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Students with ASD: How to adjust to a new routine this school year

By Megan Swinford, social worker, Thompson Autism Center at CHOC Cphildren’s

Speak to any parent, and you’ll gain insight into the roller-coaster ride they’ve been on the past several months during the COVID-19 pandemic. Parents have adapted to having their children at home full-time while balancing their own work schedule, virtual learning, and have essentially transformed themselves into teachers.

Parents of children with autism spectrum disorder (ASD) or special needs have had even more barriers to overcome, since Applied Behavior Analysis (ABA) therapy that children usually receive with a therapist in their home has declined due to the pandemic. Now that the school year is upon us, how can you prepare your child with ASD to return to school and adjust to the new normal?

Regardless of which structure your child’s school district offers, your child’s success in school will depend on their ability to adapt and be flexible to an ever-changing environment. This is no simple request considering students with ASD may have challenges with flexibility. The good news is there are ways that parents and teachers can work together to help ease their student’s anxiety:

  • Talk to the teacher about your child’s triggers for anxiety. If your child had virtual learning at home last spring, you’ve probably become more aware of their frustrations and triggers. Triggers may range from sensory issues to unstructured time to virtual interfacing with classmates or their teacher. Whatever their triggers are, it will be key for you to communicate these with your child’s teacher.
  • Create social stories with help from a behavioral analyst and/or teacher. Before in-person learning begins, reach out to your child’s therapy providers and have them practice social stories such as hand-washing, personal space and mask-wearing. This will help normalize some of the new procedures that your child will be faced with this year and prepare them for a better outcome. As a parent, getting involved in these therapy sessions, and understanding how you can translate and practice these social stories at home, will also be helpful.
  • Prepare a schedule—as best as you can. If your child will attend in-person learning this fall, get a copy of your child’s schedule and see if you’re able to visit the classroom before school is in session to build familiarity. Ask their teacher what health precautions will be enforced so that you can practice them. If your child’s school will continue with remote learning, follow these tips: try to have a start/end time each day, incorporate physical breaks that are planned for both you and your child, and create visual schedules.
  • Award flexibility with lots of praise and rewards. Make sure to award or praise even the smallest progress with your child’s flexibility toward new situations. This will encourage your child to respond positively to changes they may not be able to control. Since children with ASD can struggle without a consistent and dependable routine, teaching and reinforcing flexibility will be a strong skillset to develop.
  • Practice flexibility and openness yourself. Try to be open to unexpected outcomes, as hard as that can be. This will help model behavior for your child to follow. Flexibility and openness will be key in the next year, as schools adjust to putting new protocols in place to safeguard their students.
Explore the Thompson Autism Center at CHOC Children's

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The importance of well-checks during COVID-19

An upcoming well-check appointment for her teenage son had slipped Courtney Berney’s mind until her CHOC Children’s pediatrician called her one day with a reminder.

“I didn’t even remember that we had a well-check,” she says. “I did ask if we should still go, even with COVID-19 happening.”

Dr. Eric Ball gave Courtney an overview of the steps CHOC’s Primary Care Network had taken to keep patients, families and staff safe during the pandemic.

Dr. Eric Ball, a CHOC Children’s pediatrician

Reassured, Courtney and her son, Jackson, headed to the appointment. Upon arrival, they both wore masks, had their temperatures checked and were asked about symptoms and possible COVID-19 exposure. The waiting room was kept largely empty and all staff wore masks.

“It felt very safe,” Courtney said. “I was impressed.”

A routine visit takes an unexpected turn

Including tracking growth, checking in on mental health and ensuring current immunizations, the well-check continued like every other routine visit 15-year-old Jackson had experienced before.

But then, Dr. Ball detected an inguinal hernia during his physical exam.

These can occur when the inguinal canal, which extends down the groin, doesn’t close on its own shortly after birth. If this opening is large enough in these cases, the intestine can come into the canal and create a bulge in the groin region.

This can grow dangerous if the part of the body that protrudes from the hernia becomes stuck, which can compromise blood flow to the trapped body part.

“Apparently, Jackson was born with it and always had it and he didn’t know,” Courtney says. “He’s had this exam every year since, but this year it felt different. I wouldn’t have known that, and he wouldn’t know it without having this visit.”

Because inguinal hernias should be repaired by surgery, Dr. Ball referred Jackson to CHOC’s pediatric general and thoracic surgeons for a follow-up appointment, and Jackson recently underwent a successful outpatient procedure to repair the hernia.

“Inguinal hernias are common but should be taken care of promptly,” says Dr. Ball. “They’re also something that often only a doctor can detect during a physical examination, which underscores the importance of regular well-checks for kids – even when they’re healthy.”

Taking a personal approach

Knowing that parents may be wary of healthcare settings during a pandemic but also how critical seeking both sick and well care remains, Dr. Ball and his colleagues earlier into the COVID-19 emergency made personal phone calls to families. Today, Dr. Ball still regularly has conversations with families about the measures in place to keep families safe.

“I’m happy to connect with them and personally reassure our families about the safety of our office,”  Dr. Ball says. “We want to ensure our patients and families know that we are here for them – during a pandemic and otherwise – and how critical it is to seek both routine and regular care.”

Here’s a look at other ways CHOC is ensuring its primary care practices are safe during COVID-19:

  • separated offices, waiting rooms, exam rooms and times/days for sick visits and well visits;
  • masking for staff, patients ages 2 and older and families;
  • enhanced cleaning practices;
  • screening of all patients for COVID-19 risks, by phone when families make appointments, and upon arrival for well and sick visits;
  • in-vehicle evaluation of children symptomatic or exposed to COVID-19; and
  • limiting the number of people who can accompany a patient to an appointment to one family member.

These extra steps helped reassure Courtney that it was safe to seek routine care for her children, even during a pandemic – and she’ll be coming back.

“My son is really healthy too, but I wouldn’t pass up a well-check,” Courtney says. “I know it might be scary and new, but I trust the doctors. I have to book my appointment for my other son in a couple weeks too.”

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Acute flaccid myelitis: What parents should know

We know how alarming it can feel for parents to hear news reports about a medical emergency known as acute flaccid myelitis. This Q&A with CHOC Children’s pediatric experts offers answers to your frequently asked questions, including what to do if you suspect your child has acute flaccid myelitis.

What is acute flaccid myelitis?

Acute flaccid myelitis (AFM) is a rare condition that affects the spinal cord, which can lead to muscle weakness. It usually affects children and happens following a fever or cold symptoms.

What causes acute flaccid myelitis?

The cause is not known for sure but experts believe that viruses, including enteroviruses, might cause AFM. Most cases occur between August and November.

AFM is not a new problem, but many people are just learning about it in news reports because of recent outbreaks.

AFM is still very rare, with fewer than one in 1 million people per year being diagnoses in the U.S. It usually affects children.

What are the signs and symptoms of acute flaccid myelitis?

A child with AFM usually has progressive weakness in the arms and legs that may be rapid over hours to days. Their face may also be affected. Other symptoms of AFM include:

  • Drooping eyelids
  • Pain or numbness in one or more limbs
  • Difficulty walking
  • Headache
  • Back or neck pain
  • Difficulty talking or swallowing
  • Neck or facial weakness

Most children with AFM will have a fever or respiratory illness about six days before weakness occurs. For this reason, AFM has been associated with certain types of viruses, and specifically one called enterovirus D68.

What should I do if I think my child has acute flaccid myelitis?

If you or your child have any symptoms of AFM, get medical care right away. With AFM, a patient’s health can decline quickly, resulting in paralysis or the need for a ventilator. AFM can sometimes lead to permanently disability.

It is safe to seek the emergency and preventive care you and your children need despite the ongoing COVID-19 pandemic.

When AFM is caught early, doctors can hospitalize patients and provide optimal medical management and rehabilitation.

What is the treatment for AFM?

If doctors suspect your child has AFM, they will be hospitalized and cared for by a team of multidisciplinary specialists which may include primary care, neurology, infectious disease, physical therapy and occupational therapy. Doctors will review your child’s medical history, perform a physical exam and use an MRI to review your child’s spinal cord.

Scientists are still studying possible treatments for AFM. Possible treatments that may be used include:

  • Corticosteroids, used to treat inflammation
  • Intravenous immunoglobulin, used to treat immune disorders
  • Plasmapheresis, used to remove antibodies from the blood

Physical rehabilitation could help improve long-term outcomes. Some patients may receive nerve transfer surgery to repair nerve injuries.

Talk to your child’s doctor about specific questions you have for their care.

Can you prevent acute flaccid myelitis?

Viruses might cause AFM, so you can avoid spreading germs by:

Is acute flaccid myelitis contagious?

No, AFM is not contagious.

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Breastfeeding during COVID-19

We understand how stressful it can be to navigate life as a new parent. With the added anxiety brought on by COVID-19, we want to share trusted information to breastfeeding mothers who are COVID-19 positive or suspected positive, on whether their milk is still safe and beneficial for their baby.

COVID-19 is a new disease and researchers are still studying how the disease spreads. However, breast milk remains the best source of nutrition for most infants.

Current guidance from the Centers for Disease Control states that a mother who has been confirmed or suspected to have COVID-19 should take all precautions to avoid spreading the virus to her infant. These steps include:

  • Washing hands with soap and water for 20 seconds before touching the infant, pumping equipment or feeding supplies.
  • Wear a face mask when breastfeeding, pumping or handling the baby.
  • If using a breast pump, washing hands before touching the pump and following CDC recommendations for cleaning the pump after each use.
  • Follow current CDC guidelines for proper breastmilk handling and storage.
  • If bottle feeding pumped breast milk, have someone who is well feed the baby, if possible.

“Although there’s limited research available on whether COVID-19 is transmitted via breastmilk, studies on similar viruses did not find the virus in the milk,” said Dr. Reshmi Basu, a CHOC Children’s pediatrician. “A mother’s milk does contain specially made antibodies, produced by the mother’s body to protect her and her child from various viruses. These antibodies are transferred in breastmilk.”

Cindy Baker-Fox, registered nurse and certified lactation consultant at CHOC, explains how these antibodies make breastmilk a good source of nutrition for infants.

“Lifesaving antibodies in breastmilk protect babies from many illnesses and are one of the many unique properties found in human breast milk, making it not only a good source of nutrition but also valuable medicine for newborns and infants.”

If you have specific questions about breastfeeding and your baby, contact your pediatrician.

This article was updated August 5, 2020.

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Understanding the role of cultural stigma on seeking mental health services

By Dr. Sheila Modir, pediatric psychologist; Baleska Alfaro, licensed marriage and family therapist; and Dr. Ava Casados and Dr. Sarah Ruiz, post-doctoral fellows at CHOC Children’s

For some people, making an appointment with a mental health provider may be a personal and independent decision. For others, the decision to seek therapy services may be influenced by their culture or community, as each culture has its own understanding, interpretation and beliefs around mental health symptoms.

Our own culture also teaches us ways to cope with distress and whom to rely on for support during difficult times. This may impact whether a person seeks mental health services and treatment, or their decision not to seek care at all.

In many cultures, negative stigma about mental health symptoms or therapy services is a major obstacle to getting professional help. Research shows that people in racial and ethnic minority groups in the U.S. are less likely than White people to seek outpatient therapy services. Many ethnic minority groups are more comfortable going to their primary care physicians or family members for assistance with mental health symptoms as opposed to speaking with a mental health provider. We all want to be accepted by our communities, and sometimes fear of shame or embarrassment prevents people from seeking mental health treatment.

For instance, Black families may be understandably reluctant to seek mental health therapy due to the longstanding history of discrimination, racism and mistreatment the Black community has experienced at the hands of providers in the U.S. Instead, they tend to take an active approach in handling adversities independently and directly. They also tend to rely more on spiritual resources for emotional support. While these beliefs and approaches are valid, overly negative views of therapy can keep children who do need a higher level of care from getting that help.

Studies show that Latinx (a gender neutral reference to a person of Latin American cultural or ethnic identity in the U.S.) families are also less likely to trust mental health providers compared to White families and are more likely to rely on social support from extended family and other community members. When Latinx individuals do tell others about their experiences with stress or emotional difficulties, they often focus on physical symptoms such as trouble sleeping or loss of appetite and are less likely to discuss the thoughts or feelings that are bothering them.

For Asian American and Middle Eastern American communities, cultural beliefs that seeking mental health treatment will bring shame and dishonor to the family leads some people to internalize their symptoms instead of seeking therapy. Many Asian American children have described feeling pressured to appear perfect and successful, and therefore keep their symptoms secret. For Middle Eastern American adolescents, research has found that they tend to seek support from other family and religious community members.

While these beliefs and approaches are valid, overly negative views of therapy can keep children who do need a higher level of care from getting that help.

These examples are broad, but they illustrate just a few of the reasons why ethnic minority children are much less likely to receive therapy when they need it. Ultimately, it is the responsibility of the mental and medical health system to make services more accessible to under-served families, and to spark change to counteract myths about the stigma of mental health symptoms and mental health treatment. Parents can also play an important role in examining their family’s own cultural beliefs about treatment and identifying ways to advocate for their children to get expert help whenever they need it.

How our community can end mental health stigma

So, how do we, as parents, healthcare professionals and the community begin to work on eliminating the stigma surrounding mental health disorders and accessing mental health services? After all, one in five children experiences a mental health disorder.

Here are some tips that can help our children and families feel more comfortable with identifying, discussing, managing and accessing services for mental health.

  1. Seek reliable information — A first step that we can take to end mental health stigma is to seek out reliable and accurate information about mental health disorders, treatment options and resources in our community. Trusted sources can include, but are not limited to:

When speaking to children about mental health, use resources that are age-appropriate and engaging. A young child may find books helpful, while an older child may prefer to get information online. Look over resources with your child to help them find reputable sources of information and avoid popular social media platforms as your only source of information. Not sure how to start? Here are a few resources for kids:

  1. Use appropriate language — The resources listed above can help you understand how to talk to your children about mental health issues, as well as how to dispel mental health myths they might have heard about conditions and treatment. Using correct language can reduce any shame or guilt you or your family and friends may have about mental health and can create a space that makes it easier for children and teens to speak openly about their own struggles and seek help.


  1. Celebrities normalizing mental health conditions — Because so many people live with and manage symptoms related to a mental health condition, it isn’t hard to find a celebrity or well-known public figure your child admires who has a mental health condition. We can use celebrity or public figure examples to help normalize mental health conditions and access to mental health treatment. Our children will be more open to discussing their mental health condition and to trying out mental health services if they know that their favorite singer, actor or athlete also lives with a mental health condition.


  1. Learn to explain your child’s mental health condition to your support system and community — Once we have accurate information about our child’s mental health condition and treatment plan, it could help to share this information. If we share information about mental health with our families, schools or places of worship, as well as other members of our support system, they can each better understand the child’s mental health and how they manage symptoms. Sharing information can also help increase empathy and support for the child’s well-being.


  1. Seek support in your community — Children and teens with mental health conditions may not know anyone else with a similar diagnosis, which can impact their self-esteem. For teens especially, finding support from an online community may be a helpful way to openly speak about their mental health condition. Parents may also benefit from knowing other parents with children who have mental health conditions, as this can allow families to find a sense of community or support. Your local National Alliance on Mental Illness chapter offers peer support groups for parents and individuals with mental health conditions.


  1. Advocacy — Engaging in advocacy is another way that parents and community members can help break down mental health stigma. Organizations like National Alliance on Mental Illness engage in advocacy and policy change using individual’s stories. Advocacy can help raise awareness about important mental health issues and help dispel myths and break down stigma. It could also have positive impacts for those who are engaging in advocacy, helping to develop a sense of solidarity and common purpose.
Learn more about mental health services at CHOC

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