G6PD Deficiency

G6PD deficiency is an inherited condition in which the body doesn't have enough of the enzyme glucose-6-phosphate dehydrogenase, or G6PD, which helps red blood cells (RBCs) function normally. This deficiency can cause hemolytic anemia, usually after exposure to certain medications, foods, or even infections.

Most people with G6PD deficiency don't have any symptoms, while others develop symptoms of anemia only after RBCs have been destroyed, a condition called hemolysis. In these cases, the symptoms disappear once the cause, or trigger, is removed. In rare cases, G6PD deficiency leads to chronic anemia.

With the right precautions, a child with G6PD deficiency can lead a healthy and active life.

About G6PD Deficiency

G6PD is one of many enzymes that help the body process carbohydrates and turn them into energy. G6PD also protects red blood cells from potentially harmful byproducts that can accumulate when a person takes certain medications or when the body is fighting an infection.

In people with G6PD deficiency, either the RBCs do not make enough G6PD or what is produced cannot properly function. Without enough G6PD to protect them, RBCs can be damaged or destroyed. Hemolytic anemia occurs when the bone marrow (the soft, spongy part of the bone that produces new blood cells) cannot compensate for this destruction by increasing its production of RBCs.

Causes of G6PD Deficiency

G6PD deficiency is passed along in genes from one or both parents to a child. The gene responsible for this deficiency is on the X chromosome.

G6PD deficiency is most common in African-American males. Many African-American females are carriers of G6PD deficiency, meaning they can pass the gene for the deficiency to their children but do not have symptoms; only a few are actually affected by G6PD deficiency.

People of Mediterranean heritage, including Italians, Greeks, Arabs, and Sephardic Jews, also are commonly affected. The severity of G6PD deficiency varies among these groups — it tends to be milder in African-Americans and more severe in people of Mediterranean descent.

Why does G6PD deficiency occur more often in certain groups of people? It is known that Africa and the Mediterranean basin are high-risk areas for the infectious disease malaria. Researchers have found evidence that the parasite that causes this disease does not survive well in G6PD-deficient cells. So they believe that the deficiency may have developed as a protection against malaria.

G6PD Deficiency Symptom Triggers

Kids with G6PD deficiency typically do not show any symptoms of the disorder until their red blood cells are exposed to certain triggers, which can be:

• illness, such as bacterial and viral infections
• certain painkillers and fever-reducing drugs
• certain antibiotics (especially those that have "sulf" in their names)
• certain antimalarial drugs (especially those that have "quine" in their names)

Some kids with G6PD deficiency can tolerate the medications in small amounts; others cannot take them at all. Check with your doctor for more specific instructions, as well as a complete list of medications that could pose a problem for a child with G6PD deficiency.

Other substances can be harmful to kids with this condition when consumed — or even touched — such as fava beans and naphthalene (a chemical found in mothballs and moth crystals). Mothballs can be particularly harmful if a child accidentally swallows one, so ANY contact should be avoided.

Symptoms of G6PD Deficiency

A child with G6PD deficiency who is exposed to a medication or infection that triggers the destruction of RBCs may have no symptoms at all. In more serious cases, a child may exhibit symptoms of anemia (also known as a hemolytic crisis), including:

• paleness (in darker-skinned children paleness is sometimes best seen in the mouth, especially on the lips or tongue)
• extreme tiredness
• rapid heartbeat
• rapid breathing or shortness of breath
• jaundice, or yellowing of the skin and eyes, particularly in newborns
• an enlarged spleen
• dark, tea-colored urine

Once the trigger is removed or resolved, the symptoms of G6PD deficiency usually disappear fairly quickly, typically within a few weeks.

If symptoms are mild, no medical treatment is usually needed. As the body naturally makes new red blood cells, the anemia will improve. If symptoms are more severe, a child may need to be hospitalized for supportive medical care.

Diagnosing and Treating G6PD Deficiency

In most cases, cases of G6PD deficiency go undiagnosed until a child develops symptoms. If doctors suspect G6PD deficiency, blood tests usually are done to confirm the diagnosis and to rule out other possible causes of the anemia.

If you feel that your child may be at risk because of either a family history or your ethnic background, talk to your doctor about performing a screening with blood tests to check for G6PD deficiency.

Treating the symptoms associated with G6PD deficiency is usually as simple as removing the trigger — that is, treating the illness or infection or stopping the use of a certain drug. However, a child with severe anemia may require treatment in the hospital to receive oxygen, fluids, and, if needed, a transfusion of healthy blood cells. In rare cases, the deficiency can lead to other more serious health problems.

Caring for Your Child

The best way to care for a child with G6PD deficiency is to limit exposure to the triggers of its symptoms. With the proper precautions, G6PD deficiency should not keep your child from living a healthy, active life.

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Enlarged Adenoids

Often, tonsils and adenoids are surgically removed at the same time. Although you can see the tonsils by looking in your child's throat, adenoids aren't directly visible. Your child's doctor has to use a small mirror or a special scope to get a peek at your child's adenoids.

So, what are adenoids anyway? They're a mass of tissue, located in the passage that connects the back of the nasal cavity to the throat. Adenoids — which are also called nasopharyngeal tonsils but are separate from the tonsils in the throat — filter out bacteria and viruses entering through the nose and produce antibodies to help the body fight infections.

Some doctors believe that adenoids may not be important at all after kids reach their third birthday. In fact, adenoids usually shrink after about 5 years of age, and they often practically disappear by the teenage years.

What Are the Symptoms of Enlarged Adenoids?

Because adenoids trap germs that enter a child's body, adenoid tissue sometimes temporarily swells as it tries to fight off an infection. There are several symptoms associated with enlarged adenoids. You may notice that your child:

• complains of difficulty breathing through the nose
• is breathing through the mouth
• talks as if his or her nostrils are pinched
• breathes noisily
• snores while sleeping
• stops breathing for a few seconds while sleeping (called sleep apnea)

If enlarged adenoids are suspected, your child's doctor may:

• Ask about and then check your child's ears, nose, and throat.
• Listen to your child's breathing through a stethoscope.
• Feel your child's neck near the jaw.

To get a really close look, the doctor may even want to take one or more X-rays. For a suspected infection, the doctor may prescribe oral antibiotics or maybe an injection of penicillin.

When Is Surgery Necessary?

If enlarged or infected adenoids keep bothering your child and medicine doesn't stop them from coming back, the doctor may recommend surgically removing them with a procedure called an adenoidectomy. This may be recommended if your child experiences one or more of the following:

• difficulty breathing
• sleep apnea
• recurrent infections

Having your child's adenoids removed is especially important when repeated infections lead to sinus and ear infections. Badly swollen adenoids can interfere with ear pressure and fluid movement, which can sometimes lead to hearing loss. Therefore, kids whose infected adenoids cause frequent earaches and fluid buildup may need to get an adenoidectomy as well as ear tube surgery.

And although adenoids can be taken out without the tonsils, if your child is having tonsil problems, they may need to be removed at the same time. A tonsillectomy with an adenoidectomy is the most common operation for children.

What Happens During the Surgery?

Surgery, no matter how common or simple the procedure, is often frightening for both the child and parent. You can help prepare your child for surgery by talking about what to expect. During the adenoidectomy and/or tonsillectomy:

• Your child will receive general anesthesia. This means the surgery will be performed in an operating room so that an anesthesiologist can monitor your child.
• Your child will be asleep for about 20 minutes.
• The surgeon can get to the tonsils and/or the adenoids through your child's open mouth — there's no need to cut through skin.
• The surgeon removes the tonsils and/or the adenoids with a series of incisions and then cauterizes (or seals) the blood vessels.

Your child will wake up in the recovery area. In most cases, the total time in the hospital is 5 to 10 hours. However, kids who have trouble breathing or show signs of bleeding will return immediately to the operating room. And kids under 3 years of age and those with chronic disease, such as seizure disorders or cerebral palsy, will usually stay overnight for observation.

The typical recuperation after a tonsillectomy and/or an adenoidectomy often involves a week or more of pain and discomfort due to the exposure of the throat muscles. Because of throat pain, your child will probably prefer eating a lot of soft foods, like ice cream, pudding, and soups.

About a week after surgery, everything should return to normal. The cut area will be left to heal naturally, which means there are no stitches to worry about. There's a small chance any tissue that's left behind can swell, but it rarely causes new problems.

After surgery, a child's symptoms typically disappear immediately, unless there's a lot of swelling that could lead to some temporary symptoms.

Understanding Enlarged Adenoids

Even though some kids may need surgery, it's important to remember that enlarged adenoids are normal in others. If your child's adenoids aren't infected, the doctor may choose to wait to operate because the adenoids may eventually shrink on their own as adolescence approaches.

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Cochlear Implant

Sometimes called a "bionic ear," the cochlear implant offers the hope of regaining or restoring the ability to sense sound for some people who have experienced significant hearing loss.

Although they're not miracle devices, cochlear implants help some children and adults, whether they're born deaf or whether hearing loss occurs later in life, experience talking on the phone, listening to music, and hearing the voices of their friends and loved ones.

What Is a Cochlear Implant?

A cochlear implant is a surgically implanted device that helps overcome problems in the inner ear, or cochlea. The cochlea is a snail-shaped, curled tube located in the area of the ear where nerves are contained. Its function is to gather electrical signals from sound vibrations and transmit them to your auditory nerve (or hearing nerve). The hearing nerve then sends these signals to the brain, where they're translated into recognizable sounds.

If important parts of the cochlea aren't working properly and the hearing nerve isn't being stimulated, there's no way for the electrical signals to get to the brain. Therefore, hearing doesn't occur. (Sometimes referred to as nerve deafness, this is called sensorineural hearing loss.) By completely bypassing the damaged part of the cochlea, the cochlear implant uses its own electrical signals to stimulate the auditory nerve, allowing the person to hear.

How Normal Hearing Occurs

The ear is made up of three parts, and sound for a person who has normal hearing passes through all three on the way to the brain. The outer ear is made up of the outer, visible part of the ear and the ear canal.

When a person is exposed to a sound, the outer ear captures the sound vibration and sends it through the ear canal to the middle ear, which consists of the eardrum and three tiny bones. The sound vibration then causes motion in the three tiny bones, which makes the fluid in the cochlea move. The motion of the fluid stimulates the hair cells, which are thousands of tiny hearing receptors inside the cochlea. The hair cells bend back and forth and send electrical signals to the hearing nerve, and the hearing nerve then carries these signals to the brain, where they're interpreted.

Through aging, heredity, disease, infection, or repeated or severe exposure to loud noise, hair cells can be damaged or destroyed. If the hair cells don't work, the hearing nerve can't be stimulated and therefore can't send information to the brain. Thus, the person is unable to hear.

Hearing loss can be mild, moderate, or severe, depending on the number of hair cells that are defective, damaged, or destroyed. People with mild or moderate hearing loss may find that hearing aids, which simply make sounds louder, help. Those with profound or severe hearing loss might even have trouble understanding loud sounds. A hearing aid won't help in these cases, and a doctor might recommend a cochlear implant.

What a Cochlear Implant Does

The cochlear implant artificially stimulates the inner ear area with electrical signals, sends those signals to the hearing nerve, and allows the user to hear. Although sound quality is sometimes described as "mechanical" and not completely like that experienced by a person with normal hearing, the cochlear implant provides users with the ability to sense sound that they couldn't hear otherwise. Improvements in the way the implant processes sound information are continuously being made to make the sound seem more natural.

The actual cochlear implant consists of an implant package, which is secured inside the skull, and a sound and speech processor, which is worn externally (outside the body). Several components of the cochlear implant work together to receive sound, transfer it to the hearing nerve, and send it to the brain.

The implant package is made up of:

• a receiver-stimulator that contains all of the electronic circuits that control the flow of electrical pulses into the ear
• an antenna that receives the signals from the external sound and speech processor
• a magnet that holds the external sound and speech processor in place
• one wire containing electrodes that are inserted into the cochlea (the number of electrodes can vary depending on the cochlear implant model type used). The electrodes act much like normal functioning hair cells and provide electrical charges to stimulate the hearing nerve.

The sound and speech processor is a minicomputer that processes sound into digital information, and then sends that information to the implant package in the form of electrical signals. The sound and speech processor is worn externally and looks a lot like a normal hearing aid. Depending on the type of sound and speech processor used, it can either be worn as a headset behind the ear or in a belt, harness, or pocket.

The components of the sound and speech processor include:

• the actual sound and speech processing device (which can either be a body-level model that can be clipped onto clothing like a portable radio, or an ear-level model that's hooked over the ear)
• a microphone
• a transmitter that sends the signals to the implant package. The transmitter also includes a magnet that helps the user align the processor with the implant package.

For the cochlear implant to work, the implant package and the sound and speech processor must be aligned — that's what the magnets are for. By lining up the magnets, both the implant package and sound and speech processor are secured and work as one device.

When the implant package and the sound and speech processor aren't completely aligned, the device doesn't work and the person can't hear. Because both components need to be aligned for the user to hear, some people take the sound and speech processor off at night to sleep soundly. Others leave it on all the time.

How a Cochlear Implant Works

Knowing what, exactly, the cochlear implant does may help kids better understand their new bionic ear and the cool technology behind it that allows them to hear better.

Here's how the implant works:

• The microphone picks up sound.
• Sound is sent to the sound and speech processor.
• The sound and speech processor analyzes the sound and converts it into an electrical signal. (The signal contains information that determines how much electrical current will be sent to the electrodes.)
• The transmitter sends the signal to the implant package, where it's decoded.
• The implant package determines how much electric current should pass to the electrodes and sends the signal. The amount of electrical current will determine loudness, and the position of the electrodes will determine the sound's pitch.
• The nerve endings in the cochlea (the area where the hair cells are located) are stimulated and the message is sent to the brain along the hearing nerve.
• The brain interprets the sound and the person hears.

Cochlear Implant Surgery

The actual surgical procedure, which takes 2 to 4 hours and uses general anesthesia, involves securing the implant package under the skin and inside the skull, and then threading the wires containing the electrodes into the spirals of the cochlea.

To secure the implant, the surgeon first drills a 3- to 4-millimeter bed in the temporal bone (the skull bone that contains part of the ear canal, the middle ear, and the inner ear). Next the surgeon opens up the mastoid bone behind the ear to allow access to the middle ear. Then, a small hole is drilled in the cochlea and the wires containing the electrodes are inserted. The implant package is then secured and the incision is closed.

After having cochlear implant surgery, a child:

• will probably be able to go home the next day
• will have to wear a dressing over the implant area for 24 hours
• may be off-balance or dizzy for a few days
• may experience mild to moderate pain (the doctor may recommend giving pain medications)
• won't have to have the stitches removed — they're absorbable and dissolve on their own
• can lie on the side with the cochlear implant in a few days

Two to four weeks after surgery, the sound and speech processor is matched with the implant package and is programmed and fine-tuned to meet the child's individual hearing needs.

Learning to Use a Cochlear Implant

Because the extent and type of hair cell damage, electrical signal patterns, and sensitivity of the hearing nerve are different for each person, a specialist must fine-tune the sound and speech processor for every patient.

By measuring the lowest and highest current for each electrode, the clinician finds the softest and loudest sounds that will be heard (each electrode produces a different sound with different pitch). The sound and speech processor matches sounds on different electrodes with different volumes and attempts to create an accurate version of the original sound. However, because a limited number of electrodes are taking over the function of the thousands of hair cells in a normal ear, sounds won't be totally "natural."

After the first few programming sessions, the user begins to pick up sounds with the implant, but giving the implant full power is a gradual process that takes several months. In children who are born deaf, the stimulation from the implant will allow them to develop the brain pathways necessary to hear sounds. This is an extended process with programming and intensive therapy that often lasts for several years.

During the programming process, the user attends speech and language therapy sessions to help identify and interpret the new sounds he or she is hearing. In addition, an important part of the therapy includes parent education and training.

Therapy will help a child develop and understand spoken language through detecting, imitating, and associating meanings of sounds. These sessions last at least a year, along with parent education and training programs. In many cases, therapy has helped kids with cochlear implants develop speech and language on par with their peers and attend mainstream schools.

Some families choose to have implants in both ears. This can help with speech detection when there is background noise and in localizing the source of sounds.

Can a Cochlear Implant Restore Hearing for Everyone?

Cochlear implants are very successful for some people, but not everyone is a candidate to receive one. Ideally, children 12 months of age or older with profound hearing loss in both ears are excellent candidates, but not every child is eligible.

Some common reasons that a child may not be eligible for a cochlear implant:

• the child's hearing is "too good" (meaning the child can hear some sound and speech with hearing aids)
• the reason for hearing loss isn't a problem with the cochlea
• the child has experienced profound deafness for a long period of time
• the hearing nerve itself is damaged or absent

Each potential candidate must be evaluated by a cochlear implant team to determine whether a cochlear implant is the best option.

For those who do receive a cochlear implant, benefits can vary. The length of rehabilitation varies from person to person, and many factors (such as the condition of the hearing nerve or the presence of scar tissue in the cochlea) can hinder the success of the implant.

Expectations should be realistic, and the doctor or surgeon will help you understand the level of success the implant can reasonably achieve for your child.

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Chronic Hoarseness

All kids strain their voices every now and then: cheering for the home team at a ballgame; belting out a favorite song in the shower; calling out to friends on the playground.

Sound familiar?

Most of the time, such actions don't do any real harm to the vocal cords, the delicate bands of tissue in the larynx, or voice box. But chronic misuse of the vocal cords — caused by such things as repetitive screaming, yelling, or using the voice in an unnatural way — can lead to hoarseness. When this happens, the voice crackles and sounds rough, raspy, or breathy.

Sounding hoarse for a few hours or the day after a big game is probably nothing to worry about, and usually resolves on its own. However, chronic hoarseness that lasts for days, weeks, or even months needs to be checked out by a doctor. Speech therapy may be required to get the vocal cords back into perfect pitch.

How Vocal Cords Work

When we inhale, oxygen travels through the nose or mouth and down the throat (pharynx), passing through the voice box and windpipe (trachea), to get to the airway passages in the lungs. This route is reversed when exhaling carbon dioxide from the lungs, or talking.

To speak, air is pushed out of the lungs. In the larynx, the vocal cords — a "V"-shaped band of muscle — prepare for making sound by tightening up and moving closer together. As air passes through the vocal cords, they vibrate. This vibration, combined with the movement of the tongue, lips, and teeth, is what makes the sound of the voice.

Chronic misuse of the voice can cause excess wear and tear on the vocal cords. They may stretch too far or rub together, causing small irritations that, if not allowed to heal, turn into small calluses, or vocal cord nodules.

Causes of Chronic Hoarseness

Vocal cord nodules are the primary cause of chronic hoarseness in children. They happen when kids do any of the following for a prolonged period of time:

• yelling, screaming, cheering, or crying
• raising or lowering the pitch of the voice
• speaking in a strained voice, like imitating animals or cartoon characters
• repetitive coughing or throat clearing
• singing or talking without adequate breath (diaphragm support)
• talking extremely loud or fast
• starting words forcefully

Nodules, or growths, on the vocal cords can also be caused by vocal cord paralysis (when vocal cord nerves lose their function), smoke inhalation, chronic sinusitis or allergies, hypothyroidism, gastroesophageal reflux disease (GERD), and radiation therapy (for those undergoing treatment for throat cancer).

Detecting Vocal Cord Nodules

A child with chronic hoarseness will be referred to an otolaryngologist (also called an "ears, nose, and throat" specialist, or ENT) for evaluation. The doctor will ask for a medical history, listen for strain or breathiness in the voice, and perform a diagnostic test that provides an internal view of the voice box and vocal cord function.

Tests include:

• Flexible laryngoscopy. During this exam, a tiny, pliable, fiber-optic tube with a camera attached to the end (called a scope) is passed through a nostril and into the throat to allow doctors to get a magnified view of the larynx. Kids are asked to speak, sing, sniff, cough, and make other sounds that cause the vocal cords to vibrate. Movements are recorded on a computer monitor so that specialists can analyze them later.
• Rigid laryngoscopy. This can be performed in the office for older kids, but very young children and others who cannot tolerate a flexible laryngoscopy will undergo this test in an operating room under general anesthesia. The rigid scope is passed through the mouth to provide the best view of the vocal cords. Images of the vocal cords (at rest) are recorded.
• Laryngeal stroboscopy. To get a more accurate view of the vocal cords in action, doctors pass either a rigid or flexible scope attached to a strobe light into the throat. The strobe light flickers in sync with the vibration of the vocal cords as a person speaks, making it easier for doctors to determine the frequency of movement. Because individual vibrations are too fast for the naked eye to distinguish, the strobe technology projects the vibrations in slow motion.

Practicing Vocal Hygiene

Treatment for hoarseness caused by vocal cord nodules involves making behavioral changes so that the vocal cords can heal. Speech therapists work one-on-one with kids and their families to promote good vocal habits, or what's called "vocal hygiene."

A typical vocal hygiene program will consist of:

• isolating medical conditions (like GERD) that aggravate vocal problems, then undergoing treatment
• modifying behaviors that cause distress to the vocal cords, like yelling
• learning how to take deep breaths and relax the muscles in the throat
• taking time to speak slowly and clearly
• staying properly hydrated throughout the day
• avoiding caffeinated beverages, like soda, which dry out the vocal cords

For kids with established bad habits — like talking loudly when they're excited or clearing their throats when they're nervous — it might be difficult to implement changes in the beginning. The first step is to make kids aware of the offensive behavior and observe how often they do it.

Older kids may be able to consciously note (perhaps in a diary) how often they engage in the behavior, which is usually done unconsciously. Then they can practice the skills they've learned in therapy when at home, at school, and spending time with friends.

It's up to parents and other family members to encourage good vocal habits by setting a good example themselves. For example, rather than calling to kids from another room, walk into the other room to address them. Promote quiet times (perhaps for a half-hour each day) and using an "inside voice" when indoors.

Reward systems that encourage these new behaviors usually are successful in elementary schoolers. Parents can offer stickers, tokens, extra TV time, a later bedtime, or similar incentives to get kids on board with the new, healthier habits.

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Auditory Processing Disorder (APD)

Auditory processing disorder (APD), also known as central auditory processing disorder (CAPD), is a complex problem affecting about 5% of school-aged children. These kids can't process the information they hear in the same way as others because their ears and brain don't fully coordinate. Something adversely affects the way the brain recognizes and interprets sounds, most notably the sounds composing speech.

Kids with APD often do not recognize subtle differences between sounds in words, even when the sounds are loud and clear enough to be heard. These kinds of problems typically occur in background noise, which is a natural listening environment. So kids with APD have the basic difficulty of understanding any speech signal presented under less than optimal conditions.

Detecting APD

Kids with APD are thought to hear normally because they can usually detect pure tones that are delivered one by one in a very quiet environment (such as a sound-treated room). Those who can normally detect sounds and recognize speech in ideal listening conditions are not considered to have hearing difficulties.

However, the ability to detect the presence of sounds is only one part of the processing that occurs in the auditory system. So, most kids with APD do not have a loss of hearing sensitivity, but have a hearing problem in the sense that they do not process auditory information normally.

If the auditory deficits aren't identified and managed early, many of these kids will have speech and language delays and academic problems.

Symptoms of APD can range from mild to severe and can take many different forms. If you think your child might have a problem with how he or she processes sounds, consider these questions:

• Is your child easily distracted or unusually bothered by loud or sudden noises?
• Are noisy environments upsetting to your child?
• Does your child's behavior and performance improve in quieter settings?
• Does your child have difficulty following directions, whether simple or complicated?
• Does your child have reading, spelling, writing, or other speech-language difficulties?
• Is abstract information difficult for your child to comprehend?
• Are verbal (word) math problems difficult for your child?
• Is your child disorganized and forgetful?
• Are conversations hard for your child to follow?

APD is an often misunderstood problem because many of the behaviors noted above can also appear in other conditions like learning disabilities, attention deficit hyperactivity disorder (ADHD), and even depression. Although APD is often confused with ADHD, it is possible to have both. It is also possible to have APD and specific language impairment or learning disabilities.

Causes

The many possible causes of APD include head trauma, lead poisoning, and chronic ear infections. Sometimes the cause is unknown. Because there are many different possibilities — even combinations of causes — each child must be assessed individually.

Diagnosis

Audiologists (hearing specialists) can determine if a child has APD. Although speech-language pathologists can get an idea by interacting with the child, only audiologists can perform auditory processing testing and determine if there really is a problem.

However, some of the skills a child needs to be evaluated for auditory processing disorder don't develop until age 8 or 9. Younger kids' brains just haven't matured enough to accept and process a lot of information. Therefore, many children diagnosed with APD can develop better skills with time.

Once diagnosed, kids with APD usually work with a speech therapist. The audiologist will also recommend that they return for yearly follow-up evaluations.

Problem Areas for Kids With CAPD

The five main problem areas that can affect both home and school activities in kids with APD are:

1. Auditory Figure-Ground Problems: This is when the child can't pay attention when there's noise in the background. Noisy, low-structured classrooms could be very frustrating.
2. Auditory Memory Problems: This is when the child has difficulty remembering information such as directions, lists, or study materials. It can be immediate (i.e., "I can't remember it now") and/or delayed (i.e., "I can't remember it when I need it for later").
3. Auditory Discrimination Problems: This is when the child has difficulty hearing the difference between sounds or words that are similar (COAT/BOAT or CH/SH). This problem can affect following directions, reading, spelling, and writing skills, among others.
4. Auditory Attention Problems: This is when the child can't maintain focus for listening long enough to complete a task or requirement (such as listening to a lecture in school). Although health, motivation, and attitude might also affect attention, among other factors, a child with CAPD cannot (not will not) maintain attention.
5. Auditory Cohesion Problems: This is when higher-level listening tasks are difficult. Auditory cohesion skills — drawing inferences from conversations, understanding riddles, or comprehending verbal math problems — require heightened auditory processing and language levels. They develop best when all the other skills (levels 1 through 4 above) are intact.

How Can I Help My Child?

Strategies applied at home and school can alleviate some of the problem behaviors associated with APD. Because it's common for kids with CAPD to have difficulty following directions, for example, these tactics might help:

• Since most kids with APD have difficulty hearing amid noise, it's very important to reduce the background noise at home and at school.
• Have your child look at you when you're speaking.
• Use simple, expressive sentences.
• Speak at a slightly slower rate and at a mildly increased volume.
• Ask your child to repeat the directions back to you and to keep repeating them aloud (to you or to himself or herself) until the directions are completed.
• For directions that are to be completed at a later time, writing notes, wearing a watch, and maintaining a household routine also help. General organization and scheduling also can be beneficial.

It's especially important to teach your child to notice noisy environments, for example, and move to quieter places when listening is necessary.

Other strategies that might help:

• Provide your child with a quiet study place (not the kitchen table).
• Maintain a peaceful, organized lifestyle.
• Encourage good eating and sleeping habits.
• Assign regular and realistic chores, including keeping a neat room and desk.
• Build your child's self-esteem.

Be sure to keep in regular contact with school officials about your child's progress. Kids with APD aren't typically put in special education programs. Instead, teachers can make it easier for kids by altering seating plans so the child can sit in the front of the room or with the back to the window, or providing additional aids for study, like an assignment pad or a tape recorder.

One of the most important things that both parents and teachers can do is to acknowledge that CAPD is real. Symptoms and behaviors are not within the child's control. What is within the child's control is recognizing the problems associated with APD and applying the strategies recommended both at home and school.

A positive, realistic attitude and healthy self-esteem in a child with APD can work wonders. And kids with APD can go on to be just as successful as other classmates. Although some children do, however, grow up to be adults with APD, with coping strategies and by using techniques taught to them in speech therapy, they can be very successful adults.

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Encopresis

If your child who has bowel movements (BMs) in places other than the toilet, you know how frustrating it can be. Many parents assume that kids who soil their pants are simply misbehaving or that they're too lazy to use the bathroom when they have the urge to go.

The truth is that many kids beyond the age of toilet teaching (generally older than 4 years) who frequently soil their underwear have a condition known as encopresis. They have a problem with their bowels that dulls the normal urge to go to the bathroom — and they can't control the accidents that typically follow.

Although encopresis is estimated to affect 1% to 2% of kids under the age of 10, problems with encopresis and constipation account for more than 25% of all visits to pediatric gastroenterologists (doctors who specialize in disorders of the stomach and intestines).

Most encopresis cases (90%) are due to functional constipation — that is, constipation that has no medical cause. The stool (or BM) is hard, dry, and difficult to pass when a person is constipated. Many kids "hold" their BMs to avoid the pain of constipation, which sets the stage for having a poop accident.

Well-intentioned advice from family members and friends isn't always helpful because many people mistakenly believe that encopresis is a behavioral issue — a simple lack of self-control. Frustrated parents, grandparents, and caregivers may advocate various punishments and consequences for the soiling — which only leaves the child feeling even more alone, angry, depressed, or humiliated. Up to 20% of kids with encopresis experience feelings of low self-esteem that require the intervention of a psychologist or counselor.

Punishing or humiliating a child with encopresis will only make matters worse. Instead, talk to your doctor, who can help you and your child through this challenging but treatable problem.

Encopresis and Its Causes

Three to six times more common in boys, encopresis isn't a disease, but rather a symptom that may have different causes. To understand encopresis, it's important to understand constipation.

There's a wide range of normal when it comes to having a BM. The frequency of BMs varies with a person's age and individual nature. "Normal" pooping might range from one or two BMs per day to only three or four per week. Some kids don't poop on a regular basis, but a child who passes a soft BM without difficulty every 3 days is not constipated. However, a child who passes a hard BM (small or large) every other day is. Other kids may go every day, but they only release little, hard balls and there's always poop left behind in the colon.

So, what causes the hard poop in the first place? Any number of things, including diet, illness, decreased fluid intake, fear of the toilet during toilet teaching, or limited access to a toilet or a toilet that's not private (like at school). Some kids may develop chronic constipation after stressful life events such as a divorce or the death of a close relative. Whatever the cause, once a child begins to hold his or her BMs, the poop begins to accumulate in the colon and a vicious cycle begins.

The colon's job is to remove water from the poop before it's passed. The longer the poop is stuck there, the more water is removed — and the harder it is to push the large, dry poop out. The large poop also stretches out the colon, weakening the muscles there and affecting the nerves that tell a child when it's time to go to the bathroom. Because the flabby colon can't push the hard poop out, and it's painful to pass, the child continues to avoid having a BM, often by dancing, crossing the legs, making faces, or walking on tiptoes.

Eventually, the lower part of the colon becomes so full that it's difficult for the sphincter (the muscular valve that controls the passage of feces out of the anus) to hold the poop in. Partial BMs may pass through, causing the child to soil his or her pants. Softer poop may also leak out around the large mass of feces and stain the child's underwear when the sphincter relaxes. The child can't prevent the soiling — nor does he or she have any idea it's happening — because the nerves aren't sending the signals that regulate defecation (or pooping).

At first, parents may think their child has a simple case of diarrhea. But after repeated episodes, it becomes clear that there's another problem — especially because the soiling occurs when the child isn't sick.

Parents are often frustrated by the fact that their child seems unfazed by these accidents, which occur mostly during waking hours. Denial may be one reason for the child's nonchalance — kids just can't face the shame and guilt associated with the condition (some even try to hide their soiled underpants from their parents). Another reason may be more scientific: Because the brain eventually gets used to the smell of feces, the child may no longer notice the odor.

When to Call the Doctor

Although rectal surgery or birth defects such as Hirschsprung disease and spina bifida can cause constipation or encopresis without constipation, these are uncommon.

Call the doctor if your child shows any of the following symptoms:

• poop or liquid stool in the underwear when your child isn't ill
• hard poop or pain when having a BM
• toilet-stopping BM
• abdominal pain
• loss of appetite

Treating Encopresis

As the colon is stretched by the buildup of stool, the nerves' ability to signal to the brain that it's time for a BM is diminished. If untreated, not only will the soiling get worse, but kids with encopresis may lose their appetites or complain of stomach pain.

A large, hard poop may also cause a tear in the skin around the anus that will leave blood on the stools, the toilet paper, or in the toilet. Constipation is also associated with wetting and urinary tract infections (UTI). If you think your child has encopresis, call your doctor.

Most cases of encopresis can be managed by your doctor, but if initial efforts fail, you may be referred to a gastroenterologist.

Treatment is done in three phases:

1. The first phase involves emptying the colon of hard, retained poop. Different doctors might have different ways of helping kids with encopresis. Depending on the child's age and other factors, the doctor may recommend medicines, including a stool softener (such as mineral oil), laxatives, and/or enemas. (Laxatives and enemas should be given only under the supervision of a doctor; never give these treatments at home without first checking with your doctor.) As unpleasant as this first step sounds, it's necessary to clean out the bowels to successfully treat the constipation and end your child's soiling.
2. After the large intestine has been emptied, the doctor will help the child begin having regular BMs with the aid of stool-softening agents, most of which aren't habit-forming. At this point, it's important to continue using the stool softener to give the bowels a chance to shrink back to normal size (the muscles of the intestines have been stretched out, so they need time to be toned without the poop piling up again). Parents will also be asked to schedule potty times twice daily after meals (when the bowels are naturally stimulated), in which the child sits on the toilet for about 5 to 10 minutes. This will help the child learn to pay attention to his or her own urges. It's especially helpful for parents to keep a record of their child's daily BMs.
3. As regular BMs become established, your doctor will reduce the child's use of stool softeners.

Keep in mind that relapses are normal, so don't get discouraged if your child occasionally becomes constipated again or soils his or her pants during treatment, especially when trying to wean the child off of the medications.

A good way to keep track of your child's progress is by keeping a daily poop calendar. Make sure to note the frequency, consistency (i.e., hard, soft, dry), and size (i.e., large, small) of the BMs.

Patience is the key to treating encopresis. It may take anywhere from several months to a year for the stretched-out colon to return to its normal size and for the nerves in the colon to become effective again.

In the meantime, diet and exercise are extremely important in keeping stools soft and BMs regular. Also, make sure your child gets plenty of fiber-rich foods such as fresh fruits, dried fruits like prunes and raisins, dried beans, vegetables, and high-fiber cereal.

Because kids often cringe at the thought of fiber, try these creative ways to incorporate it into your child's diet:

• Bake cookies or muffins using whole-wheat flour instead of regular flour. Add raisins, chopped or pureed apples, or prunes to the mix.
• Add bran to baking items such as cookies and muffins, or to meatloaf or burgers, or sprinkled on cereal. (The trick is not to add too much bran or the food will taste like sawdust.)
• Serve apples topped with peanut butter.
• Create tasty treats with peanut butter and whole-wheat crackers.
• Top ice cream, frozen yogurt, or regular yogurt with high-fiber cereal for some added crunch.
• Serve bran waffles topped with fruit.
• Make pancakes with whole-grain pancake mix and top with peaches, apricots, or grapes.
• Top high-fiber cereal with fruit.
• Sneak some raisins or pureed prunes or zucchini into whole-wheat pancakes.
• Add shredded carrots or pureed zucchini to spaghetti sauce or macaroni and cheese.
• Add lentils to soup.
• Make bean burritos with whole-grain soft-taco shells.

And don't forget to have your child drink plenty of fluids each day, including water and 100% fruit juices like pear, peach, and prune to help draw water into the colon. Try mixing prune juice with another drink to make it a little tastier. Also be sure to limit your child's total daily dairy intake (including cheese, yogurt, and ice cream) to 24 ounces or less.

Successful treatment of encopresis depends on the support the child receives. Some parents find that positive reinforcement helps to encourage the child throughout treatment. Provide a small incentive, such as a star or sticker on the poop calendar, for having a BM or even just for trying, sitting on the toilet, or taking medications.

Whatever you do, don't blame or yell — it will only make your child feel bad and it won't help manage the condition. Show lots of love and support and, assure your child that he or she isn't the only one in the world with this problem. With time and understanding, your child can overcome encopresis.

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