Skepticism about the ill effects of screen time on children runs deep and has only evolved along with the ways we engage with screens. From early worries about the effects of direct-to-consumer advertising and becoming cross-eyed from sitting too close to a television screen to fears of how violence in video games affects behavior, screen time has been a topic of anticipatory guidance in every pediatric office for decades. Now the availability of screens in every purse, pocket, and car has led to even more concern about screen time. Many savvy parents know the American Academy of Pediatrics' (AAP) evidence-based screen time limits and guidance for children of different ages and consider it a challenge of modern parenting to abide by them. To say the coronavirus pandemic has fundamentally altered all aspects of modern life and childhood is an under-statement. School, extracurricular activities, and recreational interactions such as playdates, parties, and other social gatherings have all been forced to assume entirely different spaces than they did in the pre-pandemic era, with many now occurring virtually. Once the scourge of pediatricians and parents alike, screen time has become much more than a necessary evil—it has become an indispensable element for many children in terms of how they learn and connect with their peers.
Screens and the Developing Eyes
“Computer vision syndrome” (CVS) is an increasingly recognized phenomenon in both the adult and pediatric literature addressing the effect of prolonged visual fixation on a screen on numerous visual symptoms. Symptoms of CVS include eyestrain, eye fatigue, eye burning, irritation, redness, visual blurring, and eye dryness, and as pre-verbal children are less likely to complain of these symptoms, safeguarding them from these hazards falls to parents and caregivers.1
Multiple helpful mnemonics have been disseminated by professional societies focused on vision to help parents and physicians take care of children's eyes. When thinking about ideal viewing distance from a screen, the “1-2-10 rule” can be prescribed: 1 foot for a handheld personal screen (mobile phone), 2 feet from a larger personal screen (laptop or desktop computer), and 10 feet from a television.1 The American Optometric Association advises the “20/20/20” rule, which suggests taking a break from the screen to look away once every 20 minutes on something at least 20 feet away for at least 20 seconds. Taking a 10-minute break each hour from the screen altogether is also advisable for children.1 The American Academy of Ophthalmology shares a “Top 10” list of suggestions to minimize excessive eye strain summarized in Table 1.2
Top 10 Suggestions to Minimize Excessive Eye Strain in Children from Screen Time
Eyeglasses that filter blue light coming from screens have become in vogue as a preventive therapy but are not a substitute for setting appropriate screen time limits as bedtime approaches and enforcing breaks from screens. Although not expressly harmful, these glasses are not a form of screen-based personal protective equipment that is necessary for children.3
Screens and the Developing Body
Excessive use of screen time has been associated with sedentary lifestyle and obesity in children.4 The current AAP guideline to limit screen time is largely predicated on research showing that children who watched more than 5 hours a day of television were 4 times as likely to be obese than those who watched 0 to 2 hours of television.5 Quite simply, there are only so many minutes of wakeful time in a 24-hour day, and any minute spent on a screen is a minute not spent reading from a physical book, engaging in some form of physical activity, or engaging in face-to-face encounters with others. School-aged children older than age 6 years are encouraged to engage in at least 60 minutes of physical activity per day, and younger children ought to meet their physical activity needs through imaginative and physical play. Concern also exists for the co-linear activities that track with screen consumption, most notably a tendency to snack between meals.4
Screens and the Developing Brain
Entire careers and books have been dedicated to the intentionality and positive impact of Sesame Street on early childhood educational outcomes. It was designed to be a universal preschool equivalent, and it was found to bolster vocabulary, literacy, social behavior, and knowledge for children as young as age 2.5 years, with positive effects lasting into adolescence.6 Many programs have been developed to mimic the interactive style and cadence of an age-level conversation to promote learning rather than simply to entertain.
Even acknowledging this, concerns exist about the use of screens in children younger than age 2 years. Specifically, pediatricians have posited concern about the uncertain long-term health implications of excessive use of screens in young children and, albeit without a clear explanation, research demonstrates that children whose screen exposure exceeds recommended limits have reduced microstructural integrity of their brain's white matter tracts.7 Furthermore, although research remains ongoing, the studies that exist suggest that heavy screen use in children younger than age 2 years is associated with higher rates of expressive language delays. In the absence of any evidence to say media use is helpful, the AAP Council on Communications and Media discourages any regular screen time in children younger than age 2 years.4,8
For older children, parents and pediatricians have long expressed concern about the content of the media being consumed. Content with violent or highly sexualized situations when consumed without the proper context for understanding or parental supervision can inform naive minds and influence aggressive and antisocial behavior. As it pertains to the type of media consumed (eg, video game versus scripted show with narrative, or animation versus live footage), the research about cognitive skill development is ongoing; however, the content seems to be the more influential characteristic on young minds.6
As most social media platforms' user agreements require a minimum age of 13 years, social media use in children younger than this is typically discouraged by pediatricians. Even for children whose families allow a social media presence, these apps present a double-edged sword. They are often integral to an adolescent's social life and most children do not run afoul of significant problems on social media, but there are significant numbers of adolescents who are bullied by peers or preyed upon by adults.4 Social media use can also become compulsive,9 and teens (and their adult parents) often struggle with establishing and adhering to limits.
An Approach for the Present
With this knowledge as the foundation, it is an essential role of the pediatrician to first listen to parents and children who are old enough to provide their own histories about how their lives have been going since the onset of the coronavirus pandemic. Families' experiences are highly variable and may include the loss of one or multiple family members, emerging mental health or substance use problems in the home, job loss, divorce, intimate partner violence, or other familial discord. Even without these tremendous stressors, parents and children may be under duress simply due to working and learning from home in close proximity to one another.
Pediatricians in practice should acknowledge that they understand what families are going through and expect that the amount of screen time has risen in their patients' households. With this in mind, pediatricians can engage parents in helpful conversation about identifying areas for improvement. Any discussion about screen time limitation begins with addressing parental screen consumption and encouraging parents to self-reflect on their own media use. As with all things, children take their cues from their parents, and inviting parents to model the sort of behavior they expect of their children is essential. The AAP offers guidance and online tools to families about establishing a family media plan.10
While “connecting the dots” on the association between the spike in screen time use and other issues that are frequently discussed at well-child checks, such as rising body mass index, sleep disruption, and depression and anxiety, it is important to remember that screen use is often a symptom and that focusing exclusively on reducing screen time during the coronavirus pandemic ignores the real stress and life disruption that may be contributing to the change in behavior.
Pediatricians should also explain to families that the AAP screen time guidelines were not made with a child's educational and socio-emotional needs during a pandemic in mind.11
Compartmentalizing screen time into categories can be helpful when providing anticipatory guidance. For example, it does parents no good to fret that their child is spending more than than 2 hours a day in front of a screen when that is the expectation of their school. Parents similarly should not feel guilty when they elect to watch an age-appropriate family movie with their children or permit their children to engage in brief but meaningful video calls with friends or family. Effort is far better spent discouraging open-ended timeframes for gaming, viewing videos online, and perusing social media.
A huge portion of people's lives of all ages has pivoted to a heavy reliance on screens and electronic media. Although pediatricians' anticipatory guidance regarding screen time and media use will need to continue to evolve to meet the needs of the moment, it is important to remain nimble and tailor one's advice to reflect the actual experience of families bringing their children to doctor's visits. Also, the discussion about what your patient is doing on Twitter or TikTok may end up making the platform seem so un-cool that it may lead them choosing to go outdoors instead.
- Bali J, Neeraj N, Bali RT. Computer vision syndrome: a review. J Clin Ophthalmol Res. 2014;2(1):61–68. doi:10.4103/2320-3897.122661 [CrossRef]
- American Academy of Ophthalmology. Is too much screen time harming children's vision? Accessed October 11, 2020. https://www.aao.org/newsroom/news-releases/detail/is-too-much-screen-time-harming-childrens-vision
- American Academy of Pediatrics. Give your child's eyes a screen-time break: here's why. Accessed October 11, 2020. https://www.healthychildren.org/English/health-issues/conditions/eyes/Pages/What-Too-Much-Screen-Time-Does-to-Your-Childs-Eyes.aspx
- Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):1–6. doi:10.1542/peds.2016-2592 [CrossRef] PMID:27940794
- Gortmaker SL, Must A, Sobol AM, Peterson K, Colditz GA, Dietz WH. Television viewing as a cause of increasing obesity among children in the United States, 1986–1990. Arch Pediatr Adolesc Med. 1996;150(4):356–362. doi:10.1001/archpedi.1996.02170290022003 [CrossRef] PMID:8634729
- Anderson DR, Subrahmanyam KCognitive Impacts of Digital Media Workgroup. Digital screen media and cognitive development. Pediatrics. 2017;140(suppl 2):S57–S61. doi:10.1542/peds.2016-1758C [CrossRef] PMID:29093033
- Hutton JS, Dudley J, Horowitz-Kraus T, De-Witt T, Holland SK. Associations between screen-based media use and brain white matter integrity in preschool-aged children. JAMA Pediatr. 2020;174(1):e193869. doi:10.1001/jamapediatrics.2019.3869 [CrossRef] PMID:31682712
- Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):1–6. doi:10.1542/peds.2016-2591 [CrossRef] PMID:27940793
- Zendle D, Bowden-Jones H. Is excessive use of social media an addiction?BMJ. 2019;365:l2171. doi:10.1136/bmj.l2171 [CrossRef] PMID:31092392
- American Academy of Pediatrics. Family media plan. Accessed October 11, 2020. https://www.healthychildren.org/English/media/Pages/default.aspx#home.
- American Academy of Pediatrics. Finding ways to keep children occupied during these challenging times. Accessed October 11, 2020. https://services.aap.org/en/news-room/news-releases/aap/2020/aap-finding-ways-to-keep-children-occupied-during-these-challenging-times/
Top 10 Suggestions to Minimize Excessive Eye Strain in Children from Screen Time
Set a timer to remind children to take screen breaks
Alternate screen-reading with real book-reading and encourage looking up and out a window every two chapters
After completing a level in a video game, look out the window for 20 seconds
Pre-mark books with a paperclip every few chapters to encourage “look-up” breaks
Avoid using a computer outside or in brightly lit areas to reduce glare
Adjust the brightness and contrast of the screen to comfort
Use good posture
Encourage holding digital media 18 to 24 inches from the face
Create a distraction that triggers looking up periodically
Remind children to blink when watching a screen