COMMENTARY

New AAP Guideline: Kids and Media

October 21, 2016

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Editor's note: The long-anticipated report from the American Academy of Pediatrics (AAP) on media use by children was released on October 21 at the AAP National Conference & Exhibition. Medscape spoke with David L. Hill, MD, chairperson of the Council on Communications and Media, about the report and the key messages for clinicians.

Hansa Bhargava, MD: Hello. I am Dr Hansa Bhargava, medical advisor for Medscape. Today we have the honor and privilege of having Dr David Hill from the American Academy of Pediatrics (AAP) Council on Communications and Media here to discuss the just- released reports on media use in children and adolescents.[1,2,3] David, thank you so much for being here.

David L. Hill, MD: Thank you for having me.

Dr Bhargava: David, we all know that kids are using screens all the time in many different ways, especially mobile devices. How much time do the kids spend in front of screens? What are the latest data on digital media use in children?

Dr Hill: The key to this is that it is not just one identical block. A lot of people look at these data that came out of the Pew Research Center a while back that said if you add up all the screen time that teenagers have a day, it can be in excess of 11 hours a day.[4] That is a really alarming number, but if you look at more recent data that have come from a Common Sense Media survey,[5] they really break down into different numbers at different ages.

Kids are not all the same. Just because some child may spend 11 hours a day looking at a screen, this does not mean that every child spends 11 hours a day looking at a screen. There are, as with everything else, low users, high users, and middle users. If we look at children younger than 8 years, it looks like the average right now is actually under 2 hours and maybe even falling a little bit —which gives me some hope that people are actually listening and paying attention to some of the things that we have said in the past.

The Good, the Bad, and the Unknown

Dr Bhargava: With all of that use —and noting your point that some kids will use less and some kids will use more —it still seems like screen time might supplant time spent on other activities, whether it is sports, academics, friends, or even talking with family. The AAP talks about the need for creative free time.[6]

What do we know about the negative effects of screen time on kids and teens? Probably just as important, what do we not know?

Dr Hill: These are great questions. What we are trying to do is flip the question from how much screen time should a child have during a day to looking at the whole picture of the day and saying: What else should you be doing with your time?

Some of our greatest concerns revolve around sleep, for example. We have good data that the light that screens emit, not to mention some of the stimulation from that, can interfere with sleep. We know that sleep is critical for kids to function well, to control their behavior, to study, to learn.

One of the things that we really emphasize is making sure that screens are out of the bedroom at night. Ideally, they have been off 60 minutes before bedtime, to allow kids' brains time to adjust to normal light and getting ready for bed.

We do not think that people should sleep with the phone under their pillow or next to their bed. I hear sometimes that it is their alarm clock. Alarm clocks are cheap; you can get an alarm clock that is not a cell phone.

We also think about exercise. We love kids to be outside, moving around, for at least 1 hour a day.

We think about time that families can talk together and relate to each other. Mealtimes, for example, we think would be a good thing to protect. Parents as well as kids need to put down their phones, so that everybody can talk to each other and engage around the dinner table or on the way to soccer practice. Whenever your family has a chance to have a conversation, I think it is a good idea to get the screens out of the way and let that happen.

Parents as well as kids need to put down their phones, so that everybody can talk to each other and engage around the dinner table

Dr Bhargava: Are you saying, basically, put down structure and rules around the screens? Is that correct?

Dr Hill: Exactly. Ask yourself: What do my kids need in their day? Then make sure that there is space for that —space for family time, healthy meals, exercise, and sleep. If screens fit in, in a healthy way between those things, then ok.

We are trying to individualize our new guidelines to account for different families' needs, different kids' developmental stages, and make sure that there is room for all those other things that kids need to develop well and be healthy.

Dr Bhargava: That makes a lot of sense. The guidance[7] that was released in 2015, which encouraged families to develop a media plan, was unfortunately misinterpreted as a removal of recommendations to limit screen time. What are the concrete recommendations in this current report? Are you concerned that the media may interpret this differently from your intentions?

Dr Hill: Everybody comes to this with an agenda of their own. People who think that media use is good at any age, and for every moment, could say there are no rules anymore. That is not true. In fact, some of our rules seem a little bit more stringent than they were before.

Under 18 months of age, with the exception of live video chatting, such as Facetime or Skype, there does not seem to be really any role for media. There are some concerns that media can interfere with children's language development or interpersonal relationships. We still have a very strong recommendation to limit screen use under age 18 months to only real-time interface chatting with another human being.

We also very strongly recommend against screens around bedtime, after bedtime, and around the dinner table. There is still good reason to believe that decreasing TV watching can help with obesity in vulnerable children. Earlier this year, we released a statement about violent media violence.[8] There are a lot of reasons to avoid that input for kids.

We have some very strong recommendations, but at the same time, we are trying to be more flexible and let our recommendations reflect the world that parents are living in, where media are ubiquitous for children and where different families and different kids are getting different things out of different types of media use.

Dr Bhargava: It sounds like I am hearing from you that sleep protection and family protection, no matter what the circumstances of your family, are two safe havens that you really feel strongly about. Is that correct?

Until you are 12 months old, you do not need to learn how to type, tap, and swipe.

Dr Hill: That is correct. We ask: How do kids learn? What is their learning job in life? Until you are 12 months old, you do not need to learn how to type, tap, and swipe. You need to learn how to play, roll, walk, and talk. You need humans for that. You have got to interact with a person. To the degree that screens are getting in the way of babies interacting with their caretakers, then they are probably causing a problem.

If you look at a 13- year- old who is working on a class project with a bunch of his or her friends, you will think that using media is a great idea. But that is a totally different scenario. This may be an amazing way for these teens to expand their social network and their learning. The point is that it is very much a matter of how old you are and how media use is meeting your needs or distracting you from needs that you might otherwise be meeting.

Keeping It Simple

Dr Bhargava: Agreed. Having said that, though, people often come to us as pediatricians, and they just want a really simple rule or recommendation. How can we simplify this for our families? What would you say in your office, for example?

Dr Hill: In my office, I always start my visits by finding out what the needs of the family are. As a pediatrician, I need to be thinking about the entire environment around the child: the home, the school, the faith community, the air, the water. All of these things make a difference in health and development. Once I get to know this family and what their needs are, I can still give them very quick and simple advice. Sometimes I find out that a kid is playing violent video games, and I say I think that is a lousy idea; I think there are better things that this child could be doing with his or her time.

Sometimes I find that they are sleeping poorly. Somebody may come in for concerns about attention, and I find out that the child is sleeping 6 hours a night and spending the rest of the time on a video game or watching TV. My first answer is to focus on that.

I think pediatricians are going to have to decide what is important, and we are going to do what we do —look at the family's needs and the child's needs, and give just one or two simple bits of advice that help the child develop , grow, and be healthy in the best possible way.

Dr Bhargava: From the context of the practicing pediatrician, the AAP came up with two questions to find out about food insecurity in a family. Will your council be coming up with something similar —two questions to find out about such issues as sexting, cyber- bullying, and Internet gaming disorder? What are your thoughts on that?

Dr Hill: I wish it were that easy. Right now, I think it is one question, which is: How is your child using media? What role does media use play in your child's life?

Alternatively, a great question is: What rules or guidelines have you established around media? Sometimes we find out that there are none. The parents feel that there is nothing that they can do; it is just everywhere. Then we can empower them to set up the guidelines just as they would around any other health activity. Sometimes we find that they have very stringent rules, and you can move on to some other topic that may be more germane to this family.

If I had to recommend questions, they would be, first, what is the role of media in your child's life, and second, what rules do you and your family have around media?

Dr Bhargava: Knowing how short that office visit is, our pediatricians want to know how can we do this quickly but efficiently, so that we get the information that we need. Those are great questions.

David, I have to ask you this, because you are a dad. How do you do it at home? What are your rules?

Dr Hill: There are some very standard rules. Phones do not come to the table, not for the adults, not for the kids; this is time for us to talk. They live downstairs or in the parents' bedroom on airplane mode at bedtime. Nobody keeps the devices in their room when they are trying to sleep. We do have an opportunity to watch what the kids are doing, to check on them. If they have passwords, we have those passwords, and we can say at any time: Let me see your phone, let me see what you are doing.

We also do a lot of coviewing. We prefer to sit around at least with one parent if somebody is going to watch something and see what it is, because we have some amazing conversations that are driven by what we might be watching or playing at that moment.

Dr Bhargava: Excellent. That is great advice as a parent and as a pediatrician. Is there anything else you wanted to add?

Dr Hill: I would encourage parents to really get their heads into what their kids are doing online. Kids love to teach you things. They love to show you things. I would not know how to hunt a Pokémon or how to use Snapchat if I had not handed my phone to my kids and said, "Show me that cool thing that you did." As parents, you do not have to build a wall around this; you can ask your kids, "Show me what you are doing." They are going to bring you into their world, which is a really interesting place to be.

Dr Bhargava: That is a smart question — basically having conversations about this, just like you would with anything else with your kids.

Dr Hill: Exactly.

Dr Bhargava: Great. David, thank you so much for being here today.

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