Ask the Mediatrician

How can I tell if an e-book is appropriate for my 10-year-old?

Q: With the purchase of a couple of e-book tablets for our home, how can we know if the books our 10-year-old triplets will be reading on them are age appropriate? My daughter read a book she heard about in her 4^th grade class during a book report, and it ended up having significant sexual content and very questionable language. If it were a movie, it would have been rated R!
—Troubled Tablet times 3, Kinnelon, NJ

 A: Dear Troubled Tablet times 3,

It can be a difficult task trying to figure out if a book is developmentally suitable for your child. The old adage “you can’t judge a book by its cover” still holds true, even in the age of e-books. Fortunately, there are several ways to make an informed decision about whether it will be a healthy read for your child. If there is a particular book your daughter is interested in reading, like the one she heard about in her book report, review the content in one of these ways:

• Read the book yourself. As a parent, you know your child better than almost anyone else. If you are able to read the book before she does, you can see whether its content is optimal for her and can direct her to other books if you decide it isn’t.
• Sample the story. Even though one small section of the book may not accurately reflect the whole story, a chapter or two can give you a taste of the book’s content (and its level of difficulty). You can go to a library or bookstore, or you can preview chapter or two for free wherever you buy e-books.
• Start a book club. By reading and discussing the book with your daughter—and possibly with other mother/daughter pairs—you can help her process the content and her feelings about it. That may allow her to engage in more challenging material in a supportive environment.
• Check out an expert resource. Since you won’t be able to read everything that your child wants to read, look for reviews from resources you trust (try this one or this one).

When you do find books that meet your daughter’s needs, be sure to share them with others—in your book club, at your child’s school, or even by adding them to a trusted resource list.

Enjoy your media and use them wisely,
The Mediatrician®

Should I use the movie "Bully" to talk about bullying with my 10 year old?

Q: My 10-year-old son will be starting middle school in the fall. So far, he has had a pretty sheltered, drama-free experience at a great elementary school. I want him to be aware that bullying goes on and that he needs to tell someone if anything like that ever happens to him. I have thought about taking him to see the movie “Bully,” but am afraid that it will make him fear going to middle school. What do you think?
-Bothered about bullying, in Minneapolis, MN

A: Dear Bully Bothered,

Your concerns echo those of many parents who have children transitioning from one school to another. You are doing the right thing by trying to start a conversation about bullying with your son. However, your instincts on using “Bully” to introduce the subject are right on track. It may be too intense, since it includes a lot of physical and emotional child-on-child violence, as well as the suicides of bullying victims. Try opening the topic in another way.

One way approach could be to take your son for a drive and start the conversation in the car—that way, you won’t have to face each other as you talk, and his attention will be focused on the conversation (provided that he doesn’t have a book, DVD player, radio, or cell phone). Chances are your son isn’t so sheltered that he hasn’t heard about bullying, and he probably has some concerns of his own. Begin the conversation by allowing him to vocalize his thoughts:

1. Start with open-ended questions: “How are you feeling about starting middle school? What are you excited about? Worried about?”
2. It may help him talk if you depersonalize the topic, ask: “What worries do your friends have about school?”
3. If bullying hasn’t come up yet, you can present the issue from your own perspective, saying, “One thing I’m worried about is bullying, which we know can be an issue in some schools. Have you heard about that happening?" And "Please talk to me if you see anything that makes you uncomfortable. Together we can figure out a way to deal with it, and you’ll be helping to keep your school safe.”

When children and their schools see bullying as a community issue, they solve the problem by focusing on the needs of the bullies, victims, and the school community to make a positive change. This approach helps heal the community as a whole and is more effective than using a system of punishment, which often doesn’t address the core of the problem. Presenting the issue this way can help give your son a sense of shared responsibility for his school environment and will not only make him aware of bullying, but also empower him and his schoolmates against it.

For more information and resources check out:

• http://www.stopbullying.gov/
• http://www.ncpc.org/topics/bullying/what-parents-can-do

Enjoy your media and use them wisely,
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®

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.

My 10-year-old son is miserable since I took away Call of Duty--what do I do?

Q: My 10 year old used to be an avid skateboarder and baseball player—until Call of Duty on XBOX Live arrived. I didn’t in my wildest dreams think that he would become addicted to a video game. I have a 21 year old who played all of the games but was never ruled by them. Since my awakening, I have removed the game, but my son is miserable. How long does it take to deprogram him?
—Problem Gaming, in Kansas City, MO

A: Dear Problem Gaming,

More and more young people are being referred to me for Internet or video game behaviors that are causing real problems in their lives. It sounds like your 10-year-old son falls into that category. Unfortunately, time away from the game may not be enough to deprogram him—he probably needs professional help.

Even though our healthcare system that doesn’t recognize video game addiction as a formal problem, there are still steps you can take to help your son. You’ve already taken the first step: removing the game (though if he is indeed addicted, he will find other ways to keep playing). The next step is to find and make an action plan with a therapist who understands this kind of problem.

In the meantime, when talking about this with your son, frame this as a health issue, not as an issue of misbehaving. Your son's excessive game play could be a symptom of another issue—like social anxiety or depression—and it could be his way of taking refuge in a world he can control. Explain that you see how miserable he is, and that although he may not understand yet, the goal here is not to punish him but to make his life better.

For more information about signs, symptoms, and treatment, click here. Also check out this related post: My teen daughter's addiction to technology is ruining our family life--what should I do?

Enjoy your media and use them wisely,
The Mediatrician®

Could my 14-year-old son's anxiety be related to playing video games?

Q: Is there a connection between excessive video game playing and increased anxiety levels? My son is 14 and has some basic anxieties like walking the dog at night that I feel are made worse by the first-person shooter games he plays. I’d love to understand if you have seen any connections here.
-Grappling with Gaming, in Westfield, NJ

A: Dear Grappling,

As a parent, you are the best monitor of your son’s well-being. If you have seen an increase in his anxiety that has paralleled his increase in first-person shooter (FPS) game play, then it is probably worth seeing what happens if he cuts back on or eliminates playing these games. Research supports what you are observing—it has found that children and adolescents frequently respond to media violence with increased fear and anxiety, because action entertainment makes violence seem more prevalent than it actually is.

Suggest that your son stop playing video games for a while. This will be easier said than done—he will not want to stop playing, and he will probably resist in every way he can. Talk about your concerns with him, and remind him that his resistance may, in fact, indicate that he might be developing an addictive relationship with gaming. If nothing else, he will stop because he wants to prove he can. Then pay attention to his behavior and see whether his anxiety diminishes.

If he doesn’t think he can stop gaming or the anxiety doesn’t go away—that is, if either piece is limiting his life in some way—then it would be good to have him evaluated by a therapist. And remember that anxiety can affect a teen’s well-being in subtler ways, such as through increased distraction, which could appear to be ADD/ADHD.

Finally, encourage your son to pursue other activities he enjoys. Increasing physical activity and getting outdoors can reduce anxiety and increase quality of life in all kinds of ways.

Enjoy your media and use them wisely,
The Mediatrician®

When is it time for my daughter to get an email account?

Q: At what age do you think it is appropriate for a child to have a personal e-mail address? I have a 10 year old who wants one, but I don’t feel she is old enough. I think she can be trusted and has proved to be responsible, but it’s the world out there I worry about. How would we block inappropriate e-mails?
-eQuestioning in Mansfield, MA

A: Dear eQuestioning,

Treat personal email like any other tool: When it’s the right tool for the job at hand—whether that job to communicate with loved ones or to send homework to a teacher—that’s the time to introduce it to your child.

But that doesn’t mean her email needs to be private. In fact, as your child starts using this tool on her own, your supervision and guidance can help her learn to navigate that world safely and successfully. Start with an email service that allows you to access her account, set controls, and review emails yourself before she sees or sends them.

As you and she gain confidence in her email skills, give her more independence and freedom bit by bit—perhaps by checking less often and starting to let her monitor her own email, with the clear and explicit understanding that you are passing to her the responsibility to keep her email healthy and safe.

And no matter how much freedom she has with email (and with texting, which has already eclipsed email for peer-to-peer communication), check in with her continuously, and make sure she feels safe, supported, and able to reach out for your help. For more information, see these other answers:

• How can I protect my child when she's learning to use email?
• How should I get my kids set up with their first email account? 

Enjoy your media and use them wisely,
The Mediatrician®