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Friday, May 31, 2013

A Better Way to Treat Anxiety

From The Wall Street Journal Blog "The Informed Patient"

By Laura Leandro
May 27, 2013

For Teens, Therapy Turns Parents Into 'Exposure Coaches,' Not Protectors.

Getting up the nerve to order in a coffee shop used to be difficult for 16-year-old Georgiann Steely. Speaking in front of classmates was unthinkable.

New approaches to parenting children and teens with anxiety
disorders and helping them overcome social anxiety.
Informed Patient columnist Laura Landro looks at
how new behavioral therapy is helping teens,
and advice for parents on how to maintain progress.

The high-school sophomore overcame a crippling case of social anxiety as a patient in the Child and Adolescent Anxiety Disorders program at the Mayo Clinic in Rochester, Minn. Therapists there use an innovative approach early in treatment, gradually exposing children to things they fear most and teaching parents to act as "exposure coaches" rather than enable their children to avoid things and situations as a protective measure.

Georgiann Steely, 16, is developing confidence
doing things she once would have avoided,
such as ordering in a coffee shop.

When parents help children to escape from feared situations, anxiety symptoms may worsen and children frequently become more impaired, says Stephen Whiteside, a Mayo pediatric psychologist.

"Kids who avoid fearful situations don't have the opportunity to face their fears and don't learn that their fears are manageable," he says.

Anxiety disorders, comprising a dozen diagnoses including phobias and obsessive-compulsive disorder, are among the most common mental health issue in youth yet they often go undetected or untreated, experts say. They can prevent a child or teen from developing skills necessary for success later in life.

Ms. Steely plays the violin in public.

According to a report released by the Centers for Disease Control and Prevention last week, about 1.8 million children under 18 currently have anxiety disorders. Some studies suggest as many as 10% of children suffer from phobias.

There are many external reasons for a child to experience anxiety, such as bullying at school or problems at home, and it is important to assess if such factors are to blame rather than "just stressing personal coping strategies," says Howard Adelman, a psychologist and co-director of the Center for Mental Health in Schools at the University of California, Los Angeles.

But unlike the normal fears of childhood, or the shyness and insecurities of teen angst, anxiety disorders are extreme and don't subside with time. They can significantly impair a child's ability to function, according to Thomas Ollendick, director of the Child Study Center at Virginia Polytechnic Institute and State University.

Ms. Steely and her parents, Stan and Amy,
took part in a Mayo Clinic program that helps
teens overcome fear in anxiety-causing
situations with parents acting as coaches.

Children and teens with anxiety disorders don't recognize their fears as unreasonable and may have physical symptoms like stomachache and headache. They may suffer from chronic, excessive worry about school, social interactions, health and safety, and world events.

Some children with anxiety also suffer from depression, and medications may be prescribed to help with both. Mental-health professionals have also relied on cognitive behavioral therapy, which focuses on anxiety-management and relaxation skills to help children control their own physical responses to anxiety. Other customary treatments include "cognitive restructuring," which includes positive thinking, weighing evidence for and against their fears and creating a coping plan for feared situations. Typically, when exposure therapy has been used, it is usually introduced later in treatment.

But researchers at Mayo, Virginia Tech and other institutions are finding that slowly exposing children to the things they are anxious about, at an early point in treatment, can be highly effective in helping them overcome anxiety. Sometimes, it doesn't require a long course of therapy.

Dr. Ollendick developed an intensive three-hour session to help children overcome phobias such as riding in elevators or encountering a dog. His intensive approach has been shown to be more effective than treatments that emphasize education about phobias but not exposure to a feared object or situation. Therapists work with parents to reinforce and maintain what the child has learned and to schedule follow-up calls.

In addition to its regular anxiety clinics, Mayo offers intensive one-week sessions for patients who don't live locally. Dr. Whiteside is currently conducting a study evaluating the effectiveness of six sessions of parent-assisted exposure therapy.

He measures avoidance behaviors in both parents and children with questionnaires that ask parents, for example, "When your child is scared or worried about something, does he try to get away from it?" Children are asked to describe their habits, such as, "When I feel scared or worried about something I try not to go near it."

A study led by Dr. Whiteside and published in March in the journal Behavior Therapy showed that when children were slowly exposed to situations that caused fear, their parents' avoidance scores on questionnaires declined by half. Dr. Whiteside also developed a mobile app, the Anxiety Coach, which helps patients learn about anxiety, manage symptoms and make lists of activities to help them face their fears.

The gradual-exposure principles are part of the program that helped Georgiann Steely at Mayo's teen clinic. Georgiann has struggled with depression since the eighth grade and she was treated with medication. But she also seemed painfully shy, avoiding parties and gatherings of friends. Her mother, Amy, says she worried that her daughter "wasn't participating in her own life."

The Steely family was part of a random sample of Rochester residents invited to participate in research Dr. Whiteside was conducting to develop anxiety questionnaires. Mrs. Steely says even after filling out survey questions about how she reacted when her daughter tried to avoid situations, "I didn't make the connection that our stepping in and making accommodations for Georgiann could increase anxiety."

"I knew I was an overprotective Mom, but I had my reasons," she adds. She and she husband, Stan, who works as a nurse in an infusion clinic at Mayo, "thought we were helping by keeping her stress level down."

When Georgiann's depression took a turn for the worse a year ago, the family doctor steered them to Mayo's teen clinic. As part of her initial evaluation "they picked up on her anxiety right away," Mrs. Steely says.

Therapist Michael Tiede worked with Georgiann in group sessions and one on one to help her gradually do things she was afraid of and, as she says, "put myself out there." Mr. Tiede and Georgiann say she shared her goals with the group each week, whether it was agreeing to meet friends at the mall, joining in a conversation or even just wearing her hair differently one day to see that it wouldn't attract undue attention.

"It builds momentum and they do the next thing, and the next thing, and then it is not so hard anymore," Mr. Tiede says.

Recently, a friend asked Georgiann to participate in a school program to help students become more compassionate and stop bullying. She agreed to speak about her struggle with depression at a school assembly along with others sharing tough experiences. Another milestone: she played her violin in an ensemble performance with musicians she didn't know.

Georgiann says she is thinking about becoming a counselor herself someday. Mrs. Steele says the family learned to "provide support while she steps out and challenges herself."

"Every day I am astounded at how far she has come," she adds. "It's like having a different kid."

Thursday, May 30, 2013

Summer Study Skills Workshop at Landmark


"We know that strong study skills are essential to experiencing success in school."
Lauren Michaud, Director of Skills+ Program
Students who need to improve their study skills should consider Landmark School's Skills+ program this summer.
The Skills+ program (July 29 - August 9) is designed for middle and high school students to improve their study skills, succeed in school, and gain independence and confidence.
Landmark's team of Skills+ teachers understand the importance of strong and reliable study skills. Our two-week, half-day program will give students a toolkit of realistic, proven methods to manage time, materials, and information. Students will learn to plan and prioritize, create routines, set goals, focus and sustain attention, read more actively, improve writing skills and so much more...

Learn more about Skills+ at www.landmarkschool.org/skillsplus
or call us at 978-236-3209
Students who require more remedial and individualized instruction are encouraged to inquire about the full range of programs at the Landmark School. 978-236-3000.

Wednesday, May 29, 2013

Teaching Children With ADHD: Classroom Strategies To Engage The Easily Distracted

From informED by Open Colleges

By Laura Reynolds
May 23, 2013

There seems to be one in almost every classroom. That student that just can’t get it together. Maybe it’s the homework that never gets turned in or the desk that resembles a pigpen. Possibly the student is disruptive, blurting out inappropriate remarks or just can’t stop tapping her pencil even when you have asked her a million times to stop.

As teachers, we know its normal for students to forget their homework or daydream and get fidgety from time to time. But how do we distinguish between “normal” kid behavior and ADHD behavior? Are we too quick to diagnose and medicate in hopes that these behaviors simply disappear?

Is ADHD being over diagnosed when kids are just really being kids? And if it really is ADHD, how do we accommodate these students so they succeed in our classroom?

The 3 Sub-Types of ADHD

Here are a few facts to consider about ADHD, also known as Attention Deficit Hyperactivity Disorder:
  • ADHD is the most commonly studied and diagnosed psychiatric disorder in children. It is considered a neurobehavioral developmental disorder.
  • ADHD affects approximately 3-7% of all children globally with symptoms typically presenting before the age of 7.
  • Boys are 2 to 4 times more likely than girls to be diagnosed with ADHD.
  • Scientists are not sure exactly what causes ADHD, although many studies suggest that genetics and brain chemistry play a large role. It is thought that ADHD may result from a combination of factors including genetics, brain injuries, nutrition, environmental factors and/or social influences. (NIMH, National Institute of Mental Health).

To make the disorder even more confounding, ADHD has three subtypes according to the DSM-IV. A child who is diagnosed with ADHD will fall into one of the following categories:

ADHD- Predominantly Inattentive (also known as ADD)

A child with this diagnoses presents symptoms that are more inattentive in nature. They are easily distracted, forgetful, have trouble with organizing and completing a task, become bored easily, struggle to follow directions, have difficulty focusing on one thing, daydream and/or have trouble completing or turning in homework assignments.

Children with this subtype are less likely to act out or have difficulties getting along with other kids. In fact, they tend to be very quiet and are often overlooked. Parents and teachers may not notice that he or she has ADHD.

ADHD- Predominantly Hyperactive-Impulsive

Students who are diagnosed with this type of ADHD may display symptoms such as talking nonstop, fidgeting and squirming in their seats, having difficulty doing quiet tasks, are very impatient, blurt out inappropriate comments and act without regard for consequences.

ADHD- Combined Hyperactive-Impulsive and Inattentive

These students have the symptoms of hyperactivity, impulsivity and inattention. Most children who are diagnosed with ADHD fall into this category.
Diagnosing ADHD Is Not a Simple, Single Event

ADHD, and other mental illnesses, do not allow for a blood test to provide a definitive diagnoses. Instead, diagnosing the disorder is based upon the observations of the student by parents, teachers and other caregivers.

Questionnaires regarding behaviors in the classroom and at home help a mental health professional or doctor determine if a child is indeed suffering from the disorder. Professionals also look at how long the symptoms have been present and whether the behaviors are excessive or not age appropriate.

What To Do As Teachers and Parents If We Suspect ADHD?

Erin’s son, Matt, started having trouble once he began Kindergarten. He was placed on a behavior chart for inattentive behaviors. Every year, Erin would get the same email from his teacher. “Matt has trouble focusing, so we are going to start him on a behavior chart.” Erin became so sick of the smiley face, frown face chart, as they just didn’t seem to work.

Matt’s 3rd grade teacher realized that his inattentive behaviors were something that Matt couldn’t help, so she asked if she could have him observed by the Vice Principal. From there, Erin and Matt saw his pediatrician who suggested a psychologist for a diagnosis as well.

Once Matt was officially diagnosed with ADHD-Inattentive type, Erin and the school professionals wrote a 504 Plan. Erin honestly didn’t think it worked well, if at all, because the teacher didn’t follow it. She was not a good communicator, and didn’t check Matt’s backpack, as what was written in the plan.

At home, Erin tried a no sugar diet and found that didn’t help either. What does help is making sure to check Matt’s backpack every night and talking to him about school, pointing out the positives. Erin also has Matt repeat back to her directions given at home.

After about 10 months and no success using the 504 Plan, Erin decided to start Matt on ADHD medicine. Matt began on a low dose and the teacher reported seeing a difference right away, much more participation, attention and interest in math. Matt takes a low dose in the morning with the school nurse on the days he is at school. There has been a real positive change in Matt since beginning the medicine.

Is ADHD Over Diagnosed?

Are we too quick to label a student as ADHD just because he can’t sit still or because a student’s grades are slipping? A recent study conducted by the CDC (Center for Disease Control) showed that 11% of school-age children in the United States have received a diagnosis of ADHD.

What has alarmed many is that in which the rate has climbed. According to the study, the rate has skyrocketed 16% since 2007. The rise was most dramatic among boys, with an estimated 1 in 5 boys of high school age diagnosed with ADHD.

Like most mental health disorders, ADHD is not black and white. It is a perplexing condition that can affect the academic and social lives of affected children, possibly into adulthood. A point to consider about rising rates of ADHD: Family doctors, who aren’t always adequately trained in providing the detailed evaluation that a reliable diagnosis requires, are diagnosing many children with ADHD when there really may be another condition going on, or in fact, nothing at all.

This problem may lie in the detail that doctors are required to sort out a very complex condition in a short amount of time. Just because a child is showing a few symptoms does not necessarily point to a positive diagnosis. The symptoms must be present every day for a long period of time and must lead to an impairment on the child’s life.

20 Ways To Support Students With ADHD

Regardless of the how’s and why’s of ADHD, as teachers it is vital that we support our students on their academic journey. How do we support parents and students who are affected by ADHD?

1.) Learn about which subtype of ADHD the student has been diagnosed with. Get to know the individual student and be mindful of his or her uniqueness.

2.) Seat the student away from doors and windows that may distract him or her. The student may work best closest to the teacher.

3.) Allow physical activity breaks (stretching) and incorporate movement activities into a lesson. If possible, allow for outdoor instruction time.

4.) When possible, provide academic instruction to these students with ADHD in the morning. Evidence suggests that on-task behaviors of a student with ADHD worsen over the course of a day.

5.) Write important information down where the student can easily reference it, most likely at their desk.

6.) Divide large assignments into small segments. Write these segments down. Have the student cross the items off as they are completed.

7.) Provide frequent breaks for the student, to get a drink or walk around the room.

8.) Allow the student with ADHD to run errands for you (take a note to the office), or have them be in charge of sharpening the classroom pencils.

9.) Provide the student with a stress ball or other object for the student to play with discreetly at their seat, especially when they need a break.

10.) Write the schedule of the day on the student’s desk and allow him or her to cross off each item as it is completed.

11.) Recognize and praise aloud all good behaviors. Be specific in what the student is doing correctly.

12.) Provide an assignment book for the student to keep track of homework and daily work.

13.) Encourage this book to be signed by parents so parents know what is going on in the classroom. Communicate with the parent as much as possible.

14.) Form small groups for students with ADHD to work in so as not to get distracted and lost in a large group.

15. ) Allow the student with ADHD to work in a quiet zone within the classroom. This should be a place in the room that is quiet and free from visual stimulation.

16.) Establish a secret signal with the student to use as a reminder when he or she is off task.

17.) When giving directions, make eye contact with the student and be as brief as possible.

18.) Use visuals. Highlight words in colored chalk or bright ink. Underline and circle important things to remember.

19.) Use auditory cues. Set a timer and encourage the student to work uninterrupted until the timer goes off. Allow the student a break following the work period.

20.) Provide specific, well-defined rules to the student with ADHD. Write these rules down and tape them to the student’s desk. These rules should have clear consequences.

Most importantly, students need guidance, compassion and understanding from their parents and teachers as they navigate the path of dealing with ADHD. It isn’t their fault that they have been diagnosed with ADHD.

Laura Reynolds is a former fourth grade teacher with a Masters degree in Education from Drake University and a BA degree in Psychology from the University of Iowa. She currently works as an education consultant and curriculum writer. Find her on Twitter @laurareynolds75 and Google+.

Monday, May 27, 2013

Guest Post: DSM-V and Special Education

From Special Education Today

By Robert Crabtree, Esq.
May 24, 2013

As has been widely publicized and discussed, the American Psychiatric Association (APA) has recently issued a revised version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a book sometimes termed a “bible” for mental health professionals. The manual might better be called a dictionary, as it aims to provide a vocabulary established by general (though not unanimous) agreement among mental health professionals so that they can productively discuss how best to help people who exhibit disabling emotional and/or intellectual conditions.

The diagnostic labels and the lists of elements for each that appear in the manual are the product of votes taken at general conclaves held, often decades apart, by the APA after recommendations are made by committees assigned to explore current research and experience around specified types of emotional and/or intellectual dysfunction. As its authors would be the first to admit, the DSM’s resulting diagnostic categories and constituent elements are far from perfect and, while intended as a tool to help clinicians, should be used with skepticism and with a heavy dose of direct and personal clinical judgment.

The introduction to the current version of the manual, the DSM-IV, cautions users (as the new DSM-V will presumably also do) that they should treat the diagnostic criteria and definitions of disorders as “guidelines to be informed by clinical judgment … not to be used in a cookbook fashion.”

Clinicians are advised that their observation and clinical judgment may warrant the application of a diagnosis even if the subject’s symptoms do not meet all of the DSM criteria, “as long as the symptoms that are present are persistent and severe.” Because the purpose of the manual is to provide a reliable common language for professionals engaged in treatment and research, however, the user is cautioned not to veer too far from its listed criteria lest they become meaningless.

Although the DSM is meant to serve as a clinical tool, it has come to be used by insurers and by private and public institutional providers – often including public school systems – as a gateway to benefits. When fiscally-strapped providers use the DSM as a tool for triage, lock-step denials of access to services inevitably result. Compounding the problem is the lack of clinical qualifications of many who mind those gates and who are all too ready to deny services based on an individual’s failure to fit perfectly under a diagnostic label.

The new updated manual, DSM-V, is the first to be issued since 1994. It will include a number of uncontroversial changes meant to update the categorization of disorders based on research and usage in the last two decades. An example of such a change is the use of the term “intellectual disability” in place of “mental retardation.” In connection with that change, the manual will call for diagnoses to be based less on IQ scores and more on clinical assessment of an individual’s functional abilities – a welcome change to those who advocate for services for persons with cognitive impairments.

The new version will also include some controversial changes that have caused anxiety and concern among those who perceive that they will be directly affected. Chief among those changes is the deletion from the DSM of categories associated with autism that previously carried their own lists of diagnostic criteria: Asperger’s Disorder; Childhood Disintegrative Disorder; and Pervasive Developmental Disorder, NOS. The sense of those who support these changes is that the common elements among these disorders warrant using only one diagnostic category, Autism Spectrum Disorder, with diagnosticians indicating a level of severity once they determine the presence of the elements that support the diagnosis.

Many parents, advocates, and affected individuals, however, have voiced concern that the removal of these specific categories of autism from the DSM will result in some individuals’ losing the diagnostic definition altogether and, along with that, losing the services for which the diagnosis may have previously qualified them.

The DSM-V attempts to ease these concerns some have raised by advising that “individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.”

The DSM-V also includes a new category, Social Communication Disorder (“SCD”), meant to catch some who may fall outside of the Autism Spectrum Disorder category for lack of one or another element of the definition. An explanatory memo from the APA states that ASD must first be ruled out and that “SCD is characterized by a persistent difficulty with verbal and nonverbal communication that cannot be explained by low cognitive ability. Symptoms include difficulty in the acquisition and use of spoken and written language as well as problems with inappropriate responses in conversation. The disorder limits effective communication, social relationships, academic achievement, or occupational performance. Symptoms must be present in early childhood even if they are not recognized until later when speech, language, or communication demands exceed abilities.” (One commentator has suggested that this new category might be called “autism lite.”)

Since it will take time for research to build data specifically focused on such a new category, and particular service strategies will need to be borrowed from previous experience with other comparable disorders to address the needs of those who may shift, for example, from PDD-NOS to SCD, some wonder whether the latter will simply become a label without reliable treatment options for the foreseeable future.

Another change will be the introduction of Disruptive Mood Dysregulation Disorder (“DMDD”), aimed at sidestepping the controversial use of Bipolar Disorder as a pediatric diagnosis. (See a description of this new category here.) Again, the newness of the diagnostic category means that service strategies will not have been clearly defined, though much research and experience based on older comparable categories of disorder will likely be relevant. For a thoughtful discussion of the reasoning behind the creation of this new category and of some concerns about its effects, see this article.

For parents and advocates in the field of special education, we can expect that any change in the words used to define a disability will bring with it arguments over interpretation, which, in an adversarial system – i.e., where parents seek services that districts would rather not provide – will lead to delays and/or denial of services. (As a school-side special education attorney once wryly commented: “Every time a word is changed in the statutes and regulations we practice under, it means at least a hundred hours of billable time.” The same thing might be said of changes in diagnostic categories.)

Many issues will likely arise for parents and advocates as new DSM diagnostic categories and their ramifications are discussed in the process of evaluating children and developing IEPs (or not) for them. We expect to return to this subject in later posts as the process unfolds. At the outset of this transition, though, we would suggest that participants keep in mind the very real difference between DSM-V diagnostic categories and the definitions of “disabilities” in the state and federal statutes that govern our work.

The criteria for eligibility for special education and/or related services, as set forth in IDEA and in Massachusetts’ (and probably most states’) special education laws and regulations, do not refer to the DSM. In fact, those definitions are generally broader than what appears in the DSM, and accordingly should provide greater access to services.

For example, Massachusetts’ regulations define autism (at 603 CMR 28.02(7)(a)) as a “developmental disability significantly affecting verbal and nonverbal communication and social interaction,” and refer to the federal definition of autism found at 34 C.F.R. 300.8(c)(1) for elaboration. That federal definition states: “Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age three, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.”

An examination of the new DSM-V criteria for an autism spectrum diagnosis reveals a long list of component elements. Parents and advocates should keep firmly in mind, however, that those elements are not essential to a child’s meeting the definition of autism under state and federal special education law. (This is not to say that some school districts will not insist on an official DSM-V diagnosis of autism spectrum disorder before finding a student eligible for special education, but rather that there may be serious grounds on which to challenge such a denial, based on the actual words of IDEA and state law.)

Likewise, while many different diagnoses found in the DSM-V to describe emotional disorders are based on lists of elements specific to each, the definition of “emotional impairment” under IDEA and Massachusetts law is broader.

Put another way, being diagnosed with a mental illness under a DSM-V category would probably be sufficient to satisfy the definition of “emotional impairment,” but would not be necessary if the student otherwise fits the following definition from both federal and state regulations: “the student exhibits one or more of the following characteristics over a long period of time and to a marked degree that adversely affects educational performance: an inability to learn that cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; or a tendency to develop physical symptoms or fears associated with personal or school problems.” 603 CMR 28.02(7)(f) (referencing 34 C.F.R. 300.8(c)(4)).

To the extent that IDEA’s or state law’s definitions of disabilities are broader than those that appear in DSM-V, a district’s attempt to insist that a student meet DSM-V criteria would have to give way as illegally narrowing eligibility for special education.

There will be more to come on the subject of DSM-V as a factor in special education process. Watch this space!


Robert Crabtree is a partner in the Special Education & Disability Rights practice group at Kotin, Crabtree & Strong, LLP in Boston, Massachusetts.

Friday, May 24, 2013

Helping Kids with ADHD (Here and in France!): A Reader Challenges Marilyn Wedge

NOTE: On Tuesday, May 21, we posted an article by Dr. Marilyn Wedge entitled Why French Kids Don't Have ADHD (a very dubious proposition at best), along with a rebuttal by Dr. Stephanie Sarkis. Both originally appeared in the Scientific American blog "Suffer the Children." Our post was intended to stimulate discussion and seems to have served its purpose. We received a number of comments, including the following:

A Special Guest Post by Lucille Cannava
May 23, 2013

Thank goodness you included a rebuttal to (Dr. Marilyn) Wedge's misleading and potentially harmful claims.

The French have a long history of mistreating patients with mental disorders. While Americans can look back and see the same ignorance in our history, we are not still clinging to our old prejudices in the same way.

We decry the fact that psychiatrists in America rarely treat children anymore. It is much easier--and more lucrative--to see a parent and child for 15 - 20 minutes and write a prescription, rather than spending 50 minutes treating the child.

The American health care system is broken, and there is no way the (the medical, pharmaceutical and other) powerful lobbies will ever allow it to be fixed, as their profits are the highest in the world. It is most dreadful for people who cannot advocate for themselves: children and the elderly.

We have much to be ashamed of, but helping kids with ADHD is not one of them. The French way sounds like it is dangerously flirting with the age-old, "blame the mother" syndrome: the problem is in the home.

More appropriately, even a cursory glance at American classrooms will tell you that the problem may well be exacerbated by schools where distractions and sensory overload are the norm, and actual engagement with students is glossed over.

About Lucille Cannava

Currently a freelance journalist/editor and doctoral candidate in Educational Administration, Lucille Cannava has been a consultant, tutor, advocate and more recently, a special education administrator in a number of metropolitan-Boston public school districts.

Thursday, May 23, 2013

The Touch-Screen Generation

From The Atlantic

By Hanna Rosin
March 20, 2013

Young children—even toddlers—are spending more and more time with digital technology. What will it mean for their development?

On a chilly day last spring, a few dozen developers of children’s apps for phones and tablets gathered at an old beach resort in Monterey, California, to show off their games. One developer, a self-described “visionary for puzzles” who looked like a skateboarder-recently-turned-dad, displayed a jacked-up, interactive game called Puzzingo, intended for toddlers and inspired by his own son’s desire to build and smash. Two 30‑something women were eagerly seeking feedback for an app called Knock Knock Family, aimed at 1-to-4-year-olds. “We want to make sure it’s easy enough for babies to understand,” one explained.

The gathering was organized by Warren Buckleitner, a longtime reviewer of interactive children’s media who likes to bring together developers, researchers, and interest groups—and often plenty of kids, some still in diapers. It went by the Harry Potter–ish name Dust or Magic, and was held in a drafty old stone-and-wood hall barely a mile from the sea, the kind of place where Bathilda Bagshot might retire after packing up her wand. Buckleitner spent the breaks testing whether his own remote-control helicopter could reach the hall’s second story, while various children who had come with their parents looked up in awe and delight. But mostly they looked down, at the iPads and other tablets displayed around the hall like so many open boxes of candy. I walked around and talked with developers, and several paraphrased a famous saying of Maria Montessori’s, a quote imported to ennoble a touch-screen age when very young kids, who once could be counted on only to chew on a square of aluminum, are now engaging with it in increasingly sophisticated ways: “The hands are the instruments of man’s intelligence.”

What, really, would Maria Montessori have made of this scene? The 30 or so children here were not down at the shore poking their fingers in the sand or running them along mossy stones or digging for hermit crabs. Instead they were all inside, alone or in groups of two or three, their faces a few inches from a screen, their hands doing things Montessori surely did not imagine. A couple of 3-year-old girls were leaning against a pair of French doors, reading an interactive story called Ten Giggly Gorillas and fighting over which ape to tickle next. A boy in a nearby corner had turned his fingertip into a red marker to draw an ugly picture of his older brother. On an old oak table at the front of the room, a giant stuffed Angry Bird beckoned the children to come and test out tablets loaded with dozens of new apps. Some of the chairs had pillows strapped to them, since an 18-month-old might not otherwise be able to reach the table, though she’d know how to swipe once she did.

Not that long ago, there was only the television, which theoretically could be kept in the parents’ bedroom or locked behind a cabinet. Now there are smartphones and iPads, which wash up in the domestic clutter alongside keys and gum and stray hair ties. “Mom, everyone has technology but me!” my 4-year-old son sometimes wails. And why shouldn’t he feel entitled? In the same span of time it took him to learn how to say that sentence, thousands of kids’ apps have been developed—the majority aimed at preschoolers like him. To us (his parents, I mean), American childhood has undergone a somewhat alarming transformation in a very short time. But to him, it has always been possible to do so many things with the swipe of a finger, to have hundreds of games packed into a gadget the same size as Goodnight Moon.

In 2011, the American Academy of Pediatrics updated its policy on very young children and media. In 1999, the group had discouraged television viewing for children younger than 2, citing research on brain development that showed this age group’s critical need for “direct interactions with parents and other significant care givers.” The updated report began by acknowledging that things had changed significantly since then. In 2006, 90 percent of parents said that their children younger than 2 consumed some form of electronic media. Nonetheless, the group took largely the same approach it did in 1999, uniformly discouraging passive media use, on any type of screen, for these kids. (For older children, the academy noted, “high-quality programs” could have “educational benefits.”) The 2011 report mentioned “smart cell phone” and “new screen” technologies, but did not address interactive apps. Nor did it broach the possibility that has likely occurred to those 90 percent of American parents, queasy though they might be: that some good might come from those little swiping fingers.

I had come to the developers’ conference partly because I hoped that this particular set of parents, enthusiastic as they were about interactive media, might help me out of this conundrum, that they might offer some guiding principle for American parents who are clearly never going to meet the academy’s ideals, and at some level do not want to. Perhaps this group would be able to articulate some benefits of the new technology that the more cautious pediatricians weren’t ready to address. I nurtured this hope until about lunchtime, when the developers gathering in the dining hall ceased being visionaries and reverted to being ordinary parents, trying to settle their toddlers in high chairs and get them to eat something besides bread.

I fell into conversation with a woman who had helped develop Montessori Letter Sounds, an app that teaches preschoolers the Montessori methods of spelling.

She was a former Montessori teacher and a mother of four. I myself have three children who are all fans of the touch screen. What games did her kids like to play?, I asked, hoping for suggestions I could take home.

“They don’t play all that much.”

Really? Why not?

“Because I don’t allow it. We have a rule of no screen time during the week,” unless it’s clearly educational.

No screen time? None at all? That seems at the outer edge of restrictive, even by the standards of my overcontrolling parenting set.

“On the weekends, they can play. I give them a limit of half an hour and then stop. Enough. It can be too addictive, too stimulating for the brain.”

Her answer so surprised me that I decided to ask some of the other developers who were also parents what their domestic ground rules for screen time were. One said only on airplanes and long car rides. Another said Wednesdays and weekends, for half an hour. The most permissive said half an hour a day, which was about my rule at home. At one point I sat with one of the biggest developers of e-book apps for kids, and his family. The toddler was starting to fuss in her high chair, so the mom did what many of us have done at that moment—stuck an iPad in front of her and played a short movie so everyone else could enjoy their lunch. When she saw me watching, she gave me the universal tense look of mothers who feel they are being judged. “At home,” she assured me, “I only let her watch movies in Spanish.”

By their pinched reactions, these parents illuminated for me the neurosis of our age: as technology becomes ubiquitous in our lives, American parents are becoming more, not less, wary of what it might be doing to their children. Technological competence and sophistication have not, for parents, translated into comfort and ease. They have merely created yet another sphere that parents feel they have to navigate in exactly the right way. On the one hand, parents want their children to swim expertly in the digital stream that they will have to navigate all their lives; on the other hand, they fear that too much digital media, too early, will sink them. Parents end up treating tablets like precision surgical instruments, gadgets that might perform miracles for their child’s IQ and help him win some nifty robotics competition—but only if they are used just so. Otherwise, their child could end up one of those sad, pale creatures who can’t make eye contact and has an avatar for a girlfriend.

Norman Rockwell never painted Boy Swiping Finger on Screen, and our own vision of a perfect childhood has never adjusted to accommodate that now-common tableau. Add to that our modern fear that every parenting decision may have lasting consequences—that every minute of enrichment lost or mindless entertainment indulged will add up to some permanent handicap in the future—and you have deep guilt and confusion. To date, no body of research has definitively proved that the iPad will make your preschooler smarter or teach her to speak Chinese, or alternatively that it will rust her neural circuitry—the device has been out for only three years, not much more than the time it takes some academics to find funding and gather research subjects. So what’s a parent to do?

In 2001, the education and technology writer Marc Prensky popularized the term digital natives to describe the first generations of children growing up fluent in the language of computers, video games, and other technologies. (The rest of us are digital immigrants, struggling to understand.) This term took on a whole new significance in April 2010, when the iPad was released. iPhones had already been tempting young children, but the screens were a little small for pudgy toddler hands to navigate with ease and accuracy. Plus, parents tended to be more possessive of their phones, hiding them in pockets or purses. The iPad was big and bright, and a case could be made that it belonged to the family. Researchers who study children’s media immediately recognized it as a game changer.

Previously, young children had to be shown by their parents how to use a mouse or a remote, and the connection between what they were doing with their hand and what was happening on the screen took some time to grasp. But with the iPad, the connection is obvious, even to toddlers. Touch technology follows the same logic as shaking a rattle or knocking down a pile of blocks: the child swipes, and something immediately happens. A “rattle on steroids,” is what Buckleitner calls it. “All of a sudden a finger could move a bus or smush an insect or turn into a big wet gloopy paintbrush.” To a toddler, this is less magic than intuition. At a very young age, children become capable of what the psychologist Jerome Bruner called “enactive representation”; they classify objects in the world not by using words or symbols but by making gestures—say, holding an imaginary cup to their lips to signify that they want a drink. Their hands are a natural extension of their thoughts.

Norman Rockwell never painted Boy Swiping Finger on Screen, and our own vision of a perfect childhood has never adjusted to fit that now-common tableau.

I have two older children who fit the early idea of a digital native—they learned how to use a mouse or a keyboard with some help from their parents and were well into school before they felt comfortable with a device in their lap. (Now, of course, at ages 9 and 12, they can create a Web site in the time it takes me to slice an onion.) My youngest child is a whole different story. He was not yet 2 when the iPad was released. As soon as he got his hands on it, he located the Talking Baby Hippo app that one of my older children had downloaded. The little purple hippo repeats whatever you say in his own squeaky voice, and responds to other cues. My son said his name (“Giddy!”); Baby Hippo repeated it back. Gideon poked Baby Hippo; Baby Hippo laughed. Over and over, it was funny every time. Pretty soon he discovered other apps. Old MacDonald, by Duck Duck Moose, was a favorite. At first he would get frustrated trying to zoom between screens, or not knowing what to do when a message popped up. But after about two weeks, he figured all that out. I must admit, it was eerie to see a child still in diapers so competent and intent, as if he were forecasting his own adulthood. Technically I was the owner of the iPad, but in some ontological way it felt much more his than mine.

Without seeming to think much about it or resolve how they felt, parents began giving their devices over to their children to mollify, pacify, or otherwise entertain them. By 2010, two-thirds of children ages 4 to 7 had used an iPhone, according to the Joan Ganz Cooney Center, which studies children’s media. The vast majority of those phones had been lent by a family member; the center’s researchers labeled this the “pass-back effect,” a name that captures well the reluctant zone between denying and giving.

The market immediately picked up on the pass-back effect, and the opportunities it presented. In 2008, when Apple opened up its App Store, the games started arriving at the rate of dozens a day, thousands a year. For the first 23 years of his career, Buckleitner had tried to be comprehensive and cover every children’s game in his publication, Children’s Technology Review. Now, by Buckleitner’s loose count, more than 40,000 kids’ games are available on iTunes, plus thousands more on Google Play. In the iTunes “Education” category, the majority of the top-selling apps target preschool or elementary-age children. By age 3, Gideon would go to preschool and tune in to what was cool in toddler world, then come home, locate the iPad, drop it in my lap, and ask for certain games by their approximate description: “Tea? Spill?” (That’s Toca Tea Party.)

As these delights and diversions for young children have proliferated, the pass-back has become more uncomfortable, even unsustainable, for many parents:

"He’d gone to this state where you’d call his name and he wouldn’t respond to it, or you could snap your fingers in front of his face …
But, you know, we ended up actually taking the iPad away for—from him largely because, you know, this example, this thing we were talking about, about zoning out. Now, he would do that, and my wife and I would stare at him and think, Oh my God, his brain is going to turn to mush and come oozing out of his ears. And it concerned us a bit."

This is Ben Worthen, a Wall Street Journal reporter, explaining recently to NPR’s Diane Rehm why he took the iPad away from his son, even though it was the only thing that could hold the boy’s attention for long periods, and it seemed to be sparking an interest in numbers and letters. Most parents can sympathize with the disturbing sight of a toddler, who five minutes earlier had been jumping off the couch, now subdued and staring at a screen, seemingly hypnotized. In the somewhat alarmist Endangered Minds: Why Children Don’t Think—and What We Can Do About It, author Jane Healy even gives the phenomenon a name, the “ ‘zombie’ effect,” and raises the possibility that television might “suppress mental activity by putting viewers in a trance.”

Ever since viewing screens entered the home, many observers have worried that they put our brains into a stupor. An early strain of research claimed that when we watch television, our brains mostly exhibit slow alpha waves—indicating a low level of arousal, similar to when we are daydreaming. These findings have been largely discarded by the scientific community, but the myth persists that watching television is the mental equivalent of, as one Web site put it, “staring at a blank wall.” These common metaphors are misleading, argues Heather Kirkorian, who studies media and attention at the University of Wisconsin at Madison. A more accurate point of comparison for a TV viewer’s physiological state would be that of someone deep in a book, says Kirkorian, because during both activities we are still, undistracted, and mentally active.

Because interactive media are so new, most of the existing research looks at children and television. By now, “there is universal agreement that by at least age 2 and a half, children are very cognitively active when they are watching TV,” says Dan Anderson, a children’s-media expert at the University of Massachusetts at Amherst. In the 1980s, Anderson put the zombie theory to the test, by subjecting roughly 100 children to a form of TV hell. He showed a group of children ages 2 to 5 a scrambled version of Sesame Street: he pieced together scenes in random order, and had the characters speak backwards or in Greek. Then he spliced the doctored segments with unedited ones and noted how well the kids paid attention. The children looked away much more frequently during the scrambled parts of the show, and some complained that the TV was broken. Anderson later repeated the experiment with babies ages 6 months to 24 months, using Teletubbies. Once again he had the characters speak backwards and chopped the action sequences into a nonsensical order—showing, say, one of the Teletubbies catching a ball and then, after that, another one throwing it. The 6- and 12-month-olds seemed unable to tell the difference, but by 18 months the babies started looking away, and by 24 months they were turned off by programming that did not make sense.

Anderson’s series of experiments provided the first clue that even very young children can be discriminating viewers—that they are not in fact brain-dead, but rather work hard to make sense of what they see and turn it into a coherent narrative that reflects what they already know of the world. Now, 30 years later, we understand that children “can make a lot of inferences and process the information,” says Anderson. “And they can learn a lot, both positive and negative.” Researchers never abandoned the idea that parental interaction is critical for the development of very young children. But they started to see TV watching in shades of gray. If a child never interacts with adults and always watches TV, well, that is a problem. But if a child is watching TV instead of, say, playing with toys, then that is a tougher comparison, because TV, in the right circumstances, has something to offer.

How do small children actually experience electronic media, and what does that experience do to their development? Since the ’80s, researchers have spent more and more time consulting with television programmers to study and shape TV content. By tracking children’s reactions, they have identified certain rules that promote engagement: stories have to be linear and easy to follow, cuts and time lapses have to be used very sparingly, and language has to be pared down and repeated. A perfect example of a well-engineered show is Nick Jr.’s Blue’s Clues, which aired from 1996 to 2006. Each episode features Steve (or Joe, in later seasons) and Blue, a cartoon puppy, solving a mystery. Steve talks slowly and simply; he repeats words and then writes them down in his handy-dandy notebook. There are almost no cuts or unexplained gaps in time. The great innovation of Blue’s Clues is something called the “pause.” Steve asks a question and then pauses for about five seconds to let the viewer shout out an answer. Small children feel much more engaged and invested when they think they have a role to play, when they believe they are actually helping Steve and Blue piece together the clues. A longitudinal study of children older than 2 and a half showed that the ones who watched Blue’s Clues made measurably larger gains in flexible thinking and problem solving over two years of watching the show.

For toddlers, however, the situation seems slightly different. Children younger than 2 and a half exhibit what researchers call a “video deficit.” This means that they have a much easier time processing information delivered by a real person than by a person on videotape. In one series of studies, conducted by Georgene Troseth, a developmental psychologist at Vanderbilt University, children watched on a live video monitor as a person in the next room hid a stuffed dog. Others watched the exact same scene unfold directly, through a window between the rooms. The children were then unleashed into the room to find the toy. Almost all the kids who viewed the hiding through the window found the toy, but the ones who watched on the monitor had a much harder time.

A natural assumption is that toddlers are not yet cognitively equipped to handle symbolic representation. (I remember my older son, when he was 3, asking me if he could go into the TV and pet Blue.) But there is another way to interpret this particular phase of development. Toddlers are skilled at seeking out what researchers call “socially relevant information.” They tune in to people and situations that help them make a coherent narrative of the world around them. In the real world, fresh grass smells and popcorn tumbles and grown-ups smile at you or say something back when you ask them a question. On TV, nothing like that happens. A TV is static and lacks one of the most important things to toddlers, which is a “two-way exchange of information,” argues Troseth.

A few years after the original puppy-hiding experiment, in 2004, Troseth reran it, only she changed a few things. She turned the puppy into a stuffed Piglet (from the Winnie the Pooh stories). More important, she made the video demonstration explicitly interactive. Toddlers and their parents came into a room where they could see a person—the researcher—on a monitor. The researcher was in the room where Piglet would be hidden, and could in turn see the children on a monitor. Before hiding Piglet, the researcher effectively engaged the children in a form of media training. She asked them questions about their siblings, pets, and toys. She played Simon Says with them and invited them to sing popular songs with her. She told them to look for a sticker under a chair in their room. She gave them the distinct impression that she—this person on the screen—could interact with them, and that what she had to say was relevant to the world they lived in. Then the researcher told the children she was going to hide the toy and, after she did so, came back on the screen to instruct them where to find it. That exchange was enough to nearly erase the video deficit. The majority of the toddlers who participated in the live video demonstration found the toy.

Blue’s Clues was on the right track. The pause could trick children into thinking that Steve was responsive to them. But the holy grail would be creating a scenario in which the guy on the screen did actually respond—in which the toddler did something and the character reliably jumped or laughed or started to dance or talk back.

Like, for example, when Gideon said “Giddy” and Talking Baby Hippo said “Giddy” back, without fail, every time. That kind of contingent interaction (I do something, you respond) is what captivates a toddler and can be a significant source of learning for even very young children—learning that researchers hope the children can carry into the real world. It’s not exactly the ideal social partner the American Academy of Pediatrics craves. It’s certainly not a parent or caregiver. But it’s as good an approximation as we’ve ever come up with on a screen, and it’s why children’s-media researchers are so excited about the iPad’s potential.

A couple of researchers from the Children’s Media Center at Georgetown University show up at my house, carrying an iPad wrapped in a bright-orange case, the better to tempt Gideon with. They are here at the behest of Sandra Calvert, the center’s director, to conduct one of several ongoing studies on toddlers and iPads. Gideon is one of their research subjects. This study is designed to test whether a child is more likely to learn when the information he hears comes from a beloved and trusted source. The researchers put the iPad on a kitchen chair; Gideon immediately notices it, turns it on, and looks for his favorite app. They point him to the one they have invented for the experiment, and he dutifully opens it with his finger.

Onto the screen comes a floppy kangaroo-like puppet, introduced as “DoDo.” He is a nobody in the child universe, the puppet equivalent of some random guy on late-night public-access TV. Gideon barely acknowledges him. Then the narrator introduces Elmo. “Hi,” says Elmo, waving. Gideon says hi and waves back.

An image pops up on the screen, and the narrator asks, “What is this?” (It’s a banana.)

“This is a banana,” says DoDo.

“This is a grape,” says Elmo.

I smile with the inner glow of a mother who knows her child is about to impress a couple strangers. My little darling knows what a banana is. Of course he does! Gideon presses on Elmo. (The narrator says, “No, not Elmo. Try again.”) As far as I know, he’s never watched Sesame Street, never loved an Elmo doll or even coveted one at the toy store. Nonetheless, he is tuned in to the signals of toddler world and, apparently, has somehow figured out that Elmo is a supreme moral authority. His relationship with Elmo is more important to him than what he knows to be the truth. On and on the game goes, and sometimes Gideon picks Elmo even when Elmo says an orange is a pear. Later, when the characters both give made-up names for exotic fruits that few children would know by their real name, Gideon keeps doubling down on Elmo, even though DoDo has been more reliable.

By age 3, Gideon would tune in to what was cool in toddler world, then drop the iPad in my lap and ask for certain games by their approximate description.

As it happens, Gideon was not in the majority. This summer, Calvert and her team will release the results of their study, which show that most of the time, children around age 32 months go with the character who is telling the truth, whether it’s Elmo or DoDo—and quickly come to trust the one who’s been more accurate when the children don’t already know the answer. But Calvert says this merely suggests that toddlers have become even more savvy users of technology than we had imagined. She had been working off attachment theory, and thought toddlers might value an emotional bond over the correct answer. But her guess is that something about tapping the screen, about getting feedback and being corrected in real time, is itself instructive, and enables the toddlers to absorb information accurately, regardless of its source.

Calvert takes a balanced view of technology: she works in an office surrounded by hardcover books, and she sometimes edits her drafts with pen and paper. But she is very interested in how the iPad can reach children even before they’re old enough to access these traditional media.

“People say we are experimenting with our children,” she told me. “But from my perspective, it’s already happened, and there’s no way to turn it back. Children’s lives are filled with media at younger and younger ages, and we need to take advantage of what these technologies have to offer. I’m not a Pollyanna. I’m pretty much a realist. I look at what kids are doing and try to figure out how to make the best of it.”

Despite the participation of Elmo, Calvert’s research is designed to answer a series of very responsible, high-minded questions: Can toddlers learn from iPads? Can they transfer what they learn to the real world? What effect does interactivity have on learning? What role do familiar characters play in children’s learning from iPads? All worthy questions, and important, but also all considered entirely from an adult’s point of view. The reason many kids’ apps are grouped under “Education” in the iTunes store, I suspect, is to assuage parents’ guilt (though I also suspect that in the long run, all those “educational” apps merely perpetuate our neurotic relationship with technology, by reinforcing the idea that they must be sorted vigilantly into “good” or “bad”). If small children had more input, many “Education” apps would logically fall under a category called “Kids” or “Kids’ Games.” And many more of the games would probably look something like the apps designed by a Swedish game studio named Toca Boca.

The founders, Emil Ovemar and Björn Jeffery, work for Bonnier, a Swedish media company. Ovemar, an interactive-design expert, describes himself as someone who never grew up. He is still interested in superheroes, Legos, and animated movies, and says he would rather play stuck-on-an-island with his two kids and their cousins than talk to almost any adult. Jeffery is the company’s strategist and front man; I first met him at the conference in California, where he was handing out little temporary tattoos of the Toca Boca logo, a mouth open and grinning, showing off rainbow-colored teeth.

In late 2010, Ovemar and Jeffery began working on a new digital project for Bonnier, and they came up with the idea of entering the app market for kids. Ovemar began by looking into the apps available at the time. Most of them were disappointingly “instructive,” he found—“drag the butterfly into the net, that sort of thing. They were missing creativity and imagination.” Hunting for inspiration, he came upon Frank and Theresa Caplan’s 1973 book The Power of Play, a quote from which he later e-mailed to me:

"What is it that often puts the B student ahead of the A student in adult life, especially in business and creative professions? Certainly it is more than verbal skill. To create, one must have a sense of adventure and playfulness. One needs toughness to experiment and hazard the risk of failure. One has to be strong enough to start all over again if need be and alert enough to learn from whatever happens. One needs a strong ego to be propelled forward in one’s drive toward an untried goal. Above all, one has to possess the ability to play!"

Ovemar and Jeffery hunted down toy catalogs from as early as the 1950s, before the age of exploding brand tie-ins. They made a list of the blockbusters over the decades—the first Tonka trucks, the Frisbee, the Hula-Hoop, the Rubik’s Cube. Then they made a list of what these toys had in common: None really involved winning or losing against an opponent. None were part of an effort to create a separate child world that adults were excluded from, and probably hostile toward; they were designed more for family fun. Also, they were not really meant to teach you something specific—they existed mostly in the service of having fun.

In 2011 the two developers launched Toca Tea Party. The game is not all that different from a real tea party. The iPad functions almost like a tea table without legs, and the kids have to invent the rest by, for example, seating their own plushies or dolls, one on each side, and then setting the theater in motion. First, choose one of three tablecloths. Then choose plates, cups, and treats. The treats are not what your mom would feed you. They are chocolate cakes, frosted doughnuts, cookies. It’s very easy to spill the tea when you pour or take a sip, a feature added based on kids’ suggestions during a test play (kids love spills, but spilling is something you can’t do all that often at a real tea party, or you’ll get yelled at). At the end, a sink filled with soapy suds appears, and you wash the dishes, which is also part of the fun, and then start again. That’s it. The game is either very boring or terrifically exciting, depending on what you make of it. Ovemar and Jeffery knew that some parents wouldn’t get it, but for kids, the game would be fun every time, because it’s dependent entirely on imagination. Maybe today the stuffed bear will be naughty and do the spilling, while naked Barbie will pile her plate high with sweets. The child can take on the voice of a character or a scolding parent, or both. There’s no winning, and there’s no reward. Like a game of stuck-on-an-island, it can go on for five minutes or forever.

Soon after the release of Toca Tea Party, the pair introduced Toca Hair Salon, which is still to my mind the most fun game out there. The salon is no Fifth Avenue spa. It’s a rundown-looking place with cracks in the wall. The aim is not beauty but subversion. Cutting off hair, like spilling, is on the list of things kids are not supposed to do. You choose one of the odd-looking people or creatures and have your way with its hair, trimming it or dyeing it or growing it out. The blow-dryer is genius; it achieves the same effect as Tadao Cern’s Blow Job portraits, which depict people’s faces getting wildly distorted by high winds. In August 2011, Toca Boca gave away Hair Salon for free for nearly two weeks. It was downloaded more than 1 million times in the first week, and the company took off. Today, many Toca Boca games show up on lists of the most popular education apps.

Are they educational? “That’s the perspective of the parents,” Jeffery told me at the back of the grand hall in Monterey. “Is running around on the lawn educational? Every part of a child’s life can’t be held up to that standard.” As we talked, two girls were playing Toca Tea Party on the floor nearby. One had her stuffed dragon at a plate, and he was being especially naughty, grabbing all the chocolate cake and spilling everything. Her friend had taken a little Lego construction man and made him the good guy who ate neatly and helped do the dishes. Should they have been outside at the beach? Maybe, but the day would be long, and they could go outside later.

The more I talked with the developers, the more elusive and unhelpful the “Education” category seemed. (Is Where the Wild Things Are educational? Would you make your child read a textbook at bedtime? Do you watch only educational television? And why don’t children deserve high-quality fun?) Buckleitner calls his conference Dust or Magic to teach app developers a more subtle concept than pedagogy. By magic, Buckleitner has in mind an app that makes children’s fingers move and their eyes light up. By dust, he means something that was obviously (and ploddingly) designed by an adult. Some educational apps, I wouldn’t wish on the naughtiest toddler. Take, for example, Counting With the Very Hungry Caterpillar, which turns a perfectly cute book into a tedious app that asks you to “please eat 1 piece of chocolate cake” so you can count to one.

Before the conference, Buckleitner had turned me on to Noodle Words, an app created by the California designer and children’s-book writer Mark Schlichting. The app is explicitly educational. It teaches you about active verbs—spin,sparkle, stretch. It also happens to be fabulous. You tap a box, and a verb pops up and gets acted out by two insect friends who have the slapstick sensibility of the Three Stooges. If the word is shake, they shake until their eyeballs rattle. I tracked down Schlichting at the conference, and he turned out to be a little like Maurice Sendak—like many good children’s writers, that is: ruled by id and not quite tamed into adulthood. The app, he told me, was inspired by a dream he’d had in which he saw the word and floating in the air and sticking to other words like a magnet. He woke up and thought, What if words were toys?

During the course of reporting this story, I downloaded dozens of apps and let my children test them out. They didn’t much care whether the apps were marketed as educational or not, as long as they were fun. Without my prompting, Gideon fixated on a game called LetterSchool, which teaches you how to write letters more effectively and with more imagination than any penmanship textbooks I’ve ever encountered. He loves the Toca Boca games, the Duck Duck Moose games, and random games like Bugs and Buttons. My older kids love The Numberlys, a dark fantasy creation of illustrators who have worked with Pixar that happens to teach the alphabet. And all my kids, including Gideon, play Cut the Rope a lot, which is not exclusively marketed as a kids’ game. I could convince myself that the game is teaching them certain principles of physics—it’s not easy to know the exact right place to slice the rope. But do I really need that extra convincing? I like playing the game; why shouldn’t they?

Every new medium has, within a short time of its introduction, been condemned as a threat to young people. Pulp novels would destroy their morals, TV would wreck their eyesight, video games would make them violent. Each one has been accused of seducing kids into wasting time that would otherwise be spent learning about the presidents, playing with friends, or digging their toes into the sand. In our generation, the worries focus on kids’ brainpower, about unused synapses withering as children stare at the screen. People fret about television and ADHD, although that concern is largely based on a single study that has been roundly criticized and doesn’t jibe with anything we know about the disorder.

There are legitimate broader questions about how American children spend their time, but all you can do is keep them in mind as you decide what rules to set down for your own child. The statement from the American Academy of Pediatrics assumes a zero-sum game: an hour spent watching TV is an hour not spent with a parent. But parents know this is not how life works. There are enough hours in a day to go to school, play a game, and spend time with a parent, and generally these are different hours. Some people can get so drawn into screens that they want to do nothing else but play games. Experts say excessive video gaming is a real problem, but they debate whether it can be called an addiction and, if so, whether the term can be used for anything but a small portion of the population. If your child shows signs of having an addictive personality, you will probably know it. One of my kids is like that; I set stricter limits for him than for the others, and he seems to understand why.

In her excellent book Screen Time, the journalist Lisa Guernsey lays out a useful framework—what she calls the three C’s—for thinking about media consumption: content, context, and your child. She poses a series of questions—Do you think the content is appropriate? Is screen time a “relatively small part of your child’s interaction with you and the real world?”—and suggests tailoring your rules to the answers, child by child. One of the most interesting points Guernsey makes is about the importance of parents’ attitudes toward media. If they treat screen time like junk food, or “like a magazine at the hair salon”—good for passing the time in a frivolous way but nothing more—then the child will fully absorb that attitude, and the neurosis will be passed to the next generation.

“The war is over. The natives won.” So says Marc Prensky, the education and technology writer, who has the most extreme parenting philosophy of anyone I encountered in my reporting. Prensky’s 7-year-old son has access to books, TV, Legos, Wii—and Prensky treats them all the same. He does not limit access to any of them. Sometimes his son plays with a new app for hours, but then, Prensky told me, he gets tired of it. He lets his son watch TV even when he personally thinks it’s a “stupid waste.” SpongeBob SquarePants, for example, seems like an annoying, pointless show, but Prensky says he used the relationship between SpongeBob and Patrick, his starfish sidekick, to teach his son a lesson about friendship. “We live in a screen age, and to say to a kid, ‘I’d love for you to look at a book but I hate it when you look at the screen’ is just bizarre. It reflects our own prejudices and comfort zone. It’s nothing but fear of change, of being left out.”

Prensky’s worldview really stuck with me. Are books always, in every situation, inherently better than screens? My daughter, after all, often uses books as a way to avoid social interaction, while my son uses the Wii to bond with friends. I have to admit, I had the exact same experience with SpongeBob. For a long time I couldn’t stand the show, until one day I got past the fact that the show was so loud and frenetic and paid more attention to the story line, and realized I too could use it to talk with my son about friendship. After I first interviewed Prensky, I decided to conduct an experiment. For six months, I would let my toddler live by the Prensky rules. I would put the iPad in the toy basket, along with the remote-control car and the Legos. Whenever he wanted to play with it, I would let him.

Gideon tested me the very first day. He saw the iPad in his space and asked if he could play. It was 8 a.m. and we had to get ready for school. I said yes. For 45 minutes he sat on a chair and played as I got him dressed, got his backpack ready, and failed to feed him breakfast. This was extremely annoying and obviously untenable. The week went on like this—Gideon grabbing the iPad for two-hour stretches, in the morning, after school, at bedtime. Then, after about 10 days, the iPad fell out of his rotation, just like every other toy does. He dropped it under the bed and never looked for it. It was completely forgotten for about six weeks.

Now he picks it up every once in a while, but not all that often. He has just started learning letters in school, so he’s back to playing LetterSchool. A few weeks ago his older brother played with him, helping him get all the way through the uppercase and then lowercase letters. It did not seem beyond the range of possibility that if Norman Rockwell were alive, he would paint the two curly-haired boys bent over the screen, one small finger guiding a smaller one across, down, and across again to make, in their triumphant finale, the small z.


Hanna Rosin is a national correspondent for The Atlantic.

Tuesday, May 21, 2013

Point/Counterpoint: Why French Kids Don't Have ADHD, and....

From the Scientific American Blog "Suffer the Children"

By Marilyn Wedge, Ph.D.
March 8, 2012

The case against labeling and medicating children, and effective alternatives for treating them.

French children don't need medications to control their behavior.

In the United States, at least 9% of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5%. How come the epidemic of ADHD—which has become firmly established in the United States—has almost completely passed over children in France?

Is ADHD a biological-neurological disorder? Surprisingly, the answer to this question depends on whether you live in France or in the United States. In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological--psycho stimulant medications such as Ritalin and Adderall.

French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioral problems with drugs,

French doctors prefer to look for the underlying issue that is causing the child distress—not in the child's brain but in the child's social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child's brain.


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French child psychiatrists don't use the same system of classification of childhood emotional problems as American psychiatrists. They do not use the Diagnostic and Statistical Manual of Mental Disorders or DSM. According to Sociologist Manuel Vallee, the French Federation of Psychiatry developed an alternative classification system as a resistance to the influence of the DSM-3.

This alternative was the CFTMEA (Classification Française des Troubles Mentaux de L'Enfant et de L'Adolescent), first released in 1983, and updated in 1988 and 2000.

The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children's symptoms, not on finding the best pharmacological bandaids with which to mask symptoms.

To the extent that French clinicians are successful at finding and repairing what has gone awry in the child's social context, fewer children qualify for the ADHD diagnosis.

Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to "pathologize" much of what is normal childhood behavior.

The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.

The French holistic, psycho-social approach also allows for considering nutritional causes for ADHD-type symptoms—specifically the fact that the behavior of some children is worsened after eating foods with artificial colors, certain preservatives, and/or allergens. Clinicians who work with troubled children in this country—not to mention parents of many ADHD kids—are well aware that dietary interventions can sometimes help a child's problem.

In the United States, the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children's behavior.

And then, of course, there are the vastly different philosophies of child-rearing in the United States and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her recent book, Bringing up Bébé.

I believe her insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the United States.

From the time their children are born, French parents provide them with a firm cadre—the word means "frame" or "structure." Children are not allowed, for example, to snack whenever they want. Mealtimes are at four specific times of the day. French children learn to wait patiently for meals, rather than eating snack foods whenever they feel like it.

French babies, too, are expected to conform to limits set by parents and not by their crying selves. French parents let their babies "cry it out" if they are not sleeping through the night at the age of four months.

French parents, Druckerman observes, love their children just as much as American parents. They give them piano lessons, take them to sports practice, and encourage them to make the most of their talents. But French parents have a different philosophy of disciplinine.

Consistently enforced limits, in the French view, make children feel safe and secure. Clear limits, they believe, actually make a child feel happier and safer—something that is congruent with my own experience as both a therapist and a parent.

Finally, French parents believe that hearing the word "no" rescues children from the "tyranny of their own desires." And spanking, when used judiciously, is not considered child abuse in France.

As a therapist who works with children, it makes perfect sense to me that French children don't need medications to control their behavior because they learn self-control early in their lives. The children grow up in families in which the rules are well-understood, and a clear family hierarchy is firmly in place. In French families, as Druckerman describes them, parents are firmly in charge of their kids—instead of the American family style, in which the situation is all too often vice versa.

Marilyn Wedge is the author of Pills are not for Preschoolers: A Drug-Free Approach for Troubled Kids


And a Rebuttal...

French Kids Do Have ADHD

An Interview with Elias Sarkis M.D.

September 22, 2012

Moliere described ADHD in his play L'Étourdi ou Les Contretemps (The Blunderer) in 1655. However, the concept of ADHD, or "Trouble déficit de l’attention/hyperactivité" (TDAH), as a serious disorder is still not fully accepted in France.

However, ADHD impacts the functioning of 3.5% of the population of France (Lecendreux, et al. 2011). In addition, ADHD is just as prevalent in other countries as it is in the U.S. (Faraone, et al. 2003).

I interviewed Elias Sarkis M.D., a board-certified child and adolescent psychiatrist and Distinguished Fellow of the American Psychiatric Assocation, to learn more about the prevalence of ADHD in France. Dr. Sarkis lived in France for 10 years, and graduated from medical school at Universite de Lille in Lille, France. He is now the medical director of Sarkis Family Psychiatry and Sarkis Clinical Trials in Gainesville, Florida.

Dr. Sarkis returns to France on a regular basis. He said that ADHD does most certainly exist in France. Not only are there clinical studies showing the prevalence of ADHD in France, but Dr. Sarkis also has a friend, a psychiatrist, whose child has ADHD. His friend's daughter had lifelong difficulties in school, had an unplanned pregnancy, and then dropped out of school. Her mother is now watching her child so she can return to school. 

Dr. Sarkis said that in France there is a "strong negative cultural belief against medication" for children with psychiatric disorders. However, he said, children with ADHD continue to suffer the consequences of the disorder.

Regarding the impact of undiagnosed and unmedicated ADHD in France, Dr. Sarkis said, "the reality is that there are French kids in prison, a high rate of tobacco use, and kids dropping out of school".

Dr. Sarkis said said that if a French child with ADHD receives "excellent parenting, high structure, and clear expectations from parents" it can mitigate behaviors, However, it is "at the price of the child experiencing increased anxiety and internalizing problems".

For those children who are not able to receive excellent parenting and high structure, ADHD behaviors can be extremely impairing.

In France it is difficult for parents to get an evaluation and treatment for their ADHD child. It takes 8 months for a child to get an appointment with a specialist, and it can take another 8 months before a child is prescribed medication (Getin, 2011).

Fortunately, Dr. Sarkis said, the concept of ADHD as a serious, treatable disorder is gaining strength in France. Parents are learning more about ADHD via the Internet, and there are more centers being established to help treat this debiliating disorder.