Ask the Mediatrician

What can I do for my 15-year-old son, who has Asperger's and ADHD and seems addicted to video games?

Q: My son is 15 and displays symptoms of video game addiction, including lying and sneaking to try to gain access. He has Asperger’s and ADHD, and regardless of what medication regimen we try, the gaming obsession remains. I recently asked the psychiatrist to hospitalize him and treat him as they would other addicts, but they just changed his meds. Anyway, even if he were treated, he needs the computer for school. Do you have any advice for me?
-Dealing with Addiction, Orlando, FL

A: Dear Dealing with Addiction,

Unfortunately, more and more families share your story. Whether through sleep deprivation, anxiety, or social isolation, teens struggling with problematic video game or internet use are suffering, and their families are disrupted. And research shows that young people with ADHD may actually be more susceptible to problematic video game or internet use.

Part of why it’s so hard to find good treatment is that these symptoms have yet to be recognized as a formal psychiatric diagnosis in the U.S. (unlike in South Korea and China, where clinics, hospitals, and “detox” centers treat Internet Addiction Disorder). Still, there are steps you can take to help your son:

1. Keep working with mental health professionals. Make sure that his providers recognize and respect these particular problems.
2. Optimize his treatment. Just as youth with ADHD learn more effectively in the controlled computer environment than in the chaos of a classroom, they are also at higher risk for problematic internet behaviors. Similarly, the social awkwardness of Asperger’s syndrome feels more manageable online. That may be why there’s some evidence that problematic behaviors may decrease or disappear underlying issues are addressed in therapy and any medication is optimized.
3. Move his computer and internet access into common space. Your presence will help you help him regulate his computer behaviors. Be aware that smartphones and many portable digital players are wireless internet-capable, so treat them similarly.
4. Find diverse activities that fill his needs. Look for pursuits that have clear rules, and achievable goals, and that allow him to move at his own pace. Rock climbing or a martial art like tae kwan do or karate would build his mindfulness and self-discipline, while also providing exercise and positive social interaction.
5. Get him outside. Being immersed in nature has a calming and focusing effect. It can also be an effective context for treatment—wilderness therapy has worked wonders for some of my patients and could be a good option for your son.

Remember, too, that when used in moderation, computers and video games can help young people with ADHD and Asperger’s learn, grow, and thrive in ways that they cannot in more traditional educational and social contexts. For more information and resources, take a look at this website.

Enjoy your media and use them wisely,
The Mediatrician®

My 17-year-old is having serious anxiety since he started playing Call of Duty--is there a connection?

Q: My 17-year-old son started playing Call of Duty a few months ago. Since that time, he has had more trouble than usual falling asleep and has been waking up in the middle of the night. Last night, he woke me saying he felt like he was having a panic attack—racing heart and hyperventilation. I hadn’t associated it with his Call of Duty play, but when we talked about it last night, I realized that the timing lined up. Is there any evidence of violent video games bringing on stress or anxiety in young players?
     —Shoot or Scare, in Vancouver, British Columbia, Canada

A: Dear Shoot or Scare,

The key question is this: Did your son realize the association between the time when he started playing Call of Duty and his increased general anxiety punctuated by panic attacks?

The research shows that at his level of brain development, your son is more likely than an adult to have increased fear/anxiety after playing violent video games, but less likely to have the insight necessary to make the connections. He will be address this problem more effectively if he “discovers” the relationship himself and devises a solution. If he has not made the association, it will work better if you explore with him what might be stressing him at the moment, gently steering him toward his own observations rather than telling him yours.

The reason that kids get so involved with Call of Duty (the biggest selling video game to date) and other action games is that they are designed to put players on high alert—to get their adrenaline flowing and their hearts racing, ready for unexpected turns of events. Adolescents seek new experiences and sensations—it is an integral developmental task at your son’s age. Video games are one way in which they can vicariously experience fear and mastery of that fear in a situation that is not life-threatening.

Gently encourage your son to stop playing for two weeks or so and see whether his anxiety lessens. If it does, he may want to decide whether playing the game is worth living with the symptoms. If it doesn’t, the adrenaline rush of gaming may have unmasked an underlying anxiety—he may want to take a closer look at what else is happening in his life, and consider seeking help from a talk therapist to develop effective coping strategies. See this related post for more information.

Enjoy your media and use them wisely,
The Mediatrician®

Ratings Reality: Who rates our media and what that means for children

CMCH staff member Kristelle Lavallee contributed the following post to Thriving, Boston Children's Hospital's pediatric health blog.

Are you looking to take the family to a movie but aren’t sure whether your child should see The Hunger Games (PG-13) or Bully (unrated)? If you base the decision on the Motion Picture Association of American (MPAA) ratings, the answer seems pretty cut and dry—“maybe” to Hunger Games, and “no” to Bully. But are the movie ratings the best guide to making healthy media choices for your children?

Based on the best-selling novel, The Hunger Games is a fantasy story where teenagers are pitted against each other in a battle to the death broadcast on live TV. In contrast, Bully is a “slice of life” documentary about peer-on-peer bullying in American schools.

Both movies center on children and teenagers, but the fictional Hunger Games, portraying “intense violent thematic material and disturbing images” (MPAA’s description) was given a PG-13 rating, while the documentary Bully with “some language” (MPAA again) was rated R. The producers of Bully knew that accepting an R rating would greatly limit the film’s impact as an educational tool for young viewers, so they chose to release it unrated. But when a film is released without an MPAA rating, it comes at a price: Fewer theaters are willing to show it, and those that do will treat it the same way they treat films unrated for extreme violence or sex. Continue reading here.

How can I encourage parents to be involved in their kids’ online lives?

Q: My 16-year-old goddaughter’s parents are not Facebook friends with her, so when someone stole her phone and posted some degrading things to her account, they didn’t know until I told them. Another friend asked me to look at all her 19-year-old daughter’s pictures and let her know if I saw anything inappropriate. How can I encourage parents to become involved in this important space so they can do the sorts of parenting they’re asking me to do?
-Pixed Up, in Memphis, TN

A: Dear Pixed,

Suggest to your friends that they think of social media like they think of driving a car: Teens may be legally able to do it, but they still need support from someone with more life experience and a fully formed brain to learn to use it responsibly.

The idea of getting involved in teens’ online lives may seem daunting, though. Teens are digital natives, and technologies change so rapidly that it’s hard for their digital immigrant parents to keep up. Unfortunately, many parents feel so uncomfortable or clueless that they don’t even try to parent or protect their children in the digital realm—and both kids and their parents assume that this is private space.

In reality, though, the online world is part of their real world: U.S. 8- to 18-year-olds use media for about half of their waking hours, and for more time than they spend with parents or in school. It has become an important environment for many key developmental tasks of adolescence, like seeking out experience, building identity, and practicing social interaction.

Because such processes can be as confusing and difficult to manage online as offline, your friends have a lot to offer by “friending” their teens and opening conversations about what’s happening online. And this is where their status as digital immigrants can really help—they can ask their teens to teach them about their world. Remaining open and non-judgmental about whatever is shared can make teens respected and valued, which will allow the parents to start a supportive dialogue about life online. For ideas on where to go from there, see this CMCH resource on “The Internet Talk.”

Enjoy your media and use them wisely,
The Mediatrician®

Am I overreacting if I don't want my husband to play games like Grand Theft Auto with our 5-year-old?

Q: My husband plays X-box games rated for those over 16 or over 18, like Call of Duty, Grand Theft Auto, and Modern Warfare. He allows our 5-year-old son to play these games with him. I do not know anything about X-box, but I feel they are not suitable for a child that is so young. Am I over-reacting like my husband suggests? 
-Fear of Gaming, in Ireland

A: Dear Fear,

Trust your parenting instincts on this—you know your child better than anyone. Your concerns are not an over-reaction, but are supported by scientific research.

In video games, players gain or lose points for behaving in certain ways. They practice those activities over and over again, getting better and better at these “behavioral scripts.” While your husband’s adult brain can tell what’s fantasy and what’s reality, your son’s can’t—and won’t be able to for at least 3 more years. Instead, he will use these experiences to build his understanding of what the world is like and how people behave in it.

Using virtual violence as entertainment makes children of all ages less sensitive to the real-life suffering of others. It makes world seem more violent, which leads to anxiety—especially among the youngest users. And although they are unlikely to go out and do the things in real life that they do in video games, some users will think and behave more aggressively. If your son is having trouble with nightmares or aggression toward other kids, it could be related to playing these games.

Even if he isn’t visibly experiencing these kinds of problems, though, talk with your husband about what you’d like your son to learn and what kind of person you want him to become. Then brainstorm fun activities they can do together to accomplish those goals. And remind him that your son’s childhood is fleeting—their time together will build both memories and the person your son will be, so choose them mindfully.

Enjoy your media and use them wisely,
The Mediatrician®

Is The Hunger Games movie too scary for younger fans of the book?

CMCH staff contributed to the following post on Thriving, Children's Hospital Boston's pediatric health blog, about the movie The Hunger Games. The post is written by Thriving blogger Tripp Underwood.

The movie The Hunger Games opens today, and record tickets sales are expected to make the grisly, post-apocalyptic, survival tale one of the spring’s biggest blockbusters. Like the Harry Potter and Twilight series before it, The Hunger Games film is based on a book written for young adults that has captured the imaginations of readers of all ages.

Considering the ultraviolent nature of The Hunger Games’ plot line—24 teenage protagonists are pitted against each other in a fight to the death—is all this hype a good thing for young, would-be fans? The intended age for young adult novels is 12 to 17, but the books’ popularity has piqued the interest of much younger readers. Not wanting to sully their younger children’s budding interest in reading, many parents across the country have allowed them to read the story.

But just because your child has read The Hunger Game books, does that mean she’s ready to watch it’s bloody action unfold on the big screen? The answer will vary from child to child, but it’s a question parents of younger Hunger Game fans need to ask.

“[Reading about violence] is a gut experience as opposed to a head experience,’’ said Michael Rich, MD, MPH, director of Children’s Hospital Boston’s Center on Media and Child Health, in a recent Boston Globe story. “A movie is very direct. You are seeing it, you are hearing it, as compared with translating it from black ink on a page into something in your own mind.’’ Continue reading here.

Does the sound from TV affect infants?

Q: Sometimes, we watch TV while our 7 week old is in the room. She’ll typically be in our arms or sleeping in her swing at the time. She never sees the images on TV. The shows we watch tend to be PBS shows, cooking shows, and other non-violent, non-suspenseful things. I wonder if hearing the TV is okay. Is it like hearing conversations for her, or is it an inappropriate stimulus?
-Seeking sound advice, in Austin, TX

A: Dear Seeking,

Kudos to you for being careful about the content and amount of TV your infant is exposed to! The American Academy of Pediatrics recommends no screentime for babies under 2, but if you are going to have the TV on in a room with your infant, the choices you’re making should help reduce its potential negative effects.

Even so, do the following to see how the TV is affecting her and to make sure it’s not taking away from the things she needs:

1. Interact with her a lot while she’s awake. Research shows that screens can distract parents from paying attention to their children. Make sure to turn off the TV and give her some direct attention.
2. Talk to her. Unlike television voices, real-life voices respond to the baby, which is important for language development. Recorded voices can’t replace human interaction.
3. Watch her play. Babies and toddlers learn through creative, problem-solving play (like stacking blocks) and exploring their environment (like petting a dog). Studies show that background TV distracts children from those things. If you notice that she’s looking at the TV, turn it off.
4. Pay attention to how she acts, and choose content that helps keep her stress level low. Babies hear emotional tone, so watch her even during shows that seem benign to you. She might start squirming when she hears Emeril say “BAM!” but seem content during Martha Stewart’s monotone how-to’s. Notice that and change your viewing choices accordingly.
5. Notice to how she reacts to commercials. They may sound very different from the shows they surround, so consider muting them.

Enjoy your media and use them wisely,
The Mediatrician®

With video games, how can I help my kids know when enough is enough?

Q: I'm a pediatric nurse practitioner, and we have three boys ages 5, 7, and 9. Several parents/patients have told me that they have the same problem as I do enforcing video game time limits. Certain kids just seem “addicted” and can’t wait until they get more. Do you have any visual time charts, contracts, or other concrete examples of how to work with your kids on knowing when enough is enough? 
-PNP Parent in Bozeman, MT

A: Dear PNP Parent,

Try approaching this issue with a positive rather than restrictive approach. Instead of limiting video game time, focus on creating a daily schedule with your sons where there is enough time to do everything that is important to them.

Search online for “hourly calendars,” and print a copy for each child. Then, ask them to think about all the things they need to do in a day—like eating meals as a family, school, homework, active play (outside, if at all possible), spending time with friends, and getting enough sleep—and help them remember others that they forget. For each task, have them choose a color, think through how long it will take, and color in the time blocks needed.

They will see their time filling up with important activities, and they will see what time is still left. Talk about what they can do in that time. Perhaps they can spend some of it playing video games, but offer them attractive alternatives as well, like organized sports or hobbies. In this way, they will have some ownership of mindful, directed “down time” rather than simply sliding into video gaming.

By focusing on what they do want and need to do in their limited time, you can avoid making video games a forbidden fruit. Whatever choices they make, remember that they will learn from what they experience, so exercise your judgment about the content of any media they use.

• For information on video game addiction, take a look at this post: My 10-year-old son is miserable since I took away Call of Duty--what do I do?
• For ideas on creating a family media agreement, click here.

Enjoy your media and use them wisely,
The Mediatrician®

How can I block sexual content in Web searches from my 15-year-old's iPad?

Q: What is the best way I can block websites with sexual content that appear through Web searches on my 15 year old’s iPad and still let him use the Internet for safe sites? The built-in controls are a blunt instrument and block too much or all content.
-Seeking Better Blocking, in Nashville, TN

A: Dear Seeking,

As you’re finding, software controls aren’t very effective at blocking sexual content. They may allow sites that are creatively named while blocking innocuous sites on, say, breast cancer awareness. Also, if your son wants to get around them, he will. That’s why the best software for protecting your son is the knowledge in his head.

First, know that it’s natural and healthy for him to be curious about sex. But as you imply, the world of sex online is a minefield: The images he sees there are likely to be unrealistic, dehumanizing, and treating sex as a commodity—as something to buy and sell rather than an intimate expression of love and trust. That can affect his understanding of sex.

That’s where you come in. As a parent, you can direct him toward online information that will support him in developing positive sexuality (take a look at Scarleteen and GoAskAlice). You can also help him interpret the negative portrayals he sees online by having a candid conversation with him. Ask questions like, “What is really going on there?”, “How do you think that makes her feel?” and “Is that the kind of relationship you want to have?”

The more that his sexual education can occur out in the open and in contact with you, the less of an impact the schoolyard or Internet “sex ed” will have.

Enjoy your media and use them wisely,
The Mediatrician®

Is age 7 too early to learn keyboarding?

Q: My 7-year-old twin granddaughters have spent less time with computers than most kids their age. Recently, their school has started to teach keyboarding. Those who have spent a lot of time on computers are learning quickly, while my granddaughters are feeling a bit behind. I think that the girls will eventually catch up (and have reaped many benefits from less computer time in early childhood), but their mother is worried—both that they will stay behind and that it’s too early to for them to learn keyboarding. What can I tell her?
—Early-Childhood Ally in Winnetka, IL

A: Dear Ally,

First, there’s no need for your daughter to worry that her twins will be left behind. Although their peers are ahead of them right now, their developing brains should pick up this new skill fairly easily.

In terms of when to introduce computers, here’s a good rule of thumb: Introduce any media tool when children actually need that tool to complete the important tasks of daily life, including schoolwork. If the school is using computers in a thoughtful, education-focused way, then it isn’t too early to teach skills that will help your granddaughters use them effectively.

Recommend to your daughter that she talk to the teachers or principal and ask what role computers play in students’ learning. For example, what are the expectations about how kids use computers? What other tools are they learning to use for tasks that computers aren’t best for? And how are skills like online safety and cybercitizenship being taught?

Talking about this with the school should ease her mind—or, if she learns that the school isn’t using computers as thoughtfully as she’d like, it will provide an opportunity for her to offer suggestions.

Enjoy your media and use them wisely,
The Mediatrician®