The Screen Time Conspiracy and other “clinical guidelines” woes

I recently received a communiqué from a physician asserting that the “AAP [American Academy of Pediatrics] recommends no more than one hour each day of screen time.” This immediately raised my hackles on several levels, beginning with the implied criticism that I was not being a responsible parent. (Parents out there, raise your hands: how many of you limit your children’s total time watching television and using video games, computers, handheld games, or cell phones to less than one hour per day? Every day? Be honest! Include time the child spends in others’ care, including school. Are you sure? Do you know how to program your television’s V-Chip? I don’t see many hands out there. The rest of you must be BAD PARENTS.)

I checked the AAP web site. Guess what? Multiple different searches on the site failed to turn up any such recommendation. Is that the fault of my physician colleague? Probably not — I am sure she was just promoting her own agenda by quoting a misquote of a misquote promulgated by someone else with an agenda. For the record, the AAP states that “there is little evidence” to support limiting screen time, but that a reasonable guideline for prevention of childhood obesity might be 1-2 hours per day. But even that is absurd…

I’ll begin by nitpicking. To “limit” something to a range means that you are setting upper and lower limits. Saying “limited to 1-2 hours per day” means that they are recommending a minimum of one hour of television (but less than two hours) per day. Perhaps nobody would actually read it that way, but it displays a rather sad lack of rigor and precision in something posing as a scientifically-based recommendation. The literature/writing major in me is offended. And if the AAP isn’t recommending a minimum of one hour of television per day, what does the “1” in “limited to 1-2 hours per day” mean? Surely they meant “limited to 2 hours per day.” But if that’s what they mean, why make the statement wishy-washy by putting in the range? Why? Because they really don’t believe what they’re saying, so they equivocate.

Consider this list:

  1. using a computer to write an academic paper
  2. using a computer to research a topic of interest
  3. using a computer to view age-appropriate reading material
  4. using a computer side-by-side with a parent who is actively participating
  5. using a computer at school under a teacher’s direction (we’re privileged to have a highly computerized classroom, but that amounts to over an hour a day of screen time, right there)
  6. educational learning sites (see Starfall for one example)
  7. interactive, role-playing games with creative canvases, puzzles, and challenges
  8. arcade style “shoot everything that moves” games
  9. Sesame Street and similar non-commercial broadcast programs
  10. non-violent cartoons with commercials
  11. cartoons based on violence with commercials
  12. educational commercial television
  13. violent commercial television

These get identical shrift under the rubric of “screen time.”

We’ve gone from “no more than one hour per day” to “well, we don’t know, but maybe 1-2 hours/day might be a good starting point.” I see a few more hands up now — this approaches reasonable advice: two hours plus or minus might be a reasonable TV limit for a lot of children (assuming your school hasn’t already used it up with computerized education or a film). Alas, it still leaves this pesky problem: the parent who allows a 15 year old to spend 3 hours doing research on the computer for a science fair project is just as guilty of poor parenting as the ones who park their three year olds in front of the Hitler Channel. Does this make sense?

Perhaps it would make some sense if we knew about the science that prompted the guidelines. But we find that the AAP wasn’t exaggerating when they said that there was little evidence to support limits. In fact, there is almost no evidence. Generally, the guidelines don’t cite any papers. When they do cite one (and only one), you find that the AAP wants to charge you to view it. But wait, I can get a copy at the UCDMC medical library, only 11 miles away! So I pile my two children in the car, and head for… uh, oh. Here is where things get interesting. One of the things the AAP is unequivocal about is that the greatest single source of injury and death for children is motor vehicle accidents. Childhood obesity? Second-hand smoke? Abuse? Street violence? Drugs? — none of these even compare. So, naturally, they give guidelines for driving with children, right? I mean, if they’re willing to provide guidelines around screen time, with no evidence of benefit, surely they’ve recommended limits on an activity responsible for more pediatric injuries and deaths than any other. But, surprise, there are no such recommendations.

Here’s my modest proposal for addressing this oversight: First, we have to define transportation. There’s no science to guide us, but no problem. With a little help from the petroleum and automotive industries, we’ll define “transportation time” as any of:

  1. running
  2. walking
  3. riding a bicycle
  4. riding public transit
  5. riding in a car
  6. riding in an SUV, watching commercial broadcast TV in the back seat while the driver smokes a cigarette and talks on a mobile phone

Next, there is clear evidence that “transportation time” is far more dangerous than “screen time,” so we should limit it to one hour per day at the absolute maximum. By the time you’ve driven that SUV to school, swim practice, the grocery store, and home there’s naturally no time left for running, walking or biking.

We’re left with the question of why there are recommendations at all, and who invented the concept of “screen time,” which lumps a huge range of diverse activities, from productive to destructive, into a single category. Time to follow the money. Who benefits? Commercial broadcast television. Commercial TV has been struggling of late with something new to them: competition. People are increasingly looking to cable, the internet, computers, and other new media for entertainment. Commercial broadcast TV has been losing market share, but they still have strong allure. Create a system limiting “screen time,” and chances are that many people will use their precious minutes on the easiest, most passive activity. Commercial TV benefits because impressionable youngsters do not get exposed to new media, and another generation will grow up looking to commercial television as their primary entertainment source. Do you think commercial broadcast TV has no influence over the AAP? Think again. Broadcasters spend real money “supporting” the AAP, and they don’t do it out of their sense of civic duty. They wouldn’t spend the resources if they didn’t expect results. I have no evidence that broadcast TV influenced the AAP, and I’m confident they would deny such a link, but why else would an otherwise careful organization embrace a crazy concept like “screen time” and then promulgate unscientific guidelines around it?

The bigger picture is that “clinical guidelines” are proliferating all over medicine. Several recent surveys, summarized in this Journal Watch article, found that only a tiny fraction of the recommendations in clinical guidelines are based on scientific evidence. If not scientific evidence, then what? Those recommendations are simply a reflection of somebody’s agenda. At best, that agenda is solely for the public good. In that case, imbuing the unsupported opinions with the aura of scientific fact is simply unfortunate. At worst, the opinions couched in clinical guidelines published by scientific societies promote a hidden agenda masquerading as science. In either case, it makes it all too easy for those wishing to advance their own agendas to misquote the guidelines or take them out of context and then claim “The American Academy of Pediatrics recommends…”

There is no reason that organizations representing medical professionals should be bundling up this pseudoscience and promoting it as fact. Doctors, it’s time we start ignoring this bunkum unless it’s backed up by verifiable scientific fact, and for heaven’s sake, let’s not be passing it on to our patients. Patients, view these guidelines with skepticism, even when they seem to make sense or agree with what you want to believe.

— Ron Risley – 16 Mar 2009

PS: Don’t have a Journal Watch subscription? If you’re a physician, you should consider it. In any case, you can check out their source material here and here and here.