Does your patient have sleep problems? Ask about TV first

ARTICLE REPRINT • From the September 2000 AAP News, the official news magazine of the American Academy of Pediatrics

If a patient you are seeing isn't getting enough sleep, television programs and movies are likely culprits. Beyond keeping children up later to watch, mass media are a potent source of nightmares, sleep disturbances and intense anxieties. Several recent reports in medical journals support this contention.

A survey of third- through eighth-graders revealed that as the number of hours of television viewing per day increased, so did the prevalence of symptoms of anxiety, de-pression and post-traumatic stress (Singer MI, et al. J Am Acad Child Adolesc Psychiatry. 1998;37:1041-1048).

Similarly, a different survey of parents of children in kindergarten through fourth grade revealed that the amount of children's television viewing (especially at bedtime) and having a television in their own room were significantly related to the frequency of sleep disturbances (Owens J, et al. Pediatrics. 1999;104:e27). Indeed, 9% of the parents surveyed reported that their child experienced TV-induced nightmares at least once a week.

These fears should not be taken lightly.

Movie and television ratings are one place to look for information when making viewing decisions for children, but parents can't depend on them.

A recent study illustrated this point by showing not only that all 74 G-rated animated features currently available on video contain violence, but that injuries (half of which are fatal) occur in 62% of these movies (Yokota F, Thompson KM. JAMA. 2000;283:2716-2720). When Bambi's mother is killed by a hunter or when Simba (in "The Lion King") thinks he is responsible for his father's death, it's not a laughing matter for a preschooler.

An understanding of a few child development principles is a big help.

What frightens children
When trying to predict the types of media messages most likely to frighten young children (2- to 7-year-olds), keep in mind the phrase, "Seeing is believing."

First, because this age group is most sensitive to appearances, how things look is of paramount importance. Children in this age group are more likely to be frightened by something that looks scary but is actually harmless (a friendly mutant or a benevolent monster) than by something threatening with a benign exterior (a handsome villain or a beautiful yet evil witch).

Second, because this age group has not fully grasped the fantasy-reality distinction, they are just as likely to be frightened by something that's totally impossible (a sorcerer casting an evil spell) as by something that's realistic and can actually harm them (a kidnapper or burglar).

By the latter elementary school years (ages 8 to 12 years), children become more sensitive to media stories about things that are dangerous but may not look scary, and those that are realistic as opposed to fantastic or impossible. Children in this age group become increasingly sensitive to threats conveyed by the news and other realistic programming, especially stories about threats to children - events they understand actually happened and could happen again to them.

Even teen-agers often have long-term fright responses to mass media presentations, whether fictional (in drama) or real (in the news). The two themes that emerge as the most terrifying to this age group are sexual assault and stories involving the supernatural and the occult.

Getting the message out
The media industries are firm in denying the potential of their products to harm children, and they will not cooperate in promoting the message that parents need to exercise caution. But pediatricians are in a position to provide this information.

Parents need to know that media can produce overwhelming anxieties and virtually indelible memories in children and adolescents. Parents need guidance on how to select appropriate content for their children and how to talk to their children about the media. They need the skills to reassure their children when they are frightened and to encourage them to choose media that will promote rather than disturb their physical and emotional well-being.

Entertainment should be healthy as well as entertaining. A good night's sleep is a terrible thing to waste.

Joanne Cantor, Ph. D., is a professor at the University of Wisconsin-Madison and the author of the book "'Mommy, I'm Scared': How TV and Movies Frighten Children and What We Can Do to Protect Them." San Diego: Harcourt Brace;1998. (Reprinted with permission).

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Most frightening media content for different ages:

2- to 7-year-olds
o Scary visual images: vicious animals; monsters; grotesque,
mutilated or deformed characters.
o Character transformations, especially when a normal character becomes grotesque.
o Stories involving the death of a parent.
o Stories involving natural disasters, shown vividly.
8- to 12-year-olds
o More realistic threats and dangers that can happen, especially things that can happen to the child.
o Violence or the threat of violence.
o Stories involving child victims.
13 years and up
o Realistic physical harm or threats of intense harm.
o Molestation or sexual assault.
o Threats from aliens or occult forces.

Reprinted with permission. American Academy of Pediatrics, AAP News, September 2000.