Concerta, Methylphenidate ER formulations, Shortages and Formularies

The popular ADHD medicine, Concerta, has been subject of a lot of debate in the past couple of years, and that is continuing into 2015.

This is from a Canadian blogger, but I love the picture showing the difference inside.

Problem #1: Generics vs Concerta

It started when companies started making generic formulations that had a different delivery system.  (If you haven't heard of the issue, you need to read this before reading further for it to make any sense.)

The FDA said that the non-OROS formulations are not acceptable substitutions in November 2014.

Even the same active ingredient in a different delivery system could cause a problem with a child who is doing well on one type of delivery system who gets a different type the following month. The drug releases into the body at a different rate, so the drug is distributed differently throughout the day. This can be insignificant for some people, but can cause significant issues in others. I have heard that some children's medicine wears off much earlier (before the end of the school day) and much faster (leading to emotional and behavioral problems) with different delivery systems.

It is important that whatever delivery system a child does well on continues to be used. They are not interchangeable. Talk with your pharmacist every time you fill the prescription to be sure it is the same manufacturer, or in the case of Concerta, one of the manufacturers that makes the name brand or authorized generic.

Problem #2: Shortages

Since pharmacists can no longer use two of the three brands of generics to fill Concerta prescriptions, there is now a nationwide shortage of Concerta and the one generic that uses the OROS technology. The shortages are expected to last through the second quarter of 2015.

Problem #3: Formularies

To top it off, many insurance companies dropped Concerta and the authorized generic from their 2015 formularies. This means that if you buy the OROS methylphenidate medicine, it is not covered at all by insurance. You must pay cash and it does not count toward your deductible. This makes it out of reach for many most families. I am happy to see that some companies are adding it back to their formularies already -- I suspect there have been a lot of complaints. If it is not on your formulary and it is the medicine that works best for your family member, start complaining.

You will most likely need to try another medicine - or several other medicines - to make a good argument. If a formulary medicine also works, simply use it instead. Save yourself the trouble of going through the hoops to get the OROS methylphenidate. It is only if there is not a well tolerated and effective other option that you should fight for the OROS methylphenidate.

How do you fight the fight? Talk to your HR representative who deals with the insurance company. Call your insurance company directly. Send them e-mails and snail mail. Ask your physician to write a letter on your behalf. State why your family member needs the OROS technology. Give examples of how it works better than the other extended release methylphenidates and why the amphetamine class of medication failed. People were able to get the FDA to look into the issue and they agreed that there are significant differences, so insurance companies cannot pretend that it is an equal substitution.

Finding the right medicine

Due to the formulary changes and the shortage of OROS methylphenidate, I have heard that pharmacists are telling patients that they cannot fill a prescription because it cannot say "Concerta" and that they doctor must re-write the prescription as "methylphenidate ER" for them to be able to fill it. This means that they will fill it with the non-authorized generic formulation. If your child has done well on a non-OROS medicine in the past, great! If not, you must find out if it is a formulary issue or if the pharmacy is out of stock of one of the brands, since the remedy is different for different issues.

You will need to check on your formulary, usually available on your insurance company website, for the amount in milligrams that is allowable. It might be that another generic formulation of methylphenidate, not one for Concerta, is on formulary. Concerta comes in very odd sizes (18mg, 27mg, 36 mg, 54mg) and most others come in multiples of 5s or 10s. So if your formulary has only methylphenidates in multiples of 5s or 10s, you know that your child will not be getting the OROS formulation. It is more tricky if the odd sizes are available on the formulary, because unless the prescription says "Concerta", the pharmacist can pick which one to use.  All the pills with the OROS technology say "ALZA" on the pill. Look at the pills before finalizing the purchase and keep your child's medicine the same from month to month unless there are problems on it.

If a prescription is written "methylphenidate ER __ mg" instead of "Concerta __ mg" a pharmacist can fill with any of the long acting methylphenidate medicines that are the same strength, regardless of it is is OROS technology or another form of long acting medicine. The problem is that the same strength of the same active ingredient does not become usable at the same rate due to the delivery system of the pill, so try to keep your child on the same brand if he does well on it. If he doesn't do well on it, it might be better to simply try a different brand with a different delivery system, if allowable by your insurance and available at the pharmacy.

Since the prescription can no longer say "Concerta" if you want to try the other formulation, it might take a few trips between the doctor's office and the pharmacy to find a prescription to match the medicine available at the pharmacy that is covered on your formulary. Each might require a prior authorization before being able to finalize the purchase, so anticipate a few days to weeks before you will be able to take home the medicine.

It will be difficult to deal with drug shortages once the formulary issue is resolved. If your insurance allows 90 day prescriptions, this might be a good option once the dose is optimized. (This is not a good option for the first few months of a new medicine because dose changes might be needed.) Be sure to fill a new prescription as soon as possible to give time for the pharmacy to order in the drug if needed and to have any required prior authorizations completed by your doctor.

Take a deep breath. Slowly exhale. This will all pass in time, but it will be a rocky road for a bit.

Going to a new place for convenience

My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there's always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.

Image source: Wikipedia

But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home. Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well... convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent. While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks. The food wasn't the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn't of any use helping me decide if what we ate was good for us or not. Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there. Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it's usual for Convenience Cooks to bill added fees.

In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but don't offer slow-cooked BBQ, so they refer customers to BBQ-R-Us. But BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation. When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask if you should have gotten the burnt ends or the ribs. Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee.

Most people can see just how crazy it is for a restaurant to "fix" the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or after we refer to a specialist. The scenarios above are based on real phone calls about medical care.

Convenience Cooks = Urgent Cares

I'm sure I'm not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn't fixed at an urgent care. I am glad that patient families feel so comfortable with my office that you will call to ask for help, but if I am not a part of the evaluation, I can't help.

Many problems seen at urgent cares can wait. I know it's easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it's strep throat and they start an antibiotic at 8pm, they can't go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night. The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)

If your child was having an issue that did need to be seen ASAP after our office hours, we would have referred you to an urgent care that has quality pediatric providers we trust and sends us a written report of what happened. Even with that, sometimes we need to see a patient on follow up to ascertain if a treatment plan is working or if it needs to be changed.

If you call us because your child is having an allergic reaction to a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that "they're not open yet" or "they don't do phone calls, they want us to come back." Sorry. We will want to see your child before we treat him for this issue.

BBQ-R-Us = Subspecialist Referrals

As for specialist referrals, I know it's hard for people to wait for appointments, but I really can't get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. But usually it isn't really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I'm not saying that's a good thing, it's simply reality. Please don't beg me to call them to get you in sooner. I cannot invent time and I can't alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I've done this frustrating scenario many times-- often when I really want the child seen sooner than scheduled. Unfortunately, it usually doesn't significantly alter the appointment time.

After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it is usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don't like to "step on toes" if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road.

Expect higher fees any time you use a hospital based facility, whether it's for an office visit, a lab, or a procedure. They not only have charges for the physician's time, but they have facility fees to cover the costs of running the hospital. Of course the primary care physician cannot affect the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do... I can't even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that. It is hard to anticipate costs, and that is a problem with our healthcare system. I know that, but it is not in my control to fix that. We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn't help plan before the visit. I understand how that's frustrating, but I can only help with what is in my control. I cannot control how our billing and insurance system works and another office's charges are in no way under my control.

Dry Skin Tips

With the cold temperatures we've already seen this season, our skin is really taking a hit. Dry skin is often called eczema or atopic dermatitis. Whatever you call it, it's itchy and annoying!

It is really important to keep skin well hydrated or it tends to snowball. The dry skin is broken skin, which allows water to escape, which further dries it, which leads to more evaporation.... Broken skin is more likely to become secondarily infected, which leads to more problems....

Itching dry skin also contributes to its worsening by further damaging the skin and allowing more water to evaporate, so try to keep fingers from scratching! (I know this is easier said than done.)

Eczema is not simply dry skin. It can cause significant distress to infants and children. It can impair sleep. It can distract from learning at school. Children with eczema have higher rates of anxiety and depression.

Eczema doesn't simply go away with good treatment: it can come and go even with the best treatment. It can therefore be a serious problem for families.

Your goal with dry skin is to hydrate it as much as possible to repair the skin barrier. We don't always think about skin as an organ (like the heart and liver), but it is. Its functions are to help keep us at a normal temperature, to keep stuff (such as bones, blood, and nerves) inside our bodies, and it helps to keep some things (such as germs) out of our bodies. When skin is excessively dry, there is inflammation and cracking. This keeps the skin from doing its job. We must try to get it back to normal so it can help keep the rest of our body healthy.

Eczema can be from many factors.

• There is a genetic component, so if a parent or sibling has eczema, it is common for other family members to have it. 
• It is often worsened by environment, both cold dry air and excessive heat. 
• Clothing can irritate some skin, depending on the fabric and the detergent left in the fibers. 
• Any scented lotions or soaps can also irritate skin. (Don't be fooled that "baby" soaps and lotions are better for baby. I usually say to avoid any of the baby products because they are often scented. They make them to sell them, not to be better for baby's skin!)
• Allergies can exacerbate eczema.
• Saliva is very harsh on the skin. Drooling can cause problems around the mouth, chin, and chest. Thumb or finger suckers often have red, thick scaly areas on the preferred finger from the drying effects of saliva.

New eczema guidelines recently released downplay the need to alter foods to treat the skin. There are some kids who have true food allergies that manifest as atopic dermatitis (dry skin), but the large majority of kids do not. Restricting their diet can lead to nutritional deficiencies without any benefit. Talk to you doctor (and be sure they have read the newest on the topic) if you think a food might be exacerbating your child's dry skin.

My best tips for treating dry skin:

• Avoid exposures to soaps because they further damage skin. Non-soap cleansers that are fragrance free are much more mild on the skin.
• Soaking in bath water or in the shower can help hydrate the skin. After bathing the skin should be only briefly dried (remove large water droplets, but allow the skin to still be moist with water) and moisturizers (with or without steroids) must be applied immediately afterwards to prevent water from evaporating out of skin.
• Moisturizers should be hypoallergenic, fragrance free, and dye free. A good place to review if a product is good is on the National Eczema Association website. I really like the moisturizers with ceramide. This has been shown to help heal the skin barrier without steroids. Use moisturizers at least twice per day, more often as needed on the really dry spots.
• After the moisturizer soaks into the skin, cover extremely dry spots with petrolatum jelly. 
• Steroids can be used for flares. Steroids are available in 7 different strength categories. The stronger the steroid, the less often it should be used. Over the counter hydrocortisone is a very mild steroid and can be used twice a day with mild flares. Stronger (prescription) steroids should be discussed with your doctor if the eczema is more severe, but they can be safe and effective when used appropriately.
• Bleach baths have been shown to help in moderate to severe eczema. Add 2 ounces of bleach to the bath water and soak the body (not the face) for 20 minutes a few times a week.
• Oral antihistamines, such as zyrtec, allegra, or claritin (or any of their generics) can help control the itch. I recommend the long acting antihistamines over the short acting ones, especially overnight, to avoid gaps in dosing leading to the itch/scratch cycle. Avoid topical antihistamines due to variable absorption from disrupted skin.
• Add water to the air during the dry months. If your air conditioner is running you shouldn't need (or want) to add humidity. If your heat is on, you might have an attached humidifier, which is great. You can also buy a room humidifier or vaporizer to add water to the air. When there's more water in the air, the skin will have less evaporation.
• Use wet water cloths on dry patches. This can help get a child through an itchy time with a cool compress. It also helps hydrate the skin. Since it might remove the moisturizer, re-apply moisturizer when the wet cloth is removed. Some kids benefit from wet wraps (see link). This is time intensive, but very effective, so worth trying for more severe eczema patches. 
• If your child just can't stop itching, be sure nails are clipped to help avoid scratching. Sleeping with socks or mittens helps the inadvertent scratching during sleep. Many kids remove these, so sewing an old pair of socks onto the arms of long sleeve PJs can help. (Don't forget to put moisturizer on first!)
• If your child drools or sucks a finger, wipe the saliva off regularly and protect the skin with petrolatum jelly.

At times prescription medicines are needed. These can include steroids, immune modulators, and antibiotics. If your doctor recommends them, don't be afraid to use them. Many parents under utilize medical treatments out of fear of side effects. Yes, there are risks to all medicines, but there are also risks to having eczema untreated. Discuss fears with your doctor to come up with a good plan that you both agree with. Don't just not use the prescriptions.

Get control of your child's eczema. If you can't seem to do it alone, schedule an appointment with your pediatrician to see what else can be done.

For more information, see the American Academy of Pediatrics clinical report on eczema management and the American Academy of Dermatology's Guidelines.

Do Your Vaccines Contain Mercury?

We are often asked if our vaccines contain mercury. Some parents even want to see the package insert to check. Note: even if they do contain mercury, it usually doesn't say "mercury", so I suspect some of these parents wouldn't notice. Why wouldn't they notice? Because they learn one tag word that they should avoid, but they really don't understand what it is and why they need to avoid it. It's hard to talk to some parents who are adamant that they don't want vaccines for their children, but they don't know why... they just "heard they aren't safe." Really? You're not going to give your child something that has been shown time and time again to not only be safe, but that also saves lives? Just because you heard something you don't even remember details to you'll skip something that could save your child's life?

Short answer to the above question: No standard vaccine for children has had thimerosol since 2001. Some flu vaccine for older children and adults continues to have thimerosol, but most that we order for our office does not. If we offer a type with thimerosol, we will notify you before you choose to vaccinate. Not that we think it matters, but we know parents worry and want to know.

Most years I get the FluMist, but I think the year pictured it was in short supply.

Parents worry about thimerosol despite not really understanding when or why it's used. It's really sad when they ask if we have the "new" MMR without thimerosol. The MMR has never had thimerosol in it. Not ever. Yet many people share the mis-information online that it was/is the cause of autism. And people believe it. That's how much their online research has taught them.

If you hear that vaccines aren't safe from someone but don't ask for and understand the details, including looking at research papers and written articles that address the issue (along with evaluating the reliability of each research report and article) then you really shouldn't take the advice blindly. They might know as little as you on the subject and are just passing along bad information. Or the article you read might just be filling you with incorrect information. It's easy to do when a writer has a motivating factor, such as when the CDC Whistleblower "reanalyzed" data.

Mercury comes in many forms. Thimerosol (one form) is felt by scientists to be safe for use in vaccines at the very low levels required for its effect in vaccines. It has been removed from most vaccines given to children though due to a very vocal group of anti-vaxers getting some congressmen on their side. Not scientists or doctors, but law makers. This has increased the cost but not the safety, in my opinion. We use single dose vaccines except for staff flu shots, for whom we use the cheaper multi-dose vial. The multi dose must have preservatives, such as thimerosol, to keep it from getting contaminated with multiple uses. We usually have a few doses left out of that to give to patients so it's not wasted. When this type is given to patients, their parents are always told it is a multi dose type. There were only limited doses left over this season and they were gone long ago. Many parents were just happy to be able to get a flu shot for their child when they were in short supply early in the vaccine season and they trusted that it was safe.

So... would I give a vaccine with thimerosol to my kids? Yes. (And my oldest is a teen who did get the standard back when he was a baby, which was vaccines with thimerosol.)

Do we give them now? Not usually.

I think that many smart people still get blindsighted by well written but technically not correct information. They simply can't read all the studies, know how to understand the statistical significance of each study, and all the science behind everything. I have a degree in medicine and still rely on experts to do reviews and summarize the vast amount of information. I read some of the studies, but don't have enough information to make truly educated decisions based on what I have access to. Too many studies are behind pay walls and I don't want to pay to read them, nor do I have the time to read every study. 

But I trust expert panels that do.

Here are some links to pages that list the studies if you want to read them for yourself:

http://www.vaccinesafety.edu/cc-thim.htm
http://www.immunize.org/journalarticles/conc_thim.asp
http://www.immunizationinfo.org/science/mercury-vaccines

What if the flu vaccine doesn't cover the right strains?

Recent news reported that the FluMist nasal spray might not cover the Influenza A H1N1 strain as well as the injectable might. I know this may cause concern for parents whose children have already gotten the FluMist vaccine this season.

Don't panic! (Gee, I've said that a lot this year with the delayed shipments of flu vaccine...)

Why not panic? 

First, this is a theoretical concern. It is based on the findings that the FluMist didn't cover the H1N1 well last season and it is the same vaccine this year.

Second, the main strains of influenza that are starting to circulate this year are NOT that H1N1 strain anyway.

I thought FluMist was preferred this year...

The CDC continues to state that the preferred vaccine for 2-8 year olds is the FluMist because it seems to be more effective than the injectable form against the other strains contained in the vaccines. (This is of course only if the child doesn't have contraindications to the FluMist and the FluMist is available. No one should delay vaccination if one form is available to wait for another form.)

Should we wait to get the shot? I know there are shipping delays...

Both the CDC and the AAP state to give whatever vaccine is available as appropriate and to not delay giving the vaccine to wait for another type. This makes sense. If you can be vaccinated with only one type due to the shipping delays, why risk being completely unprotected when you can get a vaccine that will most likely protect. No vaccine is 100% effective. With influenza we have the additional difficulty that the flu virus changes each year, but there is some protection across types when the flu vaccine is given.

Why doesn't the strain match?

Flu strains change every year and scientists predict what strains will be circulating. The vaccine companies all make vaccine against the predicted strains. This year the main strains that have been identified in people sick with the flu are Influenza A H3N2 and Influenza B. It is still early in the season, so findings might change, but so far both the FluMist and injectable vaccines seem to be effective against those strains. The FluMist appears to offer better protection than the injectable if the strains are not quite matched.

In short: 

Any age-appropriate influenza vaccine should be used as soon as possible to protect as many people as possible against the flu.

Do kids who got the FluMist need to be given a shot this year?

No. It is not recommended to do a second vaccination unless it is the first flu vaccine and a child needs a booster dose this season. It is appropriate to use either form of the vaccine for eligible children over 2 years, and mixing and matching is okay, but there is no recommendation specifically to do that.

The good news: 

We are starting to see shipments of flu vaccine! Hopefully we'll soon be able to vaccinate your children!

Menthol for Sore Throat, Colds and Coughs... Should we use it?

I am often asked about the use of Vick's Vapo Rub (or other menthol products and refer to all brands in this post).

We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops 

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. The menthol is basically a local anesthetic which can temporarily numbs the nerves in the throat that are irritated by the cold symptoms and provide some relief. (Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm...)

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking. Since science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines, I use the "if it seems to help, use it" rule for children not at risk of choking. Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough. It should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress. Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We've all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me, and the link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with spirometry tests (but people stated they could breathe better) in this interesting study. (So people felt better, but there really was no objective improvement.) Putting menthol rubs directly under the nose, as opposed to rubbing it on the chest, may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick's BabyRub that does not contain menthol. Its ingredients have not been proven to be effective and some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

If a child ingests camphor (another ingredient along with menthol in the rubs) it can be deadly. It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations. Menthol rubs sold in the US contain camphor in a concentration that is felt to be safe if applied to intact skin in those over 2 years of age. Mucus membranes absorb medicines more readily than intact skin, so do not apply to nostrils, lips, or broken skin. Do not allow children to handle these rubs. Apply only below their necks to intact skin. 

Many people using the menthol rubs experience skin irritation. Discontinue use if this happens.

Talk About Bullying With Your Kids

Bullying. Fist fights. Cyberbullying. Mean girls. Playground scuffles.

There are many labels and many variations on the same theme. Kids aren't always nice. Even nice kids get caught up in mean behaviors. We all remember being young and getting picked on. Or maybe we were the instigator of trouble. Chances are we've been on both sides of the line. Whatever roll we had, we know that this is not new behavior. But that doesn't make it any easier for parents to watch their kids suffer at the words and actions of other kids.

photo source: Shutterstock

We all need to talk with our kids often about their lives: what they are doing, how they feel about things, what they are looking forward to, dislikes, and more. Many kids clam up when it's time to open up, and sometimes the best thing for a parent to say is simply, "I'm here if you want to talk later."

Sometimes a general talk about bullying behaviors is a good idea, whether you suspect some bullying is going on or not. As with most things, a little prevention is worth a pound of cure.

If you see your own child saying or doing something that could be interpreted as mean, pull them aside and point it out as soon as possible so the memory is fresh in their mind. Children and young teens often don't even realize what they've said or done can be taken in a negative way. Don't punish or yell at them for the words. Don't belittle them. Making them angry will only block their mind to seeing another point of view. Use this time as a teaching moment to point out what was said. They might not get it right away, but later you can role play and see if they can understand better in a different situation.

I've put together things to use as talking points. Don't try to tackle this all in one sitting. Talk about one subtopic at a time, but talk often.

What else would you add?

• A small comment that seems to not be so bad to you can make someone else feel awful, even if you didn't intend for it to be. Those comments often come out of the blue and you don't give it a second thought, but the other person can dwell on its negativity for a long time. Even worse are the comments that are repeated over time. 
• You cannot change what others do or say, but you can change how you respond to what they do and say. 
• If you did or said something hurtful, it can't be taken back, but you can ask for forgiveness.

• If you know you're tired or in a bad mood, try to be extra careful before you say anything. 
• Don't send texts when you're angry, sad, or tired. 
• Don't reply to a text that makes you angry, scared, or sad. Show an adult if it is a threatening text or if it really upsets you.
• If you have negative thoughts, keep them to yourself. This might mean that you think someone got something they didn't deserve, someone's a teacher's pet, or their hair is awful. Whatever. Nothing good comes from sharing a negative opinion. In the end, people will see that you are negative and won't want to be around you as much if you share those thoughts. 
• If in doubt about saying or sending something, save the thought overnight and see if you still think it needs to be said. Think about the wording to make it constructive and not destructive if it does need to be said. Talk to an adult if you're not sure.
• If you wouldn't say something to someone's face, don't say it at all.
• If you hear someone saying something negative, tell them to stop. Let them know you don't like hearing negative comments. This might teach them what they are saying is hurtful, because sometimes people don't realize what they are saying. They can learn to be a nicer person- what a great friend you can be to help them in this way! If they don't change their behaviors over a few days or weeks after being told what they are doing (depending on how severely or intentionally they are being hurtful) then you need to tell an adult. Doing nothing or agreeing with them puts you down to the level of being a bully, even if you didn't start it. If you don't feel comfortable telling them to stop, leave. If you stay, you’re part of the cruelty. Leaving means you refuse to be part. If they don't have an audience they won't continue.
• If you realize that something you said was hurtful to someone, talk to them about it. If you have a hard time talking face to face, a nice note can work. Have a trusted adult help you wordsmith what you will say so the words don't get twisted. You must be careful to not put blame back on the person or put them down again when you apologize. It can be tricky to find the right words, but it is possible. 
• Texting is a dangerous way to communicate emotional or sensitive issues. It is great for simple questions and answers, but short phrases in texts can easily be misunderstood or incomplete. If you are disagreeing with someone, do not use texts to talk it out. Remember that anything shared electronically is public and permanent. Even if you think you are sending it to just one person, there are many ways for it to be seen by others. These words and pictures can be very hurtful. Never send anything you wouldn't want to put on a sign on your front door for all to see.
• Kids are often afraid to tell adults things for many reasons. It is okay to tell an adult if you are trying to help someone or yourself, but not if you are trying to get someone in trouble. Think about it. There's a difference. 

Positives drown out the negatives...

• Every day write down (or discuss as a family) one thing that you really appreciate or are grateful for. It can be anything, but think of things that really mean something to you. It can be as simple as a person said something really nice when you were feeling down, or you did well on a test you studied hard for. It doesn't have to be a huge thing like winning the lottery, but it should be something that you really feel thankful or happy about. Focusing on the good things really helps keep life in a healthy perspective. It can help protect you from the negative effects of other people's behavior.
• Smiling really can make you feel better, so try it.  
• If you see a friend struggling because negative things have been said, say kind words to him or her. Be extra nice to him or her so they know they aren't alone.
• Praise people when they say nice things. Recognize the kindness. Make it contagious!
• Try to do something nice or say something nice to at least one person each day. Notice the response over time in yourself as well as others.

Everyone needs a circle of respect. You don't have to like everyone, but you need to treat everyone with respect.

• Respect yourself enough to do what is right. Eat right. Exercise. Get 9-10 hours of sleep each night. Don't take unnecessary risks, such as smoking or drinking alcohol. 
• Respect others. Say kind words and keep negative thoughts to yourself. Don't make anyone else do something they aren't comfortable doing. Don't make fun of people. 
• Be sure people respect you. If someone says or does something that you feel is disrespectful, let them know. If they don't change their behaviors, avoid them and find other people to have fun with. Get away from people who make you uncomfortable or scared immediately. Find new friends if your friends repeatedly disrespect you. Get help from an adult when needed.