Pediatricians have in the past referred to “middle childhood” as the latency phase of a child’s development, suggesting that not much occurs in a child’s physical and mental development during this period of a young person’s life.1 Now, in this issue of Pediatrics, Parasuraman et al2 highlight the “fragility” of latency. They call us to recognize new health risk behaviors in this period of development, with morbidity resulting.
Middle childhood encompasses the primary school years, which are defined as 5 to 10 years of age (by the American Academy of Pediatrics Bright Futures guidelines3 ) and 6 to 11 years (by the National Survey of Children’s Health [NSCH]). The NSCH is an address-based national survey that provides national and state estimates of key indicators of child health and well-being. The authors drew data from the 2016 and 2017 NSCH and share important findings in their study; some are reassuring, and some are surprising.
During this period, the NSCH found that more children have 2-parent families, higher parental education, and lower rates of poverty than in the recent past. Most children also live in health-promoting neighborhoods with “amenities,” such as sidewalks, playgrounds, and community centers. As clinicians assess developmental assets and protective factors as part of health supervision visits, these findings will be reassuring because they are health promoting.
Not surprising but troubling was the finding that 21% of children have a special health care need, with allergy and asthma being most common. This is also consistent with previous studies. Attention-deficit/hyperactivity disorder affected 8% to 9% of children, with the percentage increasing with age, which is consistent with the recent American Academy of Pediatrics review and update to the attention-deficit/hyperactivity disorder guidelines.4 Also not surprisingly, anxiety affected 6.5% of children, and 3% of children had autism spectrum disorder. Those of us who practice would likely find similar rates of these mental health issues in our own patient cohorts.
But Parasuraman et al2 also provide behavioral findings from the NSCH that challenge us to rethink this often-overlooked period of childhood. In the United States, children in middle childhood spend too much time with electronic devices. Their screen time increases as they age from 6 to 11 years, with a concomitant drop seen in sleep and physical activity, both of which are key components of self-care. Self-care includes not just the protective factors of sleep and exercise but also connectedness to family and peers and avoidance of risks, such as tobacco, alcohol, and marijuana. These behaviors are functionally opposite to time spent on social media or in front of a screen. Should we be concerned that more screen time and social media and less physical activity and sleep will lead to even more obesity and anxiety in a future NSCH results analysis?5,6
Early media use deserves stronger messaging in health promotion. Primary care health supervision seeks to detect disease and promote healthy choices that are intended to prevent disease and enhance wellness. These clinical encounters also provide the opportunity to give parents and youth anticipatory guidance as described in the Bright Futures guidelines. With anticipatory guidance, “child health care professionals assess emerging issues that a child and family face and give advice that is developmentally consistent. For anticipatory guidance to be effective, it must be timely (ie, delivered at the right age), appropriate to the child and family in their community, and relevant so that key recommendations are adopted by the family.”3
To prevent worsening of health risk behaviors and strengthen self-care in youth, Bright Futures suggests that primary care clinicians discuss these self-care factors, including reduction of screen time, in their anticipatory guidance at health supervision visits. But are we clinicians doing so? Are we doing it effectively? This analysis of NSCH data suggests we might more carefully address screen time with kindergarteners. And we need new language and interventions to help parents and their children see clearly how time on a screen steals time from physical activity, talking with family members, reading, and even sleep. We thank Parasuraman et al2 for drawing attention to contemporary topics that are relevant to middle childhood that might appropriately bring clinicians to rethink how we might better focus our anticipatory care before and during middle childhood.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2244.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.