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Scott Webb (Host): Welcome to Checkup Chat with EvergreenHealth. I'm Scott Webb. And with screens dominating much of our lives these days with work, remote learning, social media, TV streaming, video games, you name it; it's difficult to know how much screen time might be too much for our children. And today we have Dr. Jeremiah Pamer joining us from EvergreenHealth Primary Care Redmond to help distill this information for all of us and provide expert tips on how to manage your child's screen time to support their optimal health, development and wellbeing. Dr. Pamer, thanks for joining me. Welcome. I wantedto talk today about screen time. Before we get rolling here, tell us a little bit about yourself.

Jeremiah Pamer, DO (Guest): Sure. My name's, Dr. Pamer and I'm a board certified family physician in the fine town of Redmond, Washington, just outside of Seattle. A brief background with me. Like so many of my peers kind of came later in life. In Portland, I had a small construction company. I was hoping to be a, you know, professional skateboarder for a while. And none of that really came to a place where it was going to move forward into a career and kind of in my mid twenties, I had this epiphany of maybe I shouldn't just be lifting heavy things for a living.

There were the seeds of becoming a doctor were planted. Not exactly as a revelationary as some people's, but here I am and I love it. And I love being a family doctor. And, that's a bit of my background.

Host: That's great. I thought you were going to say that it was all the skateboarding injuries that made you feel like, you know, I'd wonder how, how do you fix these things? You know, so it's great to learn more about you. You know, we're going to talk about screen time, which is a concern that all of us have for ourselves, for our children and I think just to get into the conversation here, want to talk about what really counts as screen time, right? So does the screen time refer to when a child is fully engaged and they're really locked on that screen, or could it be more passive when the screen's just kind of nearby? So let me give you an example here.

If you have a toddler that's playing on the floor in the living room and there's a television on, has the news, you know, obviously the toddler's probably not really enthralled and really watching the news, but does it count that they're near that screen? Does that really count as screen ?

Dr. Pamer: Yeah, that's a great question. And in our society, as screens continued to proliferate, I think it's just going to accelerate with time here. COVID notwithstanding, I definitely saw an acceleration just through screen time and screens in general. To answer the question directly, I think there could be an argument made that yes, it does count as screen time with a huge asterisk in that quality is really the driving factor of screen times and using the example of the you know a toddler playing on the floor, which is great. You know, playing with toys, tactile development, 3D toys, piling things up. This is all integral important for a child's development. I would say one of the things that kind of sticks out and maybe this isn't the driving force of the screen time element, but it is important.

And I think this is actually something important to all of us, is that advertising that'll come through on the screen while the news is on. I mean, it's a passive kind of intake with the toddler. And of course the parent is perhaps even more engaged and we can get into this more later, but the monetization of attention, especially children's I think is really important thing to be aware of.

And so in that specific case, well, yes, maybe screen time, not exactly the kind of thing that I think a parent should be overly concerned about. And we'll get into the details thereof, of what would be kind of screen time that would be more impactful or something that means to have more attention. So the direct answer there is, yes, I think it is screen time, but it's definitely not something that I want a parent to worry about. Especially as we're coming out of this pandemic where everybody's life has been turned upside down. I have a lot of parents who have a lot of, I guess, guilt for lack of a better word in how much screen time their children do have. And for that matter, they have guilt in terms of how much screen time they've exposed themselves to.

I mean, we're coming out of lockdown, of course, but, these have been big considerations and the driving force here is quality versus quantity and quality is truly the thing we're going to talk about most here with quantity being kind of a secondary concern.

Host: Yeah, I see what you mean and, and such an interesting way that you put that sort of the monetization of that screen time, right? Of our, of the attention of all of us, especially our kids with this sort of 360 advertising, we're just inundated everywhere you go. Tic Tok, Instagram, everywhere you look, there's ads and people trying to sell us things.

And we can talk more about that. I think that most of us, probably just want to know doctor, like what are the impacts the potential impacts in our children, as we think about, you know, sort of policing that and being like the phone cops in our homes, right? Why are we doing that? What's going to be the benefit for our children?

Dr. Pamer: My goodness. Yes. We could spend a lot of time talking about this and I'll try and summarize in a appropriate fashion. And thinking about younger kids, but this is not only the younger kids. I think the social and communication skills that come from a active communication in this case between parent and child or child and siblings, child and friends, whatever it may be, that's huge. And so, is impacted by the passive intake of basically one way communication, ie coming through a screen, things like sleep problems become an issue. Things like lower grades in school. And that I think is really related to the social and communication skills that suffer from this. Children are reading fewer books than they would in the past.

And there's, this is kind of a secondary consideration again, but eBooks versus good old fashioned paper books, which I'll admit I have a love affair with, but that's also a podcast for a different day. But, there is some evidence out there that actual paper books are more beneficial than e-books. Again, a different consideration, less time with family and friends to build social intelligence, social skills, bonding skills, the ability to make friends, the ability to exist in society, is impacted when we are inundated, especially at a young age with this one-way communication.

We're just not building the skills that honestly, in my opinion, for the entirety of humanity have just come second nature. We communicate with our child, and that's how the child learns to figure out who they are, learns how to interact with the world. And those first experiences sometimes are being compromised with excessive screen time. There's other things to be concerned about of course, we're kind of talking about the mental and perhaps, psychiatric concerns with screen time. But of course there is no doubt that a decrease in outdoor and physical activity is associated with increased screen time.

I see it with friends and family. I see it with my own patients. Weight problems can come with this. Obesity, which obviously I think a lot of us know leads to huge problems down the road in adults, heart disease, just poor health outcomes in general. I think while there's an argument to be made that mood problems, or perhaps even psychiatric problems can come with this as a young child.

There's definitely evidence in older children. This is definitely an issue. Poor self-image and body image issues can spring from these things. You had mentioned, Tik Tok, Instagram. Our children are just being inundated with these in essence, these not models in the fashion sense, but models in terms of behavior, you know how to function in the world. They're seeing and again, going back to perhaps time before screens or, you know, even before television, mass media, as we know it now, the models where people in their everyday life, family, friends, and now that sphere is so much wider and oftentimes parents have no idea what kind of influence their children are having and in that same facet, and then perhaps we'll get into this more later as well. But the bullying aspect, especially for older children. Oftentimes children, adolescents, teens are bullied over social media. That includes obviously screen time as a component there. And oftentimes they don't tell their parents that these kinds of things are happening.

And, there's some high profile cases out there in the recent past with even, you know, God forbid suicides and stuff like that. People just being bullied mercilessly. And so these are some of the larger problems, but I think you can really break it down between, you know, the physical aspects of less exercise and just being outside and playing around and the kind of mental developments, especially in our younger children. I think those are the two largest categories that we would look at.

Host: Yeah. And there's just so many layers to this. And I, I mentioned earlier, you know, I don't want to be the police. I don't want to be a phone cop and I'm still trying to figure out as I'm sure many parents are, when we think about trying to encourage healthy limits, what's our role in this as a monitor or chaperone or police, you know, how would you define our role in trying to promote those healthy habits? Those healthy limits.

Dr. Pamer: I always had this approach kind of having mercy on yourself, having grace for yourself. And that has become even much more apparent through the pandemic, you know, whether it's just any patient that I'm seeing on a given day, that's just, you know, dealing with the state of the world and struggling with that.

But specifically in this case, a parent who's struggling in their own right with childcare, with the COVID, with job situations. And now inflation, we can go on and on and we all have to have a good idea what's going on in our world and the struggles thereof. But having some mercy for yourself, a parent who reaches for a phone to sooth or placate a child who's near meltdown status, especially when they're out and about, grocery store, restaurant or in the doctor's office.

Is this the best practice to allow your child, especially young child to reach this and have them soothed by the no, it's not, but at the same time, most of us are all doing the best that we can and sometimes these things happen.

I understand that. So I just wanted to start with that in that parents, I just want them to have a little mercy for themselves. You know, here with the demographics at my clinic, a very tech savvy community, you know, we have all of these large tech companies and a lot of my patients work there in some capacity and they understand a lot of this stuff.

And when they reach for those phones, for the children, I think there's a lot of guilt there. But I think there is a model kind of moving into recommendations and what kind of role parents can have in the policing.

The Canadian Pediatric Association, they have a system called the four M's regarding screen time. And I have adopted this and I, and I appreciate this. So the four M's, first is minimize and what that means is the actual limitations of the screen time itself. And we'll get into that, what ages, how much and all that kinds of stuff. The next one is mitigate. And that kind of means mitigating potential exposures or the negative kind of media, disturbing media, whatever it may be with children and that means an active participant with the child. And perhaps if I were to pick one thing out of. All of the things we can talk about in terms of a parent's role, a guardian's role in their child's welfare, when it comes to screen time, it's being an active participant. This is beneficial in so many ways. Not only can you have a better grasp of what kind of content your child is consuming, especially as a young child, but even as a teenager, it can be very much difficult.

I imagine your 14 year old doesn't necessarily want to sit on the couch and watch Tik Tok with you. But at the same time, there may be some inroads that can be had. For younger children, educational and interactive content. This is one way to battle the passive reception of media, of entertainment, of the screen time. And there's evidence that shows, you know, this interactive content, especially in partnership with parents, can be just as beneficial as if you were playing, you know, a game of memory or something like that, or a board game. There's a lot of good stuff here. The third M is mindfulness, and this is fairly simple.

I think being mindful of the screens and the roles that they have in our life. Anecdotally myself, I grew up in a household where the TV was on pretty much morning to night. We had the TV on at dinner time, and I think it's worthwhile to mention that if there's one time to pick during the day with a child, with your family, having the dinner as a dedicated, no screen time, where the family reconnects and discusses and you know talks about their days, the struggles, the triumphs and everything in between. That's important. And that's an easy time to have as a family. There can be other times and places in the house that are dedicated against screen time. That's fine. But I think dinner is a, a common one that we all kind of have going for us in our families. The fourth one model, and this really gets to the heart of your question here. The parents modeling behavior, not only with screen time, but every single other behavior that a parent can have. Child's watching, that child is watching all the time. And they are soaking up that information and they're integrated into who they are as a person as well.

And that's tough. I think there's some guilt with some parents out there. And that goes to what I was saying before about kind of, you know, relaxing self-criticism, but that modeling is so important. It's not only with screen time, but just everything across the board, you know, how to respond to difficult situations, how you communicate, how you love one another, how you treat yourself, how you exercise, how you eat. Every single component of behavior is soaked up by that child. And think most of us know this, but it's worth repeating for sure. So those four Ms are just kind of a nice way to organize the overall view here, but specifically with the roles that a parents can have and screen time and their children.

Host: So let's talk a little bit about the most common questions or concerns that you get. And we've covered a lot of territory already today, but when parents are coming in, whether their children are in the room or not, what kinds of things are they saying to you or questions, are they asking?

Dr. Pamer: Sure. A lot of times it's a question regarding, you know, how much time can my child spend in front of the screen. I want to know the hours, the minutes, the seconds. I want the details. And that's just a really impossible question to answer. To be fair though there are some actual solid recommendations.

Interestingly enough, the AAP, which is the American Association of Pediatrics, they had some updated screen guidelines recently, since the start of the pandemic. And I thought this was really interesting. I wanted to touch base on this really quick. Previous recommendations were pretty solid below two no screen time, from two to five, less than an hour and a half, above five, kind of a case by case situation, but definitely decreased and encourage activity and all that kind of stuff.

They actually updated this a little bit. They're saying now below 18 months, they're recommending no active screen time. And of course, that example that we talked about at the beginning with the toddler playing on the floor and the screen in the background or the TV, the news, or something like that in this case, this isn't really counting.

And they added one specific caveat that I think is worth pointing out that screen time with a conversation, whether it's a parent, that's away like a Skype or a video call or a Zoom call or something like that, they don't want to count that as screen time. That's active, two-way participant communication. And I think that's an important distinction, especially as technology advances in our society. This is an important distinction. And also, I think this probably goes without saying, but I'll mention it anyways, that when you're taking online classes, when you're taking schooling from home, that shouldn't count as screen time either.

I've had a couple patients' parents and children kind of tell me that when they were so plugged in from having school from home, interestingly enough, the other types of screen time decreased a little bit, they were after eight hours of being in front of the computer with school, they were ready to go outside and get some exercise.

And that's reassuring a little bit to me. From 18 to 24 months, going back to the AAP new recommendations, they are recommending to choose quality apps preferably together. This goes back to the second M that I was just talking about, that watching with children, that active participation, the two way communication, the interactive apps, you know, those things are okay. From two to five years, the recommendations are less than one hour per day. That's reasonable, after that, it is kind of a case by case with hopefully limiting and trying to make sure that your children are exposed to other stuff. And the other questions that I get are, what kind of impact will these screens have as we get older or even immediately on development.

And we touched on that a little bit. And it just kinda makes me ponder what things will be like in the future when you actually grow up with the personal devices, cell phones, iPads, what have you. And I think there's a lot of questions left to be answered. And so when I say speak to patients, parents specifically about these kinds of concerns, it kind of goes back to the first things that I was talking about with development issues, with physical fitness issues.

And pondering, what kind of things can happen from this that we may not see coming in the future? I think there's an argument that made that there's going to be somewhat of a backlash, I think, as a society against having screens so embedded in our lives. But this is more of a personal opinion, that's not necessarily my doctor opinion. But I think that's a possibility. I think that there may be some good things that come from this that we may not yet understand, but I also think that there's probably some negative aspects that we have yet to understand too.

Host: Yeah, I think you're right. I remember seeing this Frontline program years ago, I think it was called Digital Nation. And I'm sure there's a lot of research and literature that maybe you could share with folks like parents. Where can people turn to learn more about this, to read about current research so that we can just do the best by ourselves and our kids.

Dr. Pamer: Yeah, I think there's two good resources out there that I recommend part of it, I reviewed for even this podcast, but also I've gone there before for resources when it comes to pediatric care. The AAP, the American Association of Pediatrics, they have a healthychildren.org., that's part of their website, but is a subset of the AAP overall website.

And there's a lot of good resources there, screen time and so much other stuff too. Another good thing that I recommend when it comes to thinking about the content and the type of media that our children are consuming and Common Sense Media, they have what seem fairly comprehensive, but also good ratings for the media. There's a lot of stuff out there. A Google search, will brings so much up, but I think those two are very solid. I think the information is comprehensive. It's backed by science and they do a good job in updating things as well if new recommendations come out, those are two good resources that I recommend.

Host: As we close here, what would be your final thoughts and takeaways for parents who are maybe spending a little too much time on their phones themselves? And they are trying to sort that out for themselves, trying to be good models for our kids, trying to look out for them. What would be your best advice? I'm sure one thing is just to allow ourselves a little bit of grace and forgive ourselves a little bit for being human. But in your words, what are your takeaways, doctor?

Dr. Pamer: Absolutely. In addition to, like you said, having grace and mercy for ourselves, it's being an active participant in our child's life. Not only for screen time, but absolutely every aspect. I mean, that I think is important. And being an active participant in our child's lives, their screen time, and their consumption of media will help the parents with their own consumption. Everything kind of falls in line when that is a driving component of raising a child. Being an active participant, knowing who they are, getting to know them, loving them, being there for them, talking to them, talking through things.

Everything starts from there that is the fountain head. And that would be my final word on this.

Host: It's great. Well, I have appreciated this conversation. As I'm sure listeners did. So educational and fun and so much we covered and so much more we could cover and you gave us some great resources. So doctor, thanks so much and you stay well.

Dr. Pamer: My pleasure. Thanks for having me.

Host: And to find a primary care partner, to care for your family through every season of life, visit evergreenhealth.com/primary-care. Please remember to subscribe, rate and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.