to further evaluate a patient prior to starting a stimulant if there is any of the following:

• Shortness of breath with exercise not due to a known non-cardiac cause, such as asthma
• Poor exercise tolerance compared to children of the same age and conditioning 
• Excessively rapid heart rate, dizziness, or fainting with exercise 
• Family history of sudden cardiac death or unexplained death (such as SIDS) 
• Family or personal history of prolonged QT syndrome, heart arrythmias, cardiomyopathy, pulmonary hypertension, implantable defibrillator or pacemaker 

Common side effects for the non-stimulants include the following:

• Atomoxetine can cause initial gastroesophageal complaints (abdominal pain, decreased appetite), especially if the dose is started too high or if it is increased too rapidly. It can also cause tiredness and fatigue when it is first started or if the dose is increased too quickly. It can increase the blood pressure and heart rate, both of which should be monitored regularly during treatment with atomoxetine. There is an increased incidence in suicidal thoughts, though uncommon, so children should be monitored for mood issues on this medication. A rare complication of atomoxetine is hepatitis (inflammation of the liver with yellow jaundice and abnormal liver function labs). The hepatitis resolves with stopping the atomoxetine. 
• Guanfacine and clonidine both cause fatigue and tiredness, especially when first starting the medication or with increases in dose. Clonidine is often used at bedtime to help kids with ADHD sleep. Both of these medications can lower the blood pressure and heart rate, and these should be monitored closely while on guanfacine or clonidine.


Getting Started

The first step in treating ADHD is getting a proper diagnosis. This should be done with input from parents and teachers since symptoms should be present in at least two settings. ADHD symptoms overlap with many other conditions, and if the diagnosis is not correct, medications are more likely to cause side effects without benefit. Do not jump into medication until the symptoms have been fully evaluated and a proper diagnosis is made according to DSM criteria.

Stimulant medicines are considered first line treatment for ADHD in kids over 5 years of age. There are short acting and long acting formulations available for each type of stimulant. There are advantages and disadvantages to each. Short acting medications tend to last about 4 hours, so can be given at breakfast, lunch, and after school, allowing for hunger to return as each wears off to help kids maintain weight. They are often used later in the day after a long acting stimulant wears off for teens who need longer coverage. Long acting medicines tend to last between 6 and 12 hours, depending on the medicine and the person's metabolism. The benefit is that people don't need a mid-day dosing, which for school kids means avoiding a daily trip to the school nurse, which can be socially non-acceptable for older children. It is also easier to remember once/day medication versus multiple times/day dosing. The downside is that some children don't eat well mid-day with long acting medicines.

In general it is recommended to pick one of the stimulant medicines and start low and titrate to best effect without significant side effects. Feedback on how the child is able to focus and stay on task, and reports of other behavioral issues that were symptoms in the first place should be received from teachers and parents, as well as the child if he is able. There are many things to consider that affect focus and behavior that are not due to the medicine: sleep, hunger, pain, illness, etc. It takes at least a few days to identify if the medicine is working or not or if other issues are contributing to the focus and behaviors. The younger the child the longer I usually advise staying on a dose so a parent has a chance to hear from the teacher how things are going. I usually don't increase faster than once/week. I rely more on the student's report in middle and high school, since those students can be more insightful and they have so many teachers throughout the day that most teachers are not as helpful. Older students who are in tune with their problems and how they are responding to the medicine might be able to increase every few days, as long as there are no confounding factors that could influence symptoms, such as change in sleep pattern, big test or other stressor, or illness.

Which medicine to choose?

As you see above, there are two classes of stimulants, methylphenidates and amphetamines. While some children respond better to methylphenidates, others to amphetamines, some do equally well on either, and some cannot tolerate either. It is not possible to predict which children will do best on any type, but if there is a family history of someone responding well (or not) to a medicine, that should be taken into consideration of which to start first.


Another thing to consider is whether or not a child can swallow a pill. Some of the medicines must be swallowed whole. If you aren't sure if your child can swallow a pill, have them try swallowing a tic tack. Use a cup with a straw, since the throat is narrowed when you tilt your head back to drink from an open cup. Another option is to put it in a spoonful of yogurt or applesauce and have your child swallow without chewing. If your child cannot swallow a tic tac, you can choose a medicine that doesn't need to be swallowed. Some come in liquid or chewable formulations. Some capsules can be opened and sprinkled onto food, such as applesauce or yogurt. There is a patch (placed on the skin) available for the methylphenidate group.


I would love to say that cost shouldn't matter, that we pick the medicine based purely on medical benefit, but cost does matter. Before you go to the doctor to discuss starting medicine (this or any medicine for any condition) look at the formulary from your insurance company. All other things being equal, if one medicine is not covered at all (or is very expensive) and another is covered at a lower tier, it is recommended to try the least expensive option first. Of course, if the least expensive medicine fails, then a more expensive one might be the right choice. Also check to see if a medicine requires a prior authorization, which might require that other medicines are tried first.

The ADHD Medication Guide is a great resource to look for generics (marked with a "G"), which must be swallowed whole or can be opened or chewed (see the key on page 2). The age indications listed on page 2 are those that have FDA approval at the ages listed, but there are a lot of times that physicians use medicines outside the age range listed. Some do not even have an age indication listed. These ages are due to testing results, and can be limited because one age group might not have been tested for a specific medicine. Note that the 17 year and adult medicines are different. Is there really a difference between a 17 and an 18 year old? Not likely.

Finding the right dose

It is recommended to start with one of the two main classes of stimulants with a low dose, and slowly increase to find the best dose. If that stimulant doesn't work well or has side effects that are not tolerated, then change to the other class of stimulant. If that one does not work, you can try a different medicine from the class of stimulant that worked best. If the third medicine doesn't work, then a non-stimulant can be tried. I also recommend re-evaluating the original diagnosis at this point, since ADHD might not be the cause of the issues and finding the right cause can lead to a better treatment.

Titrating the medicine goes something like this:

• If symptoms are well controlled and there are no significant side effects, the medicine should be continued at the current dose. 
• If symptoms are not well controlled and there are no side effects that prohibit increasing, the dose should be increased as tolerated. 
• If symptoms are not well controlled (i.e. room for improvement) but there are side effects that prohibit increasing the medicine, consider a longer period of watching on this dose versus changing to a new medicine.

Things to consider

Time Off: Once a good dose is found, parents often ask if medicines need to be taken every day. Drug holidays off stimulants were once universally recommended to help kids eat better and grow on days off school. Studies ultimately did not show a benefit to this, and some kids really can't take days off due to behavior issues, including safety issues while playing (or driving for older kids). It also seems that when kids are off medicine they do not have good self esteem due to repeated failures, so taking medicine regularly is important to them.

When kids can manage their behavior adequately, it is not wrong to take days off. Stimulants work when they work, but they don't build up in the body or require consistent use. (This is not true for the non-stimulants, which are often not safe to suddenly start and stop.) Some kids fail to gain weight adequately due to appetite suppression on stimulants, so parents will take drug holidays to allow better eating. Days off the medicine also seems help to slow down the need for repeated increases in dosing for people who are rapid metabolizers.

Talk to your child's doctor if you plan on not giving your child the medicine daily to be sure that is the right choice for your child.

Remembering the medicine: It is difficult to get into the habit of giving medicine to a child every day. I wrote an entire blog on remembering medicines. My favorite tip is to put the pills in a weekly pill sorter at the beginning of each week. This allows you to see if you're running low before you run out and allows you to see if it was given today or not. These medicines should not be kept where kids who are too young to understand the responsibility of taking the medicine have access.

Controlled substances: Controlled substances, such as stimulants, cannot be called in or faxed to a pharmacy. They cannot have refills, but a prescriber can write for either three 30 day prescriptions or one 90 day prescription when they feel a patient is stable on a dose. Stimulants are not controlled substances because of increased risks to the individuals it is prescribed for, but because they have a street value -- teens often buy them from other teens as study drugs. This can be very dangerous since it isn't supervised by a physician and the dose might not be safe for the purchaser. It is of course illegal to sell these medicines. The DEA does monitor these prescriptions more closely than others. If the prescription is over 90 days old, many pharmacists cannot fill it (this will vary by state), so do not attempt to hold prescriptions to use at a later time.

Acids and Stimulants: It has been recommended that you shouldn't take ascorbic acid or vitamin C (such as with a glass of orange juice) an hour before and after you take medication. The theory is that ADHD stimulants are strongly alkaline and cannot be absorbed into the bloodstream if these organic acids are present at the same time. High doses of vitamin C (1000 mg) in pill or juice form, can also accelerate the excretion of amphetamine in the urine and act like an "off" switch on the med. In reality  have never seen this to be an issue. If anyone has noticed a difference in onset of action or effectiveness of their medicine if they take it with ascorbic acid or vitamin C, please post your comment below.

When Mom and Dad disagree: It is not uncommon that one parent wants to start a medication for their child, but the other parent does not. It is important to agree on a plan, whatever the plan is. Have a time frame for each step of the plan before a scheduled re-evaluation. If the plan isn't working, then change directions. If kids know it is a disagreement, they might fear the medicine or think that needing it makes them inferior or bad. Do not talk about the diagnosis as if it's something the child can control - they can't. Don't make the child feel guilty for having this disorder. It isn't fair to the child and it only makes the situation worse.


Having the medicine when you need it-- 

Refills: There is nothing more frustrating for a parent and child than to realize that there's a big test tomorrow and you have no medicine left and you're out of refills. Be sure to know the procedure for refills at your doctor's office. By federal law we cannot give more than 3 month's worth of a stimulant medicine. They cannot be called in to a pharmacy. In my office we see patients at least every 3 months (more often when starting a medicine or if changes are needed). I advise that they schedule the next appointment as they leave the office so they don't forget to schedule. I make these appointments longer than standard "sick" appointments, so it is hard to sneak one in on the same day. 

Travel: It is very important to plan ahead prior to travel. If you forget your child's stimulant, no one can call out a prescription since it is a controlled substance. You must plan ahead so that if a refill will be needed during the trip you will either be able to fill a prescription you have on vacation or you will need to fill the prescription in advance. Most people can get a prescription 7 days prior to the 30 day supply running out, but not sooner, so you might need to fill a couple prescriptions a few days earlier in the month each to have enough on hand to make it through your vacation. It takes planning! If you are out of town and you realize you forgot your child's non-stimulant, call your doctor to see if they will call it out. Many of the non-stimulants are not safe to suddenly stop, so they are likely to call it out. Insurance is not likely to pay for these extra pills though if it was recently filled. 

Lost prescriptions: We are able to give up to three prescriptions at one time, but most pharmacists will not keep the prescriptions. This means that you must know where the prescriptions are and not lose them for 3 months. Lost prescriptions are handled differently by different prescribers, but all should take them seriously due to the controlled substance rules of the DEA. If a parent reports losing them frequently, that usually leads to consequences, so be sure you know how your doctor handles this situation. I will generally allow a parent to write a letter documenting the lost prescription and I document this in the medical record in a way that is easy to see at future visits. If this repeats, I will not be able to continue to prescribe a controlled substance for that family, which only makes the child suffer. 

Mail order: Some insurance companies will allow mail order 90 day prescriptions. Some not only allow, but require them on daily medicines. Others do not allow it. In general I advise against a 90 day prescription if the dose is not established or if there are any concerns that it might not be the perfect dose. If there is any concern that it might need to be changed, a 30 day prescription is a better option. If you will need to do a mail order, be sure you schedule your appointment to get the prescription early enough to account for the lost time mailing. 

Before your visit:

Before you meet with your physician to discuss a new ADHD diagnosis or a possible change in treatment plan, be sure to get the following information and have it available at the visit or the visit will not be as productive as you desire:

• Insurance formulary
• Standardized testing from teachers, parents, and other significant adults 
• Verify if your child can swallow a tic tac or pill 
• Any contributing family history (family member responses to medications, family history of heart issues, etc)

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

References and resources:

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

ADHD Medication Guide

Parents Med Guide

Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder.

Developing healthcare responsibility in your children

I am writing this fully knowing I am at risk of upsetting some parents. But this is the time of year we see more school aged kids for their annual physicals, so it is the time of year I think about how parents could help their kids grow into independent adults or hinder that growth by trying to be a good parent.

source: Shutterstock

I read an article recently (The Overprotected Kid) that really hit home with me about how parents try so hard to keep their kids safe that we sometimes prevent them from learning about real life. Although the article is based on allowing kids to roam and play with things that haven't been engineered to keep them safe, it did touch on the fact that parents hang around to answer for kids and speak up for them.

I find that parents often try to help their children during visits to my office by answering questions about their health, sometimes even what they are feeling. I'm sure they want to be sure I know their (parent) perspective. Maybe they are just trying to speed up the visit so they can leave and do the other things on their to do list. But it usually ends up taking longer, because I then spend more time trying to talk to the child.

When a question is directed at the child, let the child answer. If I need parental clarification, I'll ask for it. Obviously a pre-schooler needs more help than a high schooler, but if the teen has never had the opportunity to answer for himself, he might not have the skills and confidence to do it.

Sometimes a parent will start asking their child questions or tell them to tell me about .... I'm sure they are thinking that it is helping me, but it doesn't. (I'm not talking about the parent reminding the child to tell me something they previously discussed, I'm talking about the parent who in response to something I've asked tries to draw the child into conversation-- that's my job.) I have a set amount of time to assess a child's physical exam as well as other factors, and I have a process of evaluating all the points I must consider.

When I ask a child a question, I'm not only looking for the answer they are giving, but I'm also gaining valuable information about the child. Can they speak clearly? Do they understand a question that is age appropriate? Do they make eye contact? Are they developmentally mature for their age? Do they understand how their habits effect their health?

So often well intentioned parents pipe up and answer questions directed at the child. It doesn't matter if I'm looking directly at the child, the parent answers. Even if the child starts to answer. I will often redirect to the child for clarification and the parent still answers. Some of the kids roll their eyes. Others take it in stride without much of an expression at all, as if they're used to their parent taking care of everything. Some simply turn back to their hand held game and play, ignoring the grown ups in the room. Ugh! How does that help me get to know the kid?

Sometimes I wonder how the parent makes it through the day when the child is at school since they can't be there to speak up for the child all day there. It can be that bad.

I really worry about the older school aged kids, especially those in high school, who have parents answer for them. How will they be able to assume their healthcare responsibilties once they turn 18? If they don't know about their past medical history, allergies, and family medical history how can they eventually establish healthcare with a new physician without a parent? If they can't give a clear and concise summary of what their symptoms are for an illness, what will they do when you're not there?

And yes, I see parents piping up for their high schoolers.

I guess it's a learned behavior for all. Parents get used to answering the questions for pre-verbal kids, and they keep doing it.

Please stop.

Let kids in elementary school be prepared to order off the menu when the waitress comes to the table -- after discussing their choice before she gets there if they need help deciding on a healthy item. Have older elementary kids speak up at the store to ask for help when they need a dressing room or if they need a price check. Let them talk to their teachers first if they question a grade or need help learning a concept. Let them give their own health summaries at the doctor's office. You can be there for support along the way, but offer less and less as they get older and more experienced.

If your child has true inabilities to do these things there might be an underlying problem, such as anxiety or developmental delay. Those should be addressed. But by far and away most school aged kids can do these things. Let them.

They need to do these things to be able to one day live independently. Trust me, they will appreciate it some day! Too many college kids call home for parents to "fix" things that the young adult should be able to handle. But they can't jump into the deep end of the pool without learning to swim along the way.

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.

Violence... I think parents can help prevent from home

Source: Shutterstock

I, like most of you, am horrified by the event's of last week's shooting. I have read countless articles in the aftermath about talking with kids, safety in schools, gun control, and even mental health services needing to improve.

I keep wondering if there is something each parent can do at home to help the future.

Violence in the media is constant. It is becoming more graphic and violent. Children do not have the ability to separate fantasy and reality, which makes them more vulnerable to altering behaviors depending on what they are exposed to. Until the last part of our brain matures during adulthood, we have not fully developed self control, emotional regulation, and judgement. So for those of you who think your children or teens are mature, they are still developing important parts of their brain!

If we limit exposure to violence, would it help prevent violence? If children are exposed to less violence at home and in the media, can we cultivate a society of people who can work through conflict in a civil manner?  It's been shown in study after study that violence exposure leads to violent behaviors. What about the opposite? Model positive behaviors and limit negative exposures to encourage healthy development of behaviors.

Research shows that the more violent video games kids play, the more violent they become. Very young children exposed to aggressive acts on television will be more aggressive with their play. There is even long term effects from early exposures. A study showed that men who were high TV violence viewers as children were significantly more likely to be physically aggressive with their spouse and to be convicted of a crime at three times the risk of other men. Women with high TV violence exposures as children were four times as likely as other women to be physically violent.

Parents: you can't "take back" early exposures. Don't wait until you are worried about your child/teen's behavior. Prevent it!

Some limits to violence are more difficult to enforce than others.

If kids live in violent homes, they are vulnerable on many levels. Recognizing these at risk kids and helping their situation improve or remove them from the situation is very difficult. There are free online resources to help (use a safe computer if you are at risk!) Even if you are not in an abusive situation, learn to recognize signs that someone is. You could save a life! SafeHome provides education and assistance for those in need in the Kansas City area.  The Hotline is a nationwide hotline that also has educational information on its website. 

When our children are at other homes, we don't always know the parenting styles or supervision as we do at home. Get to know the parents of your children's friends. Let them know your expectations of what your child can/cannot watch or play. Talk to your children and teens about what they do elsewhere. 

Easier fixes involve the media. (Note: I didn't say easy. I said easier.)

Remove the televisions and other electronics from bedrooms. They cut down on sleep (sleep deprivation adds to poor decision making and behaviors) and allow private, unsupervised viewing. 

Parents should screen what their children watch and play for age appropriateness. I have heard many parents say something to the effect of "He's always been around shows like this, and is not scared. He loves to watch them." Why is he not scared, if his age would typically be scared? Is he already desensitized? That scares me. Check out free on-line reviews from a reputable site, such as Common Sense Media, before deciding if something is appropriate for your child. Choose appropriate times that do not allow younger children to be exposed.

Listen to the music your children and teens enjoy and check out their reviews on Common Sense Media. Many songs promote partner violence, fighting, and sexual violence. Songs have a way of getting into our head. Fill their brains with healthy lyrics, not brainwashing songs that promote any form of dangerous behaviors!

Set maximum times children and teens may have screen time. The American Academy of Pediatrics suggests no more than 10 hours per week for children over 2 years of age. No screen time is recommended for children under 2 years. Remember that screen time includes television, movies, video games, social media, and all other things on a screen. 

Learn the technologies your children are using. If your child or teen is playing online, you need to learn how to set parental controls and monitor what has happened on line.

I am not advocating that families should never enjoy an age- appropriate movie or video game. We actually went to see The Hobbit last night. Although it is PG-13, I read reviews and decided that it was appropriate for my 11 year old. She has a strong sense of reality vs fantasy and was able to sit through the show without being scared at all. (She felt it was "boring" and too long.) It wouldn't be good for all 11 year olds though, and I don't think I would have taken her much younger. Point: parents must know their child, have the facts, and make educated decisions. Don't just say "yes" because it's easy!

And finally, the best parent is an active parent. Participate in activities with your children. Build up their self confidence. Talk to them about what's on their mind. Show them you care. Set limits and stick to them. Give healthy physical contact (hugs, high five, back pat, tickles) often, no matter how old they are, unless it makes them uncomfortable. Tell them you love them. Be their rock.  



Sources:

"Impact of Media Violence Tips." Reviews and Ratings for Family Movies, TV Shows, Websites, Video Games, Books and Music. N.p., n.d. Web. 16 Dec. 2012.

"The Teenage Brain-- Why Do Teenagers Think Differently than Adults?" The Teenage Brain-- Why Do Teenagers Think Differently than Adults? N.p., n.d. Web. 16 Dec. 2012.

"Childhood Exposure To Media Violence Predicts Young Adult Aggressive Behavior, According To A New 15-Year Study." Childhood Exposure To Media Violence Predicts Young Adult Aggressive Behavior, According To A New 15-Year Study. N.p., n.d. Web. 16 Dec. 2012.

"The Impact of Media Violence on Children and Adolescents: Opportunities for Clinical Interventions | American Academy of Child & Adolescent Psychiatry." The Impact of Media Violence on Children and Adolescents: Opportunities for Clinical Interventions | American Academy of Child & Adolescent Psychiatry. N.p., n.d. Web. 16 Dec. 2012.

"Media Violence." Media Violence. N.p., n.d. Web. 16 Dec. 2012.

Will "Standing" Hurt a Baby's Legs?

I am surprised how often I am asked if having a baby "stand" on a parent's lap will make them bow legged or otherwise hurt them.

Old Wives Tales are ingrained in our societies and because they are shared by people we trust, they are often never questioned.

photo source: www.blog.rv.net/2009/01/pj-workout

Allowing babies to stand causing problems is one of those tales.  If an adult holds a baby under the arms and supports the trunk to allow the baby to bear weight on his legs it will not harm the baby. Many babies love this position and will bounce on your leg. It allows them to be upright and see the room around them.  Supported standing can help build strong trunk muscles.

Other fun activities that build strong muscles in infants:

• Tummy time: Place baby on his tummy on a flat surface that is not too soft. Never leave baby here alone, but use this as a play time. Move brightly colored or noisy objects in front of baby's head to encourage baby to look up at it. Older siblings love to lay on the floor and play with baby this way!
• Lifting gently: When baby is able to grasp your fingers with both hands from a laying position, gently lift baby's head and back off the surface. Baby will get stronger neck muscles by lifting his head. Be careful to not make sudden jerks and to not allow baby to fall back too fast.
• Kicking: Place baby on his back with things to kick near his feet. Things that make a noise or light up when kicked make kicking fun!  You can also give gentle resistance to baby's kicks with your hand to build leg muscles.
• Sitting: Allow baby to sit on your lap or the floor with less and less support from you. An easy safe position is with the parent on the floor with legs in a "V" and baby at the bottom of the "V". When fairly stable you can put pillows behind baby and supervise independent sitting. 
• Chest to chest: From day one babies held upright against a parent's chest will start to lift their heads briefly. The more this is done, the stronger the neck muscles get. This is a great cuddle activity too! 

What were your favorite activities to help baby grow and develop strong muscles?

Cut the cord... Give them the World!

We were recently having lunch at the office and the conversation turned to sending kids off to college. One person shared the story of a friend's very smart, straight A, "jammed on the ACT" child who flunked out of college because he never went to class and played video games all day.  The point being made was that person was going to keep closer tabs on their children when they went to college to avoid letting them fail.

Dr Mellick and I both chimed in at that point, each with very similar points of view.

By college a child is no longer a child, and is treated by the law and banks as an adult.  They should have learned self control and self management long ago.  If they fail to learn along the way under the supervision of parents life's lessons, they will fail in many ways.  I had two college friends (now parents themselves) who had parents that still tried to run their schedules and keep close tabs on them.  Mom or Dad would call every night to be sure the student was in the dorm by a certain hour.  This takes the responsibility away from the college student and puts it on the parents. The students then looked for ways to outsmart the parents, rather than ways to manage their lives. They knew they had to be home by a certain time, but then they left to party or stay at a friend's apartment after they hung up.  They hadn't learned self control or time management.  They had learned to manipulate the parents and the system.  Not what I want for my kids! Not what a potential boss wants from an employee. Not what makes for a caring and supportive spouse or parent.

Kids need to learn so many things before they move out of the house to become well rounded adults who can hold down a job, lead a family, and contribute to society.  This is a process ~ not something they learn the summer before college, and hopefully not something they learn after falling on their face in life.  A recent article in the New Yorker, Spoiled Rotten Why do kids rule the roost?  highlights why American children are so spoiled they become adultescents (adults who have yet to grow up). Worth the read!

Life skills to learn:

• how to eat nutritious foods in proper portions
• to spend, save, and give wisely
• when to recognize they are tired and to get enough sleep
• time management: work, school, social/fun, rest, chores, projects, exercise, etc
• self control
• study habits
• how to clean the home 
• simple repairs around the house
• cooking
• laundry
• how to pay bills on time
• exercise daily
• following routine dental and medical care
• how to stay within a budget
• caring for others
• respect for self and others

None of these things are learned by someone telling kids how to do them.  They are best learned over time by doing each of them.  Skills build upon previous skills, so first learning basic daily needs (dressing, brushing teeth, washing body, picking up after self) and then learning to do each more independently and finally being able to organize their own schedule to get it all done.  Many of these are learned by sometimes failing, and that is okay.  For more information specifically on chores, see my past post Chores for kids become chores for parents.

Even young children can be taught to help with daily chores.  Starting with preschoolers, the "chores" can be self-skills, such as picking out weather - appropriate clothes and getting dressed, brushing teeth, and other daily activities.  It is much faster for a parent to dress a child (usually) than having a young child do it themselves, but at some point they need to learn, and the earlier, the better!  If they choose weather- inappropriate clothes after discussion of the anticipated forecast, you can help with suggestions.  Sometimes the best way for them to learn is to wear something inappropriate and seeing what it feels like to be too hot or too cold.  This is within reason, of course-- a parent needs to be sure kids are safe: the younger the child, the more supervision needed.  When they were young, I would make them carry another layer if they were underdressed, but I feel no guilt in allowing my middle schoolers to choose shorts in the winter-- their choice!

We follow this process of increasing expectations in our office. Have you noticed as your kids get older  I ask more history from them, not the parent? When Mom or Dad chimes in with the answer, I try to redirect to the child to let them answer what the symptoms are, how long they've been there, what treatments have been tried and if they worked or not. Please let your kids answer ~ they know this stuff! Eventually we offer if the kids want the parents out of the room for privacy. This allows tweens and teens to start accepting responsibility for their healthcare. 

Kids will fail, and that is okay. All part of the learning process. Allow them to learn from failure when the risks are lower as young kids, not when the risk is higher as a teen or young adult.  Kids tend to just get mad if parents always point out the failure but then "save" them by not enforcing consequences.  Examples would be yelling at a child who didn't finish chores and continuing to remind them that they didn't do the chore and you had to do it for them, yet allowing the activities they want to do. Their chore has now become your problem.  They don't own it, so they don't care.  They will continue to allow you to own that chore.  They simply have to listen to you complain about it, which doesn't build strong family bonds, but doesn't require any work on their part.  

Often parents "own" the child's work: the parents keep harping on the child to do his homework, but the child is not motivated. I have previously written about the Homework Battle Plan, and I suggest reading it if your child struggles.  Too often parents "help" by doing much of the work for the child, who complains every step of the way. There are many parents who bring in the forgotten homework because the child forgets it routinely and the parent doesn't want the grades to suffer.  Are you going to drive the homework to the college professor too?  Let young kids suffer the consequence of a bad grade to hopefully learn.  If you keep "helping" them through elementary, middle, and high school, they have never learned what is really important: being responsible for your own work. 

Each stage of growing up has a new set of skills kids can learn to help with.  As kids grow and want to be away from home more, begin by training them how a decision is made, how to spend appropriately, how to make healthy choices.

A family calendar is a great way to let them help with time management.  I love the Google Calendar for this.  Everyone who is invited to the calendar can view it (and add to it if permission is given) so potential conflicts can be identified before they even ask if something is okay to do.  

Start going through questions that are pertinent to the situation so they can learn to think about it themselves:  Is all work done before doing an activity? How will you get there and back safely?  What time do you plan to be home and what time do you have to get up in the morning-- is that enough sleep? How much does this activity cost, and do you have the money to do it? Who will be there and who will be supervising? You still make the final decision, but you might also see the light click when they realize they have other priorities that need to be done first.

Talk about money management without worrying kids about family finances. If kids want a new game, don't get it for them, have them save. Talk about how much they need to save each week to have enough money by a deadline. How will they earn the money? When kids beg to eat out, talk about how much it costs for the family to eat at XYZ restaurant and how much it would cost buy similar food at the grocery store to eat at home. (One that comes up often at my house is going out for ice cream.  How much it costs to go out for ice cream vs buy one container for home is easy to calculate and makes a great point.)  Allow teens to get a job and help them balance money spending and saving. Require that they pay for certain needs or desires.

Have young kids help with simple chores around the house, then increase responsibilities as they get older. My kids loved putting clothes on hangers as preschoolers. I admit that now my kids choose to keep their clean laundry in a pile rather than putting it away, but I suspect they will learn that it is easier to find clothes when put away in their place eventually. Kids can learn to vacuum, dust, and even clean toilets in elementary school. Initially supervising and teaching takes more time than doing it yourself, but when kids learn the skills, that time spent pays off! 

If  kids learn the complex process parents go through to make sure kids will be safe and the activity doesn't conflict with other things, they will start to learn to think through all those things too.  Model good behaviors with time and money management.  Spend quality fun family time together to build strong bonds so they will ask for help when needed ~ but don't give answers, just direction!  Over the years you will watch them grow and mature and they have the world in their hands!

Speech and Language-- What is Normal, and When To Worry?

Development has a range of normals, and it is difficult for parents not to compare their kids with others (advanced or slow).  Parents worry but are often afraid they are over reacting or under reacting, since there is such a wide range of normal.  Don't be afraid to ask questions and discuss your concerns.  Avoiding the issue or minimizing your concerns doesn't help your child.  Keep a log of what your child can do at regular intervals to help you keep it all in perspective.  Before your child's well visits is a great time to review your list because you know we'll ask!

Speaking early or late does not necessarily mean a high or low IQ, so no bragging or worry is due (as long as the late talker is still in normal range).  Many parents jump to the conclusion that a child who doesn't talk by ___ months (this varies) is autistic. But they forget that Dad didn't talk at this age either, and he's perfectly normal!

Do we need to screen for autism? Yes!

Is it the most likely answer? No!

Do we need to evaluate speech and language frequently in the critical first 3 years of life? Yes!

We question communication skills at all well visits at this age to be sure your kids are on track. Early recognition of a delay can start the process rolling for further evaluation and treatment.  Speech and language are two related but different things. Speech involves the sounds that we make with our mouths. Babbling is an early speech. Language involves the meaning of words and the use of words.  Both are part of communicating with the people around us.  If kids miss the important milestones it can signify a problem.

Speech and/or language delay is very common and has many causes.  It is difficult for parents (and pediatricians) to identify severity of the issue or the exact cause much of the time.  Any red flags to speech and language delay deserves further investigation.  Some of the underlying problems include:

• genetics - some families tend to have many members who were late talkers, other genetic disorders are known to cause speech and language problems
• bilingualism - more than one language spoken at home
• maturational delay - the kid that always seems to get there, but takes a little longer
• learning disorders or mental retardation - delayed speech and language might be the first sign of a learning disability or low overall IQ
• stubborn child - needs no explanation!  
• autism - autistic children do not communicate with others on many levels, not just words
• deafness or hearing loss - this is why we screen all newborns and at risk children as needed, frequent ear infections can decrease hearing temporarily
• psychosocial deprivation - if no one talks with or interacts with a child, they will not learn
• other neurologic and physical disorders 

Sometimes I think we just miss what they're saying, since early words are not recognizable.  My general rule of thumb: 2 out of 4 words will be understood by strangers at 2 years old, 3 out of 4 will be understood by 3years, and 4 out of 4 words should be understood by a stranger by 4 years.  If you are new to listening to your child talk at 12, 15, 18 months, you will not understand most of their words and take it for babbling.  Just watch the expression on their face and hear the intonation in their voice: They know exactly what they are saying!

Normal milestones include:

2 Months:

• Social Smile (not just gas, but really looks at you and smiles!)
• Watches your face
• Startles with loud sounds

4-6 Months: 

• Cooing and babbling
• Turn to sounds
• Blows "raspberries" and makes cough or grunting sounds as a game
• Laughs and squeals
• Begins to hold objects, stare at hands, and put things in mouth

9 Months:

• Repetetive sounds, such as "da da da"
• Imitation of sounds without meaning
• Makes sound to get attention
• Understands "no" (but doesn't always follow that command!)

12-15 Months:

• Understand several common words spoken to them
• Follow a simple command, such as "get the ball"
• Can say about 5 words
• Looks at something someone is pointing at
• Most words are not entirely clear, the beginning or end of the word might be dropped. "Ba" can mean "ball" or "bath" ~ you have to use context!
• Point by 15 months

18 Months:

• Can say 10-20 words, again most are not clear!
• Can recognize many words that are used
• Able to point to objects in a book and name them

24 months: 

• 2 word sentences
• 50+ word vocabulary, one or more new words a week!
• Able to use plurals 
• Able to repeat what they are told (depending on mood!)

30 months:

• Knows one color
• Recognizes some letters
• Names 6 body parts
• Can say words with more than 2 syllables 

3 years:

• Speaks in more complex sentences of at least 3 words
• Able to use pronouns
• Can speak in past tense (but doesn't always use "tomorrow" or "yesterday" correctly)
• Commonly stutters, not a problem if less than 6 months duration
• Very imaginative!
• Unfortunately learns to lie (He did it!)

If you have concerns about your child's hearing, language, or speech, bring it to our attention.  We might alleviate your unnecessary worries (Brother isn't talking as much as Sister did at this age, but he is in the normal age range) or we might help you find resources for further evaluation and treatment. 

References and For More Information:

Healthy Children
Kids Health
Language Express
Parents As Teachers
SpeechDelay.com