Patient Bulletins

“My sixteen-year-old daughter cannot make it through a day at school. She has every symptom of the disease except the bulging eyes. Needless to say, she feels like she is really losing her mind at times. Jennifer used to weigh 160 pounds, played volleyball, basketball, and threw shot and disc. She is 5’7’’ tall. Now she weighs 140 and doesn’t have enough energy to walk up a flight of steps.”

“My son has been diagnosed as hyperthyroid, possibly as an inherited disease, as his father and mother both are hypothyroid and his grandmother has Graves’ disease. He has many of the symptoms, such as sweating, palpitations, fatigue, memory and attention problems, blurred vision, chest pains, elevated blood pressure, and sleep disturbances. He is sixteen years old and was a very good student – A’s and B’s. Suddenly he is dropping to C’s and D’s, and now D’s and F’s.”

“Katie has had a rough time of it in school in the past year or so … short-term memory loss, easily distracted, heat intolerance, and absences due to illness. She never wanted anyone to know that she had a disease. Her biggest problem was in physical education class where she had a problem keeping up with the other kids in running. Her heat intolerance caused several problems in her regular classes. She got so tired when she was overheated that I usually had to go pick her up and bring her home for a nap.”

“I suspect my son has had it for over eighteen months because of all the symptoms he has had over this time frame. He went from a straight A student to almost dropping out of school. I attributed his change in behavior and lack of effort in school to teenage stuff, such as drugs and alcohol. Now I know it isn’t, but he has made some terrible mistakes lately and now we are in for a big struggle ahead.”

Watching a child undergo dramatic physical and emotional changes that seem uncontrollable is any parent’s nightmare. This feeling of helplessness may be compounded by the inability of the family doctor to diagnose Graves’ disease, which often occurs when subtle symptoms can easily be mistaken for other diseases that are much more common in children. It may take several appointments and tests before the doctor can pinpoint the problem. However, once the diagnosis is made, treatment and management of Graves’ disease should allow the child to return to normal routines and activities.

Definition

Graves’ disease is the most common cause of hyperthyroidism. It is an autoimmune disorder that occurs when the body’s immune system over-stimulates the thyroid. Anti-thyroid antibodies cause excess growth of the gland, leading to overproduction of the thyroid hormone. These antibodies may also attack eye muscle tissue and the skin on the shins and possibly the tops of the feet. The exact cause of Graves’ disease is unknown, although researchers suspect some kind of genetic or immune system abnormality. Trigger factors for the disease’s onset include stress, physical or emotional problems, and infections.

Graves’ disease in children rarely happens before age three and generally increases in frequency during adolescence. It occurs more often in girls than in boys, with an approximate ratio of 1:4. The incidence of childhood Graves’ disease is estimated at 1:100,000, with an average age of onset of 12.5 years. Children who have a history of thyroid disease in their families are more likely to develop thyroid disorders. Because of this tendency, doctors should be alerted to any thyroid history in the family, so that they can watch for changes in growth patterns and behavior.

Symptoms

Children generally have the same symptoms as adults, but they may not complain about them. Normal body changes during growth and puberty may mask the Graves’ disease symptoms, and children may not understand the difference between normal and abnormal changes. Quite often the biggest problems before diagnosis are restlessness and a short attention span, which lead to school difficulties and parental exasperation.

Other symptoms may include: •

• an enlarged thyroid gland or goiter
• difficulty swallowing
• prominent eyes with or without a “stare”
• an increase in appetite
• poor weight gain or loss of weight
• a sudden growth spurt
• smoother skin
• fine-textured hair
• increase in scalp hair loss
• rapid pulse
• increased blood pressure
• nervousness – visible shakiness, tremors, wringing hands, kicking feet, difficulty sitting still
• hyper-defecation or increased urination; bedwetting
• feelings of weakness or fatigue
• increased sweating
• dislike of hot weather
• lack of concentration and attentiveness
• poor memory skills
• shaky hands that cause clumsiness and poor handwriting
• rapid growth of fingernails
• losses in muscle strength and endurance
• weak shoulder and thigh muscles observed during playtime or sports
• erratic thought patterns and behaviors
• irritability; mood swings
• attitude changes
• emotional outbursts (i.e. crying or yelling)
• out-of-control or bizarre behaviors that require immediate help
• difficulty falling asleep and/or poor sleep patterns
• delays in development during normal puberty (i.e., facial and pubic hair may not develop, genitals may not enlarge)
• changes in menstrual periods

These symptoms usually develop slowly, which could explain why many children have symptoms for several weeks or even months before the disease is diagnosed.

It is not uncommon for parents to suspect that their child has a hyperactivity disorder, a psychiatric/emotional disease, or even a drug abuse problem.

Physicians need to be made aware of any questionable symptoms and also look for signs of thyroid disease that may present themselves in other childhood disorders. For example, if Attention-Deficit/ Hyperactivity Disorder (ADD or ADHD) is suspected in a child, then blood tests should be done to rule out a possible thyroid problem. Because the symptoms are similar, some children initially diagnosed with ADD or ADHD have later been found to have hyperthyroidism. Some studies indicate that ADHD can cooccur in pediatric thyroid disorders. In these rare instances, individualized treatment involving pediatricians and psychiatrists/psychologists may be needed. Diabetes, asthma, Down’s syndrome, and vitiligo are the most common coexisting illnesses associated with childhood Graves’ disease.

A rare complication of undiagnosed, untreated, or inadequately treated hyperthyroidism is a thyroid storm. Its possible symptoms include fever, nausea, vomiting, diarrhea, extreme weakness and loss of muscle, a rapid heartbeat well over 150 bpm, restlessness, mood swings, confusion, altered consciousness (even coma), and/or an enlarged liver with mild jaundice. If a thyroid storm occurs, the child needs immediate medical treatment. A thyroid storm may even be the medical emergency that leads to a diagnosis of Graves’ disease.

Once Graves’ disease is diagnosed and treated, normal growth and development and behavior patterns should resume. However, if the disease starts at an early age and persists, there may be some permanent effects, which could interfere with future development.

Eye disorders

Eye changes will be present in at least half of the children with Graves’ disease. When the immune system attacks the tissues behind the eye and the eye muscles, swelling and stiffness can result. The movement of the eyeballs may become restricted, which can occasionally lead to double vision and difficulties with reading and seeing objects clearly. Eye prominence and a “stare” are frequently seen in Graves’ disease, which at times can interfere with proper closing and blinking of the eyelids. Symptoms of burning, itching, and dryness can be relieved with eye lubricants. Children who experience eye discomfort, double vision, or any questionable eye symptoms should be evaluated by an ophthalmologist. Fortunately, eye symptoms are not as severe in children and often improve with time.

Skin disorders

Pretibial myxedema is the term used to describe a very rare skin disorder that occurs in a small percentage of Graves’ patients of any age. It takes the form of lumpy, reddish or purplish-colored thickening and/or swelling of the skin on the patient’s shins and sometimes on the tops of the feet. It has the appearance of orange rind. Pretibial myxedema is usually painless, but it can be very itchy. Although it may occur at any time, its severity is not related to the patient’s blood level of thyroid hormone.

Treatment for pretibial myxedema involves using cortisone creams on the skin or receiving steroid injections directly into the lesions/bumps themselves. For greatest effectiveness, these creams can be put on the affected skin at night under a plastic wrapping material, such as plastic food wrap, which is held in place by paper adhesive tape. It sometimes clears up on its own but can become quite disfiguring if it’s left untreated. It does not cause pain unless some of the hardened deposits begin to press on a nerve. Although researchers know that the Graves’ antibodies cause pretibial myxedema, they still do not know why it appears and why only the legs and feet tend to be involved in most patients who have this condition. Patients with symptoms of this skin disorder should consider going to a dermatologist to find out if they have pretibial myxedema and what could be done to treat it.

Treatment

To avoid prolonged illness during the developmental years, it is desirable to diagnose and adequately treat Graves’ disease early. The onset of Graves’ disease can be very gradual or very quick, but children are rarely admitted to the hospital for treatment. Parents are advised to find a pediatric endocrinologist who has experience with Graves’ patients. If blood tests confirm the diagnosis, the doctor may be able to start treatment at once. Taking the child’s age and symptoms into consideration, the doctor will recommend one of the three treatment options that are currently available. There are concerns with each of the treatments, so parents and their doctor will have to choose the best option for the child’s unique medical needs.

Treatment for children usually starts with antithyroid drugs (ATDs). The use of oral medications, usually methimazole (Tapazole™), will block thyroid hormone production, which usually helps the symptoms subside within six to eight weeks. Propylthiouracil (PTU) is no longer used as a front-line treatment option for pediatric Graves’, due to an increased risk of liver complications. Doctors generally prescribe ATDs for one to three years, although compliance and side effects or allergic reactions have often limited their use. Though drug reactions are more common in children, side effects are rare and usually minor, resulting in a rash, itchiness, upset stomach, and/or an unpleasant aftertaste. If symptoms persist, then the child can try the other ATD. In addition, doctors should be notified immediately if the child develops a fever, sore throat, and/or sores in the mouth while on ATDs. This could mean that the white blood cell count has dropped to dangerously low levels, placing the child at risk for serious bacterial infections. ATDs are more likely to fail in children with large goiters, a history of previous relapse, high levels of thyroxine, or severe eye symptoms. In some cases, ATDs are supplemented with a thyroid hormone replacement drug (levothyroxine) to replace some thyroid hormone needs if the child becomes hypothyroid. On the positive side, doctors will stop the medication if the thyroid hormone production is returning to normal. Approximately two-thirds of children will have some sort of relapse if the medication is stopped, while about one-third can control the disease without medication and experience no relapse. If Graves’ symptoms continue after the use of ATDs, then another treatment option needs to be discussed with the doctor.

A second treatment option involves radioactive iodine (RAI), which destroys part or all of the thyroid gland, depending on the dosage given. RAI helps the symptoms subside within three to six months and can be given in one or two separate doses (usually three to six months apart). RAI is used with older children, children with active symptoms after two years, non-compliant children, and children with serious reactions to ATDs. It is generally used in “tough” cases because children are more sensitive to the possible complications and risks of radiation. They also have more difficulty than adults with following certain precautions needed after RAI treatment and regulating their medication when they go hypothyroid. Children using ATDs will need to stop taking their medication at least three days prior to receiving RAI. Beta-blockers can be continued during the RAI treatment. Some children may experience a mild to moderate worsening of their Graves’ symptoms after RAI, but this short-lived occurrence can be controlled with the beta-blocker. Also, RAI could trigger eye symptoms, although children’s eyes don’t seem to react to RAI like some adults’. Finally, RAI is preferred over surgery because it is easier on the child. Approximately six months after RAI treatment, most children have the disease under control. The majority of them become hypothyroid and will have to take levothyroxine, i.e., Synthroid™ or Levothroid™, for the rest of their lives.

Surgery (thyroidectomy), removing part or all of the thyroid gland to stop thyroid hormone production, is usually the last resort for children five years and older. This third treatment option is used when thyroid nodules are detected and/or cancer is suspected, when ATDs or RAI didn’t work, or when RAI isn’t available. Surgery can offer rapid and long-term resolution of hyperthyroidism if a neartotal thyroidectomy is performed. However, there are several complications. The use of anesthesia with children is different than with adults, and children are smaller and more difficult to operate on. Also, many doctors don’t want to take the chance of surgical injury to the nerve supplying the vocal cords (resulting in a change in voice or permanent hoarseness) or accidental removal or injury to the parathyroid glands (resulting in a calcium imbalance). Occasionally, the thyroid tissue remaining after surgery will regrow, which is more common in children than in adults. Surgery will also leave a small scar in the crease of the child’s neck. Lastly, there still is a chance of the child going hypothyroid, which would require the use of thyroid hormone replacements. Surgery is used less often than in years Bulletin #36 Page 5 past, primarily because of the safety and effectiveness of the other treatment options. If surgery seems to be the best option, a skilled pediatric surgeon should perform it.

No matter which treatment option is chosen for the child, a beta-adrenergic blocking drug (beta-blocker), like Inderal™ or propranolol, may also be prescribed to alleviate severe symptoms of hyperthyroidism. Beta-blockers are used to slow down the heart and help the child feel calmer and more relaxed. They should be avoided in children with insulin-dependent diabetes mellitus, congestive heart failure, asthma, or Raynaud’s phenomenon.

During treatment, if the child is placed on levothyroxine, blood samples for TSH (Thyroid Stimulating Hormone) and/or T4 (thyroxine) measurements should be taken periodically to see if the thyroid function is within normal ranges. This check makes sure that the medication dose is adequate. Doctors often recommend that the child have blood tests at least every six months. It would also be wise to schedule a thyroid check for girls during their first menstruation, as hormonal fluctuations may warrant an adjustment in their levothyroxine dosage. Because it is essential that these tablets be taken regularly, parents must supervise the treatment. A pill minder box can be a very helpful way to monitor and train the child. Children with Graves’ disease must understand that although their symptoms are treatable their condition is permanent. If their medication is not taken regularly, symptoms will reappear.

Parents should also consult with their doctor and pharmacist before giving their child any other medications, including over-the-counter cough and cold medicines. These additional drugs contain ingredients that could aggravate the symptoms of hyperthyroidism.

Although many children with Graves’ disease have an excessive appetite, most do not gain weight because of their increased metabolism. However, the child’s diet and weight gain should be closely monitored. Many children are used to eating large portions of food before being diagnosed with Graves’ disease. After treatment, their metabolism will return to normal. If they continue their same eating patterns, they will become overweight. Proper nutritional counseling may be needed as part of the treatment process.

Children’s physical activity should also be closely monitored during treatment. Since the heart is already under strain from excessive thyroid hormone, the child has to be very careful not to compound the problem. The doctor should know the child’s particular health issues and can decide how much activity (including play, workouts, and sports) is appropriate for her. Regulating the activities of the child depends on her age and physical limitations. Parents should be careful of over-protectiveness and encourage normal childhood activities, as long as the thyroid hormone levels are normal and the heart rate is stabilized.

Monitoring the child’s symptoms is very important in both the pre- and post-treatment processes. It may be helpful for parents to chart their child’s symptoms, blood test results, and normal range values in a health journal. This practice will help parents become familiar with how their child’s thyroid function levels coincide with their child’s health and well-being, and help them better understand their child’s unique response to Graves’ disease. This information could also help the doctors determine the right medication and dosage. Questions to ask during the next doctor visit could also be written down in this record book. With early, proper, and regular treatment, the child can grow and develop normally.

The emotional side

Treatment can be a slow process, but psychological symptoms should diminish with treatment. Unfortunately, some of the cognitive effects on memory and concentration seem to continue even after treatment. Symptoms can come back, and it can be hard for parents to find the balance between being tuned into the disease and enjoying normal life activities with their child.

It is natural for parents to see their child as perfect, and the diagnosis of Graves’ disease may change a parent’s view of the child. Common reactions to the diagnosis range from denial, grief for the loss of a perfect child, feelings of guilt, inadequacy, and anger to final acceptance and adjustments to daily life. Coping with a child with Graves’ disease can also create conflict between parents. Throughout the diagnosis and treatment stages, parents need to remember to take care of themselves, also. They shouldn’t hesitate to seek professional counseling and/or support from other parents who have children with the disease.

Children will experience their own variety of emotional feelings, such as confusion, fear, anger, sadness, and guilt, after the diagnosis of Graves’ disease. Some children just aren’t sure about their own physical symptoms and feelings. Others become manipulative and blame their poor grades and behavior on their disease. It is not uncommon for children to be seeing a child psychiatrist for emotional problems or to be prescribed antidepressants to relieve symptoms of anxiety. Generally, children don’t want to be different, and seeing doctors and taking medications makes them feel different. They will need support from their entire family. Peer support can be extremely beneficial as well.

Adolescents may approach the diagnosis of Graves’ disease differently because of their natural hormonal and emotional changes. Because most adolescents are already striving for more independence and freedom, they may see the disease as a personal matter and may not seek parental help for their symptoms. Parents need to listen and be open and available.

Children of all ages need validation of their feelings regarding Graves’ disease. Parents should talk to their child about her feelings and the reality of her symptoms. They shouldn’t minimize or criticize her concerns. They should try to give her some power over her treatment and help her make good choices. Parents should also set reasonable expectations and goals and be open to negotiation. Communication between parents and the child is very important at this time.

The most crucial variable in how children handle a chronic illness is how their parents handle the situation. If parents adopt a hopeful, positive, matter-of-fact attitude, then the child will most likely follow. If parents view the child as different, vulnerable, special, needing to be coddled, or at risk, then the child may develop behavior management problems. Parents should set the same limits for all of their children. Just as parents spend time helping their child deal with Graves’ disease, they should spend time with the other siblings explaining the disease. Parents should also focus on the positives and the uniqueness of each child.

Sometimes it is very hard for parents to determine whether their child’s reactions and behavior are Graves’ related or not. Parents need to be very observant of physical and emotional changes and changes in school performance. They should pursue those gut feelings of something being wrong with their child. No question or concern is dumb – information is power. Parents should research Graves’ disease publications, find support groups, and develop close working relationships with a trusted physician and school staff.

School management

For children with Graves’ disease, a marked change in behavior can result in school difficulties. Graves’ disease could bring on poorer grades; sloppy handwriting; reading, spelling, and math difficulties; ADD or ADHD-type behaviors; problems with physical education and recess activities; and strained relationships with peers and teachers. Fortunately, studies show that these problems seem to be abated by treatment. In general, as long as the child has symptoms that interfere with learning and/or the school setting, the school needs to accommodate her. The school staff should be made aware of the child’s diagnosis and any ongoing medical recommendations. Since the school counselor and school nurse can be helpful advocates for parents during this adjustment period, it is wise to keep them updated on the child’s physical and emotional condition. Teachers need to be informed as well and may need to adjust their teaching strategies, classroom expectations, and assignments to meet the child’s current learning needs.

The Individuals With Disabilities Education Act (IDEA) of 1997 and Section 504 of the Rehabilitation Act of 1973, both federal laws, could provide help to parents and their child who is struggling with Graves’ symptoms in the school setting. Individualized plans under these laws may provide accommodations, modifications, support services, and/or supplemental aids for students who are medically, physically, emotionally, or intellectually disabled. Generally, the IDEA focuses on ways to provide free, appropriate education to students with disabilities and is referred to as Special Education. Children who don’t qualify for Special Education under the IDEA may be eligible for academic support services under Section 504, which could include students with Graves’ disease.

To qualify for academic help under either plan, students have to meet certain eligibility criteria set by the federal government and their state’s education department. To qualify for a 504 plan because of a medical condition like Graves’ disease, parents would need to provide documentation of the diagnosis from their doctor. Evidence of their child’s school work, study habits, and behavior may also need to be documented before a 504 plan can be put into place. This plan is individualized to the needs of the student and could allow for regular medical attention from the school nurse and support services in regular classroom activities.

A 504 plan could also include:

• reduced assignments
• oral presentations rather than written ones
• no penalties for poor handwriting
• special seating in the classroom
• use of assistive technology (i.e., computers and specialized software programs)
• peer tutoring and/or note-taking
• tape recorders for lectures
• teachers providing written outlines
• one-on-one tutors
• paraprofessional support in the classroom
• oral testing
• tests given in a different room with fewer distractions
• more time to take tests and finish assignments
• assignments and/or tests read to them
• opportunity to correct failed tests for a passing grade
• open book exams
• a reward system for assignment completion and/or good behavior
• alternative physical education activities
• group/individual counseling
• support services from the school’s Special Education staff
• a homebound teacher

A 504 plan would make adjustments for the child’s fatigue, weakness, lack of concentration and memory, and other symptoms brought on by Graves’ disease.

Individualized education plans under the IDEA or Section 504 could also follow the student into college, if needed. Since most colleges have programs for special needs students already in place, parents and their child would simply need to contact the college’s student services office for information.

A student with Graves’ disease may get frustrated in school because she can’t remember concepts for tests or her supplies, assignments, and appointments. The so-called normal routine at school becomes increasingly more difficult, especially if she doesn’t feel well. She may ask “Why me?” and find it harder to meet the expectations of her parents, teachers, coaches, friends, and even herself. Meanwhile, school staff are frustrated because they don’t understand what is happening and aren’t sure how to help. Frustration on both sides may eventually lead to anger, misunderstandings, sore feelings, and a lack of communication. Parents need to visit with the school staff about their child’s well-being as the first step toward resolution.

Other school management tips to try include:

• Help the student organize. Frequently monitor her school notebooks, pencil pouch, locker, book bag, desk, etc. There should be a place for everything and everything should be in its place.
• Use a daily organizer for appointments and assignments.
• Use a watch with a timer for personal reminders.
• Arrange for the student to have a “study buddy” for help with assignment organization and completion.
• Get a duplicate set of textbooks for home in case the student forgets a textbook at school.
• Reward the child for timely accomplishments with nutritional snacks, TV or computer time, favorite activities, special outings, quality time with you, and so on.
• Keep a daily or weekly journal going back and forth between the parents and teachers regarding the student’s assignments and daily performance.

General points about memorizing: The brain is one of the most important targets for thyroid-hormone action. The thyroid influences the ability to think, calculate, and develop emotional reactions. Many students with Graves’ disease complain about their lack of memory and concentration.

These students can better handle these problems by trying these memory tips:

1. Work at it. A good way to practice this is to work on remembering the names of people you meet for the first time. Watching people speak also helps.
2. Understand. It is easier to memorize material that you understand.
3. Twenty minutes. Memorize in short periods with a break in between. A general rule to follow is to memorize for twenty minutes and break for five minutes.
4. Link new material with old material. Use other study strategies like mnemonics, acronyms, flash cards, visualization, oral rehearsal, and numerous repetitions.
5. Use many senses. Use the Look-Say-Listen-Write method. Read and study out loud. Students may need to sub-vocalize to remember. If a child with Graves’ disease is having difficulty in school, there is help available. Parents should talk to their school’s staff about the IDEA, Section 504, and study skill strategies. It is important to remember that once the child is treated, academic assistance may not be necessary.

A personal note to parents

I understand how hard school can be for any child, let alone a child with Graves’ disease. I continued to teach as I learned to deal with the multiple symptoms of this strange disease in my own life. Some days I didn’t feel like going to school, but I was determined not to let the disease take control of my life. I tried to focus on the present while hoping for better days in the future. And better days did come.

Your child may have to adjust her school day so she can continue to strive for her best. She has to learn to ask for help, both academic and medical, when she needs it. She also needs to take care of herself physically by taking her medication regularly and on time, resting when needed, eating a healthy diet, exercising when possible, and telling you about any unusual symptoms or change in symptoms. As a parent, you should watch for changes in weight, behavior, appetite, and growth and development. Your child should remain under close medical supervision by a doctor who has experience with Graves’ disease, preferably a pediatric endocrinologist.

I know from experience that things will get better for your child. It just takes time. Open communication, coupled with patience, is the best approach to take. Even if your child doesn’t feel like talking, always leave that door of communication open. Whatever you can do to make your child more comfortable will help both of you tremendously.

Parents say it best:

Editor’s note: The following quotes and those at the beginning of this article are from the author’s personal correspondence and message from the NGDF Internet Bulletin Board.

“School is going good. A’s, B’s and a few C’s. Her memory is working so much better than this spring and her hand-eye coordination is vastly improved. Now she’ll write cursive, where before it was ‘No Way!’ Math is a solid B and I’m so pleased.”

“At all times I try to keep in mind that she has it a lot rougher than I do and I try my best to support her emotionally. Until now I have not had the urge to discuss this with anyone, but this ever changing can be trying. I urge you to be very open with your son (this has been a plus with my daughter) and do your best to support him. Also for yourself find a support that you can rely on, as it will be hard for you and your family.”

“My daughter was diagnosed with Graves’ at age four. Each year on the first day of school I send a letter detailing my daughter’s medical history to her teacher. I also include a letter to the school nurse and gym teacher (she has had intolerance to some activity). I have been fortunate in that each year upon receiving the letter her teacher calls me and we verbally go over any questions she has. I find this has made me feel so much more comfortable and the teachers have been very caring.”

“I am an administrator at a university. Yes, Graves’ is covered by the disabilities act, but no one can help you if you don’t let them know of your condition. The symptoms of Graves’ can mimic many other things, such as indifference (brain fog), lack of attention (fatigue) and doing badly on tests (memory, nerves). All of these behaviors are exhibited by students who do not have Graves’. Most professors are caring people and go out of their way to help students who need it. But, you have to ask for it. I know that is hard. It was difficult for me to say I need help with this, but as I got worse I simply had no choice but to ask. Don’t wait until you have no choice. Speak up and let the school know of your condition.”

“She has a paraprofessional who stays with her all day. If her behavior (crying, angry, penmanship frustration) gets out of hand, they also have three other support persons whose only job is to help whoever needs it! Through Special Education, she finally received learning aids and we meet monthly to review her progress. This new team is superb! They really care about making her school day a success, one day at a time. Before this help, she missed 3/4 of school due to being sent home. In the new school, she has only been sent home once. My advice — remember that one teacher cannot do this alone AND make your child feel good and not stand out. Please contact the school early with your fears and concerns and find a school with support in place already.”

I have tried to give you an overview of how Graves’ disease will affect your child and your home life. Remember that this illness affects every child differently. Since your child may not fit the normal patterns of Graves’ symptoms, it may take time to find the best doctor and treatment for her unique medical needs. Becoming a team member with your doctor will aid in her overall treatment. If you are not happy with your child’s medical care, don’t hesitate to look for a second opinion.

This bulletin is not intended to replace medical advice or be a substitute for a physician. Always seek the advice of a physician.

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Used with the permission of the author. Debby Jass is a Specific Learning Disabilities teacher in southwestern Minnesota. She was diagnosed with Graves’ disease and the associated Thyroid Eye Disease in 1990. This NGDF bulletin is dedicated to her outstanding doctors at the Mayo Clinic in Rochester, Minnesota: Dr. Colum Gorman, Endocrinology; Dr. James Garrity and Dr. George Bartley, Ophthalmology; and Dr. Charles Beatty, Otorhinolaryngology. A special thank you goes to Brent Jass and Kim Syverson for their support and proofreading services.