Ask the Mediatrician

What kinds of kids' activities should be available in a waiting room?

Q: I am working at a hospital in New York, and as we are opening a new children’s center this coming year, we are trying to see what types of recreational technology would be appropriate for our inpatient and outpatient waiting rooms. What would you recommend? The kids would be ages 0-17.
-Waiting is the Hardest Part in New York, NY

A: Dear Waiting,

What a great question! By simply asking this question you indicate your awareness that waiting rooms are not just a place for waiting—they are the public face of your hospital, and they are the place where patients and families may actually spend most of their visit. You can work with your hospital’s child life specialists to create waiting rooms that are in themselves therapeutic and developmentally nurturing.

As you consider what to offer in these spaces, remember that what you provide for kids as ways to pass the time will send a powerful message about what you see as fun and worthwhile in leisure time. For that reason, fill your waiting rooms with the sorts of materials that you encourage parents to have for their children in their living rooms.

Specifically, I’d recommend low-tech leisure activities that encourage imagination, creativity, and challenge. For example, put out a jigsaw puzzle that everyone can work on while they’re waiting. Tape a big piece of butcher paper to a table and put out crayons—when the mural is complete, post it on the wall. Though you should clean these communal supplies often and provide ample opportunities for hand sanitizer, some parents would still prefer that their children not touch these supplies. Consider leaving out stacks of photocopied single-page activities that parents and kids can do with their own pens -- like fun concept worksheets for younger kids, sudoku and word games for older kids. 

Entertainment technology is something your patients already know and use elsewhere, and in the context of a waiting room, it’s more likely to provide simple distraction than to really challenge their creativity. And while that one hour certainly won’t make or break a child’s upbringing, the waiting room is where we can offer patients of a model of how they can spend their time. If you decide that you do want to add a television to your waiting room, thinking about content for that wide of an age range can be a difficult task. For guidance, check out the answer to this related Ask the Mediatrician® question: How can I talk to my pediatricians about the TV in their waiting room?

Enjoy your media and use them wisely,
The Mediatrician®

How do I stop myself from parenting with television?

 Q: I am the first to admit that my children use TV, video games, and computers for more than five hours a day. I don’t like this about myself, but I also get them outside, and I guess I feel like I am doing my best at balancing all of this. I know it is easier for me to get my chores done around the house if my toddler is entertained by Noggin or Nick, Jr., and I guess I’ve let their marketing convince me that it’s okay to watch for hours on end because it’s “educational.” Sigh. How do I stop this? How can I go backward from what I am conditioned to do? What can replace these easy “babysitters” so that I can save my mental health? Very intrigued by your research.
-Looking for Balance, in Dallastown, PA

A: Dear Looking,

First of all, you have nothing to feel guilty about. Parenting requires you to make constant decisions that balance risks with benefits. Making decisions about whether and how to use media at different points in your child’s life depends on a variety of factors, including how much information you have.

Let’s start with an analogy: In the 1950s, most parents let their kids ride in cars without seat belts, and car seats were not required by law until 1978. As more families purchased more cars, more accidents happened, and a solution for keeping children safe was needed. The parents of the 1950s should not feel guilty for not buckling their kids in; they simply did not have the information or tools at the time. This is similar to the issue of media use. As more media types are created and kids use media more often, information about how to keep kids healthy is spreading, and parents can begin to think differently about their decisions.

Just because there are car accidents doesn't mean we don't use cars at all; we simply found ways to make them safer for kids. So let's do the same with media: What "seat belts" can we use here to keep kids healthy? 

An important one, as you mentioned, is limiting the amount of time your child spends with screen media so that he has more time to do things that are actively good for his growing brain. You are already on your way to making a difference there, simply by paying attention. Toddlers love to be near their parents, doing similar tasks, or feeling like they're helping. Here are some ideas for activities that can occupy him and still allow you to get your chores done:

• When you need to make dinner, hand him a box of uncooked macaroni and a big serving spoon. He’ll have a grand old time moving the noodles from one pot to the other (and even sorting out the shapes, if you put in different ones).
• When you need to pay the bills, sit at the kitchen table with him and give him some playdough or a coloring book.
• When you need to take a shower, place a dishtub of water on a towel on the bathroom floor and have him wash a baby doll.
• When you need to fold laundry, have him pick out all the socks and put them in a pile, or "fold" washcloths.

As he grows and becomes more ready to benefit from screen media, here are some ideas for other “seat belts” you can use as well.

Enjoy your media and use them wisely,
The Mediatrician®

Is it OK for my 2 year old to watch YouTube videos?

Q: Our son just turned two, and his father and I disagree about the value or potential harm of the YouTube videos they watch together, almost daily, for about a half hour. Our extremely verbal son especially loves short, educational, do-it-yourself videos about how to use tools, and I am not unsupportive of him watching these occasionally. They also watch some cartoons/short videos geared for kids, but I think most of these contribute nothing to our son’s development at best, and convey negative messages at worst. It also bothers me that our son frequently asks to watch things on the computer and cries if we say it’s time to play with toys or read books instead (although he will accept re-direction after a few minutes). Your feedback would be most welcome!
- YouTube'ing at Two, in Northern California

A: Dear YouTube'ing,

I know of one young woman who, when she was about three or four, liked the TV show "This Old House.” One day, her father walked into the room where she watching it and, thinking that she was too young to understand what was going on, said, “What does it look like they're doing there?” She looked up at him and said matter-of-factly, “They’re grouting a bathroom, Dad.”

Like this little girl--and, indeed, all children--your two year old is learning from everything in his environment. The tool videos may indeed be helpful for him, if he enjoys building and you’d like him to learn what the videos are teaching. But, as you imply in your concern about negative messages, he will also learn from everything else. He will learn from the cartoon Tom and Jerry, for example, that steamrolling a cat won’t prevent it from jumping up, uninjured, a minute later. Young children are quite literal. That's part of why one of our top five tips for using media in healthy ways is to choose content carefully. What's great about the way you're using YouTube is that your husband is not only choosing the content specifically for your son, but he's also watching it with him (another one of our tips!).

To address your concern about your son's attachment to videos, I might recommend helping him understand when he can and can't use the computer. Toddlers do really well with routines, so one approach, if you decide to keep the videos as part of his daily life, is to incorporate this YouTube time into his routine. Maybe there will be 20 minutes of video time with dad after an afternoon nap, or right before brushing his teeth in the morning. That way, your toddler will know when to expect it; he can look forward to it as part of his day and know when it's over that it will happen again tomorrow. Making it regular instead of random will also take away the sense that it's a "treat" and that if he cries for it, he might get it.

It can be tricky to get on the same page as your spouse about these issues, and it might be helpful for you to think about whether there's something that could change that would make you more comfortable with the YouTube watching (Educational videos but no cartoons? Watching for 15 minutes instead of 30?) or whether you're uncomfortable with it all together. Approach the topic in much the same way that you would discuss which school is right for your son--not as a question of right and wrong but rather as a way to figure out what you want for your son, and what guidelines you can create and honor together.

Enjoy your media and use them wisely,
The Mediatrician®

How can parents take a step back from technology when we need to use it for work?

Q: I recently got together with other parents to talk about our experiences, philosophies, and rules surrounding what seems to be non-stop virtual interaction for our kids. We came up with a lot of great ideas, one of which was for us parents to model a healthy relationship with technology. This is going to be really hard for my husband and me, who are self-employed and use online social media like Twitter and blogging for work. Do you have any practical tips for how to step back from technology in this situation?
-Media Mom, New York, NY

A: Dear Media Mom,

As you imply in your question, and as the old saying goes, what you do speaks far more loudly than what you say. And as we know from research, this applies to media too: the media use habits children see modeled by their parents and siblings make a difference in how they use media. 

It can certainly be challenging to model the behaviors you want while still using media for work—especially when you work from home! There’s always more to do, and it can be difficult to separate work time from home time. But you want to bring the same focus and discipline to the job of parenting that you use in your other job. Therefore, an important first step is to examine your own media use.

Ask yourself honestly how efficient your media use is. It’s likely that you could make it more focused and efficient in the same ways you’ll recommend to your kids, such as by using a media budget. For example, if you’re using Twitter and blogging software for work, and you work from 9:00 to 5:00, close your computer at 5:00, and focus on being home. If you need to use these technologies outside of typical work hours, that’s fine—just make a budget and stick to it. By stopping when your time is up, you leave more time for family meals, daily exercise, and connection with your kids, and you show your kids that even you set limits on yourself.

Another idea is to talk to other parents about how they carve out non-media time; perhaps you could even have a "Part 2" of the group you met with to have the initial discussion? It would be neat to check in again, maybe even regularly, to discuss new ideas since managing media use is an ongoing challenge for everyone these days.  We asked our Facebook Fans how they take a step back from technology, and here were some of their replies:

• "We have a 'cell phone drop box' in the entrance to our house. It helps keep our family connected to each other while we're home."  
• "I leave my cell phone in the car any time I know I'll be interacting with kids."
• "We have 2 hours between coming home from work and our toddler going to bed for the night, so we aim for no computer or phone use during those 2 hours."
• "Turning off the phone during dinner is a way to disconnect from technology and connect with family."

We encourage you to join us on Facebook so that you can continue to hear about great ideas from other parents!

Enjoy your media and use them wisely,
The Mediatrician®

Are kids benefiting from all these electronics?

Q: I keep hearing how younger and younger children are being exposed to electronics -- that there are computers in preschool classrooms, that kids are using smart phones to learn the alphabet, and that a children's version of the iPad is in the works at Fisher Price.  This exposure to electronics at such an early age certainly has an effect on children’s social and family life, the way they play, and their academics. My question is whether these effects are positive or negative -- is the next generation benefiting from these electronics?
Interested in the iGeneration, in Boston, MA

A: Dear Interested,

This is an important question, and unfortunately, we only have limited data to help us answer it. We do know that computers and other interactive media have immense teaching potential. They respond to the user’s actions (at least in a basic kind of way,) so for skills and drills learning (for example, memorizing the alphabet, learning numbers, practicing arithmetic), they can be a great supplement to what a teacher or parent can offer for instruction.

Electronics are not, however, good at teaching children how to think or that they should ask questions, or use creativity—all of which are critical parts of the learning process. These skills are what help young kids learn to love learning itself, which is one of the most important academic skills to gain. For that, in-person interaction is essential. A recent study, for example, helped demonstrate the difference between being read to in-person versus being read to through a screen: When the reader was physically present, there was greater activation of the child’s frontal lobe (the part of the brain associated with reasoning, emotions, and problem solving) than when the reader was on a screen.

In addition to these limitations, there is real concern that increased screen time contributes to kids being less connected to their family, friends, and others. A recent study from New Zealand showed that both today and 20 years ago, increased screen time was associated consistently with poorer attachment to parents and peers. Other issues connected with more screen time include social isolation, obesity, and increased risk of exposure to violent and sexual content. 

If electronic media are used in thoughtful, focused, and limited ways, however, they can be a boon to your kids. You can help ensure that this happens by paying attention to what kinds of electronic media they are using and how much time they spend using them. Help them learn to watch a specific show, play a certain game, or talk to a certain person, then to shut them off rather than surfing without direction.  And, as always, a good rule of thumb is to make sure that media are used after all the important tasks of life--like sleeping enough, eating good meals, getting exercise, and spending time with family--are complete.

Enjoy your media and use them wisely,
The Mediatrician®

How long should my 3-year-old play with iPhone apps?

Q: My son is 3 years old, and he loves media devices, such as computers and telephones (like the iPhone). My husband bought him a program from PBS Kids, and now he has access to all games and some shows as well. He can spend hours playing with it. Sometimes I don’t really know how to handle the situation. How long he should spend with this program?
Media Maven's Mom, in Abbington, MA

A: Dear Media Maven's Mom,

There are pros and cons of kids playing with iPhone apps so there's a lot to consider in that regard.  But research shows that the right television programming can be a positive addition to your 3-year-old's life, and you've got a great question about how to make sure that his media use stays positive. 

First, consider the program’s content. PBS Kids aims to create educational content with positive role models, and according to their website they work with educators, researchers, and subject-matter experts to ensure their shows are developmentally appropriate for kids.  While iPhone apps in general have not been on the market long enough for their effects on kids to be researched, at least the content your son is watching and playing with comes from a reputable organization. 

Another thing to note is that your son's attention span at this age is quite limited. Just as a preschooler cannot be depended upon to determine when to go to bed or whether he’s eaten enough veggies, the fact that he can play or watch for hours does not mean that doing so is ideal for him. I would recommend including these media for no more than 20 or 30 minutes, up to twice a day.

You might also want to think about setting time limits on all shows and games—even those designed to be optimal for his developmental stage. Just like you aim to get him in the habit of brushing his teeth before bed, if you can get him to have healthy media habits now, you'll set him up for success as he gets older.

Enjoy your media and use them wisely,
The Mediatrician®

How can I talk to my pediatricians about the TV screens in their waiting room?

Q: My pediatrician’s office just added a flat screen TV to their waiting area so they can run health videos for parents. However, since they haven’t created those yet, they are running Disney movies instead. When my three children (ages 2, 5, and 7) saw Ratatouille playing on the TV, my 5-year-old lost sleep for two nights with bad dreams. I feel they have a responsibility to teach appropriate media habits to their patient’s families. Do you have any advice/literature that I could pass on? This group of doctors is fabulous, so I believe they would listen if I present my case.
Screen Surprise, in Foxboro, MA

A: Dear Screen Surprise,

Many wonderful pediatricians like yours are either unaware of--or do not implement--the American Academy of Pediatrics’ (AAP) policies around media exposure for children. Although the AAP recommends no more than two hours of screen media per day for all children, and no screen media at all for those under 2, one study showed that pediatricians rarely find the time to address these issues with parents during well visits. 

In a pediatric waiting room, there is a wide range of ages and experiences with media.  There may be children for whom some movies may be fine, but there will also be children for whom they don’t work, as you discovered yourself.  Disney movies likely seemed to be a good choice because they’re G-rated and geared for children, but research has shown that 100% of animated feature films made between Snow White (1937) and the end of the 20th century contained at least one act of violence.  Although it is far from the only content of concern, media violence has been consistently correlated with three effects: desensitization to the suffering of others; increased aggressive thoughts and behaviors; and fear and anxiety, especially among younger children such as yours. Nightmares are a common response to such media exposure.

As you mention, it would be ideal for your pediatrician to remove the TV screens from the waiting room in order to set a good example for patients about media and health.  However, since they've already purchased and installed them, and have plans to use the power of media to educate parents about health issues, it's possible that they will not remove them in response to your complaint. 

If that's the case, you could focus your discussion with them on making conscious decisions about what they plan to show on the screens until they have the health videos ready, noting that your child had nightmares in response to what he saw, and possibly printing out the study that we linked to about violence in G-rated movies.  Perhaps you can brainstorm with them about content that would be more appropriate for all audiences.  One of our previous Q&A's may actually help--someone wanted to know about good movies for 5 year olds and our Facebook fans replied with lots of great ideas!

Enjoy your media and use them wisely,
The Mediatrician®

Could speech delays be related to TV watching?

Q: I am a speech therapist, and a large percentage of the children with speech delays whom I treat are allowed to “graze” on TV all day. Are there any studies showing a relationship between TV watching and speech and communication delays in the preschool population?
-Serious about Speech in Atlanta, GA

A: Dear Serious, 

We are not aware of many studies related specifically to speech delays, except for one study that suggests that “children with frequent television viewing…would have delayed development of meaningful word speech.” However, most of the media effects literature does not make a distinction between language delays and speech delays. 

So if we look at the research that refers to language development but not specifically to speech, we can find more information that might also be related.  For example, babies seem to develop language far more effectively from people in real life than from people on screen. In one study, American children between ages of 6 and 12 months were exposed to native Chinese speakers in person and to the same native Chinese speakers on video. The infants who had real people interacting with them recognized and responded to specific phonemes, and those exposed to the video did not. What this seems to show is that human interaction appears to be critical in the complex process of language development.

But when the TV is on, parents tend not to talk as much to their children. And given that babies learn language from live people—particularly their parents!—having the TV on could be detrimental to that process. And although some research found no difference in word learning between babies who did and did not watch baby videos, it also found that the strongest predictor of number of words learned was the number of hours a baby was read to.

As a speech therapist, you likely already provide parents with specific guidelines on how to help their children. Though the media effects research specifically on speech is not an often-researched area, from these others studies I described, it seems like adding media recommendations could be helpful anyway.  Perhaps you could recommend that parents decrease or eliminate TV watching and increase interactions around books.  Or you could suggest that when their kids do watch TV, parents should watch with them and look to the TV program content for new topics to talk about with their kids.  By giving them activities that include speaking to, reading with, and interacting with the child, you can help families experience the difference between learning from a person and learning from a screen.

Enjoy your media and use them wisely,
The Mediatrician ®

Do violent video games affect my 18-month-old son?

Q: I am concerned about the negative impact that violent video games may be having on my 18-month-old son. He is at a babysitter’s, where there are shooter-type video games being played often! Should I remove my son from this environment, before any harm is done?
-Curious about Childcare in Prince Albert, SK, Canada

A: Dear Curious,

First, I commend you for being aware that what’s in your son’s environment will affect him. It is important to speak with your babysitter to understand who is playing the games, and when and where they are doing so. Research has shown that even children as young as your son may be affected by what they are exposed to on a TV screen. 

Some of the effects are indirect. For example, from birth to age two, one of the things kids most need is face-to-face interaction with other people. An adult who is distracted by, say, playing video games or watching TV cannot also give a child the kind of focused attention he needs.

In addition to distracting the babysitter, research has also shown that the video games are probably also distracting your son, even if he does not appear to be paying attention to the screen. Research shows that young children who play in a room where a TV is on in the background do not stay focused on their own play as well as they do when there is no TV--and at this age, learning to maintain attention is some of his most important developmental work.

In terms of the violence in the video games, research is not clear on how much an 18-month-old can interpret from a screen. However, there is evidence that babies respond to tone, even if they don’t understand content, and that they are attuned to the feelings of their caregivers. So even if your son doesn’t understand the violence, he may feel anxiety based on the images and sounds that are in this environment.

Given the potential effects, it might be worth asking your sitter to change this part of the environment. Just as you might ask whether your babysitter knows First Aid or how they choose to address bad behavior, you can ask how he or she will use media around your child. It would be ideal if the sitter would agree to eliminate the videogames when your child is around.  However, if that is not possible, perhaps you could suggest that the games be played in a room where a door can be closed and your son will be taken elsewhere to play.

>>See related question: How can I get my husband to stop playing violent video games around our toddler?

Enjoy your media and use them wisely,
The Mediatrician®

Can toddlers learn sign language by watching DVDs?

Q: In your NPR Parents’ Journal interview, you stated that children under the age of 30 months do not learn anything about language from TV programs, but I disagree.  My 17-month-old daughter is not allowed to watch entertainment TV, but since she was 9 months old, she has watched a baby signing language DVD series about 3 times a week.  Now she knows about 80 signs (and about 60 spoken words), and learning sign language as a family has greatly enhanced our relationships because she can tell us what she needs without crying and throwing a tantrum. I feel strongly that the 1-2 hours of media exposure a week are making her toddlerhood much less frustrating and are worth whatever negative effects are possible. I would love to hear your thoughts on this matter.
-Serious about Signing, Baltimore, MD

A: Dear Serious about Signing,

Thank you for raising this important issue. My own young children signed when they were your daughter's age and I absolutely agree that baby sign language can be a wonderful tool for allowing pre-verbal children to communicate more specifically than they can with cries of distress. It sounds like the simple signs that you and your child are learning are making a world of difference, and the DVDs seem to be giving you a good deal of useful guidance.

In terms of what children under 30 months can learn from screens, research on brain development suggests that they can learn to imitate. Imitation is certainly useful—as you’ve experienced, imitation can provide a tool for asking for something specific, like milk. But their brains are not really ready to develop verbal language.

So what is going on here? Most likely, your daughter is learning to imitate motions from the DVDs and, most importantly, from you. You respond to the motions by giving her what she’s asking for, so the behavior is positively reinforced—and she’ll imitate signs on the screen even if you don’t see them because she knows that you will respond. If you responded inconsistently or not at all to her signs, however, she would probably stop using them.

What that means is that what she sees on screen is only important because you support it. And since you do, her signing is helping her create a practice of communication, which will probably serve her well when she moves on to words. Just know that what’s best for brain development at this age is manipulating her physical environment, creative problem-solving play, and time spent interacting with you—and since signing is something you do together, that works. Screens on their own won’t provide her with any of those three things.

Enjoy your media and use them wisely,
The Mediatrician