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.

October 8, 2014

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


ALAN SMITHEE, MD

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

BedtimeIpad2
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 YourTeenMag.com

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:

Decide.
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.
Decide.
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?
Decide.
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 healthychildren.org.