Cook Children’s Neuroscience Research Center, led by Christos Papadelis, PhD, is the recipient of a $50,000 research grant funded by the National Institutes of Health (NIH) through the National Pediatric Rehabilitation Resource Center, also known as CPROGRESS, for a study mapping the brain’s response to robotic-assisted rehabilitation in children with unilateral cerebral palsy.

“We are one of very few centers in the United States mapping changes in the brain as a result of robotic rehabilitation,” Dr. Papadelis said. “It’s not the rehabilitation by itself or the robotic system by itself, but it's the fact that we try to map the brain’s plasticity or what type of plasticity takes place in the brains of these kids in response to the rehabilitation.”    

Cerebral palsy is one of the most common childhood disorders in the United States. About one in every 345 children in the country have some form of the neurological disorder, which affects movement and muscle coordination. The condition can impact the lower or upper extremities, all four limbs or one side of the body. In any case, physical rehabilitation is crucial to maximizing movement and muscle control.

For children with unilateral cerebral palsy, meaning one side of the body is affected, conventional rehabilitation utilizes constraint-induced movement therapy in which the dominant, unaffected limb is immobilized in order to force the paralytic limb to do all of the work. While effective, children aren’t always cooperative with wearing constraint devices and performing this type of repetitive, or what they might call boring, therapy. 

But kids do like video games. As digital natives, they have never known a smart device they couldn’t navigate. For this reason, robotic therapy is emerging as an important rehabilitation tool for children. The digital nature of the bot captures their attention and speaks a language they understand. 

While researchers know robot-assisted rehabilitation has its benefits, there is a lot they still do not know about the application of this type of therapy in the pediatric population.

“There's not much research on how robotics help children with cerebral palsy,” Dr. Papadelis said. “We don’t yet have a gold standard on how much treatment, how many days and how intense it should be in order to have successful outcomes. We want the brain to reorganize based on the rehabilitation, but can this kind of mapping be maladaptive and go in a direction we don’t want it to go?”

Thanks to the NIH grant, Cook Children’s Neuroscience Research Center is studying the use of robot-assisted rehabilitation for children with unilateral cerebral palsy in order to address these uncertainties and establish best practices. 

The robot used is akin to a video gaming system. Using the fingers and hand of the impacted limb, patients manipulate a type of sensor-based robotic joystick while playing a video game generated by the robot’s computer system. The system measures functions such as range of motion, spasticity and strength in order to tailor the interactive video games to the patient and increase engagement. It also uses vibrations to stimulate the patient’s motor sensories.  

“There's a hypothesis that the more information we provide to the somatosensory system in the brain, the better the motor responses,” Dr. Papadelis explained.

While interacting with the robot, patients also undergo an electroencephalography (EEG) study where dozens of electrodes are placed on the scalp to measure the electrical activity of the brain. 

“Using this tool, we are able to map changes in the brain as a result of this rehabilitation. It tells us if the parameters of the treatment are sufficient, or if we need more intense treatment, less intense treatment and whether this type of treatment is beneficial for one child or for all kids,” Dr. Papadelis said. “Kids with cerebral palsy all have different underlying etiologies. For example, some kids have cerebral palsy as a result of stroke. Some as a result of infection or hemorrhage. Because cerebral palsy is an umbrella term, we're trying to understand if this treatment is beneficial and for which group of patients. And, if it's beneficial for this group of patients, how much we should provide them in terms of treatment length.”

Sadra Shahdadian, PhD, a postdoctoral research fellow under Dr. Papadelis’ supervision, serves as co-principal investigator for the study. Drs. Papadelis and Shahdadian hope that at the completion of this one-year grant cycle the research team will have collected enough preliminary data to support their hypothesis and better define the use of robot-assisted rehabilitation in children with cerebral palsy. They also hope their work leads to a larger NIH grant or philanthropic support for a more in-depth and long-term study of pediatric robotic therapy. 

As we settle into a new school year, many parents and caregivers may find themselves unsettled about the need for increased security measures in our schools. Given recent gun violence events in Texas and across our nation, school administrators have placed safety at the forefront of their concerns. With this concern, however, also comes heightened and unwanted stress, worry, and anxiety for parents, caregivers, students, and teachers. Recognizing and addressing these emotions can be fundamental in helping our children develop a sense of peace and reassurance for a successful school year.

Before adults begin having conversations with children, it is important for them to process their own thoughts and emotions around the given topic. This is best practice for any conversation, not just those involving difficult topics like school tragedies. 

When caregivers take time to process and discuss their own feelings, it better equips them to manage personal expressions and reactions as well as model desired behaviors for their children. As a parent or caregiver, this small step can have a big impact on the outcome of a child’s thoughts, expressions, and approaches to processing difficult situations. 

Limiting exposure to information in the news and media is another key component of curbing anxiety and stress. We live in a digital age where, inevitably, we are inclined to receive information through various platforms and outlets. Generally, the primary adults in a child’s life are the first line of defense for what a child hears, sees, and does. 

By limiting exposure to harsh content in the news and media, you are helping safeguard and filter information that may or may not have negative implications for your child. If and when your child does have exposure to undesirable items in the media, discuss what was seen or heard, talk through questions and concerns, and validate these feelings. Repeat this process, consistently following up with your child, until a felt sense of safety is established. These actions will show children that their concerns are important and they matter.

Finally, share with your children the importance of "trusting their gut" and speaking up when something doesn’t feel or seem right. Express to them: "If you see something, say something." Teachers, administrators, and school personnel cannot physically have eyes everywhere at all times. Students see and hear things among their peers that school personnel may never know about. 

Encourage your child to speak up if they feel uneasy or have a concern. Oftentimes, students are afraid of the negative social attention this could bring, but their instincts and initiatives to act on something that doesn’t "seem right" could be very impactful in preventing a crisis situation or even saving a life.

All of these suggestions can and will look differently depending on the age of your child.  So it’s important to take a developmentally appropriate approach when talking with your kids.  Also, these conversations can be time-consuming and prompt further discussion.  Allow plenty of time for such discussions with your child so they don't feel rushed or dismissed.

It is a good sign if your child is expressive and requests more of your time. This means you are fostering and holding a space for them to come to you with big issues and big feelings, and that is something well worth your while. These are small investments that can make a huge difference now and in the future.

Reminders to help facilitate conversations with our kids: 

• Recognize: Name the emotion, talk about it, and deal with it.
• Reflect:  Think about and work through your own feelings around a given topic. Then develop a plan for a discussion with your child.
• Review:  Be a buffer and filter the content your child may see or hear through media platforms.
• Respond & Reassure: Hold space for your child to share his or her thoughts and have a developmentally appropriate conversation by responding appropriately to his or her needs. Provide reassurance to foster a felt sense of safety and security.

In June 2018, Payton Singh arrived via ambulance to Cook Children’s Emergency Department in a barrage of flashing lights and sirens. She was just 12 years old and decided to end her short life while her parents were away from home.

Payton and her family returned to Cook Children’s this week to reunite with her medical care team who saved her on her darkest day.

“I can’t even explain the emotion and the panic that sets in as a parent,” said Brandy Lumbert, Payton’s mother. “After getting the call, I remember running into the emergency room - they knew exactly who I was. And then she flat-lined right in front of me. As a parent, you want to jump in and tell the doctors and nurses to move faster, but you’re just standing there, helpless.”

Payton and the Lumberts also shared their story on the latest episode of our Raising Joy podcast.

Payton’s brother, Kegan, found her unconscious in her room and took action well beyond his years. Though he was just 8 years old, he had the wherewithal to call 911, put the family’s dogs outside and notify his parents that help was on the way.

 When officers arrived at the Lumbert’s home in Keller, Texas, they believed Payton had been without oxygen for 12 minutes.

 “Doctors told us, ‘She’s alive but she’s not showing any brain activity,” said Nick Lumbert, Payton’s stepfather.

 The medical team was able to stabilize Payton and moved her to the pediatric intensive care unit (PICU).

 “Every day in the ICU, we’d stare at the breathing machine to see how many breaths she was taking on her own,” said Nick. “It was very hard to go through that.”

Soon after being admitted to the hospital, Payton’s neurologist pulled the Lumberts aside to show them the scans of her brain. They revealed four small spots, an encouraging sign that the damage wasn’t as dire as it could have been. Still, it was unknown if she’d ever walk or talk again.  

On day five in the PICU, something unexpected happened.

“I remember walking through the doors and we hear all of the alarms going off and we take off running to her room,” said Brandy. “She had stood up next to the bed and was ripping everything off. She looked right at us and I was flabbergasted!”

And just like that, hope began to shine on the Lumbert family.

Soon after, Payton was transferred to Cook Children’s rehabilitation unit where she embarked on the long road to recovery. Over the next six months, she underwent treatment at three different hospitals across Texas.

Now, four years later, she is returning to Cook Children’s to say ‘thank you’ to the people who saved her life.

 On Thursday, September 1, 2022, Payton and her family were reunited with the doctors, nurses, and care team members who cared for her at Cook Children’s. This emotional reunion was requested by Payton, who is now a 17-year-old high school senior. She has a job, drives a car and is planning to pursue a career as a veterinarian.

The Lumberts recently shared their story on the Raising Joy podcast in hopes of encouraging other families who may find themselves in a similar situation.

 When asked what message she has for kids and teens who are struggling with their mental health, Payton said “Get help.”

 Their episode is now available on all major podcast platforms including Apple, Google and Spotify.

 September is Suicide Prevention Awareness Month.

 Here are some signs to be aware of – though not every suicide attempt will display signs. This is why it’s important to talk to children and teens about suicide, whether you suspect they are suicidal or not. 

1. Preoccupied with death (writing, drawings)
2. Talking about feelings of hopelessness
3. Talking about being a burden to others
4. Telling loved ones goodbye
5. Decline in performance
6. Giving prized possessions away
7. Isolating and withdrawing
8. Acting highly anxious or agitated
9. Acting reckless and taking risks
10. Rages
11. Changes in sleeping and/or eating
12. Use of alcohol/drugs
13. Dramatic changes in personality and/or appearance

If you feel your child needs help, please click here to find a Cook Children's Behavioral Health location near you. You can also address your concerns with your child’s pediatrician, psychologist or therapist.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) offers 24/7 call, text and chat access to trained crisis counselors who can help people experiencing suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress. People can also dial 988 if they are worried about a loved one who may need crisis support.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

What are some of the most common concerns parents have when a child needs inpatient psychiatric care? Inspired by the Disney movie ‘Inside Out,’ Child and Adolescent Psychiatrist Rachel Talbot, M.D., wanted to find out.

On this episode of Raising Joy, Dr. Talbot explains how her research identified nine of the most common stigmas parents have about mental health care, including medication, confidentiality, treatment of the problem and social impacts for the child and family.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

A couple months ago, Pediatric Yoga Therapists Gina Shelton and Stacy Bush joined the Cook Children’s Pain Management team to lead yoga therapy classes and individual consults throughout the medical center, Inpatient Psychiatry Unit and Partial Hospitalization Program.

While yoga is a general term of practice, “yoga therapy is the process of empowering individuals to progress toward improved health and well-being through the application of the teachings and practice of yoga,” according to the International Association of Yoga Therapists.

Our yoga therapists are here to help alleviate physical and mental health conditions by cultivating the mind-body connection. 

“The main thing we teach is that your breath can change how you feel, then movement calms your nervous system. Our modern culture often forgets that our bodies are made to move, not sit still all day,” Shelton said. “And we also talk to them about their brains and how they work. So they get a little more awareness of themselves and how their brain, emotions, and body are interconnected.”

Cook Children's yoga therapy sessions consist of breathing exercises, postures, meditation and relaxation techniques. Conditions addressed may include stress, anxiety, depression, PTSD, ADHD, Musculoskeletal problems, autoimmune diseases, Insomnia, IBS, Cancer, and others. 

“Through these classes we have an opportunity to come in and teach the kids through experience,” Bush said. “When they feel it, it is easier to learn it and implement it as a coping skill. That’s the great thing about the focus we have on breath work. Your breath is always with you, no matter where you are. You don’t have to change what you’re doing – you just stop and breathe and have a moment to connect back.”

Each session is built around integrative learning approaches aimed at being more like play than therapy. The goal is to meet the patient where they are most comfortable and to implement techniques so that the patient engages willingly and in a joyful manner.

“Kids are going to have lots of energy and all kinds of different things going on, so we have to meet them where they are,” Shelton said. “In our classes, we pay attention to how we’re feeling and that brings us back to our bodies and connects mind, body and breath.”

Yoga therapy aligns the needs of the patient with the particular practice required. Our therapists are able to work with children of all developmental abilities, allowing them to participate with low back pain or physical disability with very specific yoga from their bed, chair or floor in their own room.

For example, with positions and postures to increase strength, circulation, range of motion, proprioception and balance. Likewise, with anxiety, there are specialized sessions to raise self-awareness and regulate the central nervous system.  

By developing a positive relationship with their body, the patient is more likely to have a beneficial outcome from other prescribed therapies that are part of their medical treatment.   

“We teach them to take a moment and take a breath to calm back down,” Bush said. “With this awareness, we can help them start to shift the way they think about themselves, the way they view the world and the way they move in the world. I think that’s a pretty powerful thing.”

Skylar Jones, 15, is the first patient to undergo CAR T-cell therapy at Cook Children’s. She was just 9 years old in 2014 when she was diagnosed with B-ALL. Despite undergoing intense chemotherapy, Skylar’s cancer relapsed in 2017 and again in March 2021.

CAR T-cell therapy was approved by the Food and Drug Administration (FDA) for use in refractory and relapsed B-ALL in 2017. Cook Children’s began offering the treatment for those who qualify in November 2020. For Skylar, the timing was perfect and meant she would not have to travel outside of Fort Worth and away from her long-time physicians at Cook Children’s to receive this potentially life-saving treatment.

“Had she relapsed six months earlier, we would have had to go out of town for this,” said Deby Jones, Skylar’s mother. “So for Cook Children’s to have this now and for families to not have to move to get this treatment for their kid, I mean, there’s tons of families that will benefit from this.”

Skylar’s necessary but difficult chemotherapy treatments wreaked havoc on her body. Mouth sores, headaches and rashes were common side effects. An infection required part of her lung to be removed, and the impact of chemotherapy on her bones and joints made it impossible for her to play basketball, her favorite sport.

When Skylar relapsed a second time in March, it was clear that chemotherapy was no longer the most effective course of treatment in her case. Her cancer required a different approach. This made her a good candidate for CAR T-cell therapy.

“CAR T-cell therapy is a treatment option for children with refractory B-ALL, meaning they haven’t responded to initial treatment, or kids whose cancer has relapsed,” said Holly Pacenta, M.D., a hematologist/oncologist with Cook Children’s Cellular Immunotherapy Program.

In this cell-based immunotherapy, the patient’s own T-cells, which help the body fight infection, are harvested from their blood and sent to a lab where they are reprogrammed into CAR T-cells to target their leukemia. The CAR T-cells are then reintroduced into the patient’s blood stream. From start to reinfusion, the process takes about four weeks.

The therapy begins with a procedure called leukapheresis where the healthy T-cells are removed from the patient’s blood. This takes about four to six hours and the patient is able to go home from the hospital the same day. Once the lab receives the cells, it takes a few weeks to reprogram them into CAR T-cells. Just before the CAR T-cells are reintroduced, the patient undergoes a short round of chemotherapy to lower the number of other T-cells in the body. This gives the CAR T-cells a better chance to activate inside the body to kill cancer cells. After chemotherapy, the patient returns to the hospital to be infused with their new CAR T-cells and is able to go home the same day.

Unlike chemotherapy and radiation, which affects the fast growing cells in the body, this treatment is a targeted approach that kills only the B-cells. The duration of treatment is shorter, too.

“B-ALL cells have specific markers that aren’t located on many other cells in the body, which is the part about it that’s unique,” Dr. Pacenta said. “The reason this has been so successful is because we are able to target one marker on leukemia cells to fight the disease.”

The remission rate after CAR T-cell therapy is 80%.

“Every patient is different, but we know that, in some children, this can be a long-term cure, meaning they don’t need to receive any additional treatment,” Dr. Pacenta said. “Some research studies have found that the CAR T-cells will persist in a patient’s body for as long as three and a half years, but it’s likely that the cells will be around for much longer.”

For Skylar, CAR T-cell therapy was as different from chemotherapy as night and day. She was fortunate to not experience any of the side effects associated with the therapy.

The side effects of CAR T-cell therapy include allergic reaction during and immediately following the infusion. In the weeks after, patients are closely monitored for neurotoxicity, as well as cytokine release syndrome, where the immune system becomes overactive due to the multiplying CAR T-cells releasing large amounts of chemicals called cytokines into the blood. These side effects can be very severe, with some patients requiring admission to the intensive care unit.

Now three months post infusion and Skylar's cancer is in remission. She will undergo more testing at six months post infusion, which will give her a better idea of her potential for long-term remission.

As for the possible impact of this type of cell-based immunotherapy on cancer, doctors are hopeful it could one day replace traditional treatments.

“I think there may be a day in the future where cellular therapy does replace chemotherapy, surgery and radiation for people with cancer,” Dr. Pacenta said. “But I think we are still a ways off. This therapy has been very successful initially but we still have a lot of work to do.”

When we hear the word ‘addiction,’ we often think of drugs and alcohol, but in the 21^st century, addiction has taken on a new meaning. Lisa Elliott, Ph.D., psychologist and clinic manager of the Behavioral Health Clinic at Cook Children’s in Denton, says children are becoming addicted to their phones and gaming systems, driving parents to seek help through licensed therapists.

“We have the research that shows there is a chemical addiction as well as a behavioral addiction,” Dr. Elliott said.

“I think the thing that makes it even more dangerous for me is this is happening with young children, very young children, as much as it is with teens and young adults.”

In 2019, the World Health Organization (WHO), voted to include ‘gaming disorder’ as an official condition in the International Classification of Diseases, akin to anxiety, depression, etc. This paved the way for psychologists such as Dr. Elliott to bill insurance providers, making access to care more affordable for many families with health insurance. However, aside from video gaming, adolescents and teens are also glued to their electronic devices. She says remote learning due to the global pandemic has also played a major role in this addiction.

Cheryl, a North Texas mother, says her 12-year-old daughter is obsessed with YouTube. The family is now seeking guidance from a Cook Children’s family therapist.

Cheryl and her husband didn’t allow their daughter to have a cellphone until they believed she needed it for safety purposes. She wasn’t allowed to have any social media accounts, but her parents did allow her to watch TikTok videos.

“She has a cellphone and iPad, but we made sure everything had parental controls and restrictions,” Cheryl said.

When they later deleted the TikTok account out of concern for privacy issues, they allowed her to watch YouTube videos.

“She watches kids playing innocent pranks on each other, and she gets invested in that. She consistently talks about who is dating who and is always looking forward to the next update like she knows the people in the videos,” Cheryl explained.

Cheryl added that her daughter knew exactly when the episodes were coming out and had a fear of missing out on what was next in the lives of her favorite YouTubers.

When the Cheryl and her husband realized their daughter was going behind their back to find ways to watch YouTube, after she’d been instructed otherwise, they decided to reach out for help.

“For me, it was really about correcting that behavior because right now she has this temptation in front of her and she's making bad choices,” Cheryl explained.

Why are young people becoming obsessed with a reality outside of their own? Dr. Elliott believes the global pandemic has a lot to do with this rising trend.

“I think it's pervasive, so it's not just from an academic setting, but it's also how kids are filling their downtime. It's how they're maintaining social relationships, whether they're healthy or not,” Dr. Elliott said.

Cheryl and her husband couldn’t agree more. They don’t have any issues with their daughter’s choice of content. The issue is her actions and what these minor actions could lead to in the future when bigger temptation is put in front of her.

Cheryl’s daughter sees Stephanie Golden, LPC, a therapist at Cook Children’s Alliance. Golden has been working as a mental health professional for 20+ years but says phone and social media addiction is something she has seen more in the last three to four years in her practice. While phone addiction isn’t healthy, Golden believes it is treatable.

“It’s certainly a widespread problem, but I believe one that can be improved upon with boundaries,” Golden said.

Boundaries are exactly what Cheryl believes would be beneficial for her daughter when it comes to her desire to watch YouTube videos.

In a 2019 study released by the Child Mind Institute, 1% to 10% of children and adolescents have excessive and impairing online behavior. This behavior impacts a child’s ability to focus, the hours of sleep they get at night, and their social behavior with others when they aren’t behind a screen.

Cheryl says having a daughter that’s addicted to YouTube and going behind her parent’s back to find ways to watch it is hard because there aren’t resources for this problem specifically.

“It was really hard to figure out what to do and how to handle this,” Cheryl said. “We tried every single thing we could, from taking away her devices and even sitting down with her and asking her what she needed and how we could help.”

Cheryl and her husband struggled even more because they felt their daughter’s actions were ‘minor’ and ‘innocent’ because she wasn’t struggling with substance addiction. However, Dr. Elliot says addiction is handled the same whether it’s social media or something severe like drug use and gambling. She also notes until more research is done, therapists have to continue to rely on coping mechanisms and techniques they’ve used for adults who’ve struggled with addiction for many years. However, she says that it is scary because she doesn’t want to see adolescents fall into deeper temptation in the future.

“My concern is, if children are creating this addictive response, which we know happens, what kind of addictions does this lead into later?” Dr. Elliott asked. “So I'm concerned about the potential risk they might have for other addictions down the road.”

Cheryl and her husband also struggled with the guilt of putting their daughter in therapy because they didn’t want to take a seat of a child who might’ve needed the resources more.

“She isn’t suicidal and she isn’t depressed,” Cheryl said. “But I had to remind myself that we are putting her into counseling so she can learn skills and those skills can be applied to other areas of her life as well.”

Golden agrees with that sentiment and says in situations like this, she also gives guidance to families/parents.

“Set boundaries around cell phone usage and be consistent with the rules,” Golden said. “Following suggestions from experts can help protect a child’s mental health.”

Dr. Elliott adds another reason boundaries are important is that peer pressure and the need to fit in as at an all-time high. The Child Mind Institute reports 81% of teens say social media makes them feel more connected to their friends.

Cheryl agrees her daughter fits into that category.

“When we ask her why she wants it so bad or feels the need to sneak around to get what she wants, she tells us all of her friends in class are on YouTube all the time on their devices,” she said.

Dr. Elliott urges all parents to keep a very close eye on children’s social media and device use. She says not only can addiction to devices impact schoolwork, it can affect social relationships with others. When a child’s brain is still developing, she says children need healthy and appropriate social interactions to learn empathy, how to relate and communicate, as opposed to learning unhealthy social skills through a device/gaming system.

Cheryl understands the importance of limited screen time and says adolescents don’t fully understand phone etiquette, and how to properly interact with their peers and it is important to set an example and put boundaries into place at an early age.

As Chery’s daughter continues to see Golden, and the family works through this issue, Golden says it’s important to “face the issue with compassion, understanding and firm kindness.” She goes on to add “We don’t always like to have rules, but it’s often healthy and good for us when we follow them.”

Find more technology guidelines from Dr. Elliott shares with her patients from the American Association of Pediatrics below.

• Birth to Pre-School Years
  • There should be no technology from birth to 3 years.
  • Any screen time at this age impairs social communication, development, and attachment to family members.
  • This age should be devoted to social development, sensory-motor skills, and reading skills.
  • Limited exposure may be introduced at 4 years with only high-quality programming.
  • American Academy of Pediatrics (AAP) cautions that all technology programs should be watched with their children.
  • Parents have to lead by example: Do not check messages at the dinner table, do not become absorbed by devices, look at people when they are talking – children notice and mimic everything!
  • Never undervalue unstructured “free play.”
  • Parents should not give their children a tech device as a reward for good behavior. Children must learn to self-soothe.
  • Appropriate activities for 4 year olds
    • Periodically use eReader for storytime.
    • Allow limited access to electronic toys that educate and teach numbers, letters, and vowel sounds.
    • Utilize mobile apps/tech devices for sorting shapes and finding objects.
  • It is critical children engage in physical play, have social engagements and read books!

• Grade School Age Years
  • Create a balance between technology, along with social and physical play.
  • AAP recommends no more than two hours of screen time per day with close parental supervision! And that should be less during the younger grade school ages.
  • It is critical to watch alongside your kids to point out messages that are not congruent to your values.
  • Parents need to designate media-free spaces, including bedrooms, meal times, and playtimes.
  • Screen time should be quality; age-appropriate, share your values, and engage your child’s imagination.
  • Never make screens a reward or consequence.
  • Encourage other activities such as free play outside, playing sports, creating hobbies, arts and crafts, and social activities.
  • Appropriate activities for grade school
    • The goal is to teach responsible use.
    • Use internet under supervision only.
    • Create tech-free talk each day.
    • Institute strict time limit restrictions and rules for use.
    • Monitor computer homework; eliminate all technology when screen time rules are broken.
    • Children need to stay involved with school activities and friends.
    • Model appropriate technology behavior

• Preteen and Teen Years
  • It is critical parents model appropriate technology behavior – they have to practice what they preach.
  • Parents need to establish the rule that their children will agree to “friending” them on social media platforms.
  • Parents should have access to passwords.
  • Maintain open dialogue about what is and is not appropriate sharing on social media platforms.
  • Parents and their tween/teens should develop a social media contract that includes expectations, violations as well as discipline for violations. Try out this great free tool from @AmerAcadPeds: http://www.healthychildren.org/MediaUsePlan
  • Bedrooms should be tech-free, all devices should be removed from bedrooms at night.
  • Snapchat is the most difficult platform to monitor – may be wise not to allow this platform.
  • It is imperative to teach your children about the potential consequences of their postings on social media platforms.

If laughter is the best medicine, then the therapeutic medical clowns at Cook Children’s have just the right dose to help patients and their families heal.

Each professional clown comes from a different background and different experiences, ranging from the theater to the circus. But they all come together at Cook Children’s with the common goal of making people smile.

“We’re all different, but together we make a great team,” said Susan Keys, a therapeutic medical clown known around the hospital as Dr. Yahoo.

Tiffany Riley brought Funnyatrics, the therapeutic medical clown program, to Cook Children’s in 2014 and has been directing their training workshops since the program’s inception.

“Everyone that does this has a different way of looking at the world. We like to call it clown logic,” said Riley, a therapeutic medical clown and the program’s creative consultant. “They may express that through doing magic or juggling or improvisation or being a musician, so what we do is take those skills and talents that they already have and bring them into a hospital environment."

Although the clowns are able to use their individual skills and strengths to their advantage, they all must have the ability to improvise and think on their feet.

“In our training, we teach them how to engage their audience, whether that audience is a room full of people or one patient in the ICU,” said Riley. “The idea is to be present and aware of everything going on, to have a heightened sense of awareness and to take all of that in and find a way to connect. From that connection, we can create an exchange that creates levity, uplifts the environment and gives the kid some power to make choices, which is not something they often have in a hospital.”

Some people assume that a certain patient might not benefit from interacting with clowns and even discourage a clown visit. But the art of clowning is about making connections with patients and their families, so these clowns will do whatever it takes to bring laughter or a smile to their faces, no matter how difficult the situation may be.

“There was one kid we saw that was blind and my partner played music while I sang and we had the best visit with that kid,” said Keys. “The staff couldn’t believe that he was reacting because he wasn’t doing anything before, almost like he was comatose. He couldn’t see, but he could hear.”

Medical clowns don’t need any words or special equipment to communicate with these patients. From music to magic tricks to bubbles, everything they need comes from their pockets and their imagination.

“We start with the normal stuff that we do and just keep going until we find something that works with that particular patient,” said Grainger Esch, a therapeutic medical clown who goes by the name Dr. Quack. “But there is always something we can do.”

There is something innately artful about the relationship between these clowns and the patients they serve that benefits everyone involved.

“We have a gift,” said Keys. “Somehow we give them what they need and it’s just great. One day I was in a room and this kid just wanted to hold my hand for 10 minutes, and I did. I mean, that’s all I did and it was a gift to me.”

Anyone, regardless of their situation, can benefit from spending time and interacting with the medical clowns.

“There are some kids that are ready to play the moment they see us and it’s really a lot of fun,” said Riley. “But for other kids who just look at us, seeing even the tiniest corner of their mouth turn up into a smile is a victory. It’s about us going and meeting them where they are and finding a way to draw them out or help them to get over a hump.”

Medical clowns can be a great distraction to help kids forget whatever pain or hardship they may be enduring, even if just for a moment.

“That’s why I like to teach tricks,” said Keys, “because it focuses them on something other than hurting or not feeling well, and then they forget for a minute that they don’t feel good. Not that they still don’t, but they don’t focus on the pain or how they feel.”

The clowns also assist the medical team by turning things like walking after surgery or taking medicine into a game so that the kids do not realize what they’re actually doing.

“We’re engaging that very healthy, playful spirit of a child that doesn’t go away just because they’re sick,” said Riley, “you just have to work a little harder to find it. And once you find that playful spirit, it makes healing a lot quicker and easier.”

When kids are able to laugh and play, they release endorphins that aid in their recovery.

“Scientific studies have shown that it does improve recovery rates to laugh,” said Esch, “and there is so much stress and worry already, so to have a break from that, even if it’s just for ten minutes, can really change a person’s perspective. To see that you can still laugh is a revelation that gives them the hope they need to keep fighting.”

Aside from bringing magic tricks and fun, the clowns are able to make deep, impactful connections with patients and families.

“Sometimes kids or their families just want somebody to talk to, and at that point it gets real,” said Esch. “Sometimes we go in a room and the kid is asleep, but the parents or siblings might be in there and we’re here for them as well.”

While Keys and Esch say that forming connections with patients and their families is one of the best parts of their job, it is also one of the most challenging. They usually see outpatient kids only once, but they visit oncology, bone marrow transplant unit and ICU patients on a weekly basis.

“We went to one funeral not too long ago,” said Keys, “and we’d known him for two years. That’s the hardest part of our job.”

Since there is a very emotional element to the job, a chaplain comes to the clowns’ meetings to provide counseling once a month.

But the program would not be nearly as rewarding as it is if these clowns did not form genuine connections with people and clown from the heart.

“The kids wouldn’t buy it,” said Esch. “That’s the thing about kids, they can sense when it’s not genuine so you can’t fool them in that way. You can do a magic trick and fool them with some sleight of hand, but you can’t fool them with your intentions and feelings.”

The therapeutic medical clowns at Cook Children’s continue to use songs, jokes, hugs and laughs to bring a smile to anyone who will let them, from patients and families to doctors and staff.

“We’re here for everybody,” said Esch. “It’s primarily for the kids, but everybody here needs a laugh so that’s what we try to do.”

Related stories:

• Canines Clock In At Cook Children’s
• The Art of Music: Therapy in Disguise

Funnyatrics

There's an old saying that laughter is the best medicine. At Cook Children's, we believe it's certainly good for you. That's why we offer Funnyatrics, a therapeutic medical clown program. Our professional clowns use humor and laughter to help our patients in their healing. Learn more about the program here.

To support Cook Children's, please call 682-885-4105 or donate online by clicking here. 

But do they feel welcome at your table?

If you think about our kiddos, that’s all they know these days. Just walk around at the mall. You see a kid and attached to them is a tablet.

Are tablets the worst thing in the world? I don’t think so, but they may be affecting the types of interactions we have with our children according to a study completed in Toronto, Ontario. They found that for “every 30-minute increase in daily screen time was linked to a 49 percent increased risk of what the researchers call expressive speech delay.”

Now, I know what you’re thinking, “What about those educational Apps that go over colors, ABCs or numbers?” I see your point, but that’s only part of a child’s language. Let’s think about conversational turn-taking or even play skills. I don’t think I’ve come across applications that can teach children those important skills.

I’ll be honest, my son is 2 years of age and there are times where we put him in front of a screen. It keeps him occupied while we complete chores or help his infant sister. It happens and I don’t want you thinking that you are the worst parent in the world.

Just like most things though, everything needs to be in moderation.

My son was at a birthday party recently. All the children were doing an activity and the instructor told the kids to yell for help. All the kiddos obviously said, “HELP!” Except my son, who is really into Mickey Mouse Clubhouse. He yelled out, “Ohhh Tooodles.” If that wasn’t a sign that he is watching too much TV I don’t know what is!! It’s kinda embarrassing considering I am a speech therapist.

Just like most parents, you learn as you go. There isn’t a manual for these sorts of things. If parenting wasn’t hard enough, society around us is also continuously changing. My wife and I have quickly learned that although my son asks for Mickey Mouse dance (that’s what he calls it because of the hotdog dance) it doesn’t mean we have to turn it on for him. There are so many games that we can play. Surprisingly, I was doing chores around the house and he wanted to help as well.

Here are some tips to get your kids away from the screen and be interactive with you:

1.Reenact an episode of your child's favorite show (in our case it's the Mickey Mouse Clubhouse). You can do similar games or even make up your own.

2.Pause the TV show he or she is watching and talk about what you just saw or what you think will happen next.

3.TURN THE TV OFF. Our most fun experiences have been when the power has gone out. That forces us to interact and just play.

Interaction involves an action. Just NOT sitting on the couch in front of a screen.

Click here to see the rest of the story.

By the time parents and pediatricians recognize and treat the problem or recommend a feeding evaluation, that child may have had years of unpleasant eating experiences. So what happens? They refuse to eat. They throw tantrums at the table. They make mealtimes miserable for the entire family.

What’s a parent to do? You thought your child was “fixed.” The medicine has taken away the pain and the speech therapy has dealt with the sensitivities. Why isn’t he eating? But he has to eat, right? So parents now resort to other methods. They punish and they bribe or even worse, become short order cooks. These solutions may seem to work for a short time but ultimately the issue will linger. Why? The child is scared. He isn’t just defiant or stubborn. He is terrified, and the newest toy or video game won’t be enough to battle that anxiety.

When other options fail or it’s too late, a pediatrician or speech therapist may recommend seeing a child psychologist.

I know it must be confusing and frustrating to parents when they are shifted off to another professional, especially a psychologist. It does not mean that your child is crazy. We are not going to push medications on your child or push parenting classes on you. Though you may have heard differently from other professionals or well-meaning in-laws, we know it’s not your fault your child isn’t eating. For most of the children that end up seeing psychologists, a number of factors over time have played into the development of fears and avoidance.

There are also times where a child may start out eating anything and everything put in from of him then one day just starts refusing. Green beans were fine yesterday and now anything green is off-the–literal-table. Why? Did something happen? Some kids experience food trauma. Maybe they were given milk that was a bit past its expiration. Maybe they choked on a bite of sandwich. We all have had negative experiences with food that may have left us avoiding it for some time, but eventually we try it again. It is different with these kids. They don’t have the benefit of fully developed logic to combat that single negative experience. Instead, one atypical incident becomes the rule.

So now you are face to face with this psychologist. How can she help? My job is to help the entire family (even well-meaning in-laws) understand their child’s specific fear and to set rules and limits at mealtimes. My job is also to work with the child to break down the Big Scary Food into less scary baby bites. We teach relaxation skills and offer coaching to change the way the child thinks about food. Sometimes the anxiety may get in the way of the child’s progress in speech therapy. In these cases, my job may be to help the speech therapist with motivational techniques that can get the child to participate.

Who knew eating could be this complicated? Most of us have no difficulty putting away a burger or plate of lasagna. But for families living with a child that has a feeding disorder, the stress can be debilitating. Having a team of professionals to guide treatment and provide support is essential for the child’s success. It won’t happen by dinnertime, but there is hope. You can pack away that short-order cook apron and you can stop the McDonald’s chicken nugget runs. Your child can learn to eat again.

About the Author

Alaina Everitt, Ph.D., is a licensed psychologist at Cook Children's, who sees patients in Denton and Lewisville. Cook Children's Behavioral Health services provides a broad range of care that focuses on children from ages three years through 17, and their families. We also have some limited services available for children age 2. As part of family-centered care all of our professionals are qualified both through education and experience to work with children who have behavioral and emotional challenges. Our psychiatrists are board certified in child and adolescent psychiatry and our psychologists and therapists are all licensed independently in Texas.

About Cook Children's Speech Therapists

Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Patients and physicians can make an appointment or referral by clicking here.

Pamela Sherman, M.D., is a highly specialized and skilled orthopedic hand surgeon at Cook Children’s who has more than 3,000 hand patient visits per year. In order for her patients to be successful after her surgeries she relies on highly specialized rehab therapists called hand therapists. A hand therapist can be a licensed physical or occupational therapist. To become a hand therapist requires many hours of training beyond the basic education of a physical or occupational therapist. The hand therapists at Cook Children’s work closely with Dr. Sherman in her outpatient clinics to provide collaborative and comprehensive care to the patients and families.

Hand therapy is the art and science of evaluating and treating injuries and conditions of the upper extremity (shoulder, arm, elbow, forearm, wrist, and hand). The Cook Children’s SPORTS program is staffed with hand therapists at three locations across Tarrant County whose expertise is treating children with an injury or condition that affects the arm or hand.  The hand therapists work with the kids  from birth to 21 years to assess their needs and develop a treatment plan that allows them to return to their normal activities. 

Injuries of the hand are quite common, but steps can be taken to prevent some of them from happening.  Here are a few tips to help prevent hand and arm injuries:

1. Wear protective gear, such as elbow pads and wrist guards, during sports activities.
2. Make sure children do not play near treadmills or other exercise equipment.  Be sure to turn off the equipment and/or unplug them from the power source.  
3. Supervise children when using knives or sharp scissors. 
4. When using a game controller, put pillows in your lap to rest your arms on. 
5. Take regular breaks when performing a repetitive task.  This can help prevent overuse injuries.
6. Change positions often if you are going to be holding an object for an extended amount of time.
7. Review your body mechanics and posture when performing a task.

About the author

Cara Smith, PT, CHT, is a certified hand therapist and the Hand Therapy Program coordinator for the SPORTS program at Cook Children's. Cook Children's offers hand rehabilitation services for all ages, diagnoses and stages of care. We help rehabilitate children/adolescents with a wide variety of congenital conditions and traumatic injuries.

For more information, call 817-347-2925. Cook Children's hand rehabilitation services are under the direction of our Sports Performance Orthopedic Rehabilitation Team Specialists (SPORTS). 

Cook Children's offers three SPORTS Rehab locations for hand therapy:

750 Mid Cities Blvd., Suite 130, Hurst, TX 76054

1919 8th Ave., Fort Worth, TX 76110

801 Matlock Rd., Mansfield, TX 76063

She is obviously looking for some sort of action on my part other than my smiling and nodding affirmatively. Since she’s my number one girl, I’ve learned the idiosyncrasies of her developing speech and know exactly how to handle this request. But to the layperson (or even Daddy or Grammy), I’m fairly certain I would need to come to the rescue with my toddler translator skills.

Mamas, I know you’ve been there. Your 3 year old launches into a monologue you find equal parts incomprehensible and adorable. Adorable, that is, until the tantrums and frantic attempts to understand and obey her demands kick in. In my practice, I have observed some masterful decoding mamas and some skillfully adaptive little ones navigating the waters of communication breakdown. Let’s talk a little bit about speech sound development and when to fret.

Articulation is the movement of the tongue, lips, soft palate and jaw to make speech sounds. It’s also the driving force behind your toddler’s incomprehensible speech. As parents, we are so excited when our little bundles of joy begin talking, but oftentimes, that excitement is quickly replaced with frustration when we realize we can’t understand a lick of what they’re saying.

An articulation disorder occurs when a child has difficulty forming speech sounds, most likely due to a structural or motor-based deficit. Most children tend to have some difficulty with certain speech sounds. Because creating sounds is challenging, he may substitute easy sounds for tough ones (think dumb for thumb), delete sounds (ha for hat), or distort problematic sounds (this is most often noted when children have a “slushy” quality). An articulation disorder occurs if these substitutions continue past the expected age.

Are all sounds created equal? In short, no. Children master sounds gradually. Most children can pronounce all of the speech sounds of English correctly by age 8. While each child’s speech sound acquisition is different, the following are age ranges in which most children master certain sounds:

• Introducing the “early birds”: Most wee ones will use m, n, y, b, w, d, p and h correctly between 18-30 months. That may explain why mama, dada and ball are frequently reported as first words.
• Not to be outdone, the middle of the road sounds includes: t, ng, k, g, f, v, ch and j. You may hear your little one utter these sound appropriately as early as 2 or as late as 6 years of age.
• Finally, the late bloomers include: sh, zh, r, s, z and th. This final pack of sounds contains the frequent offenders when it comes to articulation disorders. They are challenging for children to master and can wreak serious havoc on the clarity of their speech. We expect children to master these sounds between the ages of 3-8. (Based on Shriberg, 1993)

As children get older and learn new speech sounds, they gradually become easier to understand by a wider variety of listeners. Developing clear speech is a journey for our littles, albeit a frustrating one at times. And like all journeys, no two are equal. Some children are clear as a bell by their second birthday while others need a bit more time. As parents, we typically understand our babes before the rest of the world and therefore, are awarded the esteemed role of toddler translator. In many situations, one parent has a better handle on their child’s speech sound system than the other. But, as a general rule of thumb (or rule of “fum” if you happen to be a toddler):

• By 2 years of age children can be understood by familiar adults most of the time.

• By 3 years of age children can be understood by unfamiliar adults most of the time.

• By 4 years of age children can be understood by unfamiliar adults almost all of the time.

• By 5 years of age children can be understood by unfamiliar adults all of the time.

(Based on Flipsen Jr, 2006)

Although a continuum exists when it comes to speech sound development, there are a few red flags to be mindful of when chatting with your child.

It may be time to check in with your pediatrician regarding an evaluation with a speech language pathologist if your child:

• Uses only vowel sounds and a few consonants or shows limited babbling at 18 months.
• Seems to have a “slushy” (think mouth full of marbles) quality to his speech.
• Is difficult to understand and has a history of frequent ear infections.
• Leaves off the beginning or ending sounds of words (hatàha).
• Leaves off entire syllables of words (pa for purple).
• Is not understood by people outside his immediate family by age 3.
• Seems to be frustrated by his difficulty with speech or appears hesitant to interact or respond to peers or adults.

So what can you do to help him along?

Above all, it is important to always show your child you value WHAT he is saying regardless of HOW he is saying it. Always reinforce his attempts at striking up conversation with you! When you hear one of those adorable substitutions, help him to learn by repeating it correctly (If he says “tar” you can say “yes! A car!”) and moving on with the flow of conversation. Play face to face with him so he can watch the way your mouth moves to make sounds. Emphasize beginning and ending sounds in your own speech so he can hear them and begin to realize they are part of the word, too. If all else fails, ask him to SHOW you what he needs. And take comfort in the knowledge that this process is a gradual one.

Oh, and my daughter? She wanted to watch Frozen on the big T.V. and relax a little bit. Obviously.

1. Shriberg, L.D. (1993). Four new speech and prosody-voice measures for genetics research and other studies in developmental phonological disorders. Journal of Speech and Hearing Research, (36), 105-140.

2. Flipsen, P., Jr (2006). Measuring the speech intelligibility of conversational speech in children. Clinical Linguistics and Phonetics, (20) 4, 303-312.

3. http://www.asha.org/public/speech/disorders/SpeechSoundDisorders/

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.