Media Content and Externalizing Behaviors in Latino Toddlers

The relationship between video games and social-emotional delay in Chinese rural preschoolers: A comparison of five types of media video games and social-emotional delay

BACKGROUND

Recent studies have revealed a negative relationship between children's digital media use and social-emotional development. However, few studies distinguish between different digital devices and the different functions they provide that may lead to different outcomes.

METHODS

This study explored the relationship between young children's time spent on various digital devices and their social-emotional delay based on a survey of 1182 preschoolers (3 to 6 years old) in rural China. Children's social-emotional delay was assessed through a validated screening tool (ASQ-SE II).

RESULTS

Children's time spent on television, computers, tablets, or smartphones was not associated with their social-emotional delay. However, their risk of social-emotional delay increased as their time spent on game consoles increased. This relationship was reflected in five of the seven behavioural areas of children's social-emotional development (i.e., self-regulation, compliance, affect, social communications, and interactions with people). Moreover, it did not vary between children with different socioeconomic statuses.

CONCLUSIONS

This study suggests a possible relationship between children's social-emotional delay and video games, which might need to be paid more attention to than other media types.

Algorithmic Content Recommendations on a Video-Sharing Platform Used by Children

Importance

Free video-sharing platforms (VSPs) make up a high proportion of children's daily screen use. Many VSPs make algorithmic recommendations, appearing as thumbnail images from the video, which content creators use to advertise their video content.

Objective

To explore how VSP thumbnails use attention-capture designs to encourage engagement with content and to test whether VSP algorithmic recommendations offer more problematic thumbnail features over time.

Design, Setting, and Participants

In this cross-sectional study conducted in January 2022, researchers mimicked the search behavior of children on a popular VSP by randomly clicking on recommended videos in order to test whether thumbnail designs changed over 20 sequential video engagements. A digital, footprint-free data collection setting was created by using a new computer and wireless internet router. Data were collected from YouTube via an internet browser not logged into a user account. Data analysis occurred from April to December 2022.

Exposures

Manual searches using 12 top-searched terms popular with school-aged children were conducted. Researchers captured the video thumbnails recommended at the end of each video and randomly clicked subsequent videos for 20 sequential engagements.

Main Outcomes and Measures

Thumbnail content codes were developed through iterative review of screenshots by a multidisciplinary research team and applied by trained coders (reliability, κ >.70). The prevalence of problematic thumbnail content and change in prevalence over 20 engagements was calculated using the Cochran-Armitage trend test.

Results

A total of 2880 video thumbnails were analyzed and 6 features were coded, including visual loudness; drama and intrigue; lavish excess and wish fulfillment; creepy, bizarre, and disturbing; violence, peril, and pranks; and gender stereotypes. A high proportion contained problematic features including the creepy, bizarre, and disturbing feature (1283 thumbnails [44.6%]), violence, peril, and pranks feature (1170 thumbnails [40.6%]), and gender stereotypes feature (525 thumbnails [18.2%]). Other features included attention-capture designs such as the visual loudness feature (2278 thumbnails [79.1%]), drama and intrigue feature (2636 thumbnails [91.5%]) and lavish excess and wish fulfillment feature (1286 thumbnails [44.7%]). Contrary to the hypotheses, problematic feature prevalence did not increase over time, but the gender stereotypes feature increased with more engagement in the recommendations feed (P for trend < .001).

Conclusions and Relevance

In this study of video recommendations for search terms popular with children, thumbnails contained problematic and attention-capturing designs including violent, stereotyped, and frightening themes. Research is needed to understand how children respond to thumbnail designs and whether such designs influence the quality of content children consume.

High screen time and internalizing and externalizing behaviours among children aged 3 to 14 years during the COVID-19 pandemic in France

Children's screen time increased as a result of the COVID-19 pandemic. In the summer of 2021, we explored the association between high screen time over a period of one year since May 2020 and behavioural problems among children and adolescents. The data were derived from the French EpiCov cohort study, collected in spring 2020, autumn 2020, and spring 2021. Participants (N = 1089) responded to online or telephone interviews about one of their children aged 3 to 14 years. Screen time was categorized as high if the daily mean screen time exceeded recommendations at each collection time. The Strengths and Difficulties Questionnaire (SDQ) was completed by parents to identify internalizing (emotional or peer problems) and externalizing (conduct problems or hyperactivity/inattention) behaviours in their children. Among the 1,089 children, 561 (51.5%) were girls, the average age was 8.6 years (SD 3.7). Internalizing behaviours: High screen time was not associated with internalizing behaviours (OR [95% CI] 1.20 [0.90-1.59]) or emotional symptoms (1.00 [0.71-1.41]) while it was associated with peer problems (1.42 [1.04-1.95]). Externalizing behaviours: High screen time was associated with externalizing problems (1.63 [1.01-2.63]) and conduct problems (1.91 [1.15-3.22]) only among older children aged 11 to 14 years. No association with hyperactivity/inattention was found. In a French cohort, exploration of persistent high screen time in the first year of the pandemic and behaviour difficulties in Summer 2021 resulted in mixed findings according to behaviour's type and children's age. These mixed findings warrant further investigation into screen type and leisure/school screen use to enhance future pandemic responses appropriate for children.

Isotemporal substitution effect of 24-hour movement behavior on the mental health of Chinese preschool children

The 24-h movement behavior of preschoolers comprises a spectrum of activities, including moderate-to-vigorous intensity physical activity (MVPA), light-intensity physical activity (LPA), screen-based sedentary behavior (SCSB), non-screen-based sedentary behavior (NSCSB), and sleep. While previous research has shed light on the link between movement behaviors and children's mental health, the specific impacts on the unique demographic of Chinese preschoolers remain underexplored. This study significantly contributes to the literature by exploring how 24-h movement behavior affects the mental health of preschoolers in a Chinese context. The study involved205 Chinese preschool children (117 boys and 88 girls) between the ages of 3 and 6 years wore accelerometers to measure their LPA, MVPA, and sedentary behavior (SB), while their parents reported the time spent on sleep and SCSB. The parents also completed the Strength and Difficulties Questionnaire to assess their children's mental health. The study used compositional regression and isotemporal substitution models to examine the relationship between the various components of 24-h movement behavior and mental health. The results showed that greater NCSSB compared to MVPA, LPA, sleep, and SCSB was associated with good prosocial behavior and lower scores on externalizing problems. This highlights the potential of NSCSB as a beneficial component in the daily routine of preschoolers for fostering mental well-being. Replacing 15 min of sleep and SCSB with 15 min of NSCSB was associated with a decrease of 0.24 and 0.15 units, respectively, in externalizing problems. Reallocating 15 min of sleep to NSCSB was linked to an increase of 0.11 units in prosocial behavior. There were no significant substitution effects between LPA and MVPA time with any other movement behavior on prosocial behavior and externalizing problems. Given the positive associations observed, further longitudinal studies are necessary to explore the link between 24-h movement behavior and mental health in preschool children.

Associations of 24-hour movement behaviors with externalizing and internalizing problems among children and adolescents prescribed with eyeglasses/contact lenses

Background

Emerging evidence points towards the psychological benefits of meeting 24-hour movement behavior (24-HMB) guidelines, but such associations have not yet been investigated among children and adolescents of prescribed eyeglasses/contact lenses. To this end, we examined associations of meeting 24-HMB guidelines with internalizing and externalizing challenges in this population.

Methods

We used data from the 2021 National Survey of Children's Health, a cross-sectional survey including a representative sample of US children and adolescents. Data on movement behaviors (physical activity [PA], sedentary behavior operationalized via screen time [ST], and sleep duration [SL]) and internalizing and externalizing problems were collected through caregiver proxy reports. Caregivers completed questionnaires for 6030 (2799 girls) US children and adolescents of prescribed eyeglasses/contact lenses. Logistic regression analyses were conducted to determine the above-presented associations.

Results

Only 7.1 % of those prescribed eyeglasses/contact lenses met all three 24-HMB guidelines, while they were more likely to meet SL guideline alone (32.1 %) in relation to other independent guidelines including PA (2.5 %) and ST (10.9 %). Compared to not meeting any of the three 24-HMB guidelines, meeting at least two guidelines (25.22 %) was significantly linked to lower odds of internalizing problems and externalizing problems.

Conclusion

Meeting at least two components of the 24-HMB guidelines was beneficially linked to internalizing and externalizing problems. Thus, strategies or intervention programs that focus on meeting 24-HMB guidelines should be implemented among children and adolescents of those prescribed eyeglasses/contact lenses to foster coping with psychological issues.

Shyness and Socio-Emotional Adjustment among Young Chinese Children: The Moderating Role of Screen Time

The primary aim of the present study was to examine the potential moderating role of screen time in the links between shyness and indices of socio-emotional adjustment in young Chinese children. Participants were N = 211 children (112 boys, 99 girls) ages 43-66 months (M = 58.84 months, SD = 5.32) recruited from two public kindergartens in Shanghai, People's Republic of China. Mothers completed assessments of children's shyness and screen time, and both mothers and teachers completed measures of indices of children's socio-emotional functioning (prosocial, internalizing problems, learning problems). Among the results, shyness was positively associated with internalizing problems and negatively associated with prosocial behavior, whereas screen time was positively associated with internalizing problems. However, several significant shyness × screen time interaction effects were observed. The pattern of these results consistently revealed that at higher levels of screen time, links between shyness and indices of socio-emotional difficulties were exacerbated. Results are discussed in terms of the implications of shyness and screen time in early childhood.

Longitudinal Associations Between Use of Mobile Devices for Calming and Emotional Reactivity and Executive Functioning in Children Aged 3 to 5 Years

IMPORTANCE

Mobile devices are often used to keep young children occupied or calm, but it is not known whether this practice influences child development.

OBJECTIVE

To examine the longitudinal, bidirectional associations between the parent-reported frequency of using mobile devices to calm young children and children's executive functioning (EF) and emotional reactivity, testing moderation by child sex and temperament.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included a community-based convenience sample of English-speaking parents of typically developing children aged 3 to 5 years. The study duration was from August 2018 to January 2020, with baseline (T1), 3-month follow-up (T2), and 6-month follow-up (T3) waves.

EXPOSURES

Parent-reported frequency of use of mobile devices to calm children when upset (5-point Likert scale).

MAIN OUTCOMES AND MEASURES

At each wave, the child's EF was assessed with the Behavior Rating Inventory of Executive Function-Preschool Version Global Executive Composite and emotional reactivity with the Child Behavior Checklist Emotional Reactivity subscale. Structural equation models were built to examine cross-lagged associations of the use of devices for calming, EF, and emotional reactivity, testing for moderation by child sex or temperament (Child Behavior Questionnaire-Very Short Form surgency score, median split).

RESULTS

Of 422 eligible parents with data at T1, 375 (88.9%) provided data at T2 and 366 (86.7%) at T3. At baseline, the mean (SD) age of the 422 children was 3.8 (0.5) years, the number of boys in the sample was 224 (53.1%), the number of individuals of non-Hispanic White race and ethnicity was 313 (74.2%), and among the parents, 254 (60.2%) had a college degree or higher. Among the boys, the use of devices to calm at T2 was associated with higher emotional reactivity at T3 (r [standardized regression coefficient] = 0.20; 95% CI, 0.10-0.30), while higher emotional reactivity at T2 had a nonsignificant association with increased device use for calming at T3 (r = 0.10; 95% CI, -0.01 to 0.21). Among children with high temperamental surgency, the use of devices to calm at T2 was associated with increased emotional reactivity at T3 (r = 0.11; 95% CI, 0.01-0.22), while higher emotional reactivity at T2 was associated with increased device use for calming at T3 (r = 0.13; 95% CI, 0.02-0.24).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the frequent use of mobile devices for calming young children may displace their opportunities for learning emotion-regulation strategies over time; therefore, pediatric health care professionals may wish to encourage alternate calming approaches.

Supporting Reading Aloud Beginning Prenatally and in Early Infancy: A Randomized Trial in Brazil

OBJECTIVE

A previous study of a reading aloud intervention in Brazil, called Universidade do Bebê (UBB), demonstrated impacts on parenting and child outcomes for families with toddlers and preschoolers, even for parents with low literacy, and cognitive stimulation mediated effects on child outcomes. In a new study, we sought to determine whether similar results would be found when UBB was provided beginning in pregnancy through early toddlerhood, including (1) impacts on parenting and child development, (2) variation in impact on parenting and child outcomes by parent literacy level, and (3) indirect impacts on child outcomes through cognitive stimulation.

METHOD

Women with low income who were either pregnant or with children aged 0 to 24 months were randomized to UBB or control groups. UBB consisted of monthly workshops focused on reading aloud complemented by a book-lending library. Participants were evaluated at baseline and approximately 11 months later (M = 11.0, SD = 0.4; range 9.9-12.2 months) on parenting (cognitive stimulation, beliefs about early reading, screen time, and discipline) and child development.

RESULTS

Four hundred families (n = 200 UBB) were randomized; 286 (71.5%; n = 150 UBB) received 11-month follow-up. UBB families showed increased cognitive stimulation (Cohen's d = 0.92) and awareness about the importance of early reading ( d = 0.90) than controls, with no differences by parent literacy level. UBB was associated with reduced screen time and increased vocabulary, but only for families with low parent literacy. UBB effects on child outcomes were mediated by cognitive stimulation.

CONCLUSION

The findings support implementation of reading aloud programs beginning in pregnancy and early childhood.

Feasibility of Measuring Screen Time, Activity, and Context Among Families With Preschoolers: Intensive Longitudinal Pilot Study

Background

Digital media has made screen time more available across multiple contexts, but our understanding of the ways children and families use digital media has lagged behind the rapid adoption of this technology.

Objective

This study evaluated the feasibility of an intensive longitudinal data collection protocol to objectively measure digital media use, physical activity, sleep, sedentary behavior, and socioemotional context among caregiver-child dyads. This paper also describes preliminary convergent validity of ecological momentary assessment (EMA) measures and preliminary agreement between caregiver self-reported phone use and phone use collected from passive mobile sensing.

Methods

Caregivers and their preschool-aged child (3-5 years) were recruited to complete a 30-day assessment protocol. Within 30-days, caregivers completed 7 days of EMA to measure child behavior problems and caregiver stress. Caregivers and children wore an Axivity AX3 (Newcastle Upon Tyne) accelerometer to assess physical activity, sedentary behavior, and sleep. Phone use was assessed via passive mobile sensing; we used Chronicle for Android users and screenshots of iOS screen time metrics for iOS users. Participants were invited to complete a second 14-day protocol approximately 3-12 months after their first assessment. We used Pearson correlations to examine preliminary convergent validity between validated questionnaire measures of caregiver psychological functioning, child behavior, and EMA items. Root mean square errors were computed to examine the preliminary agreement between caregiver self-reported phone use and objective phone use.

Results

Of 110 consenting participants, 105 completed all protocols (105/110, 95.5% retention rate). Compliance was defined a priori as completing ≥70%-75% of each protocol task. There were high compliance rates for passive mobile sensing for both Android (38/40, 95%) and iOS (64/65, 98%). EMA compliance was high (105/105, 100%), but fewer caregivers and children were compliant with accelerometry (62/99, 63% and 40/100, 40%, respectively). Average daily phone use was 383.4 (SD 157.0) minutes for Android users and 354.7 (SD 137.6) minutes for iOS users. There was poor agreement between objective and caregiver self-reported phone use; root mean square errors were 157.1 and 81.4 for Android and iOS users, respectively. Among families who completed the first assessment, 91 re-enrolled to complete the protocol a second time, approximately 7 months later (91/105, 86.7% retention rate).

Conclusions

It is feasible to collect intensive longitudinal data on objective digital media use simultaneously with accelerometry and EMA from an economically and racially diverse sample of families with preschool-aged children. The high compliance and retention of the study sample are encouraging signs that these methods of intensive longitudinal data collection can be completed in a longitudinal cohort study. The lack of agreement between self-reported and objectively measured mobile phone use highlights the need for additional research using objective methods to measure digital media use.

International Registered Report Identifier (IRRID)

RR2-36240

Factors Associated With Trajectories of Externalizing Behavior in Preschoolers

OBJECTIVE

More media exposure and life stressors are associated with higher levels of externalizing behaviors in young children; however, their joint impact on externalizing behavior trajectory is unknown. This study assessed the relationship of stressful life events (SLE), media exposure, and additional demographic and family variables on the trajectory of externalizing behaviors in preschool-aged children.

METHODS

Participants were children ages 3 to 5 years from a large, 18-month duration, randomized control trial to reduce inappropriate media exposure. The sample was recruited from community pediatrics' practices. Intervention and control groups were collapsed, with study arm a covariate. Latent growth modeling (LGM) was conducted, with main outcome of externalizing behaviors at 6, 12, and 18 months after study initiation. Primary exposures of interest were total daily media hours, SLE, intimate partner violence, and harsh parenting.

RESULTS

Final analyses included 613 children. LGM without covariates revealed a significant decrease in mean externalizing score between baseline and 18 months. LGM with covariates revealed that individuals with more media exposure exhibited more externalizing behaviors and SLE significantly predicted a slower decline in externalizing behaviors. Externalizing behavior at 18 months was significantly predicted by SLE, child age, white non-Hispanic race, and harsh parenting.

CONCLUSIONS

Exposure to a greater number of stressful life events appears to slow the age-appropriate decline in externalizing behaviors for preschool-aged children, while harsh parenting and media exposure are associated with more externalizing behavior. Findings highlight the importance of screening and surveillance in primary care and the need for early intervention efforts targeted to these risks.

Association Between Screen Time Trajectory and Early Childhood Development in Children in China

IMPORTANCE

Screen time has become an integral part of children's daily lives. Nevertheless, the developmental consequences of screen exposure in young children remain unclear.

OBJECTIVE

To investigate the screen time trajectory from 6 to 72 months of age and its association with children's development at age 72 months in a prospective birth cohort.

DESIGN, SETTING, AND PARTICIPANTS

Women in Shanghai, China, who were at 34 to 36 gestational weeks and had an expected delivery date between May 2012 and July 2013 were recruited for this cohort study. Their children were followed up at 6, 9, 12, 18, 24, 36, 48, and 72 months of age. Children's screen time was classified into 3 groups at age 6 months: continued low (ie, stable amount of screen time), late increasing (ie, sharp increase in screen time at age 36 months), and early increasing (ie, large amount of screen time in early stages that remained stable after age 36 months). Cognitive development was assessed by specially trained research staff in a research clinic. Of 262 eligible mother-offspring pairs, 152 dyads had complete data regarding all variables of interest and were included in the analyses. Data were analyzed from September 2019 to November 2021.

EXPOSURES

Mothers reported screen times of children at 6, 9, 12, 18, 24, 36, 48, and 72 months of age.

MAIN OUTCOMES AND MEASURES

The cognitive development of children was evaluated using the Wechsler Intelligence Scale for Children, 4th edition, at age 72 months. Social-emotional development was measured by the Strengths and Difficulties Questionnaire, which was completed by the child's mother. The study described demographic characteristics, maternal mental health, child's temperament at age 6 months, and mental development at age 12 months by subgroups clustered by a group-based trajectory model. Group difference was examined by analysis of variance.

RESULTS

A total of 152 mother-offspring dyads were included in this study, including 77 girls (50.7%) and 75 boys (49.3%) (mean [SD] age of the mothers was 29.7 [3.3] years). Children's screen time trajectory from age 6 to 72 months was classified into 3 groups: continued low (110 [72.4%]), late increasing (17 [11.2%]), and early increasing (25 [16.4%]). Compared with the continued low group, the late increasing group had lower scores on the Full-Scale Intelligence Quotient (β coefficient, -8.23; 95% CI, -15.16 to -1.30; P < .05) and the General Ability Index (β coefficient, -6.42; 95% CI, -13.70 to 0.86; P = .08); the early increasing group presented with lower scores on the Full-Scale Intelligence Quotient (β coefficient, -6.68; 95% CI, -12.35 to -1.02; P < .05) and the Cognitive Proficiency Index (β coefficient, -10.56; 95% CI, -17.23 to -3.90; P < .01) and a higher total difficulties score (β coefficient, 2.62; 95% CI, 0.49-4.76; P < .05).

CONCLUSIONS AND RELEVANCE

This cohort study found that excessive screen time in early years was associated with poor cognitive and social-emotional development. This finding may be helpful in encouraging awareness among parents of the importance of onset and duration of children's screen time.

Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systematic Review and Meta-analysis

Importance

Currently, there is a lack of consensus in the literature on the association between screen time (eg, television, video games) and children's behavior problems.

Objective

To assess the association between the duration of screen time and externalizing and internalizing behavior problems among children 12 years or younger.

Data Sources

For this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO databases were searched for articles published from January 1960 to May 2021. Reference lists were manually searched for additional studies.

Study Selection

Included studies measured screen time (ie, duration) and externalizing or internalizing behavior problems in children 12 years or younger, were observational or experimental (with baseline data), were available in English, and had data that could be transformed into an effect size. Studies conducted during the COVID-19 pandemic were excluded. Of 25 196 nonduplicate articles identified and screened for inclusion, 595 met the selection criteria.

Data Extraction and Synthesis

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Extracted variables were child age, sex, and socioeconomic status; informants and measurement type for screen time and behavior problems; study publication year; and study design and quality. Data were extracted by 2 independent coders and were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was the association of screen time duration with externalizing (eg, aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, depression, anxiety) behaviors or diagnoses.

Results

Of the 595 full-text articles assessed for eligibility, 87 studies met all inclusion criteria, comprising 98 independent samples and 159 425 participants (mean [SD] age, 6.07 [2.89] years; 83 246 [51.30%] male). Increased duration of screen time had a small but significant correlation with more externalizing problems (90 samples; r, 0.11; 95% CI, 0.10-0.12) and internalizing problems (43 samples; r, 0.07; 95% CI, 0.05-0.08) in children. Several methodological moderators explained between-study heterogeneity. There was evidence of significant between study heterogeneity (I2 = 87.80).

Conclusions and Relevance

This systematic review and meta-analysis found small but significant correlations between screen time and children's behavior problems. Methodological differences across studies likely contributed to the mixed findings in the literature.

Screen Media Overuse and Associated Physical, Cognitive, and Emotional/Behavioral Outcomes in Children and Adolescents: An Integrative Review

INTRODUCTION

Screen media overuse is seen as a public health concern because of its negative effects on child and adolescent health. This integrative literature review examines recent empirical evidence on the relationship between screen media overuse and physical, cognitive, and emotional/behavioral outcomes in children and adolescents.

METHODS

Empirical research of experimental design, observational studies, and systematic reviews from several data sources was reviewed and synthesized to form the basis of this integrative review.

RESULTS

Screen media overuse is associated with poor sleep quality, shorter sleep duration, greater likelihood for overweight/obesity, lower executive functioning, poorer academic performance, and increased internalizing and externalizing problems. Bidirectional associations may exist.

DISCUSSION

Findings support the importance of understanding the impact of screen media use on health and wellbeing. Generating screen time guidelines and developing effective prevention/intervention strategies are critical to mitigating screen media overuse and its adverse outcomes in children and families.

Measuring Micro Temporal Processes Underlying Preschoolers Screen Use and Behavioral Health: Protocol for the Tots & Tech Study (Preprint)

Background

Excessive screen time is associated with poor health and behavioral outcomes in children. However, research on screen time use has been hindered by methodological limitations, including retrospective reports of usual screen time and lack of momentary etiologic processes occurring within each day.

Objective

This study is designed to assess the feasibility and utility of a comprehensive multibehavior protocol to measure the digital media use and screen time context among a racially and economically diverse sample of preschoolers and their families. This paper describes the recruitment, data collection, and analytical protocols for the Tots and Tech study.

Methods

The Tots and Tech study is a longitudinal, observational study of 100 dyads: caregivers and their preschool-age children (aged 3-5 years). Both caregivers and children will wear an Axivity AX3 accelerometer (Axivity Ltd) for 30 days to assess their physical activity, sedentary behavior, and sleep. Caregivers will complete ecological momentary assessments (EMAs) for 1 week to measure child behavioral problems, caregiver stress, and child screen time.

Results

The Tots and Tech study was funded in March 2020. This study maintains rolling recruitment, with each dyad on their own assessment schedule, depending on the time of enrollment. Enrollment was scheduled to take place between September 2020 and May 2022. We aim to enroll 100 caregiver-child dyads. The Tots and Tech outcome paper is expected to be published in 2022.

Conclusions

The Tots and Tech study attempts to overcome previous methodological limitations by using objective measures of screen time, physical activity, sedentary behavior, and sleep behaviors with contextual factors measured by EMA. The results will be used to evaluate the feasibility and utility of a comprehensive multibehavior protocol using objective measures of mobile screen time and accelerometry in conjunction with EMA among caregiver-child dyads. Future observational and intervention studies will be able to use this study protocol to better measure screen time and its context.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36240

Bidirectional associations between screen time and children's externalizing and internalizing behaviors

BACKGROUND

While it has been purported that excessive screen time can lead to behavioral problems, it has also been suggested that children with behavioral dysregulation receive more access to screens to manage problematic behavior. In this study, both temporally stable and longitudinal associations between screen time and externalizing and internalizing behaviors across childhood are examined to directly address this issue of directionality.

METHODS

Data are from a prospective cohort of 10,172 Irish children, collected between 2010 and 2018 when children were ages 3, 5, 7, and 9. Children's screen time (hours/day) and externalizing and internalizing behaviors (Strengths and Difficulties Questionnaire) were assessed via caregiver report. Random-intercepts cross-lagged panel models were used to estimate longitudinal bidirectional associations while controlling for temporally stable (i.e., 'time-invariant' or 'trait-like') differences between children.

RESULTS

Temporally stable differences between children were observed for both screen time and behavior problems. Longitudinal trajectories for screen time lacked stability; however, and externalizing and internalizing behaviors stabilized increasingly during later childhood. Greater externalizing and internalizing behaviors at age 3 were directionally associated with increased screen time at age 5. Greater screen time at ages 3 and 5 was directionally associated with increased internalizing behaviors at ages 5 and 7, respectively. More screen time at age 7 was directionally associated with fewer internalizing behaviors at age 9. Screen time was not associated with later externalizing behaviors.

CONCLUSIONS

Bidirectional associations between screen time and internalizing behaviors were observed for preschoolers. Directional associations between screen time and internalizing difficulties were observed across childhood. These findings can inform screen use guidelines and family media planning at different ages and stages of development.

Links between television exposure and toddler dysregulation: Does culture matter?

Television exposure in early childhood has increased, with concerns raised regarding adverse effects on social-emotional development, and emerging self-regulation in particular. The present study addressed television exposure (i.e., amount of time watching TV) and its associations with toddler behavioral/emotional dysregulation, examining potential differences across 14 cultures. The sample consisted of an average of 60 toddlers from each of the 14 countries from the Joint Effort Toddler Temperament Consortium (JETTC; Gartstein & Putnam, 2018). Analyses were conducted relying on the multi-level modeling framework (MLM), accounting for between- and within-culture variability, and examining the extent to which TV exposure contributions were universal vs. variable across sites. Effects of time watching TV were evaluated in relation to temperament reactivity and regulation, as well as measures of emotional reactivity, attention difficulties, and aggression. Results indicated that more time spent watching TV was associated with higher ratings on Negative Emotionality, emotional reactivity, aggression, and attention problems, as well as lower levels of soothability. However, links between TV exposure and both attention problems and soothability varied significantly between cultures. Taken together, results demonstrate that increased time spent watching television was generally associated with dysregulation, although effects were not consistently uniform, but rather varied as a function of culturally-dependent contextual factors.

Electronic Media and Early Childhood: A Review

BACKGROUND

This review summarizes the state of knowledge of use of new media on the development in early childhood in 6 sections: descriptive utilization data, psychosocial and emotional development, cognition and language, motor development, nutrition and sleep, and influence of parental media consumption.

METHODS

The review is based on a literature search of this topic in peer-reviewed journals. We included 87 articles, books, and book chapters. The used literature data bases were ERIC, PsycARTICLES, PsycINFO and PSYNDEX.

RESULTS

Manifold studies describe in young children's utilization data the pervasive nature of digital exposure and impressive usage times and availability. They confirm adverse influences of electronic media use (television, video games) on children's emotional and behavioral problems and well-being, e. g. on physical activity, sleep and obesity. In general a positive effect in sense of knowledge transfer of age could be found for high quality educational media, however predominantly the impact of media use at younger age was negative.

CONCLUSIONS

High frequent media use in early childhood is likely to have a negative impact on psychosocial development, positive effects such as knowledge transfer may be seen beyond the age of 18 months. As parental media use is a strong predictor of child media habits, reducing parental media use and enhancing parent-child interactions might be important areas to address when trying to change the media behavior of young children. In view of the scarcity of studies for early childhood, it is advisable to use digital play and communication devices cautiously and restrictively in this vulnerable development phase.

[The evolution of child psychiatry emergencies: Results and reflections from a Nancy University Hospital study]

INTRODUCTION

Mental illness is one of the most common causes of disability, morbidity and mortality in childhood. According to the scientific literature, the prevalence of mental health disorders is an estimated 10% to 20% in the USA and similar results are found in France. Although primordial, outpatient care often appears insufficient with inequalities in its geographical distribution and its accessibility. These past decades have been marked by an increase in consultations for mental disorders in pediatric emergency departments. Is this trend indicative of a "defect" in the healthcare organization? Identifying the root causes of this inflation in psychiatric consultations seems of paramount importance in the improvement of healthcare policies. In France and worldwide, only a few studies deal with this subject. That is why we proposed to observe the evolution of the number of consultations for mental health reasons in the pediatric emergency department of Nancy University Hospital and to detail their characteristics.

MATERIALS AND METHODS

Ancillary comparative and retrospective study (2003-2013) on minors having received a child psychiatry consultation within the pediatric emergency department of Nancy University Hospital.

RESULTS

The number of consultations for mental health reasons increased by 119% (97 in 2003; 212 in 2013), while consultations for pediatrics reasons remained stable over the period studied. Consultations mainly dealt with females representing 55.6% of consultations in 2003 and 63.7% in 2013. Mean age of consultants was stable: 13.9 years (standard deviation=3.3 years) in 2003; 14.1 (2.5) years in 2013. Family structure witnessed a three-fold increase in the single-parent model. Regarding consultation motives, behavioral disorders were significantly more represented in 2013: 27.7% (RR=1.7; 95% CI 1.0-2.8; P<0.05) versus 16.5%. As far as diagnosis is concerned (ICD-10), emotional and behavioral disorders increased to 35.9% from 12.6% (RR=2.8; IC95% 1.6-5.1; P=0.0001).

CONCLUSIONS

In France, as well as in other western countries, the number of visits in pediatric emergency departments for mental health reasons more than doubled over a 10-year span. This growth mostly concerned externalizing disorders as a motive for consultation. Causes for this increase are multifactorial and closely related to the prevalence of psychiatric disorders in children. Some studies showed that economic factors played a major role on mental illness during such a downturn as the financial crisis of 2007-2008. Unemployment caused by economic crises can weaken pediatric caregivers and therefore their patients. Evolution of family structure and value also explains this trend. These past decades, the two-parent model, relevant till the 1960s, has evolved to a point where single parents are more quickly overwhelmed. Family values are now focused on consensus rather than duty and hedonism has become a central value. Women are more involved in the working world which became for all a performance field. Several studies have shown that social settings where competitiveness is the norm breed externalized disorders in children by advocating short-term efficiency. Moreover, the widespread use of screens in households as well as early exposure impact the psychomotor development, decrease the amount of sleep and may be responsible for the occurrence of many psychiatric disorders. There are some epidemiological reasons too. In 1971, Omran introduced a concept called "epidemiological transition" explaining how mental health issues appeared in the limelight through to the decline of infectious and cardiovascular diseases. This phenomenon has already occurred in western countries which could explain the increase in the prevalence of psychiatric disorders. In Africa, there is evidence it may have already started. Beyond all these considerations, the increase in consultations for mental disorders in pediatric emergency departments can be explained by a change in care consumption habits. Going straight to the local emergency department, accessible on a 24/7 basis, is easier than waiting for an outpatient appointment and is also free for the have-nots lacking proper insurance coverage. Scarce resources in ambulatory care may also explain the increased recourse to emergency services. Several reports have shown a lack of child psychiatrists and their uneven geographical distribution. For example, in the US only a third of children with mental disorders receive proper care, a lack which doubled between 1997 and 2010. Despite the reason for this trend, it is important to propose a better fitting of the healthcare system to the population needs, and to improve prevention and early identification. All these changes require further collective reflection.

The Relationships between Screen Use and Health Indicators among Infants, Toddlers, and Preschoolers: A Meta-Analysis and Systematic Review

Evidence suggests that excessive screen time in early childhood is related to children's physical and mental health. This study aimed to review the relationships between screen media use and several health indicators in infants, toddlers, and preschoolers. A systematic search was conducted by two independent reviewers on PubMed, Web of Science, Embase, and Cochrane Library to identify the eligible studies, with an end date of 13 August 2019. Included studies (published in English) were peer-reviewed and met the determinate population (children aged 0-7 years with screen media exposure and related health outcomes). The AHRQ, NOS, and the Cochrane Handbook were used to evaluate the cross-sectional study, cohort study, and RCT, respectively. A meta-analysis and narrative syntheses were employed separately. Eighty studies (23 studies for meta-analysis) met the inclusion criteria for the systematic review. Strong evidence of the meta-analysis suggested that excessive screen time was associated with overweight/obesity and shorter sleep duration among toddlers and preschoolers. Excessive screen use was associated with various health indicators in physical, behavioral, and psychosocial aspects. Better-quality research on newer media devices, on various kinds of contents in young children, and on dose-response relationships between excessive screen use and health indicators are needed to update recommendations of screen use.

Longitudinal Associations Between Early Childhood Externalizing Behavior, Parenting Stress, and Child Media Use

Limited research has examined bidirectional associations between modern media (e.g., smartphone, tablet) use and behavior in early childhood. This study aimed to test the hypotheses that, over 6 months, (H1) child externalizing behavior would predict later media use, mediated by parenting stress, and (H2) media use would predict later externalizing behavior. Participants included mothers and fathers from 183 heterosexual couples with a child 1-5 years old, followed for 6 months-assessed at baseline, 1, and 6 months. Frequency of child media use was assessed at baseline and 6 months through parent report across eight items (e.g., television [TV], smartphone, tablet use). Child externalizing behavior was assessed through the Child Behavioral Checklist, and parent stress through the Parenting Stress Index. Hypotheses were tested using structural equation modeling. Mothers were 31.8 (standard deviation [SD] = 4.2), fathers 33.3 (SD = 4.9), and children 3.0 years old (SD = 1.2). Structural equation models showed good overall fit. As hypothesized, we found that (H1) greater child externalizing behavior predicted greater parenting stress (β = 0.48, p < 0.001), which predicted increases in child media use (β = 0.15, p < 0.05); however, (H2) child media use did not predict later externalizing behavior (β = 0.06, p = 0.23). In post hoc analyses, results differed slightly by specific type of media; for example, externalizing behavior was associated with later tablet and game use, whereas TV use predicted increases in externalizing behavior. Our results suggest that child behavior problems associate with later media use habits, possibly as a parent coping strategy, which should be considered when providing clinical guidance.

Prolonged touch screen device usage is associated with emotional and behavioral problems, but not language delay, in toddlers

BACKGROUND

Touch screen devices are now ubiquitous, and their usage by young children is increasing. However, the effects of these devices on young children are still unknown. Therefore, this study aimed to address the associations of touch screen device exposure with symptomatic emotional and behavioral problems and language development in children between the ages of 18 and 36 months.

METHOD

A total of 161 primary caregivers of children between the ages of 18 and 36 months were recruited from the pediatric ward and outpatient clinic at a medical center in southern Taiwan. All caregivers were asked to fill out the Child Behavior Checklist for Ages 1½-5 (CBCL 1½-5) and a questionnaire on basic personal information and touch screen device usage, and they were also interviewed with the Communication and Language Screening Test for Birth to Three Chinese-Speaking Infant-Toddlers (CLST). Independent t-test and one-way ANOVA were used to examine the differences among the categories in the demographic variables and to characterize the touch screen device usage behaviors. Pearson's correlation was used to analyze the relationship between language delay and the extent of touch screen device exposure. After primary univariate analysis, we used multiple regression models to examine the relationships among the effects of touch screen device usage behaviors on children's emotional and behavioral problems and language development.

RESULT

The children's mean age was 25.63 months (SD = 5.35). Children who spent more time on touch screen devices were more likely to have emotional problems (β = .219, p < .010, 95 % CI: .279-1.518), anxious/depressive symptoms (β = .206, p < .050, 95 % CI: .170-1.244), somatic complaints (β = .291, p < .001, 95% CI: .455-1.462), social withdrawal symptoms (β = .194, p < .050, 95 % CI: 0.133-1.150), attention problems (β = .300, p < .001, 95 % CI: .432-1.267), and aggressive behaviors (β = .247, p < .010, 95 % CI: .967-3.983). The effects were not noted on language development (β = -.136, p < .100, 95 % CI: -2.595-.147).

CONCLUSION

Young children who spent more time on touch screen devices were more likely to have emotional problems, anxious/depressive symptoms, somatic complaints, social withdrawal symptoms, attention problems, and aggressive behaviors, but not language delay.

Excessive Screen Time and Psychosocial Well-Being: The Mediating Role of Body Mass Index, Sleep Duration, and Parent-Child Interaction

OBJECTIVES

To examine the relationship between excessive screen time and psychosocial well-being in preschool children, and the potential mediating role of body mass index, sleep duration, and parent-child interaction.

STUDY DESIGN

A cross-sectional survey was conducted in Shanghai, China using stratified random sampling design. A representative sample of 20 324 children aged 3-4 years old from 191 kindergartens participated in this study. Parents completed the Strengths and Difficulties Questionnaire and reported the child's time spent on screen exposure, sleep duration, height, weight, and parent-child interactive activities.

RESULTS

Preschool children in Shanghai were exposed to 2.8 (95% CI 2.7, 2.9) hours/day of screen time, with 78.6% (95% CI 77.8,79.3) exceeding 1 hour/day and 53% (95% CI 52.0,53.9) exceeding 2 hours/day. Every additional hour of screen time was associated with increased risk for poor psychosocial well-being. Body mass index, sleep duration, and parent-child interaction mediated the effect of excessive screen time on children's psychosocial well-being, among which parent-child interaction contributed most. Parent-child interaction could explain 28.1% of the effect on total difficulties and 58.6% on prosocial behavior.

CONCLUSIONS

Excessive screen time during early childhood exists in Shanghai preschool children. Excessive screen exposure was associated with poor psychosocial well-being in preschool children via a number of mediators, mostly by reducing parent-child interaction.

Screen-Related Parenting Practices in Low-Income Mexican American Families

OBJECTIVES

To (1) examine whether the Information-Motivation-Behavioral Skills Model predicts maternal screen-related parenting practices and (2) evaluate the relationship of American Academy of Pediatrics (AAP)-recommended parenting practices with child television (TV) use behaviors.

METHODS

In this cross-sectional study, 312 Spanish-speaking and/or English-speaking female primary caregivers of Mexican descent with a child 3 to 5 years of age were recruited from safety-net pediatric clinics. Participants completed a phone interview and screen media diary. Measures included maternal screen-related beliefs, self-efficacy, parenting practices (time restriction, TV in the child's bedroom, allowing viewing while eating meals and while eating snacks), and child viewing behaviors (amount of TV viewing, frequency of eating while viewing). Two path analytic models were estimated.

RESULTS

Positive general beliefs about TV viewing and positive functional beliefs were negatively associated with maternal self-efficacy to restrict TV time (β = -0.14, P < .05; β = -0.27, P < .001). Greater self-efficacy to restrict time was associated with more maternal restriction of time (β = 0.29, P < .001). Greater positive functional beliefs were associated with less self-efficacy to restrict TV viewing with snacks (odds ratio = 0.56; 95% confidence interval, 0.38-0.81). High self-efficacy to restrict viewing with snacks was associated with less allowing of viewing while snacking (β = -0.16, P < .01). Time restriction, TV in the child's bedroom, and allowing viewing while snacking were associated with child TV viewing behaviors.

CONCLUSIONS

Providers should consider maternal beliefs, including beliefs regarding the functional use of screens, and self-efficacy to engage in AAP-recommended parenting practices, when counseling on screen use in this population.

Screen time exposure and sleep among children with developmental disabilities

AIM

Children with developmental disabilities are at risk of excessive screen time and are more vulnerable to sleep problems. The aim of this study was to determine the extent of screen time use in children with developmental disabilities and its relationship with sleep duration.

METHODS

Consecutive children aged 6-15 years diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth or Fifth Edition (DSM-IV or DSM-5) developmental disabilities were recruited for this study from December 2014 to April 2015. Of those recruited, 87.0% of families gave consent and provided questionnaire information on demographics and child's screen time use and completed the Children's Sleep Habits Questionnaire.

RESULTS

Parents of 102 children in a tertiary-care developmental clinic completed the study. The mean age of children was 10 years, 1 month (standard deviation (SD), 22.7 months). The mean daily total screen time exposure was 2 h, 52.7 min (172.7 min, SD 120.8 min), with a median of 150.0 min. The mean amount of sleep per weekday was 8 h, 23.3 min (SD 64.6 min). Linear regression showed that, for every additional 9.17 min of screen time per day, sleep was reduced by 1 min (β = -0.11, P = 0.04). Older age (β = -0.64, P = 0.02) and living with a single parent (β = -69.29, P = 0.003) were also associated with less sleep.

CONCLUSIONS

Among children with developmental disabilities, greater daily screen time is associated with lower sleep duration. Older children and those from single-parent families are at risk of lower sleep duration. Clinicians should routinely ask about screen time exposure and sleep habits in order to provide appropriate anticipatory guidance.

Reciprocal Associations between Electronic Media Use and Behavioral Difficulties in Preschoolers

The use of electronic media has increased substantially and is already observable in young children. The present study explored associations of preschoolers’ use of electronic media with age, gender, and socio-economic status, investigated time trends, and examined reciprocal longitudinal relations between children’s use of electronic media and their behavioral difficulties. The study participants included 527 German two- to six-year-old children whose parents had provided information on their use of electronic media and their behavioral difficulties at two time points, with approximately 12 months between baseline and follow-up. The analyses revealed that older vs. younger children, as well as children from families with a lower vs. higher socio-economic status, were more often reported to use electronic media. Furthermore, the usage of mobile phones increased significantly between 2011 and 2016. Most interestingly, baseline usage of computer/Internet predicted more emotional and conduct problems at follow-up, and baseline usage of mobile phones was associated with more conduct problems and hyperactivity or inattention at follow-up. Peer relationship problems at baseline, on the other hand, increased the likelihood of using computer/Internet and mobile phones at follow-up. The findings indicate that preschoolers’ use of electronic media, especially newer media such as computer/Internet and mobile phones, and their behavioral difficulties are mutually related over time.

Real-World Usage of Educational Media Does Not Promote Parent-Child Cognitive Stimulation Activities

OBJECTIVE

To determine whether educational media as actually used by low-income families promote parent-child cognitive stimulation activities.

METHODS

We performed secondary analysis of the control group of a longitudinal cohort of mother-infant dyads enrolled postpartum in an urban public hospital. Educational media exposure (via a 24-hour recall diary) and parent-child activities that may promote cognitive stimulation in the home (using StimQ) were assessed at 6, 14, 24, and 36 months.

RESULTS

Data from 149 mother-child dyads, 93.3% Latino, were analyzed. Mean (standard deviation) educational media exposure at 6, 14, 24, and 36 months was, respectively, 25 (40), 42 (58), 39 (49), and 39 (50) minutes per day. In multilevel model analyses, prior educational media exposure had small positive relationship with subsequent total StimQ scores (β = 0.11, P = .03) but was nonsignificant (β = 0.08, P = .09) after adjusting for confounders (child: age, gender, birth order, noneducational media exposure, language; mother: age, ethnicity, marital status, country of origin, language, depressive symptoms). Educational media did predict small increases in verbal interactions and toy provision (adjusted models, respectively: β = 0.13, P = .02; β = 0.11; P = .03). In contrast, more consistent relationships were seen for models of the relationship between prior StimQ (total, verbal interactions and teaching; adjusted models, respectively: β = 0.20, P = .002; β = 0.15, P = .006; β = 0.20, P = .001) and predicted subsequent educational media.

CONCLUSIONS

Educational media as used by this sample of low-income families does not promote cognitive stimulation activities important for early child development or activities such as reading and teaching.

Predictors of screen viewing time in young Singaporean children: the GUSTO cohort

Background

Higher screen viewing time (SVT) in childhood has been associated with adverse health outcomes, but the predictors of SVT in early childhood are poorly understood. We examined the sociodemographic and behavioral predictors of total and device-specific SVT in a Singaporean cohort.

Methods

At ages 2 and 3 years, SVT of 910 children was reported by their parents. Interviewer-administered questionnaires assessed SVT on weekdays and weekends for television, computer, and hand-held devices. Multivariable linear mixed-effect models were used to examine the associations of total and device-specific SVT at ages 2 and 3 with predictors, including children’s sex, ethnicity, birth order, family income, and parental age, education, BMI, and television viewing time.

Results

At age 2, children’s total SVT averaged 2.4 ± 2.2 (mean ± SD) hours/day, including 1.6 ± 1.6 and 0.7 ± 1.0 h/day for television and hand-held devices, respectively. At age 3, hand-held device SVT was 0.3 (95% CI: 0.2, 0.4) hours/day higher, while no increases were observed for other devices. SVT tracked moderately from 2 to 3 years (r = 0.49, p < 0.0001). Compared to Chinese children, Malay and Indian children spent 1.04 (0.66, 1.41) and 0.54 (0.15, 0.94) more hours/day watching screens, respectively. Other predictors of longer SVT were younger maternal age, lower maternal education, and longer parental television time.

Conclusions

In our cohort, the main predictors of longer children’s SVT were Malay and Indian ethnicity, younger maternal age, lower education and longer parental television viewing time. Our study may help target populations for future interventions in Asia, but also in other technology-centered societies.

Trial registration

This ongoing study was first registered on July 1, 2010 on NCT01174875 as. Retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0562-3) contains supplementary material, which is available to authorized users.

Prevalence, trajectories, and determinants of television viewing time in an ethnically diverse sample of young children from the UK

Background

Excessive screen viewing in early childhood is associated with poor physical and psycho-social health and poor cognitive development. This study aimed to understand the prevalence, trajectory and determinants of television viewing time in early childhood to inform intervention development.

Methods

In this prospective longitudinal study, mothers of 1558 children (589 white British, 757 Pakistani heritage, 212 other ethnicities) completed questionnaires when their children were approximately 6, 12, 18, 24 and 36 months old. Mothers answered questions about their own and their child’s TV-time. TV-time trajectories were estimated by linear longitudinal multilevel modeling, potential determinants were considered in models.

Results

The modelled trajectory estimated that 75% of children aged 12 months exceeded guidelines of zero screen-time. At 12 months of age an accelerated increase in TV-time was observed (<1 h/day at 14 months, >2 h/day by 30 months old). For every hour of mothers’ TV-time and every hour the TV was on in the home, children’s TV-time was 8 min and 1 min higher respectively at 6 months old (P < 0.05), and 15 min and 3 min higher respectively at 36 months old (P < 0.05). Children whose mothers did not agree that it was important their child did not watch too much TV, had 17 min more TV-time than their counterparts (P < 0.05). Children of first time mothers had 6 min more TV-time (P < 0.05). At 12 months of age, children of mothers experiencing stress watched 8 min more TV (P < 0.05). By 36 months, children of Pakistani heritage mothers had 22 min more TV-time than those of white British mothers (P < 0.05), and an additional 35 min of TV-time if their mother was not born in the UK (P < 0.05).

Conclusions

High levels of TV-time were prevalent. Intervention developers should consider targeting interventions before 12 months of age. Modifiable determinants included mothers’ own TV-time, the time the television is on in the home and mothers’ attitude towards child TV-time. These behaviours may be key components to address in interventions for parents. Mothers experiencing stress, first time mothers, and Pakistani heritage mothers (particularly those born outside of the UK), may be priority groups for intervention.

A review of early influences on physical activity and sedentary behaviors of preschool-age children in high-income countries

PURPOSE

Promoting physical activity (PA) is a key component of preventing and controlling childhood obesity. Despite well-documented benefits of PA, globally, rates of PA among young children have declined over the past decades, and most children are not accruing sufficient PA daily. Helping children develop the foundation for PA habits early in life is critical for the promotion of health in childhood and prevention of chronic diseases later in life, and will ultimately promote longer and healthier lives for individuals and the general population. The purpose of this review is to provide a synthesis of current evidence on influences on PA and sedentary behaviors of preschool-age children in high-income countries.

DESIGN AND METHODS

A systematic review of three databases was performed. Studies conducted in high-income countries and published from 2000 onward that addressed influences on PA and sedentary behaviors of preschool-age children were identified and reviewed. Additionally, reference lists of identified articles and relevant published reviews were reviewed. Studies that met the following inclusion criteria were considered: (a) sample included preschoolers (age ≤5 years); (b) PA and/or sedentary behaviors or factors associated with PA and/or sedentary behaviors was assessed; (c) published in English; (d) used either quantitative or qualitative methods; and (e) conducted in a high-income country. Data were extracted from selected studies to identify influences on PA and sedentary behaviors of preschool-age children and organized using the social-ecological model according to multiple levels of influence.

RESULTS

Results from included studies identify multiple factors that influence PA and sedentary behaviors of young children in high-income countries at the various levels of the social-ecological model including intrapersonal, interpersonal, environmental, organizational, and policy.

PRACTICE IMPLICATIONS

Given pediatric nurses' role as primary care providers, and their frequent and continued contact with parents and their children throughout childhood through well-child visits, immunization, and minor acute illnesses, they are well positioned to promote and support the development of early healthful PA habits of children starting in early childhood.

Demographic correlates of screen time and objectively measured sedentary time and physical activity among toddlers: a cross-sectional study

Background

Determining the most important demographic correlates of sedentary behavior and physical activity will help identify the groups of children that are most in need of intervention. Little is known in regards to the demographic correlates of sedentary behavior and physical activity in toddlers (aged 12–35 months), where long-term behavioral patterns may initially be formed. Therefore, the objective of this study was to examine the associations between demographic correlates and specific types of sedentary behavior and physical activity in this age group.

Methods

Findings are based on 149 toddlers (19.0 ± 1.9 months) and their parents (33.7 ± 4.7 years) recruited from immunization clinics in Edmonton, Canada as part of the Parents’ Role in Establishing healthy Physical activity and Sedentary behavior habits (PREPS) project. Toddlers’ and parental demographic characteristics and toddlers’ television viewing, video/computer games, and overall screen time were measured via the PREPS parental questionnaire. Toddlers’ objectively measured sedentary time and physical activity (light, moderate to vigorous, and total) were accelerometer-derived using Actigraph wGT3X-BT monitors. Simple and multiple linear regression models were conducted to examine associations.

Results

In the multiple linear regression models, toddlers’ age, toddlers’ sex (female versus male), toddlers’ race/ethnicity (other versus European-Canadian/Caucasian), and household income ($50,001 to $100,000 versus > $100,000) were significantly positively associated, and main type of child care (child care center versus parental care) was significantly negatively associated with screen time. Similar findings were observed with television viewing, except null associations were observed for toddlers’ sex. Toddlers’ race/ethnicity (other versus European-Canadian/Caucasian) was significantly positively associated and main type of child care (child care center, day home, other versus parental care) was significantly negatively associated with video/computer games. Toddlers’ sex (female versus male) was significantly positively associated with sedentary time and significantly negatively associated with moderate- to vigorous-intensity physical activity.

Conclusions

Female toddlers, toddlers from ethnic minority groups, toddlers from families of lower income, and toddlers whose main type of child care is not center-based may be important targets for screen time interventions in toddlers. Apart from sex, demographic correlates may not be important targets for objectively measured sedentary time and physical activity in toddlers.

Media and Young Minds

Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children's media use, not only in terms of content or time limits, but also emphasizing the importance of parent-child shared media use and allowing the child time to take part in other developmentally healthy activities.

Children and Adolescents and Digital Media

Today's children and adolescents are immersed in both traditional and new forms of digital media. Research on traditional media, such as television, has identified health concerns and negative outcomes that correlate with the duration and content of viewing. Over the past decade, the use of digital media, including interactive and social media, has grown, and research evidence suggests that these newer media offer both benefits and risks to the health of children and teenagers. Evidence-based benefits identified from the use of digital and social media include early learning, exposure to new ideas and knowledge, increased opportunities for social contact and support, and new opportunities to access health promotion messages and information. Risks of such media include negative health effects on sleep, attention, and learning; a higher incidence of obesity and depression; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. This technical report reviews the literature regarding these opportunities and risks, framed around clinical questions, for children from birth to adulthood. To promote health and wellness in children and adolescents, it is important to maintain adequate physical activity, healthy nutrition, good sleep hygiene, and a nurturing social environment. A healthy Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that is individualized for a specific child, teenager, or family can identify an appropriate balance between screen time/online time and other activities, set boundaries for accessing content, guide displays of personal information, encourage age-appropriate critical thinking and digital literacy, and support open family communication and implementation of consistent rules about media use.

Increased Screen Time: Implications for Early Childhood Development and Behavior

The authors review trends in adoption of new digital technologies (eg, mobile and interactive media) by families with young children (ages 0-8 years), continued use of television and video games, and the evidence for learning from digital versus hands-on play. The authors also discuss continued concerns about health and developmental/behavioral risks of excessive media use for child cognitive, language, literacy, and social-emotional development. This evidence is then applied to clinical care in terms of the screening questions providers can use, tools available to providers and parents, and changes in anticipatory guidance.

Prevalence of sedentary behavior in children under 2years: A systematic review

Sedentary behavior has negative health outcomes, evident even in young children. Identifying the prevalence of sedentary behavior in children <2years is important for determining the necessity for intervention strategies. The aim of this systematic review was to determine the prevalence of sedentary behavior in children <2years. Medline, PsycINFO, SPORTDiscus, and Education Research Complete electronic databases were searched, as were reference lists of included articles and the authors' own collections. Inclusion criteria were: published in a peer-reviewed English language journal; mean age of children <2years; and a reported measure of the prevalence of sedentary behavior. Twenty-four studies met the inclusion criteria. Most studies used parent-reported screen time as the sedentary behavior measure; only one study reported time spent restrained (i.e., kept inactive) and no studies reported objectively assessed sedentary time. Estimates of young children's screen time ranged from 36.6 to 330.9min/day. The proportion of children meeting the zero screen time recommendation ranged from 2.3% to 83.0%. In conclusion, very little is known about sedentary behaviors other than screen time in this age group. Although highly variable, findings suggest that children are already engaging in high levels of screen time by age 2 and the majority exceed current recommendations.

Early childhood physical activity, sedentary behaviors and psychosocial well-being: a systematic review

OBJECTIVES

Little is known about how health behaviors such as physical activity (PA) and sedentary behaviors (SB) may be associated with psychosocial well-being during the crucial early childhood period. The aim of this study was to undertake a systematic review of associations between PA, SB and psychosocial well-being during early childhood.

METHODS

In February 2013, MEDLINE, PsycINFO, SPORTDiscus and Embase electronic databases were searched. Inclusion criteria were: 1. peer-reviewed publication since 1980 in English; 2. children aged birth-5 years; 3. PA or SB measured during early childhood; 4. an indicator of child psychosocial well-being; and 5. association between PA/SB and psychosocial well-being reported. Studies could be observational or interventions. Data were extracted by one author and entered into a standardized form in February and March 2013.

RESULTS

19 studies were identified: four examined PA, 13 examined SB and two examined PA and SB. No interventions met the inclusion criteria; all included studies were observational. In total, 21 indicators of psychosocial well-being were examined, 13 only once with the remaining eight reported in more than one study. Some dose-response evidence was identified suggesting that PA is positively, and SB inversely, associated with psychosocial well-being.

CONCLUSIONS

Too few studies exist to draw conclusions regarding associations. Future high-quality cohort and intervention studies are warranted particularly investigating dose-response associations.

Children under the age of two are more likely to watch inappropriate background media than older children

AIM

To establish whether young children watched foreground electronic media or background media that was not aimed at them or was inappropriate for their age.

METHODS

We performed a longitudinal analysis of mother-infant dyads participating in a larger parenting study. The primary dependent variable was maternal reports of watching habits from media diaries at 6, 14, 24 and 36 months. Independent variables were child age, programme content and whether the programme was turned on specifically for the child.

RESULTS

We analysed 3570 programme exposures in 527 children, mostly from television. Children were significantly more likely to actually watch programmes if they were older, if the content was coded as 'educational young child' or if the parent tuned on the programme specifically so the child could watch it. Children under the age of two were more likely than older children to watch background media that featured age-inappropriate content or had not been turned on for them to watch [30% versus 16% of programmes; AOR = 2.19 (95%CI 1.82-2.65)].

CONCLUSION

Young children under the age of two frequently watch background media that has age-inappropriate content or has not been turned on for them to watch.

Screen time use in children under 3 years old: a systematic review of correlates

Background

A large percentage (68%) of children under age 3 use screen media, such as television, DVDs and video games, on a daily basis. Research suggests that increased screen time in young children is linked to negative health outcomes, including increased BMI, decreased cognitive and language development and reduced academic success. Reviews on correlates of screen time for young children have included preschool age children and children up to age 7; however, none have focused specifically on correlates among infants and toddlers. As research suggests that screen media use increases with age, examining correlates of early media exposure is essential to reducing exposure later in life. Thus, this paper systemically reviews literature published between January 1999 and January 2013 on correlates of screen time among children between 0 and 36 months of age.

Methods

Two methods were used to conduct this review: (1) Computerized searches of databases (PubMed, PsycINFO, ERIC, Medline); and (2) Reference sections of existing reviews and primary studies. Inclusion criteria were: (1) The article included separate data for children 36 months and younger, (2) English language, (3) peer reviewed article, (4) analysis reported for screen viewing as a dependent variable, (5) original research article and, (6) examined correlates or associations between screen time and other demographic, contextual or behavioral variables. Articles were compiled between 2011 and 2013 and evaluation occurred in 2012 and 2013.

Results

The literature search identified 29 studies that met inclusion criteria. These studies investigated a total of 33 potential correlates, which were examined in this review. Findings suggest demographic variables most commonly correlated with high screen time among infants and toddlers are child’s age (older) and race/ethnicity (minority). Child BMI, maternal distress/depression, television viewing time of the mother and cognitive stimulation in the home environment were also associated with screen media use. Studies reported that child sex, first born status, paternal education, non-English speaking family, two-parent household, number of children in the home and non-parental childcare were not associated with screen time among children aged 0–36 months. Associations were unclear (fewer than 60% of studies report an association) for maternal age, maternal education and household income. The remaining correlates were investigated in fewer than three studies and thus not coded for an association.

Conclusions

The correlates identified in this study point to avenues for intervention to reduce screen time use in young children. However, further research is necessary to explore a number of environmental, socio-cultural and behavioral correlates that are under-examined in this population and may further inform prevention and intervention strategies.

Television viewing in low-income latino children: variation by ethnic subgroup and English proficiency

BACKGROUND

Television viewing is associated with an increased risk for obesity in children. Latino children are at high risk for obesity and yet little is known about differences in television viewing habits within this population. The purpose of this study is to determine if hours of television viewed by young children with low-income Latina mothers differs by maternal ethnic subgroup and English language proficiency.

METHODS

This was a cross-sectional analysis of data from the Welfare, Children, & Families: A Three City Study. Participants were 422 low-income Latina mothers of Mexican and Puerto Rican descent with children ages 0-4 years old. The dependent variable was hours of daily television viewed by the child. The independent variable was maternal ethnic subgroup and English language proficiency. Analyses involved the use of multiple negative binomial regression models, which were adjusted for demographic variables.

RESULTS

Multivariable regression analyses showed that compared to children with mothers of Mexican descent, children of mothers of Puerto Rican descent watch more daily television (<2 years old, incidence rate ratio (IRR)=4.18, 95% confidence interval (CI) 1.68, 10.42; 2-4 years, IRR=1.54, 95% CI 1.06, 2.26). For children with mothers of Mexican descent, higher maternal English language proficiency was associated with higher amounts of child television viewing (IRR=1.29, 95% CI 1.04, 1.61). No relationship was found for children of Puerto Rican descent.

CONCLUSIONS

Child television viewing varies in low-income Latino children by maternal ethnic subgroup and English language proficiency. Interventionists must consider the varying sociocultural contexts of Latino children and their influence on television viewing.

Systematic review of sedentary behaviour and health indicators in the early years (aged 0-4 years)

Accumulating evidence suggests that young children spend excessive time being sedentary. The purpose of this systematic review was to determine the relationship between sedentary behaviours and health indicators during the early years (ages 0-4 years). Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, this review aimed to present the best available evidence on the threshold of sedentary behaviour associated with healthy measures of adiposity, bone health, motor skill development, psychosocial health, cognitive development, and cardiometabolic health indicators in infants, toddlers, and preschoolers. Online databases, personal libraries, and government documents were searched for relevant studies. Studies that included an intervention (or experimental) group or prospective analysis were included. Twenty-one unique studies, representing 23 papers and 22 417 participants, met inclusion criteria; 7 studies included information on infants, 13 on toddlers, and 10 on preschoolers. Of these, 11, 6, and 8 studies reported data on adiposity, psychosocial health, and cognitive development, respectively. No included study reported on motor skill development, bone, or cardiometabolic health indicators. In conclusion, this review found low- to moderate-quality evidence to suggest that increased television viewing is associated with unfavourable measures of adiposity and decreased scores on measures of psychosocial health and cognitive development. No evidence existed to indicate that television viewing is beneficial for improving psychosocial health or cognitive development. In several instances a dose-response relationship was evident between increased time spent watching television and decreased psychosocial health or cognitive development. This work may be used as evidence to inform public health guidelines. (PROSPERO registration: CRD4011001280.).

Randomized controlled trial of primary care pediatric parenting programs: effect on reduced media exposure in infants, mediated through enhanced parent-child interaction

OBJECTIVES

To determine whether pediatric primary care-based programs to enhance parenting and early child development reduce media exposure and whether enhanced parenting mediates the effects.

DESIGN

Randomized controlled trial.

SETTING

Urban public hospital pediatric primary care clinic.

PARTICIPANTS

A total of 410 mother-newborn dyads enrolled after childbirth.

INTERVENTIONS

Patients were randomly assigned to 1 of 2 interventions, the Video Interaction Project (VIP) and Building Blocks (BB) interventions, or to a control group. The VIP intervention comprised 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading through review of videotapes made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. The BB intervention mailed parenting materials, including age-specific newsletters suggesting activities to facilitate interactions, learning materials, and parent-completed developmental questionnaires (Ages and Stages questionnaires).

OUTCOME MEASURES

Electronic media exposure in the home using a 24-hour recall diary.

RESULTS

The mean (SD) exposure at 6 months was 146.5 (125.0) min/d. Exposure to VIP was associated with reduced total duration of media exposure compared with the BB and control groups (mean [SD] min/d for VIP, 131.6 [118.7]; BB, 151.2 [116.7]; control, 155.4 [138.7]; P = .009). Enhanced parent-child interactions were found to partially mediate relations between VIP and media exposure for families with a ninth grade or higher literacy level (Sobel statistic = 2.49; P = .01).

CONCLUSION

Pediatric primary care may represent an important venue for addressing the public health problem of media exposure in young children at a population level.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212576.

Infant media exposure and toddler development

OBJECTIVE

To determine whether duration and content of media exposure in 6-month-old infants are associated with development at age 14 months.

DESIGN

Longitudinal analysis of 259 mother-infant dyads participating in a long-term study related to early child development, from November 23, 2005, through January 14, 2008.

SETTING

An urban public hospital.

PARTICIPANTS

Mothers with low socioeconomic status and their infants.

MAIN EXPOSURE

Duration and content of media exposure at age 6 months.

MAIN OUTCOME MEASURES

Cognitive and language development at age 14 months.

RESULTS

Of 259 infants, 249 (96.1%) were exposed to media at age 6 months, with mean (SD) total exposure of 152.7 (124.5) min/d. In unadjusted and adjusted analyses, duration of media exposure at age 6 months was associated with lower cognitive development at age 14 months (unadjusted: r = -0.17, P < .01; adjusted: β = -0.15, P = .02) and lower language development (r = -0.16, P < .01; β = -0.16, P < .01). Of 3 types of content assessed, only 1 (older child/adult-oriented) was associated with lower cognitive and language development at age 14 months. No significant associations were seen with exposure to young child-oriented educational or noneducational content.

CONCLUSIONS

This study is the first, to our knowledge, to have longitudinally assessed associations between media exposure in infancy and subsequent developmental outcomes in children from families with low socioeconomic status in the United States. Findings provide strong evidence in support of the American Academy of Pediatrics recommendations of no media exposure prior to age 2 years, although further research is needed.

Do Verbal Interactions with Infants During Electronic Media Exposure Mitigate Adverse Impacts on their Language Development as Toddlers?

The goal of this study was to determine whether verbal interactions between mothers and their 6-month-old infants during media exposure ('media verbal interactions') might have direct positive impacts, or mitigate any potential adverse impacts of media exposure, on language development at 14 months. For 253 low-income mother-infant dyads participating in a longitudinal study, media exposure and media verbal interactions were assessed using 24-hour recall diaries. Additionally, general level of cognitive stimulation in the home [StimQ] was assessed at 6 months and language development [Preschool Language Scale-4] was assessed at 14 months. Results suggest that media verbal interactions play a role in the language development of infants from low-income, immigrant families. Evidence showed that media verbal interactions moderated adverse impacts of media exposure found on 14-month language development, with adverse associations found only in the absence the these interactions. Findings also suggest that media verbal interactions may have some direct positive impacts on language development, in that media verbal interactions during the co-viewing of media with educational content (but not other content) were predictive of 14-month language independently of overall level of cognitive stimulation in the home.

Television viewing by young Hispanic children: evidence of heterogeneity

OBJECTIVES

To determine if hours of daily television viewed by varying age groups of young children with Hispanic mothers differs by maternal language preference and to compare these differences with young children with white mothers.

DESIGN

Cross-sectional analysis of data collected in 2000 from the National Survey of Early Childhood Health.

SETTING

Nationally representative sample.

PARTICIPANTS

One thousand three hundred forty-seven mothers of children aged 4 to 35 months.

MAIN EXPOSURE

Subgroups of self-reported maternal race/ethnicity (white or Hispanic) and within Hispanic race/ethnicity, stratification by maternal language preference (English or Spanish).

OUTCOME MEASURE

Hours of daily television the child viewed.

RESULTS

Bivariate analyses showed that children of English- vs Spanish-speaking Hispanic mothers watched more television daily (1.88 vs 1.31 hours, P < .01). Multivariable regression analyses stratified by age revealed differences by age group. Among 4- to 11-month-old infants, those of English- and Spanish-speaking Hispanic mothers watched similar amounts. However, among children aged 12 to 23 and 24 to 35 months, those of English-speaking Hispanic mothers watched more television than children of Spanish-speaking Hispanic mothers (incidence rate ratio [IRR], 1.61; 95% confidence interval [CI], 1.17-2.22; IRR, 1.66; 95% CI, 1.10-2.51, respectively). Compared with children of white mothers, children of both Hispanic subgroups watched similar amounts among the 4- to 11-month-old group. However, among 12- to 23-month-old children, those of English-speaking Hispanic mothers watched more compared with children of white mothers (IRR, 1.57; 95% CI, 1.18-2.11). Among 24- to 35-month-old children, those of English-speaking Hispanic mothers watched similar amounts compared with children of white mothers, but children of Spanish-speaking Hispanic mothers watched less (IRR, 0.69; 95% CI, 0.50-0.95).

CONCLUSION

Television-viewing amounts among young children with Hispanic mothers vary by child age and maternal language preference, supporting the need to explore sociocultural factors that influence viewing in Hispanic children.