September 10, 2014

Bedtime with the iPad: Total Mom Fail

It’s 10:15 pm and my 2 1/2 –year-old is still awake, touching my mouse while I try to type.  She took a late nap and now we’re paying the consequences.  A few months ago the same thing happened and I did the unthinkable—I put her back in her bed, with the iPad.
Total mom fail—isn’t that against all the recommendations of all the academies of everything medical?
I have my excuses—I had worked the overnight shift the night before and neither my husband nor I could keep our eyes open and we just couldn’t allow a 2-year-old to wander around the house unsupervised.  I figured she would fall asleep while watching Caillou and we’d find the iPad next to her bed in the morning.
Wrong.  Here’s what really happened: around 3 am we were awakened by the sound of two little feet running to our bedroom, and a little voice that said, “Caillou not working!”  She had been watching that iPad for three whole hours, and she was wide awake.
I should have known that iPads don’t put kids to bed—I’ve already read the research that shows otherwise.  A study of more than 2000 kids found that, on average, kids spend about 30 minutes watching screens in the 90 minutes before they go to bed.  Kids who had more screen time before bed took longer to fall asleep.  This was true for kids of all ages—toddlers through teens.
Why do kids who watch TV before bed have trouble falling asleep?  We’re not quite sure, but a leading hypothesis has to do with melatonin.  Melatonin is a natural hormone produced by your body that causes sleepiness.  When your body’s natural clock is working right, you (and your child) get a burst of melatonin about 30 minutes before you fall asleep.  It’s that “I feel really sleepy” feeling that you get around bedtime.  You can choose to fight through it or give in to sweet sleep and close your eyes.  This melatonin burst is triggered by darkness, or a dimming of light.  External light, including that glow from your favorite screen, can prevent melatonin release.   For more on this topic, see my article, “Kids, Sleep and Melatonin.”
This is bad news for those of us who love to give our kids screen time that is good for them.  And there are times when it really is okay to let your toddler play with your iPad.  But bedtime is not time for interactive stories in HD, despite the multitude of “bedtime stories” available in the app store, or the movies on Netflix and Amazon Prime.
Later bedtimes don’t just make sleepy kids.  Kids who don’t get enough sleep suffer academically in school, and are more likely to struggle socially.  Tired kids are also at higher risk for a host of medical problems from injuries to obesity.  So stick to your old fashioned bedtime story books, and put away the screens before bed.  Your children will go to sleep faster.  And earlier bedtimes for kids usually means earlier bedtimes for parents . . .       

August 19, 2014

Screen Limits and Young Children—Location, Location, Location!*

April Khadijah Inniss, MD, MSc
Robert Wood Johnson Foundation Clinical Scholar, 2012-2014
Clinical Lecturer
University of Michigan
Department of Pediatrics & Communicable Diseases

Given rapid changes in the media landscape with newer technologies like tablets and smartphones, limiting young children’s entertainment screen time remains a challenge—and not just for parents, but for the pediatricians charged with assessing children’s exposure and counseling families.

In 2010, the American Academy of Pediatrics (AAP) issued guidelines discouraging any screen time for children less than two years of age, and no more than two hours daily for older children.  In 2013, the AAP released updated recommendations that reaffirmed the principles in the 2010 guideline, and offered practical ways families can manage media use, such as keeping media devices out of children’s bedrooms, and keeping family routines like mealtime screen-free.

To understand parents’ attitudes and behaviors in relation to these recommendations, the C.S. Mott Children’s Hospital National Poll on Children’s Health surveyed a national sample of 560 parents with young children (1-5 years old).

Some of our findings weren’t surprising at all—many kids are still getting too much screen time (25% of parents surveyed reported average daily screen time of 3 or more hours for their young children).  However, a couple key findings stood out to our research team because they seem to hold the most practical application to how we counsel our young patients’ families. 

More parents are limiting screen time by location, rather than time. Parents reported the strategies they are already using to limit entertainment screen time.  About one-half (53%) of parents of young children limit the locations where children can use media devices (i.e., not in their bedrooms or at mealtimes). About one-quarter (28%) of parents report having a combination of location limits and time limits (Figure 1).  Only 6% of parents report limiting the amount of screen time for their children by setting a daily time limit.

So, while the AAP speaks of screen time limits in terms of hours, we 
found that most of the parents that we surveyed are thinking more about limits in terms of location—suggesting that this approach may be more practical than watching the clock!  

Parents’ views about reasonable screen time differ by the age of their children, and do not necessarily match the AAP recommendations. Among parents of children younger than two years old, only 12% think that no entertainment screen time is reasonable.  In contrast, among parents of children 2-5 years old, 88% say that two hours or less of daily entertainment screen time is reasonable. 
This finding suggests that targeting parents of children under 2 years of age should be a major priority for education about potential adverse effects of too much screen time.
In sum, I think most of us in Pediatrics have observed how quickly new devices are emerging and evolving, and how entertainment screen time is therefore playing a progressively larger role in our young patients’ daily lives.  We know that parents ultimately want to do what’s best for their children, but many still struggle in the area of limiting entertainment screen time.

Based on these findings, perhaps we can better assist these families in the following ways: 1) intentionally targeting families sooner (specifically those caring for children 0-2 years of age) with education and other practical tools to keep their young ones engaged, and 2) counseling families vis-à-vis strategies other parents just like them are using to limit screen time (i.e. emphasizing things like screen-free bedrooms and mealtimes).

*All findings reported here are statistically significant (p < 0.05).  Only some findings are presented here; full manuscript is in preparation highlighting other findings will be submitted for peer-reviewed publication.

July 26, 2014

Tool or Toy? And What Do They Cost You?

Gayle Schrier Smith, MD, FAAP
adapted from a post from PartnersinPediatrics

To bring awareness to the many screens that surround us, I have begun to ask my patients and their parents, “Tool or Toy? How do you see screen time in your home, and what does it cost you?” Tools live in the world of work, learning and efficiency (something grown-ups value.) Toys define the world of fun, relaxation and play. Both have their place in healthy families, and I would argue that each role is valuable to consider if it is the intention of parents to serve up a healthy media diet.  The cost of screen time is both monetary in what our devices cost, but also in the price of lost time…  that face to face encounter we want to have with one another.

As I have begun to talk more about the importance of a balanced media diet, the ‘tools and toys’ image has been useful to open those conversations. The sound-bite doesn’t feel judgmental to me, nor does it feel as though I am endorsing any one view of screen time over another. I sometimes share ways in which my iPhone is both a tool and toy, but I am also honest in saying that I have begun to monitor my own ‘play’ time on it.

There is a rapidly changing landscape of available media tools and toys, and they are, to some degree, both good and bad for how they influence  children. It is simply time for pediatricians  to leverage our ability to engage families, and ask them to learn with us as we all expand our expertise, with evidence-based ideas tested by time and research. It is only with a meaningful and ongoing partnership that we will really understand how much screen time is enough or too much.  Meanwhile, a screen time question at every wellness visit will certainly create value for families and a memorable sound- bite.  “Tool or Toy” may serve as a frequent reminder that screens are both tool and toy, that they are present everywhere and should be purposefully balanced in a family’s life.

July 1, 2014

Is There An Unlocked Gun in Your House?

By Peggy Stager, M.D. FAAP
Originally posted on

Did you know that 1 in 3 homes in America with children have guns?  Guns are the second leading cause of death among children and teens, and there are over 15,000 youth injured or killed by guns every year. One question could save your child’s life.  The American Academy of Pediatrics is sponsoring the ASK campaign, encouraging parents to ask one simple question.  When your pre-teen or teen goes to a friend’s house to hang out, do you know if that house has a gun in it?  The AAP recommends that you call the other parent and ask, “Is there an unlocked gun in your house?” 42% of parents with guns keep at least one gun unlocked and 25% of parents with guns keep at least one gun always loaded.  Most of the time, the teens know where the guns are kept in the home.  This means that curious teens, especially bored teens, might go looking for that gun, or find it while looking for something else.  There have been too many injuries and deaths from unlocked guns in the home because the teen didn’t think the gun was loaded, was “playing around”, and accidentally shot his friend.  It doesn’t have to be this way. As a parent, you already know what it is like to ask awkward or uncomfortable questions to other parents like, “Are you going to be home tonight when the girls are there?”,  “I think the boys may have been drinking last night.  Did you notice that too?”  While this may feel uncomfortable at first, keep in mind you are asking in your teen’s best interest.  Besides, what is the worst thing that could happen?  A parent may be offended, or even laugh at you.  But in the long run one simple question may save a teen’s life. 

June 24, 2014

Media and Your Teen -- Ask them to DECIDE

Kate Land, MD FAAP

The American Academy of Pediatrics has clear words for parents seeking advice about screen time limits for children. No screen time for kids under 2 and no more that 2 hours a day for kids over 2. Less is better and content matters.

While I find these guidelines challenging in my office and in my home, my mother would have had no trouble enforcing these guidelines with me - for most of my childhood we did not have a television. I remember mornings in junior high school as being rough. Not only because it was too early and too cold to want to get out of bed but also because once I made it to school everyone around me was discussing last night's episode of this or that show. I tried to look casual and preoccupied while they sounded so.... cool.

As a Pediatrician, I understand the social power that being up-to-date with the latest show, game or video has. Being connected on each of the latest social media tools be they Instagram, Vine or Snapchat, matters on today's Monday mornings.

However, I want my teens and my teen patients to turn off their screens more. I know that doing so will broaden their horizons and shrink their waistlines. They also on some level, get this. It isn’t easy to translate advice and understanding into action. Teens especially do not like to accept rules made for them without their input and buy-in. At my house, I always begin change with a discussion around the dinner table. It is a perfect chance to ask and listen. 

It is perhaps ironic that I found some words to inspire teens to turn off their screens from a recent episode of Grey's Anatomy. They have just the right touch of inspirational simplicity that appeals to the Pinterest set:

We are all going to die. We don't get to decide where or when.
But we do get to decide how we are going to live. So do it.
Is this the life you want to live? Is this the person you want to love?
Is this the best you can be? Can you be stronger, kinder, more compassionate?
Breathe in, breathe out and decide.

When you put it this way, few kids would choose to spend their time in front of a screen and definitely not the average of seven hours a day that our kids are currently spending. Tonight at dinner, ask your kids to decide. Then take action and come up with a plan together for media use in your home.
For ideas about how to decrease your family's media use see “How to Make a Family Media Use Plan” at the AAP’s parent web page

May 17, 2014

Can kids learn from TV? Or, are we kidding our selves?

"Sid The Science Kid: TV" show review by COCM member Don Shifrin, M.D., F.A.A.P, as seen in the NY Times, September 1, 2008:

By Neil Genzlinger (bolding for emphasis by Don Shifrin, MD, FAAP), New York Times

"If it takes a village, then we should all be concerned about Sid. The lad is only maybe 3 or 4, but already it’s obvious that he’s headed for trouble.

Sid is the host of “Sid the Science Kid,” a series for preschoolers that begins Monday on PBS. And he has a desperate-for-attention problem that is only moderately irksome now, but when he’s older will lead him to either put those oversize tires on the back of his car or seek a career in musical theater.

PBS is employing Sid, who is animated in a process called digital puppetry, as an ambassador for what education20types might call science readiness. His show, done in that hyperactive style that adults have determined is what the very young prefer, seeks to put across the fundamentals of science.

How fundamental? The first episode is all about charts. Sid makes a chart to record how many chores he has done, since once he has done enough he will get a new Turbo Robot Megaship toy. In school he and his classmates make charts of which kid has brought what snack to school. What does this have to do with science? Well, um, scientists use charts a lot, and, uh, that’s pretty much it.

There’s no point in trying to analyze whether this show will accomplish its educational objective, because who knows, really, what speaks to small children? So the only thing to do with “Sid the Science Kid” is to ponder it as a sociological statement.

Sid is never without his toy microphone, which he is constantly yapping into or shoving in other people’s faces. He is, in other words, always performing. So are many of the other characters, including his teacher. It’s no accident that one recurring feature of the show, a joke of the day, is delivered via portholes reminiscent of the “Rowan & Martin’s Laugh-In” wall. This is introductory science tailored for the age of self-indulgence and short attention spans.

The show bears the Jim Henson Comp any’s name, so it probably has merit. Still, it’s hard not to think that the only bearable person in this animated world is Sid’s grandmother, who points out to him that she never needed to be bribed with the promise of a new gewgaw to do her chores. Take it from Grandma, kid: Life is not your own personal TV show, and sometimes — a lot of the time, actually — you need to just sit down, shut up and do the work."

Dr. Don's 2cents:
OK, so the take on this 'new' form of PBS entertainment in the genre of Jimmy Neutron, boy genius is, inevitably, flawed.

Over and over we find that programming from toddlerhood to teens is replete with features geared to induce or is it produce short attention spans.
Note here that the great Jon Stewart started out professional life on Comedy Central's short attention span theater which ran from 1989-1994.
This is not definable learning, as no research will be done as to the impact of the 'lessons' featured, but another controversial point in the ongoing discussion about 2-D versus 3-D interactive learning.

And when these shows go 'virtually' into the digital interactive world where children can touch the screen or digitally participate in their 'learning', will it be a thoughtful, focused exercise, or will it be just more buttons to push quickly.

Already there is concern over the way children-and adults read in digital formats versus traditional reading styles. See the August issue of Atlantic Monthly where Nicolas Carr has written a 4000 word article, Is Google Making Us Stupid"?
As the media theorist Marshall McLuhan pointed out in the 1960s, media are not just passive channels of information. They supply the stuff of thought, but they also shape the process of thought. And what the Net seems to be doing is chipping away my capacity for concentration and contemplation. My mind now expects to take in information the way the Net distributes it: in a swiftly moving stream of particles. Once I was a scuba diver in the sea of words. Now I zip along the surface like a guy on a Jet Ski.

Do parents see this coming, or, are they too, drowning in a sea of media that they think is well-intended to prepare and instruct their children faster and better than they ever could using past methods?
Who among us is likely to shout out at the passing parade of web, TV, DVD, and read-along devices, " the Emperor has no clothes"............

Opportunity, Means, And Motive

David Hill MD, FAAP

“So, Doctor, what are some things people can do about this problem?” If you’ve ever faced a reporter then you’ve probably answered some version of this question. If you had adequate time to prepare, you may have even emailed your advice in advance to provide bullet points for the graphic. This is, after all, “news you can use!” (What would they call it if “news” and “use” didn’t rhyme?)

But do you ever wonder how many people actually do the stuff you recommend? I imagine it depends in part on the nature of the advice. “Keep your children indoors while these wildfires rage,” probably sees a lot of takers. “Be sure and get your child’s flu vaccine this season,” wins some, if not as many as we’d like. “Don’t let your child have a television in his bedroom,” gets...(crickets).

What do we hope to accomplish as pediatricians by engaging the media, aside of course from the fame, fortune, and autograph-seekers we so enjoy? Personally, I hope to extend my mission beyond the exam room into people’s living rooms, where my advice can help children live healthier lives. But if that’s our goal, how can we be best accomplish it?

In the clinic, I know the answer. My career has spanned the transition from a paternalistic model of behavior change (“Of course you’ll do what I say; can’t you see how crisply pressed my white coat is?”) to the awkwardly named transtheoretical model (“So is it okay if we talk for a moment about your habit of sharing cigarettes with your child?”). This transition has given birth to motivational interviewing, a technique that pretty much blows everything else out of the water when it comes to helping people embrace healthier behaviors.

Motivational interviewing is far too involved to fully explain in this space, but the four core concepts are pithy enough to hit. The first idea, “express empathy,” suggests we start by listening to where our patients are coming from and trying to connect, i.e., “I can see how smoking with your child gives you two a chance to bond.”

Second comes, “develop discrepancy,” meaning to help patients see how their current behaviors might lead to outcomes they don’t desire, as in, “You’ve said you wished you could quit smoking. How do you feel about your child smoking?” Third, and most alliterative, is, “roll with resistance,” meaning we must accept that patients’ reluctance to change is a normal part of human nature and not a moral failure, like, “It sounds as though you feel the time you share smoking with your child is strengthening your relationship. I see why you might not want to give that up.” 

This leads to the final step, “support self-efficacy,” a toughie; both because it’s nearly impossible to say three times fast and because it doesn’t just mean being supportive when patients do what we suggest. It means being equally supportive when they don’t, as in, “I’ve enjoyed our conversation today. If we can talk about this smoking thing again some time, please let me know!”

Motivational interviewing isn’t magic, but when practiced one-on-one it has posted impressive results for changing behaviors ranging from overeating to alcohol abuse. The question I struggle with is how to make this face-to-face intervention work when addressing a whole population, as we do in the media. Can we ask what people’s most common reasons are for, say, not vaccinating their kids? (It turns out more parents are worried about pain and fever than about autism.) Can we show empathy for those in our audience who may resist change, citing those reasons? Can we avoid moralistic language when talking about people whose decisions we think are unwise?

I don’t pretend to have mastered the art of translating motivational interviewing techniques to a sound bite that may last well under a minute. I do think, however, that those of us who can pull off that trick will be the most effective medical communicators ever. As for myself, I can live without autograph-seekers. I wouldn’t want them to wrinkle my white coat.