Children

ADHD

Attention - Deficit / Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a developmental and behavioral disorder that affects 3% to 5% of all school-age children.

Although the condition usually manifests in childhood, it can persist into adulthood, causing difficulties at home, at school and at work if not recognized and treated.

What Are the Symptoms?

The symptoms of ADHD include inattention, impulsiveness and hyperactivity that are inappropriate for a person's age level.

Children who have ADHD often:

Are easily distracted by sights and sounds in their environment.
Are unable to concentrate for long periods of time on low stimulation tasks (homework vs. video games).
Are restless and impulsive.
Have a tendency to daydream.
Are slow to complete tasks.

Symptoms of ADHD vary by individual and range from mild to severe.

Causes

The exact cause of ADHD isn't known.

Experts do know that there are changes in the brains of people with the condition. It is not caused by home or school situations or by poor parenting.

Diagnosis

There is no single test used to diagnose ADHD. It is diagnosed after a child has shown some or all of symptoms of ADHD on a regular basis for more than 6 months.

The diagnosis of ADHD involves the gathering of information from several sources, including school, caregivers, and parents. The health care provider will consider how a child's behavior compares with that of other children the same age.

The health care provider will also do a physical exam to look for any medical problems that may affect a child's behavior.

Treatment

Although there is no cure for ADHD, treatment can help control symptoms. There are several types of treatments available.

Stimulants

Stimulant medications (or psychostimulants) have been used to successfully treat ADHD symptoms for many years. Stimulants are used to treat both moderate and severe ADHD in adults and children over age 6, with the exception of Adderal, Dexedrine, and Dextrostat, which can be safely used in children as young as age 3.

Stimulants used to treat ADHD include:

Adderall, Adderall XR
Concerta
Dexedrine, Dexedrine Spansule Capsules, Dextrostat
Focalin, Focalin XR
Metadate CD, Metadate ER
Methylin, Methylin ER
Ritalin, Ritalin LA, Ritalin SR

Nonstimulant Therapy

In November 2003, the FDA approved Strattera as the first nonstimulant treatment for ADHD. It is the first treatment approved to control ADHD symptoms in children, adolescents, and adults. In September 2005, the FDA issued a warning about the increased risk of suicidal thinking in children and adolescents taking Strattera. Doctors are advised to watch for this behavior and alter medications as needed.

Antidepressant Therapy

Several types of antidepressant drugs can be used to treat ADHD. Antidepressant therapy for ADHD is sometimes used as the initial treatment in children or adults who also suffer from significant depression. Antidepressants, however, are generally not as effective as stimulants or the newer nonstimulant treatments at improving attention span and concentration. It also may take 2-4 weeks for the full benefits of antidepressants to appear.

Note: In October 2004, The FDA has determined that antidepressant medications increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. If you have questions or concerns, discuss them with your health care provider. Learn more

Other Drugs

Two drugs, Catapres and Tenex, normally taken to treat high blood pressure, have been shown to be of some benefit for ADHD when used alone or in combination with stimulant drugs.

Behavior Management

Learning behavior management techniques is considered to be an essential part of any successful ADHD treatment program. Most experts agree that combining medication treatments with extended behavior management is the most effective way to manage ADHD in children and adolescents.

Reviewed by the doctors at The Cleveland Clinic Children's Hospital (2005).

Edited by Tracy Shuman, MD, WebMD, October 2005.

SOURCES: National Institutes of Mental Health, The Food and Drug Administration, A.D.D Warehouse.

Portions of this page © The Cleveland Clinic 2000-2004

Childhood Obesity

Overview

One out of every five children in the U. S. is overweight, and this number is continuing to grow. Children have fewer weight-related health and medical problems than adults, however, overweight children are at high risk of becoming overweight adolescents and adults, placing them at risk of developing chronic diseases such as heart disease and diabetes later in life.

Causes

Children become overweight for a variety of reasons. The most common causes are genetic factors, lack of physical activity, unhealthy eating patterns, or a combination of these factors. Only in rare cases is being overweight caused by a medical condition such as a hormonal problem. A physical exam and some blood tests can rule out the possibility of a medical condition.

Although weight problems run in families, not all children with a family history of obesity will be overweight. Children whose parents or brothers or sisters are overweight may be at an increased risk of becoming overweight themselves, but this can be link to shared family behaviors such as eating and activity habits.

A child's total diet and activity level play an important role in determining a child's weight. Today, many children spend a lot time being inactive. For example, the average child spends approximately 24 hours each week watching television. As computers and video games become increasingly popular, the number of hours of inactivity may only increase.

What Diseases Are Obese Children at Risk For?

Obese children are at risk for a number of conditions, including:

High cholesterol
High blood pressure
Early heart disease
Diabetes
Bone problems
Skin conditions such as heat rash, fungal infections and acne

How Do I Know if My Child Is Overweight?

The best person to determine whether or not your child is overweight is your child's doctor. In determining whether or not your child is overweight, the doctor will measure your child's weight and height. The doctor will also consider your child's age and growth patterns. Assessing obesity in children can be difficult because children can grow in unpredictable spurts. For example, it is not unusual for boys to appear overweight, but they may grow taller and "grow into the weight" a few years later.

Treatment

If your child is overweight, it is very important that you allow him or her to know that you will be supportive. Children's feelings about themselves often are based on their parents' feelings about them and if you accept your children at any weight, they will be more likely to feel good about themselves. It is also important to talk to your children about their weight, allowing them to share their concerns with you.

It is not recommended that parents set children apart because of their weight. Instead, parents should focus on gradually changing their family's physical activity and eating habits. By involving the entire family, everyone is taught healthful habits and the overweight child does not feel singled out.

How Can I Involve My Family in Healthful Habits?

There are many ways to involve the entire family in healthy habits, but increasing the family's physical activity is especially important. Some ways to accomplish this include:

Lead by example. If your children see that you are physically active and having fun, they are more likely to be active and stay active for the rest of their lives.
Plan family activities that provide everyone with exercise, like walking, biking, or swimming.
Be sensitive to your child's needs. Overweight children may feel uncomfortable about participating in certain activities. It is important to help your child find physical activities that they enjoy and that aren't embarrassing or too difficult.
Make an effort to reduce the amount of time you and your family spend in sedentary activities, such as watching TV or playing video games.

Whatever approach parents choose to take, the purpose is not to make physical activity and following a healthy diet a chore, but to make the most of the opportunities you and your family have to be active and healthy.

Reviewed by the Department of Nutrition Therapy at The Cleveland Clinic.

Edited by Charlotte Grayson, MD, WebMD, August 2004.

Potty Training

When to start

Your child must be both physically and emotionally ready for toilet training. Most children are ready when they are between 22 and 30 months of age, although every child is different. Toilet training usually becomes a long and frustrating process if you try to start it before your child is ready.

Before children can use the toilet, they must be able to control their bowel and bladder muscles. Some signs of this control are having bowel movements around the same time each day, not having bowel movements at night, and having a dry diaper after a nap or for at least 2 hours at a time. Children must also be able to climb, talk, remove clothing, and have mastered other basic motor skills before they can use the toilet by themselves.

Most children are physically ready to toilet train before they are emotionally ready. Your child must want to use the toilet and be willing to cooperate with you. He or she may even talk about being a "big boy" or "big girl" and wearing underpants rather than diapers. Training generally does not go well if your child is in the stage where "no" is his or her automatic response to every request.

Home Treatment

There are many different strategies and approaches to toilet training. The most successful methods use positive reinforcement and begin intensive training only when a child is physically and emotionally ready. Introduce the basic concepts of toilet use gradually and repetitively to your child. As your child gains the necessary skills, he or she will show a sincere interest in using the toilet.

How to get ready

Before you decide to start toilet training, make sure the household environment is stable and that all family members are prepared to help in the process. Trying to start potty training soon after having another child, while remodeling your home, while having a succession of household guests, right before going on vacation, or during a time of marital problems will likely not be as successful as during a calm period when the family can focus on helping your young child reach this significant developmental milestone.

Talk with your child about having a bowel movement and about urinating. Your child may be more comfortable saying "poop" and "pee." It is fine to use these words, but use the proper terms as well so the child learns what they mean.

Start to talk with your child about how to use the toilet. Explain how the toilet works and how your child will be able to use it when he or she is ready. Be enthusiastic and always speak positively about your child's using the potty. Talk about how he or she will no longer need to wear diapers, will get to wear underpants that are more comfortable, and can go just like a big boy or girl.

Getting prepared

Take your child with you to select a potty that is sturdy and comfortable. Be patient and give your child time to get used to and comfortable with it. Some ways to do this are by:

Allowing your child to move a portable potty into his or her room or other play area to get used to having it around.
Helping make the potty special by personalizing it, such as painting it or writing your child's name on it.
Allowing your child to sit on it and read a book or sit on it with his or her diaper on while having a stool or urinating. You can say, "This is your special chair for you to go pee-pee and poop in. Soon you will use it just like grownups use the toilet."

Your child may want to join you when you use the toilet. If you feel comfortable with an audience, allow him or her to join you. Talk with your child about what you are doing.

Toilet training is usually more successful if you are relaxed and patient with your child.

Do not attempt to begin toilet training before your child is physically and emotionally ready. Trying to toilet train your child before this time creates frustration for both of you.
Avoid power struggles, which will only make toilet training more stressful and last longer. All experiences and associations with toilet training should be positive. Do not scold, punish, or embarrass your child for failing to use the toilet.
Do not verbally or physically force your child to sit on a potty. Allow your child to sit on the potty only for 5 minutes at a time unless he or she is beginning to pass stool or urine.
Tell your child that it is up to him or her to decide when to use the toilet.

Where to start

Eventually, your child will show an interest in using the toilet. When this happens, follow your child's lead and start the process. General suggestions that can make this process go more smoothly are to:

Dress your child in clothing that is easy for him or her to remove. Clothes that have elastic waistbands or easy-to-open fasteners (such as Velcro) work best. Pull-on diapers also work well during toilet training. Bib overalls and one-piece outfits are hard for a child to take off.
Help your child feel comfortable and safe on the toilet. Assure your child that he or she will not fall in. Some children feel more comfortable sitting backward, facing the toilet tank.
Teach your boy how to urinate as he sits on the toilet. (Some boys may need to push down on their penis so that the urine stream goes into the bowl and not over the front of the toilet seat.) As he grows taller, he can learn to urinate from a standing position. A small step stool may help him reach the toilet bowl and improve his accuracy.
Teach your child to wipe properly. Show him or her how to remove toilet paper from the roll, wipe, and throw the used toilet paper in the toilet. Instruct girls to wipe from front to back, which helps avoid infection caused by getting stool near the urethra or the vagina. Many children need help to wipe effectively, especially after a bowel movement, until about age 4 or 5. You may want to keep diaper wipes near the toilet to help remove residue without chafing your child's skin.
Help your child flush the toilet. Some children are afraid of the sucking mechanism of the toilet. If your child develops this fear, it is fine for you to flush the toilet after he or she leaves the room. Eventually, your child will be able to flush the toilet without a problem.
Teach your child how to wash his or her hands after using the toilet.

What to think about

Praise and encourage your child for success. You can say, "You are sitting on your potty just like mommy (or daddy, or big sister)," or "You are trying really hard to poop (or pee) in your potty." Reward your child for attempting to use the toilet with verbal praise and fun activities, such as stickers or special playtime with you.

Accidents happen. Do not scold or punish your child for accidentally wetting or soiling his or her pants. Be matter-of-fact and reassure your child that it's okay and that he or she will get better with practice.

The most important things to remember for toilet training are to wait until your child and family is ready and to make it a positive experience. Be patient, but look forward to the days ahead of freedom from diapers!

The Flu & Colds

The Flu

Children are at high risk of complications and serious illness from the flu. Indeed, only elderly people over age 74 are at higher risk.

Fact: Children under 2 years old -- even healthy children -- are more likely than other children to be hospitalized from the flu.

Flu season spans November through March.

How can you tell if your child may have the flu?

Flu symptoms are more severe than those with colds and tend to come on abruptly. Flu symptoms in children may include:

A sudden fever (usually above 101º)
Chills and shakes with the fever
Extreme tiredness
Headache and body aches
Dry, hacking cough
Sore throat
Vomiting and belly pain
Stuffy nose

A child will usually feel the worst during the first two or three days.

Complications of the flu may include a sinus infection or pneumonia. Call your pediatrician if the fever last more than three to four days, or if your child complains of trouble breathing, ear pain, congestion in the face or head, or a persistent cough.

Prevention

The No. 1 way to prevent the flu is by getting an annual flu shot.

The "flu shot" does not contain live virus. It is an inactivated vaccine that is given by injection.
It is approved for use in anyone older than 6 months, including healthy people and people with chronic medical conditions.
All children aged 6 to 23 months should get a flu shot because they are at high risk of complications.

During the 2003-2004 season, there were 152 flu-related deaths among children under 18. Most of these children were less than 5 years old, and the majority of them did not get the flu shot, according to the CDC.

A nasal flu vaccine also exists. It is called FluMist and contains weakened viruses. These weakened strains usually do not cause illness because they have lost strength, but they can sometimes cause flu. Only healthy children aged 5 or older may receive the nasal-spray flu vaccine. Younger children may not.

The best time to get vaccinated is October or November.

Children getting a flu shot for the first time need two doses given a month apart. About two weeks after vaccination, antibodies develop that protect against infection. Flu vaccines will not protect against flu-like illnesses caused by other viruses.

The American Lung Association offers an online flu vaccine clinic locator. Visit www.flucliniclocator.org, enter a zip code and a date (or dates) and receive information about clinics scheduled in your area.

Treatment

Antibiotics are ineffective against the flu. Home treatments include:

Rest
Drink plenty of liquids
Use acetaminophen or ibuprofen to lower fever and reduce aches. Both are available in children's formulations.
Do not give aspirin to children or teenagers who have flu-like symptoms, particularly fever. Aspirin may increase risk of Reye's syndrome, a rare disorder that occurs almost exclusively in children under the age of 15 and can cause severe liver and brain damage.
Talk with your doctor before giving any child under age 6 an over-the-counter cold or flu medicine.
In very young children with congestion, use a nasal bulb to gently remove mucus. You may also spray three drops of saline nasal spray into each nostril.

Antiviral drugs are also available by prescription to treat the flu. In some cases, they can also be used to prevent infection. These drugs block the replication of the flu virus; preventing its spread. Antiviral medications include:

Tamiflu (oseltamivir) - for children 1 year and older
Flumadine (rimantadine) -- for children 1 year and older
Symmetrel (amantadine) -- for children 1 year and older
Relenza (zanamivir) - for children 7 years and older

Colds

Colds are minor infections of the nose and throat that are caused by more than 250 different types of cold viruses. Rhinoviruses are the most common. Colds typically last for one week, but may linger in children.

Fact: Children get an average of six to eight colds per year.

Cold season runs from about September until March or April.

Diagnosis

Cold symptoms tend to come on gradually, and may include:

Runny nose
Congestion
Sneezing
Reduced sense of taste and smell
Scratchy throat
Cough

Prevention

Colds are hard to prevent, but here are top tips from experts:

Avoid contact with people who have a cold.
Wash your hands after touching anyone with a cold.
Keep your child home when they are sick to help prevent others from catching the cold.
Encourage your child to cover his or her mouth and nose with a tissue when coughing or sneezing.
Discourage your child from touching his or her eyes, nose, or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

Treatment

Antibiotics are ineffective against colds. They should only be used if there are clear signs of a bacterial infection, such as an increasing cough and thickened, cloudy mucus. Recommended care for children with colds includes:

Rest
Drink plenty of liquids (including tea, water, and juice).
Put a humidifier in your child's room to provide extra moisture, which helps reduce congestion.
Use acetaminophen or ibuprofen to lower fever and reduce aches. Both are available in children's formulations.
Do not give aspirin to children or teenagers who have flu-like symptoms, particularly fever. Aspirin may increase risk of Reye's syndrome, a rare disorder that occurs almost exclusively in children under the age of 15 and can cause severe liver and brain damage.
Over-the-counter cold remedies are fine for children over age 6. But talk with your doctor before giving any child under age 6 an over-the-counter cold medicine.
In very young children with congestion, use a nasal bulb to gently remove mucus. You may also spray three drops of saline nasal spray into each nostril.

SOURCES: The American Academy of Pediatrics. The American Lung Association. The Centers for Disease Prevention and Control. Schachter N, The Good Doctor's Guide to Colds and Flu, Collins 2005.

Vaccines

Schedules for various vaccines

Diphtheria/Tetanus/Pertussis (DTaP) -- Five-dose Series

2-4 months:
First two of five doses at 2 and 4 months

4-6 months:
Third of five doses at 6 months

15-18 months / 4-6 years:
Fourth and fifth of five doses

Tetanus and Diphtheria (Td)

11-16 years:
One dose between 11 and 16 years if at least five years have elapsed since the last dose of DTaP, DPT or DT. Boosters every ten years throughout adulthood.

Hepatitis A (Hep A) -- Two-dose Series

2-16 years:
Some states recommend between 24 months and 16 years; check with your doctor or health department for local recommendations.

Hepatitis B (Hep B) -- Three-dose Series

Birth to 2 months:
First dose by 2 months

2-4 months:
Second dose at least one month later, between 2 to 4 months

6-18 months:
Third dose at least four months after the first and two months after the second, between 6 to 18 months

2-18 years:
Three-dose series should be given to all children under 18 who didn't get the vaccine as infants

H. influenzae type b (Hib) -- Four-dose Series

2-4 months:
First two at 2, and 4 months

4-6 months:
Third dose of a three-dose series at 6 months

6-18 months:
Additional dose between 12 and 15 months (check with your doctor)

Measles/Mumps/Rubella (MMR) -- Two-dose Series

6-18 months:
First dose usually given between 12 to 15 months

4-6 years:
Second of two doses, usually given between 4 to 6 years.

6-12 years:
Two-dose series should be completed by 11 to 12 years if not completed earlier.

Pneumococcus (PCV7) -- Four-dose Series

2-4 months:
First two of four doses at 2 and 4 months

4-6 months:
Third of four-dose series at 6 months

6-18 months:
Fourth of four doses between 12 and 15 months

24-6 years:
Recommended for children ages 2 to 5 years at high risk due to sickle cell disease, HIV, and other immune-compromising diseases, if not completed earlier.

Polio (IPV) -- Four-dose Series

2-4 months:
First two of four-dose series of injectable polio vaccine at 2 and 4 months

6-18 months:
Third dose of a four-dose series of injectable polio vaccine, between 6 to 18 months

4-6 years:
Fourth of four doses of injectable polio vaccine

*Due to the risk of vaccine-associated paralytic polio, oral polio vaccine should be used only under special circumstances; check with your doctor.

Chickenpox (Varicella)

6-18 months:
One dose after the first birthday, usually given between 12 and 18 months

13 and up:
Two doses at least one month apart for susceptible individuals over 13 years; check with your doctor.

MEDICAL REVIEW: Reviewed by Cynthia Haines, MD, April 2005

SOURCE DOCUMENTATION: Sources: American Academy of Pediatrics, the American Academy of Family Physicians, U.S. Centers for Disease Control and Prevention.