Digital Ecosystems for Children and Adolescents, Literacy and Developmental Screening of Preschool-Aged Children During Primary Care

Support for Pediatrics on Call comes from Children's Health. Ranked in all 11 Pediatric Specialties by U.S. News and World Report, Children's Health is leading the way in pediatric care in Texas and across the nation. See how we're doing the incredible at Children's Health dot com. From the American Academy of Pediatrics. Digital platforms can be powerful spaces for Children's Development, but of course, there can be downsides. A new policy statement looks at the impact of digital ecosystems on children and adolescents. We as pediatricians have a really important and exciting opportunity to partner with families to spell out the ways the digital ecosystem is not serving us and also to push back on what that digital ecosystem is serving families. Plus, we'll discuss literacy and developmental screening of preschool age children during primary care. This is really an important component of what we do in outpatient pediatric practice. And if there is an ability for us to again do this short assessment and then get kids connected to those resources they need to be successful, it'll be well worth it. These stories are more on Pediatrics on Call. The podcast on Children's Health from the AAP. I'm Dr. David Hill. And I'm Dr. Joanna Parkabalinky. This podcast is for everyone in the medical community, keeping our children healthy and safe. It's a show by pediatricians for pediatricians. But anyone who cares about kids will get a lot out of it as well. Let's start today's episode with the discussion about digital ecosystems. My kids are all young adults and I'm sort of glad when they were little that social media wasn't such a big deal and that AI essentially didn't exist. Well, you are very lucky, David. Navigating digital technology with kids is becoming increasingly complex and stressful. It's gone beyond screen time to which screen, what app is that? And who are you chatting with? You know, almost a decade ago, I helped author a policy statement, media and young minds for the AAP that started to deal with some of those questions, Joanna. But in the last 10 years, we have just seen an explosion of what's possible online and what we need to worry about for our kids. You will be happy to know the AAP has a new policy statement that I helped co-author called digital ecosystems, children and adolescents. And the lead author is here to discuss with us, Dr. Tiffany Munser. Dr. Munser is an assistant professor of developmental and behavioral pediatrics at University of Michigan Health and the CSMOT Children's Hospital. Her research focuses on child development and technology use. Tiffany, welcome to the show. Oh my goodness, what a treat to be here with you both. And as a podcast super fan, I'm just so like it's such a delight to be here. Thank you for taking the time. The pleasure is all ours. We're so excited to have you. And we wanted to start out with a definition. What are digital ecosystems? Yeah, it's a really great question. So digital ecosystems are really any kind of technology that kids and families are engaging with. Digital environment that's including the internet algorithms, artificial intelligence, social media apps, video games, TV, interactive agents, tablets and mobile devices. So it really includes an encompasses a broad range of digital media technologies that families are engaging with. So knowing that we live in this very digital world, how much control do parents have over their children's experiences with technology? Yeah, so of course, parents and caregivers are often the gatekeepers to these types of technologies for families. But one really key and important piece has been that digital media contains so many elements in the design of digital technology that's really immersive and commodified and pervasive for families. And so there are a lot of design elements that just make it harder for families to feel really 100% in control of their experiences. And so that was one thing that we really wanted to expand upon in this policy statement. When you say design elements, can you give an example of some of these things? Yeah, so we talk about in this policy statement, engagement-based designs. And there's this new area of research that's really investigating how these types of designs keep users' attention. So some of it might include designs with an algorithm that's really specific to your interests and liking. And it keeps you wanting to come back for more because it just gets who you are and the underlying psychology of what you might want to see. Or it might include little kind of treats or behavioral reinforcements that keep you playing longer. And so some of those designs make it harder for families and kids to transition away from digital media. So some of these designs we talk about in this policy statement. And previously the AAP was known for screen time guidelines. And with this evolving technology that's become more complex, is screen time still a good way to think about how children interact with their devices? Yeah, so that's a really great question. And you're right that digital media are really a lot more complex now. It's in our pockets. It's not just in the corner of our living room. It's everywhere. And the experiences are so much more immersive. And so it's really hard to think about screen time alone as our key indicator of children's outcomes. It's about so many other things, including the quality of digital media, the people around you who might be watching and then who you are as an individual as well. And some of the strengths that you might have and some of the unique challenges you might bring to the table. So it's about a lot more than just screen time. And so we dive into all of the different factors that families are thinking about, you know, when there might be engaging with technology. Are those factors part of this socio-ecological model that you're introduced in this policy statement? And you so can you tell us a little more about that? Yeah. So the socio-ecological model is something that's been around for decades. And the American Academy of Pediatrics has done a great job of trying to consider all of these factors that might go into shaping children's well-being. And those factors include, you know, the child themselves, you know, what is their temperament and what are their unique strengths and challenges? What is it that the child brings to the table? And how are they interacting with digital designs? And then who is that caregiver? Who's taking care of them? How are they using digital media? What are some of the parenting approaches that they're taking around digital media? What's the stress like in their life? You know, what are the other competing factors that they might have in their day-to-day living? And then what's the caregiver child relationship? We know that relationships are so important and digital media and devices are not just personal devices. They might be in places where parents and kids are interacting with each other and might be a part of kind of the relational fabric too. And then what's the digital ecosystem around them? What are some designs that can be more child-centered, that contribute to child's well-being? And what are some designs that might be more engagement driving that make it harder for families to transition away from their devices? And then finally, these systems levels and drivers of families experience really include government and policy, schools, community, the access to opportunity that kids might have, child care, third spaces. All of those are also shaping families experiences online. So if kids can't get access to safe outdoor green spaces, then families of course might lean on digital technologies or digital media to provide entertainment. So it's not just about the digital media time, it's about all of these other factors that are shaping families experiences. And when you talk about how immersive digital media can be for families is your fear there that they're engaging with a lot of AI products and that might be bad? Yeah, you know, we know that AI is already out there and there's a recent study that was published that found that 80% of teens have seen an ad for AI. And so not only is that tool out there, but kids are actively being marketed to use AI when we just don't have quite the evidence base to be able to know how it might support learning and development versus ways that it might impede children's learning and development. And what about AI enabled toys? Is that something that parents should be thinking about using as a tool for their young children? Yeah, AI toys are now on the market and there's some really interesting and exciting research in this space that's found that when AI is designed in a way that's very child centered, you know, really integrating kids' experiences and feedback for young children, there's some emerging work that's found that it can really help with literacy outcomes, it can help kids understand science better, but these are very elegantly designed AI systems and they're done in partnership with organizations like PBS Kids and National Science Foundation. And the AI that's used in those systems is really using AI to process children's language. And then there's a very standardized response to those kids that's very constrained. So the responses to those children's conversation is very, very restricted and very limited to a certain set. But the AI toys out in the market right now, unfortunately, don't have that same level of like thought and care in the responses. And so some of the responses are just from the large language models that are used and embedded in whatever that toy is. And often these large language models that are available for popular use, they themselves say that it's really for kids 13 and older. So there's a mismatch between what we know in the literature can be really helpful for kids versus, you know, how some of these AI toys are currently designed. And we know that LLMs have had responses that sometimes are not child appropriate. And so I think for now, AI toys, we still need to learn more about how they work before making a recommendation that they're going to be suitable and appropriate for kids. Well, you've described so many changes in this field since we last came out with policy statements. What's a good way now for pediatricians to have conversations about media use in their well child exams for families? Yeah, so pediatricians are still some of the most trusted individuals, you know, with regard to health information. And even though it may not seem that way based on all of the noise that families are encountering in other information systems, they really are these trusted providers and families often turn to pediatricians still to get insight and advice about their children's well-being. And so I think, you know, the pediatric providers that I've had the privilege of learning from, they've often taken a very curious and open-ended approach to understanding family's experiences. And so I think the first thing that pediatricians can do is just to get us lay of the land and understand how families are using digital media. They can use the framework called the five Cs, which is a framework from the AAP center of excellence on social media and youth mental health. And it gets at five important questions, you know, around how families are using digital media. The first C is about the child, you know, who are they? What are their strengths? What are they like doing? The second C is around the content, you know, what kind of content are kids interacting with? The third C is about calming and maybe how are kids using media to help suit themselves or calm themselves? And if so, what are some ideas that we can brainstorm together about replacement activities that can help kids feel calm and in control of their body? The fourth C is about crowding out what is digital media getting in the way of? Are there other activities that are really important that kids might be missing out on because they're using too much digital media? And then the final C is around communication. How is the family itself having conversations about digital media? And can you also describe the AAP family media plan to us? I know it's a tool families can use to outline their media goals, but how does that work? Yeah, so the family media plan is a tool that was developed by the American Academy of Pediatrics that really takes families through some questions of how they might like to use media in the home. And when you go online, you can select a different age category for each child. So it's very developmentally driven and they ask questions around not just the amount of time that kids are spending on digital media, but they also ask questions around digital literacy. Like how are you guys asking open-ended questions about how kids are engaging with media? Are there screen-free spaces in your home? How are you powering down at the end of the long day, you know? And are you getting the sleep that you need? And then what are some goals that we can set together as a family? So it's not just about kids screen time. It's about the whole family setting goals together. And you can kind of print out the whole sheet and put it on your fridge or just use it as a guide to kind of talk through together and create rules that work for the whole family. Not just one person, the kid in the family. The support emphasizes that families and even pediatricians can't do the work of helping kids interact with digital media on their own. So what are some policy changes that could help ease the stress felt by parents trying to monitor their children's interactions with all these new technologies? Yeah, so I think one key aspect has been that there's been a big investment in our digital ecosystem while there hasn't been this substantial investment in our in-person social infrastructure. And so one of the key things that pediatricians know so well is that we really need to advocate for these pro-social third spaces in-person supports for families, adequate child care, opportunities for extracurriculars, and then paid parental leave. Those are things that really can help families access opportunities that are offline that are really fulfilling. In addition to accessing these important offline spaces, pediatricians can advocate for child-centered media. So nonprofit organizations like PBS kids really have so much more child-centered design and have this strong evidence base for benefiting users. So that's another place where we can advocate for families. And then we just need to do a better job in terms of our regulatory practices and making sure that kids aren't fed harmful content from their algorithms and that algorithms are not inferring kids' interests in harmful content, like self-harm or eating disorders or suicide. And then we should develop effective age assurance so that we know who's actually using the product. And if it's a child, then they shouldn't be able to access some of this content that has adverse impact on their mental well-being and physical well-being too. I do love that the emphasis is not just on the parent to be the one in charge of this entire digital ecosystem, but given that the digital ecosystem is so large, everyone has to go read this policy statement. And what is one takeaway you want people to understand before they go and do that? Yeah, well, I think the biggest takeaway is that children really grow and learn and play in these nested circles of care, these ecosystems. And when those systems are supportive of kids and families, they really thrive. And so our digital ecosystem can be designed to be more supportive in what kids and families need. And so for the families out there, it's really not anything you're doing wrong. It's that the digital ecosystem is designed in a way that doesn't necessarily support kids well-being. And so I think we as pediatricians have a really important and exciting opportunity to partner with families to spell out the ways the digital ecosystem is not serving us. And also to push back on what that digital ecosystem is serving families. So I think that would be my main takeaway from this policy statement that I'd love for our families, pediatricians and kids to know. Well, I love all the work that you and the council have done on this policy statement. And I cannot thank you enough for joining us today and telling us more about it. Thank you so much for having me here today. To read digital ecosystems, children and adolescents policy statement, go to aap.org/podcast. Coming up, we'll look at the comparison of literacy and developmental screening of preschool age children during primary care. When parents across North Texas and the country want the best, they choose children's health, a nationally ranked pediatric hospital in Dallas, Fort Worth that's leading the way in innovation, research and pediatric specialties. From rare split-liver transplants to multi-disciplinary Wilms tumor treatments, children's health offers advanced patient care through innovative treatments and procedures. See how we're doing the incredible at childrenshealth.com. David, when you were in general pediatric practice, did you ever use the reading house? You know, I can't say that I did. I absolutely loved to reach out and read, but we didn't use a specific screen for literacy, except to ask parents how their kids were doing and to encourage reading together. It's so important to get a parents perspective on how their child is learning to read and coupling that with more objective data and how they're attempting to read can give you a well-rounded picture of the supports that that child needs. So is the reading house a good screening tool to use for child literacy? I can't answer that question, but I know who can. Dr. Sarah Bodie, she is the first author on a new paper in pediatrics, comparison of literacy and developmental screening of preschool age children during primary care. Dr. Bodie is a general pediatrician and the medical director for nationwide children's hospital school-based health program, a medical consultant for Columbia City Schools, and past chair of the AAP Council on School Health. Sarah, welcome to the show. Thank you for having me. Sarah, we could spend this whole podcast talking about the importance of reading and literacy and child development, but are you able to summarize in just a few sentences why reading matters so much for young children? Well, literacy is one of the core components of not only school readiness, but then ultimately school success. So children need to learn how to read, and then after third grade, they read to learn. So if they don't get this standard literacy skills, it really puts them behind for the rest of their education. So earlier we mentioned the reading house for those who don't know what is it exactly. So the reading house is a book. It's a seven-page book. It's got a lot of pictures on it, letters inside it, numbers, and really what happens is a coordinator or the person that's completing the screening goes into the exam room and they sit down next to the child and they say, "Can I share a book with you?" And then they ask some very scripted questions about what's in the book and getting the child's participation. So for example, here's some letters on the page, do you recognize any of these? You know, what makes this sound? So it asks about print knowledge, vocabulary, letters, rhyming, and as you go through each page of the book, there's a couple of questions that you continue to ask. At the end of that, and it takes less than five minutes to complete, then you have a score. So you have the expectation of what a three-year-old should know about the book, what a four-year-old should know, and then you use that score to determine if they're on track with those emergent literacy skills. You're not expecting that the child is reading words in the book, but they should be starting, again, to understand how to hold the book, how to open it, and then start to know some of the letters and sounds and other rhyming words within that. This child sounds really helpful. If pediatricians aren't using the reading house, how are they screening for literacy in their clinics? Well, we really don't. I think that's the point, right? So Pediatrics has a long history of literacy promotion. I mean, reach out and read it is an amazing program. We've always known literacy is important. And so we've always talked with parents about that importance, but we really have never done any direct assessment of their skills. This was really important to me because as I was in outpatient pediatric practice, what I was noticing is we had many of our kids coming in for all of their appointments prior to kindergarten. I was doing developmental screening tools, literacy promotion, all of the things you would expect. And then what I found is when these kids were coming back to me after they'd been in kindergarten, they were behind. They had failed their kindergarten assessments that the teacher had done the first quarter. And when I'm going back and looking in their medical records, I had no clue. So there was a gap there. And I wanted to think about how we could close that gap. And when you're looking at something like that, how do you test for the efficiency of the reading house as a tool? So we actually did two studies. Our first study was some quality improvement work we did for feasibility. So we wanted to know who could we train to administer this tool? How would it fit into the flow of well-child checks? We can't slow down the clinic. We have to understand how this is going to fit into the process. So there was a lot of learning to be done over the first couple years as we administered this tool. We had a coordinator or support staff go in and do this. It was not the provider. That way the provider could have the results back when they went into the room. And it was really all about the timing and getting it in and out. And what would be the action steps that we would take after the screening was completed? Okay. That sounds pretty complicated. What did you find? Did this end up being better than just talking to families about how their children are reading? Yeah. This has been such a critical part of our visits now. So I think we've learned a couple of things. First is we wanted to compare this literacy screening tool with the developmental screeners we were already doing. Because if they were identifying the same kids, then why add the tool? But what we found is we had a lot of kids that were passing their developmental screening tools, but were below average on the reading house. That was critical because it was saying to the pediatrician, here's a kid that seems to be doing well, but isn't where they need to be with this literacy. So that was an aha moment for the clinic. The second thing is often this is an aha moment for the parents as well. Parents don't always know what should their child be learning and doing before they start kindergarten and how do they do that? And so by doing this screening tool and the parents watching your interaction with the child, they begin to understand what they should be doing at home to be parents' first teacher. So that was another important component. And then the last thing was great. Now how do you get them resources? So we have a lot of materials that we give to families to help with literacy promotion at home, but then we also do care coordination to connect them to quality early childhood experiences. Well, that's preschool library programs, all those things that can supplement their learning before they start school. You know, one thing I learned from this paper too was about a profession I'd never heard about before kindergarten readiness coordinators or KRCs. Can you describe what they are? Yeah. So our KRCs are folks that we have hired to work in the clinics alongside us that are early childhood educators that have helped us every step of the way to develop this program and can really sit with the parents and again help the parents understand how to be child as first teachers. I will say that this program started with that so that we could develop the content, the materials, but anyone can administer this screening tool. It's been studied and validated for medical assistance, nurses, doctors, support staff. So it really doesn't have to be an educator that gives the tool, but they've been really helpful for us in, again, understanding what those next steps are going to be. So I think this paper is going to leave people with a lot of ideas and they're going to want to read it. However, do you have any less takeaways for people before they check it out? Yes, I'm a practicing pediatrician and I understand when we read things or hear from people about one more assessment to do in such a busy pediatric practice, I think everyone is a little skeptical and may groan about that. But I really think when we think about education, in my opinion, that is the most important social determinant of health. If you have a child that starts behind in kindergarten, evidence shows us they're going to stay behind in third grade and then when they need to read to learn, they're really going to struggle. And for kids that don't do well and meet success academically, their outcomes are so much worse. So I think this is really an important component of what we do in outpatient pediatric practice. And if there is an ability for us to, again, do this short assessment and then get kids connected to those resources they need to be successful, it'll be well worth it. Well, our listeners are going to learn a lot from reading your paper. Dr. Sarah Bodie, thank you so much for joining us today. Thank you again. To read the paper, comparison of literacy and developmental screening of preschool age children during primary care, visit our website at aap.org/podcast. At the end of every episode, we'd like to leave you with something positive or enlightening. We call this segment, say, "David, what's your say this week?" Well, I'm afraid it's going to be about moving to Seattle for a while. But I am currently in the stage of this move that I'm calling everything is hard and weird. And the enlightening part about that is everyone here has been so helpful and so lovely from a neighbor walking down the street to someone on the dog walk who told us it was okay to take a picture of Mount Rainier every single day because that is what we're doing from that particular part of the dog walk to everyone at the hospitals helping me get oriented and pointing me in the right direction. So there is a lot positive and enlightening even if there is much confusing as well. While speaking of snowy Mount Rainier, it made me think of my say, which is it snows not that often in Philadelphia, but we get a few good sledding days and we got a really good sledding day with the kids the other day. And it was so fun. Yeah, we were outside for hours. You know, I think the baby is still plus or minus on this whole idea of the cold and snow with the older two kids love it. So it was just so much fun. Oh, there is nothing better that is great. Well, that's it for today's episode. If you like Pediatrics on Call, please subscribe on your favorite podcast app and help us spread the word. Follow us on YouTube, Facebook and Instagram at Pediatrics on Call. Pediatrics on Call is a production of the American Academy of Pediatrics. Our producers and editors are Ann Johnson and Claire Keating. Our audio engineer is Doug Nagel. Joe Puskars is our associate producer and Susan Martin is our executive producer. Our theme music was composed by Matthew Simonson. Join us next week, we'll bring you the February edition of First Up. We'll speak to the associate editor of blogs, Dr. Rachel Moon. I'm Dr. David Hill. And I'm Dr. Joanna Bargobolinky. Thanks for listening. [Music]