October 2, 2015

Anonymity and Denial in the Twitterverse

Kathleen Lovlie MD FAAP
Gulf Shores AL
Author of "Practical Parenting: An Un-Politically Correct Guide from the Trenches"

Playwright Tom Stoppard said, “Words are sacred. They deserve respect. If you get the right ones, in the right order, you can nudge the world a little.”
I am old enough to be amazed by social media, with its multitude of words and pictures. It did not exist when I was new. If we wanted enlightenment, we went to the library or read the Post. By the time we found our information, the events were already in the past. We knew people of different cultures existed, and events happened, but it was knowledge that came at a distance, blurred by its time-consuming transformation into letters and pictures.
When we curious children wanted to see what a woman looked like without her clothes, we stole our parent’s National Geographic and leafed through it for pictures of deepest Africa. Kennedy and Lennon were shot, but there were no cell phone videos or instant interviews. The stories unfolded over weeks, with time to adjust and get a little distance.
Social media now comes with immediacy and savage intensity. People’s lives are flayed open and placed on the screen for my perusal. If I presume to know anything about that woman in Africa, she can knock me upside the head minutes later, because she is in reality just a hairsbreadth away. If I pretend to wisdom, the whole world can judge me and let me know where they think are my errors in judgment.
This brilliant transparency should make us more authentic, more determined to write nothing that we would not stand behind to our deaths. We should claim our words without reservation. These words. are. me. Sadly, from a place of weakness and fear it can instead make us deny what we know, as we buffer our truth so as not to be responsible for it.
We write, “Tweets do not replace medical advice; retweets are not to be considered an endorsement.” We backtrack and pad ourselves against risk. The most powerful thing we can do – put out thoughts into words for other people to see – we disclaim and weaken with “tweets are not meant to be advice.”
Of course they are! What would be the point, otherwise?
If we give thought to and write words down, then they need to be true. Words are sacred. We record our words in the hopes that they will “nudge the world a little.” If our words are our truth, then they have earned our faith: we have to stand behind them with our names and our identities.
Weakening our words by buying into a fear of lawsuits and judgment is a betrayal of our selves; it costs us a piece of our souls. Our words are us, and denying them, even in a small part, allows decay to eat away at our own value.
Conversely, since we wrote those words with our very own minds and hands, we should never, in the rush to say something, write down what we know is not truth: those words will also follow us through our lives. People sometimes feel that they can be nasty, petty, or judgmental on the internet because they are anonymous. They can twist the facts just a little to make their point. We must realize that there is no such thing as true anonymity. Even if no one else ever knows who wrote those words, you yourself do.
Persian poet Hafez wrote, “The words you speak become the house you live in.” Write only words that have a strong foundation and the solidity of truth, so that your house is yours alone and can hold up  the hurricane force winds of opinion. Hafez’s words are as true on the internet today as they were in the fourteenth century in ink on paper. Such is the power of words. Believe in them and in your self.

September 14, 2015

Media Diet

Katie Noorbakhsh, MD FAAP
Children's Hospital of Pittsburgh

Media diet [mee-dee-uh dahy-it]: noun - The phrase that changed the way I thought about my children’s interaction with media.

For years, my goal was simply to keep my children’s screen time to less than two hours per day.  The concept of the media diet for my kids resonated with me, in part because I realized I would never take such a simplistic attitude with feeding them. Teaching and modeling how to eat in a healthy manner is far more complex than just limiting yourself to an arbitrary number of daily calories. In much the same way, teaching my children to interact with media in a healthy manner is also more complex than simply limiting their screen time to a number of minutes.

Until a few months ago, we had a habit of starting our mornings with cartoons. I have three children under five and work in the Emergency Department.  A thirty minute cartoon at 6 a.m. allowed us to ease into my post-shift mornings, limiting my role as a human jungle gym just long enough to finish a mostly-hot cup of coffee. And thirty minutes of cartoons is not a big deal. The trouble begins with ‘just one more.’ “Just one more show. Please, mom?” Just one more cup of coffee. OK, kids? Just a few more minutes of peace. Before I knew it, three hours of our day could evaporate into brightly colored, overly enthusiastic, two-dimensional story lines. Add on a request to play an iPad app (It’s educational!) or a family movie night (It’s a classic!) and I started to worry how we would manage screen time when our children were older and the demands became more challenging.

The concept of a “media diet” pops up in marketing  and communications  literature from the early 1980s. The term gained popularity in the news media  in the 1990’s with the introduction of the v-chip and increasing discussion of how types of media might impact young children. The August 2000 publication of the Journal of Adolescent Medicine featured two articles that addressed the concept.  In Media and youth: access, exposure and privatization  Donald F. Roberts discusses the results of a survey regarding the volume and breadth of media exposure among American children. Jane Brown’s article, Adolescents' sexual media diets  lays out a media food pyramid, illustrating types of media consumed and the range of involvement, from passive to active, as individuals select and interact with different forms of media. There have been a smattering of articles investigating media diets since then, primarily focusing on the violent or sexual content of media consumption.

A true media food pyramid with specific goals for how our children should be consuming information has yet to be described. However, if media is a diet, then early morning cartoons are probably the doughnuts and juice of television. My kids don’t start their mornings with a thousand calories of doughnuts and juice (although given the opportunity, I’m confident that my two and four year old would be happy to do just that), and I have no problem saying no to cookies and candy at the grocery store. We fill our cart with fruits and vegetables; yogurt and cheese; peanut butter and whole grain bread. At home we cook and eat together. This is all intentional. Healthy habits start young. Healthy eating is key to the development of a healthy body image  and to preventing obesity, heart disease  and diabetes. I don’t have to count my children’s calories because counting isn’t the goal. The goal is healthy choices.

In order to transfer the rules of the kitchen table to our coffee table effectively, I had to cut out the junk. No more morning cartoons. Even after late shifts in the Emergency Department. This was a direct threat to my hot coffee drinking preferences. But I did it. We woke up and went downstairs and started our day with no TV. And the kids? They protested vehemently. They cried. They yelled. They begged. They pouted. And then they played. The next few mornings were similar but the protests waned. Now we regularly start our days playing games that the kids make up. (My personal favorites include “Sharks and dinosaurs” and “Sitting in traffic.”)

Without the cartoons, we suddenly had an empty basket to fill with healthy media choices. I considered books and music to be the vegetables and fruits – always available and encouraged in our house. But what are healthy ways for young children to interact with television, computers and phones? I started by showing them how I could look up information on our computer. A map to illustrate how rivers go to the ocean to illustrate how rivers go to the ocean. An interactive website to lern the parts of a mushroom. I showed my four year old how to practice his letters in Microsoft Word and hit Ctrl+P. Our printer cartridge is out of red and orange right now, but he has never been more enthusiastic about sounding out his name.

The more I think about the media choices I make for them, the easier it is to manage their screen time. I no longer guiltily wonder if volcano videos at the museum or Face-timing with grandparents “count” as screen time. I don’t count calories and I don't count media minutes. We aren't close to exceeding our daily limits. And when my husband and I hire a sitter and go on a date, I don't hesitate to let the kids splurge on their favorite treats: pizza, popsicles and a cartoon movie.

August 28, 2015

Want Kids to Get Enough Sleep? Turn Off Screens at Bedtime


Don Shifrin MD FAAP

Clinical Professor Pediatrics

University of Washington School of Medicine

Twitter: @peddoc07

From toddler to teen there aren't many mothers who don't answer the question, "Is your child getting to bed on time and getting enough sleep?" with a horrified look and a resounding "Are you kidding?"

From separation anxiety for parents at 18 months to separation anxiety up to 18 years about their electronic devices, children’s, tweens’, and teens’ sleep debt rivals our national debt. What can be done?

Well, first - you gotta ask. So ask (and I often do ask teens and tweens directly, not just their parents) in a neutral voice, what could possibly be keeping them up that late? For children and middle schoolers it is often screens. I admit that high schoolers with school, activities, athletics, and homework often have only 3-4 hours during the day to get 'everything' done. (Not very efficient however if they are multi-tasking with social media, YouTube , Spotify, texting). That said, they still need as much sleep as they can (and do) allocate.

Then ask, especially about teens, when do they go to bed in the summer (generally late) and when do they wake up (usually later)? This delayed sleep phase in summer is normal, but is a huge detriment once school starts. But it will tell you unequivocally how much sleep their bodies desire to get if left alone without an alarm to wake them. Now translate that to the fall and school. There is no way you can guarantee them the 9-10+ hours they are probably getting in summer, and definitely should need during school.

That means that every minute of sleep they are losing is vital, because they are already, by definition, incurring a sleep debt Monday-Friday. Then, and only then, can you state that when they take their devices to bed, next to the bed, or cease using them right before bed, their brains will not be sleepy for 15-30 minutes at a minimum. And they need every one of those precious minutes for rejuvenation for school attention, focus, homework, and athletics.  

Parents now are paying rapt attention as they have, by their own admission, been pleading with their kids to cease and desist taking their devices to bed. I make the point that their bed is a sacred place where it is OK, and a must, to disconnect. You will get pushback and the usual denials. As well as the dreaded FOMO (fear of missing out). But the time you can put in clinically to alleviate this habit is well worth the effort to try to insure them at least 8 hours of uninterrupted sleep. And the moms will love you for it!

Oh, and be sure to follow up at the next visit.

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: