Jenny S. Radesky

Children and Adolescents and Digital Media

Today’s children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.

Use of Mobile Technology to Calm Upset Children: Associations With Social-Emotional Development

Use of Mobile Technology to Calm Upset Children: Associations With Social-Emotional Development Although it is known that parents of infants and toddlers with difficult behavior disproportionately use television and videos as calming tools,1 there are no published data regarding to what degree mobile technologies (such as cell phones and tablets) are used for this purpose. Previous qualitative work with parents has suggested that parental perceived control, defined as feelings of control over children’s behavior and development, may determine how parents set limits around screen media use2 and respond to difficult child behavior.3 We therefore sought to further explore this observation by examining associations between the social-emotional development of toddlers and mobile media use in a sample of parenttoddler dyads, and to determine whether potential associations are modified by parental perceived control.

Overstimulated Consumers or Next-Generation Learners? Parent Tensions About Child Mobile Technology Use

PURPOSE Mobile technology is ubiquitous, but its impact on family life has not been thoroughly addressed in the scientific literature or in clinical practice guidelines. We aimed to understand parents’ views regarding mobile technology use by young children, aged 0 to 8 years, including perceived benefits, concerns, and effects on family interactions, with the goal of informing pediatric guidelines. METHODS We conducted 35 in-depth, semistructured group and individual interviews with English-speaking caregivers of diverse ethnic backgrounds, educational levels, and employment statuses. After thematic saturation, results were validated through expert triangulation and member checking. RESULTS Participants included 22 mothers, 9 fathers, and 4 grandmothers; 31.4% were single parents, 42.9% were of nonwhite race or ethnicity, and 40.0% completed high school or less. Participants consistently expressed a high degree of tension regarding their child’s mobile technology use, from which several themes emerged: (1) effects on the child—fear of missing out on educational benefits vs concerns about negative effects on thinking and imagination; (2) locus of control—wanting to use digital devices in beneficial ways vs feeling that rapidly evolving technologies are beyond their control (a tension more common in low-income caregivers); and (3) family stress—the necessity of device use in stressed families (eg, to control a child’s behavior or as an inexpensive learning/entertainment tool) vs its displacement of family time. CONCLUSIONS Caregivers of young children describe many novel concepts regarding use of mobile technology, raising issues not addressed by current anticipatory guidance. Guidance may be more effectively implemented if it takes into account parents’ uncertainties, locus of control, and functional uses of mobile devices in families.

Parent perspectives on their mobile technology use: the excitement and exhaustion of parenting while connected

Objective: Parent use of mobile devices (e.g., smartphones, tablets) while around their young children may be associated with fewer or more negative parent-child interactions, but parent perspectives regarding this issue have not been explored. We aimed to understand parent views regarding their mobile device use to identify actionable targets of potential intervention. Method: We conducted 35 in-depth semi-structured group and individual interviews with English-speaking caregivers of children 0 to 8 years old, purposively sampled from diverse ethnic backgrounds, educational levels, and employment statuses. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Participants included 22 mothers, 9 fathers, and 4 grandmothers; 31% were single parents, 43% nonwhite race/ethnicity, and 40% completed high school or less. Participants consistently expressed a high degree of internal tension regarding their own mobile technology use, which centered around 3 themes relevant to intervention planning: (1) Cognitive tensions (multitasking between work and children, leading to information/role overload), (2) emotional tensions (stress-inducing and reducing effects), and (3) tensions around the parent-child dyad (disrupting family routines vs serving as a tool to keep the peace). Conclusion: Caregivers of young children describe many internal conflicts regarding their use of mobile technology, which may be windows for intervention. Helping caregivers understand such emotional and cognitive responses may help them balance family time with technology-based demands.

Cross-cultural Parenting: Reflections on Autonomy and Interdependence

As pediatricians to an ever-diversifying population, we encounter a range of parenting styles and beliefs, particularly among recent immigrants to the United States. Most pediatricians received some cultural competency training during medical school, focused mainly on how different cultures interpret and treat illness. However, at many well-child visits, the conversation inevitably turns to questions about child behavior, development, and parenting, which are similarly influenced by culture but inadequately addressed in training. This commentary discusses 2 culturally informed themes of parenting in the anthropology literature: autonomy and interdependence.1–4 These themes can help pediatricians understand the origins and goals of many parenting behaviors, especially when different from their personal beliefs. When we examine our own attitudes toward autonomy and interdependence, we may strengthen our relationships with families, demonstrate cultural sensitivity, and more effectively offer anticipatory guidance around certain childrearing practices consistent with children’s developmental stage. Parenting goals and behavior are influenced by cultural norms and informed by expectations of adult behaviors that are valued by a particular society. In general, the United States, Europe, and other “Western” cultures emphasize autonomy : individual achievement, self-reliance, and self-assertiveness. The United States was founded on these characteristics, as reflected in the iconic imagery of explorers, frontiersmen, and entrepreneurs. In addition, the practice of bronzing a baby’s first pair of shoes symbolizes pride in his or her independent steps, away from the parent. To raise self-confident, individualistic children, parents offer frequent praise, favor verbal feedback over physical contact, and promote … Address correspondence to Barry Zuckerman, MD, Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, 771 Albany St, Dowling Bldg, 3rd Floor, Boston, MA 02118. E-mail: barry.zuckerman{at}bmc.org

Embrace the Complexity: The US Preventive Services Task Force Recommendation on Screening for Autism Spectrum Disorder.

In this issue of JAMA, the US Preventive Services Task Force (USPSTF) presents final recommendations for screening childrenaged18 to30months forautismspectrumdisorder (ASD).1 Autism spectrum disorder canbe responsible for significant, long-term impairment in social interaction, communication, and functional capacity. Emerging evidence suggests that early intensive behavioral therapy has the potential to improveoutcomes.2TheprevalenceofASDhas increased inrecentyearsand isestimatedtobeashighas 1 in68children,3 suggesting that improving long-termoutcomescouldhavesubstantial societal impact. TheUSPSTF reviews topics that focus only onasymptomatic populations and services provided in (or referable from) primary care and makes its recommendations by following a transparent set ofmethodologic processes.4 TheUSPSTFconcluded that, “the current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in young childrenforwhomnoconcernsofASDhavebeenraisedbytheir parents or a clinician”1 andhas given the recommendation an Igrade.The Igradestems fromthesmall sizeandvariablequality of intervention studies and from a lack of direct evidence that screening leads to clinical improvement.1 Although this recommendation may be disappointing to manypeople, theUSPSTFhas appropriately applied itsmethodology to the question of ASD screening and has fulfilled its charge of applying rigorous analysis to the best available evidence. Asking the USPSTF to consider downstream policy or practice ramifications of its decision, or others’ interpretations of it, would be to devalue its critical role as an impartial evaluator of evidence. Professional societies, constituent groups, families, and individual clinicians will need to contextualize the USPSTF’s evaluation within a broader discussiononpolicyandpatientcareandassess,basedonthisbroader context, whether universal ASD screening is warranted. In considering the USPSTF’s recommendation, the issue of “direct evidence” is critical. Although validation studies might prove a screening test to be good at identifying a certaincondition, andseparate interventional studiesmight show improvement in those treated for that condition, this piecemeal analytic frameworkdemonstratesonly the strengthof individual links in a complicated process chain that includes screening, diagnostic evaluation, engagement with treatment, and improved health outcomes. Conversely, higherlevel direct evidence addresses the more overarching question of whether universal screening results in clinical improvement—abroaderanalytic frameworkthatconsiders the process chain in its entirety. Depending on the condition in question and the strength of the contributing research, evidence supporting individual links in a chain may be sufficient toproduceapositive recommendation. In thecaseofASD screening, the USPSTF decided that the evidence was not. Inexplaining thisdecision, theUSPSTFquestionswhether the interventional studies included in their reviewcouldbeextrapolated to a screen-detected population and cites the likelihood that children identified through screening would be youngerandlessseverelyaffectedthantheparticipantsof these studies.1While thismaybeanappropriate justification, it isonly onedimensionof abroaderquestion regarding the level of evidence necessary to demonstrate the value of a clinical process as complicated as screening for, diagnosing, and treating ASD. Autismspectrumdisorder is aheterogeneouscondition.3,5 Its considerable variability in prevalence and age of diagnosis demarcates fault linesof socioeconomicstatus, race,ethnicity, and geography3,6—suggesting both disparities in access to servicesanddivergent, regional culturesofpractice.Thecomplex behavioral interventionsadministeredtochildrenwithASDvary in both content anddelivery, involve a set of clinicians outside the domain of primary care, and produce variable outcomes amongtheheterogeneouspopulationofchildrenwithASD.7At each step along this screening-to-treatment chain are children (and families) who get screened or do not, get diagnosed with ASD or do not, and respond to therapy or do not. This sorting happensbasedonnonrandomfactors, likely (butnotnecessarily)having todowithaccessibilityof services,patient-provider communication,serviceengagement,culturalrelevanceofcare, andhealth literacy.Studyingsuchaprocesschainas individual links ignores these complexities, and it is inadequate to prove, or disprove, the effectiveness of ASD screening. Somecritics of theUSPSTF’sdecisionhaveargued that accumulatingdirect evidence that accounts for all the complexities around diagnostic confirmation and engagement with treatment is prohibitively expensive andnot feasible.8,9While it is important to recognize the challenges involved with accumulating such evidence, the complexity of a clinical problem isno justification for adjusting theUSPSTF’s standards for a positive recommendation. Rather, consistent with the intent of an I statement,10 the currentUSPSTFreport isanopportunitytomotivatebetter,more Related article page 691 Opinion

A qualitative study of parenting stress, coping, and discipline approaches among low-income traumatized mothers

Objective: The use of harsh discipline is a risk factor for child maltreatment and is more common among families in which mothers have previously experienced trauma. We sought to understand the stressors experienced by low-income traumatized mothers and the perceived impact of those stressors on their discipline approaches. Methods: We conducted 30 in-depth qualitative interviews with low-income mothers with a history of trauma. We triangulated the results with experts in behavioral health, and with a subset of the informants themselves, to ensure data reliability. Results: We identified the following themes: (1) Repetitive child behaviors are the most stressful. (2) Mothers commonly cope by taking time away; this can result in prolonged unsupervised periods for children. (3) Harsh discipline is used deliberately to prevent future behavior problems. (4) Mothers relate their childrens negative behaviors to their own past experiences; in particular, those who have suffered domestic violence fear that their children will be violent adults. Conclusions: Our findings suggest that trauma-informed interventions to promote positive discipline and prevent child maltreatment should help mothers predict and plan for stressful parent-child interactions; identify supports that will allow them to cope with stress without leaving their children for prolonged periods; and explicitly address long-term goals for their children and the impact of different discipline approaches.

The 30 Million–Word Gap: Relevance for Pediatrics

As many as 40% to 50% of the children pediatric clinicians serve are growing up in low-income households. Among the myriad physical and mental health sequelae of early adversity and toxic stress, language development appears to be one area particularly vulnerable to the stressors associated with poverty. The effects of poverty on language development have been documented in children as young as 9 months, becoming more clinically evident by 24 months.1 The consequences of early adversity–related language delays may be profound, leading to later learning delays, school failure, and lifelong social and economic consequences.2 This income-related gap in children’s language development has been linked in numerous studies to the quantity and quality of language input children receive from their parents, family members, and caregivers. Hart and Risley3 carried out the landmark study documenting this influence of children’s early environments on their later vocabulary growth. They observed that young children from low-income families heard approximately 600 words per hour compared with 2100 words per hour for children from high-income families. Extrapolating from this hourly discrepancy data, they estimated that by the time children reached age 4 years, those from higher-income families were likely to have heard roughly 30 million more words than low-income children. In addition, lower-income parents have been observed to use fewer complex sentences and rare vocabulary words, ask fewer questions of children, and use more prohibitives and directives—language that tells children what to do and not do—rather than pose comments that might elicit conversation. This qualitative and quantitative difference in language exposure, the “word gap,” is significant in that it often leads to later disparities in children’s academic achievement via effects not only on language development2 but also on cognitive processing1 and building self-regulation skills.4 Numerous community-based interventions have been shown to be effective in improving children’s language learning environments and outcomes.5 Some of the largest-scale endeavors include Providence Talks (a program in which low-income families with young children in Providence, Rhode Island, are given audiorecording technology that provides feedback about how many words their children hear every day), Georgia’s Talk to Me Baby program, and the Talking Is Teaching initiative of Too Small to Fail. However, some recent commentators have criticized the emphasis placed on word gap initiatives, with opposition to the “simplistic” approach of focusing on number of words spoken as a solution to poverty’s health effects as well as concern for implicit bias in the way researchers describe low-income and minority parenting.6 We argue that emphasis on the word gap in pediatric practice is not only appropriate but also a valuable tool for partnering with families and teaching trainees.

Technoference: longitudinal associations between parent technology use, parenting stress, and child behavior problems

Background and objectivesHeavy parent digital technology use has been associated with suboptimal parent–child interactions and internalizing/externalizing child behavior, but directionality of associations is unclear. This study aims to investigate longitudinal bidirectional associations between parent technology use and child behavior, and understand whether this is mediated by parenting stress.MethodsParticipants included 183 couples with a young child (age 0–5 years, mean = 3.0 years) who completed surveys at baseline, 1, 3 and 6 months. Cross-lagged structural equation models of parent technology interference during parent–child activities, parenting stress, and child externalizing and internalizing behavior were tested.ResultsControlling for potential confounders, we found that across all time points (1) greater child externalizing behavior predicted greater technology interference, via greater parenting stress; and (2) technology interference often predicted greater externalizing behavior. Although associations between child internalizing behavior and technology interference were relatively weaker, bidirectional associations were more consistent for child withdrawal behaviors.ConclusionsOur results suggest bidirectional dynamics in which (a) parents, stressed by their child’s difficult behavior, may then withdraw from parent–child interactions with technology and (b) this higher technology use during parent–child interactions may influence externalizing and withdrawal behaviors over time.

Parenting and Digital Media

Understanding the family dynamic surrounding media use is crucial to our understanding of media effects, policy development, and the targeting of individuals and families for interventions to benefit child health and development. The Families, Parenting, and Media Workgroup reviewed the relevant research from the past few decades. We find that child characteristics, the parent-child relationship, parental mediation practices, and parents’ own use of media all can influence children’s media use, their attitudes regarding media, and the effects of media on children. However, gaps remain. First, more research is needed on best practices of parental mediation for both traditional and new media. Ideally, this research will involve large-scale, longitudinal studies that manage children from infancy to adulthood. Second, we need to better understand the relationship between parent media use and child media use and specifically how media may interfere with or strengthen parent-child relationships. Finally, longitudinal research on how developmental processes and individual child characteristics influence the intersection between media and family life is needed. The majority of children’s media use takes place within a wider family dynamic. An understanding of this dynamic is crucial to understanding child media use as a whole.