Is TV Viewing The Unhealthiest Screen Time For Kids?

Tuesday, April 9th, 2013

A new study published in Pediatrics suggests that it may be, at least when it comes to risk for obesity. 

WHAT DID THE STUDY DO?

91 teens (45 girls) around 14 years of age responded multiple times a day – via an electronic diary – to questions about what they were doing, over a 1-week period. Included were questions about a variety of screen time activities (for example, TV, video games, computer) and how much attention they were paying to each activity. Electronic diaries are an excellent method for getting kids to report on what they are doing in “real time” – it’s quick and easy for them to do and studies have shown that they provide reliable data using this method. The kids also had their height and weight measured by the research team in order to calculate their body mass index (BMI) – which is one metric used to measure risk for obesity.

WHAT DID THE STUDY FIND?

The overall findings were intriguing. First, the raw amount of screen time reported by the kids was not associated with their BMI. The statistical association of interest involved TV, but again it wasn’t about how much TV the kids were watching. Rather, it was how engaged the kids were when watching TV that was associated with BMI – the more a kid reported that they were paying the MOST attention to TV (versus all other activities), the higher their BMI.

WHAT DOES THE STUDY MEAN?

There are limitations to the study design that need to be addressed. The most prominent is that each teen was only observed during the 1-week period (this was a “cross-sectional” study).  Finding statistical associations in a cross-sectional design limits what we conclude because we can’t tease apart what leads to what.  It could be that kids with the highest BMI levels were the most likely to become engaged in TV viewing. It could be that TV viewing was one of the causative factors for their increased BMI levels. The point is that with these kinds of data we can’t distinguish between those interpretations. And of course we don’t have data on younger kids from this study, so technically there are no inferences to be made on non-teens.

WHAT SPECULATIONS CAME OUT OF THE STUDY?

Noting the limitation discussed above, researchers use cross-sectional data to generate and support hypotheses to be tested in future studies. The interesting idea that comes out of this paper is the speculation on the specific health risks associated with TV viewing versus other forms of screen time. One deserves particular mention. They note the potential impact of commercials promoting unhealthy foods – which may be particularly influential for kids who are highly engaged watchers. What’s interesting here is the idea that it’s not just about screen time, and it’s not just about TV – it’s about the specific risk of being a highly engaged TV viewer that seems to be linked with BMI. But future work will need to measure all these things and evaluate them longitudinally.

WHAT’S THE TAKE-HOME MESSAGE HERE?

Clearly this paper is the beginning, and not the end, of the story. The story, however, may be quite informative for parents if future studies replicate and expand the finding – and particularly if longitudinal studies provide clearer evidence of the directionality of the findings and support for the hypothesized mechanisms. Starting with younger samples of kids and tracking them across time will help determine if engaged TV viewing is especially linked with increases in BMI. But right now the interesting idea for parents to think about – at all ages – the potential downside of when kids get too attached to passive activities. This study suggests that TV may be the worst culprit for multiple reasons. But the bigger picture is that we are probably moving away from talking about screen time per se – many kids are increasing rather than decreasing screen time – and shifting toward a focus on unhealthy habits and unhealthy content that may be linked with specific types of screen time.

So … right now keep on eye on when your kid seems most likely to pair eating with screen time, and see if you can discourage that link. And see for yourself at home if it seems to happen more when they are especially glued to the tube.

Remote Control and Salty Snack via Shutterstock.com

Enrichment + Protection = Healthy Development

Monday, April 8th, 2013

Such is a key take-home message from the Early Childhood Summit 2013: Innovation and Opportunity - held in Boston on Friday, April 5th as part of the ongoing celebration of the 100th anniversary of the Boston Children’s Museum.

This meeting brought together leaders from pediatrics, developmental science, public health, the non-profit sector, and top business leaders in the Boston region. The focus was on sharing new ideas about the challenges that some kids and families face, along with possible creative solutions to ensure that kids have early experiences that serve as a platform for healthy and adaptive development. And the idea of thinking about “enrichment” and “protection” as critical components of a child’s rearing environment particularly resonated with me.

This idea was offered by Jack P. Shonkoff, MD, who is the Director of the Center on the Developing Child at Harvard University. As discussed by Dr. Shonkoff, “enrichment” refers to all the good things parents should be doing in the early years to promote social, emotional, and cognitive development. These are the fundamental building blocks of parenting, including spending lots of time talking to babies and toddlers, being emotionally responsive and engaged, and promoting and supporting curiosity and play. But Dr. Shonkoff emphasized – using the platform of neuroscience research – how critical it is that babies and toddlers also be protected from the toxic effects of excessive stress. Overexposure to harsh rearing environments – including those characterized by overt discord, anger, hostility, and criticism – can take a psychological toll in the early years which can have lasting effects due to the neurodevelopmental sensitivity to extreme stress. Even babies and toddlers can show stress responses that get turned on too much – and don’t shut down quick enough – which predicts a host of problems down the road, both in terms of cognitive and social functioning as well as physical health.

Jack P. Shonkoff, MD, Harvard University

By integrating the concepts of enrichment and protection, we have a framework that simultaneously emphasizes both the good things that parents should be doing lots of, and the bad things that parents shouldn’t do much at all. For those of us who study kids – and in particular track kids from infancy through adulthood – we keep seeing more and more evidence that those early years matter greatly in terms of influencing brain development at a critical period of life. Putting effort into enrichment and providing protection against toxic stress is indeed an equation that predicts healthy development (physical and psychological) from the early years all the way into adulthood.

Photo of Jack P. Shonkoff, MD, addressing the Early Childhood Summit 2013: Innovation and Opportunity meeting (April 5, 2013, Boston, MA) courtesy of Gus Freedman

Is ADHD On The Rise – Or Just Overdiagnosed?

Monday, April 1st, 2013

The latest numbers on the rate of ADHD are extraordinary. The New York Times has reported data collected from the Centers for Disease Control and Prevention which suggest that 11% of youth (between 4 and 17 years of age) have been diagnosed with ADHD at some point in their lifetime. 

This is troubling – primarily because the data come from phone surveys of parents. This means that parents are receiving this diagnosis at unprecedented rates – not that kids are being properly diagnosed with ADHD at higher rates than before. It is too easy for kids to get labeled ADHD and not go through the comprehensive screening that should take place as administered by a multidisciplinary team of professionals.

It’s becoming clear that ADHD is being used as a label to try to provide a quick handle on behavior that may – or even may not – be somewhat troublesome. ADHD involves much more than not sitting still and not paying attention. All kids exhibit “ADHD” like behaviors now and then. It’s a difficult condition to diagnose because it is based on increased frequencies of a number of behaviors across a number of contexts (home and school) for a sustained period of time which cause impairment for the child. Without a detailed diagnostic process, it can be too easy to misread normative behaviors as symptoms of ADHD.

Part of the increase comes from diagnoses of older kids including those in high school. Diagnostic criteria are beginning to reflect the thinking that symptoms can develop later in childhood and even in the teen years (and not just the early years). That said, it can also become another convenient label for a kid who is not doing well in school. At the other end of the spectrum, diagnosing preschoolers can raise related issues in terms of figuring out which kids are really showing early signs and which kids are just being kids.

There are a number of problems with overdiagnosis. Kids typically get treated with drugs that are not appropriate for them. They get labeled rather than receive the kind of attention that they deserve (for example, to improve their engagement in the classroom). And some kids get diagnosed simply because they are in very large classrooms which promote inattention and not sitting still.

The less obvious issue is that the cursory diagnosing that may be going on is also a disservice to kids who do suffer from ADHD. They should be getting full assessments and comprehensive treatment plans that find optimal combinations of psychosocial intervention and, when necessary, well monitored use of drug therapy. Tossing around labels and drugs as a diagnostic and treatment strategy is not going to give them the help they need, especially since we know that ADHD can persist into adulthood and cause much in the way of academic and social impairment.

The bottom line? If you are a parent, and you (or someone else) suspects that your child might have ADHD, try to seek out an assessment from a multidisciplinary team that has the requisite experience to know how to sort out normative behaviors and issues from clinically meaningful ADHD. You might need to network with other parents, your pediatrician, and educators to locate a provider. But it will be worth your time and effort to make sure your child isn’t misdiagnosed as having ADHD – or not given the proper assessment and treatment plan if they do show the clinically meaningful symptoms of ADHD.

ADHD image via Shutterstock.com

Why Is Autism So Common Now?

Monday, April 1st, 2013

In 1980, the rate of autism was typically quoted as 4 in 10,000. The most recent rate reported is 1 in 50. While it is difficult to get a precise estimate, it’s abundantly clear that rates of autism have increased dramatically since 1980 – and in fact over the last decade. So what has changed?

There are a number of factors that have brought the startling levels of autism to our attention. These include:

Better Awareness: In 1980, autism was first introduced as a separate diagnostic category in the third addition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Prior to that time, clinicians using the DSM applied other categories such as childhood schizophrenia. Since 1980, there has been extraordinary growth in awareness – both for professionals and parents alike. This is particularly so over the past decade. Advocacy groups have done an admirable job of helping us understand what autism is (and isn’t). Pediatricians now screen for early warning signs – as do parents. These actions have all led to a much greater awareness of the symptoms of autism which undoubtedly translates in more proper diagnoses being made. In addition, the increased awareness has permitted older kids to be diagnosed more properly when the signs earlier in life were not recognized as autism.

Expansion Of The Symptoms: In parallel with efforts to increase awareness, diagnostic changes that recognized autism as a spectrum – now referred to as Autism Spectrum Disorder (ASD) – helped capture the wide range of symptoms that go beyond “classic” autism. Including a much broader representation of social, communicative, and repetitive/stereotyped behaviors certainly helped recognize the disorder in many youth who would not have been diagnosed in past years. Of course, there is debate about how the changes in the upcoming DSM-5 may result in a reduction in the rate of diagnosed ASD in the future. But up until now, recognizing the variation in symptoms that can characterize ASD has certainly been a factor in understanding how common autism really is.

Changes In Etiological Factors: Less understood is the role of new causative factors that increase risk for ASD. Much attention is being given to a large number of potential environmental contributors. There is the suggestion that specific genetic mutations that may be linked to autism – and associated with paternal age – are more common in the population because of average increases in paternal age over the last few decades. Much of this work, though, is work in progress, as it is believed that ASD typically results from the combination of a number of environmental and genetic risk factors. But many researchers operate under the assumption that there are both environmental and genetic risk factors that may be increasing in the population, though they remain elusive.

So, since 1980, what we have learned? We know now that autism is very common, is best thought of as a spectrum that includes substantial variation in how symptoms are expressed, and may be influenced by increasing levels of risk factors that are not well understood at this time. For all these reasons, it is critical that we keep researching the causes of autism, and continue to promote awareness of the early signs and symptoms in order to support early diagnosis and intervention.

Image: Autism Awareness Ribbon via Shutterstock

Red-Hot Parenting Recap March 2013: Mental Health In Kids

Sunday, March 31st, 2013

This month a primary focus was on mental health. Three broad themes were examined:

Getting Mental Health Services

Many parents ask me for advice on how to get their kids mental health services. I related 4 key tips that make a difference in terms of finding and receiving good treatment.

ADHD: Outcomes and Treatments

Two issues were in the air. First, new data were published showing that nearly 30% of kids with ADHD go on to still have ADHD as adults. Second, although ADHD is being diagnosed in preschoolers, a new study suggests that traditional treatments – primarily drug therapies – are not effective over time. I suggest a heightened need for more intensive psychosocial interventions in the early years.

Autism: On the Rise Again?

Each new estimate of autism suggests the rate is higher than ever – the newest figure is 1 in 50. I discuss some key issues in interpreting the new study. I also geared up for Autism Awareness Month by asking readers to ask me questions about autism that I can answer in blog posts during April.