Adenovirus Infections

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It's been a relatively sick winter season, and I keep hoping it is winding down.  But as one season winds down, another starts.

This week my eyes have been watering and burning and my nose is a little stuffy. (I think my nose would be worse if I didn't do twice daily nasal washes - I am a true believer in them!)

But my eyes are driving me nuts. I first thought it was due to allergies since earlier this week I knew that local pollen counts were up, but as I consider what I'm seeing in the office, I wonder if I have a mild adenovirus. (Yes, even doctors have a hard time determining what is going on. This is why I say to never trust someone when they say "it's just my allergies." Make them wash their hands!)

We start to see adenovirus this time of year. I don't test for it but when I start seeing certain trends, I suspect it's here.  It causes many types of symptoms, different in different people.

Red eyes without mucus discharge is one common finding. It is not "pink eye" or bacterial conjunctivitis, but we have many kids sent in from schools and daycares because they think it's "pink eye." I usually just write a note that eye drops are not needed and they can return to daycare since it is a virus.

I have seen quite a few red eyes this week...

Other symptoms are much like a common cold: fever, runny nose, cough, swollen glands, and sore throat. It can cause wheezing in infants and croup (yes, we're seeing those now too).

Sometimes vomiting and diarrhea are due to adenovirus - and right now we are blaming all the stomach problems on the new Sydney Norovirus, but it could be something more typical too.

Prevention is key with any illness. Continue to wash hands and surfaces well all year long, not just when the flu is in the news. Keep sick family members home if they are sick to avoid spreading germs to others.

Most children with adenovirus can be treated at home.

• Treat with a pain reliever/fever reducer as needed for comfort. Remember it is not how high a fever is, but how a child acts that is most important (as long as they are over 3 months and immunized). 
• Push fluids. 
• Use a humidifier or vaporizer if the air is dry to help the airway. 
• Use saline rinses or sprays in the nose as tolerated. 
• Kids over 1 year can use honey for cough. I don't recommend cough medicines since they haven't been shown to work, are expensive, and have side effects. 
• And for those red, burning, watery, itchy eyes: cool compresses. Since allergy season overlaps with adenovirus season and they symptoms are very similar, you can try age-appropriate allergy medicine to see if it helps the red, itchy, watery eyes. Watch for yellow mucus discharge of the eyes. Since kids rarely wash their hands before rubbing their eyes, they are more likely to secondarily infect their eyes with repeated rubbing of irritated eyes. 
• Wash hands frequently!

When to see your doctor:

• Sore throat and fever in children should be evaluated for Strep throat by a throat swab and test during business hours. Strep throat can look exactly like a sore throat from adenovirus or other viruses, so it needs to be tested before appropriate treatment can be determined.
• If there are breathing problems such as rapid breathing, ribs sucking in and out, child is not able to complete a sentence due to shortness of breath, or other concerns your child should be seen ASAP.
• If your child looks dehydrated (no tears, dry mouth, poor urine volume) he should be seen ASAP.
• If the eyes are red with discharge, your child should be seen during business hours to see if antibiotic eye drops are needed. 
• A child with symptoms of a urinary tract infection (symptoms may include fever, painful urination, frequent urination, blood in urine, or urinary accidents) should have their urine tested for infection. If symptoms are mild, you can wait until business hours, but if associated with high fever, vomiting, or other concerns, bring in for assessment ASAP.

For more reading:

KidsHealth Adenovirus

CDC - About Adenoviruses

Sick, Sick, and More Sick.

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It isn't news that we are experiencing a rough winter as far as illnesses go. Flu is all over the news. Schools have high rates of absenteeism. You hear coughs wherever you are in public places.

A few nuggets of information that might help you treat your family this sick season:

Fever

Fever is a symptom of illness and makes us feel achey and miserable, but the number on the thermometer does not necessarily correlate with the diagnosis or treatment needed. Look at your child. If they are happy with a fever, over 3 months and immunized, let it run its course. If they complain of pain (or if your immunized infant over 2-3 months is fussy) give a pain reliever/fever reducer. Push fluids to avoid dehydration. Treat other symptoms as needed. Don't worry if the temperature on the thermometer goes up ~ worry if your child is in severe pain, having difficulty breathing, or looks dehydrated.

Cough

Coughs do not need medicine generally. Honey (for those over 1 year) has been shown to be safer and more effective than other cough suppressants. Adding humidification to the air does wonders to loosen mucus and ease breathing.

If the cough is accompanied by rapid breathing, sucking in of the ribs or abdomen, or followed by vomiting, your child should be seen by a medical practitioner for further evaluation and treatment.

If your child has a history of asthma or other wheezing, it is okay to see if the rescue medicine (albuterol or levalbuterol) helps the cough. If not, it either is really bad wheezing that needs further evaluation or a cough. And don't forget your prevention medicine if you use it!

If your child has been exposed to whooping cough and develops a cough, please see your medical provider for evaluation and treatment.

Water's Power

Water is good for most illnesses. Increase fluids to prevent dehydration and help the body repair itself. Sips of water can help a sore throat and ease a cough. Add humidification to the air when the weather is cold and dry. Use saline to clear the mucus from the nose and open nasal passageways. Never underestimate the power of water!

Tamiflu 

Tamiflu is recommended for certain high risk people who are exposed to or sick with influenza. Prophylaxis can be given to prevent illness in children over 1 year of age who have known exposure within the past 48 hours if they meet high risk indications. Treatment of illness can be given to those over 2 weeks of age if they meet high risk criteria. There are shortages beginning this season and resistance can easily develop, so its use should be limited to those who truly need it.

High risks include: less than 2 years, lung disorders, immunologic disorders (immune compromised), chronic metabolic disease, and neuromuscular disorders.

If influenza symptoms have been present for more than 48 hours, it is not indicated unless there are special circumstances.

Tamiflu shortens the symptoms of influenza by 26 hours, about a day. It can help prevent the spread of the virus. It can have side effects, most commonly nausea and vomiting, but also more serious rashes and neurologic symptoms (confusion, delirium, and hallucinations).

Flu Vaccine

Vaccination is the best prevention against influenza. It does not make people get the flu. It is safe and indicated for everyone over 6 months of age. Thank you to all my patients who were vaccinated this year!  Although it is not 100% effective, it should lessen the risk of influenza to you.

Please don't wait to see if it will be a bad season before deciding if it's worth it to get the vaccine. Once the season has started it is less effective because it takes your body about 2 weeks to build immunity. Waiting also puts you at risk for being left out if there are shortages. Our office gave more vaccine than ever this year, but we still ran out earlier than ever this year.

If your family still needs the vaccine, check your local health department and pharmacies.  When we start vaccinating again this summer for next season, be sure to get your family vaccinated! (We will publicize availability on our website, Facebook page, and by email to those registered on our website.)

Vomiting and/or diarrhea

Vomiting and diarrhea can result from many viruses, usually NOT influenza. Treat with an electrolyte solution (such as Pedialyte, Gatorade's G2 - less sugar than regular). Give small volumes frequently. When kids get thirsty, they might gulp and then vomit, so put only 1 teaspoon in a small cup or syringe, or give a popsicle made of the electrolyte solution. Juice, carbonated lemon/lime drinks, and other high sugar drinks should be avoided.

Dairy increases stomach upset, and I generally say to avoid all milk products (except human milk) for 48 hours after the last vomiting or diarrhea. Breast milk can sometimes be tolerated, but it must be given slowly too, so often breast feeding should be stopped. Pump and give the expressed milk by the teaspoon in a syringe.

Facebook Tips to Not Miss Page Posts

This is an off topic blog, but I use Facebook regularly to share great health and behavior tips to parents, and I find that only a small percentage of them are able to see the posts regularly. It makes sense that if you have hundreds of friends plus follow scores of pages, you won't see every post every day. But if you really like a page and want to be sure to see all of its posts, I have found the best way is to add it to an interest group. There are two ways to add pages to your interest group, both described below.

I have seen many posts about how to make things show in your News Feed by selecting "Get Notifications" and "Show in News Feed", but I find that those simply don't work. (I follow many pages since I administrate my office FB page, so maybe that affects it, but I still miss pages that way.)

You will be able to set up various interest lists if you want. (They STILL don't always show up in your news feed, see BIG TIP below.)

First, log into Facebook for either method of setting up interest groups or adding to your group. (Note: if you are a page administrator, you must be logged in as your personal account, not your Page.)

First method: This works well if you are on a page and want to add it to an interest group. Click on the little gear/arrow (in blue below) and then add to Interest Lists.

Second method:  This works well if you want to add several favorite pages all at once or if you want to follow an interest group that is public.

From the Home screen view: Along the left sidebar there are several categories: Favorites, Apps, Interests, and more.  Before you set up interests, it will just have "Add Interests..."  Once you have set them up, you can select the Interest Group you want to see.  My Interests are pictured here:

The blue Interest "Work help" is one I've made, and it consists of pages I often find interesting articles to repost. "Health Causes" and "Child Causes" (green) are standard public groups that I follow to see if I find new pages to "Like".  If you click on "Add Interests..." you will find many pages either similar to pages you already follow or ones your friends follow.  You can also make your own interest group(s), which is where you can put pages you don't want to miss:

BIG TIP: Once you have your interest groups set, you need to remember to actually look at them since they don't automatically pull into your news feed. The only pages that show up at that point are those from that group. (No friend updates or other pages.) You will then simply click on "Home" to return to your usual News Feed.

I hope this helps... at least until Facebook changes its settings again!

Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night's sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

This is the season we are seeing a lot of sickness. It's been about 11 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn't help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn't make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments (because my son had wheezing so we had everything we needed to give a treatment at home) despite the fact that they didn't seem to help her much. It was probably the humidified air that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn't helping, so I wanted to at least try the asthma medicine. She kept wheezing. We brought her in to the office 3 days in a row to have someone else check her. I can't check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams. She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times/minute for days. I still don't know how. I remember wishing her oxygen level would drop enough that we could hospitalize her, not critically, just enough. Then she'd be on monitors, and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick, and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn't that we are holding out on a treatment that will fix the illness, it's just that we don't have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn't predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I've heard a parent complain that someone else "missed" something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse called because a fever had started. New symptom, so another exam was done. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don't resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

Money is probably the biggest issue. It is not because we want your co pay. The "we" I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I've seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the co pay because we did "something wrong" or "missed a diagnosis" the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate co pay is charged. We must adhere to legal contracts or it would be considered insurance fraud.

Increasing our numbers for "production" is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don't want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.

We want to see your child again because we need to see your child to know what to do. Maybe now the child's symptoms have changed.  Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever's been going on long enough without any identifiable cause, which requires lab and/or xray evaluation. 

Please remember that if you get a different answer at a different visit, it doesn't mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change. Human bodies are not static.

Top 10 Posts

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There are many Top 10 lists at the end of the year. Since I've been running low on blog ideas and short on time with the holidays, I thought I'd do my Top 10 blog posts.

What started as a quick project has sent me down memory lane, since most posts are triggered by an event (or series of events) that make me want to write about the topic. I'm adding a bonus #11 because it is one of my favorites and I am feeling nostalgic.

11. Potty Training is one of my most personal blogs, describing my own potty training parent moments. Sorry kids!

10. Walk In Clinic Etiquette was written in part because of my frustration of the many options of urgent cares, some with good treatment, others with less than ideal treatment. It also highlights some of the issues our walk in clinic providers deal with regularly.

9. Fever is... one of the biggest worries of parents. There are so many real fears but also a lot of exaggerated fear. My attempt to set the record straight.

8. Cut the cord... Give them the World! My thoughts on parenting to allow kids to grow to be independent and productive adults.

7. Parenting when you're angry: Keep Cool We've all been there.

6. Oh, what a (sick) season! This is one of my newest posts. Tips on what to do if your family gets what's going around are still pertinent.

5. Itchy Bottom? Is it Pinworms? What to do? We had a number of pinworm calls from worried parents and I wanted to help our phone nurses out since the treatment options are confusing to parents.

4. Got Milk? Cow, Coconut, Soy, or Almond? Questions on milk alternatives are common for kids with dairy allergy or family preference.

3. Ear Wax: Both Good and Bad Ear wax is another common frustration to parents. When to leave it and when (and how) it should be removed are discussed.

2. Car Seat Confusion and Booster Boo Boos I love that this has been so widely read. It is such an important topic. Please share this one!

1. New Guidelines for Treatment of Strep Throat This surprised me as the most read post. I'm glad people are interested in reading things like this. I hope it decreases the demand for unnecessary antibiotics and educates people about why we do some of what we do in medicine.

One final "bonus" blog update. Pediatric Partners joined Team Mighty Maxwell (March for Babies) in support of Dr. Ratliff's son. Max remains at Children's Mercy. He continues to require help breathing with a ventilator but his doctors are trying to slowly decrease the amount of help he needs. He has had surgeries to help reduce pressure in his eyes and is seeming to be happier overall. For more updates, check out his CaringBridge page.

Oh, what a (sick) season!

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This cold and flu season has started early and hit hard! The number of kids we are seeing with severe illness, such as prolonged fevers (over 5 days over 101.5F) and difficulty breathing, are not typical for this time of year. On more than one occasion we have tried to admit a sick child, only to be told there are no available beds. While we are familiar with this in January, this started in November and is more common this month. I feel the need to review a few helpful tips.

What are we seeing right now? A bit of everything. Fever. Vomiting. Diarrhea. Strep throat. Influenza (fever, cough, sore throat, body aches). Bronchiolitis (from RSV and other viruses). Pneumonias. Asthma flare ups. Sore throats from viruses. Whooping cough. Mild colds and coughs. Basically, if you ask if it's going around, chances are the answer right now is "yes".

Wash hands and surfaces! First and foremost is control of spreading infection. You never know when someone is shedding a virus before they feel sick. If you are taking care of sick kids, you are at risk of getting sick along with them. Wash hands and surfaces often. Don't share food and drinks, even with your family! Avoid touching the eyes, nose, and mouth. These are where germs enter to make you sick! When's the last time you cleaned your phones and keyboards?

Fever can be a good thing. We worry in infants under 3 months, those who are immune compromised, or those that are not up to date on vaccines ~ they should always have a medical exam with fevers. If a fever lasts longer than 3-5 days kids should also be seen. For everyone else, we treat symptoms, not the thermometer. If a child is playful at 101F, no need to treat other than pushing fluids and watching carefully. Usually by 102F kids start feeling body aches and feel better with treatment. Watch your child's symptoms, don't worry about the actual degree on the thermometer. Use either acetaminophen or ibuprofen, but most pediatricians don't recommend alternating. Follow dosing charts for weight, and if weight is not known, use age. For dosing charts, see our Medication Dosing page.

Stay home if sick. Again, this is paramount for controlling the spread of all the germs. Don't try to mask symptoms with a fever reducer so you can send kids to school or you can go to work. Stay home and rest!

Never underestimate the power of water. If there is vomiting, an electrolyte drink in small volumes frequently is best. For most colds and coughs, simply drink more water. If there is congestion, runny nose, or cough, add water to the air with a vaporizer or humidifier while you sleep. Even if you have a home humidifier, using an additional one in the bedroom helps. Use saline in the nose. Drops are okay for infants. Older children and adults can learn to flush the nose with saline. Check out Nasopure for tips on learning how to do this and videos to see that it's not as bad as it sounds. (I am not associated with or paid by Nasopure. I just like their product.)

Antibiotics don't make viruses go away any faster. Please don't ask for a prescription if cold and cough symptoms just started within the past 10 days. Unless there is an identified infection requiring antibiotics, they won't help. Even some things we often treat with antibiotics don't need them. Many ear infections and sinus infections are viral and will resolve without antibiotics. At your office visit ask about the need for antibiotics if your child has one of these infections.

We cannot make any diagnosis over the phone. As descriptive as you are on the phone, there is no substitute for examining a child. I encourage people to go to their medical home as often as possible and use other urgent care centers or emergency rooms for true urgent/emergent needs. Going to the same office for sick visits helps to track infection rates to identify kids who might need another treatment, such as ear tubes for frequent ear infections. Even if you get good care elsewhere, it is hard to keep track of dates they were sick and which medicines were used. With most pediatricians open extended hours these days, it is usually possible to be seen by someone you know and trust in a familiar setting.

Some illnesses need multiple visits. I know this is time consuming (and expensive with many insurance plans) but illnesses progress, symptoms change, and exams change. Just because your child was seen a day or two ago and it was "just a cold" doesn't mean it won't progress into an ear infection, pneumonia, or dehydration over time. Unless your child is really sick, you don't need to bring them in at the first sign of a runny nose or fever. Try home therapies first. Coming in early doesn't stop the progression of illness. Preventative antibiotics are not recommended, even if your child has a history of frequent ear infections.

We are in the middle of a whooping cough epidemic. Unfortunately whooping cough can mimic mild colds at the beginning, but the cough can last for several months if not treated in the first couple weeks. A small percentage of people who have been vaccinated still develop whooping cough, though it may be milder it is still contagious. If you child has been exposed to whooping cough and develops any cough, visit your doctor for evaluation and treatment. If your child develops a cough that is followed by a whoop or a cough followed by vomiting, he or she should be evaluated for whooping cough. Be sure kids and all care givers are up to date on vaccine. Typical pertussis vaccine is given at 2, 4, 6, and 12-18 months, 4-6 years, and 11 years. If not given at 11-12 years of age, the Tdap should be given to all teens/adults once. Get vaccinated!

Our influenza season has started earlier than usual and is predicted to be a bad season. Flu vaccines are the best prevention against influenza, so yearly vaccination for all over 6 months of age is recommended. We gave more influenza vaccine than ever in our office this season, but we are out of stock. If your family has not been vaccinated, check with your health department and other locations offering flu vaccines.

If you need information on treating specific illnesses, use our tips on Illnesses and Symptoms, but please see someone at your usual physician's office as well if you are concerned. 

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

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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.