Differences in Parent-Toddler Interactions With Electronic Versus Print Books

Mobile Media Content Exposure and Toddlers' Responses to Attention Prompts and Behavioral Requests

Importance

With personalized touch-screen tablets, young children can choose content and engage in play-like activities. However, tablets may also reduce shared engagement as the action of viewing or touching the screen is often not visible to nearby adults. This may impact communicative gazing and pointing, which is critical to the formation of shared awareness and in turn supports language development.

Objective

To assess the association of tablet media content with toddlers' responses to joint attention prompts and behavioral requests.

Design, Setting, and Participants

This cohort study took place at a behavioral research laboratory and included toddlers who were aged 18 to 32 months with neurotypical development who were recruited from a volunteer and community sample. Toddlers engaged with a real toy or 3 different types of tablet content (ie, viewing video of toy play, playing with a digital toy, or playing a commercial game) while an experimenter delivered joint attention prompts. Data were acquired from June 2021 November XX 2022, and data analysis occurred from January 2023 to May 2024.

Main Outcomes and Measures

Main outcomes included child response to joint attention (number of prompts with joint attention response per number of prompts delivered) and child response to behavioral request (ie, the prompt on which the child responded to the behavioral request). Measures included crossed random effects, Wald tests, and likelihood ratio tests.

Results

In this study, 63 toddlers were enrolled, and data from 62 were included (31 female [49%]; mean [SD] age, 26.1 [3.4] months; median [IQR] age, 25.0 [18.6-32.6] months). When toddlers were playing a commercial game on a tablet, they responded to fewer joint attention prompts (crossed random effects model, -0.15; 95% CI, -0.24 to -0.06 prompts) and male toddlers took longer to acknowledge a behavioral request (interaction of content and sex, -0.75; 95% CI, -1.36 to -0.17). The negative impact of the tablet game was larger as child age increased (τ = -2.30; 95% CI, -0.05 to 0; P = .03). Greater media use at home was associated with decreased responding to joint attention prompts during the tablet game (ρ = -0.47; P < .001), while better language skills were associated with more joint attention during play with a real toy (ρ = 0.31; P = .02).

Conclusions and Relevance

In this cohort study, a touch-screen tablet game was associated with decreased joint attention among toddlers and they were less likely to respond to a behavioral request. In a laboratory setting, it was difficult for toddlers to engage in social-communicative interactions with adults when using a tablet media device.

Touchscreens can promote infant object-interlocutor reference switching

We re-examine whether the type of object played with influences parent-infant joint attention. A within-participants comparison of 24 parent-9-month-old dyads, used head-mounted eye-tracking to measure parental naming and infant attention during play with touchscreen apps on a touchscreen tablet or matched interactive toys. Infants engaged in sustained attention more to the toy than the tablet. Parents named objects less in toy play. Infants exhibited more gaze shifts between the object and their parent during tablet play. Contrasting previous studies, these findings suggest that joint tablet play can be more interactive than with toys, and raise questions about the recommendation that infants should not be exposed at all to such technology.

Surveying Parents of Preschool Children about Digital and Analogue Play and Parent-Child Interaction

The addition of digital toys to the child's toy box has resulted in the development of the new 'digital play', which differs from analogue play. Research shows that digital toys are available from infancy onwards and are significantly changing the way children engage in play and communicate with parents during play. How this influences the child's development must be established. The choice of toys and the manner in which they are used depend greatly on the parents. In the present study, parents' opinions and experiences of their child's digital and analogue play were explored in order to gain insight into the parents' perceptions of the impact of different types of play on their child's development. We were particularly interested in the differences in a child's engagement with a toy and the child-parent interaction and communication. In this descriptive study, we administered a questionnaire in order to collect data from 306 parents of children of an average age of 3.6 years. The results show that parents perceived traditional toys as the most stimulating toys for a toddler's sensory, motor, cognitive, and socio-emotional development. During analogue play, significantly more parent-child interaction, as well as more language input from parents and toddlers, occurred. Parents also used different intervention and mediation strategies with different types of toys.

Effects of screen exposure on young children's cognitive development: A review

The past decade has witnessed a rapid increase in the use of screen media in families, and infants are exposed to screens at younger ages than ever before. The objective of this review is twofold: (1) to understand the correlates and demographic factors determining exposure to screens, including interactive screens, when available, and (2) to study the effects of watching screens and using touchscreens on cognitive development, during the first 3 years of life. We argue that the effects of screen viewing depend mostly on contextual aspects of the viewing rather than on the quantity of viewing. That context includes the behavior of adult caregivers during viewing, the watched content in relation to the child's age, the interactivity of the screen and whether the screen is in the background or not. Depending on the context, screen viewing can have positive, neutral or negative effects on infants' cognition.

Moment-to-Moment Observation of Parental Media Use and Parent-Child Interaction: Quality and Media Multitasking

Mobile media proliferation throughout society has infused and complicated environments that formerly were interaction rich (e.g., waiting rooms, restaurants, and playgrounds) with the presence of smart devices. Ethnographic studies have indicated that parental use negatively impacts parent-child interaction quality. The current study reviews and expands on previous research through observing systematically parent-child interaction quality throughout the course of an entire meal (30-140 minutes). Utilizing five-minute intervals, across 93 parent-child dyads, we assessed both within- and between-person moment-to-moment changes in parenting quality (i.e., parental positivity, negativity, and engagement) in the context of parental media use. Between-person, only positivity appeared to decrease when comparing low and high parental media use. Within-person findings indicated that when the parent demonstrated higher than their typical media use, we noted a significant decrease in the quality of engagement and positivity. Differing from ethnographic studies, no change in negativity was identified within-person. Utilizing a lagged interval analysis, we identified a pattern of increased parental engagement with their child following intervals with parental media use, identifying a pattern of parental media multitasking heretofore only observed in ethnographic studies. Implications of findings in the context of previous research and future directions are discussed.

Survey of public library use in the Ambulatory Clinic in the Children’s Hospital Winnipeg

Introduction

Recent studies highlight synergies for families receiving early childhood literacy support from their health care provider and public library, with more reading at home and higher quality book-sharing interactions. Our primary objective was to determine the percentage of Children’s Hospital Winnipeg Ambulatory Clinic’s patients who had ever used a public library. The clinic has a longstanding early-childhood literacy program and serves remote communities and low-income Winnipeg families.

Methods

A structured survey was administered to parents or legal guardians by the first author. It explored library barriers and covariates that might affect library use. Analysis included descriptive statistics and a logistic regression model for predictors of library use.

Results

Ninety-seven nearly consecutive surveys were administered, half prior to the COVID-19 pandemic. Most respondents were female, from Winnipeg, and in the two lowest neighbourhood income quintiles. Roughly half (46.4%) of children had used a library. Most respondents wanted health care providers to promote literacy and provide information about public libraries, and more supported in-clinic distribution of books. The number of children per household positively predicted library use, possibly a proxy for experience with community resources. About 2/3 of respondents believed that library fines should be abolished. Most identified other barriers, for example, inconvenient hours, distance, or concerns about COVID-19.

Conclusion

Less than half of surveyed families used public libraries, citing multiple barriers, including fines. Moreover, not all health care providers can offer new books and anticipatory guidance. Clinics that promote use of public libraries may therefore represent a low-cost, stand-alone alternative.

Parent Verbalizations and Toddler Responses With Touchscreen Tablet Nursery Rhyme Apps

OBJECTIVES

In some studies, parents and toddlers verbalize less when engaging with a tablet versus a print book. More needs to be known regarding child contributions to specific parent verbalizations. We examined parent-toddler contingent interactions with tablet applications versus print books, as well as moderators of these associations.

METHODS

We conducted a laboratory-based, within-subjects counterbalanced study of 72 parent-toddler dyads engaging with a nursery rhyme application (with enhanced + autonarration [E+A] and enhanced formats) and print book. We coded parent verbalizations (eg, dialogic, nondialogic) and proportions of child responses to these in 5-second epochs. Poisson regressions were used to analyze within-subjects variance by tablet or print format. We tested effect modification by child emotion regulation and home media practices.

RESULTS

Children responded more to parent overall (print 0.38; E+A 0.31, P = .04; enhanced 0.11, P = .01), dialogic (print 0.21; E+A 0.13, P = .04; enhanced 0.1, P = .02), and nondialogic (print 0.45; E+A 0.27, P < .001; enhanced 0.32, P < .001) verbalizations during print book versus tablet. Stronger child emotion regulation, greater frequency of co-viewing, and instructive practices moderated associations such that differences between conditions were no longer significant for some parent verbalizations and child responses.

CONCLUSIONS

Parent-toddler reciprocal verbal interactions occurred less frequently with tablet versus print book use. Child emotion regulation and parent home media practices moderated some of these associations. Pediatricians may wish to promote co-viewing and instructive media practices but may also consider that child emotion regulation may determine response to interactive tablet design.

The negative effects of new screens on the cognitive functions of young children require new recommendations

Television studies have shown that some negative effects of screens could depend on exposure time, but more importantly on the characteristics of the child, the type of content viewed, and the context in which it is viewed. Studies on newer screens show that these factors are still valid but new ones now play a negative role: portable screens increase the duration of exposure and lowered the age at which exposure begins. More worryingly, new screen persuasive designs and dark patterns largely used incite more frequent use, attracting the attention of children and parents, resultantly interfering deeply in parent/child relationships. In this text we suggest that current academic recommendations have to be more broadly shared but also that new recommendations are needed: especially to advise parents not to let their screen interactions compete with real interactions with their child which are the core of learnings (especially language) and emotional regulations but also of their security.

Promoting Early Literacy Using Digital Devices: A Pilot Randomized Controlled Trial

OBJECTIVE

To determine feasibility and explore effects of literacy promotion using e-books versus board books on the home reading environment, book reading, television use, and child development.

METHODS

Randomized controlled trial comparing digital literacy promotion (DLP) using e-books to standard literacy promotion (SLP) using board books among Medicaid-eligible infants. DLP participants received e-books on home digital devices, while SLP participants received board books at well visits between 6 and 12 months of age. Differences in StimQ Read Subscale (StimQ-Read) scores, parent-reported reading and television use, and Bayley Scales of Infant Development-3rd Edition (Bayley-3) scores between groups were assessed using intention-to-treat analysis.

RESULTS

A total of 104 Medicaid-eligible infants were enrolled and randomized from 3 pediatric practices. There were no differences in sociodemographic characteristics between groups at baseline. Children in the DLP group initially had lower StimQ-Read scores but showed similar increases in StimQ-Read scores over time as children in the SLP group. Parents in the DLP group reported greater use of digital devices to read or engage their child (65% vs 23%, P < .001) but similar board book reading and television viewing. There were no differences between groups in cognitive or motor scale scores, but DLP participants had marginally lower language scales scores (DLP 85.7 vs SLP 89.7; P = .10) at the 6-month follow-up.

CONCLUSIONS/DISCUSSION

Literacy promotion using e-books was feasible and associated with greater e-book usage but no difference in board book reading, television viewing, or home reading environment scores. A potential adverse impact of e-books on language development should be confirmed in future study.

Infant media use: A harm reduction approach

There are a myriad of potentially harmful developmental outcomes associated with infant digital media use. Studies revealing risk associated with early media use have informed the current American Academy of Pediatrics (AAP) recommendations that discourage most digital media use among children under 18 months of age. Recent research advances, however, suggest potential benefits of technology engagement in this age group. Additionally, surveys of parents reveal that most infants engage with digital media for at least 30 min a day, exceeding the AAP recommendations. In response to these discoveries and cultural trends, some scholars have made compelling cases to adapt the AAP guidelines for infants. A helpful model for developing infant digital media use guidelines for families may be the harm reduction approach. The intent of this review is to suggest adaptations to the AAP guidelines for infant media engagement using a harm reduction framework. This review describes the challenge of restrictive guidelines, briefly summarizes the harm reduction approach, provides a review of risks and benefits associated with infant media use in each developmental domain (physical, cognitive, and socioemotional), summarizes correlates of infant screen media use, and examines intervention strategies for reducing screen time. The paper concludes with examples of possible adaptations to current AAP infant media use recommendations using harm reduction and bioecological frameworks.

Development of an Eco-Biodevelopmental Model of Emergent Literacy Before Kindergarten: A Review

IMPORTANCE

Literacy has been described as an important social determinant of health. Its components emerge in infancy and are dependent on genetic, medical, and environmental factors. The American Academy of Pediatrics advocates a substantial role for pediatricians in literacy promotion, developmental surveillance, and school readiness to promote cognitive, relational, and brain development. Many children, especially those from minority and underserved households, enter kindergarten unprepared to learn to read and subsequently have difficulty in school.

OBSERVATIONS

Emergent literacy is a developmental process beginning in infancy. Component skills are supported by brain regions that must be adequately stimulated and integrated to form a functional reading network. Trajectories are associated with genetic, medical, and environmental factors, notably the home literacy environment, which is defined as resources, motivation, and stimulation that encourage the literacy development process. Eco-biodevelopmental models are advocated by the American Academy of Pediatrics, and these models offer insights into the neurobiological processes associated with environmental factors and the ways in which these processes may be addressed to improve outcomes. Emergent literacy is well suited for such a model, particularly because the mechanisms underlying component skills are elucidated. In addition to cognitive-behavioral benefits, the association of home literacy environment with the developing brain before kindergarten has recently been described via neuroimaging. Rather than a passive approach, which may subject the child to stress and engender negative attitudes, early literacy screening and interventions that are administered by pediatric practitioners can help identify potential reading difficulties, address risk factors during a period when neural plasticity is high, and improve outcomes.

CONCLUSIONS AND RELEVANCE

Neuroimaging and behavioral evidence inform an eco-biodevelopmental model of emergent literacy that is associated with genetic, medical, and home literacy environmental factors before kindergarten, a time of rapid brain development. This framework is consistent with recommendations from the American Academy of Pediatrics and provides insights to help identify risk factors and signs of potential reading difficulties, tailor guidance, and provide direction for future research.

Longitudinal Associations Between Screen Use and Reading in Preschool-Aged Children

BACKGROUND AND OBJECTIVES

The home literacy environment has been identified as a key predictor of children's language, school readiness, academic achievement, and behavioral outcomes. With the increased accessibility and consumption of digital media, it is important to understand whether screen use impacts off-line enrichment activities such as reading or whether reading activities offset screen use. Using a prospective birth cohort, we examined reading and screen use at 24, 36, and 60 months to elucidate the directional association between screen use and reading over time.

METHODS

This study included data from 2440 mothers and children in Calgary, Alberta, drawn from the All Our Families cohort. Children's screen use and reading activities were assessed via maternal report at age 24, 36, and 60 months. Sociodemographic covariates were also collected.

RESULTS

Using a random-intercepts cross-lagged panel model, which statistically controls for individual-level confounds, this study revealed that greater screen use at 24 months was associated with lower reading at 36 months (β = -.08; 95% confidence interval: -0.13 to -0.02). In turn, lower reading at 36 months was associated with greater screen use at 60 months (β = -.11; 95% confidence interval: -0.19 to -0.02). Covariates did not modify the associations.

CONCLUSIONS

A reciprocal relationship between screen use and reading was identified. Early screen use was associated with lower reading activities, resulting in greater screen use at later ages. Findings emphasize the need for practitioners and educators to discuss screen use guidelines and encourage families to engage in device-free activities to foster early literacy exposure.

How educational are 'educational' apps for young children? App store content analysis using the Four Pillars of Learning framework

Experts have expressed concerns about the lack of evidence demonstrating that children's "educational" applications (apps) have educational value. This study aimed to operationalize Hirsh-Pasek, Zosh, et al.'s (2015) Four Pillars of Learning into a reliable coding scheme (Pillar 1: Active Learning, Pillar 2: Engagement in the Learning Process, Pillar 3: Meaningful Learning, Pillar 4: Social Interaction), describe the educational quality of commercially-available apps, and examine differences in educational quality between free and paid apps. We analyzed 100 children's educational apps with the highest downloads from Google Play and Apple app stores, as well as 24 apps most frequently played by preschool-age children in a longitudinal cohort study. We developed a coding scheme in which each app earned a value of 0-3 for each Pillar, defining lower-quality apps as those scoring ≤ 4, summed across the Four Pillars. Overall scores were low across all Pillars. Free apps had significantly lower Pillar 2 (Engagement in Learning Process) scores (t-test, p < .0001) and overall scores (t-test, p < .0047) when compared to paid apps, due to the presence of distracting enhancements. These results highlight the need for improved design of educational apps guided by developmental science.

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.

Parent-Toddler Social Reciprocity During Reading From Electronic Tablets vs Print Books

IMPORTANCE

Although the American Academy of Pediatrics recommends parent-child joint engagement with digital media, recent evidence suggests this may be challenging when tablets contain interactive enhancements.

OBJECTIVE

To examine parent-toddler social reciprocity while reading enhanced (eg, with sound effects, animation) and basic tablet-based books compared with print books.

DESIGN, SETTING, AND PARTICIPANTS

This within-participants comparison included 37 parent-toddler dyads in a counterbalanced crossover, video-recorded laboratory design at the University of Michigan from May 31 to November 7, 2017. The volunteer sample was recruited from an online research registry and community sites. Dyads included children aged 24 to 36 months with no developmental delay or serious medical condition, parents who were the legal guardians and read English sufficiently for consent, and parents and children without uncorrected hearing or vision impairments. Data were analyzed from October 18, 2017, through April 30, 2018.

EXPOSURES

Reading an enhanced tablet-based book, a basic tablet-based book, and a print book in counterbalanced order for 5 minutes each.

MAIN OUTCOMES AND MEASURES

Video recordings were coded continuously for nonverbal aspects of parent-toddler social reciprocity, including body position (child body posture limiting parental book access coded in 10-second intervals), control behaviors (child closing the book, child grabbing the book or tablet, parent or child pivoting their body away from the other), and intrusive behaviors (parent or child pushing the other's hand away). Coding intracorrelation coefficients were greater than 0.75. Poisson regression was used to compare each outcome by book format.

RESULTS

Among the 37 parent-child dyads, mean (SD) parent age was 33.5 (4.0) years; 30 (81%) were mothers, and 28 (76%) had a 4-year college degree or greater educational attainment. Mean (SD) age of children was 29.2 (4.2) months, 20 (54%) were boys, 21 (57%) were white non-Hispanic, and 6 (16%) were black non-Hispanic. Compared with print books, greater frequency of child body posture limiting parental book access (mean [SD], 7.9 [1.9; P = .01] for enhanced; 8.4 [1.8; P = .006] for basic), child closing the book (mean [SD], 1.2 [0.4; P = .007] for enhanced; 1.2 [0.5; P < .001] for basic), parent pivoting (mean [SD], 0.4 [0.2; P = .05] for enhanced; 0.9 [0.4; P = .004] for basic), child pushing parent's hand (mean [SD], 0.6 [0.2; P < .001] for enhanced; 0.4 [0.2; P = .002] for basic), and parent pushing child's hand (mean [SD], 1.7 [0.3; P < .001] for enhanced; 2.4 [0.5; P < .001] for basic) occurred while reading enhanced and basic tablet-based books. Child pivots occurred more frequently while reading basic tablet-based books than print (mean [SD], 1.0 [0.3] vs 0.3 [0.1]; P = .005).

CONCLUSIONS AND RELEVANCE

In this study, toddlers and parents engaged in more frequent social control behaviors and less social reciprocity when reading tablet-based vs print books. These findings suggest that toddlers may have difficulty engaging in shared tablet experiences with their parents.