March 26, 2015

Reading Kids’ Social Cues is Hard Enough

Jenny Radesky MD, FAAP
Assistant Professor of Developmental Behavioral Pediatrics
Boston University School of Medicine

Last summer, a small but fascinating study in the journal Computers in Human Behavior,  showed that if you take  away  preteens’ mobile devices and make them hang out with their peers in the country for one week, they get better at reading other people’s facial expressions.  So which has more influence on preteen social skills, the unplugged time with peers or communing with nature?  Hard to tell, but developmental science suggests the former plays a large role. 

Reading someone else’s facial expressions and other body language such as gestures, posture, how their eyes look, how their voice sounds is key for social and emotional communication.  Developmental psychologists believe these nonverbal cues are central to infant-caregiver attachment.  For example, infants come to understand their own emotional states and experiences by looking at  trusted caregivers and reading their facial expressions, and modulating their reactions accordingly.  (“This is new…is mom OK? Alright then I’m OK”). 

Toddlers and preschoolers develop social skills by learning to reference, read, and react to other people’s behavior.  My patients with ADHD and autism often struggle to read peer social cues correctly, with frustrating consequences.  We spend lots of time, energy, and money trying to explicitly teach these children social skills through  the practice of interacting with others over and over again to tighten up the synaptic connections that regulate social communication.  What is lost when preteens and teens look at smartphones and devices for so many hours a day are opportunities for practicing face-to-face social interactions.  This may explain the study’s findings.

However my chief concern regarding reading social cues (and my focus of research) is parents of children under 6, especially parents of fussy, intensely reactive, or poorly regulated children.  These children can be hard to read.  What did that cry mean?  That tantrum out of the blue?  This insistence on suddenly refusing baths?

In order to effectively teach children how to regulate their behavior, we need to interact with them in what psychologist Lev Vygotsky termed the child’s “Zone of Proximal Development (ZPD).”  This means  knowing their cognitive and emotional sweet spots: what they can do on their own, what they can’t do, and what they can do and learn with an adult’s help.  You can’t fit the puzzle pieces in yet?   Let me guide your hand a little bit until you figure it out by yourself.  You can’t calm down when you’re frustrated yet.   Let me help you identify what emotion you’re feeling and then show you some options for calming your body down.  And I’ll slowly take my support away until you can do this skill on your own.

Caregivers need to be tuned in to a child’s temperament, developmental stage, and emotional state to be able to read her social cues and teach her within her ZPD.  In order to be attuned to a child, adults need practice observing him, over and over, through multiple experiences, interactions, reactions, and social settings, to know his rhythms and quirks.  We don’t need to be helicopter parents, observing and attuning to every single detail, but we do need a ‘good enough’ amount of experiences to know what the child might need when he or she is acting out.

Which brings me to why I study parent mobile device use, specifically the absorption that occurs with the multitudes of important or attention-grabbing things we do with our mobile devices.  With this sort of competition for attention, infants can’t always get a facial expression reaction that helps them understand their experience; toddlers may act out more (at least mine does) to get our attention, which is unpleasant when we are trying to concentrate on something important on the device. When we are absorbed with devices, we may not be as cognitively flexible or emotionally ready to “read” what annoying child behavior means and how to meet children in their zone.  We may miss important social-emotional teaching opportunities.  So far, my research findings suggest that when parents’ attention is directed at a device, they are less conversationally responsive, have fewer nonverbal interactions with children, and are potentially more hostile when children make bids for their attention.  I am crafting my future studies to understand the mechanisms of these findings, so that guidance for parents can be developed. 

In the meantime, we can continue to recommend unplugged family time, family dinners, and parent-child play, so parents can know their child’s zones.  These Common Sense Media videos are also a good start:

March 2, 2015

The Role of Media on Children's Body Image

Jacqueline Dougé, MD, MPH, FAAP
Medical Director    Bureau of Child Health, Howard County Health Department

I remember watching this year’s Super bowl with my family and the Monday morning discussion that was not about the game but about the commercials. One commercial in particular caught my attention, Always #LikeaGirl.  The video featured individuals answering the question, “What is it to be like a girl?” The video starts with adults and a young boy and ends with younger girls.  The adults and boy had a remarkably different definition of what a girl is than the younger girls.  The younger girls were more positive The point of the commercial was that as young girls grow up, their image of themselves grows more negative.  The message hit me hard and made me think about myself and if I had experienced the same feelings as I grew up.  The answer was a resounding yes, and I’m not the only one. 

The other day while I was watching a talk show, one of the TV hosts was brought to tears discussing the pain and stigma she felt because she was overweight. I could only imagine what young women and girls experience when they think of themselves. 

Common Sense Media’s recently released research article, Children, Teens, Media, and Body Image,  examines the role of media on how children view their body image.  Highlights from the research indicate the following:

         Body image has an impact on self-esteem and health.  Poor body image is linked to low    self-esteem and depression 
  Young children have body image issues
         Both boys and girls experience body image issues
         Parents’ views about their own body image can influence their children
         Social media could be used as an intervention strategy

Both girls and boys are surrounded by images of what is perfect.  Most TV shows have thin and attractive lead characters whereas the side kick is usually heavier and not seen as attractive.  Children are also exposed to distorted images in magazines, toys (Barbie dolls and action figures) and online.  But traditional media is not solely responsible for how children determine their own body images.  Family, parents, peers and society also play an important role.  How many times have you heard yourself say that you don’t look pretty enough or you’re too fat? How many times do you tell yourself that  you need to lose 5-10 pounds?  How many times do we tell ourselves that we’re not good enough?  Our kids are listening to and watching us. 

There is opportunity to change the conversation about what beauty or handsomeness means.  Common Sense Media has provided resources for parents and providers  to have positive discussions about body image:

All children should be able to feel good about themselves. Adults too.  We all don’t like something about ourselves, but we must also consider that those things are what make us unique and beautiful.  We can’t just believe the negative.  Our visions of ourselves impact how our children see themselves. 

Something to think about. 

January 19, 2015

Common Core Education - The New Third Grade

Nancy M. Silva, MD, FAAP
Small World Pediatrics
Wesley Chapel, FL

My son is in third grade.  This year has been a year of many education system changes.  Common Core has officially hit his grade.  He is also using Canvas, an online learning management system, and we are using Remind101.  As a result, his learning life has changed.

Common Core means more time on the internet, more time on math, and more communication with the teacher.  This is an excellent  advantage of this new curriculum.  Communication between teacher and parent helps the students do their best work.  We also receive reminders via an app, Remind101.  I’ve actually become reliant on it.  As a consequence, when there have been times that a reminder wasn’t given, it felt as if something went terribly wrong.
 My son definitely needs a computer now.  The school uses “ a flip classroom”, which essentially reverses the learning model.  The lesson is at home on the computer.  The review is at school and solidifies the lesson through exercises, projects, explanations, and discussions.  Students view the next day’s math lesson every night on the internet.  The math lesson is a YouTube video prerecorded by one of the third grade teachers.  After each class, there is a small quiz available on the Canvas website.  The results of the quiz informs the teacher which students need more help with the next day’s lesson.  It helps me as well to now know what lessons my son needs help with day by day.  Why is this so helpful?  With so many learning strategies they are required to learn, there simply isn’t enough time to learn them all expertly in the classroom.  Hence, teaching, reviewing, and learning continue at home, more so than it did pre Common Core.
The Canvas website has also been a huge change.  Canvas is all encompassing.  It has links to every math lesson from the beginning of the year.  It has science lessons, writing assignments, homework assignments, and even encourages students to offer positive feedback to fellow classmates on their weekly writing assignments.  Canvas  also allows students to send messages to each other.  It’s wonderful that this is all available in one place.
Some features of Common Core are very good.  Math can be broken down into many strategies.  These are strategies that I learned on my own over the years.  It’s nice to know that my son is learning them earlier.  However, simple math is made more complicated because there are so many new strategies to learn.  Since there doesn’t seem to be enough time to learn them all in the classroom, parents need to be more involved.
The most important change this year has been the excellent communication between his school and us third grade parents.  A special meeting explained Common Core to us.  The third grade teachers work as a team to maximize children's success with Common Core.  His teacher is amazing.  We communicate in person and via email on how to make the most of his strengths through this growth period.  
My son has begun his journey with computer education, online lessons as "flip classrooms”, and intranet social communications between classmates related to school work.  I feel like a dog learning new tricks, some of which I like a lot, and others, not so much.  Either way, this old dog is learning the new tricks.  The reality is that education changes are just one aspect of his life that is changing.   At the end of the day, one thing is never going to change; I am a mom who is going to be there for my child.  I will always support and encourage him to be and do his very best!

October 30, 2014

Cyberbullying: Notes from the Field

Ellen Selkie, MD, MPH
Adolescent Medicine Fellow, University of Washington/Seattle Children’s
As an adolescent medicine provider, I’m constantly working to keep up with media trends—a great conversation with my patients is often started when I ask what websites they use, or their favorite platform for staying connected with friends.   However, I’ve also seen peer relationships turn sour through media—particularly when it comes to cyberbullying.  
The CDC defines bullying as “unwanted aggressive behavior(s) by another youth or group of youths who are not siblings or current dating partners that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated.” Notably, bullying falls on the spectrums of aggression and violence, but not all violent or aggressive behaviors are necessarily bullying.  
How does this definition fit cyberbullying?  Well, we certainly see unwanted aggressive behaviors online—name calling and rumor spreading can be easily done by commenting or posting on social media, and text messaging is a quick way to threaten someone else.  The “power imbalance” may not be a physical one, but having secrets about a peer can be very powerful…especially if you decide to talk about them online without permission. For some teens, it may be “easier” to bully others online because of the anonymity that the Internet can offer as well as the potential for a large audience to see nasty messages quickly.  
It’s important to note that most kids who experience cyberbullying are also being bullied in person (“traditional” bullying).  They usually have some idea of who is cyberbullying them, though not always a specific person.  In fact, many studies show that cyberbullying is less common in prevalence than traditional bullying.  But whereas bullying that happens in person is usually limited by the timing and place of the school environment, cyberbullying can happen anywhere, at any time.  I’ve had multiple patients tell me that they check their Instagram at 2 or 3 in the morning “just in case” someone has posted a mean comment, so that they can delete it before too many people see it.
 The potential permanency of messages on the Internet calls into question whether a single post, while not “repeated multiple times,” would still constitute bullying behavior.  I think this is where we get into the topic of why we care about bullying in general.  We know that bullying, both as a bully and a victim, is associated with poor mental health, suicidality, school failure, and other negative health outcomes.  Cyberbullying has also been associated with these negative outcomes, and in some studies is more strongly associated with suicidality than traditional bullying alone.  It’s unclear why this might be, and further research is needed in this area.  But if a single mean post on Facebook is hurtful enough, and a teen can look at it over and over, might that not lead to distress, poor sleep, depression, or other negative consequences?
Regardless, I’m making sure to ask my patients about both in-person bullying AND cyberbullying, and most importantly, how they are coping if they are experiencing bullying.   While some teens view these aggressive behaviors as “drama” that is easily ignored, others take their peers’ online comments to heart.  Knowing each individual teen and their support system is key to identifying those most at risk.  
For more resources on these topics, visit and the Cyberbullying Research Center for further information.

October 8, 2014

Why I chose to be a real doctor with a fake name


My interest in studying medicine began in high school. I’d always loved science, and as I considered what I wanted from a career, being a physician seemed to make the most sense. I imagine my reasons for wanting to do so are relatively generic among members of our profession.
But the thing that really filled me with joy was writing for the school newspaper. I had a column on the opinion page, and every time a new issue was published I’d wait with eager expectation for the reactions of my classmates. Had they liked it? Did they think the jokes were funny? While it hardly catapulted me to prom king status, it at least gave me the chance to participate in the life of the school that suited me.
However, as I focused my studies on medicine, writing fell away entirely. The only writing I did was for classes, and nothing for my own enjoyment or a wider audience.
When the opportunity to write for a moderately successful politics/general interest blog came up a few years ago, I was delighted. It was an outlet I’d enjoyed, and I’d contributed a guest post or two. When they invited me to contribute regularly, I jumped.
As it happened, I was at a small turning point in my career. I was leaving a job that I’d come to consider a poor fit, and was taking a new one. Since I had no idea if my new employers would look kindly on my spouting my opinions on the Internet, I opted to use a pen name. It seemed a good way to keep my medical self and this nascent writer self separate.
Several months ago, I managed to get something published in one of the bigger online magazines, an outlet I’ll call The Behemoth. Many of the blog’s other writers had gone on to paying gigs, and with their help I pitched a piece to a couple of places. The Behemoth ran it.
It ended up being more successful than I’d ever dreamed it would be, and went “kablooey” on social media. I’d taken a relatively controversial stance on a very fraught issue that pediatricians continue to face, and clearly touched a nerve. While many, many people expressed support and agreement with what I’d written, I got plenty of blowback. Including from fellow pediatricians.
Given the success of that first piece, I was offered a regular contributor spot, and have been churning out content on a weekly basis or so since. Writing for a general audience site like The Behemoth is not without its headaches and issues, which I think are normative for the industry as a whole. (I’ve had a few articles run at a place I’ll call Parlor, and my experiences there are about the same.) Perhaps I’ll talk about those issues in a later post.
As I’ve adjusted to the (still surprising) phenomenon of being paid to write things, I’ve toyed with the notion of dispensing with the pseudonym. In comments on some of my more controversial pieces (which I know I shouldn’t read anyway), sometimes in between accusations of being a shill for Big Pharma someone will question my integrity since I’m hiding being a fake name. It’s a criticism I can’t entirely dismiss.
Thus far, I’ve opted to keep the pen name. I doubt I’d be able to speak as freely or as honestly if I had to worry about being as nice as I strive to be when wearing my pediatrician hat. (Editorial decisions about how to frame my writing sometimes come off as less nice than even I would have chosen. See above: re headaches.) I think we pediatricians work very hard to be perceived as kind and sensitive, and I suspect sometimes that impulse could get in the way of expressing my thoughts quite as clearly as I’d like.
There are many pediatrician-writers out there who use their real names. I follow the work of many of them, and admire much of it immensely. (One whose work I particularly like disagreed quite pointedly with what I’d written in that first Behemoth piece in a segment for Headline News, which I found about as enjoyable as you’d expect.) Sometimes I wonder if I made a mistake when I chose to write with an assumed name rather than the one on the sign out front. Lots of others have made it work after deciding differently.
For now, the fake name stays. My partners in the practice all know I write and are fine with my dropping it, but the freedom it affords still offers a little bit of comfort. I don’t work super hard to maintain it, and perhaps one day I’ll offend some particularly enterprising individual with enough time and motivation to unravel it. In the meantime, the opinions I express come out just a little more easily, which my writer self finds reason enough to keep the separation in place.

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.