- The Washington Times - Sunday, August 27, 2000

As summer wound down and school approached, Rafa Rahman arrived for a physical at Kaiser Permanente's Fair Oaks office. In addition to checking the 5-year-old Centreville girl's height, weight and immunization record, the medical staff talked to the first-grader about the importance of wearing a bicycle helmet and eating dairy products. Rafa's parents were asked whether they had guns in their home.

Welcome to a school physical, circa 2000. Millions of children have them this time of year to get required paperwork updated for new schools or to be eligible to play sports.

But what patients and their parents look at as a routine wellness checkup, many doctors see as their best chance to get a clear picture of a family's health. And since a child's health concerns change from year to year, doctors advise parents to use the school physical wisely it may be an optimal opportunity to get advice while not under the stress of dealing with a sick child.

"Requiring school physicals ensures a healthy community," says Dr. Barbara Frankowski, executive board member of the American Academy of Pediatrics' (AAP) section on school health. "It is important for doctors to get to know families and their issues in the long term."

The AAP advises yearly checkups for children until they are age 6, then every other year until age 12, says Dr. Frankowski, who practices in Burlington, Vt. The AAP advises that patients return to an annual schedule during the teen years, when a teen-ager's medical concerns not to mention the risk of forming health-harming habits such as smoking and drinking change rapidly.

The early years

A doctor conducting a physical for a child about to enter kindergarten should review the child's immunizations, screen for vision and hearing problems, and chart his or her growth, Dr. Frankowski says.

But a big part of an exam at age 5 or 6 is screening for school readiness, she says. A doctor or nurse practitioner can help a parent determine whether a child is emotionally mature enough to spend an extended day in the classroom.

"We usually take a developmental history," Dr. Frankowski says. "I like to look at everything from speech is it easy to understand? to whether a child knows his first and last name and his phone number. Sometimes I ask him what he would do if he got on the wrong bus. Issues like attention deficit disorder and the signs of it may or may not have come up.

"I also like to help the parents identify issues they have that they can go over with a teacher, such as whether the child is unusually shy or whether there has been some trauma in the home, such as death and divorce."

Basic signs to determine school readiness include whether a child can sit quietly to listen to a story; whether he can use the bathroom himself; and whether he can write and spell his first name, hold a pencil correctly, cut with scissors, and copy or trace a line or circle.

"The early exam assesses the child in

his total environment," says Dr. Les Ellwood, a pediatrician at Kaiser Permanente's Fair Oaks office. "We can tell a lot from how a child is eating, sleeping and behaving."

A year or two later, that child already will have had some time in school, and the 6- or 7-year-old visit is an ideal time to check the patient's progress, Dr. Ellwood says.

"After kindergarten, I always ask how school is," Dr. Frankowski says. "Are they getting their homework done? Are there problems with other kids? Problems following directions?"

The 6- or 7-year-old visit might include a talk with parents on how to help their child adjust to the increased demands of school, such as the importance of both structured and unstructured activities after school, organizing book bags the night before to save time in the morning, setting aside a fixed time for homework and providing a study space.

Age 6 or 7 is a good time to discuss a child's routine, Dr. Ellwood says. At his office, doctors usually ask about a child's exercise habits and discuss how much time the child spends watching television or playing video games (they advise no more than two hours a day). This is a good time to discuss safety issues such as seat belts, bike helmets and guns in the home.

More than birds and bees

The changes that approach with puberty aren't just biological, Dr. Frankowski points out.

"By ages 10 or 12, it is the relationships within the family that change," she says. "Here is where peers become important and parents have become 'dumb.' This is when a lot of kids will start drinking, smoking and giving in to peer pressure. I have been in practice 15 years, and I always hear things such as, 'But he's only 8 …' I don't know if children are doing things younger, but the influences, whether from peers or the media, certainly are more widespread."

That is why the preteen visits are the best time to check on how parents and children are relating, Dr. Frankowski says.

"The kids who get through this time well are the ones who are connected, whether to school or clubs or sports or church," she says. "I remind parents of children this age to always ask about their child's day."

Adolescence is an important time to begin looking for signs of psychosocial issues, Dr. Ellwood says. This is a good time for parents to know the signs of depression, such as poor sleeping habits, a change in appetite, a loss of friends or a drastic change in school performance.

An adolescent physical also should include a discussion of healthy eating habits and the importance, particularly for young girls, of drinking milk rather than soda.

"I show them a growth chart and show them how important it is to eat well if they want to continue growing," Dr. Frankowski says.

These visits are also the time to discuss eating disorders with young girls who might feel pressure from the impossible media images of thinness, says Dr. Jennifer Johnson, an Irvine, Calif., pediatrician and chairman of the AAP's adolescent medicine section.

"Getting a kid in here for a physical whether it is for school, sports or just updated immunizations is our best chance to nail them with questions," she says. "Of course, we can get their full medical history and do a physical checkup, but doctors are here not so much for education, but for reinforcement from peer pressure. Our goal is to be able to establish some rapport. Things change so quickly at this age. We may be the only adult some children can talk about certain things with."

Getting ready to play

Gaining medical clearance to play sports is what brings many junior high and high school students to the doctor. Dr. Frankowski says she uses the opportunity to conduct a complete physical.

"It is important for doctors to pay attention to anything that could cause trouble, particularly in contact or collision sports," she says. "The AP does have criteria as to who passes a sports physical. They want to be cautious."

An important area of scrutiny in a sports physical is the heart, including congenital heart disease, irregular heart rhythm, an abnormal heart valve, high blood pressure or carditis (an infection or inflammation of the heart that can cause sudden death with exertion). The presence of any of these conditions probably would require at least further evaluation before giving an athlete clearance to play, Dr. Frankowski says.

If a child has lost an organ or has received an organ transplant, contact sports such as football or hockey would not be recommended, she adds. If a student has had more than three concussions, he also might be advised to take up a less risky sport.

Conditions such as asthma or allergies usually wouldn't disqualify an athlete, but the coaching staff should be made aware of the condition, she says.

"Very few children are totally disqualified," Dr. Frankowski says. "But everyone needs to be aware of possible medical problems. There are no absolute guarantees when it comes to children's health and sports, but we try and do the best we can to make sure the child is not taking undue risk."

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