School Starts for Children & Moms

Nancy M. Silva, MD, FAAP

Our son just started kindergarten.  It was really exciting!  I didn’t cry, but was amazed by the flashbacks of when I was little girl in school.  I loved to learn.  It was great to be with other kids. Kindergarten was filled with playtime.

Kindergarten sure isn’t playtime anymore.  And, everyone doesn’t have the same experience anymore either.  Before, regulated day care & pre-K classes didn’t exist.  As for my son, he has been in day care since he was 3 months old.  You’d think he’d be prepared.  But, it’s just as hard for him as the other kids who have stay-at-home mommies.  He had to say good-bye to his old routine, his old friends, his old teachers, basically to the life he knew for over 5 years.  Now, playtime is over; it’s learning time with a little bit of playtime.  After school, there’s the bus ride to day care too.  He has a long day.  That’s hard on anybody.

Did I mention it’s hard on us too?  No one likes change.  And this was a lot of change.  This house wakes up earlier.  He has to eat breakfast within a certain time frame.  Lunch bags need to be prepared.  How is a 5 year-old going to carry a backpack, a lunch bag & a snack bag?  How is he going to put it all up, repack stuff, coordinate all those little things?  I don’t know; but others have done it for years.  It’s just our turn this time.

Technology has changed in schools as well.  My son’s teacher has his homework schedule on her blog, which is very convenient.  She also offers communication via email.  Remember when it used to only be notes and/or phone calls?  Even the PTA is modernized.  The PTA has its own website with many helpful links.  They even have a Facebook page.  If we want to know what the PTA school functions are, we must refer to the website and Facebook.  For example, the PTA ran Family Bingo Night.  There was no note in his folder, like there would have been in the past; instead, all the details were on the website.  By relying on technology, a lot can be accomplished.  I must say, I’m amazed that this school is using technology as a part of communication, not a replacement for it.  It’s a public school that has family at its heart.

Despite all the changes, there is one thing that doesn’t change … the human experience.  Letting go isn’t easy.  Trusting others to teach your kids & care for them isn’t easy either. 

Yet, somehow, we are surviving.  He’s starting to make friends, but it’s not as easy as in day care.  And he feels it.  Positive affirmations and pep talks are given.  Reviewing the day, homework, and coaching are done.  Clearly, our roles have expanded.  I must admit I’m feeling more tired than before.  The great news is that he is excited.  In the end, that’s all that matters.

So, this pediatrician, this mommy, is going through growing pains along with my patients’ moms.  It’s nice to bond with families at this special time in our children’s lives.  It’s nice to share in the difficult times and the joyous ones as well.  After all, being a parent is the toughest and most rewarding job of all.

The Verdict Is In

Don Shifrin, MD, FAAP

In June’s United States’ Supreme Court decision in Brown (Governor of California) versus the Entertainment Merchants Association, the “nine” (actually 7-2) voted to reject a California law prohibiting the sale or rental of violent M-rated games to minors under 18. (According to the Entertainment Software Rating Board, “Titles rated M (Mature) have content that may be suitable for those ages 17 and older. Titles in this category may contain intense violence, blood and gore, sexual content and/or strong language.”)

Apparently, there was a “lack of credible evidence” that created enough of a “reasonable doubt” to convince a majority of the justices that viewing or playing violent video games would not influence young minds and imaginations in morally perverse ways. Therefore, First Amendment freedoms could not be marginalized. Case closed.

True, the California law was vague and would have been difficult to enforce. But childhood advocates and most (unfortunately not all) researchers agree that viewing violence can influence behaviors, desensitize emotions to real life aggression, and produce a perspective that the real world has a violent landscape.

But here’s the thing -- the court established decades ago that laws could protect children from sex and pornography in the media. Albeit, apparently just not violent pornography against prostitutes as in Grand Theft Auto: Liberty City Stories. In all honesty, a large majority of programming in cable, movies, games, and the Internet breach those laws daily.

The gaming industry, as well as TV, movies, and the music industry, proudly defend their individual rating systems, and device features, as evidence that parents can control exactly what their kids view or play.

In the “life imitating art” lesson here, I participated in an Israeli Army training session 3 years ago.At an Army training center, we were given M-16 rifles with laser sights and then watched a video on a room-sized screen where various terrorist scenarios were played as live situations. Shooters (of laser bullets) were graded on reaction time, terrorists killed or wounded, and civilians spared, or not. This video exercise has been in place for years to train soldiers to instinctively recognize, react, and respond appropriately with lethal force. I could say, in all honesty, that I was certainly desensitized to real life violence after multiple encounters. And that was after only 30 minutes of “playing time.”  The true point of the exercise?  Get used to assessing and shooting quickly and efficiently. The exercise is about desensitization. Appropriate for people going to war, not to school.

Training soldiers to react, shoot, and kill produces shooters like Michael Carneal. At Heath High School in Paducah Kentucky on Dec. 1, 1997, Michael, an expert gamer who had never fired a real gun, took a pistol to school, pulled it out in the hall and fired eight shots in succession. All eight hit students; five were head shots. (Something even law officers cannot accomplish most of the time.) He was heard to reply after he dropped the gun, “Kill me please; I can’t believe I did that.”

In 1999, the parents of three victims filed a $33 million lawsuit against two Internet pornography sites, several computer game companies, and makers and distributors of the films Natural Born Killers and The Basketball Diaries. They claimed that media violence inspired Michael and should be held responsible. The 6th U.S. Circuit Court of Appeals ruled it was “simply too far a leap from shooting characters on a video screen to shooting people in a classroom.”  Both the parents’ attorney and the 79th U.S. Attorney General, John Ashcroft, went on record as stating that Michael’s proficient marksmanship was due to practice in violent video games.

No small wonder Lt. David Grossman, author of the book “Stop Teaching Our Kids to Kill,” calls these games “murder simulators”.  We should not be surprised then when kids and teens enter emergency rooms after being shot with real bullets and they exclaim, “I didn’t know it could hurt this much.” Certainly it is a fact that pain or negative consequences of violent acts are rarely seen on screens.  Research from the landmark three-year National Cable Television Violence Study in 1997 demonstrated that conclusively.

For every Cheryl Olson (former Harvard psychiatry professor), who maintains there is no “credible evidence” that violent games cause children psychological or neurological harm, or make them more aggressive and likely to harm others, the evidence is slowly but surely going to cast “a reasonable doubt” on their assumptions.  Many think ample evidence exists to support that connection already.

So far, we do not know which children are most at risk or when; what kind of content in these games could cause psychological changes; and how much exposure it takes.

We do know, based on sex and pornography, that books are different from videos.  So comparing violence in a book to a video, done by one Supreme Court justice, seems simplistic at best.  And, to lump in that consideration that violent games have benefits, causes most researchers to reach for their antacids.

With this affirmation of free speech, the two dissenting justices did reaffirm the rightful job of mothers, fathers, grandparents, and caregivers to filter, monitor, and regulate children’s exposure. You and I both know that with devices galore and connections aplenty, that is now a seemingly endless task.

Note here that the Entertainment Software Ratings Board (ESRB) rated around 1,600 games in 2010.  That job was done by humans watching a DVD submitted by the game’s publisher, which includes the worst violence, language, and sexual scenes.  Evidently, they do not “play” the game.  But at least humans are involved -- for now.  The ESRB will now have computers rate online console games for Xbox, Wii, and PlayStation based on extensive ‘questionnaires’ submitted by the publishers.  Humans will not see or review the online games until it is on the Web.  As for the increasing number of apps, social, and mobile games, Apple and Zynga/Facebook have taken no action concerning any ratings system to date.

Ever the pragmatist, Michael Gallagher, President and CEO of the Entertainment Software Association, called the Brown decision, “An overwhelming endorsement of the first amendment: the right to free expression.”  Additionally, “It’s also a great victory for parents and the rights of parents.”

Really Mr. Gallagher?  I am sure if you put your ear to the rail you will hear a different kind of rhetoric from parents and the public.

The great Harlem Baptist preacher Calvin Butts once declared, “Violence is an American tradition.”  It’s also big business now left virtually unfettered.  And, at least in the court of this pediatrician’s opinion, money may not be all it is generating.

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.

Teens, Multi-Tasking and Attention Span: The New Normal

Susan Buttross, MD, FAAP
Professor of Pediatrics
Developmental and Behavioral Pediatrics
University of Mississippi Medical Center

Have you ever thought about what’s really happening when teens are watching television, waiting for an appointment in an exam room, sitting in a classroom or talking to you? Most likely, it’s not just that one thing. Look carefully and you’ll see that our preteens and teens are absolute masters at multi-tasking.

Watching television exclusively rarely happens, nor does talking to you directly. Typically, while watching a movie on the TV (which by the way is becoming almost extinct for many) that same guy may be on his laptop or iPad and also texting or checking texts. Just when you think there is no way that the teen can be listening to you, he proves you wrong by answering a question that you didn’t think he heard, right? Amazing how they possess the ability to move back and forth from one type of task to another. Seems great; but, many of us, who did not grow up in the tech era, have distinct difficulty wrapping our heads around what is really happening and what possible ripple effects this may have on our previously accepted behavioral and societal norms.

So let’s take this a little further. If someone is not looking at us, can they really be paying attention? To learn something, must a child stay on task for 25 minutes at a time? At 5 years, we expect a child’s attention span to be about 10-15 minutes (that’s the basic standard of about 2 to 3 minutes of attention per year of age), by 12 years that length has doubled. For most individuals, there seems to be little real growth in the length after that, even into adulthood. However, with rapidly moving and exciting programs available electronically, the needed attention span may be only a few seconds because of the “machine gun-like” rapid-fire movement of the tasks.

Over the last 20 plus years, Adele Diamond, Russell Barkley, Doug Cantwell and other researchers in attention deficit hyperactivity disorder (ADHD) have spoken about executive function and working memory as the major deficits in the disorder. As Dr. Diamond hypothesizes, individuals with ADHD-I (the inattentive type of ADHD) have sluggish “cognitive tempo.” Thus, they are easily bored. Perhaps, changing the tempo of presentations may prevent that boredom and improve the performance of the child. Something that can keep the adrenaline (or dopamine) going improves the attention span in those with ADHD. Maybe that is true of all children. Perhaps children, in general, are better able to engage when their adrenaline is peaked. This would explain the incredible success and even addiction that many children and adults, for that matter, have for video games. The tempo is rapid fire; risks are there; adrenaline is up and so the hook is there that makes one able to stay with something for hours without boredom.

Sitting, talking and watching TV, individually are typically slow paced tasks. Multi-tasking is a way for someone to stay engaged without boredom. This phenomenon of multi-tasking when faced with conventionally slow placed tasks seems pervasive in much of the teen population and may increase their ability to have sustained attention to the task at hand.

We know in the past the “normal and respectful” way to be was to look a person in the eye and certainly NOT to do something else when you are talking to that person. Fast-forward to now…really fast, and perhaps the norm is changing.

The diagnosis of ADHD is on the rise. There has been an explosion of medication use and alternative therapies created for the treatment of this disorder.

Don’t misconstrue my comments to mean that I don’t agree with using medication for the treatment of ADHD. ADHD is a real disorder and often individuals need medication to help in its treatment. But understand that, with the growing use of technology occupying the majority of our children’s waking lives, if our society continues to try to educate children in the same manner that we have in the past, we may be facing an ever-increasing number of children who meet the criteria for ADHD. Perhaps, we need to consider incorporating learning into different formats and look more closely at how we can really hold the attention span of our children. As we change as a society, we may need to take a hard look at the way we teach and the way we define what is really ADHD.

Oh Mickey You’re So Fine, You’re So Fine You Blow My Mind- Hey Mickey

Oh Mickey You’re So Fine, You’re So Fine You Blow My Mind - Hey Mickey
Don Shifrin, MD, FAAP

When Disney announced in 2010 that it was buying Playdom, an online social gaming company, for $532 million, it was lauded as part of a long-term strategy to have a more formidable presence in the video game industry. This followed their purchase of Club Penguin in 2007 for $350 million. Seems like Mickey may have had his eye on a lot more than just webpages.

In May Playdom/Disney paid to settle federal charges that it illegally collected and disclosed personal information from hundreds of thousands of children under 13 without parental consent. Talk about success! The Federal Trade Commission (FTC) noted that the ‘settlement’ was the largest civil penalty ever for a violation of the Children’s Online Privacy Protection Act (COPPA). Just to make sure, let me reiterate. Ever.

Does Mouse central consider this a setback, akin to when the FTC investigated whether their Baby Einstein series was marketed falsely as “educational”? Although the complaint was dismissed in 2007, Disney responded in 2009 to the continuing bad publicity by offering a refund to parents who might have purchased DVDs with visions of Harvard on their children’s horizon. Actually, I am not sure what would embarrass Mickey these days. But I digress.

According to the FTC, Playdom operated 20 websites that collected children’s ages and email addresses and allowed children to post names, email addresses, and locations on personal pages and in online forums. Prior to Disney’s purchase in July of 2010, about 400,000 children registered with Playdom sites. An additional 800,000 registered with its Pony Stars site as well. (Pony Stars was purchased by Playdom when they bought Acclaim Games two months before the Disney deal swallowing them both). A July, 2010 Disney release announcing the purchase stated, “By acquiring Playdom, Disney will strengthen its already robust digital gaming portfolio, acquire a first-rate management team and provide consumers new ways to interact with the company on popular social networks like Facebook and MySpace.”

Well, not exactly what Mickey’s shareholders had in mind; last fiscal quarter Disney’s interactive unit lost $155 million -- $100 million more than the previous year. The culprit? Well Playdom came on board for $500+ million. True, most of the blame for the FTC’s ire is on Acclaim. But when you pay over half a billion (plus maybe another $200+ million in incentives), one assumes that due diligence should be a given.

Let’s get back to the FTC. No question that Disney/Playdom/Acclaim violated the COPPA law, which became active April 2000. As of last week, Representative Edward Markey of Massachusetts proposed new COPAA legislation to “extend, enhance, and revise the ability of companies to collect, use, and disperse personal information from minors.”

So after we have a clear FTC violation, what was Disney’s response? Not so coincidentally, the same response has been in the playbook for years by children’s food companies investigated by the FTC for deceptive marketing practices; admit no wrongdoing even though you have been found to be unscrupulous by the FTC. Then declare happily that the infraction is all behind you.

Predictably, Disney’s release reads, “This matter involved a FTC investigation of the practices of Acclaim Games, a company that was acquired by Playdom prior to Disney’s acquisition of Playdom in 2010,” textbook boilerplate language acknowledging no wrongdoing on Disney’s part. Then the happy ending, “Disney is pleased that Playdom and the FTC have now resolved this problem amicably.”

The amicable resolution of the “problem” was a mandate for the largest civil penalty ever. Did I mention ever? Wait for it -- 3 million dollars. For a company whose recent quarterly profit was $942 million, that amount could be found on the mailroom floor. That represents less than 1% of their purchase price for Playdom.

If and when a new COPPA law is instituted, do we really think that companies targeting children will be afraid to play chicken with the FTC? Not at those prices.

Adjusting to the new digital reality: why pediatricians may need to rethink—or at least refine—their messaging.

Claire McCarthy, MD, FAAP


A couple of weeks ago I went to a Verizon store to upgrade my phone (to an iPhone!). I had my 10-year-old and 5-year-old with me, as my big kids weren’t available for babysitting; this will be quick, I told them.

Of course (in that Murphy’s Law kind of way) it wasn’t quick at all; I had to wait more than twenty minutes for someone to help me. But Natasha and Liam didn’t mind. They went straight to the iPads on display, and navigated them without any help from me. Natasha found a puzzle application and started putting puzzles together. Liam found a drum set application and started making up songs, adding his own lyrics and dance moves.

As I watched them so fully and happily engaged in activities that required concentration and creativity, I thought (as I have so many times): there’s a lot that’s good about digital media.

We pediatricians tend to be very negative about “screens” when we talk with families. We stress the 2-hour limit to help prevent obesity. We warn about Facebook depression, exposure to violence and sex, cyberbullying and online predators. We talk about how texting can keep kids up at night and how video games can contribute to ADHD.

Don’t get me wrong: these are important messages. There are very real risks associated with the Internet and media. We need to keep kids healthy and safe; that’s our job as pediatricians.

But if we are just negative, we miss two important points:
• It’s not all bad. Children these days literally have the world at their fingertips. In our house, questions don’t go unanswered; when something comes up in a conversation, we Google it (often on someone’s smart phone at the dinner table). They have the ability to connect within seconds with people all over the world and to learn about lives that are very different from theirs. There are thousands of websites and applications that can teach them anything and everything, from science to writing to sign language.
• For better or worse, digital media is here to stay. This is the reality of our patients’ lives. Whether we like it or not, they are surfing the web (including for health information), communicating via text and Facebook and Twitter, reading and writing blogs, watching and creating videos. We can’t turn back the clock.

It’s not unlike when cars were invented. We didn’t insist that everyone keep riding horses. Instead, we created seatbelts and car seats and stoplights and traffic laws. And while it’s true, cars still bring risks and pollution they also make our lives better and easier in so many ways. We can’t imagine life without them. Already, it’s hard to imagine life without the Internet and digital media. They have incredible potential to improve our lives, if managed well.

If we are just negative, we may miss the opportunity to inform the discussion. We may miss the opportunity to guide children and families on the best uses of technology. Someone else will step in and do it, someone who doesn’t understand child health and development the way we do.

It’s hard to teach what you don’t know. So explore the Web. See what’s out there. Do the health searches your patients might do—and see what pops up. Find sites and applications that you like and can recommend. Talk to your patients and their families about how they use technology at home—learn from them. Check out Facebook and Twitter and YouTube. Consider using social media yourself.

Really, this is about meeting patients where they are, about being relevant in their changing world. It’s about making a difference in the lives of youth today.

And that is undeniably our job as pediatricians.


Dr. McCarthy is member of the American Academy of Pediatrics’ Council on Communications and Media. For more information regarding social media and its impact, please see The Council on Communications and Media’s full clinical report, “The Impact of Social Media on Children, Adolescents and Families.”

Social Media and Public Health

Jacqueline R. Dougé, MD, MPH, FAAP

Social media has become an important public health tool. It is inexpensive; it reaches millions, and can positively affect behavioral change. However, for the busy pediatrician it can be hard to stay abreast of all the new and beneficial tools out there. Below are a few that I have found particularly helpful and innovative.

Healthychildren.org is a website developed by the American Academy of Pediatrics to provide health information to parents. Parents can search for pediatric providers, get answers to health questions or look up health topics. It is a great resource to link to your practice’s website and to share with your parents.

Text4Baby recently celebrated its one year anniversary. It is a project of the National Healthy Mothers, Healthy Babies Coalition; the American Academy of Pediatrics is among its many partners. Text4baby provides free health information to pregnant and new mothers via free text messages. The messages coincide with a woman's due date or the baby's date of birth. Moms receive information on topics such as breastfeeding, immunizations, safe sleep, nutrition and smoking cessation. Mothers are also connected to community services. This is a great resource to refer new parents.

The National Association of County and City Health Officials (NACCHO) recently developed a campaign to promote the Vaccine for Children’s Program (VFC). VFC is a federal program that provides free immunizations to millions of children enrolled in Medicaid or who are uninsured. The campaign promotes the program and educates parents as to how they can access vaccinations for their children.

Health and Human Services (HHS) launched a website, InsureKidsNow.gov. This site increases awareness about what programs are available across the country for uninsured children and helps parents enroll their children into affordable health insurance plans.

Lastly, the First Lady’s Let’s Move Campaign uses social media to prevent childhood obesity. The site is bringing together health care providers, parents, children and industry to find ways to promote healthy eating and physical activity.

These social media campaigns not only promote but improve the public’s health. They illustrate how the field of medicine and public health are changing. It is an exciting time to be both a pediatrician and public health professional. Personally, I like to think all pediatricians are also public health professionals and as such it behoves us to familiarize ourselves with the tools and campaigns out there and to share this information with our patients. Social media is a great tool to promote health and improve health behaviors.

To learn more about current social media campaigns and about social media in general, check out the The Centers for Disease Control (CDC) website or the May issue of AAP News.