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Some time ago I asked a teenager on whom I was doing a complete physical about physical education in his school. He told me he was taking life skills classes instead of physical education. Despite his explanation, I didn't fully understand what these classes entail until I read "Life skills training: A prevention program that works" (May). This appears to be a good program, and apparently it's effective.
I wonder, however, if the program has any role for parents. A lot of problems may originate in the home. A short program to orient the parents as to what their children are learning might be a good idea. It would help parents to encourage teens, directly or indirectly, to adapt to the new life skills they are learning. And parents might learn something about how their lives affect their children.
Theodora Ewusi-Mensah, MDPhillips Ranch, CA
The authors reply: Parents do indeed have an important role to play in promoting positive youth development and preventing health problems resulting from maladaptive behaviors such as tobacco, alcohol, and illicit drug use. For this reason, we are in the process of developing and testing a parent component to our successful school-based program. The parent component is designed to be used in combination with our classroom program by providing parents with (1) information about the life skills training program their children are receiving in school, (2) activities that parents may do with their children to reinforce the material being taught in the life skills training classes, and (3) family-related risk factors and what parents can do to reduce them.
Parents are taught the importance of their own behavior as role models for nondrug use and positive health behaviors, the need to convey clear and consistent antidrug attitudes and establish antidrug-use family norms, and the need for monitoring their children's behavior and providing adequate supervision after school. Finally, parents are taught a set of family management skills intended to promote family communications, how to develop an appropriate set of family rules, and guidelines concerning fair and consistent disciplinary practices.
While school programs can do a great deal to reduce drug abuse and promote positive health practices, we wholeheartedly agree that involving parents is likely to further increase the power of effective prevention programs.
As a neonatologist (and hence a hospitalist) I was very interested in "When pediatric hospitalists make sense" (April). In my experience, most pediatricians welcome hospitalists. Pediatricians are very reluctant to interrupt their busy daytime schedules and leave an office full of patients to run through traffic to the hospital to a cesarean section, for example. They call me instead and sometimes ask me to have my nurse practitioner attend a newborn infant at another hospital where they are on staff.
The key to acceptance for a hospitalist is to have good communication and interpersonal skills. Pediatricians tend to resent neonatologists who don't talk to them. In addition, as Dr. Heldrich points out, hospitalists should avoid competing with private physicians in the community. They should not have a private practice outside the hospital.
Donald E. Buchanan, MDLas Vegas, NV
The author replies: Dr. Buchanan's comments indicate that he is a neonatologist who is welcomed by the pediatricians in his community. This is understandable since he realizes that having "good communication and interpersonal skills" is critical to success. Pediatricians enthusiastically support neonatologists who have these attributes in addition to ability. The hospitalist with a cooperative approach also can provide pediatricians with continuing medical education that may not qualify for Category I credits but is of inestimable value.
Dr. Stashwick's reply to the question about intended teen pregnancy in "Behavior: Ask the experts" (March) provides important guidelines for the physician. I would also recommend considering the possibility of sexual abuse or exploitation, especially among younger adolescent girls and socially disadvantaged teens. What is the age or developmental gap between the teen and her partner? Does the young woman intend to become pregnant because of psychological coercion? The pediatrician may need to call in child protective services or the police when dealing with young teenagers, predatory adult males, or dysfunctional, exploitative, or neglectful families.
I greatly enjoyed "Caring for the young dancer" by Jordon D. Metzl, MD (June). However, I have several concerns about the stretches presented on page 137, "Exercises for muscle flexibility."
I have always been taught that the pictured sitting hurdler's stretch is inappropriate because it puts a great deal of rotational stress on the knee. This exercise can still be used as a hamstring stretch if the knee is bent so that the heel is in the groin and the athlete uses a gentle forward bend to stretch the hamstring muscle.
The standing hamstring stretch must be carefully demonstrated to athletes lest they hyperextend their backs. I have them perform this stretch lying face down on the floor to avoid injury.
The Achilles stretch pictured is a good one, but I have been cautioned by my sports medicine colleagues that it should only be performed when the athlete is very warm, after a workout. Other, less stressful floor calf stretches can be performed during warm up.
I greatly enjoy your publication and find many useful pieces of information in every issue. Keep up the good work.
Lynne S. Wirth, MDRaleigh, NC
"Caring for the young dancer" by Jordan D. Metzl, MD (June), is an excellent article. Is there any information regarding younger children, from 5 to 10 years old, who participate in dance and complain of limb pain or trauma?
Stephen P. Combs, MDKingsport, TN
The author replies: Dr. Wirth's concerns about stretches raise an important issue. A truism about adolescent development is that an adolescent can never stretch or study too much. Stretching is a sports-dependent activity; the stretches needed for baseball are different from the stretches needed for soccer. In addition, what one child can tolerate without discomfort, another child finds difficult. Young athletes should be taught to stretch before, and, most important, after exercise.
The hurdler's stretch, if done properly, is safe and produces little torsion about the knee. Stretches like this one put much less stress on the knee than the rigors of competition. The Achilles stretch, like all stretches, should be performed in a gradual fashion with an attempt to limit ballistic, rapid movements. Muscle injury can result from overzealous stretching, but it is easily avoided if the stretch is gradual and not forced. If the Achilles stretch is not tolerated, the athlete can lie on his or her back, put the foot in the air, and hold a towel around the base of the foot. By pulling back, the athlete stretches the Achilles tendon in a more gradual fashion.
In response to Dr. Combs' comments, children 5 to 10 years old have only recently begun to participate in organized sports in large numbers. So data on dancers, figure skaters, and gymnasts that age are limited. As a rule, kids enjoy sports. If they come in complaining of an injury, it's important to listen to their concerns and evaluate them fully. I would take an X-ray if there was any joint swelling, or if complaints persisted for more than three weeks.
For further information, see the Journal of Dance Medicine & Science, an excellent quarterly that addresses dance-related concerns. A special issue (vol. 3, no. 2), entitled "Dance and Development in Children and Adolescents" is a valuable resource.
Jordan D. Metzl, MDNew York, NY
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Iris Rosendahl. Letters. Contemporary Pediatrics 1999;10:22.