Occupational Therapists Speak Out

A Baltimore County occupational therapist writes about the 1:1 tablet initiative in Baltimore County Public Schools and the health implications for the national push for more computer time in school.

There remains mounting concern over the initiative for children to have increased access to technological devices throughout a typical school day.  Between parents, pediatricians, occupational therapists and other developmental specialists, our voices should be heard and acknowledged.

Research continues to evolve that analyzes the developmental effect the increased use of tablets and other screen devices have on children and their growing brains.  While many may argue that students are more “engaged,” appear to pay more attention, and learn some academic skills at a quicker rate, they are fast to ignore the decrease in social engagement, play skills, fine motor skill use and muscle strengthening.

As a pediatric occupational therapist working with children with various mild to severe diagnoses or delays, it is evident that there is a rise in children presenting with motor delays, which at times can be linked to overuse of tablets, cell phones and other technological devices. Overexposure to the vast pieces of technological equipment can be linked to impaired learning, increased impulsivity, executive functioning delays, decreased ability to self-regulate and tantrums. 

What about eye strain? Or posture maintenance as a child’s neck is constantly looking down at a tablet and they begin to hunch over in their chair? Finger strength diminishes as they no longer need to maintain a grasp pattern on a pencil or crayon and apply or assert pressure to write and color.  Can a child become addicted to technology? Some studies seem to think so.  Even more alarming is the thought of radiation emission from wireless devices flooding the classroom. It has even warranted the American Academy of Pediatrics to request review of EMF radiation emissions from technology devices.

The American Academy of Pediatrics (AAP) released a policy statement titled “Media Use by Children Younger Than 2 Years” in 1999 with the purpose to provide parental education about the negative effects of media exposure to this age group.  As the years have passed and further research has been conducted, a more recent policy statement was released by the AAP and published in November 2011 in their Pediatric journal.  This article states that media use has been associated with obesity, sleep issues, aggressive behaviors and attention issues.  The AAP continues to stand by its statement that there are no known positive effects, but yet potentially negative effects for children younger than two years when exposed to media use.

In an article written by Perri Klass, M.D., in the New York Times titled “Fixated by Screens, but Seemingly Nothing Else”, screen use and attentional issues were discussed.  The author stated that increased screen time may be linked to and also a consequence of A.D.H.D.  This article also referenced a study in 2010 in the journal Pediatrics that stated viewing more television and playing more video games were associated with attention problems in school age children and college undergraduates.

(Editor’s note: The difference between gaming/TV time vs. “educational” screen time is quickly diminishing with the current mode of software-delivered lessons via “gamification” (dopamine-surge video game-style) and numerous videos accessed by isolated students wearing head phones. See also this article by longtime education researcher and expert on the proper use of laptops in classrooms, Larry Cuban “Some Technology Leaders Worry about Children and Digital Devices: They Should.” )

Children are exposed to bright screens with intense visual stimulation which can alter the wiring of the brain. As children become so accustomed to the screen and intense visual stimulation, they are in turn less able to focus on a teacher or a “still” environment that does not produce the same visual stimulus.  Dr. Dimitri Christakis, a pediatrician at the University of Washington School of Medicine stated “if a child’s brain gets habituated to that pace (of a video game or highly stimulating screen) and to the extreme alertness needed to keep responding and winning, the child may find the realities of the world underwhelming, understimulating.”  Learning and functioning behind a screen is not always indicative of the real world.

In an article in the Huffington Post, Cris Rowan writes “diagnoses of ADHD, autism, coordination disorder, developmental delays, unintelligible speech, learning difficulties, sensory processing disorder, anxiety, depression, and sleep disorders are associated with technology overuse and are increasing at an alarming rate.”

While I am a strong component of the use of technology, I suggest limits should be set and a healthy occupational balance should be maintained.  This means shorter time periods of tablet/device use and the continuation of functional activities such as handwriting, creative and imaginative play and sensory motor play and experiences.  I occasionally use an iPad as a therapeutic tool in therapy sessions; but, it does not replace the use of various other practical tasks.

With the growth of technology in today’s world, we can assume that a majority of children have access to tablets and devices at home. If they are spending so much time at home on them, is it necessary that we also force their use in the classroom?  I welcome the opportunity to further discuss this emergent epidemic as we watch our children grow in an environment overwhelmed with screens.

Letter by Lindsay Marzoli, one of two occupational therapists who spoke recently before the Baltimore County Board of Education.

Lindsay Marzoli, MS, OTR/L #06167

Licensed and Registered Pediatric Occupational Therapist

Director of Occupational Therapy Services

Learning and Therapy Corner, LLC

1818 Pot Spring Road, Suite 100

Lutherville, MD 21093





American Academy of Pediatrics. (2011). Policy Statement: Media Use by Children Younger Than

2 Years. Retrieved November 21, 2013 by pediatrics.aappublications.org

Blog Post by Cris Rowan, Pediatric Occupational Therapist. Posted on 3/6/2014 and updated on

3/24/2014 titled 10 Reasons Why Handheld Devices Should Be Banned for Children

Under the Age of 12.

Huffington Post. The Impact of Technology on the Developing Child.

Cris Rowan, OTR. Posted on 5/29/2013 and updated on 7/29/2013.

The New York Times. May 9, 2011. Screen Fixation and A.D.H.D- Fixated by Screens, but

Seemingly Nothing Else. Dr. Perri Klass. NYTimes.com

And here is an anonymous response by another Baltimore County occupational therapist:

I agree with the OT’s perspective about technology in the classroom. The STAT program can play an important role in learning, but it needs to be used in moderation. BCPS OTs report to each other that they are seeing more referrals and the students do not have the same quality of fine motor skills than in previous years. They attribute this to children spending more time indoors and on devices. The children are not playing with toys and are not playing outside with other children. Eye strain, decreased finger coordination and strength, and decreased sustained attention to tasks that are not on a screen are all concerns from my point of view. Every year I observe 2-3 kindergarten students who just cannot hold a pencil. They are “all thumbs.” I ask them if they play on their i-pads a lot at home. Every single one of them lights up and tells me, “Yes!”.

I see both pros and cons for the use of technology, but the demise of handwriting skills because of technology is not the only reason; the alignment of the curriculum to the state curriculum also plays into children’s difficulties with handwriting. Developmentally appropriate pre-writing and handwriting is not stressed in the Pre-K, K, and 1st grade curriculums. By the second quarter, kindergarten students are encouraged to compose ideas, but they do not know how to form the letters with the appropriate sequence of strokes. They draw the letters to the best of their abilities and do not receive feedback about their letter formation. They receive feedback about their thoughts. I do not want to have their creativity squelched, but they also need to learn the basics of writing. Pencil grasp and the accurate sequence of strokes for letter formation take a back seat to composing ideas. I have 1st and 2nd grade teachers tell me that it is painful to get these ideas out of the children because they do not have that higher level thinking at this time in their development. I see Pre-K students copying words without instruction on how to hold a pencil or how to hold a crayon. They are copying words but can’t identify all of the letters, much less pronounce the words. I see Pre-K students drawing and coloring with full-fisted grasps and their fingers wrapped all around crayons. Schools need to stop purchasing standard pencils and standard crayons for Pre-K and K classrooms. All of the children would benefit from using beginner crayons and the thicker beginner pencils. Modify the tools so that it is easier for them to complete the task. This way they are not holding onto the pencil or crayon with a tight grasp and hyperextension at their finger joints. Stop pushing human development. School curriculums and social norms change, but the rate of human development has not changed over these past 20 years. Pre-school classrooms also should have less worksheet activities and more multi-sensory instruction. Letter instruction: make playdoh letters, shaving cream letters.

Cursive handwriting is barely taught in BCPS schools. This is a national trend, not just a BCPS trend. It is taught as filler time. Some people believe that cursive is a dying form of communication and it is true that school systems have phased it out of the curriculum. Cursive writing has been shown to be a more effective mode of communication than manuscript for children with learning disabilities because it eliminates the constant starting and stopping of each individual letter. The letter formation also discourages letter reversals. Despite this research, BCPS does not provide in-depth instruction in cursive handwriting for children with diagnosed learning disabilities. Are the occupational therapists then allowed to provide this instruction to the children with learning disabilities? No, because that is considered handwriting instruction. The occupational therapists are to focus their interventions on the visual motor and fine motor components of handwriting, not teach handwriting. Unless a parent intervenes with private OT services or works on cursive handwriting at home, the child will not be provided with this intervention.

There is a benefit to having the STAT program for children with learning disabilities. Before the children were provided with 1:1 devices, it was difficult to obtain devices for the students. The majority of these children did not have IEPs; they had 504 plans or no formal accommodations. Accommodations are provided at the school level, not through Assistive Technology, and the schools were not providing devices to these children. My child has a learning disability of dysgraphia. His teacher was putting him on her teacher laptop (this was before the teachers were provided with their own devices), because the computers in her classroom were antiquated. I could have gone the Assistive Technology route, but that would have taken months by the time he was teamed, assessed, and provided with a device. I bought him a Chromebook and he used that for 4th and 5th grade. It worked out great, but not every family has the resources to purchase a computer for their child for in the school. Now I see students with dysgraphia having the opportunities for keyboarding everyday. That was not true before STAT. Children are also provided with having Kurzweil for reading and writing difficulties.

If we are providing 1:1 devices, we also need to provide keyboarding instruction. Do we expect kindergarten students to automatically know how to form their letters? No, so why does BCPS assume that children will know how to operate a keyboard and touch screen? It is up to the teacher to fit it into their day. This time does not exist unless it is mandated by the curriculum. Dreambox math program is mandated by BCPS. Teachers are told that the children must have X amount of minutes of Dreambox per week. If Dreambox can be mandated, why can’t a typing program be mandated by BCPS? Before STAT, I would recommend that children with processing difficulties use word processing and I would always hear that their typing was too slow. Of course their typing was slow. They didn’t know the keyboard. Teachers would be told to fit it into their day. This time did not exist. These children had difficulties with attention and processing; everything already took longer than their peers. Providing keyboarding instruction for all children helps level the playing field for all of the children.

I have concerns about screen time and altering the wiring of the brain. I see children having difficulties with sustaining their attention to paper/pencil activities. Life is not an actively moving pixel. I do not like seeing Pre-K students dancing to song after song from YouTube. The movements are so fast and they cannot keep up with the movements. They are also watching the screen, like it’s a giant TV. Daily calendar or question of the day using the white board also eliminates the fine motor and visual motor aspects of the task. Also, in the upper elementary grades, the teachers cannot monitor that the children are using the technology appropriately all of the time.

One aspect that has not been brought up is how does this decrease the socio-economic gap in education? Outside of my current school, I work in Title I schools. Many of the families do not have internet access and do not have the ability to access BCPSOne, much less a tablet with a keyboard or a computer. Are we unintentionally increasing the gap as our more affluent families access BCPSOne? What programs are in place to encourage our less affluent families to play more educational games and access BCPSOne? Could STAT be a way of encouraging these families to be a more active participant in the educational process? If BCPS is going to be a leader in STAT, they need to think outside of the box so that all socio-economic levels are participating in STAT.

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