Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Bob Underwood. Before we introduce our guest, I'd like to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and then click the CME button. Today, we have an expert in Developmental and Behavioral Pediatrics from Children's Mercy, Dr. Libby Milkovich. And we're going to be discussing this critical topic of screen time and its effect on pediatric mental health. Dr. Milkovich, welcome to the episode.

Libby Milkovich, MD: Well, thank you for having me. I'm very excited to be here.

Host: Yeah. This is really interesting and really pertinent stuff in today's day and age, I think. And you do a ton of work looking at the effects of media on kids. So from your clinical perspective, what's the most concerning mental health trend that you're seeing in children related to screen time?

Libby Milkovich, MD: For me, what I see clinically, what is most concerning is the dependency on screen time. I see that as young as one, two, three-year-olds that come in have difficulty self-regulating when they're away from their screen time.

Host: One to three years old, I mean, that seems really young.

Libby Milkovich, MD: It is really young, but it's a very complex system that encourages early exposure to screen time. And so, these early habits that we are seeing in young children often predict future use of screens. And so, by the time they're adolescents and they have their own smartphone, these habits are well-established.

Host: So, can you explain the neurological or behavioral mechanisms that are behind screen time effects on mood or attention that you see in children?

Libby Milkovich, MD: I think about it from a behavioral approach, since that's my expertise, I feel like screens impact mental health in three different ways. The first one is what we're most familiar with, is the exposure to negative content, whether it's cyberbullying or something traumatic, that can directly affect the way that you emotionally respond to technology. So, that's the one that we most commonly think about.

The second part is we're also squeezing out opportunities to have in-person interactions, physical activity, and sleep. So, activities that really promote our emotional well-being. So, that's really the second piece. And then the third is-- and this is why I love talking to parents of young children-- just like I talked about the very beginning, when there's early exposure to screens, children lose the opportunity to learn emotion regulation skills, social skills, executive functioning skills, all these things that we think about that are so important that is difficult to do when we spend a lot of time in front of a screen.

Host: I think that you're kind of giving us a scientific basis of what a lot of us observe in our day-to-day lives when it comes to screen time in kids. So, recent studies suggests that there may be a bi-directional relationship between screen use and emotional problems. So, can you unpack what that really means for parents and for providers?

Libby Milkovich, MD: So, I am part of the American Academy of Pediatrics Council and Communications and Media. And we are currently writing the new digital media policy, and we are really focusing and highlighting that. Because that is why we as a society struggle with thinking about how we use digital media or social media or gaming, because there is benefit, especially for some of those children that are most at risk.

Host: We all know that kids go through developmental stages. How do those stages influence a child's vulnerability to screen-related mental health issues?

Libby Milkovich, MD: This kind of relates back to the first question, because we all have different-- it's hard to be prescriptive when we talk about screen time. And I think we get confused because that same Digital Media Policy that I talked about before 2016, it said two hours of screen time or less. In today's world, that's not feasible. And so, how do we make recommendations that make sense, not only with differences between children, but between themselves as they develop because we respond differently to digital media when we were younger, like a young child versus when we are in elementary school, middle school? And then, when our brain's fully developed, that neural circuit that needs that immediate gratification, we can resist those temptations as we get a little bit older.

Host: So, what role does the type of screen content play? We kind of alluded to this a little bit earlier, in shaping outcomes. In other words, educational apps or video chats, are those less harmful than passive video watching or gaming? You kind of made mention to it before, but tell us some details behind that.

Libby Milkovich, MD: This is actually really fascinating. I feel like this is a great opportunity for pediatricians to guide parents on the type of content. There's some really fascinating studies where researchers have analyzed educational content in apps that are most popular in the educational app title. So, what I'm trying to say is that researchers looked at them and coded them for their quality and 90%, the vast majority, were very poor quality regarding educational apps. And so, that's very concerning when families think that they are trying to support their kids' education. And when I say poor quality, that means that they had lots of digital advertising, fast paced, loud, bright. So, it really triggers that need to continue use. They were more profit-centered design as opposed to child-centered design.

Host: Would you see a rating system coming out that is kind of like movies potentially that would help parents with guidance?

Libby Milkovich, MD: That would be incredible. This is exactly what we are trying to figure out as we write a digital media policy, is to make recommendations more concrete so that they can be transferred from clinician to parent to child. Because I think right now, when we talk about the research, it's very broad and abstract, but what does that mean for the clinic setting?

Host: Right. So based on this discussion, and we're talking about parents, what are some real practical strategies that you might recommend for families who are trying to manage that screen time in a way that supports mental and emotional well-being for the children?

Libby Milkovich, MD: I'm going to flip it a little bit, and what I really want to focus on is parent technology use. I wish there'd be some sort of education prenatally that families could get because what we know is that infants gravitate to what parents' attention is to, and that includes cell phones. So even in the infant stage, they are learning from their parents' modeling of technology behavior. Not only that, but it also truly interrupts that very important parent-child bonding that occurs in the infant stage. And then, these interruptions create what we call technoference or when technology interrupts in-person relationships, which decreases the quality of relationships, which then it's like just a ripple down effect, right?

And so, parent media use, I feel like is the number one thing that I want parents to hear is really focus on their own use because they are modeling it. And if they have high use, they're interrupting the development of their parent-child relationship, which then increases their own child's media use. So, that is the one thing that I want to highlight I feel like we were missing out on.

Host: Yeah. And so, it becomes almost a vicious cycle so that everybody's looking for that dopamine hit of the immediate gratification that you just spoke of.

Libby Milkovich, MD: Right. And often, we kind of went back to what are some positives of media use. I remember one of my research mentors was talking about, yes, we recognize that some parents use media in front of their young children, but it might be because they have to use their media to emotionally regulate and maybe that is better than them yelling at them or hitting them or something like that. So, there is that piece that we think about the benefit versus risk. But we also know that parents that use digital media for emotion regulation themselves are more likely to give digital media to their child to emotionally regulate too. And so, it's this kind of complex system that is not going to respond to pediatricians is saying two hours in media or less. So, we need to be more creative.

Host: Yeah. This positive feedback mechanism that becomes destructive in it's feedback mechanism. So looking ahead, what kind of research do you think that we need to be doing as we develop perhaps more policy changes? What's out there on the horizon for this?

Libby Milkovich, MD: Intervention development. That is where we are going. We clearly understand there's a bi-directional relationship between digital media exposure and mental health. What we don't know is how to support families in having a balanced media household. So, that is the piece that I feel like is missing, and I feel like that is what is going to be coming up, clear intervention to have positive outcomes.

Host: So as we close, this is I think affirmation to what a lot of people feel that they're seeing in children as it associates to media use. Anything else that you'd like to add as going away points for providers who may be listening in or parents?

Libby Milkovich, MD: I would hope that providers would come to families with curiosity. I recognize in myself that I have my own biases when I see young children on technology, but I come out of it with curiosity. Why are they having exposure to technology? And that way you can work collaboratively with a family as opposed to being judgmental or shameful, And how do you really support the family to think about ways to have alternatives than screen time to help their child regulate. That's my main message is just please be curious.

Host: Dr. Milkovich, thank you for being with us today. This is really important stuff.

Libby Milkovich, MD: Well, thank you for having me. It was a lot of fun.

Host: Absolutely. And as a reminder, please claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast and click the Claim CME button. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you, I'm your host, Dr. Bob Underwood. And this is Pediatrics in Practice, a CME podcast.