Learning and Behavior Series Part 2: Who's who in learning and behavior testing

This is part 2 in a series of posts on Learning and Behavior issues.

Parents are sometimes surprised to learn that I treat ADHD, anxiety, and some other behavioral disorders. There are some pediatricians who don't, but I find there is a huge need, and I feel that in many cases since I've followed a child for years, I know them well and can help better than a specialist who will only see them a few times. That being said, I do use specialists often. Of course the professionals at school are imperative to being part of the team. And there are times when the diagnosis isn't clear, or a child doesn't respond to the treatment well and other healthcare specialists are very helpful to assess the issues.

Many different professionals typically work together to help assess learning and behavioral concerns, each using his area of expertise to contribute to the whole picture. There are no specific laboratory or imaging tests available to determine a diagnosis on a routine basis. This can make it a little tricky if the symptoms are not clear cut. Many learning and behavior problems have similar symptoms, so it might take several professionals to help evaluate the situation. We often base our diagnosis on the symptoms parents and teachers (and older children) report and by ruling out other disorders. There are standardized questionnaires or tests for various conditions that have been validated. Each condition has specific treatments that have been shown to benefit the condition. There are also tests available, such as EEG for ADHD, that are not shown to be beneficial and can increase cost without adding to the diagnostic evaluation. There are of course many tests and treatments available that have not been proven to help. If it sounds too good to be true, it probably is. Discuss tests you are considering with your child's doctor first, especially if there is a large price tag attached.

The evaluation includes several types of assessments because there are many things that can cause learning or behavioral issues. Contributing issues include but are not limited to: ADHD, anemia, anxiety, bullying or abuse, chronic illness, depression, hearing or vision problems, learning disabilities, malnutrition, oppositional defiant disorder, sensory integration disorder, and sleep deprivation.

A big part of the diagnosis lays in the symptoms noted at home and school, so there are a lot of questions about how your child fares at each. Both parents and teachers and any other significant adults should fill out standardized questionnaires as recommended by the clinician doing the evaluation for many behavioral issues. It is important to answer each question as honestly as possible to avoid misrepresentation of symptoms, which can lead to an improper diagnosis. It is also important to review the family history, since many of these issues run in families. A physical exam should be done to help identify any physical symptoms that can contribute to learning or behavioral problems. This should include hearing and vision assessments by appropriate professionals. Some clinicians may go to your child's classroom to observe behaviors. Psychological and IQ testing might be performed, depending on the symptoms.

So where does everyone fit into the diagnosis and treatment of kids with behavioral or learning issues?

• Parents (or primary caregivers) are critical to giving insight into how children learn and behave. They should be interviewed and fill out standardized questionnaires to help with the diagnosis and then their feedback on how each treatment is working is helpful in fine tuning treatment plans.
• Teachers are imperative in helping assess the issues and concerns since they can compare any one child to a room of their peers and they know how your child handles various situations and what their typical behaviors are. Teachers with advanced background in learning disabilities are used to help address specific concerns. It is recommended that each teacher fill out standardized questionnaires to help with the initial evaluation of focus and behavior disorders and again to assess responses to treatments. Schools may put students on IEP or 504 Plans to help with their education. For more on these see IEP & 504 Plan. 
• Physical Therapists, Occupational Therapists, Audiologists, and Speech Therapists can be school based or private, but they are helpful in addressing specific motor skills, sensory issues, hearing issues, or speech/language concerns. They do not prescribe medication, but work within their area to improve certain skills that affect learning and behavior.
• Psychologists (clinical psychologists, cognitive psychologists, educational psychologists and neuropsychologists) and clinical social workers offer testing as well as therapy for many disorders. They can do parent training to help parents manage behaviors at home. They cannot prescribe medications, but many people find that the therapy provides enough benefit that medication is not needed or that the therapy in addition to medicine helps better than either treatment alone. Cognitive behavioral therapy is the preferred first line treatment for certain disorders, such as ADHD in a young child or anxiety. These therapists also often provide social skills training, which is needed for many children with behavioral and learning issues who don't learn social skills as easily as their peers. You should check your insurance list of providers to see who is covered. It also might be worth pricing some who do not take your insurance but will give you a bill to submit yourself. It may be that even if a person is out of network your cost is about the same as a person who is harder to get in to see but on your plan.

• Physicians (pediatrician, family physician, developmental pediatrician, neurologist, and psychiatrist) can prescribe medications for treatment of certain diagnoses, such as ADHD or anxiety. Not all have experience with each of these issues so you must ask what their experience is. It can take quite awhile to get into specialists and they can be expensive, so starting with your primary physician often is easier and very helpful to rule out medical issues and to do the evaluation and treatment if they are comfortable. Many psychiatrists do not accept insurance and they are typically difficult to get in to see. Physicians (including psychiatrists) generally do not do therapy. They focus on the medication benefits and side effects.
• Nurse practitioners and physician assistants can work with physicians (and independently in some states) to diagnose disorders and prescribe medications to treat them. They do not offer psychotherapy. Benefits include that they are generally easier to get in to see and they are relatively inexpensive compared to physicians. Not all are comfortable with treating these issues.

The types of professionals who work with any given child to assist in diagnosis and treatment vary depending on the issues at hand, but the most important thing is that they work as a team and communicate with one another. This communication is often done through parents and written reports, but it is important that all members of the team have access to what the others are doing. 

Resources available:

• Finding More Help is a list of online resources as well as local professionals.
• CHADD is a national organization to support those with ADHD. Membership includes vast resources for learning more about ADHD.
• ADHDKC is a local chapter of CHADD and offers free parent meetings with great speakers on a variety of topics related to ADHD.
• Learning Disabilities Association of Kansas (LDAK) is a volunteer organization whose purpose is to advance the education and general well-being of children and adults with learning disabilities.
  
  

  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
  
  

Learning and Behavior Series Part 1: Labels - Why should my child be diagnosed?

This is the first in a series of posts about learning and behavior I will do over the next several months.

I see a lot of children with various behavioral and learning issues. Teachers and parents often first think of ADHD with any problem, but that isn't always the problem, or at least the primary one. It is simply one of the most common diagnoses. Since it is so common, I will focus on this topic often, but it can mimic other problems and it often co-exists with other issues.

I firmly believe that kids with learning and behavioral problems cannot just "work harder" to fix the problem. When I am sleep deprived, I cannot focus as well. I cannot read and comprehend what would typically be easily understood and retained. I lose track of things. I lose my temper more easily or get upset about the little things that usually wouldn't phase me. I must put extra effort into everything, which is even more exhausting. I liken this to how some people feel most of the time. How can we possibly expect them to just try harder without professional assessment and treatment?

One reason parents don't want to have their child diagnosed with ADHD or any other learning or behavioral problem is that they fear a label. What is a label? It is not a diagnosis, but the way we are perceived. Think about how many judgements and labels you make in a day. I try really hard to not judge because it's not my place, but those thoughts sneak into my mind all the time:

That person is rude. 

That's my shy (hyper, loud, smart, active, loving, etc) child.

That was a dumb statement. 

That group of giggling girls is too loud and out of control. 

I don't say anything with these thoughts most of the time because it's usually not my place. I often mentally rebuke myself for having them, but I still have opinions. The truth is that we all make judgements all the time. And when a child acts out a lot, he is judged and labeled. If a child never seems to be organized, she is judged and labeled. If a child falls behind academically, he is judged and labeled. It happens with or without a diagnosis. The label is there.

Wouldn't it be better to get a professional's evaluation and treatment? With proper management, your child might lose the negative labels and be able to succeed!

One of the problems with diagnosing many learning and behavioral disorders is they are difficult to test for since there is a continuum of symptoms of normal and atypical and there are so many variables (such as sleep) that can affect both learning and behavior. Even though ADHD is common, studies vary and disagree as to exactly how common it really is. Some experts think people are under diagnosed. Others claim too many are over diagnosed. The same goes for treatment: too few kids are medicated or too many kids are medicated. I think that all stems from the fact that the symptoms of ADHD are common to any neurotypical person, just to a larger degree, and symptoms often overlap with other disorders -- making a correct diagnosis difficult. There are still many people who think behaviors and focus problems are due to bad parenting. If it is a parenting issue alone, how would a medicine help? Probably in part due to this stigma, parents worry about how the diagnosis will reflect on the child and family more than any other diagnosis I know. If a child has an infectious disease or  a chronic condition such as asthma, there is much less hesitation to assess, diagnose, and treat the illness.

There are many reasons for parents to be hesitant to begin an evaluation when their kids are showing signs of a learning or behavioral problem. Some think it's just a phase. Many wonder if another few months of maturity will help the child. Some think the child is just misbehaving, and stricter rules or harsher punishments will help. Others think the child is just looking for attention and giving more praise will help. Some parents think it is because of the other children around -- you know, "Little Johnny is always messing around in class so my Angel Baby gets in trouble talking to him."

While I am all for looking for things on your own that can help a child's behavior and optimize their learning, I also think that avoiding the issue too long can lead to secondary problems: academic failures, poor self esteem, depression, drug/alcohol abuse, and more. Working with the school and seeking professional help outside of school can help your child succeed. If a parent is not wanting to start medication, there are other things that can be done that might help the child succeed once the specific issues are identified.

Why wouldn't you want to start a treatment that works? Asking a child with ADHD to just focus harder is like asking someone with nearsightedness to just focus harder. Without the help of glasses a person with nearsightedness can't see well. Without a medicine to help, some people just can't focus. If a child needs glasses to focus parents rarely say they'll just make the child try harder. They get glasses for the child. Without the glasses a child may have more injuries from not being able to see. He might have physical symptoms, such as headaches, from the eye strain. His grades might fall because he can't see the board. People see the vision issue as a medical one, yet when a brain has trouble with neurotransmitters causing focus problems, they often resist the medical treatment. Untreated ADHD also has consequences. The children suffer from poor self esteem because they constantly are reminded that their behavior is bad. They have a harder time doing tasks at school because they lose focus. They get distracted and miss important information. Children get in trouble for talking inappropriately, acting out or for invading other's personal space. They lag behind peers with social skills and often have a hard time interpreting how others react to their behaviors. Their impulsivity can get them into dangerous situations, causing more injuries. Older kids might suffer from depression and anxiety from years of "failures".

If you still worry about labeling your child with a diagnosis, think about what the root of your worry really is. Remember that the diagnosis is only a word. It doesn't define the best treatments for your child, but it opens the doors to allow investigation of treatments that might help your child. In the end most parents want healthy, happy kids who will become productive members of society. How can you best help them get there?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

• ADHD: CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am on the board of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!
• Anxiety: Many parents are surprised to learn how much anxiety can affect behavior and learning. The Kansas City Center for Anxiety Treatment has support groups for their current and former patients.  

• Autism: The Autism Society has a list of resources 
• Dyslexia: Dyslexia Support Group for youth with dyslexia

• Learning Disabilities: Learning Disabilities Association of Kansas
• Tourette's Syndromr and Tic Disorders: Tourette's Syndrome Association is a great resource for people with tic disorders. They have an active local chapter.
• General Support Group List: List of many support groups in Kansas: Support Groups in Kansas  (I found the search function to work best with the bottom option.)

I'll be writing a lot on this general topic over the next few months, so let me know if there are any specifics you'd like addressed!

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

Ticks!

We are getting a ton of phone calls every day because kids have had ticks and parents are worried, so I thought I'd run through the most important things: prevention of ticks, tick removal, and diseases from ticks.

Prevention is of utmost importance in most things, and tick bites are no different. If you are going to be in an area that is likely to have ticks (trees and tall grass), wear boots or tuck pants into socks, long sleeves, long pants, and hats. Use repellents that contain 20 - 30% DEET on exposed skin and clothing for protection that lasts up to several hours. Always follow product instructions. Parents should apply this product to their children, avoiding hands, eyes, and mouth. You can use products that contain permethrin on clothing - ones that come pre-treated may be protective longer. Treat clothing and gear, such as boots, pants, socks and tents with products containing 0.5% permethrin, following package directions. For more information on insect repellants and how to choose the best for your situation, visit this EPA page.

If you have been in areas where ticks are likely, check for ticks daily. If ticks are removed within 24 hours there is less chance of disease transmission. Pay careful attention to the head and ears, under arms, around the waist and between the legs, and in the belly button. (Don't forget to check your pets and any gear you might bring inside!) Bathe as soon as possible after coming inside. Tumble clothes in a dryer on high heat for an hour to kill remaining ticks. (Some research suggests that shorter drying times may also be effective, particularly if the clothing is not wet.)

If you find a tick, proper removal is important. I've heard wild stories about drowning ticks or burning them off. These things are dangerous- the chemicals or heat can burn your skin and could cause the tick to regurgitate back into the skin, increasing risk of disease transmission. The best method is to use a pair of thin-tipped tweezers to grab the tick as close as possible to the skin (not the belly of the tick!) and pull firmly but gently. 

photo source: Shutterstock

There are many tick - borne diseases, but only a few in our area. For a listing by geographic area, see this CDC page. The most common symptoms of diseases caused by ticks:

Body/muscle aches
Fever
Headaches
Fatigue
Joint pain
Rash
Stiff neck
Facial paralysis

Rashes are often characteristic of the disease and are used in the diagnosis. Many of these diseases don't rely on lab testing, but rather the risk of exposure and the symptoms. Most have treatments available, but every tick bite should not be treated to "prevent" because that would expose people to unnecessary antibiotics most of the time. To see the target rash typical of Lyme, Rocky Mountain Spotted Fever, tularemia, and more, visit this CDC page. 

Ticks in the Midwest carry these diseases:

• Rocky Mountain Spotted Fever (RMSF): Symptoms include fever, headache, abdominal pain, vomiting, and muscle pain. A rash may also develop after a few days, but not in all people. RMSF can be a severe or even fatal illness if not treated in the first few days of symptoms. Doxycycline is the treatment of choice for adults and children of all ages, and is most effective if started before the fifth day of symptoms. Treatment should be started based on clinical diagnosis before the disease is confirmed by lab testing.

• Tularemia: People can be infected with tularemia from contact with infected rabbits, hares, and rodents, tick and deer fly bites, ingestion of contaminated water, or inhalation of contaminated dusts. Symptoms vary depending upon the route of infection. 

• Ulceroglandular or Glandular: This form comes from a tick or deer fly bite or after handing of an infected animal. A skin ulcer appears at the site where the organism entered the body in the ulceroglandular form. In both forms lymph nodes (glands) swell in the area of the exposure.  

• Oculoglandular This form occurs when the bacteria enter through the eye. This can occur when a person is butchering an infected animal and touches his or her eyes. Symptoms include irritation and inflammation of eye and swelling of lymph glands in front of the ear.
• Oropharyngeal This form results from eating or drinking contaminated food or water. People with orophyangeal tularemia may have sore throat, mouth ulcers, tonsillitis, and swelling of lymph glands in the neck.
• Pneumonic This is the most serious form of tularemia and comes from inhaling contaminated air particles or if another form is untreated and spreads to the lungs. Symptoms include cough, chest pain, and difficulty breathing.

• Heartland Virus: As a newly discovered virus, there are still a lot of unknowns, but it seems to be carried by ticks in Missouri and Tennessee. Symptoms include fever, extreme fatigue, headaches, muscle aches, diarrhea, loss of appetite, and upset stomach. There is no lab test for it yet. There is no known treatment, but most people recover.

Lyme disease is probably the most well known but most misunderstood tick disease. Ticks in our area don't commonly have Lyme disease, but it is the most commonly found tick-borne disease in the US. Symptoms vary based on time:

• Early localized phase (3-30 days after bite): A target shaped rash in the area of the bite develops in about 70% of people with Lyme disease. A red mark at the site of the bite is normal, not a sign of infection, but if the area grows and looks like a bullseye, that is the erythema migrans rash that can be associated with Lyme disease. People might also have fever, chills, fatigue, headache, muscle and joint aches, and swollen lymph nodes.
• Early disseminated phase (days to weeks after bite): The rash can spread to other parts of the body. A facial paralysis can occur. Severe headache, stiff neck, joint swelling and pain, dizziness, and heart flutters can occur. Most of these symptoms will eventually resolve without treatment, but further complications can develop.
• Late disseminated phase (months to years after bite): Arthritis, numbness and tingling of hands and feet, pains, and short term memory problems may develop without treatment in earlier stages.
• Lingering symptoms after treatment: About 10-20% of people will have symptoms months to years after treatment despite treatment. These include muscle and joint pains, sleep problems, fatigue, and cognitive problems. It is thought that this is an autoimmune problem resulting from the infection, and antibiotics do not help (and might worsen) symptoms at this point.
• For more on Lyme disease please visit the CDC's comprehensive Lyme pages.

Summertime = School Physical Time!

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

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

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

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

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

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

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

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

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

My child swallowed....

It happens all the time. Kids put things in their mouth that aren't supposed to be eaten. Parents often call about what to do when their toddlers or children swallow things. Most of the time things will just pass -- though I'm not a fan of watching the stools for the swallowed object because it just worries parents if they miss it.

The biggest risk group is children between the ages of 6 months and 6 years, but anyone can be at risk. I have seen an older school aged child swallow a magnet after putting 2 small strong magnets on either side of their tongue to look like a tongue piercing. Adults have been known to swallow things such as needles (many sewers put the needle in their mouth if you think about it).

If you are around kids it is a good idea to know child CPR and refresh your skills every couple years. Classes are often held at local Red Cross stations, hospitals, or fire departments. You can also find classes by searching "CPR" and your zip code. For great information on signs and symptoms of choking and general treatment of choking, visit this KidsHealth Choking link.

If your child seems to put more non-food items in his mouth than other kids, he is at risk of pica. Pica is when a person compulsively puts non-foods in his mouth. For more see the KidsHealth Pica link.

Always keep the poison control number (1-800-222-1222) stored in all your phones! You will see below that I refer to them often. If you call your doctor about a potentially toxic substance, chances are we will refer to poison control. They have the best database of substance risks and their treatments. Don't delay treatment by calling the doctor!

For more information: http://www.aapcc.org

Here's a list of common things and what to do.

• Balloons: Balloons are statistically some of the most inhaled or ingested foreign bodies. One reason is they are so popular with kids, and often are found at parties or other large crowds, where toddlers and young children are often less directly supervised. They can suffocate a child quickly if they are inhaled. Call 911 if there is any difficulty breathing, drooling, or other signs of distress. If swallowed, they will pass on their own.
• Batteries: If you think your child has swallowed a battery, whether or not he appears distressed, immediately take him to an emergency room. If there is distress, call 911. Batteries can cause voltage burns or leak, causing acidic burns as soon as four hours after being swallowed. X-rays will confirm if the battery is in the chest or abdomen. They usually need to be removed to prevent serious injury. Be sure to keep all of your batteries, especially the small button batteries, safely stored away from children.
• Bugs: Most of us has swallowed a bug some time in our life. You might not even know if a small one hides in your soda can and you take a big gulp. A little extra protein, right? Unless your child chokes, or if it has a stinger (bee, wasp) there is nothing to worry about. If he's choking, follow choking instructions (link at top). If you suspect a bee or wasp was swallowed, especially if your child seems to be reacting to a sting in the mouth, or there's sudden difficulty breathing, drooling, or choking, call 911. Serious reactions to stings in the mouth can occur.
• Buttons: Buttons, much like coins, are generally harmless unless they get stuck. See the information on coins. Unlike coins, they are not easily seen on X-ray, which can make identification of a stuck coin a little trickier, but if you suspect an issue, talk to your doctor.
• Cleaning products, laundry detergent, and other chemicals: These are highly dangerous and you should call poison control with any suspicion of ingestion or 911 if there are signs of distress. These should always be stored away from children to prevent the possibility of swallowing in the first place. Even the "green" products are usually not safe with ingestion.
• Coins: Coins are some of the most frequently swallowed objects. These usually pass through the body without any problems. Unfortunately many parents never see it come out the other end. Since it is so common you would think there would be a consensus as to how to manage it. There isn't. Of course if there is any distress, drooling, breathing difficulty or coughing, your child should be seen immediately, ideally in an ER so that an immediate surgical consult can be made if necessary. If it was inhaled into the windpipe instead of swallowed into the esophagus or stuck high in the esophagus causing compression on the wind pipe, it may need to be removed. As for kids who swallow coins and have no symptoms, it isn't as clear cut. Some doctors get X-rays for all children who swallow a coin to be sure it isn't stuck in the esophagus (about a third of those stuck eventually end up passing, but most need to be removed). Others only X-ray if there are symptoms. Some remove the ones in the esophagus immediately, others will wait up to 48 hours if there is no distress. Generally once it reaches the stomach it will pass.
• Crayons or play doh: I used to wonder why so many things were labeled "non-toxic" -- at least until I had a child of my own. They put everything in their mouth! These are generally safe (again, unless they choke), although it is possible that these things contain lead or other contaminants. If your child frequently puts them in the mouth, it is probably a good idea to not allow them near your child and talk to your doctor about pica (see link above for more information). 
• Dirt or rocks: Unless your baby chokes or bites down on a rock and breaks a tooth, dirt and rocks are generally harmless. If your child seems to crave these and eats dirt compulsively, see the pica link above.
• Energy drink: Energy drinks are a popular choice for many, but they contain caffeine and other stimulants that can make them dangerous for children. Call poison control for instructions.
• Grass or plants: Unless the grass was recently chemically treated or if the plant is poisonous, there is little to worry about here. If you're unsure about a plant being poisonous, contact poison control. If there is choking, do CPR or call 911.
• Gum: Contrary to popular belief, the occasional swallowed gum does not stay in your gut for years. It isn't digested like other foods, but unless it gets stuck along the way, it finds its way out just like all your other food. 
• Hand sanitizer: Hand sanitizer in small amounts, such as putting fingers in the mouth after rubbing sanitizer on the hands, is generally safe. Larger amounts can be dangerous and you should call poison control if you suspect ingestion.
• Magnets: A single magnet is not a worrisome as multiple magnets, but since it often is not known exactly what a child swallows, it is always recommended to take your child to be evaluated if there is a suspicion of swallowed magnets. They will need X-rays and if there are multiple magnets, they must be removed to prevent perforation of the gut.
• Medicines, vitamins, supplements: If your child swallowed (or potentially swallowed) a medication or supplement, call the poison control number ASAP. Have the bottle with you so you can answer their questions.
• Nicotine: Sadly ingested nicotine has been an increasing problem since e-cigarrettes have been on the market, but even regular cigarettes, cigars, and their ashes pose problems. Effects of nicotine poisoning include vomiting, sweating, lethargy and tremors in mild poisoning and confusion, paralysis, and seizures in severe poisoning. If you even think your child has eaten a nicotine product, call poison control (or 911 if significant symptoms).
• Pet food: As disgusting as it smells to me, kids love to eat pet food. The biggest risk here is choking. If they choke, use your CPR skills. If you're not confident with CPR, call 911 and they will walk you through it.

• Pop-top from a can: The flip top that opens a soft drink can is usually not a concern unless a child chokes on it. It generally will pass through the intestines if swallowed, but if there are signs that it was inhaled or is stuck in the intestine, a child should be seen. These do not show up on X-ray because they are made of aluminum. 
• Poop: This one is gross, but happens more than any parent wants to know. Many babies stick their hand down their diaper and then the hand goes to his mouth. While this is really gross, it does not cause any danger to the child. If it is his own poop, he will not be exposed to any new germs. If your child finds someone else's poop, usually animal poop, there is a little more concern for infection but still pretty low risk. Symptoms of nausea, vomiting, diarrhea, and low grade fever usually happen within 30 minutes to 4 hours after the ingestion if they are affected. In this case, treat symptoms as you would any other stomach bug and call your doctor. For specific information of various types of poop (even raccoon!) check out the Illinois Poison Control blog on poop. 
• Salt and baking soda: These common kitchen items do not raise fear in many people, but if either is taken in large amounts, they can cause serious problems. One tablespoon of salt in a toddler can cause seizures due to electrolyte imbalances. More can be deadly. One tablespoon of baking soda changes a body's pH and can cause serious injury. If your child swallows either of these, call poison control immediately. 
• Sharp objects: Any pointed object such as toothpicks, wire, chicken bones, open safety pins and hair pins can pierce the gut. If you think or know your child has swallowed one of these, get the child to the emergency room immediately. 

Screen Free Challenge

Are you up for a challenge?

Join thousands of other families who want to reconnect by going screen free for the week of May 5 – 11, 2014.

What does screen free mean? To put it simply: do not use anything with a screen unless it is directly related to work or school. Televisions, computers, smart phones and other screens are all a part of our world, but they can overtake our lives. By consciously avoiding non-essential screen time, we can reconnect with our family and friends and even ourselves.

Does going screen free for a week sound impossible?

For many people screens are an essential part of our lives. We use online calendars so we can remember our daily schedule and share it with family. We use online resources to make purchases, or research a topic. Computers help us conduct business and more. Texting allows quick communication. Less essentially we use screens to keep up with friends or to share what we’re up to. We play games. We watch movies and television shows. We use screens as a cheap babysitter. It is a huge recreational pastime. It’s easy and inexpensive.

But there are many costs.

• Do your kids complain that you’re always on your phone or computer? Maybe they don’t verbalize it but they might show it with disruptive behaviors. And remember you’re their role model. They will do as you do. But they’d rather spend time with you. Even the teens who deny it. 
• Do your children throw a fit when you tell them to turn the screen off? This can be a sign of addiction, or at least poor self-control. Aggressive tendencies are often exacerbated by screen time.
• Children lose time outdoors and in other active and creative play because they’d prefer to watch television or play a video game. Screen time is directly correlated with obesity, behavior issues, and sleep problems. Active play and social interactions can help with each of these problems.
• Infants and children learn best through human interactions and exploration, yet a screen sometimes mesmerizes them for hours at a time. Some of us feel comforted that our kids are learning by playing some of these games or watching certain “educational” programs, but this is often not the case. Studies do not show beneficial learning, especially in young children, with screen interactions. In many cases time spent on these games and programs is detrimental to their development.
• The typical school aged child has more screen time than ANY other activity except sleep!

Just think of all the free time you will make by turning off the screens. Have every member of your family make the commitment and help each other find new ways to connect.

Because most of spend over 2 hours a day with recreational screen time, we can capture that time to play a game with our kids, take a walk, read a book, write poetry, do a craft project, clean out the garage, garden… the list goes on. Let your kids do things and experience life instead of letting them watch or play with something someone else created for them. And it’s okay to just spend time together talking. Sometimes it’s those simple times that become our most special memories.

Unplug. Start with just one week. See where it takes you!

101 Screen Free Activities

Related posts:

Screen Free Week April 29-May 5, 2013

Screen time: Do you have a love - hate relationship with it?

Quest for Health: Why Screen Free?

Quest for Health: Screen Free Week Reflections

Resources and More From Around the Web:

Screen Free Week is Just around the Corner!

Following FTC Complaint, Baby App Developer Stops Making Educational Claims

These Apps Will Not Educate Your Baby

ScreenFreeWeek.org

Screen time: Do you have a love - hate relationship with it?

Screen time. Parents often have a love - hate relationship with it. We've all heard the warnings that it is bad for our kids, but we've experienced the benefits of it keeping our kids occupied while we get things done. And some programs and games have an educational component -- do we group those in the same category as purely entertaining ones?

Most parents by now have heard the recommendations that kids under 2 years should have no screen time. At all. And older kids should have no more than 10 hours / week total.

Most parents are also fully aware that their kids exceed those guidelines. Some by a little. Others by a  lot. There are all kinds of reasons parents have for allowing this. Some are good reasons, others are not.

To be honest, there is still a lot we don't know about screen time. Research continues. When I was a child, television and movies were just passive watching. Thankfully there wasn't much offered, and with a limited number of channels, we usually stuck to watching tv only on Saturday mornings. Other times we played outside. Shows were not as action packed and overstimulating as those of today. Compare Mr. Rogers to pretty much any show designed for kids today with quick scene changes, music in the background and motion everywhere. Now there are interactive games, many of which are educational, or at least they seem to be teaching letters, counting, or other skills. There's even Wii and Kinect that use whole body movements to get kids off the couch. One can get a good workout with some of the games, but Wii bowling is nothing compared to real bowling.

So how do you count educational and active game time? Should it be included in that 10 hours/ week, or should you allow extra time for it? Are e-readers a form of screen? They often allow interaction like a computer and many can show videos and offer games.

Short answer about counting total screen time: We don't know.  Experts can give thoughtful opinions, but really at this point it's all educated guesses.

Some studies show that kids learn better when things are presented on a computer or video format. Maybe it keeps their attention better than a paper workbook. I love the ability to hold my finger on a word in an electronic e-reader and have the pronunciation and definition pop up. How many times as a young reader did I simply skip over words I didn't know? My daughter likes to increase the font size so only a sentence or two are on the screen. She feels like she reads faster because she "turns the page" more often. Does this build her confidence reading? Does it actually slow her down? I don't know. But she's happier to read and it seems to work for her. (This does drive me nuts if I pick up the Kindle after she's changed the settings... but I can change it back to my preferences easily.) Are kids losing the ability to find things in alphabetical order, such as using an encyclopedia to look something up, since they just hit "search" and find the answers? Does it matter?

Parents must really pay attention to what kids are watching and playing as well as how much time they are spending on a screen. For every minute they are on a screen they aren't interacting with people to work on social skills, they aren't outside playing games and getting exercise. If the games they are playing help develop thinking skills, strategy, math, reading, and more, then some screen time every day can benefit. If the content has violence or other age inappropriate material, it can be very detrimental. If they are online playing against other people, dangers multiply. While I can see kids who hate to read actually not notice how much they must read to play a game on a computer or tablet, are there better ways to get them pumped into reading a book?

There's a time and place for everything. The dinner table and bedroom are never a good place for online/screen time. Watch and play with your kids. They will love the time with you and you can better supervise what they're exposure is and modify it as needed.

More information:
Media Resolutions Every Family Should Make in 2014 has some tips to help monitor and limit screen time.
For information on internet safety, check out YourSphere for Parents.
American Academy of Pediatrics Media page.