Monday, September 1, 2014

Behavior 101

Dear Melissa,
I recently started watching my 4 ½ year old nephew while my sister works full time.  He is a really sweet boy, but he is so impulsive, so full of energy, and is very quick to throw a tantrum. I feel like I have to watch him more closely than I watch my own 2 year old! Do you have any tips to help with behavior problems in a preschooler?

If I had a one-size-fits-all quick fix for behavior problems, I would be a millionaire!  However, I do have a large bag of tricks which I have used as a mom and as an Occupational Therapist. That is one of the things I love the most about my job! I get to try new ideas at home, then practice them at work, and vice-versa! Now, I absolutely do NOT claim to have all the answers. My own children have their cranky/meltdown moments, just like any other child.  However, here are a few of my favorite ideas to help solve behavior difficulties in ANY child, both those with disabilities, and those without: 

Be consistent.  
This is parenting/childcare rule #1.  If a child is able to cry for 10 minutes and gets his way, then he will try crying for 15 minutes the next time to get his way.  If you say something is a rule, it is a rule.  Period.  Let your word be your bond.  I will admit, there have been times...especially after my child has screamed for 20 minutes...when I have thought to myself, “Why do I even care if my child takes his plate to the sink? It’s really no big deal! I will just take it there myself!” However, if you said something needs to be done, it needs to be done. Stand your ground! You can do this!

Avoid saying “NO.” 
Yes, all children need to learn to remain calm when they hear the dreaded “no,” but I have learned that avoiding “no” as much as possible makes your life so much easier. This does NOT, however, mean that you should give in. It means rather that you learn to get creative with your responses to your child’s requests. I always like to respond to requests with “of course” followed by a qualifier. When the child asks “Can I go outside?” you reply, “Of course you can, when it stops raining.” When a child asks “Can I have a snack?” you reply, “Of course you can, after you pick up your toys.” When a child asks, “Can I watch TV?” you reply, “Of course you can, after school.” When the child asks, “Can I have a private island in the Bahamas?” you reply “Of course you can, when you win the lottery!” You get the idea. 

Keep to a regular schedule.  
Children thrive on structure and routine. The more struggles a child has with impulsivity, attention, and behavior, the stricter the routine needs to be. It may seem cruel to leave a party early in order to respect the bedtime routine, but it really is for the best. Children are just little guys & gals. They don’t know what to expect from their world, and they have little control over it.  The more they can learn to predict their daily routine, the more they can learn to remain calm and not worry about what is happening next. If you notice the schedule posted in any quality preschool classroom, you will find that they have the full day scheduled down to the minute.  Again, this predictability makes life calmer and simpler for everyone. 

Use picture/written schedules.  
This helps to keep things on schedule even more. Depending on the reading abilities of the child, this can either be written out with words, or you can use photographs or drawn pictures.  The “Super Nanny” Jo Frost always created a huge poster board schedule when working with her families on TV, and she had some doozies!  I always use this technique in the clinic and with my own children as well. This helps make a clear picture of the predictable schedule and can be used to prepare a child for any changes in the day (which are bound to happen). If a child needs pictures rather than words, consider taking photos of activities, printing them off, laminating the pics and adding Velcro to the back. This will allow you to create a quick visual schedule each day and easily make changes as needed.

Use a visual/auditory timer.  
This goes back to the fact that kiddos need predictable schedules and structure. Whether utilizing an alarm app on your phone, a wristwatch alarm, a kitchen timer, or a simple sand timer, you can create a definite cue that it is time to move to a different activity.

 Give choices as much as possible.  
OK, this one really does seem like “magic fairy dust,” but hear me out and give it a try. You tell the child to brush his teeth, and she refuses. Then you simply ask if she wants to brush her teeth in the upstairs or the downstairs bathroom. And she magically chooses to brush her teeth upstairs!  I am completely floored that this one actually works.  It seems too simple! Please, give it a try, and let me know. I promise that you will be amazed more often than not!

Avoid the hungry/sleepy/tired situations.  
Simple, right? Wrong! This singular concept will probably be the topic of many future blogs. But in short, respect regular meal and snack times, respect nap times and bedtimes, and always keep a healthy snack on hand for emergencies!

Again, I could go on, and on, and on…These are just my favorites! In addition, these are only tips for setting a child up for success. Yes, sometimes consequences are necessary, but we will save those for another day. My philosophy is that it is much easier to set a child up for success than try to get creative with deciding on appropriate consequences. I would love to hear your favorite tips/tricks to help with difficult behaviors at home. Please share!

If you would like additional tips for addressing behavior difficulties in your child, please explore the following resources: 

Monday, August 25, 2014

When is a comfort blankie not OK?

image credit: Envato
Dear Melissa,
My 3-year-old daughter is identified as having Sensory Processing Disorder, and she just LOVES her blanket. She sleeps with it every night and rubs her hands on it as she falls asleep. Throughout the day, she will even take “breaks” from playing with her sister, go to her room and fidget with her blanket for a few minutes before coming back into the playroom to rejoin her sister. My husband is concerned that we are encouraging an abnormal behavior. What should we do about this?

To be honest, this is not the type of thing that really has much research behind it. So, I will give my opinion as an OT who has worked for years with kiddos on the Sensory Spectrum.  

In my opinion, all kids (and adults!) do their own quirky, sensory, self-soothing activities.  When these activities are repetitive and frequent in nature, it is referred to as “stimming.”  In general, as long as the stimming behavior does not interfere with daily living and does not break social norms, I say “leave well enough alone.” The stimming serves a very important function to calm the body down. If you suddenly take away the calming activity, it can often lead to meltdowns. These are no fun for anyone!

Again, people regularly have all types of self-stimming behaviors. Many people twirl their hair, pace while talking on the phone, chew gum, twirl their pencil, jingle coins in their pocket, etc.  These are all self-calming behaviors which society has deemed to be acceptable. Once again, as long as they do not interfere with daily living or social norms, they are not problematic. 

However, what do you do if you decide that the stimming behavior is interfering with daily living or social norms? For example, it could be problematic for the child to take the blanket everywhere, such as to the park where it would get torn and dirty. Or one might be concerned if a child wants to hold her blanket all the time and never plays with her sister.  

Addressing a stimming behavior needs to be done very carefully.  If you simply take it away,  1) it can lead to extreme sensory meltdowns, and 2) the child will replace it with another self-stimming behavior, possibly one that is even less desirable! Therefore, when trying to stop a self-stim, make sure you replace it with a similar activity, but one that will not disrupt daily living activities or break social norms.  

For a child who is carrying a blanket everywhere she goes, you might start with limiting blanket usage to her room or in the car. You can set a timer to ensure that she does not use it for extended periods of time. You might also try to find a similar fabric to the blanket that could be tied to a belt loop or a bracelet so that the child could fidget with it throughout the day. 

This is the perfect time to work with your child’s Occupational Therapist or Child Psychologist. They will know your child and her likes/dislikes. Together, you can create even more ideas to help replace the stimming behaviors with more appropriate activities .

Further Related Reading: 

Monday, August 18, 2014

Sleep Worries

Image Credit: Envato
Dear Melissa,
I have 3 boys ranging from preschool to elementary school. We have had a very relaxed summer, staying up late to play outside and sleeping until 9 or so every morning. I’m worried that starting back to school will be a bit of a shock to their currently lenient sleep routine.  What can I do to help them to get “back on track” for school? 

The backpack and lunch box have been picked out; new school clothes are selected; fifteen trips have been made to the store to ensure that you have the EXACT items on the school list (the 24 pack of crayons, not the 16 or the 64 pack, but the 24 pack of Crayolas!). Kudos to you for realizing that sleep health should also be on your back-to-school list!

Importance of sleep:  In order to feel calm and rested, the National Sleep Foundation makes the following recommendations:

  • 1-3 years: 12-14 hours per day (including an afternoon nap of 1-2 hours)
  • 3-6 years: 10-12 hours per day (most children stop the afternoon nap sometime in this age range; only 24% of 5-year-olds continue to nap)
  • 7-12 years: 10-11 hours per day
  • 13-18 years: 8-9 hours per day

Many, many children fall far short of the recommendations listed above….and this creates the cranky, sleepy child situation that we all want to avoid. (Is anyone noticing a general theme of my blogs: “How to prevent the cranky child”?) But it is not just irritability that we need to worry about. Think back to your days as a new parent. Remember how little sleep you got?  Remember how you felt physically ill, grouchy and foggy-headed? Don’t recall this? Clearly the lack of sleep has affected your memory! 

A sleep-deprived state obviously has a negative impact on a child’s academic performance. Multiple studies on a wide age range of students consistently report that children who get more sleep per night perform better on individual tests, as well as overall academic performance. In addition, research from the University of Michigan found that as many as 25% of kids diagnosed with ADHD have an underlying sleep disorder causing their symptoms.   

So, you've “drunk the Kool-Aid.” You are ready to focus on healthy sleep, but how? The following are tips that we could ALL use to get better sleep: 
1) No TV in the bedroom. Ever. Period. This also goes for iPads, computers, smart phones, video games, etc. The bedroom is a place for sleep and relaxation. Electronics are for other areas of the house.  
2) Consistent bedtime/wake time, even on the weekends.  The body is simply unable to follow 2 different schedules in a 7-day period.
3) Establish a sleep routine.  In my house, it is bath, 1 show (NOT in the bedroom), books, bed. This will vary for each family. Some kiddos find the bath calming. However, my personal little monkeys get wound up at bath time, so it is at the beginning of our routine. Know your child. Find a reasonable routine. Stick to it – even on the weekend. 
4) Sleep environment.  The TV is already gone.  Ideally toys are out as well. This creates a space that is just for sleeping.  Temperature should be slightly cool. Overhead lights are off. A nightlight is generally good (but optional). “White noise” machines are often fantastic for the kiddo who really has a hard time sleeping. This takes some trial and error, but you can work with your child to create what works for them. 
5) INDIVIDUAL sleep environment. This is not necessarily a separate room, but this separation often is beneficial. However, each child should have his own bed, even if it is just a mattress on the floor. This prevents territorial wars between kiddos at bedtime. In addition, the child should sleep in the SAME SPACE each night.  Avoid the “musical bed” situation where he sleeps in the family room on the weekend, your bed sometimes during the week and his own bed at other times. Again, consistency is the key!
6) No caffeine. Hopefully your child doesn’t eat/drink any caffeine...but if your older child enjoys an occasional Coke, make sure that it is early in the afternoon and not close to bedtime. 
7) Snack. Some children find a light bedtime snack helpful as part of the bedtime routine. However, avoid a heavy meal 1-2 hours before bedtime as it can keep your kiddo awake.

What are your plans for getting back on track 
with your sleep habits for the new school year? 
I would love to hear your tips and ideas!

Also, if you have a question you would like me to address in my Weekly Blog,

Monday, August 11, 2014

What should I share about my child?

Dear Melissa,
My son will start kindergarten this fall. He has been in private Occupational Therapy for the past 2 years addressing sensory and behavioral difficulties and mild developmental delay.  My son’s OT says he is doing so well and advises us to decrease our therapy from 2x per week to 1x per week when school starts. Although he doesn't have any specific diagnosis, should I let the school know ahead of time about his delays? Or, do I just let him begin and see how kindergarten goes? I don’t want him to have a negative stigma, but I also want to set him up for success. Any ideas? 

What? A parent is worried about sending his/her little one to kindergarten? You are not alone!  I think I get asked this question by EVERY kindergarten parent this time of year! Yes, most parents worry about their child’s first day of school. However, if your child has been identified as “delayed” in the past, this can cause even more anxiety than usual. While I have listed several resources below, this decision is a tricky one and is largely based on your own attitudes, beliefs, and preferences. I think this is a good time to collaborate with your spouse, other family members, your child’s OT and any other adult who you trust who may know your child well.  Because there are no easy answers, I will simply state the pros and cons of the disclosure as I see it. 

If you decide to talk to the school, you may ask your spouse or child’s OT to join you for a meeting with the school principal before school starts. They will likely not know the identity of your child’s kindergarten teacher, but a kindergarten teacher representative can attend as well.  These meetings often occur the week or two before school starts. In this meeting, you can discuss your child’s strengths/weaknesses as well as any modifications that have worked well in the past that may help (behavior charts, picture schedules, timers, sensory diet, etc). Though you generally can’t request a specific teacher, you can also discuss what parenting/teaching styles work best for your child, and the school can try to assign the best match for your child. A quick poll of my friends who are teachers offers a resounding “YES, please let us know ahead of time!” The downside to having this conversation is that you have potentially given the child a “label” before the teacher has had the opportunity to see your child and make her own judgments. 
If you decide not to talk to the school, the teacher gets to observe your child with a fresh set of eyes, just as she does every other kiddo in that classroom on the first day of school. The CDC reports that 1 in 6 school-aged children have a developmental delay. And, approximately half of children with delays are not identified when they start kindergarten. Therefore, any good kindergarten teacher should be very aware that the kiddos in her class may have difficulties that have not yet been identified. Maybe she will pick up on the fact that your child may need a bit of extra help. Or maybe all those years of therapy will make your child SO prepared for school that he just fits right in. (Because that’s the goal of therapy, right?) OR, maybe your child will be completely overwhelmed by the natural chaos of the new kindergarten environment and completely shut down. It is a bit of a gamble…

If your child gets to kindergarten and you decide that he would benefit from additional help in the school setting, you can talk to the teacher/principal about beginning the process for services through the school (in addition to your private services). This can be in the form of special education, speech therapy, occupational therapy, etc. However, there is a long specific process for getting the ball rolling on these services, and it often requires several months. If needed, the Arkansas Support Network is a wonderful resource to help parents navigate the services which the school system can provide and help set your child up for success.


Arkansas Support Network479-927-4100

Are you a parent of a kindergartner? How has your family dealt with this transition?
I would love to hear any more ideas that you may have!

Also, if you have a question you would like me to address in my Weekly Blog

Monday, August 4, 2014

Too young for treatment?

image credit: Envato

Dear Melissa,
My son was recently diagnosed with Autism by a Developmental Pediatrician. The pediatrician recommended several different types of services, but it seems very confusing. Is all of this really necessary? He is only 2!

Forgive me for being blunt, but the short answer is YES!!! Study after study has found that beginning early with intensive services provides the best outcomes. But there are many, many, many different options. For most of us, after a problem has been identified, we simply want to “fix it” as quickly as possible. However, there are no simple “quick fixes” when it comes to Autism. In fact, many adults with Autism Spectrum Disorders (ASD) argue that they don’t want to be “fixed” at all! As I stated last week, the Autistic brain works in a fabulously different way than what is considered “typical,” and this causes many people with ASD to have wonderful strengths, even above and beyond what is considered “typical.” It is important to find treatment options that work well with your child, your family and your philosophies. This will help your child meet his fullest functional potential while continuing to retain his Autistic gifts. 

As stated earlier, there are many different treatment/therapy options.  Most of these can be provided in home, daycare, school or clinic settings (depending on your area).  Some different interventions for ASD include:
  1. Occupational Therapy (OT):  teaches skills needed for daily living such as dressing, writing, eating, bathing and socializing.
  2. Speech Therapy (ST):  helps to improve both receptive and expressive communication skills. They can also use various types of devices (from very simple to quite complex) to help children with low verbal skills learn to express themselves more effectively.
  3. Physical Therapy: helps a child with gross motor coordination, which is often affected by ASD. 
  4. Sensory Integration Therapy: helps a person interpret and appropriately handle sensory information such as sight, sound, smell, taste and touch. This therapy is often done in OT sessions. 
  5. Applied Behavioral Analysis (ABA): a specialized behavior training technique which breaks tasks down into very small parts and provides immediate rewards for appropriate responses.  
  6. Other types of behavior modification therapy: often completed with a psychologist, ST, OT or teacher trained in various behavior techniques. 
  7. Dietary modifications: typically involves eliminating foods that can negatively impact behavior.  
  8. Medical/pharmacological approaches: this can potentially help with the symptoms of ASD, but no pill can actually “cure” Autism. 
  9. *Complementary and alternative treatments: These can include various supplements, chelation, hyperbarics, etc...  
Still confused? Totally understandable! Feel free to seek further advice from your child’s pediatrician. In addition, check out other resources such as your local ASD support group, a pediatric therapist or your child's preschool teacher.

*An important note about alternative treatments: The CDC reports that approximately one-third of all parents of children with ASD have tried complementary and alternative treatments.  
However, 10% of these parents may actually be using potentially harmful treatments. It is important to discuss all treatments, both traditional and non-traditional, with your child’s doctor.  Many of the alternative treatments fall under the category of parent thought such as “can’t hurt, worth a try, everyone child is different,”  but you definitely don’t want to risk your child’s health with a potentially dangerous intervention. 

Local Northwest Arkansas Resources:
ABA Service Providers, TEAM Parent Resource
Arkansas Support Network479-927-4100

Other Resources:

Do you have a question you would like me to address in my Weekly Blog? 

Monday, July 28, 2014

Is Water Play Therapy?

Turning a little red wagon into a splash table...what fun! This week I suggest activities for children pre-K & older, but as you can see toddlers really enjoy water play as well.

Dear Melissa,
My son LOVES coming to therapy when it is Water Week at the clinic. But is this all just fun and games or is he really working toward his therapy goals? And if all of that fun is really therapeutic, then how can I recreate these opportunities at home? 

OK, after a relatively cool summer, it has officially turned HOT! Last week at Children’s Therapy TEAM’s Fayetteville Clinic, we had our annual Water Week. Don’t worry, our Bentonville clinic has one scheduled soon! The kids absolutely love it, and we "big kid therapists" love it too! It is a great, messy, wet, fun way to help kiddos achieve their therapy goals. The kiddos have a blast without even knowing that they are working! And THAT, my friends, is the hallmark of any good therapy session. 

Sooo...grab some neighborhood kids or some cousins, put them in their swimsuits and head to your backyard! You can have your own backyard water day with very little cash. You don’t even need a pool to keep cool this summer and the kiddos won’t even know that they are working on their back-to-school skills! 

The following are many of my favorite therapy games:  both during water week and with my own kiddos at Casa De Foster. 

1. Water Balloons: Yes, you can simply toss a balloon back and forth to work on eye-hand coordination. You can also toss it back and forth while taking turns counting, saying ABCs, or listing items in a stated category (e.g., colors, things you wear, fruit/vegetables). This helps improve response speed and attention to task. I also love to quickly pass water balloons to play “Hot Potato” for improved response speed. Another idea: line up a group of kiddos and pass water balloons overhead and between the legs to work on motor planning. Tired of the mess that the water balloons leave in your yard? Have the kids search the yard to pick up the pieces to work on visual scanning skills. They can also use tongs to pick up the pieces for improved fine motor skills. Yea, water balloon therapy!

 2. Wet Sponges: Tired of filling water balloons? Grab a bucket and some sponges and any of the above activities could be done with simple drippy sponges. In addition, wringing out sponges is a great way to improve hand strength. You can also have relay races. The teams will race to dunk their sponges in the buckets across the yard and run back to squeeze out their sponge and pass it to the next player. The team who fills up their bucket first wins!

3. Sidewalk Chalk: Chalk is fabulous for finger strengthening and offers the perfect way to work on handwriting without actually writing! Wait, your little one doesn't know how to correctly hold the chalk yet? Try breaking the piece in half (so that it is only 1-2 inches long) and have her write on a vertical surface such as a brick wall or fence. This is magical at promoting proper pencil grasp.

4. Relay Races/Obstacle Courses: Run through the sprinklers, zigzag through cones, jump over sticks, crab walk, skip, gallop...use your imagination! Obstacle courses are a great way to work on motor planning skills and sequencing. Want to add some more pizzazz to your obstacle course? Give the kiddos a “secret message” asking them to retrieve certain plastic alphabet letters by the end of the obstacle course; this helps them to work on attention and letter recognition. Need more adventure? Give the kids an ice cube in their hands and see how many times they can run through the obstacle. 

5. Water Squirters: Did you make a mess with all that chalk? Time to wash it off! Squirting traditional water guns strengthens the index finger for handwriting and aiming at a target is great for eye/hand coordination. The small squishy water squirters are also good for strengthening little ones' fingers. In addition, the two-handed water cannons work on sequencing and bilateral hand coordination; the child has to pull out the handle of the cannon to suck up the water and then push the handle back in again to shoot out the stream. 

5. Relay Races/Obstacle Courses: Run through the sprinklers, zigzag through cones, jump over sticks, crab walk, skip, gallop...use your imagination! Obstacle courses are a great way to work on motor planning skills and sequencing. Want to add some more pizzazz to your obstacle course? Give the kiddos a “secret message” asking them to retrieve certain plastic alphabet letters by the end of the obstacle course; this helps them to work on attention and letter recognition. Need more adventure? Give the kids an ice cube in their hands and see how many times they can run through the obstacle. 

6. Water Table: You can either fill up a kiddie pool with water or simply use a large flat storage tub to make a water table. Fill it with water and throw in some plastic sea creature toys. It is a great way to work on pretend play! Preschoolers can use plastic cups to work on scooping & pouring. Picking-up sea creatures with small nets is also a great way to work on eye/ hand coordination and bilateral hand coordination. 

7. Shaving cream: Shaving cream therapy is often a messy task indoors, but who cares if it’s messy outside? The kids can locate small plastic objects hidden in a bucket to improve fine motor skills. They can also use their index finger to draw or write messages in shaving cream. The water play is very motivating for most kiddos! However, many children, especially those with sensory sensitivities, will find the shaving cream, grass on their bare feet, and/or splashing water very uncomfortable...even scary! Feel free to take your time and provide gentle encouragement for participating in these tasks. If it is still too overwhelming for your little guy, encourage him to watch others having fun with these activities; this can be a great first step in lowering sensory defensiveness. And, as always, DON’T FORGET THE SUNBLOCK! 

Want even more fun water ideas? Follow the links below. 
Kids Activities: Outside Water Play
Parenting: 11 Water Games and Outdoor Activities for Kids
The Stir: 8 Awesome Water Games for Backyard Fun on Hot Days

Share your questions and ideas at

Monday, July 21, 2014

Too young to diagnosis Autism?

Dear Melissa,
At 18 months, is it too early to diagnose Autism? 

Let me start by admitting that this blog is a bit more serious than the last few. Although this topic takes on a very serious tone, I must make a confession:  
I LOVE children with Autism. Period.  
It is my passion. It is what I do.  
Children with Autism see the world in a delightfully unusual way, and I love it. However, the world of Autism is largely unknown, and many people are scared. With the CDC reporting that 1:68 children in America now have a diagnosis of Autism Spectrum Disorder (ASD), most of us know at least one child (or adult) with this diagnosis. This also has many parents in a panic. 

How do you know if your child has Autism? This is the tricky part. Unlike diabetes or a broken arm, there is no simple blood test or x-ray to make a definitive diagnosis. Many clinicians speak of “Autism-like symptoms,” but what does this mean? And at what age do you know you have a problem? 

The CDC states that by 2 years of age, a diagnosis of Autism Spectrum Disorder given by a medical professional is “highly reliable.” They also report that an accurate diagnosis of ASD can be made at 18 months or even younger. In my personal practice, I have seen several cases of children who come to me for a 14-month evaluation for something other than Autism (e.g., food aversion, not walking), and it was obvious that these children had Autism. These children went on to receive an ASD diagnosis by a physician around 2 years of age.

What should parents look for? Possible “red flags” for Autism include:
>Not responding to their name by 12 months.
>Not pointing to objects of interest by 14 months.
>Not playing “pretend” games (e.g., tea party) by 18 months.
>Avoiding eye contact and preferring to be alone.
>Delayed speech/language skills.
>Repeating words/phrases over and over (echolalia).
>Demonstrating obsessive interests.
>Flapping their hands, rocking body, spinning in circles, or other unusual repetitive movements.
>Unusual reactions to the way things smell, look, taste, or feel.
>Any significant loss of skills that were once mastered.

Now, I am a firm believer that kiddos are just quirky. Aren't we all? If you have a child that displays a single one of these characteristics for a month or two and then basically grows out of it, there is no need to worry. A typically developing child may think a movement (such as spinning) is really neat for a month or two, and then move on to the next fascination (such as obsessing over trains). However, if a “red flag” behavior persists for more than a month or two, definitely consult your pediatrician. For me, the biggest concern is the loss of any skills that were once mastered by the child. This is most certainly a reason to have a discussion with your pediatrician, pronto!

A good question to ask is "does my child repeat a particular behavior because it is a great way for him to engage with me?"  For a parent of a young child with Autism, the answer to this question will likely be no. Children with Autism tend to not be highly relational with their preferred activities. In contrast, a typically developing child may choose to repeat activities over and over to gain his parent's focus and attention.   

Early intervention and treatment of Autism is vital to creating the most functional outcomes.  On an upcoming topic I will discuss the importance of receiving early interventions and the treatment options available to parents.  

Early Warning Signs, UC SanDiego 
Autism Symptoms, Mayo Clinic 
Diagnosing Autism, American Academy of Pediatrics