Seattle Mama Doc

A blog by Dr. Wendy Sue Swanson.

A mom, a pediatrician, and her insights about keeping your kids healthy.

Vaccination Nation: How Healthy Is Your School?

aap-vax-mapFrom the moment we become parents, we work to keep our children’s environment safe. We child-proof our homes and make sure poisons and dangerous objects are secured wherever our kids spend time. But we aren’t always as diligent about making sure the community spaces where our children learn and play are protected from threats we can’t see, like infectious diseases.

Just this fall there was a vaccine-preventable disease reported in my son’s 2nd grade cohort. When he started kindergarten a couple years ago we were told the class was 100 percent up-to-date on immunizations, so I got done worrying about things like exposures to chicken pox, measles and mumps from his classmates. We know vaccines aren’t 100 percent protective, of course, but I took stock in knowing that his class of children was protected as best they could be.

So, when I heard about the case of chicken pox, it reminded me I needed to check back in.

Because he’s fully immunized, I wasn’t worried when I heard the news about this case of chicken pox (varicella vaccine has a high vaccine effectiveness, with 98 percent of children protected after two doses). But it got me thinking that I needed to contact the school and see how we’re doing. Not just on the state-mandated vaccines, where we scored 100 percent a couple years ago, but on influenza vaccine, too. Often we have no idea the percent of a class that is protected on this essential, every-year vaccine.

Influenza and complications from the infection are hardest on infants and young children, pregnant women, the elderly and those with underlying health conditions that make it harder to deal with the infection. Depending on the season, influenza causes anywhere between 4,000 and 50,000 deaths a year in the US. Thankfully, each year only a couple hundred of those deaths are children. The flu vaccine is recommended for ALL infants and children ages 6 months & up to protect them from the infection, their community, and severe complications. Even though the nasal flu mist isn’t recommended this year, now is still a great time to get your children and family immunized leading up to the holidays.

More than ever before, clearly articulating that you vaccinate your child and that you want your child amid a group that does the same is essential.”

Every parent should know if their child resides, learns, and plays in a safe environment, and knowing their child’s “world” is up-to-date on vaccines is an important data point. Knowing where your community stands just got a little easier. The new AAP interactive infographic is a great, high-level view into knowing how your state fares with status on vaccines and protections from outbreaks of infections like measles and pertussis, as well as influenza. 

Although we know 9 out of 10 parents immunize their children based on the AAP and CDC schedules, we know the public often feels like many more children aren’t getting vaccines. I’m haunted by the data published in Pediatrics in 2011 that found that more than 1 in 4 parents (28%) who followed the recommended schedule seemed to think those children whose parents who didn’t – who delayed vaccines or followed an alternative schedule — were safer. Not a single study finding a delayed or alternative schedule is safer and yet here we are with many parents following our recommendations but not entirely trusting them. Yuck. All those parents who immunize need to speak up.

To me, there is no question that pediatricians’ time and passion communicating truths and opportunities with vaccines will always be time well spent. Recent data out this year proves it: a third of vaccine-hesitant parents change their mind and agree to have their child receive a vaccine after their doctor provided vaccine education. But there is something else in me that knows, over time, we’ll tighten the gap on trust with parents when their peers step up and demand higher vaccine rates in their schools, their playgrounds, their communities, and even their play dates. When pro-vaccine parents share their feelings of trust, support, and desire to have a community up-to-date, that’s when we’ll reach the 95 percent level we want.

Pediatricians and parents can partner unlike ever before and with tools unlike we’ve ever had to make sure the spaces where our children spend their days is as safe as possible.”

Knowing where you live and how your community is doing on vaccines and speaking up about what you believe matters. More than ever before, clearly articulating that you vaccinate your child and that you want your child amid a group that does the same is essential. Check out your state’s data in the AAP infographic. Get even deeper into the data with online resources like School Digger that allow you to peruse the data on vaccine status at the school level.

Pediatricians and parents can partner unlike ever before and with tools unlike we’ve ever had  to make sure the spaces where our children spend their days is as safe as possible. Speak up, ask about rates at your schools and tell other parents how much you value vaccines that protect your children and their friends. 

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That Could Have Been Me: When An 8 Year-Old Knows She Belongs

harry-potterDuring carpool recently I witnessed an 8-year-old realize her relevance and her sense of belonging even more than before. What a total profundity. It happened by accident and this involves J.K. Rowling…

It’s my belief that getting a child to understand their import is a hope housed in almost every parent, teacher, auntie, or grandfather. When those of us, even peripherally involved in a child’s life, witness a child discovering their capacity, import, potential, and connectedness the moment can be immense. I don’t think I’m overstating this.

Everyone wants to feel they are capable. Everyone wants to feel they belong. We learn and see and feel our connection in infinite ways.

You’ve probably read a lot about parenting your children more with a focus on “grit” than with a focus on accomplishment. I think most of us can all agree that perseverance and a steadiness in keeping a “can-do” attitude is far more important for survival and for joy in life than any accomplishment we’ll ever have. In fact it’s in our failure that we perhaps find ourselves feeling more connected and less alone.

The best moments we have with our children are therefore neither about grit nor honing success — they are typically about presence. Being aware of the sincere vitality in being alive together and a part of when our children grow, delight, see, or be seen is a thunderous thing. The moments when it happens are hard to contain in our heart, no matter how big it is.

Working to cultivate grit is certainly a meme in the perfect-parenthood swirl of advice this decade. Working to extend yourself so you fail is something all of us want to do when we think about tapping into our true potential as workers, mothers, fathers, sisters, brothers, and community members. But it’s hard to push to fail and sometimes, as odd as it sounds, it’s hard to fail well.

Sometimes failure happens because we’ve stretched ourselves too far. Sometimes, of course, it is the external factors that bring failure. Most of the time it’s a combination of the two. Sometimes we learn about failure through our own experiences as we stumble and then heal our own scars.

Connectedness, togetherness, and the capacity to contribute to things greater than ourselves will always be foundational for humans. Every day should be about building more and more of this entanglement with each other, with those that we love, as best we can.

So back to that day carpooling. On the way to school, my car full of delightful school children, we got talking about about the Harry Potter series and specifically J.K. Rowling. I mentioned that I remembered hearing she’d submitted her book, “about 7 times before a publisher had accepted it” and now she’s the author that has sold books faster than any other human on earth. When I realized I wasn’t certain about my facts, I did something I DON’T typically do. I asked my 10 year-old to grab my cellphone (!!) and look up the real story of J.K. Rowling and her attempts to publish her first Harry Potter book.

He used wiki, then he used a search engine and landed on a version of the story. At this point we’d parked at school and so an 8 year-old now was leaning over his shoulder helping interpret what he was reading online. Curiosity was abloom.  The children found this explanation: Read full post »

HPV Vaccine On Time: Only 2 Doses

hpv-2-doseWelcomed news out this fall about immunizations. If children and teens get their HPV vaccine on-time between the age of 11 and 14 years, they won’t need to do 3 doses as previously recommended. HPV vaccine given, starting at age 11, can be just 2 doses now, spaced 6 months apart! Celebration.

This new HPV shot recommendation from the CDC is based on research that has found when younger children are immunized, their immune response is greater at younger ages (age 11 versus age 16, for example). It’s also based on data on durability of the vaccine response — data has found teens immunized in the “tween” years continue to be protected years and years after the vaccine is given. So don’t wait to get teens immunized! In fact, waiting isn’t safer in any way, just leaves your child open to exposure for a longer period of time and the vaccine has the same side effects (most notably pain at the injection site!). Plus, you’re now reducing the amount of shots your child needs from 3 –> 2. Huge win!

The hope in this new recommendation is three-fold: more teens will get immunized on-time, they’ll be better protected from HPV infections and cancer risks early, and it will be easier to complete the entire series. Last year, for example, about half of boys ages 13 to 17 had gotten at least one of the recommended three doses, while about 63 percent of girls had gotten at least one dose, according to the CDC. However, not all teens finish the series and the new recommendation may help. In some areas only about 1/3 complete it.

HPV vaccine is an anti-cancer vaccine.

If your child has started the HPV series but not completed it, there is no reason to re-start the series — those shots still count. Just schedule a visit to finish what they started. If your child is between age 11 and 15 and there has been 6 months since their last HPV shot, under the new recs they will only need one more dose.
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5 Ways To Fight Loneliness

img_1673It seems to me that some of the greatest suffering in life comes with loss. Loss has all sorts of shapes and various hues of intensity. Comparing one loss to another in unlikely to ever do anyone any good. What feels big to someone you love IS big. For you, for your children, for your mom, or for your friend. Perspective shaping is important at times but acknowledging pain in loss is tantamount. Losses we feel can be immense (the loss of a person’s life) or obscure (the loss of personal direction) or even simply burdensome (where are those *&$#-ing keys?!?!?). We humans, including our little ones, feel worst when we’re disconnected, when we feel we’re somehow disorganized with our community and don’t belong, or when we are enveloped with a sense of loneliness.

Bullies know this well, of course, in part because of their own isolation. But so does everyone who has ever felt love. Being lonesome is agonizing.

Loneliness is bad for your health. In some research it’s on par with the effects of obesity and heart disease, injuries or violence.

For some, holidays are like blood-letting when it comes to loneliness. When any single one of us suffers we all lose a little. Those of us who are feeling disconnected will only sense and experience solitude with greater fervor as families, groups, friends and co-workers join hands to celebrate this time of year. Look around and imagine.

Or think about a starling murmuration and its beauty. It’s the choreography that makes it a thing of elegance but it’s also the intimacy in knowing that all those birds fit — all of them have a dependence and place with each other. Those little birds feed on both the single bird next to them but the group, en mass, too. I have to think they feel they belong as they twirl in the sky and progress across it. They give to and take from the group. And it reminds me that those outside of the murmurations typically want in.

We can all make this better for ourselves and for those around us. As we ready to step earnestly into December, I say we do more for each other this month. Counteract the forces and gravitational pulls of loneliness and isolation around us. Teach our children they can help, too. At dinner tonight and tomorrow maybe bring it up?

5 Ways To Fight Loneliness

  1. ONE: We can talk with our families about who we could invite to our homes, to our parties, and to our celebrations. Just imagine making a goal to invite one person into your fold you may not have thought to include. Just one person to one day or one event you wouldn’t have thought to include before. Even if they don’t typically don’t “celebrate” what you do. Make an invitation to someone by Friday, December 2nd.
  2. TWO: If loneliness seeps into you on any of these days, grab your bearings by turning off the noise of the murmurations around you. I think of this in terms of making sure you don’t stare at the masses. Turn off social media for 12 hours (or 3 days!) and immerse yourself in something you love. Be fastidious with yourself — put the devices down or turn them OFF if they lead you only to those murmurations and inclusions you don’t feel a part.
  3. THREE: Practice gratitude. This can be brisk and powerful in the face of loneliness. Write a quick thank-you note this week or jot down in a journal 3 things for which you’re thankful every day, for a week. The minute you elevate those around you in import is the same minute we feel truthfully happier.
  4. FOUR: If you sense someone around you is lonely, call. Don’t just text. If they don’t pick up the phone, call again. Invite them to a quick walking meeting, coffee, or lunch. Just do it.
  5. FIVE: Get a good night’s sleep. However banal that sounds we know sleep deprivation has us look at the world with cloudy lenses. We also know it even has us remember improperly (we color our memories negatively when sleep deprived). I seriously believe we all feel less alone after 7 to 8 hours (more for children!) of sleep.

Get Rid Of Constipation In Children

Children's legs hanging down from a chamber-potConstipation is really, very truly, no fun for anyone. No fun for baby or child, no fun for the parent who worries and watches and cleans the clogged toilet, and clearly nothing wonderful for the sister or brother who waits while a family supports a child in the room next door. In general, constipation is a frustrating, sometimes hugely embarrassing, and often a chronic problem for young children. In my experience, parents worry a lot about hard infant or toddler poop in the diaper (goal is always peanut butter consistency or softer) but it’s when constipation sneaks up on many families in school-aged children that BIG suffering ensues.

I can’t say this loud enough: if you’re worried about constipation in your child do consider seeing your pediatrician, nurse, family doc or physician assistant to make a long-term plan. Constipation DOES get better but do know it’s over weeks to months. When your child’s intestinal tubing is stretched out for weeks it takes weeks to re-configure sometimes — quick fixes won’t be long term solutions. More below on which remedies to use and how.

Constipation sneaks up because after children are toilet trained and wiping themselves (around age 4 or 5) many parents no longer gaze in the toilet bowl so gone are the days of tracking daily poops. Before you reach for OTC medications, consider what is normal and what is not normal when it comes to poop (below). I usually break this down for children (and parents) in visual terms. I talk about things you find outside:

In general, poop in the toilet can look like a pond, a snakea log, or a pebble. When it comes to poop, we’re always looking for snakes. It seems to me that framed this way, school age children can do a better job knowing if they’re constipated or not. We’re looking for  Snakes in the Lake, people! Frame it this way with your child and perhaps they will be more likely to get a glimpse of what they produce in the toilet? Or at least a report?

Lots of foods, hydration and OTC medicines can quickly change the game with constipation. Before I detail more specifics on constipation and highlight some remedies, I do want to call attention to some potential concerns of polyethylene glycol (PEG 3350). The medicine PEG 3350 is an odorless, tasteless laxative that can be easily diluted in juice or water. It’s a big polymer and can’t be absorbed by the intestine so it works by binding to water so that water ingested can’t leave the intestines, colon, and rectum. The great news is it doesn’t cause cramping or more pain and isn’t addictive. Used daily (often for days or weeks) the powder binds to water and disallows the colon to dehydrate the poop so it just doesn’t get hard. Therefore the poop that comes out is soft and often helps produce less painful pooping — and often it comes out more often! It’s commonly sold under both brand (Miralax) and various generic names. However, the Food and Drug Administration (FDA) has only approved its use in adults, not children. Currently, PEG 3350 is being studied as well as the bi-products of PEG 3350, specifically ethylene glycol (EG) and diethylene glycol (DEG), to determine whether it might be absorbed by children and whether use of the laxatives is linked to development of psychiatric or neurodevelopmental problems. The New York Times has done 2 stories on this topic: one in 2012 and one more recently in 2015, both worth a read if you are debating giving your child PEG3350. For children and families with severe constipation often the benefits of using it far outweigh the concerns.

What Is Constipation And Why?

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Give Children Probiotics When Taking Antibiotics

Probiotics are a little bit the rage these days. The more we learn about the microbiome (all the bacteria that happily live in and on us to support digestion and immune function), the more we learn we want to preserve them. Probiotics are supplements (not medicines) so the data on their use is in the early stages but taking probiotics while taking antibiotics really does make medical sense. New data out in JAMA Pediatrics makes this more compelling. Taken orally, probiotics re-populate your gastrointestinal tract with “good” bacteria to help aid in digestion — so using them at the time you are taking antibiotics for an infection may help alleviate side effects like diarrhea that result after the “good” bacteria are killed off.

Antibiotics are the most commonly prescribed medication to children yet estimates show that 1 in 3 to half of antibiotics prescribed are unnecessary. Typically that means that antibiotics are prescribed when they won’t do any good for a viral infection or when a child will recover from an infection without intervention. Trouble is, antibiotics kill BOTH the good and bad bacteria in our bodies. Sometimes this is necessary when it comes to treating things like whooping cough, strep throat and urinary tract infections, while others it is not (colds, bronchitis and fluid in the ear). Of course in addition to using antibiotics more than we’d like to, antibiotics also cause side effects like: diarrhea, abdominal cramping, hives and nausea.

The estimated incidence of antibiotic-associated diarrhea among children is 11%  among outpatients and 21% among inpatients — Probiotics and Prevention of Antibiotic Associated Diarrhea in Infants and Children, JAMA Pediatrics

The recent JAMA Pediatrics  clinical synopsis (summary of a larger Cochrane review) provides us new insights on how we can help children who may be struggling with side effects caused by antibiotics. The study found that providing children with probiotics during antibiotic use can reduce both the chance of diarrhea and the number of days it lasts. Probiotics are live bacteria and yeasts that can help replenish the bacteria in our guts that antibiotics kill. Probiotics often come in capsules you can open up in your children’s food or bottle or they come in packets you can sprinkle.

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New Data And 10 Ways To Reduce SIDS And Suffocation Risk In Babies

Mommy-copy-e1273260009105Any parent to a newborn worries about Sudden Infant Death Syndrome (SIDS) and Sudden Unexpected Infant Death (SUID) and what they can do to prevent it. SIDS deaths are unexplained while SUID deaths in infants are secondary to things like suffocation, entrapment, infections, or trauma. The new recommendations take research on all of these risks into account and are specific to guide parents to reduce risks for SIDS and sleep-related suffocation, asphyxia, and entrapment among infants in the general population.

I’ve been interviewed a lot lately about all the fancy new baby trackers, monitors and even smart cribs available to the public being marketed as SIDS reducers. These are not the answer to safer sleep — no data to prove it. I’m a digital enthusiast but it doesn’t change my concern that these devices are entering the market out of the place of fear, not science for improved safety. I think we have to acknowledge that these trackers might amp and rev up anxiety more than they will decrease it in some parents.

What we CAN do to decrease risk of SIDS is follow new research-based guidelines published this month from the American Academy of Pediatrics (AAP) to reduce the likelihood of SIDS and suffocation. This new set of guidelines are updates to the 2011 recommendations, some being similar, and others a bit different. Big changes from my perspective are the stronger recommendations for pacifier use in infants, the strong recommendation against feeding babies in the nursing chair at night, and the ongoing urging to have your babies in BARE, BORING, BASIC sleeping environments in a parents room. Pillows, blankets, bumpers, and stuffed animals are cute but not safe for infants under 1 year of age. Where we feed our hungry babies in the middle of the night matters, too. The recs out this month help define ways to do this with more confidence you’re reducing risk.

“Parents should never place the baby on a sofa, couch, or cushioned chair, either alone or sleeping with another person. We know that these surfaces are extremely hazardous.” ~Rachel Moon, the lead author of the new guidelines and professor of pediatrics at University of Virginia School of Medicine

10 Ways To Reduce Risk Of SIDS And Suffocation

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Teens Use Cough Medication To Get High

sma-cough-syrup-medicine-bottle-with-icon

We’re thankfully in the middle of a national conversation about ways to protect the public from drugs of abuse. The opioid epidemic has brought the issue of medicines and risk to the forefront and has awakened a new understanding about the lethality of drugs of abuse and addiction. There are other medicines, even over-the-counter medicines, that are used recreationally and can be risky, too. This can be especially true with children and teens. Enter cough medicines…

Data shows approximately 1 in 30 teens, or approximately one child in every high school class math class, has abused over-the-counter (OTC) cough medicine to get high. Typically teens use DXM — dextromethorphan when looking to get high. I’m partnering with the Stop Medicine Abuse campaign to spread the word among parents. Have you seen this “PARENTS” icon on cough and cold medicine packaging lately? It’s there to raise awareness of medicines that contain dextromethorphan (DXM). Look for the icon when making purchases and think through some safe storage tactics if you purchase medicines with the label or already have products within your home.

  1. Monitor Your Medicine Cabinet: Take steps to protect your teens by safeguarding all the medicines you have in your home that could be abused. Know what you have and how much, so you will know if anything goes missing.
  2. Monitor Your Teen: Be aware of what your teen does online, the websites they visit and the amount of time they are logged on. Ask them. There are many websites and online communities promoting DXM abuse with instructions on how to achieve certain levels of highs. If you see the sites in your browser’s cache it’s worth your while to check in. Teens are less likely to use alcohol or even drugs of abuse if they know risks and that their parents disapprove. Let it be known what you know!

Facts On DXM Abuse In Teens:

  • DXM is an active ingredient found in over 100 cough and cold medicines. Used appropriately, it is a safe medicine that alleviates coughs in children older than 4 years of age.
  • Abuse: Approximately 1 in 30 teens have abused cough medicine to get high, and 1 in 3 teens in grades 9-12 knows someone who has abused cough medicine to get high. Ask your teen what they know. Without judgment provide information about risks of using cough medicine to get high. Judgment can be stifling; information and guidance is love.
  • Available: Teens may feel it is harder to get their hands on it as teen perception of access has gone down 24 percent. In 2010, 65% of teens agreed that DXM was “very/fairly easy to get.” That number has since gone down to 41% in the last few years.
  • What Does It Do? Taken in excessive doses, DXM has intoxicating, disassociative, and psychoactive properties. This means cough medicines taken in excess can potentially really change the way a teen thinks. The most common side effects include: vomiting, rapid heartbeat, and loss of motor control.
  • How Much? Teens report taking up to 25 times or more of the recommended dose of cough medicine to get high. Side effects from abuse include nausea and vomiting, distortions of color and sound, hallucinations, and loss of motor control.
  • Dangerous when combined: DXM is more dangerous when combined with other substances (other drugs and alcohol). Risks elevate with multiple substances and side effects can even be lethal. Tell teens this so they know the serious risks when mixing medicines/drugs. Make sure every teen knows they can always call Poison Control and get help immediately if they need it — safe and won’t get them into trouble. Ever. Just a team of people who want to help if they are ever worried about an ingestion or an ingestion in someone they know. Put it in your teen’s phone today: 1-800-222-1222.
  • No question that what parents say matters. Teens who learn a lot about the risks of drugs from their parents are 50% less likely to use drugs. True.

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Empathy And Compassion For Transgender and Gender Non-conforming Children and Teens

gender-bathroomI saw this bathroom sign in my sons’ school a week ago. Talk about inclusion. I’m not only pleased that my boys are being exposed to open inclusion, I’m delighted they are getting the message that they can be whoever they are at home and at school. NO question in my mind the data proves if a child, teen or adult has questions about their gender their life is at risk for being harder. This is manifest in the high rates of anxiety and depression, bullying and ridicule, and feelings of isolation in those who are gender non-conforming and transgender. This is only estimated to be about 1% of the population (numbers are imprecise as many people hide this challenge) but how we all support those who question their gender matters for us all, the 99% of us who don’t have this challenge.

We must have compassion and empathy for children and teens who are transgender and gender non-conforming. We must accept children and teens and their families, and we can connect children and families who struggle with resources (below).

Children Are Born With Gender, Parenting Has Little To Do With It

  • Research shows that gender is established at birth. That means children are often born knowing if they are a boy or a girl irregardless of their sex (the chromosomes/genes that determine their body’s appearance and sexual characteristics). Sometimes children know this early, sometimes later in life.
  • Research shows that there is no evidence that parenting is responsible for a child having a different gender than their sex. Meaning — parents don’t have control, with their actions, over their child’s gender. They can’t change a child’s gender.
  • Research shows that children are less likely to end their life when they have challenges with their gender identity if they are accepted by their families. This means children who grow up in homes who accept them are less likely to suffer. Maybe a no-duh, but it’s something all parents should know.

This is complicated stuff, of course, and isn’t the same for all children and teens. Some children question their gender early in life (as early as preschool years) and will traverse childhood knowing they are transgender while other teens may find out at the onset of puberty that something isn’t quite right. Some children or teens just don’t identify with one gender or another (gender non-conforming). When they question this, we want to make sure they get what they need.

The most important message is that we must be open to what children express, connect children, teens and families with resources they need, and be aware of the risks for suffering in children who question their gender. Thankfully, there are lots of people to help and resources. Seattle Children’s Hospital now offers a specific clinic to support transgender and gender non-conforming children and teens (age 8-21 years). Experts and staff provide support for puberty blocking (stopping onset of pubertal development) or hormone therapy (hormones to have body characteristics match gender). They can also support conversations and planning for those who want to transition.

Statistics & Risks For Transgender Children And Teens

  • Transgender population is hard to define, probably less than 1% of adolescents
  • All gender non-conforming are at increased risk for bullying, anxiety, depression & suicide
  • 71% of transgender people said they hid their gender or gender transition to try to avoid discrimination

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When Is It ADHD In A Child?

I talked with Erin Schoenfelder, PhD,a specialist in ADHD and Director of Behavioral Treatment at the PEARL Clinic (Program to Enhance Attention, Regulation & Learning) here at Seattle Children’s Hospital, about ways to recognize ADHD in children and teens. The previous post we shared included the acknowledgment that it may be harder to parent a child with ADHD and provided reasons for it along with 5 tips to help parents and families. In the podcast above, Dr. Schoenfelder helps parents, teachers, and pediatricians understand what ADHD is and identifies ways to support, diagnose, and evaluate children with whom parents and teacher hold concern. First and foremost make sure you understand how a child sleeps before doing any further work-ups! Sleep challenges can be a big mimicker of ADHD as deprivation causes inattention and distractibility.

What is ADHD?

  • Developmentally atypical symptoms of inattention and/or hyperactivity/impulsivity.
  • Developmental disorder that persists over time and years and is consistent across settings (i.e. children have challenges at school, at home, during sports activities, at a synagogue or church).

Signs, Symptoms, Red Flags

  • Problems in multiple settings completing work, getting along with others, following directions, and succeeding
  • Teacher noticing the child is standing out from others
  • Child an outlier in a group – soccer practice, birthday parties, home
  • Risky behavior, getting injured due to impulsivity
  • Falling behind in learning due to off-task behavior

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