By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Summary Points
- This study from Finland is drawn from a more comprehensive child development study with parent recruitment beginning at 32 weeks of gestation and follow-up measurements via parental questionnaires occurring periodically until age 5 years.
- At 18 months of age, children in the study spent a mean time of 31.0 min/day on a device. Higher times spent on a device at 18 months of age were associated with an unadjusted increased risk of peer problems at 5 years of age. However, this association became nonsignificant when results were adjusted for multiple covariates, including gender, maternal education, number of siblings, and daycare participation.
- At 5 years of age, children spent a mean time of 114.1 min/day on a device, with 94.6% spending > 1 hour daily. Higher times spent on a device were associated with a variety of psychosocial problems in the unadjusted model.
- When screen time was specified as either program viewing or electronic games, results showed an association of multiple psychosocial problems, with higher program viewing at age 5 years, but no significant problems with higher use of electronic games at this same age.
SYNOPSIS: This Finnish study looking at electronic media (e-media) use in young children found 95% of 5-year-olds in the study exceeded guidelines for time spent with e-media, noted an association between increased screen time and increased psychosocial symptoms at 5 years old and found these associations were less prominent when measuring use of electronic games alone.
SOURCE: Niiranen J, Kiviruusu O, Vornanen R, et al. High-dose electronic media use in five-year-olds and its association with their psychosocial symptoms: a cohort study. BMJ Open 2021;11:e040848.
With electronics becoming an ever-increasing part of our lives, guidelines from the American Academy of Pediatrics (AAP) state:1
- For children younger than 18 months, avoid use of screen media other than video-chatting. Parents of children 18 to 24 months of age who want to introduce digital media should choose high-quality programming and watch it with their children to help them understand what they are seeing.
- For children ages 2 to 5 years, limit screen use to one hour per day of high-quality programs. Parents should co-view media with children to help them understand what they are seeing and apply it to the world around them.
These recommendations from the AAP echo guidelines from the World Health Organization (WHO) regarding young children and electronic media (e-media), which is defined as watching programs, using social media, and playing electronic games.1,2
Given the evolving nature and prevalence of e-media, studies pointing toward detrimental and beneficial effects of its use in young children, and the lack of longitudinal data, Niiranen et al designed a study to investigate the amount of e-media use at 18 months of age and any association with psychosocial symptoms at 5 years of age.3,4 This investigation also looked at e-media use at age 5 years and associated psychosocial symptoms as well as evaluated such symptoms in the context of viewing programs vs. playing electronic games.
Participants for this study were drawn from a larger Finnish investigation — the CHILD-SLEEP longitudinal birth cohort study — for which parents were recruited at 32 weeks of gestation and followed periodically postpartum until the child reached 5 years of age.5 The 699 children in the Niiranen et al study all had parents who completed one or both questionnaires regarding behavior at the five-year check-in and replied to the e-media usage questions. Out of this group, 585 of these children had parental documentation of e-media use at age 18 months; psychosocial symptoms were not assesed at this age.
Parents of 18-month- and 5-year-olds reported children’s e-media use per weekday and weekend. The parents of 5-year-olds were asked to differentiate program viewing vs. electronic game playing. Notably, this was omitted for the 18-month-olds, since there were few games available for this age group at the time of the study. In a nod to the rapid growth of e-media, Niiranen et al noted that, by the conclusion of the study, electronic games for 18-month-olds were more common.
To determine median frequency of use, a weighted daily average of e-media use in minutes was calculated. For the 5-year-olds, this was divided into separate averages for program vs. electronic game playing as well as total use. A 75-percentile cut-off was determined for each category to represent the children with the highest reported use of e-media.
The questionnaires used to measure psychosocial symptoms are validated, frequently used research tools for this age group. The Five to Fifteen and Strengths and Difficulties (SDQ) questionnaires have subscales measuring emotional problems, behavioral problems and inattention and are designed to be completed by parents or guardians.6,7 Table 1 displays some basic study findings.
Table 1. Electronic Media Use of Children Aged 18 Months and 5 Years | |||||
|
Age |
Mean Time on Device |
> 60 minutes E-Media Use/Day |
75th Percentile for Total Use |
Program Viewing Time |
Electronic Game Time |
|
18 months (n = 585) |
32.4 minutes (range 0-253 minutes) |
22.7% |
> 46 minutes/day |
N/A (only total e-media use measured) |
N/A (only total e-media use measured) |
|
5 years (n = 699) |
114.1 minutes (range 0-321.4 minutes) |
94.6% |
> 135 minutes/day |
80.4 minutes (range 0-225 minutes) |
33.4 minutes (range 0-182.1 minutes) |
|
E-media: electronic media | |||||
When looking at children in the 75th percentile for e-media use, it appears that, at 18 months, the highest users of e-media had a high level of peer problems (as measured by a SDQ subscore) at 5 years of age. However, this association became nonsignificant when results were adjusted for multiple covariates, including gender, maternal education, number of siblings, and daycare participation.
At age 5 years, increased level of screen time was associated with a variety of psychosocial symptoms, but this association became nonsignificant for most symptoms when the results were adjusted for the multiple covariates. The only exception was a continued association with internalizing symptoms (such as depression and anxiety).
Finally, when analyzing time spent viewing programs vs. playing games at five years, these results show a significant association of program viewing with multiple psychosocial symptoms, even with multivariable adjustment. On the other hand, playing games has no statistically significant association with psychosocial symptoms in the fully adjusted model. Table 2 displays these results.
Table 2. 75th Percentile of E-Media Users and Association with High Levels of Psychosocial Problems (Results Adjusted for Multivariables) | ||||
|
Symptoms (Questionnaire) |
Age 18 Months |
Age 5 Years, Total Viewing |
Age 5 Years, Program Viewing |
Age 5 Years, Electronic Game Playing |
|
Attention and concentration (FTF) |
OR 1.41 (95% CI, 0.89-2.22); P = 0.14 |
OR 1.57 (95% CI, 0.97-2.53); P = 0.07 |
OR 1.91 (95% CI, 1.19-3.08); P = 0.01* |
OR 0.67 (95% CI, 0.38-1.17); P = 0.16 |
|
Hyperactive/impulsive (FTF) |
OR 1.14 (95% CI, 0.72-1.80); P = 0.59 |
OR 1.14 (95% CI, 0.72-1.80); P = 0.59 |
OR 1.67 (95% CI, 1.04-2.69); P = 0.03* |
OR 0.82 (95% CI, 0.48-1.42); P = 0.48 |
|
Internalizing symptoms (e.g., depression) (FTF) |
OR 1.13 (95% CI, 0.69-1.72); P = 0.82 |
OR 2.01 (95% CI, 1.21-3.34); P = 0.01* |
OR 1.71 (95% CI, 1.03-2.84); P = 0.04* |
OR 1.36 (95% CI, 0.78-2.40); P = 0.28 |
|
Externalizing symptoms (e.g., conduct) (FTF) |
OR 1.06 (95% CI, 0.65-1.72); P= 0.82 |
OR 1.54 (95% CI, 0.94-2.52); P = 0.09 |
OR 1.19 (95% CI, 0.72-1.96); P = 0.50 |
OR 1.42 (95% CI, 0.83-2.42); P = 0.20 |
|
Peer problems (SDQ) |
OR 1.56 (95% CI, 0.98-2.46); P = 0.06 |
OR 0.85 (95% CI, 0.51-1.42); P = 0.53 |
OR 0.87 (95% CI, 0.52-1.44); P = 0.58 |
OR 0.83 (95% CI, 0.48-1.44); P = 0.51 |
|
E-media: electronic media; OR: odds ratio; CI: confidence interval; FTF: Five to Fifteen Questionnaire; SDQ: Strengths and Difficulties Questionnaire *Statistically significant values | ||||
COMMENTARY
This longitudinal study adds depth to our baseline knowledge about the potential risks and use of e-media for young children and suggests that high e-media use at a young age (5 years), especially program viewing, is associated with a range of psychosocial symptoms. However, there was little indication that high e-media use at age 18 months translated to more psychosocial problems at age 5 years, and it appeared that higher use of e-games was not associated with psychosocial symptoms. That being said, the median time spent playing games at age 5 years was less than one-half the median time for program viewing, which may have skewed the results and deserves further study. It is notable that there may be a bidirectional association at play here, with parents encouraging behaviorally challenging children to settle down using e-media. This is an avenue for future investigations.
The rapidly evolving nature of technology makes the effect of e-media use in young children a difficult area to study and draw conclusions. This phenomenon is well illustrated in this investigation; Niiranen et al note that electronic games were not differentiated from screen viewing at age 18 months because, at the onset of the study, these games were not as available for this age group as they were at the conclusion. It is likely that, as games and e-media in general continue to change to keep pace with demand (or to change and encourage demand), use patterns and association with psychosocial symptoms also may evolve.
While recognizing recommendations and limits may change over time, this study lends data to an area of concern for many parents of young children. The guidelines regarding time limits on e-media for young children provided by WHO, AAP, and other organizations are clear, but it is equally clear from this study and others that many parents do not adhere to these recommendations. For example, a 2020 U.S. survey (with the last interview concluded prepandemic) found that total e-media use among 2- to 4-year-olds averaged 2.5 hours daily — more than double the recommended amount of e-media time for young children.8
This U.S. survey was conducted by Common Sense Media, which may be the only organization systematically tracking use of e-media in young children in the United States. With data going back to 2011, Common Sense Media noted the total amount of screen time is slowly rising among the 0- to 8-year-old age group (median use in 2011 was two hours and 16 minutes), but the type of devices and content viewed is changing dramatically. For example, time spent on online video sites, such as YouTube, has doubled since 2011, and mobile device viewing is more prominent, with nearly one-half (46%) of 2- to 4-year-olds having a device (tablet or smartphone).8
While this longitudinal study can only point to associations and not determine cause and effect, it is worth considering that time spent on e-media may not in itself be detrimental to a child’s emotional and social development. However, it may be replacing more optimal interactions for a child. This is another area worth exploring as research in the field continues. The results of this study suggest that high levels of e-media use may come at a developmental and behavioral cost for young children.
While this study is far from conclusive, it is clear that e-media occupies a central role in the daily life of many young children. The integrative provider is well-situated to remind parents of general guidelines for e-media use, including recommended time limits and co-viewing, and to explore with them pros and cons of adopting such limits.
REFERENCES
- American Academy of Pediatrics. American Academy of Pediatrics announces new recommendations for children’s media use. Published Oct. 21, 2016. https://www.aap.org/en/news-room/news-releases/aap/2016/aap-announces-new-recommendations-for-media-use/
- American Optometric Association. New WHO guidance: Very limited daily screen time recommended for children under 5. Published May 6, 2019. https://www.aoa.org/news/clinical-eye-care/public-health/screen-time-for-children-under-5?sso=y
- Ralph R. Media and technology in preschool classrooms: Manifesting prosocial sharing behaviours when using iPads. Tech Know Learn 2018;23:199-221.
- Lawrence A, Choe DE. Mobile media and young children’s cognitive skills: A review. Acad Pediatr 2021;21:996-1000.
- Saarenpää-Heikkilä O, Paavonen J, Himanen S, et al. Child sleep — The Finnish birth cohort study. Sleep Med 2013;14(Suppl 1):e252-e253.
- Lambek R, Trillingsgaard A. Elaboration, validation and standardization of the five to fifteen (FTF) questionnaire in a Danish population sample. Res Dev Disabil 2015;38:161-170.
- [No authors listed]. What is the SDQ? Updated Jan. 1, 2012. https://www.sdqinfo.org/a0.html
- Rideout V, Robb MB. The Common Sense census: Media use by kids age zero to eight. https://www.commonsensemedia.org/sites/default/files/uploads/research/2020_zero_to_eight_census_final_web.pdf
This Finnish investigation of electronic media (e-media) use in young children revealed 95% of 5-year-olds studied exceeded guidelines for time spent with e-media. The authors noted an association between more screen time and additional psychosocial symptoms at 5 years old and found these associations were less prominent when measuring use of electronic games alone.
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