Digital Diets and the Impact of Screen Time on Development
Let’s start with some statistics
In 2011, 38% of children, age eight and under used tablets and smartphones. In 2013, it went up to 72%. COVID-19 2020 could not have helped. In 2018, one-in-four children under the age of 6 had a smartphone. Use of mobile devices and children has risen from five minutes a day in 2011, to 48 minutes a day in 2017. Recent studies are revealing that kids and babies, under the age of two, are spending more than double the time in front of screens than they did in the 1990's. However, it’s not until around the age of 18 months that a baby's brain has developed to the point where the symbols on a screen begin to represent their equivalent in the real world. So what are they focusing on? Children under the age of two are wired to learn and remember things through experiences and by doing, but what researchers found is that children watching screens imitate 50% less actions than those children who engage in live three-dimensional interactions. Hindering their learning.
Let me give you an example of this hindrance - Baby Einstein videos have seven scene changes in just 20 seconds of video. So there's about one scene change every three seconds. What's actually keeping them engaged? The color changes and continuous changes in the screen! As a result; a real farm isn't keeping them engaged, and for every 30 minutes of screen time, there is a 49% increased risk of expressive speech delay. This statistic comes from a 2017 Canadian study by Dr. Catherine Birken, the first study that reports a link between handheld devices and expressive language delays. And now there are over 200 peer reviewed studies that point to screen time correlating to increased ADHD, addiction to screens, increased aggression, depression, anxiety, and even psychosis. The National Institute of Health is currently doing a $300 billion study using functional MRIs to examine the changes in brain structure among children who use smartphones and other screen devices. The first batch of results shows that kids who spend more than two hours a day on screens scored lower on language and thinking tests, kids who spend seven hours per day on electronic 5 devices show premature thinning of the cortex (underdevelopment).
Recommendation
From an OT’s perspective, I would recommend less than 2 hours a day 5 to 18 year olds, no more than one hour a day for children aged 2 to 5, and none for children younger than 18 months. Per day.
Research is showing us that children aged 3 to 5, whose parents read through electronic books, they had lower reading comprehension, compared to physical books because of all of the interactive features from electronic books that distract them from a focus on the actual story. Distractions, and being able to touch a feature of the visual representation is making it a different activity that doesn't involve as much learning required for reading comprehension, and word meaning. 80% of learning apps are targeted specifically towards young children, many claim to help children learn to read, but most don't.
Let’s take a look at some of the people that invented the tech
Most of the tech executives don’t allow children near certain devices. One specific school in the Bay Area where 75% of the parents are tech executives, do not allow any tech in the school. No iPads, no promethium boards, no whiteboards, no Chromebooks. Also, Silicon Valley nannies actually have to sign no technology agreements, meaning they won't be on a device and they won’t allow the children on a device while they're in their care.
It makes you take a step back to think about how these applications are made. Tech devices were made to keep people invested and entertained, not for learning. It’s recommended to use technology as a tool, not a toy.
There is much more details to go into so if you are curious and want to know more. Please feel free to reach out to me and book a free 30 minute consultation!
Medicate or Not?
As pediatric practitioners, we often hear about medication and ways to help with symptoms for psychiatric diagnoses, in combination with our treatment. But how safe is medication? Do they have an affect on their health? As a focus of a previous blog, we looked into the prevalence and symptoms of ADHD…
“Symptoms are often noticed during the early childhood years before 3 years of age. However, caution is advised on early diagnosis and will most often be made during elementary school years when behavior is interfering with school performance. Some other notes on symptoms:
Occurs in 5%-8% of elementary school aged children.
Prevalence in boys to girls is a 3:1 ratio, most common in first born boys.
Partial remission may occur in ages 12-20. Hyperactivity may disappear during these years to allow for a productive adolescence but distractibility and impulsivity can persist.
Symptoms persist into adulthood in 60% of cases.”
In reference to treatment of something like ADHD, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Behavior Disorder, there are usually a combination of treatments. Behavioral techniques, and medications. But most importantly, before your doctor gives you a script for a prescribed medication- there should be a thorough process to make sure that your child is diagnosed appropriately.
It’s true, that medication for ADHD can be overused, but the under-diagnosed and under-treated factor for ADHD is more often than over treatment. Your child should not be diagnosed as having ADHD after a 10 minute exam. There should be behavior reports from multiple sources, surveys, medical history, and a clinical interview with your child.
After a thorough evaluation, you can discuss options with your doctor. The most common medication is Methylphenidate (Ritalin, Concerta, Metadate, Daytrana, Quillivant), and has been used for over 50 years for symptom management of inattention, impulsivity, and hyperactivity. If symptoms are affecting your child's quality of life and learning, it’s something to consider with the supervision of your doctor. Side effects seem to be not life threatening according to research, there may be problems with sleeping, or decreased appetite, but you can always discuss adjusting the dosing with your doctor to get a better fit.
Other treatment options:
Occupational Therapy is one of the specialized treatments that can help your child perform in school and at home. When I treat in schools, there were often times that I would go into the classroom with the child to help learn different coping strategies and techniques to facilitate his or her attention. We also took time to educate the teacher on the strategies we were working on in order to facilitate learning. Also, as an occupational therapist I encourage participation in functional activities and extracurricular activities (at their pace), to help with time management, organizational skills, positive social interaction, and an outlet to feel successful in.
References:
https://www.bmj.com/content/351/bmj.h5203
https://www.health.harvard.edu/blog/adhd-medication-for-kids-is-it-safe-does-it-help-201603049235
A Video Game for ADHD?
After hearing about a new FDA approved prescription video game for ADHD, I had to read the research myself to believe it. At first thought, it seemed counterproductive to me. How can something that typically has been known to be a distractor help ADHD? Don’t get me wrong, technology has its pros, such as increased productivity for the workplace, convenience of shopping from home, even working from home thanks to COVID but it still makes me question the effectiveness of a video game to improve your attention.
In today’s day and age, technology is such a large part of our lives. Screen time on our phones increase, and our threshold for the amount of “multitasking” for the first hour of our work day has drastically increased over the past 20 years. Below is part of the research study that I found. I hope you find this useful!
ADHD is a widely known diagnosis that children struggle with, it accounts for about 5% of US children, and is the most commonly diagnosed pediatric mental health disorder. As we learn more about mental health in the US, we want to find the safest treatment - especially for children who are still developing and growing. Medication has it’s side-effects, and has short-term efficacy. I was especially surprised to hear that the trials used for pharmacological efficacy for ADHD typically used parent rated or clinician rated symptom measures! This means the research to back these drugs used for ADHD are mostly based on the parent or clinicians subjective opinion. Having alternate methods outside of pharmacological intervention is important, especially if it has limited improvements that become outweighed by side effects.
Participants: 8-12 years old with ADHD, No Medication even if regularly taken, 348 kids
About the Study Design: Randomized, Double-Blind, Parallel-group, Controlled Trial
The video game trial would be an alternative method that would be engaging, but also reduces adverse effects (negative side effects). The novel digital therapeutic. AKL-T01 (Akili Interactive Labs, Boston, MA, USA), was made to engage children with ADHD but also targets attentional control to improve completion of tasks and shift attention more efficiently between tasks. What makes this trial unique to research for the ADHD population, is that it uses objective cognitive assessments to measure outcomes. So, findings are not based on a parent or clinician opinion of the results, but tests administered to the child. The trial showed significant improvement in attention-related measures with children that used the video game AKL-T01, compared to the group that did not. It also reduces negative side effects for the child. The only reported adverse effects included 7% of children using AKL-T01 were frustration and headache, versus 40-60% of children in trials of commonly used stimulant medications (which has a lengthy list depending on the medication). Specifically, trials done for stimulant medications don't have research on the functional improvement on a validated measure that this study has. There definitely needs more research done to see the long term effects of this video game, but it’s a novel treatment technique that may be safer and more accessible to families in the future.
References
Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol 2014; 43: 434–42.
Catalá-López F, Hutton B, Núñez-Beltrán A, et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: a systematic review with network meta-analyses of randomised trials. PLoS One 2017; 12: e0180355.
Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry 2018; 5: 727–38.
Shams TA, Foussias G, Zawadzki JA, et al. The effects of video games on cognition and brain structure: potential implications for neuropsychiatric disorders. Curr Psychiatry Rep 2015; 17: 71.
Kollins SH. Moving beyond symptom remission to optimize long-term treatment of attention-deficit/hyperactivity disorder. JAMA Pediatr 2018; 172: 901–02.
Kollins SH, DeLoss DJ, et al. A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomized controlled trial. Lancet Digital Health 2020: Volume 2, Issue 4, E168-e178.
Wolraich ML, Greenhill LL, Pelham W, et al. Randomized, controlled trial of oros methylphenidate once a day in children with attention-deficit/hyperactivity disorder. Pediatrics 2001; 108: 883–92.
You Are What You Eat - Or Are You?
Most of us have heard the term, “You are what you eat.” Or craving certain foods, usually carbs while in quarantine. Diet has a huge effect on your well-being and quality of life and there is a reason why we might be craving a bagel (daily).
There has been research on certain foods to help us understand and balance our diet that could be beneficial for you and your family. Especially those with children, parents will do anything to help their child get proper nutrition.
We’ll start with, “Sugar High” Debunked
Wouldn’t it be easier to blame a behavior on a specific food? To know what may be causing certain behaviors, and have better control or at least prediction of how your child will feel. Especially those with children with diagnoses as ADHD, to better manage symptoms. It’s a myth that has gone around but has been proven to have no effect on children's behavior unfortunately. Research conducted included 94 thorough studies testing normal Preschool children whose parents described them as “children with sensitivity to sugar.” In this study, some children were given items with sugar, and others with diet substitutes or sweetened with aspartame/artificial sweeteners. The children were then given 9 cognitive and behavioral measures. The parents, nor the children or researchers knew who got which items to make the study valid. It was found that sugar does not affect kids behavior or cognition.
Though sugar does not affect children’s behavior, it is still recommended to reduce sugar intake to reduce risk of obesity, Type 2 Diabetes, and heart disease.
Food nutrients, and timing of meals are correlated with mood and behavior. Research indicates that high protein and low carb diets may assist in increasing concentration and alertness. Nutrients may also be a therapeutic agent for reducing symptoms of Depression, Insomnia, Hyperactivity, Chronic Pain. Neuroendocrinologist at MIT Dr. Richard J Wurtman reports “It's likely that early in life people make associations between the consumption of certain foods and changes in how they feel... then, later on, they unconsciously turn to those foods to recreate the desired feelings.” Thus eliciting an emotional response when it’s seeked. Carbohydrates for example will typically give us a feeling of relaxation or calmness due to the increase in level of serotonin in your brain. If only getting a runner's high was as easy as taking a bite of a donut, we’d all be marathoners.
It’s something to consider, especially in this time of quarantine and isolation. We may find ourselves seeking comfort in what is safe, which is food. Unfortunately, the odds (or increase in serotonin) are not in our favor when it comes to dieting with low carb and high protein, ''These diets induce a serotonin deficiency in the brain which in turn could trigger carbohydrate cravings to correct the imbalance,'' says Dr. Wurtman.
Food/nutrients are the precursors for neurotransmitters to send signals to the brain. That facilitates mood and behavior. Tryptophan, an amino acid, raises sleep promoting serotonin and melatonin. Anyone else need to nap after that (Tryptophan filled) turkey at thanksgiving? So tryptophan contained meats and fishes may be able to treat mild sleep insomnia without mood effects or central-nervous-system depression. Tryptophan can also help with sensitivity to pain without side effects as reported by Dr. Dorothy Dewart.
Children with high consumption of caffeine however did report with more hyperactivity, frustration/anger than children with less intake. It was found that sugar actually had a calming effect on children studied by Dr. Rapaport, which reflects our findings of carbohydrates. Also, some may not feel the effects of coffee in the morning because the stimulation is combined with the effects of a roll or bread in the morning with the opposite effect. It’s also suggested that nutrients eaten on an empty stomach have more of an effect on mood and behavior. But eating breakfast nonetheless would help a child's performance in school, especially if it’s high in protein.
Sources:
https://www.nytimes.com/2020/02/21/well/eat/is-there-such-a-thing-as-a-sugar-high.html
https://jamanetwork.com/journals/jamapediatrics/article-abstract/1173788
https://pubmed.ncbi.nlm.nih.gov/669509/?from_single_result=669509&expanded_search_query=669509
https://pubmed.ncbi.nlm.nih.gov/8277950/?from_single_result=8277950&expanded_search_query=8277950
https://pubmed.ncbi.nlm.nih.gov/8277958/?from_single_result=8277958&expanded_search_query=8277958
Hoyland, A., Dye, L., & Lawton, C. (2009). A systematic review of the effect of breakfast on the cognitive performance of children and adolescents. Nutrition Research Reviews, 22(2), 220-243. doi:10.1017/S0954422409990175
Bourre JM. Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain. Part 1: micronutrients. J Nutr Health Aging. 2006;10(5):377‐385.
The Real Deal with ADHD
We often hear people say that they think they may have ADHD if they are having trouble focusing on school or work. ADHD is a well known diagnosis that people may misinterpret or misdiagnose.
If you have ever wondered if you may have ADHD, it’s always best to speak to a doctor. However, here is some background on the topic in order to help those that are curious.
Etiology is unknown, however there are suggested contributing factors including:
Genetic factors - higher occurrence in monozygotic twins than in dizygotic twins, 2X the occurance in siblings of hyperactive children. This leads us to believe there’s a correlation in passing it down in families.
Neurological factors - possibility of minimal brain damage due to circulatory, toxic, metabolic, or mechanical effects during fetal development, and infection inflammation, and/or trauma during early childhood.
Neurochemical dysfunction related to neurotransmitters in the adrenergic and the dopaminergic systems.
Psychosocial factors - stress, anxiety, or predisposing factors such as temperament.
According to the American Psychiatric Association (APA) there are three types of ADHD as defined by Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). There are three subtypes of ADHD; Predominantly Inattentive type, Predominantly hyperactive-impulsive type, and Combined type. Depending on the symptoms, your doctor will be able to diagnose your subtype.
Symptoms
Symptoms are often noticed during the early childhood years before 3 years of age. However, caution is advised on early diagnosis and will most often be made during elementary school years when behavior is interfering with school performance. Some other notes on symptoms:
Occurs in 5%-8% of elementary school aged children.
Prevalence in boys to girls is a 3:1 ratio, most common in first born boys.
Partial remission may occur in ages 12-20. Hyperactivity may disappear during these years to allow for a productive adolescence but distractibility and impulsivity can persist.
Symptoms persist into adulthood in 60% of cases.
Diagnostic Criteria
Presence of 6 or more symptoms are required in three Domains (or subcategories).
Symptoms in the inattention/hyperactivity domain that interfere with occupational activities are present for at least 6 months.
Inattention Domain Symptoms may include: lack of attention to detail, poor listening, limited follow through of tasks, difficulty with organization, and avoidance of tasks that require sustained attention, tendency to lose things, distractibility, and forgetfulness.
Hyperactivity Domain Symptoms may include: fidgeting, inability to remain seated, inappropriate activity level for a given situation, difficulty with quiet sedentary activities, frequent movement and excessive talking.
Impulsivity Domain Symptoms may include: answering questions before they are fully stated, difficulty with turn taking, and interrupting the conversations of activities of others.
Other symptoms that may be present: Visual-perceptual, auditory-perceptual, language, cognitive problems.
Some of the symptoms presented were evident before the age of 7.
Symptoms result in difficulty in 2 of these settings: school, home, and/or work.
Symptom management
Medication as prescribed and monitored by a doctor, Psychotherapy, behavior modification, parent and individual counseling may be indicated.
Impacts on function
Infants may be overactive, difficult to soothe when crying, and demonstrate poor sleeping habits.
You may see defensiveness to environmental stimuli, frequent irritability, aggressive behavior, emotional lability, and unpredictable performance. These are all in response to difficulty with attention, it creates a barrier to learning and performance.
There may also be disorders in school related tasks or learning disabilities, which can be assisted with a team approach to your child’s care at school.
Caregivers may also see an increased risk for depression due to frustration and difficulty with learning. Checking up and addressing your child’s self esteem is important during this time to avoid progression. Those with symptoms remaining in adolescence and adulthood are at an increased risk of antisocial personality disorders, and substance-related disorders.
Considerations for Occupational Therapy
Occupational Therapists will work with children and their families on behaviors that may contribute to difficulty in school, play/leisure, and social participation. This may include environmental modification for facilitated learning, training in social skills/self-management, promotion of sensory modulation. Consultations to family, teachers, and employees regarding strategies are also implemented for treatment.
If you have any questions, please feel free to reach out to me directly smplytherapy@gmail.ccom
References
Glanzman, M. M., & Nathan J. Blum. (2007). Attention deficits and hyperactivity. In M. L. Bathshaw, L. Pellegrino, & N. J. Roizen (Eds.), Children with Disabilities, 6th ed. (ppp. 345-365). Baltimore, MD: Paul H. Brooks
American Psychiatric Association. (2000). DSM-IV-TR: Diagnostic and statistical manual of mental disorders, text revision, 4th ed. Washington, DC: Author.