Pediatric Associates of Richmond

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  1. Enriching Sibling Relationships

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    “PARdon Me” a blog series by Laura Duke, CPNP, IBCLC

    PARdon me…but how is the brotherly/sisterly love flowing at your house?  Siblings are spending an unprecedented amount of time together.  They are not headed off in different directions for sports or activities.  Friends may only be available by screen.  Schoolwork has come to a close.  In the end, the only person to hang out with….other than, heaven forbid, mom or dad….may be their brother or sister. 

    Almost 80% of children grow up with at least one brother or sister. (  Unlike friends who may come and go, siblings are connected for a lifetime.  Pamela Dugdale says, “Siblings are the people we practice on, the people who teach us about fairness and cooperation and kindness and caring quite often the hard way.”  Through sibling and other family relationships, we learn how to deal with conflicts, how to appreciate individual differences and how to see life and the world around us from a different perspective.  What can parents do to foster these relationships?

    Embrace Differences:  “Everybody’s beautiful…in their own way.”  (Ray Stevens)

    Siblings may look almost identical but be very different in personality and aptitude.  This is something to celebrate!  Encourage your children to have separate interests.  Embrace their individuality.  Avoid comparisons verbal or nonverbal. 

    Foster Fun:  “Never underestimate the importance of having fun.” (Randy Pausch)

    Encourage your kids to be silly.  Make a game out of being nice to your brother or sister.  Once again, I refer you to Pinterest.  There are tons of pins featuring activities that encourage sibling bonding and help with rivalry and fighting.  Many are geared towards siblings of varied ages.  You don’t have to come up with the ideas yourself.

    Allow Disagreements:  “Siblings that say they never fight are most definitely hiding something.”  (Lemony Snicket)  

    Siblings will fight.  It is how we learn conflict resolution.  Your job as a parent is NOT to solve every argument.  That would be impossible.  You should also not ignore disagreements.  Take the time to hear both sides and help your kids identify how to compromise or resolve the issue.  It is OK to have parameters such as no hitting or physical contact, no name calling or bad language and no property damage.  Sometimes a little quiet time apart may be necessary  before working towards a resolution.  Remember that rarely is only one person completely right in a conflict.  There are always two sides.  Some physical contact between siblings is normal and age appropriate.  James Patterson observed, “Half the time, when brothers wrestle, it’s just an excuse to hug each other.”  I am pretty sure that if you point this out to them, they will stop. 

    Encourage Teamwork:  “There is no I in team.” (Michael Jordan and every coach ever) 

    Find ways for your kids to work towards a common goal.  Have them race mom and dad to finish a household chore.  Give them an age appropriate project to work on together and follow it up with a simple reward.  Let them gang up on you sometimes!

    Know When to Separate:  “If you are lonely when you are alone, you’re in bad company.” (Jean-Paul Satre)

    Recognize when the sibling togetherness is starting to wear thin and encourage your kids to spend some time alone.  Allow them to engage in some activities on their own without their brother or sister around.  Take time to allow kids to spend some one on one time with each parent.  You will get as much out of it as they will.    

    As I have often said, give yourself and your kids some grace.  It is a very different time.  They are trying to navigate it as we are and sometimes that means lashing out at the safest people in their life.  Building strong sibling bonds takes time and practice.  We make mistakes along the way and keep trying.

    In the meantime…..PARdon me……

    Previous PARdon Me blog entries

  2. Three Chopt check-ups & other office changes

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    If you’ve held off scheduling your child’s check-up until appointments re-opened at Three Chopt, the wait is nearly over. Beginning June 1st, we will resume having check-ups at the Three Chopt location.

    Sick visits will continue to be only at the Three Chopt location, but will be in a completely different wing from the check-ups, and will use a separate entrance. Those coming for sick visits will enter the building as they normally would, but enter our west wing through a door immediately to the left. They WILL NOT go through our main glass doors with our logo on it. This will be the entry point for check-ups. Follow signs for more details.

    As has been the case for the last 10+ weeks, our phone screening protocols will remain in place to ensure patients with possible or likely COVID-19 are evaluated in the parking lot.

    On June 1st we will also be expanding our start time to 8:30 a.m. for the Mechanicsville and Short Pump locations. They will both remain well-child only for now. We appreciate it is less convenient for those who prefer these locations to come to the Three Chopt office for sick visits. But in order to optimize safety for you and our staff, this is the best option for now.

    The following have not changed:

    1. Parking Lot check-in for all 3 locations (no waiting rooms)
    2. Closing at 5:00 p.m. at all 3 locations
    3. Three Chopt location sick visit appointments start at 7:30 a.m. Monday-Friday
    4. Telemedicine appointments for select complaints/concerns during business hours Monday-Friday
    5. Saturday morning newborn and sick visit appointments

    We are excited to have more check-up appointments available, and at a 3rd convenient location. The above changes will also ensure we can safely continue to care for sick children.

  3. COVID-19 & Multi-System Inflammatory Syndrome in Children (MIS-C): What You Need to Know as a Parent in RVA

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    Let’s start with what we know about COVID-19.

    COVID-19 is a disease that is caused by a novel (i.e. new) coronavirus – SARS-CoV 2.  It was first recognized in December 2019 and was declared a pandemic by the World Health Organization on March 11, 2020. The first confirmed pediatric case of COVID-19 was March 2, 2020.  As of May 17, 2020, CDC data for which age demographics are available show that children (0-17 years old) make up about 3% of confirmed cases in the U.S. COVID-19 remains an uncommon disease in pediatrics.

    What about MIS-C? Where did this come from? On April 26, 2020 health care providers in the United Kingdom began to report a severe inflammatory syndrome in previously healthy children. It was similar to toxic shock syndrome and Kawasaki disease.  These children had a persistent fever, elevated inflammatory markers (blood tests), low blood pressure and multiorgan (heart, skin, gut, kidneys, brain and blood) involvement.  These patients had either tested positive for COVID-19 or had a significant exposure. The original name given was Pediatric Inflammatory Multisystem Syndrome (PIMS). The CDC renamed it MIS-C on May 14, 2020 in order more specifically define criteria for diagnosis, treatment and data collection.

    In May, the New York City Health Department began to receive similar reports. Many, but not all, of the children in New York had tested positive for COVID-19. The CDC released an advisory to health care providers on May 14, 2020 to look out for this rare and unusual syndrome. 

    For those into numbers, consider that in NYC as of 5/17/20 only 3% (4,955) of their total cases (190,408) have been in children. Of those 4,955 confirmed cases in children, there have been 145 cases of MIS-C. In summary, about 3% of all COVID-19 cases in NYC have been in children, and only 3% of those 3% have experienced MIS-C. So while yes it is a serious syndrome, it is thankfully quite rare.

    Let’s briefly compare Virginia to NYC (we know this isn’t comparing apples to apples because of the population sizes, but it does give more perspective for us). As of May 17, NYC has had about 3,000 MORE pediatric cases of COVID-19 than all of Virginia, and more than half of Virginia’s pediatric cases (1,030 of 2,048) have been in Fairfax, Alexandria and Prince William (i.e. Northern Virginia). These data are not shared to diminish the impact this syndrome has on a patient or their family. But we think it’s helpful for parents at our practice to keep perspective on how rare this is, especially in Richmond, VA. And hopefully this helps you to worry less.

    Scientists and clinicians are hard at work studying MIS-C and developing effective treatment.  Having lots of experience treating toxic shock syndrome and Kawasaki disease has helped. Typically patients are monitored closely and treated in intensive care units.

    When should you worry as a parent?  Keep in mind that COVID-19 remains uncommon in children and MIS-C is a VERY rare condition (see above). Symptoms that would indicate that your child needs to be evaluated include:

                -a persistent fever

                -rash or changes in skin color

                -abdominal pain, vomiting or diarrhea

                -trouble breathing

                -confusion or difficulty arousing your child        

    We are here for you.  Call if you have any questions or concerns. As always, is an excellent resource offered by the American Academy of Pediatrics that is frequently updated. 


  4. Guiding Teens through Missed Milestones

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    This will be quite a tough May for many of our teenagers. May is prom season. It’s when spring athletes would be finishing up their seasons and possibly competing for championships. It’s when those in performing arts showcase all their hard work through instrumental talents, singing, dancing or acting. Perhaps most notable is that May signals preparation for graduation. This year’s senior class won’t get to experience these milestones the way they had expected or planned just a couple short (er, very long) months ago. For many, coping with that has been, or will be, trying.

    Similar to grieving the loss of a loved one, grieving the loss of these milestones is frustrating, maddening, confusing and sad. The phrase, “Life isn’t fair” has never been more true than it is right now. But that’s not what our teens need to hear. And it’s certainly not what they want to hear. Never more have our teens needed our empathy than in the face of missing these events, which likely are or would be the best, most memorable experiences of their young lives.

    As we parents fumble our way through helping our teens cope, there are many things we could say that may be hurtful rather than helpful – even if they’re well-intentioned. We may have the ideas of (1) telling our teen how much better the next phase of life is; (2) recounting horror stories from our own lives at the same stage; or (3) saying, “well at least you won’t have to deal with or worry about ______.” These types of statements attempt to help our teens look on the brighter side, but maybe they want, and quite frankly need, to wade in these waters of sadness and disappointment for a little while. Trying to help them look on the brighter side could invalidate or devalue the emotions they’re feeling, and lead to that dreaded phrase no parents want to hear: “you just don’t understand!”

    So, what can we do to help our teens navigate these milestones? (NOTE: these tips are in part from Dr. Neil Sonenklar, child and adolescent psychiatry, Children’s Hospital of Richmond – adapted from his Zoom lecture “Mental Health in Teens During Quarantine”)

    1. State the obvious: Life sucks! Or however you’d like to phrase it. This acknowledges their sense of loss, and helps them to see you “get it.”
    2. Let them vent. Not all day, everyday. Give them 10 minutes everyday to express their frustration, sadness, or other emotions of grief. But after that they need to drop it (until the next day).
    3. Ask: “Is there something we can do to honor this occasion?” Keep it open-ended. It could be something to do now. It could be something in a couple months when restrictions are loosened. It could be both. Don’t offer your suggestions, at least not at first. There’s going to be awkward silence. That’s ok. Again, if you’re grieving the loss of a loved one there are a lot of moments of awkward silence. Honoring something or someone fosters acknowledgement, celebration, remembrance of good, reflection on a long path successfully navigated, and assurance that though not physically experienced these milestones won’t be forgotten.

    Unless they ask for your input, it’s best for your teen to explore how honoring a missed milestone would be most meaningful to them. Your role as parent is to support, and help guide them through this. Not to do things for them in hopes of cheering them up. So start a dialogue, and let your teen know you’re there when they’re ready to talk.

  5. Anxiety Management Tips

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    “PARdon Me” a blog series by Laura Duke, CPNP, IBCLC

    PARdon me…but how are the worriers at your house?  Has the anxiety level hit the red zone?  Even if you were able to answer some of your child’s questions using the strategies we discussed last time, it is normal for your child to be anxious in our current situation.   How do you know when your child has too much anxiety and what can you do to help?

    Anxiety can be a very normal and healthy emotion.  It alerts us.  It recruits our defense mechanisms and internal problem-solving skills.  It may cause distress but is not always a medical condition.  It becomes a problem when its duration or severity is out of proportion to the circumstances. 

    Anxiety is not always easy to recognize, especially in children.  Children are not always able to put words to their feelings or express that they are anxious.  Restlessness, difficulty concentrating, irritability, temper tantrums or rages, increased fatigue, poor eating and/or frequent trips to the bathroom may all be signs that your child is anxious.  Nausea, stomachaches, and headaches, in the absence of other signs of illness, may also be symptoms of excessive anxiety.

    How can you help your family manage their anxiety?  Now more than ever, mental health resources are available at your fingertips from the comfort of your couch. 

    Meditation and Mindfulness

    We cannot remove stress or worries from our children’s lives but we can help them develop a toolbox of strategies that help.  Anxiety often changes our breathing patterns.  Taking the time to pause and slow our breathing pattern can have a big impact on how we feel.  Phone apps like Calm or Headspace are excellent for teens and older children to build a meditation practice or structure their breathing.  Pinterest is not just for recipes or home décor. Just search under anxiety and kids.  You will find creative tools for youth of all ages.  You can make your own mindfulness jar or teach your younger child starfish or five finger breathing patterns. There are charts, ideas for play therapy and lists of helpful books.

    Channeling Worries

    As parents, we want to reassure our children.  However, telling an anxious child not to worry or that everything is going to be all right does not typically take the anxiety away.  What we can do is help our children express and channel their worries.  Allow them to worry but contain it.  Have them help you identify what are worries they can control and what are worries they cannot control.  Make a worry box in which they can place written-down worries they cannot control, and let them go.  Give them a worry they can solve:  What shall we have for dinner Friday night?  What game will we play outside tomorrow?  Dr. Nelson loves to ask kids, “What ice cream flavor has not yet been invented?”

    Check Yourself

    Your children watch you.  You are often their barometer to what is going on in the world.  They may not hear you ask them for the tenth time to make their bed but they are listening to everything else you say.  There is a time and place for adult conversations.  Before you help your kids with their anxiety, make sure you are addressing your own.  Take care of yourself and give yourself some grace.  And as I have said before, turn off the television.

    Let us know if despite these strategies your child’s excessive anxiety persists.  We are here to help.

    In the meantime……PARdon me…

    We are here for you…..if there is a topic that you would like addressed in a future blog, please let us know in the comment section. 

  6. Telemedicine Options Now Available for Specific Concerns

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    In an effort to adapt to the current climate and best serve our patients, we are making more telemedicine options available to our patients at this time. Although nothing is a substitute for an in-person visit and the ability to communicate face-to-face with a healthcare provider, utilizing this strategy for specific cases makes a lot of sense for the time being. To begin, virtual visits will be made available to those with one of the following concerns:

    • Behavioral/Developmental concerns
    • Cold symptoms (mild) without fever
    • Conjunctivitis (pink eye)
    • Constipation
    • Diarrhea
    • Feeding concerns
    • Lacerations (cuts) to determine the possible need for stitches
    • Mental Health follow up & Med Checks for stable patients (home weight measurement recommended)
    • Rash
    • Seasonal/Environmental Allergies (not food allergies/allergic reactions)
    • Skin infections
    • Sleep Concerns
    • Vomiting

    Please be aware that in the course of a telemedicine encounter we may determine that a virtual visit is not appropriate or sufficient to provide the best care for your child. In these cases we will recommend you bring your child to our office for further evaluation. 

    Routine check-ups will not be done by telemedicine. Additionally, we can not diagnose or treat the following without in-person examination and/or testing (not a complete list):

    • Ear infections
    • Strep throat
    • Urinary tract infections
    • Wheezing, Bronchitis, or other Respiratory (breathing) concerns

    All telemedicine visits will be scheduled with a provider who has an open appointment slot, and will occur during business hours, Monday through Friday. They are billed the same as an in-person visit. Depending on your insurance company, there may be a co-pay associated with the visit. If so, you will be mailed a statement/invoice from our billing office; this can be paid online.

    You will receive a text from our office prior to your virtual visit with instructions for connecting with your scheduled provider. Please ensure you confirm with us your preferred mobile phone number to receive this text. We also request you be in a private, quiet room with good lighting and a strong wireless or wifi signal during the virtual visit.

    Our telemedicine visits will be conducted primarily via Zoom. Zoom is not typically HIPAA compliant, but the regulations have recently been loosened by our governing bodies to allow for more telemedicine. Further, our meetings are password protected and we utilize a virtual waiting room that allows providers to control who enters the meeting. Please download the Zoom app or software prior to your appointment time.

    Thank you for continuing to trust us to care for your children.

    In Case You Missed It

  7. Talking to Your Kids about COVID-19

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    “PARdon Me” – a blog series by Laura Duke, CPNP, IBCLC

    PARdon me…but do you sometimes find it hard to answer your child’s questions about COVID-19 and our world today? Are you or your kids experiencing some anxiety? It is hard NOT to be anxious these days. We are simultaneously dealing with too much information and so many unanswered questions. A well planned, thought out strategy can help you and your family navigate this current pandemic world.

    Time is on Your Side…Yes it Is

    As mentioned in a previous blog entry, children respond well to some sense of structure or routine. While our lives have changed greatly, maintaining some routine provides security. Within that routine, allow your child some time for questions. Check in on a regular basis. This can be as simple as sitting together at the table for at least one meal a day or spending some one-on-one time before bed at night. Family walks are another opportunity for conversation. 

    Just the Facts, Ma’am

    Arm yourself with facts. “What is Coronavirus?” by Chrstine Borst, PhD, LMFT, is a digital children’s book about the virus that is helpful. So as not to become completely overwhelmed yourself, pick one or two trusted resources. I have mentioned in past blogs the COVID-19 page by the American Academy of Pediatrics. It is constantly updated with what is known about COVID-19, and includes resources for parenting during a pandemic. The National Institutes of Health and the Centers for Disease Control and Prevention are also reliable resources.  Turn off the television. The steady stream of daily news is overwhelming for all of us. If your child is older and asks to watch the news, watch it together and with time limits. 

    Can You Repeat the Question?

    When your child asks a question, make sure you are answering what is asked. Repeat it if necessary…it gives you time to think. Answer in simple language. Do you have an articulate child? Remember that children’s language may be mature though their thinking is still very concrete. Confirm that you have answered what they have asked.

    People Who Need People

    Keep connections. As previously mentioned, there are an unprecedented number of ways to maintain social connections. Giving children other people with whom to connect provides them resources for questions and concerns.

    Accentuate the Positive

    It is so easy to get bogged down with mourning what we are missing these days. Help your kids celebrate the positives too. A gratitude list is an excellent tool to accomplish this. Have each family member identify 3 to 5 things they are grateful for. Their list can be simple or silly. It is their list.  Ask them to share their favorite part of their day.

    Put on Your Oxygen Mask

    You cannot be a positive resource for you family if you yourself are depleted. Self care is an overused phrase these days that conveys the sense of one more thing to add to our to do list. Work with your partner to find ways to allow each other some me time.  Self care can be as simple as taking a breath, at times putting yourself first, and above all giving yourself some grace.

    Next week we will look at signs that anxiety is persisting despite questions being answered, and explore strategies to help worriers.

    Until then, PARdon me….

    Previous PARdon me blog entries

  8. Shelter-In-Place Activities

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    “PARdon Me” – a blog series by Laura Duke, CPNP, IBCLC

    Do Something….

    PARdon me…did you DO SOMETHING today?  Is your family finding a purpose in their day while sheltering in together?  Last week, I mentioned that Dr. Lori Evans of Sirius Doctor Radio’s show “About Our Kids” encourages each family member to set a goal of doing 4 things every day:  something social, something active, something fun and something productive.  How are you doing?

    Do Something Social

    Now more than ever, it is vital for us all to keep social connections.  Never before have there been so many ways to do this from your couch or backyard.  Encourage your family members to reach out to friends via Skype, WhatsApp, Facetime or Zoom to name a few video platforms.  Houseparty is an app that connects teens via chatting and games.  Trying to get away from the screen?  Everyone loves getting mail.  Encourage your child to reach out to a classmate or relative as a pen pal. 

    Do Something Active

    Keep moving.  Dance in your kitchen.  Cosmic Yoga offers classes on YouTube that combines movement with stories.   Get outside.   Ride your bike or scooter…with a helmet, appropriately distancing, of course.  Take walks.  It does not have to be sunny.  A little rain never hurt anyone.  Many communities are holding teddy bear hunts in which residents place bears or stuffed animals in their windows.  Some neighborhoods are posting scavenger hunts.

    Do Something Fun

    Do something fun every day.  Let your child identify what is fun for them.  Be creative.  Now may be a time to encourage your child to explore an interest or hobby.  Gardening gets everyone outside.  Many museums and zoos are doing virtual tours.  Pull out your art supplies. 

    Do Something Productive

    Most schools, if not providing online instruction, are offering enrichment activities.  Help your child set up a space and plan time to get their work done.  There are other ways to be productive.  Is there a home project you have been meaning to tackle?  A meme circulating on Facebook states “I always said I would deep clean my house, if I ever had the time…it turns out that was not the reason.”  Projects can be overwhelming.  Break them down to small manageable tasks.  One of our doctors developed this home/life skills scavenger hunt for their teens. 

    Dr. Evans states that there is no double dipping.  The goal is to have something separate for each category.  All of these are just options.  Remember that if you are adding stress to your life trying to hit the mark for all four categories, keep it simple.  Part of the fun is gathering at the end of the day and asking your kids how they did.  As always, give yourself some grace…you get credit if you DO SOMETHING!

    In Case you Missed It…

  9. Well Child Check-Ups Still Recommended During COVID-19 Pandemic

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    PAR continues to recommend scheduling and keeping routine, on-time check-ups – a policy reaffirmed by an AAP statement earlier today (4/15/2020). We have received many calls and questions about check-ups, and whether or not parents should keep their child’s appointment. Parental concerns are understandable. Today’s post will address these concerns in the context of current governmental and medical recommendations.

    Regularly scheduled check-ups are vital for ensuring that a child is growing well, developing appropriately, and receiving vaccines to protect against serious, and sometimes deadly, infections. As many parents can attest, it is also a time during which we address parents’ questions & concerns. Well child care, including vaccines, has therefore remained a top priority for PAR. As previously noted, this approach is supported and (today) reaffirmed by the American Academy of Pediatrics.

    To optimize the safety of wellness visits, we have:

    • Made the Three Chopt office sick visits only, and Short Pump & Mechanicsville offices well visits only
    • Had only one parent/guardian accompany each child to their visit
    • Eliminated waiting rooms by providing online check-in in the parking lots
    • Administered vaccines in the exam rooms instead of at nurse’s stations, where we had traditionally done so
    • Utilized phone triage to ensure individuals coming to the well offices are healthy and without known exposures to COVID-19
    • Placed signs on front doors of each office location reinforcing phone triage screening

    We strongly believe that taking these steps has made the aforementioned benefits of check-ups much greater than the low risk of being exposed to coronavirus.

    If you have unique questions about your child and our recommendations to continue routine check-ups, please call (804) 282-4205 and ask to speak with a member of the clinical team. If you are wondering if your child is due for any vaccines at their upcoming visit, you may reference our Check-Ups and Vaccines schedule.

  10. Shelter-In-Place Strategies

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    “PARdon Me” – a blog series by Laura Duke, CPNP, IBCLC

    PARdon me…but how is your shelter-in-place family time going?  Families are spending an unprecedented amount of time together, often in close quarters.  This can be a blessing AND a challenge.  Routine, purpose and a lot of grace can help us navigate this time. 

    The internet is filled with ideas and recommendations for families sheltering in and learning from home.  One very common theme is the importance of routine.  When things are turned upside down, routines can help maintain some sense of normalcy.  Encourage members of your family to make their beds.  Get up in the morning and shower and dress as if you are going to school or work. 

    Nutrition and sleep are keys to staying healthy.  Eat regular, balanced meals and maintain sleep routines.  Let your kids be involved planning menus and helping in the kitchen.  Make a game out of trying new foods.  Make a rainbow chart and have your picky eater fill it with the colorful foods he or she has tried. 

    Keep bedtimes similar or consistent.  Good sleep hygiene is essential.  Bedrooms should be cool and dark.  As always, the bedroom should be a screen free zone.  A 2016 review article in JAMA (Journal of the American Medical Association) Pediatrics found that children 6 to 19 years old with “media device presence in the bedroom (even without use) was associated with an increased odds of detrimental sleep outcomes,” (i.e. inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness). 

    Having a purpose to your day helps kids and parents with the monotony of sheltering in.  Dr. Lori Evans of Doctor Radio’s show “About Our Kids” encourages everyone to have four goals for their day:

    1. Do something SOCIAL
    2. Do something ACTIVE
    3. Do something FUN
    4. Do something PRODUCTIVE

    I’ll expand on these four in next week’s blog post, but I would also add Do something FOR SOMEONE ELSE.

    It is easy for us to focus on our own situations and mourn what we are missing.  Encourage your child to reach out to someone else.  Call an isolated family member.  Send artwork to members of a local nursing home that may not have other family.  Chalk messages on your driveway or sidewalk for neighbors.  Leave a card for your postal worker or delivery person.  Do something nice for your brother or sister.  Surprise them by making their bed.  Play a game that they pick. 

    This sounds like a lot and can be overwhelming.  Help is available.  The resource I referenced last week is constantly updating content. is full of activities for kids as well as resources for parents. 

    At the end of the day, give yourself some grace.  You can not take care of your family if you do not take care of yourself.  It takes human beings to raise human children.  No one is perfect.  Waking up every day striving to make the best of sheltering in for your family is a noble goal.  We are here for you.

    Until next week, PARdon me…


    In Case You Missed It