As the developing child matures simultaneously in separate, but interrelated areas, this article will discuss television's impact on cognitive development and growth. Television's influences on growth stem from its effect upon nutrition, eating habits and subsequent obesity. The influence on cognitive development reflects an interaction between viewing time, program content, and cognition. We will discuss these areas in greater detail and offer some suggestions on the pediatrician's role in moderating these effects and influencing television in general.
EFFECTS OF TELEVISION ON NUTRITION
The influence of television on children's eating habits and their nutritional status is mediated by three types of explicit and implicit messages. First, television advertising directly influences family food purchases and the snacking behavior of children. Second, the frequent use of food in television programs may provide an implicit message regarding the use of food for a variety of activities other than the satisfaction of hunger. Third, the paucity of obese children and adults in either television commercials or programs misrepresents the prevalence of this problem in the population, and suggests that food consumption, or the consumption of foods advertised on television have no implications for health or nutritional status. In this section, we will examine the effects of television on eating behavior and nutritional status. We will then explore the potential mechanisms by which television can influence these behaviors.
We have recently shown that the time spent viewing television by 6 to 11 year old children and 12 to 17 year old adolescents is directly associated with the prevalence of obesity in these two populations.1 These observations were derived from the examination of data collected during Cycles 11 and HI of the National Health Examination Survey (NHES).
In Cycle II, children aged 6 to 11 years old were studied during the period from 1963 to 1965. Cycle III evaluated adolescents aged 12 to 17 years old during the period from 1966 to 1970. Approximately one-third of the 6 to U year old children studied during Cycle II were restudied during Cycle III when they were 12 to 17 years old. Therefore these surveys provided two cross-sectional and one prospective sample. Each cycle was representative of the non-institutionalized population of United States children and adolescents in the same age group. Obesity was defined as a triceps skinfold greater than the 85th percentile for children of the same age and sex.
In each cross-sectional sample, as well as the prospective sample, we observed a direct relationship between the prevalence of obesity, and the time spent viewing television. In each sample, the association persisted after successive controls for region, season, population density, socioeconomic status, parental education, and other leisure time variables were introduced. In the prospective sample, time spent viewing television at age 6 to 11 years proved the most powerful predictor of subsequent obesity at age 12 to 17 years old after prior obesity was controlled.
These observations suggested that the association of television viewing and obesity was causal. First, the observations were consistent; statistically significant associations were observed in two cross-sectional and one prospective study. In each survey, a dose-response effect of television viewing and obesity could be demonstrated. In the prospective study, a temporal relationship of television viewing and obesity was observed. The relationship between television viewing and obesity was also specific, insofar as it persisted after controlling for other variables that affected the prevalence of obesity. Finally, as discussed in greater detail below, children watching television are not participating in more energy intensive activities, and tend to consume more of the high calorie density foods advertised on television. Eating while watching television may be an additional source of excess calories. For example, over 80% of adolescents consume food while viewing television.2
Food and Obesity in Programming
Although commercial advertisements are an important source of information about foods, the use of food iri television programs and the images portrayed on prime time television convey several implicit messages that relate to nutritional status. In a survey often topranked prime time programs, references to food occurred two to three times per program, and were more frequent in program content than in commercials.3 The largest proportion of references to beverages and sweets was found in program content rather than in commercials. Furthermore, food references in program content were more frequently to nonnutritious foods than in commercials.3 The frequency of snacking (39% of all eating or drinking episodes) is almost as great as the consumption of breakfast, lunch, and dinner combined (42%). 2
Despite the high frequency of food messages and advertising on prime time and children's television, the prevalence of obesity among prime time characters is low. Children and teenagers are almost never overweight or obese, and only 12% of adults are in an overweight category.3 However, 90% of obese persons on television were black, despite the widely recognized phenomenon that blacks in the population tend to be thinner than whites at all ages.3
These observations may suggest to children and adolescents that televised characters can consume food without consequences for their weight. This assumption is clearly contradicted by the finding that time spent viewing television is directly associated with the prevalence of obesity in the population.
The linkage between food advertising and consumption is suggested by the frequency of commercial advertisements in children's programming and is supported by several lines of observational evidence. Time spent viewing television increases between-mealsnacking.4·5 Consumption of foods advertised on television is directly related to time spent viewing television.4 Furthermore, in an experimental study that tested the relative efforts of children to continue watching either programs or commercials on television, 5 a significant positive relationship was observed between the efforts a child made to continue viewing commercials and the number of attempts the child made to influence his or her parent's purchases in the supermarket. In addition, the total number of hours per week of commercial television that a child viewed was directly and significantly associated with the number of attempts made by the child to influence the parent's supermarket purchases.
As shown in the Table, food advertising accounts for the largest proportion of advertising during weekday and weekend commercial programming directed at children.6 As the Table indicates, most of the foods advertised are foods of high caloric density. The logical implication of the implicit messages regarding snacking and snack choices on prime time television, and the advertisements for high caloric density foods on children's commercial television is that the two will increase consumption of calories. Inspection of growth curves of obese children reveals that their obesity can be accounted for by the ingestion of 50 to 100 excess calories pet day (W. H. Dieti, unpublished observations). Therefore, the combination of excess calorie consumption promoted by television viewing with the reduced activity that accompanies television viewing could easily account for a caloric imbalance of this magnitude.
EFFECTS OF TELEVISION ON COGNITIVE DEVELOPMENT
Although there has been a large volume of literature dealing with the effects of violent programming and commercials, television's impact on cognitive development has only recently been investigated. The literature suggests a very powerful, as well as complex, interaction between television viewing, cognitive development, and learning. The simplest approach would be to compare varying television experiences and some measure of cognitive development. Although it would be impossible to attempt within this country, Williams7 was able to compare three Canadian towns of differing television exposure: one town without television; another with only one channel; and a third with several. As one might predict, the children (second and third graders) in the town without television scored higher reading scores than those in the town with only one channel. The children in the one-channel town scored higher than those in the multi-channel town. More importantly, this difference disappeared two years after the town without television received a channel. There are a number of possible explanations for this phenomenon. The most obvious would simply seem to be that television viewing displaces time potentially spent in other activities, such as reading, studying and playing. Supporting this theory would be a study in Japan8 which found that children with television sets experienced a decline in both reading skills and homework time.
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Earlier studies initially evaluated a simple relationship between IQ and viewing time. Although students with IQs greater than 115 initially viewed more television than those of lower IQ scores, subsequently, after ages 10 to 13, the higher IQ group viewed less.9 Overall, however, most studies demonstrate a negative association between IQ and time spent watching television. Such studies certainly do not prove that television lowers IQ, but simply a complex interaction between the two variables that is at least mutually reinforcing.
Another possible explanation would be a more direct adverse effect on cognitive development. This is, unfortunately, much more difficult to prove. There are, however, numerous studies which demonstrate such an effect of television viewing on learning and achievement. Studies by Burton and Medrich have demonstrated that younger children who watch more television do less well in reading and overall achievement than those who watch less television.10,11 The relationship between viewing and achievement, however, is not always linear. For example, in a large DHEW study in 1984, it was found that students watching one to two hours of television a day scored higher in reading achievement than those who watched less.12 As the viewing time increased, the reading scores decreased. The difficulty witK these studies was the unfortunate lack of appropriate controls, for example, IQ and socioeconomic status (SES). There have been studies which eliminated the SES factor with similar findings; a negative correlation between TV viewing and achievement.13 Morgan and Gross also controlled for IQ and found that although most negative associations were reduced, they remained negative.13
As stated above, in many studies there is a curvilinear relationship that often emerges between viewing and achievement. Therefore, there does seem to be some beneficial effect of limited viewing; for example, improved reading and vocabulary scores. This may be especially true in those children with lower IQ scores. This relationship, however, becomes negative as viewing time and age increase. It should also be noted that these effects are greater in boys.
To further demonstrate the complexity of this issue, we can again look at the influence of television on time spent reading. Morgan found a positive relationship between viewing time and reading time, a consistent finding even when controlled for IQ.14 This relationship is both significant and interestingly longitudinally consistent. The content of the reading material of heavy viewers, however, seems to reflect viewing preferences - for example, love stories, adolescent stories, and stories about movie and TV stars. More importantly, their comprehension may not be as great as light viewers.
To add to the complexity, not all areas of achievement are similarly affected. For example, math scores, when IQ is controlled, are not affected by viewing patterns but language and reading comprehension scores are.
It does appear, therefore, that television's effect on viewing is indeed complex. As the landmark NIMH report states: "In sum, there is no one effect of television on achievement, nor is there even one relationship. Above all, the patterns vary tremendously by sex, by IQ group, and by the specific area of achievement. It seems likely at this point that younger students and those with higher IQ scores show stronger negative and monotonie associations between amount of viewing and achievement. While there are a substantial number of replicated results, there are many exceptions as well, and that in itself may be the primary finding."15
There has been some recent fascinating research that investigated the influence of the television medium on the child's concept of that medium. Solomon has stated that ". . . the perceptions of the medium's demands affect effort investment," and that "unless children are specifically instructed to treat the stimulus differently than usual, they invest little effort in it and extract little inferential knowledge from it. In other words, they appear to be relatively effortless televiewers^ performing below their real levels of ability." A consequence of this observation may be the findings that ". . . heavy television consumers produce narratives that are choppier, entail fewer words per sentence, and are more descriptive of external surface elements than those produced by light television viewers. In other words, the preconceptions that are successfully applied to television may be transferred to other kinds of information." These studies would imply a definite direct effect on cognitive processing, an implication of great concern meriting much further research.
In summary then, as the NIMH report states, "the primary finding is that not only the intensity, but even the direction on television's consequences for education - both achievement and aspirations - seem to depend on a wide variety of other factors which mediate, condition, diminish or reverse the associations. Television viewing may be seen as a "quasi-demographic" variable which has one set of implications for some, and another set of implications for others. It consistently makes a difference, although that difference is clearly not the same for all students. Television viewing may lead to conflicts in behavior, attitudes, and behavioral expectations. We can be fairly sure that at any given time, adolescents who watch more television will score lower in achievement, particularly in reading, and they will express lower ambitions for both schooling and career. But heavy viewers may also, ultimately, spend more time reading and, if they have lower IQs, their reading scores will be higher; and, if female they will express higher educational aspirations than do light viewers two years later. The questions of how the underlying processes of interaction with other social, personal, and familyrelated factors actually work are still wide open."
Concern over such issues as discussed above, has led to the involvement of pediatricians and other child advocates in the legislative arena. The Federal Trade Commission (FTC), Federal Communications Commission (FCC), and the Congress represent the three major organizations through which changes in television programming or advertising can be implemented. All are potentially capable of responding to public pressure. Each will be briefly considered in turn.
The Federal Trade Commission was initially charged to respond to unfair methods of competition in commerce, but gradually began to regulate deceptive advertising as a form of unfair competition. In 1976, acting on a complaint by Action for Children's Television, the FTC ordered the Hudson Pharmaceutical Company to cease advertising Spiderman vitamins on children's programming because such advertisements tended ". . . to induce children to take excessive amounts of the vitamin supplements which may cause injury to their health." Later, the FTC attempted to ban all advertising on children's programming. However, the response of the FTC to such complaints was a function of the political climate. In the last six years, the goal of the FTC has been the deregulation of broadcasting. If one is concerned, however, about the impact of commercials and unfair advertising upon children, the FTC would be the agency to notify.
The Federal Communications Commission was established to oversee the licensure of stations that use the public airways, and also the protection of the rights of viewers and listeners. The FTC does not have the power to tell broadcasters what programs or commercials they should air, nor has it dictated the quantity of programming that should be directed at specific segments of the viewing audience, such as children. Nonetheless, FCC rules and regulations are designed to keep broadcasters operating according to the "public interest, convenience, and necessity." There have been a number of policy statements put forth by the FCC that has resulted in the National Association of Broadcasters, a private, voluntary organization of broadcasters introducing self-regulatory steps that include guidelines to eliminate deceptive advertising; to reduce commercials from 16 to 12 minutes per hour; advertisements that show breakfast cereals in the context of a balanced diet; and to eliminate advertisements that could encourage the excessive ingestion of candy and snacks. In 1974, advertising time was further reduced; vitamin/drug commercials were prohibited and selling by program hosts was prohibited. Programs and advertisements were separated by disclosure, and product advertisements had to conform to generally accepted safety standards. These guidelines persuaded the FCC that there was adequate self-regulation by industry and further action by the FCC was unnecessary. Thus, there exist no established federal standards for either programming or advertising directed at children. No action has been taken to regulate the recent cartoons that incorporate major characters that are designed to be sold as toys (program-length commercials).
With both regulatory agencies more concerned about deregulation, it is now left to Congress to introduce bills on behalf of children's television. The most significant such bill has been introduced in the House by Congressman Wirth (D-Colorado) and Senator Lautenberg (D-New Jersey) in the Senate. This bill is known as "The Children's Television Education Act of 1985." The bill requires the FCC to conduct an inquiry into program- length commercials and report to Congress its findings after nine months. More importantly, the bill requires each station to provide a minimum of seven hours per week of educational and instructional programming for children, five hours of which is to be shown Monday through Friday as a condition for license renewal. Support of this bill would be an important activity of pediatricians and health care providers.
In conclusion, a large body of federal law exists which considers the airways as a public resource that must be used by broadcasters in a fashion that insures the rights of listeners and viewers. Children are clearly part of the public, and because of their special needs are not currently adequately served by a medium that is designed exclusively to sell products under the guise of entertainment. With few exceptions, the regulatory agencies have failed to act in the interest of children. The deregulatory climate in Washington makes any future agency action unlikely. Currently, the body most responsive to action appears to be the Congress. The most important consumer group acting on behalf of children over the past fifteen years has been Action for Children's Television (ACT) based in Newtonville, Massachusetts. The recent formation of a task force on children and television by the American Academy of Pediatrics indicates the concern of pediatricians with the influence of this medium, and the need to develop approaches to educate physicians and parents with respect to television's positive and negative efforts. Such efforts may alter viewing habits, but the medium itself will only change in response to political efforts directed at Congress and the regulatory agencies.
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