Fighting and Biting in Children

All people have aggressive feelings. As adults, we learn how to control these feelings. Children, however, are often physically aggressive B they hit, bite and scratch others. These behaviors are fairly common and often appear by the child's first birthday. Parents often struggle over how to manage their child's aggressive and/or destructive behavior.

While some biting can occur during normal development, persistent biting can be a sign that a child has emotional or behavioral problems. While many children occasionally fight with or hit others, frequent and/or severe physical aggression may mean that a child is having serious emotional or behavioral problems that require professional evaluation and intervention. Persistent fighting or biting when a child is in daycare or preschool can be a serious problem. At this age, children have much more contact with peers and are expected to be able to make friends and get along.

Many children start aggressive biting between one and three years of age. Biting can be a way for a child to test his or her power or to get attention. Some children bite because they are unhappy, anxious or jealous. Sometimes biting may result from excessive or harsh discipline or exposure to physical violence. Parents should remember that children who are teething might also bite. Biting is the most common reason children get expelled from day care.

What to do:

* Say "no", immediately, in a calm but firm and disapproving tone.
* For a toddler (1-2 years), firmly hold the child, or put the child down.
* For a young child (2-3 years) say, "biting is not okay because it hurts people."
* Do NOT bite a child to show how biting feels. This teaches the child aggressive behavior.
* If biting persists, try a negative consequence. For example, do not hold or play with a child for five minutes after he or she bites.

If these techniques or interventions are not effective, parents should talk to their family physician.

Toddlers and preschool age children often fight over toys. Sometimes children are unintentionally rewarded for aggressive behavior. For example, one child may push another child down and take away a toy. If the child cries and walks away, the aggressive child feels successful since he or she got the toy. It is important to identify whether this pattern is occurring in children who are aggressive.

What to do:

* It is more effective to intervene before a child starts hitting. For example, intervene as soon as you see the child is very frustrated or getting upset.
* When young children fight a lot, supervise them more closely.
* If a child hits another child, immediately separate the children. Then try to comfort and attend to the other child.
* For a toddler (1-2 years) say, "No hitting. Hitting hurts."
* For a young child (2-3 years) say, "I know you are angry, but don't hit. Hitting hurts." This begins to teach empathy to your child.
* Do NOT hit a child if he or she is hitting others. This teaches the child to use aggressive behavior.
* Parents should not ignore or down play fighting between siblings.

When hitting or fighting is frequent, it may be a sign that a child has other problems. For example, he or she may be sad or upset, have problems controlling anger, have witnessed violence or may have been the victim of abuse at day care, school, or home.

Research has shown that children who are physically aggressive at a younger age are more likely to continue this behavior when they are older. Studies have also shown that children who are repeatedly exposed to violence and aggression from TV, videos and movies act more aggressively. If a young child has a persistent problem with fighting and biting or aggressive behavior, parents should seek professional assistance from a child and adolescent psychiatrist or other mental health professional who specializes in the evaluation and treatment of behavior problems in very young children.

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Surviving the Teen Years

When you consider that the teen years are a period of intense growth, not only physically but morally and intellectually, it's understandable that it's a time of confusion and upheaval for many families.

Despite some adults' negative perceptions about teenagers, they are often energetic, thoughtful, and idealistic, with a deep interest in what's fair and right. So, although it can be a period of conflict between parent and teen, the teen years are also a time to help teenagers grow into the distinct individuals they will become.

Understanding the Teen Years—

So when, exactly, does adolescence start? The message to send your kid is: Everybody's different. There are early bloomers, late arrivers, speedy developers, and slow-but-steady growers. In other words, there's a wide range of what's considered normal.

But it's important to make a (somewhat artificial) distinction between puberty and adolescence. Most of us think of puberty as the development of adult sexual characteristics: breasts, menstrual periods, pubic hair, and facial hair. These are certainly the most visible signs of impending adulthood, but teenagers who are showing physical changes (between the ages of 8 and 14 or so) can also be going through a bunch of changes that aren't readily seen from the outside. These are the changes of adolescence.

Many teenagers announce the onset of adolescence with a dramatic change in behavior around their moms & dads. They're starting to separate from Mom and Dad and to become more independent. At the same time, teenagers this age are increasingly aware of how others, especially their peers, see them and are desperately trying to fit in.

Teenagers often start "trying on" different looks and identities, and they become acutely aware of how they differ from their peers, which can result in episodes of distress and conflict with moms & dads.

Butting Heads—

One of the common stereotypes of adolescence is the rebellious, wild teen continually at odds with Mom and Dad. Although it may be the case for some teenagers and this is a time of emotional ups and downs, that stereotype certainly is not representative of most teenagers.

But the primary goal of the teen years is to achieve independence. For this to occur, teenagers will start pulling away from their moms & dads — especially the parent whom they're the closest to. This can come across as teenagers always seeming to have different opinions than their moms & dads or not wanting to be around their moms & dads in the same way they used to.

As teenagers mature, they start to think more abstractly and rationally. They're forming their moral code. And moms & dads of teenagers may find that teenagers who previously had been willing to conform to please them will suddenly begin asserting themselves — and their opinions — strongly and rebelling against parental control.

You may need to look closely at how much room you give your teen to be an individual and ask yourself questions such as: "Am I a controlling parent?," "Do I listen to my teen?," and "Do I allow my teen's opinions and tastes to differ from my own?"

Tips for Parenting During the Teen Years—

Looking for a roadmap to find your way through these years? Here are some tips:

Educate Yourself:

Read books about teenagers. Think back on your own teen years. Remember your struggles with acne or your embarrassment at developing early — or late. Expect some mood changes in your typically sunny teen, and be prepared for more conflict as he or she matures as an individual. Moms & dads who know what's coming can cope with it better. And the more you know, the better you can prepare.

Talk to Your Teen Early Enough:

Talking about menstruation or wet dreams after they've already started means you're too late. Answer the early questions teenagers have about bodies, such as the differences between boys and girls and where babies come from. But don't overload them with information — just answer their questions.

You know your teenagers. You can hear when your teen's starting to tell jokes about sex or when attention to personal appearance is increasing. This is a good time to jump in with your own questions such as:

· Are you having any strange feelings?
· Are you noticing any changes in your body?
· Are you sad sometimes and don't know why?

A yearly physical exam is a great time to bring up these things. A doctor can tell your preadolescent — and you — what to expect in the next few years. An exam can serve as a jumping-off point for a good parent/teen discussion. The later you wait to have this discussion, the more likely your teen will be to form misconceptions or become embarrassed about or afraid of physical and emotional changes.

Furthermore, the earlier you open the lines of communication, the better chance you have of keeping them open through the teen years. Give your teen books on puberty written for teenagers going through it. Share memories of your own adolescence. There's nothing like knowing that Mom or Dad went through it, too, to put a teen more at ease.

Put Yourself in Your Teen's Place:

Practice empathy by helping your teen understand that it's normal to be a bit concerned or self-conscious, and that it's OK to feel grown-up one minute and like a kid the next.

Pick Your Battles:

If teenagers want to dye their hair, paint their fingernails black, or wear funky clothes, think twice before you object. Teenagers want to shock their moms & dads and it's a lot better to let them do something temporary and harmless; leave the objections to things that really matter, like tobacco, drugs and alcohol.

Maintain Your Expectations:

Teenagers will likely act unhappy with expectations their moms & dads place on them. However, they usually understand and need to know that their moms & dads care enough about them to expect certain things such as good grades, acceptable behavior, and adherence to the rules of the house. If moms & dads have appropriate expectations, teenagers will likely try to meet them.

Inform Your Teen — and Stay Informed Yourself:

The teen years often are a time of experimentation, and sometimes that experimentation includes risky behaviors. Don't avoid the subjects of sex, or drug, alcohol, and tobacco use; discussing these things openly with teenagers before they're exposed to them increases the chance that they'll act responsibly when the time comes.

Know your teen's friends — and know their friends' moms & dads. Regular communication between moms & dads can go a long way toward creating a safe environment for all teenagers in a peer group. Moms & dads can help each other keep track of the teenagers' activities without making the teenagers feel that they're being watched.

Know the Warning Signs:

A certain amount of change may be normal during the teen years, but too drastic or long-lasting a switch in personality or behavior may signal real trouble — the kind that needs professional help. Watch for one or more of these warning signs:

· talk or even jokes about suicide
· sudden change in friends
· sleep problems
· skipping school continually
· signs of tobacco, alcohol, or drug use
· run-ins with the law
· rapid, drastic changes in personality
· falling grades
· extreme weight gain or loss

Any other inappropriate behavior that lasts for more than 6 weeks can be a sign of underlying trouble, too. You may expect a glitch or two in your teen's behavior or grades during this time, but your A/B student shouldn't suddenly be failing, and your normally outgoing kid shouldn't suddenly become constantly withdrawn. Your doctor or a local counselor, psychologist, or psychiatrist can help you find proper counseling.

Respect Teenagers' Privacy:

Some moms & dads, understandably, have a very hard time with this one. They may feel that anything their teenagers do is their business. But to help your teen become a young adult, you'll need to grant some privacy. If you notice warning signs of trouble, then you can invade your teen's privacy until you get to the heart of the problem. But otherwise, it's a good idea to back off.

In other words, your teenager's room and phone calls should be private. You also shouldn't expect your teen to share all thoughts or activities with you at all times. Of course, for safety reasons, you should always know where teenagers are going, what they're doing, and with whom, but you don't need to know every detail. And you definitely shouldn't expect to be invited along!

Monitor What Teenagers See and Read:

TV shows, magazines and books, the Internet — teenagers have access to tons of information. Be aware of what yours watch and read. Don't be afraid to set limits on the amount of time spent in front of the computer or the TV. Know what they're learning from the media and who they may be communicating with online.

Make Appropriate Rules:

Bedtime for a teenager should be age appropriate, just as it was when your teen was a baby. Reward your teen for being trustworthy. Does your teen keep to a 10 PM curfew? Move it to 10:30 PM. And does a teen always have to go along on family outings? Decide what your expectations are, and don't be insulted when your growing teen doesn't always want to be with you. Think back: You probably felt the same way about your mom and dad.

Will This Ever Be Over?

As teenagers progress through the teen years, you'll notice a slowing of the highs and lows of adolescence. And, eventually, they'll become independent, responsible, communicative young adults. So remember the motto of many moms & dads with teenagers: We're going through this together, and we'll come out of it — together!

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Do Antidepressants Increase the Risk of Suicide in Children and Adolescents?

The question is counter-intuitive. Could the antidepressants we use to treat depression, specifically the serotonin reuptake inhibitors (SSRI) so widely used in children and adults, actually increase the risk of suicide in children and adolescents? This question has arisen in the past year, and unless you have been in isolation in medical school or residency, you have probably seen or read something about it. This article will review the events of the past year, look at possible hypotheses to explain an increased risk, if one exists, and finally will examine what we know about the data that sparked the controversy.

In June 2003, The Medicines and Healthcare Products Regulatory Agency (MHRA), the U. S. Food and Drug Administration (FDA) counterpart in the United Kingdom, warned physicians about the possible increased risk of suicidal ideas or suicide in children and adolescents taking paroxetine (an SSRI). After further analysis of data on all the SSRI’s, the MHRA in December, 2003, found that, with the exception of fluoxetine, SSRI’s have not been proven effective for youth with depression and may increase the risk of suicidal thinking or attempts. It is important to note that “lack of proven effectiveness” is not the same as “proven ineffective”. The FDA, partly in response to the actions in the U.K., issued a warning concerning paroxetine, and held hearings on the issue of SSRI’s and suicide in February, 2004. As a result of the hearings, the FDA issued a Public Health Advisory and asked the makers of all the newer antidepressants, including fluoxetine, to add a warning statement to their labeling recommending close observation of adults and children treated with these agents for worsening depression or the emergence of suicidality. The FDA also established the Suicidality Classification Project to improve the definition of suicidal behaviors, and to re-analyze all the available data from the studies. The need for improved classification of suicidal behavior stems from the inclusion of behaviors not directly related to suicidal behavior in the MHRA analysis of suicide risk. They included non-suicidal self-harm and harm to others in the analyses. The FDA then decided to pusue further analysis of the data before taking any more action.

What could be happening to cause this effect, if it exists? There are several theories. First, a long-held belief among psychiatrists hypothesizes that as one’s depression improves, a person becomes more energetic, less apathetic, and better able to make decisions. If a patient remains suicidal when this occurs, the risk of suicide would increase. While this hypothesis has some appeal, there has never been any evidence to support or refute it. In the July 21 issue of JAMA, Jick and colleagues1 studied suicidal behavior after initiating antidepressant treatment, and found an increased risk in the first month of treatment, and particularly in the first 9 days, compared to the risk of suicidal ideas and behavior later in the course of treatment. Nothing can be inferred about whether the medications caused this increased early risk, since there is no placebo control group. In fact, the authors speculate that people starting antidepressants begin this treatment when their depression is at its worst, and therefore at highest risk for suicidal behavior. There were no significant differences in the rate of suicidal behavior among the 4 drugs studied. The study investigated two tricyclic antidepressants (amytriptyline and dothiepin) and two SSRIs (fluoxetine and paroxetine). There was also no difference in those aged 10-19 from adults. However the numbers in the study were small for this age group. This study gives some indication of increased risk of suicidal behavior early in treatment, but does not compare active drugs to placebo. The study further provides evidence against the hypothesis that withdrawal from antidepressant medication causes suicidal behavior. Also of interest is that the database they used, the UK General Practice Research Database for 1993-1999, included 15 children age 10-19 who committed suicide. None of these 15 children had received a prescription for an antidepressant medicine.

A second hypothesis concerns possible side effects of antidepressants: activation, agitation, impulsivity and disinhibition. Psychiatrists sometimes see these side effects in patients taking antidepressants, especially early in the course of treatment. Could they increase the risk of considering suicide? Again, no evidence exists to support the hypothesis, and agitation does not necessarily equate to suicidal behavior. However, clinical practice has been to consider that patients are at increased risk early in the course of treatment.

Finally, antidepressants have been found to sometimes precipitate manic episodes, especially if there is a family history of bipolar disorder. While there is also an increased risk of suicide in patients with bipolar disorder, there is no evidence that a patient switching from depression to mania due to antidepressant treatment has increased risk.

So, what are the findings that have led to these warnings about an increased risk of suicide for children and adolescents taking SSRI’s? Data available on the FDA website lists all the current randomized controlled trials (RCT) on SSRI’s.

For paroxetine, the drug the U.K. MHRA first warned physicians about, there are three RCT’s. Only one of the 3 studies shows a difference between drug and placebo in “possibly suicide-related” (6.5% to 1.1%) or “suicide attempts” (5.4% to 0%). For 2 other studies, there is no difference (3.9% for drug versus 4.2% for placebo, and 1.0% for drug versus 1.0% for placebo). For fluoxetine, on the other hand, 1 of three studies shows placebo having higher levels of suicidal behavior (0% to 5.3%) or attempts (0% to 5.3%), while the other 2 show no difference. It is important to note that none of the studies (analyzed individually) for any of the SSRI or SNRI antidepressants show a statistically significant difference between drug and placebo in suicidal ideation or attempts. Also, none of the over 4000 children or adolescents participating in any of the antidepressant trials actually committed suicide.

One final comment should be made concerning the U.K. MHRA decision. They based the recommendation not to use any antidepressant, with the exception of fluoxetine, in children and adolescents based on their criteria for showing a medication is effective: the MHRA requires at least 2 positive randomized trials. Only fluoxetine has 2 positive RCT’s in children and adolescents. There is also some disagreement among scientists about what constitutes a positive trial. For instance, if data from the 2 trials for sertraline are combined, the outcome is positive, while neither study in isolation reaches significance at p= 0.05. Citalopram and paroxetine (for adolescents only) also have one positive study, but not two. So there is evidence for effectiveness, but more research is needed.

Another important issue to consider is whether there is evidence that antidepressants actually decrease the risk of suicide by treating the depression that brings the risk in the first place. Suicide rates have been declining since about 1987 for adults and since the mid nineties for children and adolescents.

Many factors could play a role in this decrease. Is the increased use of antidepressant medications one of the factors? For children, there are increases in the early to mid 1970s, followed by relatively stable rates of suicide in the 1980s and early 1990s. In the mid 1990s (about 1994), the rate began to decline. The use of antidepressant medicines in children has increased dramatically over the past 10-15 years2. Some epidemiological evidence suggests that antidepressant use in children and adolescents has decreased suicide rates. A study by Olfson and colleagues3 analyzed prescription data from the nation’s largest pharmacy benefit company and compared change in antidepressant medication treatment with suicide rate in youth aged 10-19. They found a significant inverse relationship between changes in antidepressant use and suicide, and concluded that there may be a role for antidepressant medications in suicide prevention efforts. While these studies are associational and do not prove causality, they do suggest that increasing use of antidepressant medication may have a role in the decrease in suicide over this time period.

Another new study, the Treatment of Adolescent Depression Study (TADS), was published August 18, 20044. This is arguably the most important study ever published on the treatment of depression in children. This study randomly assigned 439 depressed 12-17 year olds to one of 4 conditions: 1. placebo; 2. fluoxetine alone; 3. cognitive-behavioral therapy (CBT) alone; and 4. CBT combined with fluoxetine. The results are strongly supportive of the use of fluoxetine in depressed adolescents: the combination of CBT and fluoxetine was significantly more effective than placebo, CBT alone or fluoxetine alone. Neither fluoxetine alone nor CBT alone were significantly different from placebo, although the fluoxetine alone group improved significantly more than the CBT alone group. The rates of positive response to treatment among the adolescents were: CBT plus fluoxetine 71.0%, fluoxetine alone 60.6%, CBT alone 43.2%, and placebo 34.8%.

The TADS study also examined suicide-related events. All three treatment arms significantly reduced suicidal ideas compared to the placebo group. Additionally, suicide attempts were not significantly associated with SSRI use. However there was a significantly higher rate of “harm-related events” in the adolescents treated with fluoxetine. These events include both suicidal and non-suicidal (for example cutting oneself without suicidal intent) self-harm, increase in suicidal ideas, or thought or acts of harm to others or property. This much broader definition reached significance.

Although no individual drug trial shows a statistically significant increase of suicide attempt or suicidal ideas, there is a consistent increase in risk ratio of about 1.5-2 among all the antidepressants. Even when data from studies for the same drug are pooled and data on suicidal thinking is combined with suicidal behavior, only venlafaxine has a statistically significant increase from placebo (although paroxetine is very close to significant). The evidence of a signal is rather weak, but the implications are significant. These data prompted the FDA advisory panel to recommend on a split vote (15-8) a “black box” warning for all antidepressants (including tricyclic antidepressants and other new drugs). This is the most serious warning the FDA gives short of prohibiting use of the drug. Clearly, parents and teens need to be informed of this potential risk. But the risk is relatively small (a risk ratio of 1.5-2 would mean between 2 and 3 children per 100 taking these medication would have suicidal thought or behaviors as a result). The impact of a new black box warning may have unintended consequences. Parents and primary care physicians may react to this news by refusing to use antidepressant medications in children and adolescents who need them. Untreated depression in adults is associated with a 15% suicide rate. If the reduction in the rate of suicide in this country is at least partially due to the dramatic increases in the rate of SSRI use, then we may see a reversal of the trend for decreasing suicide rates in adolescents. It is critical to quickly fund further research to answer these questions.

What are we to make of all this data? Should children and adolescents be treated with antidepressants? Do they really cause an increased risk of suicidal behavior? Or do they cause a decrease in suicidal behavior? Is fluoxetine the only one that really works? Clinicians clearly believe other antidepressants are effective. The answer is we just don’t have enough research to know with any certainty. We must await further data to make a final decision. Further research on the possible long term decrease in suicide due to SSRI antidepressants is not currently available. Until we see the data and can evaluate the risks more fully, it would be wise to use SSRI’s in children and adolescents with caution, monitor for the possible problems discussed above, and pay special attention to suicide risk assessment when treating children and adolescents, especially early in their treatment, with these medications.

Finally, I would add that the strongly positive results of the TADS study indicate that medication treatment is vital for effective treatment of adolescent depression. With the confusing results of studies to date, fluoxetine is a good first choice for antidepressant treatment of adolescents. However, there may be reasons that clinicians choose to start other antidepressants instead. For instance, adolescents with a good prior response to another antidepressant, who are currently on another antidepressant with good response, or who have a history of poor response to fluoxetine, would probably be started or stay on another antidepressant.

References:

1. Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA 2004; 292:338-343

2. Zito JM, Safer DJ, DosReis S, Gardner JF, Magder, L, Soeken K, Boles M, Lynch F, Riddle MA. Psychotropic practice patterns for youth: A 10-year perspective. Arch Pediatr Adolesc Med 2003; 157(1):17-25.

3. Olfson M, Shaffer D, Marcus SC, Greenberg T. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 2003; 60:978.

4. Treatment for Adolescents with Depression Study Team. Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents With Depression: Treatment for Adolescents With Depression Study (TADS) Randomized Controlled Trial. JAMA. 2004; 292:807-820.

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Children Who Play With Fire

For moms & dads, the dangers of fire are so apparent that the sight of a child anywhere near a flame is enough to send them scrambling. And fortunately, most children are afraid of fire and understand that it can hurt them and others.

But it's not unusual for children to be curious about fire. After all, we gather around them when we're making campfires or singing over birthday cakes. That's why it's so important to educate children about the dangers of fire and to keep them away from matches, lighters, and other fire-starting tools.

Even with the best efforts from moms & dads, children might play with fire. Most of the time this can be handled by explaining the dangers and setting clear ground rules and consequences for not following them. But sometimes children seem to be especially preoccupied with fire and repeatedly attempt to set things on fire, which can be a sign of emotional and behavioral issues that require professional help.

Why Children Set Fires—

Young children who set fires usually do so out of curiosity or accidentally while playing with fire, matches, or lighters, and don't know how dangerous fire can be. During the preschool years, fire is just another part of the world they're exploring. Unfortunately, these fires tend to be the most deadly because children in that age group don't know how to respond to a fire, and may set it in a small, enclosed space, such as a closet.

As children get a little older, they might be fascinated with fire. It's fairly common for them to do things like light paper with matches, set things on fire using a magnifying glass, or play with candles or other things that have a flame. That's usually not a cause for concern.

But if a school-age child deliberately sets fires, even after being reprimanded or punished, a parent needs to talk to the child and consider getting professional help. That's especially true if the child is setting fires to larger objects or in areas where the flames can easily spread and cause injury and damage.

Talk with your child's doctor or consult a mental health professional if your child exhibits behaviors such as:

· pocketing matches or hiding fire-starting materials
· lighting candles, fireworks, and other things, despite being told not to
· adding more fuel to fires in the fireplace, grill, or campfires, even when told not to

Children might set fires for any number of reasons. They may be angry or looking for attention. They may be struggling with stressful problems at home, at school, or with friends. Some set fires as a cry for help because they're being neglected at home or even abused. Even though they may know how dangerous fire can be, they may have other problems that involve difficulty with impulse control.

Whatever the reason for firesetting, moms & dads need to get to the root of the behavior and address underlying problems. It's important to consider seeking professional help as soon as possible to prevent serious damage or injury.

What to Do if Your Child Sets a Fire—

If you discover your child setting a fire, it's important not to ignore it or assume that with punishment, your child has learned the lesson. Because even one small fire can have disastrous consequences, it's vital to stop the behavior immediately. Many children who set fires do so repeatedly, especially if there is no intervention.

If your child is very young, prevent access to the tools that can start another fire. Keep matches, lighters, and any other sources of fire safely out of your child's reach and view.

Talk to your child about how dangerous fire is and how it can hurt your child and your family. If you haven't established any specific rules about fire, this is a good time to do so. Explain that, just like other things that are off-limits (like touching knives or the oven), matches and lighters are things only adults should use.

If your child is beyond the preschool years (around age 5 or older) and is setting fires, talk with your child's doctor, school counselor, or a mental health professional. You might also want to contact your local fire department — many have programs designed to teach children who have set fires about the dangers and consequences of firesetting.

Preventing Children From Starting Fires—

· Don't allow smoking in your home. It's more difficult to keep lighters and matches away from children in homes where adults smoke. Children in these homes also see adults using fire repeatedly throughout the day, which can influence their behavior.

· Keep your house safe. Never leave matches or lighters in a room where a child spends unsupervised time. If you have preschool-age children, keep matches out of sight and locked up. Although many lighters are labeled child-resistant, none are fully childproof so make sure these are inaccessible too. And never leave a burning candle and a young child in the same room unattended.

· Set a good example. Use fire only in appropriate ways — to light candles or as a tool in your grill, camp, wood stove, or fireplace. Never amuse children by playing with matches or lighters, or even burning candle wax. Show them how you always put out fires completely when you are through with them and that you never leave a fire burning when you're not there.

· Teach children about fire safety. Make sure children understand — from a young age — that even a small fire can be dangerous and deadly. Keep small children far from the stove (at least 3 feet away) while it's on and explain why. Teach children to tell you when they find matches or lighters or if they see other children carrying them or playing with fire. Teach them what to do if their clothes catch fire (stop, drop, and roll) and what to do if there's a fire in your house.

Moms & dads play an important role in making children aware of the dangers posed by fire and establishing ground rules about how to handle it. By keeping matches and lighters out of reach and staying alert to signs that a child may be playing with fire, you can help ensure that your entire family stays safe.

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