July 11, 2015

The Facebook Imperative

Gregory Lawton, MD, FAAP
The Children’s Hospital of Philadelphia
A Musing Pediatrician on Medscape


The average first time diaper changing parent is twenty six years old and will be in a preschool carpool at the age of thirty-one.

According to the Houston Chronicle, seventy-nine percent of Facebook’s 200 million North American users are between the ages of twenty-one and thirty-four.

This means that for every toddler struggling with toilet training, there is a very likely a parent with a smartphone and Facebook app nearby.

This is not a parent who surfs the web. She scrolls through a Facebook News Feed or the Twitter trends.  He does not actively search for information (other than using Google). Rather, based on his likes and preferences, information is directed to him in the form of hashtag messages, birthday notifications, and alerts.

Most pediatric practices in the United States have a website that boasts practice hours, staff members, and general policies. Websites, however, are passive information repositories. They don’t reach out and engage the app-using, smartphone-touting, social media consuming parent.

The next time a high school in your area has a pertussis outbreak, consider what message you want to push out on your practice’s Facebook page. When an ice storm cuts power to both your office and the computers of your patients, perhaps a Tweet will reach more parents on their mobile devices. When an unexpected change in a clinician schedule means there are suddenly five or six extra appointment slots for those coveted physicals, maybe an announcement on social media would be the best way to fill those slots.

For these scenarios to become reality, however, three things need to take place.

First, the American Academy of Pediatrics needs to publish specific guidelines for practices enlisting social media for the purpose of communicating with families. What constitutes appropriate content? Who can post and who monitors the site? What statements are needed to mitigate liability?

Second, it is important for large healthcare organizations to recognize that an institution social media presence is not a substitute for a local office presence. In order for a practice Facebook page to reach YOUR patients, in YOUR neighborhood, it needs to be YOUR practice’s page. To be sure, it can link back to the mother ship, but it needs to be local.

Third, pediatricians need to become more adept at using social media at the practice level. This means moving beyond links to YouTube uploads or vacation pictures. Think about a post that the flu vaccine is in and you have a wide open flu clinic on Thursday. Consider a tweet when there is a local story about Lyme Disease or the uptick in driving accidents around prom season. Announce the retirement of a beloved nurse or clinician in the practice.

For the social media-savvy, communication minded pediatrician who thinks about taking care of the healthcare needs of the entire practice population, Facebook is where the patients are. Twitter is where the teens are. It’s time to enter this arena.

June 15, 2015

Advocating for Children’s Health Issues Through Advanced Social Media Skills: My AAP Legislative Conference Experience

Margaret Stager, M.D., F.A.A.P
Director, Division of Adolescent Health
MetroHealth Medical System, Cleveland, Ohio


In April, I was one of 130 pediatricians who attended the 2015 AAP Legislative Conference in Washington, D.C.  We were from all parts of the country: large states, small states, big cities, little towns; some still in residency, and others well into their third decade of practice. And while we represented a wide range of practice and academic settings, we all shared the common interest in becoming more active advocates for children’s health issues. 

The conference began with two full days packed with dynamic speakers and informative training sessions.  Secretary of Agriculture Tom Vilsack spoke about the importance of school nutrition programs, and Congressman Jim McGovern of Massachusetts and retired Congressman Henry Waxman of California encouraged us to continue to pursue our advocacy efforts to better the lives of our nation’s children.  Breakout sessions included topics such as Poverty and Its Effect on Child Health; The Art of Negotiation; Coalition Building; Crafting your Message; and Speaking up for Kids Through Social Media.  We were briefed extensively on the upcoming vote to extend the CHIP program, as well as the need for child resistant packaging for liquid nicotine containers for e-cigarettes. 

On day three came the pinnacle event: the walk to Capitol Hill to meet with our regional Congressmen/Congresswomen, and Senators. We were well prepared and the bus ride to Capitol Hill was filled with chatter and excitement.  Before our individual meetings, Congresswoman Katherine Clark, a relatively new Congresswoman and an advocate for many child health related issues, met with us to inspire us to take our messages to the Hill and continue to be the voice for children’s health issues.  Many of used our professional Twitter accounts to post pictures and words of encouragement and thanks.  See #AAPLegCon for all the great photos and inspiring messages.

I am proud to report that the vote was held the afternoon of our meetings, and the Medicare Access and CHIP Reauthorization Act of 2015 was passed and signed into law. The child resistant safety packaging for the liquid nicotine containers is making progress and needs your support. (Child Nicotine Poisoning Prevention Act)  I encourage you to go to http://federaladvocacy.aap.org and contacting your members of Congress to gain their support for this very important measure. 

Tips for those currently active in social media:

Use your platform to advocate for children’s health issues that are nearing a vote or need impetus to get a hearing.

Bear in mind that the Capitol Hill staffers follow what’s trending on Twitter, especially as it relates to issues important to the legislator.

Legislators and their staffers appreciate being recognized or acknowledged on Twitter so be sure to send messages of thanks when a meeting or a vote is supported by their office. 

Advocacy can occur on many levels: national, state, community, or by topic.  In order to stay abreast of all current AAP advocacy efforts, consider signing up for the various list serves and email messaging provided by the AAP.  e.g. AAP Department of Federal Affairs, (kids1st@aap.org)  In addition, there are opportunities for committee and section involvement at the AAP as well. 

Symplur website (www.symplur.com) has created the Healthcare Hashtag project which allows you to see where the healthcare conversations are taking place, and what healthcare topics are trending in real time.  It also lists current and pending TweetChats in a variety of health topic areas. 

TweetDeck (www.Tweetdeck.twitter.com) allows you to follow multiple twitter conversations simultaneously.  Sign in with your Twitter account information and you can custom build your page to follow up to 9 conversations at once. 

April 28, 2015

#pediatrics: How Social Media is Becoming Integrated into the Pediatric Conference Experience

Megan A Moreno, MD, MSEd, MPH
Associate Professor of Pediatrics
University of Washington
National pediatric conferences are a common way for clinicians to learn what is new in the research and clinical worlds, connect with colleagues and immerse themselves in a learning environment.  Over the past ten years, media and technology have slowly grown within national conferences as a topic of research, a new clinical tool, and a part of the meeting experience itself.  With the rise of social media, these novel tools are also being integrated into the conference experience. Social media tools such as Facebook and Twitter can enhance one’s conference experience, or it can serve as a distraction to oneself or others. Here are a few ways in which I’ve seen them intertwine within the pediatric meetings I have attended the past few years, for better and for worse.
For better:
Meeting through tweeting: It is common practice now to use Twitter during conferences.  Active Twitter users may interact digitally throughout an entire meeting even if they haven’t met in person before.  At a conference I attended this fall, I saw attendees seeking out fellow Twitter users using their profile picture so that they could introduce themselves with comments such as: “I’ve been following your tweets the whole meeting, it is great to meet you!” This bridging of online-to-offline social circles allows you to expand your social network during meetings in new ways, and gives you easy ways to keep in touch after the meeting.
Presentation feedback: For presenters at national meetings, it can be challenging to get feedback.  Twitter provides a new way to get feedback by reviewing the conference Twitter feed that was active during your presentation.  Twitter users will be highly engaged during a good presentation, and will retweet quotes or data they find particularly useful.  This  allows the presenter to see what points really hit home in the presentation.
For worse:
#wififail: At a recent meeting I attended, the conference heavily promoted the use of social media and provided a unique hashtag, but then did not provide wifi in the conference center.  Conference organizers and venue providers should pay heightened attention to the availability of wifi. 
#presenterfail: At a national conference, I attended a 3 person panel presentation about social media and how it is changing youth engagement and social norms.  One message of the presentation was that adolescents are too distracted by social media. All panel members sat on stage facing the audience throughout the presentation, and (somewhat ironically) one of the panel presenters was using his mobile device while the others were presenting. This gave the audience the feeling that the presenter was uninterested in what the other panelists were saying. It’s unclear whether the presenter was tweeting, checking email, or just playing Angry Birds.  Even in our age of digital immersion, there are times when it is not appropriate to tweet.
It is likely that the role and frequency of social media use during conferences will

 continue to grow in coming years.  Thus, pediatric conferences have opportunities to

consider how they want to integrate it into the experience and help shape the etiquette of

social media use during conferences.  One unique contribution conference organizers

could consider is to provide sessions to educate pediatricians about using these tools

during the conference experience. Conferences may consider having a hands-on session

early in the meeting where social media newbies could stop by and learn how to set up a

Twitter account so they can start using it right away. Woven into these sessions could be

 discussions about the etiquette of social media. This hands-on training could lower the

barriers to joining the online conversation, and may be a valuable training opportunities

for busy pediatricians who otherwise wouldn’t take the time to learn how to use these

 tools.  As the social media presence at our national meetings grows, we should consider

 innovative possibilities to ensure pediatricians are joining the conversation.

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 StopBullying.gov and the Cyberbullying Research Center for further information.