Michael Rich, MD, MPH

Michael Rich, MD, MPH, is Children’s Hospital Boston’s media expert and director of Children’s Center on Media and Child Health. Take a look at his blog archive or follow him on Twitter @CMCH_Boston

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®

By Kristelle Lavallee, staff member at Boston Children’s Hospital’s Center on Media and Child Health

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.

Clearly the MPAA has a lot of power in terms of how many people will be able to see a film, but who really applies these standards, and what criteria do they use?

The MPAA is made up of six major American movie studios and serves as the “voice and advocate” for the film and television industry. That means the MPAA is the tool that media producers use to govern themselves and represent their interests to the government and public. Since 1968, the MPAA has assigned movie ratings, which it claims “exists to give parents clear, concise information about a film’s content, in order to help them determine whether a movie is suitable for their children.”

Movie poster for the film Bully

Sounds like a useful tool. But it is important to remember that the primary goals of the MPAA studios are to protect their movies from external restrictions and to attract as many ticket buyers as possible. The MPAA decides the criteria on which ratings decisions are made, chooses the members of the ratings board, and administers the ratings in partnership with the National Association of Theater Owners, many of whom will not show any film that is unrated.

So who does the MPAA employ to make these decisions? Parents. Film ratings are not assigned by child psychologists, educators, pediatricians, or anyone with child development credentials, but by a full-time board of eight to 13 parents whose only qualifying credential is that they have at least one child between the age of 5 and 17. (And even that is loosely applied—for an in-depth look at the ratings process, see the documentary This Film is Not Yet Rated.)

According to the MPAA, the job of the ratings board is to “reflect what they believe would be the majority view of their fellow American parents in assigning a rating to a film.” In short, our film ratings are determined by the opinions of a few parents on what their peers will find socially acceptable.

But research has shown that this system has been inconsistent. For example, one study found that the amount of violent content allowed in PG-13 rated films significantly increased from the late 1980s until the mid 2000s, resulting in a shift of one full rating level every 11 years. Both this and other studies concluded that child development and health care professionals should participate in assigning ratings, so the decision-making can combine parental opinions with research-based guidance.

Since each child will interpret and react to on-screen action differently, parental input about what is and isn’t best for children to see is still essential. A film like Bully may be considered R material by the MPAA, but can be accepted, even embraced by parents who understand the film’s important message. At the same time, despite the MPAA’s reassurance that viewing does not require adult supervision, The Hunger Games story of children being forced to kill other children may be too potent for young viewers, even those that have read the book. These nuances aren’t captured by ratings.

For that reason, the ratings system can be used, at best, as a starting point—and then parents can take into account the individual child, media content and expert advice to help them choose what to share with their children.

Update added after original publishing:

On April 5^th, The Weinstein Company announced that the documentary, Bully, will be released with a PG-13 rating. The announcement follows an agreement that Weinstein Co. made with the MPAA to re-cut the film. As a result, Bully editors removed the audio on three obscenities, however, the controversial school bus scene that features three F-words (uttered by children) remained untouched. The new cut of Bully makes the film an exception to the MPAA’S standard of giving an R rating to any film that features the F-word more than twice.

The new PG-13 rated version of Bully allows all children to see the film without an adult. The rated version will also be shown in most major theater chains, which typically have policies against showing unrated movies.  Bully opens nationwide on April 13^th.

For other helpful resources on making these choices, please visit the Center on Media and Child Health at: http://www.cmch.tv/

You can also ask Children’s Hospital Boston’s own ‘Mediatrician’ at: www.askthemediatrician.org

For useful parent-friendly film reviews, try: http://www.commonsensemedia.org/movie-reviews/

Scene from The Hunger Games movie

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.

Michael Rich, MD, MPH

“[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.’’

It may seem counter intuitive that a child who is ready for a book might not be ready for the movie version of the same story. But, as mentioned in one of Rich’s past Ask the Mediatrician posts, books and movies have very different ways of creating worlds. When we read a book, our minds generate the details that are described there—and young readers will imagine only what their brains are ready for. But movies provide all those details for them, which means that a child watching a movie may be exposed to images and sounds for which they are not prepared.

In addition, reading allows children to set their own pace with the story. If it becomes too intense, they can take breaks or even skip over sections. In a movie—especially in a theater—it’s hard to get space from the intensity. The scary parts may be scarier on the big screen, especially because it’s harder to escape them.

If you’re unsure about whether your child is prepared to see The Hunger Games, watch it without her first, and see what you think. As a parent, you know your child best: If you think it will be too intense for her, have her wait to see it.

Are you letting your pre teen see The Hunger Games this weekend? Why or why not? We’d love to hear your thoughts on how appropriate the movie is for younger viewers. Let us know via twitter: @ThrivingKids or on our Facebook page.

For more information about how media affects children, please visit Boston’s Center on Media and Child Health. If you have a media related question you’d like to ask Dr. Rich, send an email to cmch@childrens.harvard.edu or click here.

Michael Rich, MD, MPH

Michael Rich, MD, MPH, is Children’s Hospital Boston’s media expert and director of Children’s Center on Media and Child Health. Take a look at his blog archive or follow him on Twitter @CMCH_Boston

Q: I have an son who’s 11 and a daughter who’s 9½, and for many years, they have sat close to the TV when watching. I have asked them to sit farther away, and they do move back maybe a foot…but they always go back to viewing the show close up, even if the screen is a 40” color flat screen. Any studies that show why? Any concerns? My wife and I sit 8 to 10 feet from the TV.
-Up Close and Personal, in Rochester Hills, MI

A: Dear Up Close,

Concern about sitting close to TV screens, like concern about reading in low light, is founded more on what our parents told us when we were little than on research. The worries about sitting close dates from the (not so long ago) time when TVs were actually “tubes”—cathode ray tubes, that is—and people were uncertain about how the cathode radiation emitted might affect a viewer’s eyes. Today’s TVs flatscreens only emit the light you see, which removes that concern. And there’s no evidence that sitting close to either kind of screen hurts your eyes.

That said, the fact that your children sit so close to the TV may be a sign that they are near-sighted and that this distance is where they best resolve the pixels of color, light, and darkness into a coherent image. Bring them in for an eye exam to see whether they need glasses.

If their eyes are fine, then they probably sit close because they like having the screen fill their peripheral vision. That shouldn’t cause any problems. Just make sure that they aren’t staring at screens all the time—that can cause eye strain and, of course, will take time away from all of the other activities they need to accomplish in a day to be happy and healthy.

Enjoy your media and use them wisely,
The Mediatrician®

Q: My seven-year-old daughter loves movies, and there are many 3D movies geared toward kids this holiday season—Arthur Christmas, Happy Feet 2, Hugo, Puss in Boots, and The Muppets. But when my friend took her to see Puss in Boots, which opens with snow falling, the 3-D snow really freaked my daughter out, and she refused to put the glasses back on the remainder of the film. Is this something she will grow out of? What should I do?
-Multidimensional in Atlanta, GA

A: Dear Multidimensional,

These movies can be exciting and fun—for some viewers. The 3D effect that is so engaging demands that our eyes and brains combine two artificially created 2D images into a single 3D image. This is much harder for the brain to do than it is to visually process objects that actually have three dimensions, like snow falling in real life. This processing uses parts of the brain that do not fully develop until the mid-20s (although even adults can develop eyestrain, headaches, and even nausea from watching 3D movies).

Michael Rich, MD, MPH

Because her brain is not fully mature, doing this work may be really uncomfortable for your daughter. It may also feel overwhelming to be “surrounded” by the movie, especially when it gets loud or scary. That’s part of what a lot of people like about 3D, but it isn’t enjoyable for everyone.

The fact that she took off the glasses and refused to put them back on actually sounds like a good thing: She’s taking care of herself. She’s determining for herself what feels good, and adjusting what she can to make herself comfortable. Those are good skills for a seven year old—or anyone—to have.

So even though your daughter may grow out of any physical discomfort with 3D, follow her lead. It’s not important for her to feel comfortable with or even like 3D. If you want to bring her to a movie, take a look at some reviews to make sure the content is right for her, and then watch it in 2D (which you can usually do in the same cineplex where it’s showing in 3D). After all, if she’s not enjoying the movie, her time—and yours—is definitely better spent elsewhere.

Enjoy your media and use them wisely,
The Mediatrician®

Michael Rich, MD, MPH

Michael Rich, MD, MPH, is Children’s Hospital Boston’s media expert and director of Children’s Center on Media and Child Health. Take a look at his blog archive or follow him on Twitter @CMCH_Boston

Q: We have a 16-year-old daughter and a 14-year-old son who are at the same school. They have voluntarily given up Facebook because of the time drain it can be, and both have fairly heavy academic loads. They are interested in starting a blog together. What are the pros and cons?
-Benefits of Blogging in Roseville, CA

A: Dear Benefits,

What a great way for adolescent siblings to connect and use their creativity together! This kind of self-expression that can be incredibly powerful—even therapeutic—for teens pursuing the developmental tasks of finding themselves and connecting with their peers. But it can also be as much of a time sink as Facebook. To help them focus their efforts and make the time they spend on this project rewarding and positive, ask your teens these questions:

“What is the mission of your blog?” Do they want their blog to focus on sports, or music, or issues in their school, or what it’s like to be a teenager? Maybe they want to offer their different age, grade level, and gender perspectives on issues that interest them both. Having a vision and mission will help them focus their blog, limit the time they spend updating it, and create a unique niche in the blogosphere that will draw readers.

“Who is your audience?” Knowing who they’d like to have read and respond to their blog will help them focus their posts. They should choose what they write with an understanding that the blog will be accessible and interesting to many people—like teachers, coaches, grandparents, friends, and crushes—and not just to their intended audience.

“How will you handle comments?” Blog comments can lead to productive, exciting conversation, but they can also be a breeding ground for gossip and attacks. If your teens want to allow comments on their blog, encourage them make themselves moderators of the comments, so that no comment actually posts without their approval. That can help them create a space for thoughtful, responsible, useful communication—and prevent the bullying behaviors that could occur there.

Enjoy your media and use them wisely,
The Mediatrician®

Michael Rich, MD, MPH

Michael Rich, MD, MPH, is Children’s Hospital Boston’s media expert and director of Children’s Center on Media and Child Health. Take a look at his blog archive or follow him on Twitter @CMCH_Boston

Q:My father-in-law bonds with my 4-year-old son by playing video games. Recently, he bought a LEGO pirates game, rated for 10 year olds, and the two play it for about an hour every time they see each other. I love that they spend time together, but since they started playing this game, my son has become more violent. My father-in-law doesn’t see the problem, even though I’ve tried talking with him about it. Is there research that might help convince him to choose other bonding activities?

-Baffled over bonding in Palo Alto, CA

A: Dear Baffled,

You know your child better than anyone else, so you are most sensitive to a change in his behavior—and you are in the best position to guide him toward the person you want him to become.

Research agrees with your observations, showing that video games are excellent tools for teaching whatever they focus on. They can teach players to build a city—or to see violent acts as okay, as may be true in your son’s case. The fact that these games are such good teachers might help explain why research has linked playing violent ones with increased aggressive behavior, increased attention problems, and decreased helping behaviors.

Thus, there are good reasons to help your father-in-law shift how he connects with your son. First, point out the important role he plays in your son’s life—because he is a trusted and loved role model, your son will see anything he brings as something he endorses. So if he wants to connect through video games, encourage him to choose games that offer information and skills that he wants his grandson to have. And don’t rely on the age recommendations on the labels—researchshows that games are often rated by the industry ratings as less violent than they actually are. Instead, look at parent-oriented reviews  for ideas.

Finally, encourage your father-in-law to connect with his grandson through creative, hands-on activities like playing with real building blocks and developing stories about them together. Such imaginative, open-ended play is a great way to build your 4 year old’s brain, and it’s a great way for him to connect with his grandfather.

Enjoy your media and use them wisely,
The Mediatrician®

Michael Rich, MD, MPH

Michael Rich, MD, MPH, is Children’s Hospital Boston’s media expert and director of Children’s Center on Media and Child Health. Take a look at his blog archive or follow him on Twitter @CMCH_Boston

On Monday, the American Academy of Pediatrics came out with a revised policy on media for kids two and younger. The recommendations for this age group are much the same as they were in 1999—that it is best for their developing brains and bodies to avoid both screen use (such as placing a toddler in front of a TV or video) and background media (such as leaving the TV on in the same room where a baby is playing)—but there is new scientific evidence to support these recommendations. An infant’s brain triples in volume in the first two years of life and research suggests that brain development during that time can benefit the most from:

We already knew that newborn brains develop in response to whatever is in their environment. New research from the past 12 years suggests that interacting with people, exploring the physical world (like stacking blocks or “reading” board books), and playing in open-ended ways are great for that development. And no matter how “educational” their content, screen media can’t provide that kind of environment.

That said, screen media aren’t toxic for babies—they’re just not really what they need. And other kinds of media, like music and books, can be great for kids of this age group. The updated AAP policy statement also recognizes that there are good screen media options for preschoolers, whose brains have developed to the point where they can learn from electronic screens.

The reality, of course, is that sometimes you just need get the laundry done or get dinner on the table, so you need a way to occupy your baby or toddler. While you’re taking care of the business of life, try some of these non-screen activities that can occupy and optimize their brain development:

• When you need to make dinner, hand your toddler 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 your child wash a baby doll.
• When you need to fold laundry, have her help by picking out all the socks and put them in a pile, or “fold” washcloths.

As your child grows older and becomes ready to benefit from screen media, here are some ideas on ways to manage it wisely.

Enjoy your media and use them wisely, The Mediatrician®