Screens and Teens: The Downside

Azadeh Sami, DO, MSPH

A typical encounter for pediatricians:  We walk into a room to begin a well check for a teenager, whose eyes are glued to a cell phone.  We gently ask for the teen’s attention to begin the visit, as he/she reluctantly turns the phone over to the parents.  When reviewing lifestyle habits, we discover that although a 9:30pm bedtime is reported, actual sleep onset occurs 2 hours later.  When asked what they typically do before bed, the teens’ answers consist mainly of “on the phone”, “texting”, or “on my computer.”  Homework is online, texting maintains social status among peers, study breaks consist of video games, and by the end of the day, the teen has spent at least 6 hours of the day on the screen.  Parents note, by the way, that the patient has recently been feeling very fatigued.

Thankfully, journals and websites have raised awareness of this overwhelming problem, in ways that are now hitting home for many families.  Recently, Forbes magazine published an article effectively illustrating the link between screen time and shifts in brain activity.  The infographic in this article strikingly notes that brain imaging research shows screen technologies and cocaine affect our brain’s frontal cortex in the same way.  This correlation is exactly what we as pediatricians need to help make our advice more concrete for the new generation.

 The article presents a Cincinnati Children’s Hospital study examining brain activity in those who spend more time on screens versus reading books.  Screen time was linked to poorer connectivity in areas that govern language and cognitive control. Reading, on the other hand, was linked to better connectivity in these regions.  Furthermore, another study cited in the article demonstrated that GABA levels were increased in those who were addicted to the internet. More specifically, the rise in GABA levels is believed to be a functional loss of integration and regulation of processing in the cognitive and emotional neural network.  But no need to worry, as these changes generally reversed when the teens went through cognitive behavior therapy (CBT) for their addiction.

I recently gave a community lecture regarding How to Increase Your Child’s Success in School, incorporating the AAP’s recommendations as well as studies done by psychologists regarding the true  qualities needed for success in life.  In preparing for this lecture, I learned about the role of excess screen time on the balance between the visual system and the vestibular system.  When the two are not in sync, as when the visual system has been overly stimulated by the bright screen, without allowing the rest of the body to “catch up”, young children begin to feel restless.  For that, I like to recommend to patients to put a timer near the screen.  For every hour spent on the screen, when the timer goes off, they must stop and engage in some sort of physical activity for one hour.  The invention of the Wii seemed initially to be the answer to our struggles, but to our disappointment, we have discovered that levels of physical activity did not significantly change with the coming of this exciting “exer-gaming” concept.

Not to mention the added effects of social media. Patients who are perpetually exposed to their peers’ posts about the car they drive, the parties they went to, or the vacations they took, acquire a feeling of inadequacy.  Over time, the sense of inadequacy can become so uncontrollable, it ultimately develops into depression.  The Forbes article cites a study showing that about 48% of those who spent five or more hours a day on their phones had thought about suicide or made plans for it, as compared to 28% of the teens who spent only one hour per day on their phones.

With regards to sleep onset and quality, we know that the type of light emitted by screens is primarily blue light.  This blue light is what the sun emits, which in turn suppresses melatonin.  

The bottom line is this:  the effect of screen time is multi-fold.  Poor vision.  Depression.  Inactivity, and thus, obesity.  Delayed sleep onset.  Poor sleep quality. Poor brain connectivity leading to poor school performance.  Suicide.  It’s overwhelming.

I hope the information presented in this blog is helpful for those pediatricians who feel they are truly struggling to convince their patients the dangers of excessive screen time.  At least I’m sure you can all relate.

Is Your Child Being "Brain Hacked"? Part 2

Paul Smolen MD FAAP

Semi Retired Pediatrician Charlotte, NC

Founder of the pediatric blog, docsmo.com, Portable Practical Pediatrics

Author of Can Doesn't Mean Should, Essential Knowledge for 21st Century Parents

Let's get started thinking through how parents can manage this technology with their children. As I see it, there are two big questions when it comes to children and digital technologies - “Do I grant access” and, if I do,  “When and with what restrictions".  To answer these questions, I always like to consider the extremes. By examining the extremes of a decision, I find it easier to make tough decisions.

So first the question, “Do I grant access"?  Here the extremes are between total denial of access to digital technology and unrestricted access do as you wish use. Neither of these choices are very satisfying for most parents, so the answer will be somewhere in between. Defining that point will be difficult, and different for every parent, but at least that may offer a starting point.

Assuming you have decided to provide your children with digital technologies, questions arise; at what age, how much, and what other restrictions do you need to impose?  If you want to see why parents are currently getting smartphones for their children, at what age they provide them, and what children are doing with them, check out this 2016 Nielsen survey.   

According to the survey, the most common age children get a smartphone is between 10-12 years. For me that's way too young but is in keeping with what I see among my patients. Ultimately, every parent needs to decide for themselves about age and restrictions. The best advice I have to offer is what I would do if I were raising children today. So here goes.

Ownership of smart phones- Let's face it, ownership of a smartphone is both expensive and dangerous. I feel that having possession of a smartphone is not for most children.  For me, the criteria for ownership is when they have proven to be responsible, tend not to lose things, and have good decision-making skills.  You know, when they begin to demonstrate adult-like judgment and have earned your trust.  Harsh but true. I feel that before then, having possession of a mobile smart device makes them too susceptible to cyber bullying, sexting, curiosity seeking in dangerous places on the Internet, and interaction with dangerous people.  I know this very much goes against the trend I see with children in my community. Check this article entitled "Can You Raise a Teen Today without a Smart Phone", if you think this opinion is too extreme.

Simple cell phones w/out Internet access- Cell phones without online access and limited or no texting ability should be considered for the parent’s convenience and possibly a child's safety. Allowing a child to carry a cell phone does give parents and their children instant access to one another and that can be very helpful.

Online access via desktops, tablets and laptops at home- All screen activities for children should be supervised by parents, including and especially social media sites. We were all taught that keeping secrets was bad when we were young, right? Does that change with online activities? An emphatic no! I find services like Snapchat and Wickr particularly dangerous for children because they are invisible to parents. This type of communication should be forbidden because they preclude adult supervision. 

Appropriate online parental controls need to be used with these devices, and most, if not all, computing should be done in a public part of your home. Some of the families I care for turn off  Wi-Fi at bedtime, a good idea because many children will wander on the Internet in the middle of the night. Bottom line - when it comes to online activities, there should be no secrets. You as a parent have a right to know how these devices are being used and that your children are safe while using them.

Final thoughts

Thankfully, not all children are susceptible to internet addiction and brain hacking, but sadly, many are.  Your best strategy for minimizing the dangers these technologies pose is to limit your children's access to them as much as possible, but probably not altogether. They will need the skills associated with digital technologies for the rest of their lives, as internet communication is part of our world. But they also need to recognize a dangerous technology when they see it. It is up to you, their parents, to help them understand the dangers and make their Internet experiences healthy ones. Discuss the dangers of online communication with your children frequently. Watch what they do carefully even if that leads to some uncomfortable confrontations. And don't forget, to set a good example, never forgetting that you are not immune to internet addiction and brain hacking either.

Is Your Child Being "Brain Hacked"?

Paul Smolen MD FAAP

Semi Retired Pediatrician Charlotte, NC

Founder of the pediatric blog, docsmo.com, Portable Practical Pediatrics

Author of Can Doesn't Mean Should, Essential Knowledge for 21st Century Parents

Still not sure about if or when to get your children a smart phone or allow them access to social media? Tech expert Roger McNamee, an early investor in and advisor to Facebook, has an interesting perspective about the power these tech giants have over your children.   He introduced me to the term “brain hacking technologies" that he says were designed to maximize and sustain the attention of both you and your children. 

What is Brain Hacking?

Here's a link to Mr. McNamee’s full article in USA Today so you can read it for yourself, but these are three big themes from the article:

Point # 1: Facebook took its lead from the gambling industry, using their techniques to “addict” users to their content. Quoting from Mr. McNamee’s article, “Like gambling, nicotine, alcohol or heroin, Facebook and Google - most importantly through its YouTube subsidiary - produce short-term happiness with serious negative consequences in the long term.“

The companies running social media are in the business of grabbing your children’s attention and they have learned to do it very effectively. Many of today’s children are consumed by their smart phones, social media sites, and on-line chatting. You know this is true. Just go to any restaurant and watch older children. They are often more focused on texting and the chatter in cyberspace than engaged with the people sitting right in front of them. And it doesn't just happen when they are with their families - the same behavior occurs even when they are with friends. For this generation social interaction seems to be much safer and preferable digitally than face to face. Whether it be a video game, virtual athletics, a conversation with a friend, or flirting, social interaction seems to be happening for today’s children virtually - physically separated from the people they are interacting with. Children seem dependent on and addicted to their devices.

Point # 2: Big Internet companies like Google and Facebook know a lot about your children. Each word children choose to use on Facebook reveals information about their education, socioeconomic class, buying habits, favorite stores, wants, and desires. Knowing these things allows the tech companies to target children like a cruise missile closing in on its target. As your children’s wants and desires change, so does their data, changing the marketing campaigns social media giants direct at them. Your child’s online behavior allows the media giant to know what makes your children tick and to leverage that information to its own advantage.

Point #3: Once someone is addicted, an Internet company can manipulate that users moods with the newsfeed. Your child is having a day when they are angry at authority figures in their life?  We have a newsfeed for them that will justify and intensify those feelings. Your child is feeling depressed or sad one day?  Advertisers can take advantage of that by marketing products and services to them that will resonate with those feelings as well. The point is, once the addiction has occurred and the digital content supplier knows your children's motivations and interests, they become susceptible to manipulation, often by companies who wish to sell them something or influence them in some way. Not a good place for children to be.

Advice about managing your children's digital life

You can see that allowing your children unfettered access to digital devices (smart phones, computers, tablets etc.) is a serious decision you need to consider carefully. But also understand that you have a choice and ultimately, you are in control. In fact, I would say that you must be in control. What's the old expression, measure twice, cut once?  Once you grant your children free access to the online world, it will be very difficult to take it away. My advice?  Consider the decision to grant your children unchaperoned access to the Internet very carefully. I think you will find all these resources helpful: AAP screen guidelines for children,  Common Sense Media and a Charlotte based organization called Families Managing Media. 

to be continued

Plagiarism: A Hidden Problem in Academic Medicine

Irène Mathieu. M.D. 

Dr. Mathieu is a resident in pediatrics and poet who lives in Philadelphia. For more of her work please visit her website: irenemathieu.com.

The last time I heard anyone explicitly lecture about plagiarism was around the fourth grade. An aspiring writer, I remember thinking that it sounded like such a horrific breach of integrity that I couldn’t imagine anyone needing to reiterate such a thing. True to my instinct, no one ever did. Except for a brief discussion of my college’s honor code, I never again received any specific education around plagiarism and authorship – not as an undergraduate or medical student, and not in the nearly three years that I’ve been a pediatric resident. I never thought that it would happen to me.

However I am still in residency and have had more than one unfortunate experience around authorship. These experiences have been professionally distressing and disappointing, as the perpetrators are my peers – pediatricians close to my level of training who purport to be interested in social justice and equity. One specific instance was particularly egregious.

A mutual mentor introduced me to a colleague a few years ahead of me in training who had similar interests and perspectives. I was very excited to meet this person several years ago, and I began to think about possible collaboration almost immediately. When I approached her about writing a commentary on a topic of mutual interest she said yes without hesitation. She was just out of residency, and I was a fourth-year medical student with quite a bit of time flexibility, so I offered to do the background research and write the initial draft. We discussed authorship extensively over email during this phase of planning, and agreed that I would be the first author, she would be the second author, and that we would later invite a more senior pediatrician to provide further direction and to be the third author.

Over several months I completed background research for the commentary and wrote multiple drafts, to which my colleague provided feedback and direction. I created a framework, laying out the problem as we saw it and potential solutions. After several rounds of edits, I felt the piece was finally approaching readiness for publication in a major journal. Then things suddenly shifted.

My colleague told me that she didn’t like my writing style and that she wanted to make sure any piece with her name attached was consistent with her personal style. Therefore she proposed making herself first author after making more substantive edits, and sent me a modified version that was organized differently from what I had been working on for weeks. I was taken aback, as she had seen multiple drafts and had not brought up this concern previously, so we discussed it further over the phone. We came up with an alternative solution. We would write two papers – one in which she was the sole author and would lay out the scope of the problem, and one in which I was sole author, in which I would cite the papers I had researched and lay out the solutions that I had drafted. We would submit them as parallel papers, with the hope that they might be published in successive issues of a major journal. I agreed to the plan because I didn’t want to lose the work that I had already done, but the whole situation left me with a foreboding feeling.

At this point our communication dropped off. Months passed. One day I opened the latest issue of a major journal – the one in which we had been aiming to publish – and saw the article. There were the problem and the solutions, in a framework nearly identical to the one I had originally developed, complete with the data and citations that I had researched. My colleague was the first author, and two other people were second and third authors. My name did not appear anywhere in the piece, not even in the acknowledgments. Perhaps worst of all was how I discovered that the manuscript had made it to press.

I had no idea what to do, and I still don’t. No one taught me what steps you are supposed to take when you have been plagiarized. While I believe this piece was important and I’m glad that it found a home in a prominent place, my trust in my colleagues suffered from the betrayal. I flinch now when I come across her name, and even when I sat down to write this piece I had the same sick feeling in the pit of my stomach that rose up when I first saw the published paper.

I still want to be an academic pediatrician, and I trust that most of my present and future colleagues are people of integrity and good intentions. But I wish that at some point in the last ten years someone had crafted a lecture around authorship, how to reduce the chances of being plagiarized, and what to do if it happens. I know that many of us in academic medicine are bent on productivity and that we face intense pressure to publish. However this should not be at the expense of integrity and ethical teamwork. As a future mentor to medical students and residents, I will use my experiences as learning opportunities. Hopefully the day will come when plagiarism is omitted from medical education, not because it is uncomfortable to discuss, but because it no longer happens.

Top 10 Tips for Hosting a Twitter Chat

Peggy Stager, M.D.

Director, Division of Adolescent Health

MetroHealth Medical Center

Cleveland, Ohio

By now, as a savvy #Tweetiatrician you have likely participated in a Twitter chat.  It is usually hosted by one individual or organization, centers around one topic, and has a specific date and start/stop time (typically lasting 1 hour).  The conversation is posted on a single specific hashtag, such as #HPVvaccine, to allow for a central location for all to “attend”.  The chat platform creates an open forum for questions/answers, postings of resources, and sharing of ideas and solutions to particular challenges or issues.  The role of the host is to post questions to generate discussion, engage the participants, and summarize resources or links related to the topic of discussion.  It’s an excellent tool for meeting people who are champions or experts in the field, and for sharing ideas.  Think of it as a power learning collaborative condensed into one hour.

If you are experienced with Twitter chats, are you ready to host one? Anyone can host a Twitter chat. Hosts can be an individual, organization, or campaign with a desire to generate discussion around a specific issue. I was approached by the AAP Media team and hosted my first Twitter chat in October on the hashtag #AskAPediatrician.  The chat was sponsored by the AAP and focused on the topic of parental resistance to the HPV vaccine, as well as general information about the vaccine. I learned a lot from the experience and if you’d like to host a Twitter chat then consider my top ten tips: 

1. 1. Pick a specific healthcare issue.  If the topic is too broad, the conversation may be too diffuse without addressing pertinent questions or discussion points.  
2. 2. Recruit organizational sponsors.  Reach out to those organizations whose work centers around the topic. Many organizations have large numbers of people following them which will expand your potential audience. For example if your topic is related to sports concussions, contact sports medicine professional organizations, or concussion prevention awareness campaign organizations.   
3. 3. Consider the specifics of your topic.  Ask yourself, “What specific questions need discussion?”, “What do I want to be sure to convey?” This will help in the preparation of your questions and slides.
4. 4. Reach out to individuals on Twitter who are experts on the subject – even if you’ve never met them.  In addition, there are many non-physician advocates/educators on Twitter who have powerful voices and platforms for their causes.  Examples include: Moms Demand Action (gun control).
5. 5. Set the date and time and announce it on Twitter frequently.  Be sure to mention the sponsors, and experts who’ll be on the chat.  Create a colorful powerpoint slide as promotion for the chat. You may want to include a logo or a jpeg picture to set the visual theme.  Once you have your slide design selected, use it for every subsequent slide.
6. 6. Create 4-5 questions that flow as a progression of the topic.  Again, I recommend powerpoint slides with the same design as the announcement slide.  Label each question 1-5 so as participants respond they can label their responses as “A1”, meaning answer to question 1, etc.  Have the slides at easy access during the chat.  
7. 7. Send out countdown messages as the chat time approaches: one day prior, 4 hours prior, 1 hour prior and 5 minutes prior.  Be sure to include your specific chat hashtag on every message.  Countdown messages can be posted on other platforms like Facebook, organizational websites, or Instagram.  
8. 8. Create a distraction-free setting.  The participants’ posts come fast and furiously and you’ll need to be typing and responding as quickly as you can.  I advise working from your computer with your cell phone as a backup.  
9. 9. Welcome all of the participants and invited experts. Post your questions every 10-12 minutes, and watch how the conversation is flowing and evolving.  Retweet and like those posts that you want to be sure to share and amplify.  
10. 10. Wrap up the chat with a summary statement.  As the hour comes to an end, thank the participants. Offer to share additional resources and links post-chat.  

If you’d like to see the reach of your chat, Twitter has analytics embedded in each account. But keep in mind the analytics won’t track the specific hashtag of the chat.  For that information, you can try Symplur.  It’s a software product that allows you to track a hashtag and get specific data on your chat such as number of participants, impressions, and top influencers.  In closing, hosting a Twitter chat is a great opportunity to create an open forum for dialogue on a specific healthcare topic.  You’ll likely meet new people, connect with fellow advocates, and learn from other healthcare professionals from all around the country- in one quick hour!

Centering the Power of Our Networks With Our Hearts

Julie M. Linton, MD, FAAP

Executive Committee, AAP Council on Community Pediatrics 

Co-Chair, AAP Immigrant Health Special Interest Group

A Culture of Health Leader (1)

This is my first solo blog. Typical of most of my social media interactions, I confess I have not been an early adopter. I didn’t join Facebook until 2010. I joined Twitter in 2014 — but didn’t really use it until 2016 and am still getting the hang of it. I still don’t really understand LinkedIn.

And yet, I am curious, willing to explore, and at times even hungry to understand why certain ideas that seem unjust or unfounded are often perpetuated through the power of networks. Where I struggle is the balance between the breadth of connections via these often artificial networks and the depth of genuine human connection.

When I see patients (in my case, when I see children), I often have only a short time to understand the essence what is ailing them. That understanding is based on an instinct for human connection.  To do so, physicians have a responsibility to establish an environment of cultural safety, embody cultural humility, and embrace shared humanity.

In medicine, the network for care must not only include the child but the family. Taking that to a broader level, it includes the community. And when I consider the impact of policy on the children I see - the risk of family separation due to threatened deportation, educational inequity based on race or zip code  -  I recognize that clinical care falls within an even broader network. And that is where my daily human connections intersect with the power to combat inequity with networks.

Pediatricians inherently see advocacy as fundamental to our field. This concept is increasingly recognized across the field of medicine (see the recent Blog by Dr. Esther Choo, https://opmed.doximity.com/dr-esther-choo-discusses-why-advocacy-is-medicine-too-cdce79f784f1). We can take this even further, towards a world where most physicians are part of authentic partnerships between sectors that may not lie within traditional views of health, such as education, business, and law. And again, that is where the power of the network has its appeal.

One approach to communication, called the Heart, Head & Hand framework by Thaler Pekar (http://pndblog.typepad.com/pndblog/2010/09/heart-head-hand.html) prioritizes the critical role of appealing to the heart with stories, the head with data, and the hand with a call to action. And this, I believe, is the essence of my role as a physician, a social scientist, and an advocate.

I am still not sure what this intersection will look like. But as a pediatrician to the core, I am committed to explore respect for intimate human connection with recognition of the power of the network.

1. Culture of Health Leaders is a national leadership program supported by the Robert Wood Johnson Foundation to support leaders—from all sectors that have an influence on people’s health—to create collaborative solutions that address health inequities and move their communities and organizations toward a Culture of Health.

EMR; Harming My Patient Relationships

Mary McAteer MD FAAP
General Pediatrician
President Indianapolis Medical Society
Indianapolis, IN


One of the biggest failures in health care is the use of the electronic medical record.  By proving to be inefficient and unreliable, EMR systems have undermined confidence in the patient/physician relationship.  The quality of the relationship is essential to improving our patients’ health outcomes and the health of our profession.  Building that relationship involves developing trust by personally committing to creating respectful communication and defining mutual expectations. 

Workflows involving EMR distract doctors from practicing the complicated skills involved in treating patients.  Using EMR requires doctors to validate, navigate and input data in the system, rather than give personal attention to their patients.  This has resulted in dissatisfaction for all involved in the patient experience, a known factor leading to physician burnout. Patients are given the impression that the doctor is not communicating meaningfully with them, which disengages patients from being open, decreases compliance and worsens health outcomes.  Patients come with expectations that their health information is valid and complete, like their experiences conducting searches for themselves.  Physicians also expect the information to be valid. But with the inefficiencies of data entry and retrieval, that reliance on validity is up for grabs.

I believe our patients trust us to bring it all together for them, and I hope they realize how much we all would like that too.  To illustrate the cooperation needed, here is my story about Chris, who came to my office for his wellness visit prior to college.  We are in the exam room laughing about the last time he received shots and passed out in his dad’s arms.  He swallows hard when he asks about shots he may need this visit, believing that they are necessary and good.  I turn to the electronic version of our 18-year relationship, which had previously existed on paper.  I am searching his data, still searching, his laughter is getting a little more anxious. I am getting a bit more anxious too, trying to talk about the Colts' upcoming season or something….anything else. 

Soon, Chris offers his help. He has rebuilt computers, has programming experience and feels confident with anything electronic.  Appreciatively, I show him his EMR and the vast array of possible spaces where his records of past immunizations may reside.  He studies the screen and we navigate through some of the options.  After a while, he stands up and shrugs saying, “This is a mess. I feel sorry for you, so go ahead and give me any of the shots you think I might need.”  My office staff interrupts us with a knock on the door, supplying the old paper records.  Upon consulting those, he receives the appropriate vaccinations.  The tragedy of this story is the waste of time, precious time, that we could have spent preparing him for this new phase of his life.  

I have heard many defenses of the EMR as a necessary evolution in health care. Using an unreliable and inefficient tool will never evolve into better health care.  It is imperative to develop better technologic tools to result in more productive and reliable communication, reasonable expectations, and personal commitment to patient care.  We need improvements focusing on more efficient workflows and communication that uses valid clinical information.  The standard for adopting clinical tools should be primarily to improve the quality of the patient experience, leading to rewarding, trusting relationships with physicians.  With tools designed with the goal of serving the patient/physician relationship we will rejuvenate health care.