As we turn our minds to our children going back to school, we think of meeting teachers, buying clothes and school supplies and making sure our children are socially ready for new challenges.
Now is also an ideal time to make sure your child is physically ready to go back to school. Many behavioral, attention or learning problems may, in fact, have a physical cause, ranging from underlying medical conditions or allergies to sleep problems or difficulty seeing or hearing. Here are some questions to ask about your child.
Is He Healthy?
Many doctors recommend a well-child check once a year through age 18, while others recommend one every other year after age 5. “Try to do it in the summer when there are not so many illnesses and acute problems,” advises Dr. Benjamin Danielson, medical director of the Odessa Brown Children’s Clinic in Seattle.
Exams usually include a calculation of body mass index – a measure of body fat in relation to height and weight – and a discussion of healthy lifestyles and eating habits. “Sometimes it’s better if someone else, other than mom, gives the child those messages,” Danielson notes. A doctor should also look for sleep abnormalities and healthy sleep habits, since inadequate sleep can cause inattention, irritability and lack of focus.
Danielson advises parents to ask whether the pediatrician or family doctor checks for developmental milestones, a key to school readiness. “We do these for babies, but often not for 6-year-olds,” he says. “That’s a shame because a child may need just a little fine motor practice or a little speech therapy, and then he’ll be fine.”
The doctor should ask questions or conduct tests to look at social, verbal, fine motor and gross motor skills. At Odessa Brown, for example, doctors have 5- and 6-year-olds draw pictures to test small motor skills and get a sense of their imagination and perceptions. Many doctors will also do hearing and vision screening, and may make referrals to optometrists or audiologists if necessary.
As children reach middle school, it’s good to incorporate some confidential time with the teen and the doctor, Danielson says. “It helps teens begin to take responsibility for their own health and to develop self reliance,” he says.
Danielson warns that sports physicals – especially quick checks of lungs, muscles and blood pressure – do not substitute for a thorough well-child check. Even worse is filling out a checklist on a form, and then assuming that everything is OK.
“A good sports physical should look at gait, flexibility and strength, and identify any muscle or back problems,” Danielson says. “It’s important to look at family history – for example, if an uncle had a heart attack at age 30.” The exam should also include a review of any asthma or allergy issues and consider how the student can compensate for them and still compete.
“If nothing else, a well-child exam gives reassurance that everything is OK,” Danielson says, “and it’s a chance for a quick recap of how things went last year and what you’d like to see in the next year.”
Although the Washington state does not require an eye exam or screening before a child begins school, the American Optometric Association recommends that a child receive a complete eye exam at age 3 as she starts preschool and at age 5 as she enters kindergarten. Exams should be given every two years if there are no eye problems detected earlier or every year if a vision problem is being treated. Some defects such as amblyopia or “lazy eye” (a weak eye that does not get used as much as the stronger eye) can be successfully treated if caught early, but are difficult to correct later.
Parents should not rely on the “Big E” eye chart, used in schools, to screen for vision problems. Since most children are far-sighted, they pass the test, even though their vision may be blurry at closer ranges.
Just because a young child has no vision problems, does not mean that she will not develop any later, says Dr. Karen Preston of Northwest Pediatric Eye Care in Bellevue, past president of the Optometric Physicians of Washington. “Nearsightedness – being able to see close objects well, but having difficulty seeing faraway objects – can come on at any age and is more likely as you get older,” she points out. “Right around third grade, we see problems with tracking or focusing at close distances as students begin reading whole paragraphs instead of word to word.”
Sometimes, eye problems will masquerade as other issues. For example, Preston says, a parent may think a child with headaches is hypoglycemic (having low blood sugar) because when they give him food after school, the headaches go away. In fact, the child may have headaches from straining his eyes at school, and they go away a couple of hours after school is over. She recently saw a patient who was referred to an occupational therapist because he wasn’t holding his pencil right and wasn’t interested in books. It turned out that he was extremely far-sighted and could not focus on close objects.
Here are some indications that your child may have a vision problem: • Eyes don’t line up, one eye appears crossed or wanders out • Eyes are watery, red, inflamed or “goopy” • The child rubs her eyes a lot when she is not sleepy • She seems to have difficulty seeing detail at a distance or close at hand • She closes or covers one eye to read, watch TV or see better • She avoids activities that require near vision, such as coloring, reading or using the computer • She consistently sits too close to the TV or holds a book too close • She thrusts her head forward or tilts it to see better • She omits or confuses small words when reading, or makes frequent reversals when reading or writing • She blinks more than usual, squints or frowns • Her eyes feel itchy, burning or scratchy • She says her vision is blurred or fuzzy or she sees double • She feels dizzy, sick or nauseous or has a headache after reading
At an eye exam, you should expect the optometrist to use flashlights and lenses to look into the eyeball to check focus, to check eye alignment and to screen for rare physical problems, such as cataracts, glaucoma or tumors. When your child is 3, the doctor will check for amblyopia and for alignment of the six eye muscles, which can cause eyes to cross or to wander. Before the child starts school and at subsequent school-year exams, the doctor will check for near and far-sightedness and astigmatism (distorted vision because the eyeball is not perfectly round), as well as how the eyes work together, how well they track, and how well they shift focus from near to far.
For more information, contact the Optometric Physicians of Washington at 425-455-0874 or visit www.eyes.org and click on For Educators. The American Optometric Association has a free Ready for School kit; call 1-800-365-2219 or download it at www.aoa.org/x5068.xml. VISION USA is a program of the American Optometric Association providing free eye exams for families who cannot afford them; call 1-800-766-4466 or visit www.aoa.org/x5607.xml.
Can He Hear?
If a child is deaf or has a profound hearing loss, parents will find out at his newborn screening or soon afterward. A baby who is premature or has spent time in a Newborn Intensive Care Unit will also be routinely checked for hearing loss throughout his early childhood. However, this misses a lot of children with hearing problems.
“A mild loss can escape some of the newborn screening, and some hearing impairments develop later on,” notes Dr. Thomas Littman, former chief clinical officer of the Hearing, Speech and Deafness Center in Seattle. “In addition, some kinds of hearing loss can fluctuate, especially if a child has ear infections.”
Hearing is difficult to check in preschoolers, Littman notes, and usually involves a tool similar to the one used in newborns, along with having the child play a game where he must respond to cues. Children in this age group are most susceptible to middle ear disease (ear infections) that may interfere with hearing and slow their normal development and communication skills. A 30-second tympanogram – a pressure or "impedance" test – can indicate how the ear canal, eardrum, Eustachian tube and middle ear bones are working. It is not a complete hearing test.
School-age children can respond to conventional audiometry, in which they are instructed to raise their hand or point to the appropriate ear when they hear a tone. “Having a hearing screening is a great way to make sure your child starts the school year out right,” Littman says. “It’s best to do it before school, before ear infections and colds and flu start in.”
The American Speech-Language-Hearing Association (ASHA) notes that school-age children with even minimal hearing loss are at risk for academic and communication difficulties. A child should be screened as he first enters school, every year from kindergarten through third grade, in seventh grade, in 11th grade and when he repeats a grade or enters a special education program, according to ASHA guidelines.
Some schools conduct hearing evaluations, but they generally catch only the most serious hearing loss and the noisy setting may compromise the results, Littman says.
“A complete hearing evaluation has to be part of a battery of tests if a child is diagnosed with ADHD or a learning disability,” he adds. “We’ve seen some misdiagnoses of learning disabilities. Inability to pay attention is a big indicator of hearing loss – soft sounds aren’t interesting to the child. It’s too much work to pick them up, and so he would much rather look at visual things.”
Here are some other indicators that your child may need a hearing evaluation: • Delays in speech development • Inconsistent responses to speech • Always turning up the volume of TVs and other equipment • Family history of early-onset hearing loss • Frequent ear infections or fluid in the middle ear • Allergies or upper respiratory infections • Exposure to excessive noise • Head injury or trauma
A child with some of the risk factors should have a hearing test from an audiologist or speech-language pathologist who has a Certificate of Competence from the ASHA.
For more information, contact: The Hearing Speech and Deafness Center in Seattle, 206-323-5770, TTY 206-388-1275, www.hsdc.org/Child. The American Speech-Language-Hearing Association, 1-800-638-8255, www.asha.org/public/hearing/testing.
Are Vaccinations Up to Date?
Washington State law requires that all students have a certificate of immunization status on file with their local public or private school or licensed child care center. Parents may claim a medical, personal or religious exemption, with the understanding that their child may be excluded from school, preschool or childcare if there is an outbreak of a vaccine-preventable disease.
Here are required vaccines, as listed by the Washington State Department of Health:
Varicella (Chickenpox) – The requirement began in 2006 and is being phased in. In 2008, children entering kindergarten must receive two doses beginning on or after their first birthday; a parent’s report that a child has had chickenpox will not suffice. Children entering first, second and sixth grades must have one dose, on or after their first birthday; in this case, parents can report that a child has had the disease. Recommended, but not required, for other grades.
Diphtheria, Tetanus and Pertussis (Whooping Cough) – Four doses of DTaP are required for children entering kindergarten, with the last dose given on or after the fourth birthday. Three doses of DTaP, DT or Td are required for grades one through five, with the last dose given on or after the fourth birthday. In 2008, students entering sixth and seventh grades must get one dose of Ddap (a booster shot for most children, including protection for pertussis) in addition to the three doses required for younger children, if they are 11 years old and it has been at least five years since their last DTaP, DT or Td shot. Three doses of DTaP, DT or Td are required for grades eight through 12, with the last dose given on or after the 4th birthday; Tdap (a combination recommended for adolescents 11 and older) may be substituted for one of the doses.
Polio – Four doses are required if all doses are given before the fourth birthday, three doses if the last dose is given on or after the fourth birthday. Required for all grades, K-12.
Measles, Mumps and Rubella (MMR) – Two doses of MMR are required. The first dose must be given on or after the 1st birthday, and the second dose must be given at least 28 days after the first dose. A blood test showing immunity to measles, mumps or rubella (German measles) is accepted. Required for all grades, K-12.
Hepatitis B – Three doses are required for students in grades K-11. The doses must be carefully spaced, should not be completed in less than four months and should be completed within nine months of staring school. Recommended, but not required, for students in 12th grade.
Beyond the requirements, the Department of Health and the federal Centers for Disease Control and Prevention recommend:
Haemophilus influenzae type b conjugate (Hib) for babies, ideally at ages 2-12 months, but up to 18 months
Meningococcal vaccine (MCV4) for children ages 2-10 if they are in a high-risk group, for all children ages 11-12, and as a catch-up for ages 13-18 or at college age, if they have not had the vaccine earlier
Pneumococcal vaccine (PCV) for ages 2-18 months and for high-risk children (PPV) ages 2-18 years
Influenza vaccine annually for children 6 months to 5 years old and for high risk children 6-18 years
Rotavirus for babies 2-12 months
Hepatitis A vaccine (HepA), ideally administered in two doses, six months apart, at age 12-24 months, and to high-risk children ages 2-18
Human Papillomavirus (HPV) to females ages 11-12 in three doses, and to females ages 13-18, if not given earlier.
* The rotavirus, HPV and second varicella vaccines are given free to children in Washington state.
For more information, contact: The Washington State Department of Health Immunization Program, 1-866-397-0337, www.doh.wa.gov/cfh/immunize.
CHILD Profile and its immunization registry, 1-800-325-5599, www.childprofile.com.
The Centers for Disease Control and Prevention, English/Spanish Hotline, 1-800-232-4636, http://www.cdc.gov">www.cdc.gov - Click on Immunizations.
For help finding an immunization clinic or for free immunizations for families who cannot afford them, call your local county health department: Public Health Seattle & King County, 206-296-4949, www.metrokc.gov/health/immunization/school.htm; Tacoma/Pierce County Health Department, 253-798-2987, www.tpchd.org; or Snohomish Health District, 425-339-5200, www.snohd.org.
Wenda Reed is a local health writer and frequent contributor to Seattle’s Child.
This article has been updated since it was first published in August 2006.
