Dimitri Christakis, MD, MPH
Dr. Dimitri Christakis, a general pediatrician who conducts research on the impact of early childhood experiences on children’s development, addresses questions about screen time for children. Christakis is a member of the American Academy of Pediatrics (AAP) Executive Committee on Children and the Media and director of Seattle Children’s Center for Child Health, Behavior and Development.
Thank you to Dr. Matt Allen, a pediatrician at Ballard Pediatric Clinic and a member of Children’s medical staff, for submitting these questions.
Q. It now seems shockingly common to find a 4-year-old playing Angry Birds on a smartphone during a check-up. How much time are children currently spending on-screen, and what are the AAP recommendations?
A. The amount of time varies by age, but the typical preschool child spends about 4.4 hours a day using screen media, and screen time increases to up to 7 hours a day by adolescence. Children spend more time watching screen media than doing any other activity except sleep.
The recommendation from the AAP Executive Committee on Children and Media is to limit “recreational” screen time to up to two hours per day, in addition to any screen time for academic work. However, I think two hours is too much because it doesn’t leave enough time for other activities that are important developmentally and physically.
The recommendation also implies that children will stop one activity and start another, when most children today are multitasking. How do you count recreational screen time if an adolescent is Facebooking or iChatting while doing homework? My personal recommendation is no more than an hour of recreational screen time per day.
Q. You have been on the leading edge of research regarding attention-deficit hyperactivity disorder (ADHD) and behavioral issues in children related to television. Could you summarize the current evidence?
A. A child who watches two hours of TV per day before the age of 2 is 20% more likely to have attentional problems at age 7 compared to a child who watches none.
Our work also suggests that it is the pacing that increases the risk, with fast-paced programs posing greater risk than slow-paced programs. Others have also found short-term attentional deficits in young school-age children immediately after watching episodes of fast-paced programs.
In contrast, children who receive more cognitive stimulation before age 3 (such as having parents who read to them, take them to museums or sing to them) have a lower likelihood of attentional problems at school age.
Rather than looking at a diagnosis of ADHD, I prefer to look at attentional capacity as a core part of executive function. There is a bell-shaped curve for attentional capacity, and while we draw a line at the 90th percentile for making a diagnosis of ADHD, a child who is close to the 90th percentile also has challenges.
Q. There are many forms of screen time (e.g., computers, texting, smartphones, television, video games). Is there any evidence that certain forms of screen time are more concerning than others?
A: It’s not as important to distinguish between platforms as it is to look at content. Two hours of a violent cartoon is very different from a two-hour documentary on the Civil War in terms of the pacing of the program and the educational value. I’d suggest moving away from the mantra of reducing screen time and focusing more on quality.
If you watch the same program on television, a laptop or a smartphone, it has the same effects. I consider texting phone time rather than screen time.
Q. It’s hard to ignore the relationship between physical inactivity and obesity. Is there any data to support screen time limits as part of a weight management plan?
A. There is an association between TV viewing and obesity, and, in fact, screen time reductions have been shown to reduce excess weight gain. However, there is a misconception that TV’s effects on obesity are mediated through sedentary behavior because you’re not expending calories if you’re watching TV. As a comparison, reading is also sedentary, but it hasn’t been implicated as a cause of obesity.
The link between TV viewing and obesity is because of exposure to advertising for unhealthy foods and overeating while viewing. Children watch TV because they are sedentary; they are not sedentary because they watch TV. We keep our children indoors more than we should, and once indoors, there are few ways to expend significant calories. Notably, one of those ways is now with active video games like Kinect for Xbox 360.
Q. What advice do you have for parents about successfully limiting screen exposure in their children?
A. I encourage parents to think about their children’s media diet. There’s a healthy media diet, just like a food diet, that should consider a healthy amount and appropriate quality.
But even good programming should be limited. Just as eating two bushels of carrots a day is not healthy for a child, watching a good TV program for six hours a day is too much because they are substituting media for other important activities.
For more information, see presentations by Christakis at Children’s Grand Rounds (CME credit available) and TEDxRainier.
References
- Christakis DA, Garrison MM, Herrenkohl T, Haggerty K, Rivara FP, Zhou C, Liekweg K. Modifying media content for preschool children: a randomized controlled trial. Pediatrics 2013;131(3):431–438
- Tandon PS, Zhou C, Lozano P, Christakis DA. Preschoolers’ total daily screen time at
home and by type of child care. J Pediatr. 2011;158(2):297–300
- Zimmerman FJ, Christakis DA. Associations between content types of early media exposure and subsequent attentional problems. Pediatrics. 2007;120(5):986-992
- Christakis DA, Zimmerman FJ. The Elephant in the Living Room: Make Television
Work for Your Kids. Emmaus, PA: Rodale; 2006
- Christakis DA, Zimmerman FJ, DiGiuseppe DL, McCarty CA. Early television exposure
and subsequent attentional problems in children. Pediatrics. 2004;113(4):708–713
Historically, insurers in Washington state covered a limited range of services for children diagnosed with autism, including mental health services and limited speech and occupational therapy. However, children are often denied coverage for one of the most successful intervention therapies for autism – applied behavior analysis (ABA).
ABA is a teaching methodology that applies specific behavioral intervention principles in a systematic, meaningful way to teach skills (like communication) to children with autism. It is widely accepted as a standard intervention for children with autism, and it benefits children across the autism spectrum. ABA is intensive – and expensive – sometimes requiring 10 to 25 hours of therapy a week.
“Some mental health diagnoses have parity status, which means they are recognized as equivalent to physical illnesses and cannot have annual or lifetime limits on treatment imposed,” says Dr. Mendy Minjarez, clinical psychologist at Seattle Children’s Autism Center. “Although autism is one of these diagnoses, insurers haven’t always provided the required coverage. Families are saying that’s not OK and have filed lawsuits to pass legislation that would mandate ABA coverage.”
Current status of ABA coverage
As of January 2013, ABA coverage is currently provided to children covered under Medicaid, Uniform Medical Plan (insurance for Washington state employees and their families administered by Regence Blue Shield), and Group Health Washington.
Providers who treat children with autism should follow the referral processes outlined below to obtain ABA coverage from these insurers:
Medicaid
- Requires a referral from an autism expert: psychologist, developmental pediatrician, psychiatrist, neurologist or nurse practitioner with autism training. Read more or email for more information.
Uniform Medical Plan
- Requires a referral from a general pediatrician, psychologist, developmental pediatrician, psychiatrist or neurologist. Call 888-849-3681. Learn more about requesting a preauthorization.
Group Health Washington
- Providers should call 888-767-4670 for benefits and eligibility information.
More change is likely coming. To stay current on ABA coverage for children with autism, visit the Washington Autism Alliance and Advocacy website.
You may also contact Seattle Children’s Autism Center with questions. Call 206-987-8080 or visit the autism center website.