Because we recognize the importance of schoolwork for our patients, Cook Children’s partners with Fort Worth Independent School District to provide school services to eligible patients while in the hospital setting. Our teachers work specifically with children and teens who have a chronic or complex diagnosis, are experiencing an extended hospitalization, or have sustained a life-threatening injury.

Whether they’re attending a session at the bedside or in the patient classroom on the first floor of the Fort Worth medical center, students receive one-on-one services to help them keep up with their schoolwork.

Get to know each of our incredible teachers, Marissa Glasschroeder, Laura Ralston and Nicole Rogers, by watching the videos below.

After all, this is a modern classic. So much so that October 3 has become #MeanGirlsDay.

From Heathers to Mean Girls, these ‘rites of passage’ movies have given us insight into the lives of teenage girls. While they may be full of snobs, cliques and at times, cruel behavior, they can’t fully prepare any girl for the reality of social bullying.

Parents, you may know social bullying all too well and not even realize it. This occurs when a group decides to leave someone out on purpose or tells other kids not be friends with a certain child or teen.

But unlike your favorite teen movie, there's not always a happy ending for the kids being bullied.

Social bullying, along with verbal bullying, is often referred to as “mean girl” behavior, said Lisa Elliott, Ph.D., a licensed psychologist and clinic manager of Cook Children’s Behavioral Health Clinic in Denton.

She says this form of bullying also includes name-calling, backstabbing, gossiping and spreading rumors.

“When ‘mean girls’ take this negative and aggressive behavior into the world of social media, it now includes cyberbullying, making it even more hurtful and instilling feelings of powerlessness,” Elliott said. “This can be quite painful and has the potential to be psychologically harmful.”

Girls may engage in this type of behavior for several reasons, including:

• Peer pressure.
• Trying to improve their status on the social ladder.
• Excluding those who may be perceived as a threat to their social status.

Regardless of the type of bullying, three elements are generally present:

1. An imbalance of power.
2. Aggressive behavior intended to hurt someone emotionally and/or physically.
3. Pleasure in observing the pain (or assuming there is pain) caused to the person being bullied.

Elliott says your daughter’s response to the mean girl is key.

“All bully behavior is intended to empower the bully, so your daughter’s response is critical – she must be able to acknowledge what the “mean girl(s)” are doing, but also communicate that they don’t have emotional power over her,” Elliott said.

She says if the victim communicates any type of negative emotion (verbally and/or nonverbally) – whether that be pain, hurt, rejection, fear, anger, frustration etc. then she has validated the bully. The bully will only be encouraged to continue the “mean girl” behavior, simply because it empowers them.

Instead, girls should try to respond to the bullies by using select words such as ‘so,’ ‘OK,’ ‘who cares,’ ‘whatever’ and ‘big deal.’

“These words communicate ‘I hear you, but you have no impact on me,’” Elliott said. “However, equally important is the tone in which these words are communicated. It is critical these words are conveyed with NO emotion! If ‘mean girls’ pick up on any emotional weakness, they will continue the negative behavior.”

Another strategy to apply is humor, where you laugh at yourself thus deflecting any hurtfulness.

“It’s important your daughter displays confidence and can defend herself in an assertive manner that is respectful, does not lower her to their level and does not encourage them,” Elliott said.

In addition to having a prepared response, Elliott encourages girls to stay strong, appear confident and smile, primarily because “mean girls” are quite adept at discerning which girls they can manipulate and control. The more confident your daughter portrays herself (not appearing dejected, insecure, hurt, nervous, left-out), the less likely the “mean girls” will repeat their aggressive behavior to her.

Equally important is being a positive bystander. If your daughter sees “mean girl” behavior happening to others, ask her not to stand by and watch. When “mean girls” do not have an audience, they lose power.

To foster your daughter’s self-confidence, help her find areas she can feel success in, such as school, sports, church, community service clubs, or talents like singing or playing an instrument.

You should also monitor her computer and cell phone, and encourage her to spend less time on social media. If bullying expands onto social media, then you need to talk to her teacher, coach or another school official.

While we’ve addressed “mean girls” in this article, no child is bully-proof.

Elliott points to the death of David Molak, a 16-year old San Antonio boy, as an example of the harm that comes from the constant harassment a child receives in the world of cyber bullying. She offers parents the following talking points when speaking to their child about bullying:

• Even people who say they're your friends can bully you.
• You should confront your friends when they're being hurtful to you or others.
• Retaliating may feel good temporarily, but refusing to stoop to the bully's level will win you more popularity in the long run.
• When you hear a false rumor, just ignore it and be yourself.
• You're most likeable when you respect yourself and others.
• Bullies usually have their own insecurities. Returning meanness with kindness is the best way to break down their defense.

In the end, kids should know they may be the best resources to end bullying where they live.

Stories related to this topic:

• Bullying is a ‘serious public health problem’
• Are popular kids bullied?
• Is your teen's smart phone making them depressed?
• The warning signs of teen suicide
• Cutting: Why kids do it

Dr. Vivek H. Murthy said e-cigarettes are the most commonly used form of tobacco among young people in the United States, surpassing conventional tobacco products, including cigarettes, cigars, chewing tobacco and hookahs.

From 2011 to 2015, e-cigarette use among high school students increased 900 percent.

"Compared with older adults, the brain of youth and young adults is more vulnerable to the negative consequences of nicotine exposure," Dr.. Murthy said. 

During the press conference, Dr. Murthy took the opportunity to introduce a new interactive website to provide the facts on e-cigarette use among young and young adults. 

The site states that 6 of 10 American teens believe that e-cigarettes cause little or only some harm as long as they are used sometimes, but not every day. However, the site says that e-cigarettes pose a "significant -- and avoidable -- health risk to young people in the United States. Besides increasing hte possibility of addiction and long-term harm to brain development and respiratory health, e-cigarettes use is associated with the use of tobacco products that can do even more damage to the body. Even breathing e-cigarette aerosol that someone else has exhaled poses potential health risks.

To learn more about e-cigarettes, we talked to Don Wilson, M.D., an endocrinologist and an Endowed Chair of Cardiovascular Health and Risk Prevention at Cook Children’s.

What do e-cigarettes do?

E-cigarettes are designed to simulate the act of smoking and deliver nicotine without the toxic chemicals produced by burning tobacco. The use of nicotine, however, is highly addictive. Recent research suggested nicotine exposure may also cause the brain to become addicted to other substances. Vapor from some e-cigarettes has also been shown to contain known cancer producing and toxic chemicals, such as diethylene glycol and nitrosamines, as well as small particles of toxic metals. Although not well studied, there is the potential for second hand exposure by others in the environment.

How do e-cigarettes work?

E-cigarettes are smokeless, battery operated devices designed to deliver nicotine mixed with a variety of flavorings (fruit, mint, chocolate, etc.) and other chemicals via an inhaled aerosol. They typically resemble regular tobacco cigarettes, cigars, pipes or everyday items like pins or USB memory sticks.

Most e-cigarettes generally contain three components: a cartridge that contains a liquid solution containing various amounts of nicotine, flavoring and other chemicals, a heating device or vaporizer, and a rechargeable battery. Puffing on the e-cigarette activates the battery powered heating device causing the liquid to vaporize. The vapor is inhaled by the user. E-cigarette vapor may include metals, rubber and ceramics which may be aerosolized and have adverse health effects.

Are e-cigarettes safe?

Although a limited number of studies have been conducted, the safety of e-cigarettes has not thoroughly been evaluated in scientific studies.

Here are a few points to consider:

• Nicotine is highly addictive and has negative effects on brain development from infancy to teens.
• Potential consequences of using e-cigarettes among youth include nicotine addiction, withdrawal and the potential for overdose.
• The use of a variety of flavoring in the liquid solution of e-cigarettes has created concern for accidental ingestion by smaller children.
• With the rapid increase in use of electronic nicotine delivery systems (ENDS), users and nonusers are exposed to the aerosol product. While e-cigarette aerosol may contain fewer toxins than cigarette smoke, studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive.

Bottom line: e-cigarettes are often promoted as safer alternatives to cigarette smoking. Although very little is known about their safety, they are increasingly being used by youth and young adults.

What about second hand exposure?

The potential exists for secondhand nicotine and other tobacco-related toxin exposures to others. Studies have shown that e-cigarettes are a source of secondhand exposure to nicotine but not to combustion toxins. Thus, while use of e-cigarettes in indoor environments may involuntarily expose nonsmokers to nicotine, it does not seem to expose them to toxic, tobacco-specific combustion products.

What does the American Academy of Pediatrics recommend?

To protect the health of youth, the American Academy of Pediatrics has made the following recommendations:

• Sales of e-cigarettes to minors (under 18 years of age) should be prohibited.
• Candy and fruit flavored e-cigarettes, which encouraged youth smoking initiation, should be banded.
• To avoid exposing others to potential harm, laws should mandate smoke-free environments which include e-cigarette vapor.
• To prevent poisoning, all e-liquids should be required to be sold in child-proof packaging.

At Cook Children’s SPORTS Rehab, we’ve noticed a shift in what we see in our clinic. Over the past decade, the three major changes we’ve seen are the number of overuse injuries, the amount of early sports specialization and the way we treat concussions.

The first two issues I mentioned go hand-in-hand. It’s no coincidence that we are seeing more overuse injuries at the same time we are seeing early sports specialization. Overuse injuries come from repetitive micro-trauma to tendons, bones, and joints caused by repeating the same type of activity over and over.

If kids are playing the same sport all year around they are repeating the same movement patterns over and over again. Growing up in the 1980s and 1990s there wasn’t the opportunity to play year round sports like there is now. You may have had a favorite sport, but you had to wait for that season to roll around, and in the mean time you would play another sport if you wanted to stay active.

Now, if your favorite sport is baseball, you can find leagues to play in all year round, and the same is true for most other sports. As a result of this early specialization, we are seeing more and more overuse injuries in our young athletes.

In our baseball and softball players we are seeing more elbow and shoulder injuries, and the number one risk factor for overuse injuries of the shoulder and elbow is the volume of throws. If an athlete is playing baseball year round, the volume of throws is going to be significantly greater than an athlete that takes a break to play another sport.

A recent study showed that 15-19 year olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions (Tommy John) performed between 2007-2011.This means over half of these surgeries are being performed on patients who haven’t even finished their freshman year of college. While early specialization is a contributor to the uptick in these overuse injuries it is not the only factor. Things like poor mechanics, poor flexibility and inadequate strength all contribute to overuse injuries. As more and more kids participate in athletics there becomes more and more need for good conditioning and injury prevention programs. Increased sports participation is a great problem to have, because that means our kids are being active, but it also increases the need for our coaches, and we as parents, to be more aware of ways to keep our kids safe from these overuse injuries.

Treatment of concussion has been a popular topic in the news as of late, and this is an area that has changed significantly over the last decade and continues to evolve as we learn more about these injuries. Ten years ago we tried to grade concussions based on the severity. The concussions were graded 1-3 based on the patient’s symptoms and whether they lost consciousness. In some cases of Grade 1 concussions, the athlete was allowed to return to activities the same day as the injury.

We then switched to saying the athlete either has a concussion or they don’t, and all athletes that were deemed to have a concussion were disqualified from participation until cleared by a physician. In most cases we would shut these athletes down completely; limiting TV, school, phone time and interaction with other people in an attempt to let them get complete cognitive rest until their symptoms resolved. Then once symptoms resolved we would start a return to school and return to play protocol.

Now kids still have to be cleared by a physician, and they still have to follow a return to play protocol, but we have realized that completely isolating these kids while they recover and limiting their interaction with friends was doing more harm than good.

So after a brief period of brain rest (approximately three days), we start slowly integrating kids back into activities of daily life as tolerated. It is important to have a physician that deals with concussions involved in the patients return to activity so that they are getting the appropriate accommodations at school and home to allow for the appropriate amount of rest, but that will still allow enough activity to stimulate the patient enough to promote recovery and keep them from becoming isolated.

For more on the specifics of how treatments have changed for all of these areas, and for information on other changes in sports medicine, we would love for you to attend our annual Cook Children’s Sports Medicine Symposium July 21, 2016.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annualSPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

Unfortunately, it’s also a troubling trend among today’s high school athletes.

Cook Children’s pediatrician David H. Goff, M.D., FAAP, calls overstressed, busy children a huge problem – both in the classroom and on the playing field. In his Denton office, Dr. Goff sees patients who suffer from a variety of symptoms like chronic abdominal pain, anxiety and depression.

“I see this over and over. I look in the child’s eyes. They are exhausted. I say to the parents, ‘You need to cut back,’” Dr. Goff said. “And it is amazing to me. They say, ‘We can’t. No way. We have a tournament this weekend.’ For any successes we have, we have 100 more burnouts.”

The American Academy of Pediatrics agrees with Dr. Goff. A group of eight organizations, including the AAP, released a consensus statement regarding their concern with today’s high school athlete.

The AAP states, “Student athletes report higher rates of sleep disturbances, loss of appetite, mood disturbances, short tempers and inability to concentrate than non-athletes.”

The recommendations focused on the importance of educating students, parents and coaches on mental disorders in student-athletes; the stress involved with today’s athletes and ways to monitor their behavior.

Concerns of the AAP included the injuries and stress related to student athletes training year round, which doesn’t give them time to rest and recover.

The AAP said these athletes also face stress from poor performance on the playing field, injuries, concerns about getting cut from the team and trouble keeping up with school work, along with their extracurricular activities.

Because of the stress involved, student-athletes may suffer from “a pattern of lack of sleep and under-recovery” and chronic fatigue that puts him or her at risk for anxiety and depression. Other issues include:

• Physical (Physical conditioning, injuries, environmental conditions)
• Mental (Game strategy, meeting coaches’ expectations, attention from media and fellow students, time spent in sport, community-service requirements, and less personal and family time)
• Academic (classes, study time, projects, papers, examinations, attaining and maintaining the required grade point average to remain on the team, and earning and maintaining a collegiate or academic scholarship).

David Gray, M.D., medical director of Cook Children’s Orthopedics and SPORTS, agrees with Dr. Goff that too much activity can simply be harmful to a young person.

With the advent of select sports and recreational leagues, Dr. Gray said children now play the same sport year round without getting a break from those activities. He wants young athletes to have variation in their activities. If not, the repetitive nature of the same sport creates stress and strain especially on growing bones.

Dr. Gray and his colleagues see children who never have a break during the year sometimes playing on two or three different teams during the same season. He said it’s too much stress on their growing skeleton, causing muscle aches, strains and pain.

Both Dr. Gray and Dr. Goff stress children, especially before they reach high school, should focus on participating in several different sports to prevent using the same muscles year round. They say it also helps the child avoid getting burned out on that specific sport.

“For kids, sports are great and you learn a lot from them, but they should be fun,” Dr. Gray said. “Kids need to enjoy them too. You don’t really want a 12 or 13 year old performing to the point where they are having injuries that could actually impact them as an adult.”

Dr. Goff admits this subject quickly places him on his soapbox. But it’s because he sees so many of his patients facing stress and are simply not happy.

He sees them come in with dark circles under their eyes and behind closed doors and just one-on-one with him, they admit to a different story than what they have been telling to their parents.

Far too often, Dr. Goff hears the regrets of parents, but only when it’s too late. The child has gone off to college and the parent wishes they had taken a trip to the Grand Canyon with their family, instead of racing off to another game.

“I ask the parents to leave the room so I can talk to the child,” Dr. Goff said. “I ask, ‘Do you really want to do this?” They say, ‘No I’m tired.”

The scary part of this story is that far too often the parents are trying to do what’s best for their child, but in reality they are doing harm.

Dr. Gray said he is beginning to see injuries in children as young as 8 years old with ACL injuries. Injuries that were once thought not to happen until children were much older.

“Another problem is that the really good, young kids are getting left behind,” Dr. Gray said. “They are burned out because they are pegged to be the superstar and they get over worked, over trained and over pushed. Some get burned out and pushed to the wayside and other kids, who were not as big, catch up by the time they are in middle school. They have more passion and they are not burned out. And they pass them by.”

Both Dr. Gray and Dr. Goff also see phantom injuries – muscle aches or headaches. Anatomically there seems to be nothing wrong with the child. In reality it’s the child hinting he or she needs a break.

So what should a parent do? Here’s a start:

• During the year give the child down time and a chance to recuperate. This is the case physically for sports and mentally for school.

• Vary the child’s routine to avoid burnout

• Give your children an opportunity to tell you if they are enjoying themselves.

“It’s easy to succumb to parental peer pressure,” Dr. Gray said. “Parents are afraid if they don’t do something their child will be left behind. What’s most important is that your children enjoy sports, or enjoy their activities and has a good mental outlook on life. It’s hard for parents to not live vicariously through their children. It’s a hard lesson for parents. You want the best for your child and want your child to be successful. But sometimes less is more.”

Time for school, which means shopping for school supplies, meet the teacher night and contracting parasites. Many diseases increase in frequency when you gather school aged children back together again for the start of the year (common colds and strep throat are great examples). Today, I am going to talk about three parasites that tend to cause outbreaks in school classrooms.

Head lice

Head lice are common; some consider their acquisition a rite of passage for elementary school. They are parasitic insects that live on the scalp and cause itching. They are not dangerous but very annoying and can be identified by finding their characteristic eggs (called nits). Less commonly, a caregiver can find live lice moving on the scalp. Treatment most often involves using medicated shampoo. A few tips on treatment:

1. There are many great over the counter shampoos. Follow the written directions closely as too much could be harmful and too little will not be effective. Contact your pediatrician if things are not improving.
2. Many doctors recommend clearing the nits off the scalp with a fine-tooth comb.
3. Many shampoos require a repeat dose in one week.

Scabies

Scabies are less common than head lice. but equally annoying and also not dangerous. The mites that cause scabies burrow down just under the top layer of skin and cause severe itching and a fine red rash. It is common to find the rash on the wrist and between fingers and toes. Diagnosis requires a visit to the doctor who generally makes the diagnosis based on the story and the characteristic rash. Treatment involves applying a cream to the skin to kill the mite.A few tips on treatment:

Apply the cream to all skin from the neck to the toes, not just the area with the rash.Leave the cream on for 8-12 hours (overnight works great).Wash all sheets and towels the next morning on the hottest cycle of your washing machine.Repeat the treatment in 1 week.

Cooties

Cooties are the most common parasite in the elementary age child. All children at one point or another have been exposed to and contracted cooties. Cooties are contracted by close contact with another child of the same age, but opposite gender. Diagnosis is sometimes difficult, but it is pretty safe to assume that all children ages 4-10 are infected at all times. There is no treatment for cooties although it is thought that passing them on to another child does provide some temporary relief.

Thankfully, there is a vaccination for cooties which your child's friend can provide by tracing a circle on your child’s arm and reciting, “Circle, circle, dot, dot…now you have the cootie shot."

Part 2 - Elementary and Middle School

I'd guess the titledidn't fool as many of you as it did in Part 1. I probably would've clicked angrily on the link and went to disprove the fact that homeschooling is for everyone too, but I assume that the rest of you who clicked on today are actually interested in how you can help your child learn. Remember these posts are all about the fact that despite the fact that we delegate a lot of our role of educating our children to the school we choose to send them to, the responsibility of their education still falls on us, the parents.

I thought of two different things to post about. First I considered writing about feeding your child breakfast. Several studies show that doing so will increase their grades and especially their ability to pay attention throughout the morning. So, feed your child breakfast. Moving on.

One of the major predictors of success in school and in the future for our children is our involvement in their school and their education.

The school will do what they can, but they are limited by many factors:

1)   Your child is not the only child in class. Vying for the teacher's attention can be difficult.

2)   Your child may learn faster or slower than the average person in class and adjustments are often difficult.

3)   Schools have limited financial and personnel resources that don't allow for curriculum to be differentiated for each student.

So, how do we compensate for each of the above deficiencies? We get involved. More specifically, we get involved in the right way. A study done at the University of New Hampshire showed that it would take $1,000 per student per year of extra spending for the school  to achieve the same results as parent involvement.

A comprehensive review of parent involvement was released by the National Center for Family and Community Connections with Schools in 2002 called "A New Wave of Evidence." I know it's 10 years old, but it's so comprehensive, I couldn't imagine using anything else.

So, how does parental involvement improve performance?

Here are just a few of the ways (New Wave of Evidence-pg 13):

•      Earn higher grades and test scores, and enroll in higher-level programs.
•      Be promoted, pass their classes, and earn credits.
•      Attend school regularly.
•      Have better social skills, show improved behavior, and adapt well to school.
•      Graduate and go on to postsecondary education.

But, how do you do it right?  As with anything, you can even mess up being involved in your child's school and education if you don't think about what you're doing.

Here's what studies say actually works (New Wave of Evidence-pg 87):

     1) Provide a stimulating literacy and material environment.

     2) High expectations and moderate levels of parent support and supervision.

     3) Monitoring of TV viewing and homework completion.

     4) Joint learning activities at home.

     5) Emphasis on effort rather than ability.

     6) Promoting of independence and self-reliance.

Let's go through each for a little discussion:

1) Provide a stimulating literacy and material environment - Have stuff around that stimulates your child to want to learn. This is simple in all stages of life but you just have to be careful to provide it. Keep books easily accessible in the current reading level and one reading level above your child so that they can explore what’s next. Read in front of them (no child is going to read in the room where you are watching TV). Keep art supplies, building toys and other items easily accessible and limit screen time so that your kids have time to play with them.

2) High expectations and moderate levels of parent support and supervision - Don't hover over their shoulder the whole time they are doing homework but check in frequently to make sure they are on task and don't have questions for you. I usually get my son started on something and then walk away and come back a few minutes later. He gets a lot more done when I'm not standing there and he doesn't rely on me to help him along the way.  My favorite thing to see him do is when I come back and he says, "I had a little trouble with this one so I moved on to the next one till you could help me." “Awesome, bud, let’s do it.”

3) Monitoring of TV viewing and homework completion - Set a rule for the TV and homework completion.  I guess it doesn't have to be, but I would think that having the same rule for all the children in the house would be helpful.  You could choose to have no TV until homework is complete or maybe one show (15-30 minutes) before you start.  Sometimes that break can be a refresher for a kid who is worn out from a long day at school but for other kids is impossible to get them back on task.  You need to decide what works best for your family and stick to the plan.

4) Joint learning activities at home - This is where you get to be creative. You can read my post called: Your Child is Gifted to get more advice on how to do this well.

5) Emphasis on effort rather than ability - You can see my entire post about this: You're So Smart.

6) Promoting of independence and self-reliance  -Remember that your goal is to get your child to be independent and ready to move off and do something else when they finish high school. It's hard to remember to think about it when they are young but giving them opportunities to be independent now when you are still close by is a great way to teach them to make better decisions later.

While we're at it, here are some things you should not do whenever it comes to being involved with your child's education:

1) Don't do their homework or projects for them. It's OK to help them if they are choosing wisely but it's also OK to let them make a bad grade if they are relying on you to do it all for them.

2) Don't ever tell you child's teacher that they are "bored" because the class is to easy. It may be completely true, but after saying it, you have eliminated almost any chance you had of working to get a solution to the problem.  Some other things you could say: How can we challenge him/her? Is there some way we could change x/y?

3) Don't go above your child's teacher to the principal unless you've tried to work with the teacher first. It actually causes a problem for everyone involved. The principal doesn't like it, the teacher doesn't like it and you're unlikely to get the results you desire.

4) Don't reward solely for grades. Everyone handles grades a little differently. Some families dole out huge money for good grades, some none and others everywhere in between. Rewarding for grades alone sets them up to choose easier classes and cut corners (cheat?) to get better grades.

Let’s be involved with our kids’ schools, but do it in the right way. The results could be amazing!

About the author

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.