Are Your Child's Behaviors or Emotional Reactions of Concern?

Are your child's behaviors or emotional reactions a serious problem?  Truly this is a question that comes up many times a day in my office.  Mostly I find that I can offer reassurance and guidance on what to do and what to expect next.  Many concerns simply represent normal and predictable parts of a child or adolescent's development.  Sometimes I must dig a little deeper.

Keep in mind that I am a general pediatrician and a mother, not a psychiatrist or psychologist.  I received the education a board-certified pediatrician is exposed to during her training and ongoing maintenance of certification.  My experience has developed over the years, as I have interacted and provided health care for many children.  I have a few validated assessment tools I can use when I need a more objective point of view.  However, to get an idea of what is going on, mostly I talk to parents and children and observe children in my office. 

Now, having properly oriented you, I want to let you in on some of the big things I consider when trying to help parents figure out if their child has a behavioral or emotional problem beyond the range of normal variation or development. 

1.  HAPPY?
I want children generally to be happy and able to participate in school and the activities they usually want to do.   Certainly a child will have ups and downs, good days and bad, temper tantrums, mood swings, and upsetting things that happen to them.  However, overall, a child will normally stay interested and have some enthusiasm for family, activities, friends, and at least some parts of the school day.

2.  PARTICIPATING IN LIFE?
I don't want a child's behaviors or emotional reactions over time to significantly limit their participation in family life, the school setting, friendships, and individual interests.  Again, this doesn't just mean having a bad day, or week.  The overall arc of a child's day-to-day life should allow them have the experiences they need to develop meaningful relationships, independence, confidence, and self-esteem.

3.  FITTING INTO THE FAMILY?
We have to get to know our children.  Different temperaments respond better to various forms of discipline and structure.  A frown and slight shake of the head may bring one three-year-old to the point of tears, while another won't respond until they have had several time-outs and a toy taken away!  Still, unless it is necessary because of a child's young age or special needs, a family should not have to adjust everything they do around a child's behavior or emotional reactions.  If, because of their child, parents find themselves usually quite limited in the places they can go, food they can eat, and people they can visit, this might be a concern.  Or, if a time-consuming amount of planning is necessary to get out the door, get a child to school, stay on a schedule, make sure the right snack and drink is available, etc. then this could be a red flag.

Can I generalize and say that if a child is usually happy, participates willingly in life, and fits into the family then there is nothing to worry about?  Probably it's not that easy!  However, if one or more of the above three questions starts to reveal a persistent problem, then I know I will have to look into it further.

Your personal pediatrician is a resource for you in helping to figure out what is normal for your child.  Other pieces of the puzzle may be filled in by talking to your child's teacher or daycare provider, other parents, relatives, or a school administrator or counselor. 

Answering the question of what to do about a particular behavior or emotional reaction will always involve trying to determine if it is a major or minor problem, if it is a part of normal and expected development, and if it is affecting multiple areas of a child's life.  I hope, as you struggle through the ups and downs of parenting, this gives you some ideas about how to think clearly about your child.

Help Your Child Remember "You are Loved!"

It's the early weeks of the school year and the excitement and novelty is wearing off.  You might start hearing some comments like "I want to stay home with you," or "I don't want to go to school."  Little bits of the school day are revealed at odd times in the evening--sometimes sending a jolt of panic through the center of your chest.

"My teacher never calls on me when I raise my hand."  "When I got back from the bathroom everyone was doing a new assignment and I didn't know what to do."  "No one would play with me at recess."  "I didn't have time to eat my lunch."

You can't be with your child all the time any more, and that can be hard for her and for you.  Some children, and parents, have to be very brave to make it through each school day.  It's time to remind yourself that an appropriate amount of independence and successful, gradual, separation from you will help your son or daughter become more confident, with higher self-esteem.  However, as you ponder these theories, you still need a way to get both of you through the school day.

I don't have all the answers, but I do have some ideas.  Some books for children address this topic in an appealing, caring way.  I found the following books amazingly helpful:

The Invisible String, by Patrice Karst, describes in a touching simple way how we can be connected to each other by an invisible string of love, even when we are apart.  Two children are woken by a thunder storm and run to find their mother.  On each page the family explores how they are linked to different people they love.




The Kissing Hand, by Audrey Penn, stars a baby raccoon who doesn't want to go to school, but would rather stay home with his mommy and familiar toys.  His mother kisses the palm of his hand and tells him that if he puts his hand up to his cheek he will feel her love any time he wants.  The story is sweet, and concept easy to understand at almost any age.




Wemberly Worried, by Kevin Henkes, is about a little mouse who can't go anywhere without his special blanket.  His mother comes up with a creative solution so he can secretly take his blankie whereever he goes.

After the first week of school my youngest daughter and I read The Invisible String together.  We made red construction paper hearts, exchanged lipstick kisses imprinted on the hearts, and put them onto necklaces of string to wear the next day.  In this way we can carry a tangible symbol of love, that hopefully will carry us through until we can be together again.  Maybe some of you will see me with my "heart on a string" tomorrow in the office.



I would love to hear comments on book suggestions or ideas you have to help with separation anxiety, or other special traditions you have that help you feel closer when you have to be apart!  Maybe you can find some books about children and their fathers, too.  Good luck.

What to do with a Fever

Fevers are common in children.  They are probably the number one reason for after hour phone calls to the doctor.  Many parents feel panicky when the thermometer indicates fever.  So what should you do? 

First, and most important, don't panic!  Keep trying to think logically and stay calm.  Your sick child needs you to be able to make rational decisions.  Understand that if the temperature is under 100.5 F, then it is not actually a fever, and you should simply monitor the situation.  Also remember that fever can be helpful in fighting some infections. 

Fever is a sign that your child's body is reacting to an infection.  When there is a fever we try to figure out if the infection is a serious one.  The fever itself won't hurt your child, but a serious infection can be a cause for concern.  If your child has a fever, but is older than three months of age and is looking and acting just fine, you do not automatically need to call the doctor.  Fairly normal behavior and energy level often mean the fever is caused by a more minor infection.

Here are some things to think about.  If your child is under three months of age and has a rectal temperature of 100.5 or higher, you should probably call the doctor.  You could consider unwrapping your baby, making sure that too many blankets isn't the problem.  In general, though, for an infant under three months old with a fever, you should call.

If your child is over three months of age, then her behavior and appearance are important in evaluating how serious of an infection it is.  There is no automatic temperature at which you should "panic" and rush to the ER.  103, 104, and 105 F are all "high" fevers.  When the fever is high you also need to consider how sick your child looks.  If they are very irritable or lethargic, it is more concerning.

When I am called about a child's high fever I frequently ask parents to give a dose of ibuprofen or acetaminophen, and then reassess their child in an hour.  If she feels and looks much better with such a simple intervention, then it may be ok to wait until the next day before bringing her in.  The goal of using anti-fever medicine is not to bring the temperature back down to normal, but to temporarily bring it down a little and to make your child feel better.  It is a good sign if something basic like acetaminophen or ibuprofen can make a big difference in how your child feels.

Giving a cold bath is kind of dramatic and old-fashioned.  I don't usually recommend it because I don't think it would be very soothing to already feel awful with a high fever and then get plunged into icy water.  Cool wet washcloths on the forehead and back of the neck will be much more comfortable for your child.

106 F or higher makes me think of heat stroke, so at that level you should call or take your child to the hospital.  103 F and higher, in addition to a lethargic or irritable child who does not improve with acetaminophen or ibuprofen, would be another reason to call or have your child evaluated right away.
In addition, with any level of fever (that's 100.5 or higher) when your child is also very irritable or lethargic and not improving with anti-fever medicines, you should consider calling or taking your child in.

A child who is lethargic and irritable is usually not smiling, not eating and drinking, is very sleepy or won't stop crying or moaning.  The child can be very restless or almost impossible to comfort and console.  When the doctor asks about "lethargic" she does not mean that your child just wants to sit around and watch TV, or that they seem a little more tired than usual.

When there is a fever, this is what you should do:

Before you call the doctor, take a few seconds to think clearly about your child and his fever.  What other symptoms does he have? What illnesses was he exposed to?  How long has he been sick?  Can you help him cool off by undressing him, using cool cloths on the forehead and neck, and giving him anti-fever medicine?  Did you give the right amount of ibuprofen or acetaminophen, and did you give the medicine enough time to work?  Was there improvement in his appearance, mood, discomfort, and energy level? 

If you are reassured by improvement in your feverish child's appearance, then you may be able to manage this at home for the time being.  You could make an appointment in the next day or two if the fever doesn't go away.  If you continue to be quite concerned and worried about your child even after trying some things to help them feel better, then don't wait to check in with the doctor.

Disclaimer:  As usual, my advice in this blog is general and may not apply to your specific situation, or to your child's special circumstances.  This blog is not intended to be a substitute for the personal attention your own doctor can provide.