Addressing psychiatric and psychosocial issues related to children and adolescents
Over the past few decades, screen time use has drastically increased in childhood. Electronic devices have grown steadily less expensive, making them more accessible. If parents limit television, their children can easily substitute a cell phone, gaming system, computer, or tablet. In addition, children are pressured at school by peers to be active on the newest form of social media or new video game, to the point where electronics and social media are part of their culture. In 2011, a nationally representative survey found 52% of children age ≤8 had access to a mobile device; by 2013, this access had increased to 75% (Reid Chassiakos, Radesky, Christakis, Moreno, & Cross, 2016). Studies show the average daily media time is 2 hours 39 minutes for 2 to 4 year olds, 2 hours 56 minutes for 5 to 8 year olds, and 5 hours 55 minutes for 8 to 12 year olds, which is mostly spent in passive consumption (i.e., watching television, movies, or videos) largely out of parental supervision starting at age 8 (Common Sense Media, 2015, 2017; Rideout, Foehr, & Roberts, 2010).
Impact of Technology on Development
Technology can facilitate or inhibit child development. During Erickson's stage of Industry vs Inferiority, children are developing self-confidence through competence and attaining the tools needed to be successful adults. Children learn how to be responsible, develop a sense of right and wrong, and identify where they fit in within social order. Technology can enhance industry in many ways but can create inferiority if not balanced with real-world activity. Children need time away from digital technology to develop in-person interpersonal skills, limits on what is inappropriate digital content, and adequate sleep and exercise (Gorrindo, Fishel, & Beresin, 2012).
Earlier age of media use, higher amounts of media use, and poor media quality content are all significant predictors of poor executive functioning (e.g., impulse control, self-regulation, mental flexibility) and emotional intelligence deficits (i.e., the ability to understand others' thoughts and feelings) (Reid Chassiakos et al., 2016). Heavy media use is related to poorer self-regulation. Media use may be inversely related to the development of children's self-regulation, adding to the difficulty children are facing as school and society are increasing the demands for self-regulated behavior (McClelland, 2018). Current children's television shows that feature cartoons or animations, rather than human interaction, make it harder for children to grasp the correlation between actions and consequences in real life, but children can learn from pro-social entertainment programs especially when watched with parents (Cingel, 2017; Coyne et al., 2018; Uhls, Felt, & Wong, 2017).
Researchers evaluated screen time and its effects on 894 children, ages 6 months to 2 years, participating in TARGet Kids!, a Toronto practice-based research network. Study results showed increased expressive speech delays in children with increased hand-held screen time. In addition, each 30-minute increase in handheld screen time was associated with a 49% increased risk of expressive speech delay. No other communication delays, such as social interactions and body language or gestures, were found (Ma, Van der Heuvel, Maguire, Parkin, & Birken, 2017). This study supports the American Academy of Pediatrics (AAP) recommendation to discourage any type of screen media in children younger than 18 months because “children younger than 2 years need hands-on exploration and social interaction with trusted caregivers to develop their cognitive, language, motor, and social-emotional skills” (Council on Communications and Media, 2016, para. 2). Children ages 3 to 5 can benefit from programs, like Sesame Street, when viewed with parents who interact and interpret the program, which may help children develop literacy skills (Council on Communications and Media, 2016).
Overuse of media can lead to negative outcomes on learning. Use of media during academic tasks, in the form of multitasking, has been found to negatively impact learning (Council on Communications and Media, 2016). In children ages 8 to 12, a study found that screen time was linked to poorer connectivity in areas that govern language and cognitive control, whereas reading was associated with higher functional connectivity (Horowitz-Kraus & Hutton, 2018). Access to video games has been found to displace afterschool educational activities in kids ages 6 to 9 (Weis & Cerankosky, 2010).
Impact of Technology on Health
Increased use of computer and video games has been associated with a number of mental health conditions, including increased diagnoses of attention-deficit/hyperactivity disorder (ADHD) later in adolescence (Wu, Ohinmaa, & Veugelers, 2016). Children with ADHD have more difficulty stopping video games without parental intervention, which may put them at an increased risk for media addiction in later years (Bioulac, Arfi, & Bouvard, 2008). Overuse of online media increases the risk of problematic internet use, and heavy users of video games are at risk of internet gaming disorder (Council on Communications and Media, 2016). Viewing (or playing) violent content increases the likelihood of developing violent behavior, especially when combined with other risk factors, including pre-existing aggressiveness or violence in the home (Common Sense Media, 2013).
Studies consistently show excessive screen time as a contributor to obesity (Council on Communications and Media, 2011). For children ages 4 to 9, viewing time of more than 1.5 hours per day was a risk factor for obesity due to increased sedentary activity, unhealthy eating in programming and advertisements, increased snacking while viewing, and interference with normal sleep patterns (de Jong et al., 2013). In addition, media consumption influences body image and behaviors in school-age children. One half of girls and one third of boys ages 6 to 8 report their ideal bodies are thinner than their current body, and one third of children ages 5 to 6 choose an ideal body size that is thinner than their current perceived size; children are also aware of dieting by age 6 (Dohnt & Tiggemann, 2004, 2006; Hayes & Tantleff-Dunn, 2010; Lowes & Tiggemann, 2003).
Media access in the bedroom is a risk factor for disrupted sleep. Bedroom media access has been associated with less sleep for children with ADHD or autism spectrum disorder (ASD), and in particular, an even stronger association between media exposure and sleep among boys with ASD (Engelhardt, Mazurek, & Sohl, 2013). The presence of a television in the bedroom is a powerful predictor of overall sleep disturbance, followed by the duration of television watching per day; the sleep domains found to be most affected are bedtime resistance, sleep onset delay, anxiety around sleep, and shortened sleep duration (Owens et al., 1999).
Dennison, Russo, Burdick, and Jenkins (2004) conducted a randomized controlled trial (RCT) that evaluated an intervention to reduce television viewing by preschool children ages 2.6 through 5.5 years, located in 16 preschool and/or daycare centers in rural upstate New York. Prior to the study, children in the intervention group viewed 11.9 hours of television per week, whereas children in the control group reported viewing 14 hours per week. Children in the intervention group received a seven-session program designed to reduce television use, whereas children in the control group received information on safety and injury prevention. After the intervention, the parents of the children in the intervention group reported a decrease in viewing to 8.8 hours of television per week, and the control group reported an increase in viewing to 15.6 hours per week. The number of children in the intervention group who were watching television for more than 2 hours per day decreased from 33% to 18% compared to an increase of 41% to 47% for children in the control group (Dennison et al., 2004).
In another RCT, Yilmaz, Demirli Caylan, and Karacan (2015) evaluated an intervention for preschool children during well-child visits to help reduce screen time. Children ages 2 to 6 were randomly assigned to a treatment group that received an intervention to reduce their screen time or to a control group that received no intervention. The researchers were also interested in assessing any correlation with length of screen time, body mass index (BMI), and parental report of aggressive behavior. At 2, 6, and 9 months, home visits occurred, and parents completed questionnaires to report their child's screen time use and behaviors. The researchers found that parents in the intervention group reported less screen time and fewer aggressive behaviors than those in the control group; however, there were no differences in the children's BMI scores (Yilmaz et al., 2015).
Friedrich, Polet, Schuch, and Wagner (2014) conducted a meta-analysis of RCTs to evaluate the effects of intervention programs in schools to reduce electronic screen time use; 16 studies were selected. The researchers identified the following salient interventions: challenging students in a school competition to turn off electronics for 10 days; incorporating dance classes into the school curriculum to increase physical activity and direct youth away from their computers and cell phones; and initiating the 2-1-5 Challenge, a school nutrition policy initiative to encourage students and families to spend ≤2 hours per day on media, participate in 1 hour of physical activity, and consume five servings of fruits and vegetables daily. The interventions assessed as a group in the RCTs significantly reduced screen time in youth and demonstrated the positive effects of decreased electronic use in children (Friedrich et al., 2014).
In a systematic review of the literature, Schmidt et al. (2012) analyzed 29 studies with successful interventions to reduce television use, such as television monitoring devices, contingent feedback systems, and clinic-based counseling. Several studies used education in schools as their intervention, providing child, parent, and teacher education sessions on healthy nutrition, physical activity, and importance of reducing television. Schmidt et al. (2012) concluded that of the school-based studies, eight of the 15 significantly reduced television and/or screen media use. In the home-based studies included in this systematic review, interventions included: electronic television monitors to set a television budget, computer monitors to set limits on viewing activity, and parent and child education sessions. Television allowance devices, monetary incentives, and sticker charts were found to be successful, with children in this study reducing their television time to 50% of baseline (Schmidt et al., 2012). Electronic monitors and devices to set limits on screen media use were also found to reduce screen time by approximately 1 hour per day (Schmidt et al., 2012). In all, 62% of the studies reported statistically significant reductions in television viewing or total screen time after implementing the chosen intervention (Schmidt et al., 2012).
In another systematic review of the literature, Altenburg, Kistvan Holthe, and Chinapaw (2016) analyzed 21 studies on the effectiveness of intervention strategies aimed at reducing children's sedentary time. Using the Quality Assessment Tool for Quantitative Studies of the Effective Public Health Practice Project (EPHPP), eight of the 21 studies selected were moderate quality studies, with four studies reporting significant intervention effects on sedentary time and four studies reporting no significant effects. The most successful strategies found to reduce children's sedentary time included implementing a television turnoff week and standing desks in classrooms. Other interventions from this study included: education sessions for parents, using contingency planning with the family to create a list of non-television–related activities, using a television diary to track amount of time spent in front of the television screen, and setting weekly time budgets for television viewing and computer use using a television control device (Altenburg et al., 2016).
A cross-sectional survey completed by Gentile et al. (2004) was sent to members of the AAP Minnesota chapter to evaluate awareness of, agreement with, and implementation of the AAP media-use guidelines among providers. The survey also inquired about their frequency of media recommendations as part of anticipatory guidance during well-child visits. Three hundred sixty-five pediatric care providers completed the 58-question survey. Investigators found that most providers were familiar with and agree with AAP recommendations concerning media use, and 77% of pediatricians reported providing age-appropriate media recommendations to parents at least sometimes. Female pediatricians were more likely to agree with and be knowledgeable about the AAP media plan and the importance of limiting children's media time. The most frequent barriers reported were lack of parental motivation and support, as well as lack of time for media discussion (Gentile et al., 2004).
Analysis and Synthesis
The current review of the literature supports several evidence-based interventions to reduce problematic technology use among children and teenagers. Dennison et al. (2004) and Yilmaz et al. (2015) conducted RCTs with interventions for reducing television viewing in preschool-aged children. Strengths of the studies included randomly assigned groups and blinding of the data collection, which reduced bias. Yilmaz et al. (2015) found that education at health maintenance visits was effective in reducing the number of hours spent on electronic devices up to 9 months after completion of the intervention. The researchers reported a reduction in media use in the control group (mean = 93.96 min/d [SD = 18.84] and the intervention group (21.15 min/d [SD = 6.12]) (t = 50.1, p < 0.001) (Yilmaz et al., 2015). Similarly, Dennison et al. (2004) assessed the provision of healthy media use education. The intervention group decreased their viewing time by 3.1 hours per week, whereas children in the control group increased their viewing by 1.6 hours per week. Researchers calculated an adjusted difference between groups of −4.7 hours per week (95% confidence interval [CI] [−8.4, −1.0]; p = 0.02). Although Dennison et al. (2004) had the limitation of a small sample (N = 77), Yilmaz et al. (2015) had a large population of 412 participants. In both studies, the control and intervention groups received additional education about media use, which did not pose risk to participants or their families.
Altenburg et al. (2016) and Schmidt et al. (2012) completed systematic literature reviews to identify successful strategies and interventions to reduce electronic use in youth. Altenburg et al. (2016) focused on strategies that exclusively target reducing sedentary time. Twenty-one studies, including Yilmaz et al. (2015) and Dennison et al. (2004), were included. Three databases were searched, and the EPHPP Quality Assessment Tool for Quantitative Studies was used to critically appraise the quality of the studies selected. Even with eight moderate quality studies, researchers found insufficient evidence for the effectiveness of interventions; however, the two most promising interventions were encouragement of a television turnoff week and implementation of standing desks in classrooms (Altenburg et al., 2016).
Schmidt et al. (2012) completed a systematic review of research from seven databases and were able to identify several successful strategies and interventions, all which reduced electronic use in children. Although Altenburg et al. (2016) performed a limited search of only databases, Schmidt et al. (2012) performed a very broad search, which is a strength of their study. The main limitation is that a meta-analysis was not possible due to the wide variety of methods used in the studies. Nonetheless, 62% of the studies reported statistically significant reduction in television viewing or total screen time after intervention (Schmidt et al., 2012).
In a meta-analysis of 16 studies, Friedrich et al. (2014) found similar results in articles that had successful interventions in reducing media time in children, with a standard mean difference of 0.25 hours per day between the intervention group and control group (95% CI [−0.37, −0.13], p < 0.01).
Implications for Practice
Studies have shown the negative impact of excessive media use in the pediatric population and recommend screening to identify which patients exceed media-use guidelines so providers can intervene with appropriate interventions and education. According to AAP recommendations, health care providers should ask at least two media-related questions, followed by a more detailed assessment based on the responses: “How much entertainment media per day is the child or adolescent watching? Is there a television set or internet access in the child's or adolescent's bedroom?” (Council on Communications and Media, 2011). Parents should be educated to set limits and be knowledgeable about what their children are doing online. Media use, like all other activities, should have reasonable limits, and unplugged playtime should be a daily priority. Providers are encouraged to educate themselves on the AAP Family Media Plan (access https://www.healthychildren.org/English/media/Pages/default.aspx), which is a resource and tool for families to set guidelines for electronic use in their home. Providers should consider the health, education, and entertainment needs of each child as well as the whole family (Council on Communications and Media, 2016). Through the AAP Family Media Plan, parents can create contracts or personalized media plans with their children, including media-free zones and media-free times.
Providers should encourage parents to be good role models for their children and incorporate a balanced life. Parents can be more available for and connected with their children when interacting, hugging, and playing with them rather than being focused on their own screens (Shifrin, Brown, Hill, Jana, & Flinn, 2015). Parents need to know that screen time does not always mean solitary time. Co-viewing, co-playing, and co-engaging with children when they are using screens will encourage social interactions, bonding, and learning. Playing a video game with children is a good way to demonstrate sportsmanship and gaming etiquette. Watching a show with children gives opportunity to introduce and share one's own life experiences, perspectives, and guidance. Media can be a useful tool when used in moderation.
In addition, there are a number of parental control applications (apps) that can monitor the amount and types of technology children are using and provide parents the ability to see what social media sites and games children are viewing. One example of these apps is Screentime (access https://screentimelabs.com), which parents can download and set daily limits for technology use. Moreover, parents can use these apps to help children learn to manage technology devices and establish a healthier balance of online and offline time. Parents should familiarize themselves with these apps and smart-phone options as another method for reinforcing appropriate technology use.
Providers have a unique opportunity to help parents and children learn about the potential benefits and risks of technology use. Currently, only approximately 16% of pediatric providers ask families about media use (Shifrin et al., 2015). Parents need education about the dangers of media overuse and possible exposure to inappropriate content. Children need to develop self-regulation skills, and providers can educate parents on how to help children develop these skills by role modeling responsible media use and setting limits on usage. Provider conversations that begin in examination rooms hopefully will continue as important dialogue for parents and children as they discover ways to learn to use technology responsibly.
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