Time for a View on Screen Time
The study of ST as a public health subject is relatively new, and the associations between ST and health risk cited in the observational studies above do not prove direct causation. While it is not possible within the confines of this paper to describe and compare the design and independent variables, including the demographic profile of each study, others are beginning to do so. For example, a meta-analysis of relevant studies, including some of the above, involving European, US and Australian populations on ST and risk of Type 2 Diabetes, CVD and all-cause mortality carried out at the Harvard School of Public Health, included large sample sizes, long durations of follow-up, and well established prospective studies. In addition, their pooled estimates were based on prospective analyses with detailed adjustment for a wide range of confounding variables. After adjusting for BMI or other obesity measures and dietary variables, the associations with health risk still remained highly significant.
The various studies finding associations between ST and subsequent attention problems were predominantly prospective and controlled for relevant confounding variables including pre-existing attention problems. Several of the above studies on ST and psychosocial well-being used cross-sectional designs, making it more difficult to determine whether higher levels of ST were associated with the development of negative well-being, or negative well-being preceded higher levels of ST. For example, whether children with psychological difficulties, such as extreme shyness, are more likely to gravitate towards ST over more sociable activities.
However, the prospective longitudinal Canadian study controlling for pre-existing psychosocial problems found significant associations with ST.
There are additional concerns not addressed above, regarding safeguarding children from online exploitation and exposure to inappropriate material. There are also emerging concerns about the potential effect of 3D screens on the development of the child's stereoscopic vision and depth perception through possible alterations in the development of the 'fusion center' of the brain. Interestingly, in their 'Nintendo 3DS—Parents' Information, 3D Concerns', Nintendo of America states, 'children 6 and under should not use the 3D feature of the Nintendo 3DS system.
The simple arithmetic of hours of eye-to-screen contact versus eye-to-eye contact are making clear the profound implications of such extensive ST for family and social relationships. In 2007, when children had access to far fewer screens, a large-scale study by Britain's Children's Society found that television alone was already displacing the parental role, eclipsing 'by a factor of five or ten the time parents spend actively engaging with children'.
An ongoing study of families in situ by the University of California–Los Angeles has found that social disengagement is rapidly increasing, as side-by-side and eye-to-eye human interactions in the home are being displaced by the eye-to-screen relationship. It was reported that 'family members seldom came together as a group.' The number of parents who were ignored or unacknowledged on their return home because children were 'otherwise engaged in [screen] activity… comprised a substantial percentage of observed behavior'. The high level of being unacknowledged 'encountered by fathers when they reunited with their children was particularly striking… These latter results are particularly noteworthy. Social scientists have long documented the near universality of positive behavior in the form of greetings when two or more people reunite after being apart for a period of time. Greetings recognize a person's arrival, status and display positive intentions that universally facilitate the transition into social interaction with another.' ST has changed this.
Although this paper is concerned with ST, when one includes screen content—which may be very much at odds with the values and desires of parents, but which children may be absorbing for many hours a day, the distorting effect on the parental role in imparting their own values and providing boundaries for adolescence could be considerable. A decade ago, in their 'Analysis of Children's Programming Provision', the British Government's Broadcasting Standards Commission concluded 'The television is almost like a member of the family in its own right'. With subsequent birth of multiple screens, today extensive ST appears to have created the three-parent family.
Both within and outside the family, children learn the rules of relationships through extensive routine face-to-face experience. Yet, as social media consumes a larger portion of a child's daily life, this is likely to create difficulties in extrapolating on-line 'un-boundaried' relationships to those of the 'real' world, thereby affecting those relationships.
The family environment has been described as an ecosystem of interruption technologies. Background media that is not being actively viewed by the child is increasingly associated with developmental risks. A study of 5–6-year-olds found that both active TV viewing and background 'passive' TV exposure was related to shorter sleep duration, sleeping disorders and overall sleep disturbances. Moreover, passive exposure to TV of more than 3 h/day was strongly related to sleep disturbances, therefore, 'parents should control the quantity of TV viewing and … limit children's exposure to passive TV.' A study of 1–3-year-olds found that background TV significantly reduced the amount of time they played with their toys, and the amount of time they spent in focused attention during play. Researchers concluded, 'These findings have implications for subsequent cognitive development.'Researchers have also found both the quantity and the quality of interactions between parents and children decline markedly when background TV is on, which 'may have a negative impact on development'. Current US estimates for children 8 months to 8 years of age are 3.9 h of background TV per day. The report by AAP 'recommends that parents and caregivers … recognize that their own [background] media use can have a negative effect on children'. The AAP considers claims by media industry executives that educational media programmes are meant to be watched by both the parent and the child to facilitate social interactions and the learning process as having quite the opposite effect.
There are limitations in simply advising parents to reduce children's ST. As with many preventative health initiatives, such advice may be least effective in families where it matters most. However, it is wrong to assume that it is simply the underprivileged families being referred to. The AAP recently reported 'Parents who believe that educational television is "very important for healthy development" are twice as likely to keep the television on all or most of the time.' Most parents want to reduce health risks for their children, provided they understand the rationale behind the advisory, and a clear course of action is offered. For example, between 1996 and 2007, children in England, exposed to passive smoking, declined by nearly 70%. Most interestingly, declines were greatest in the 2 years immediately preceding legislation as the result of, it is thought, the media campaigns and greater publicity on the impacts of passive smoking during this period. Subsequent research has found that 'absolute declines in exposure were greater in those most exposed at the outset … including those living in lower sociodemographic status households'.
At the moment, most parents and physicians are unaware of ST as a health issue, and if they do harbour concerns, they remain unaware of the rationale or a clear rule of thumb as a course of action. It is, therefore, an imperative to first redress this knowledge void. Given that many parents have grown to rely on ST as a means of occupying their children—'the electronic babysitter'—any guidance on ST would benefit from the inclusion of suggestions for developing constructive practical alternatives to ST.
Although children may be regularly involved in various screen activities and using different screen devices, most ST is recreational, that is, discretionary, and it is this ST that should be the primary public health target for reduction. There may be scope for further reductions. Preschool and infant schools, if made aware of this issue, could easily reduce ST, as much of it is predominantly discretionary at that stage of education. Junior and secondary schools could reconsider the extent to which entertainment TV programmes and films are used as lessons and as 'golden time'. There is a concern that not to expose young children to screen technology puts them at a developmental and educational disadvantage. Furthermore, it is often assumed that if children do not 'get used to' screen technology early on, they will in some way be intimidated by it, or be less competent at using it later. However, research has found that even Rhesus monkeys are comfortable with, and capable of using, the same screen technology that children are exposed to. The charity, Orangutan Outreach, has been conducting trials gauging iPad interaction with their apes. The director has reported 'It's not really toy-like because they are engaging with them as devices … it's definitely going in the cognitive direction.'
Perhaps because ST is not a dangerous substance or a visibly risky activity, it has eluded the scrutiny that other health issues attract. Additionally, there is little funding and public gratitude in looking for the negative effects of the world's favourite pastime. In 2006, American paediatric researchers writing in the American Medical Association's Archives of Pediatric and Adolescent Medicine asked rhetorically: 'Why is it that something that is widely recognised as being so influential and potentially dangerous has resulted in so little effective action? To be sure, there has been some lack of political will to take on the enormously powerful and influential entertainment industry … [Screen] media need to be recognised as a major public health issue'.
Rather than paediatricians, it has been the academics in ICT, media literacy, education, marketing and social and cognitive psychology, whose research is often funded by TV, software and technology industries, who have dominated research, public and professional understanding of, and policy considerations on, ST and child health. Few seem to have spotted the most salient point: their focus is not on child health, but as one leading institution advising successive British governments states, 'research focuses on children's and young people's interactions with [author's italics] electronic media, and on media education.'
Moreover, while medical journals, such as the BMJ group have instituted measures to identify competing interests and sources of funding, particularly regarding the pharmaceutical industry, in order to minimise such influence within their publications, thereby maintaining a high standard of information hygiene, the culture and standard of hygiene with respect to research on screen media and children is very different in media, psychology and education journals.
As the most valid impartial arbiter of child health, British and European paediatric medicine must in future be at the centre of research, public understanding and policy formation on ST.
In other areas of child health and development, when considering the potential effects of profound new developments, the paediatric health profession instinctively adopts a principle of precaution. Yet, to date, the increasingly excessive levels of child ST have been met with relative silence. While many questions remain regarding the precise nature of the association between ST and adverse outcomes, the advice from a growing number of both researchers and other medical associations and government health departments elsewhere is becoming unequivocal: reduce ST. Irrespective of whether this will endear paediatricians to the public or not, Britain and Europe's medical establishments, including the RCPCH, EAP and Department of Health, should now formally express some concern over ST.
A drop in viewing figures may be bad for TV executives' blood pressure, but may prove to be very good for child health.
Discussion
The study of ST as a public health subject is relatively new, and the associations between ST and health risk cited in the observational studies above do not prove direct causation. While it is not possible within the confines of this paper to describe and compare the design and independent variables, including the demographic profile of each study, others are beginning to do so. For example, a meta-analysis of relevant studies, including some of the above, involving European, US and Australian populations on ST and risk of Type 2 Diabetes, CVD and all-cause mortality carried out at the Harvard School of Public Health, included large sample sizes, long durations of follow-up, and well established prospective studies. In addition, their pooled estimates were based on prospective analyses with detailed adjustment for a wide range of confounding variables. After adjusting for BMI or other obesity measures and dietary variables, the associations with health risk still remained highly significant.
The various studies finding associations between ST and subsequent attention problems were predominantly prospective and controlled for relevant confounding variables including pre-existing attention problems. Several of the above studies on ST and psychosocial well-being used cross-sectional designs, making it more difficult to determine whether higher levels of ST were associated with the development of negative well-being, or negative well-being preceded higher levels of ST. For example, whether children with psychological difficulties, such as extreme shyness, are more likely to gravitate towards ST over more sociable activities.
However, the prospective longitudinal Canadian study controlling for pre-existing psychosocial problems found significant associations with ST.
There are additional concerns not addressed above, regarding safeguarding children from online exploitation and exposure to inappropriate material. There are also emerging concerns about the potential effect of 3D screens on the development of the child's stereoscopic vision and depth perception through possible alterations in the development of the 'fusion center' of the brain. Interestingly, in their 'Nintendo 3DS—Parents' Information, 3D Concerns', Nintendo of America states, 'children 6 and under should not use the 3D feature of the Nintendo 3DS system.
The simple arithmetic of hours of eye-to-screen contact versus eye-to-eye contact are making clear the profound implications of such extensive ST for family and social relationships. In 2007, when children had access to far fewer screens, a large-scale study by Britain's Children's Society found that television alone was already displacing the parental role, eclipsing 'by a factor of five or ten the time parents spend actively engaging with children'.
An ongoing study of families in situ by the University of California–Los Angeles has found that social disengagement is rapidly increasing, as side-by-side and eye-to-eye human interactions in the home are being displaced by the eye-to-screen relationship. It was reported that 'family members seldom came together as a group.' The number of parents who were ignored or unacknowledged on their return home because children were 'otherwise engaged in [screen] activity… comprised a substantial percentage of observed behavior'. The high level of being unacknowledged 'encountered by fathers when they reunited with their children was particularly striking… These latter results are particularly noteworthy. Social scientists have long documented the near universality of positive behavior in the form of greetings when two or more people reunite after being apart for a period of time. Greetings recognize a person's arrival, status and display positive intentions that universally facilitate the transition into social interaction with another.' ST has changed this.
Although this paper is concerned with ST, when one includes screen content—which may be very much at odds with the values and desires of parents, but which children may be absorbing for many hours a day, the distorting effect on the parental role in imparting their own values and providing boundaries for adolescence could be considerable. A decade ago, in their 'Analysis of Children's Programming Provision', the British Government's Broadcasting Standards Commission concluded 'The television is almost like a member of the family in its own right'. With subsequent birth of multiple screens, today extensive ST appears to have created the three-parent family.
Both within and outside the family, children learn the rules of relationships through extensive routine face-to-face experience. Yet, as social media consumes a larger portion of a child's daily life, this is likely to create difficulties in extrapolating on-line 'un-boundaried' relationships to those of the 'real' world, thereby affecting those relationships.
The family environment has been described as an ecosystem of interruption technologies. Background media that is not being actively viewed by the child is increasingly associated with developmental risks. A study of 5–6-year-olds found that both active TV viewing and background 'passive' TV exposure was related to shorter sleep duration, sleeping disorders and overall sleep disturbances. Moreover, passive exposure to TV of more than 3 h/day was strongly related to sleep disturbances, therefore, 'parents should control the quantity of TV viewing and … limit children's exposure to passive TV.' A study of 1–3-year-olds found that background TV significantly reduced the amount of time they played with their toys, and the amount of time they spent in focused attention during play. Researchers concluded, 'These findings have implications for subsequent cognitive development.'Researchers have also found both the quantity and the quality of interactions between parents and children decline markedly when background TV is on, which 'may have a negative impact on development'. Current US estimates for children 8 months to 8 years of age are 3.9 h of background TV per day. The report by AAP 'recommends that parents and caregivers … recognize that their own [background] media use can have a negative effect on children'. The AAP considers claims by media industry executives that educational media programmes are meant to be watched by both the parent and the child to facilitate social interactions and the learning process as having quite the opposite effect.
There are limitations in simply advising parents to reduce children's ST. As with many preventative health initiatives, such advice may be least effective in families where it matters most. However, it is wrong to assume that it is simply the underprivileged families being referred to. The AAP recently reported 'Parents who believe that educational television is "very important for healthy development" are twice as likely to keep the television on all or most of the time.' Most parents want to reduce health risks for their children, provided they understand the rationale behind the advisory, and a clear course of action is offered. For example, between 1996 and 2007, children in England, exposed to passive smoking, declined by nearly 70%. Most interestingly, declines were greatest in the 2 years immediately preceding legislation as the result of, it is thought, the media campaigns and greater publicity on the impacts of passive smoking during this period. Subsequent research has found that 'absolute declines in exposure were greater in those most exposed at the outset … including those living in lower sociodemographic status households'.
At the moment, most parents and physicians are unaware of ST as a health issue, and if they do harbour concerns, they remain unaware of the rationale or a clear rule of thumb as a course of action. It is, therefore, an imperative to first redress this knowledge void. Given that many parents have grown to rely on ST as a means of occupying their children—'the electronic babysitter'—any guidance on ST would benefit from the inclusion of suggestions for developing constructive practical alternatives to ST.
Although children may be regularly involved in various screen activities and using different screen devices, most ST is recreational, that is, discretionary, and it is this ST that should be the primary public health target for reduction. There may be scope for further reductions. Preschool and infant schools, if made aware of this issue, could easily reduce ST, as much of it is predominantly discretionary at that stage of education. Junior and secondary schools could reconsider the extent to which entertainment TV programmes and films are used as lessons and as 'golden time'. There is a concern that not to expose young children to screen technology puts them at a developmental and educational disadvantage. Furthermore, it is often assumed that if children do not 'get used to' screen technology early on, they will in some way be intimidated by it, or be less competent at using it later. However, research has found that even Rhesus monkeys are comfortable with, and capable of using, the same screen technology that children are exposed to. The charity, Orangutan Outreach, has been conducting trials gauging iPad interaction with their apes. The director has reported 'It's not really toy-like because they are engaging with them as devices … it's definitely going in the cognitive direction.'
Political Implications
Perhaps because ST is not a dangerous substance or a visibly risky activity, it has eluded the scrutiny that other health issues attract. Additionally, there is little funding and public gratitude in looking for the negative effects of the world's favourite pastime. In 2006, American paediatric researchers writing in the American Medical Association's Archives of Pediatric and Adolescent Medicine asked rhetorically: 'Why is it that something that is widely recognised as being so influential and potentially dangerous has resulted in so little effective action? To be sure, there has been some lack of political will to take on the enormously powerful and influential entertainment industry … [Screen] media need to be recognised as a major public health issue'.
A Problem of Provenance
Rather than paediatricians, it has been the academics in ICT, media literacy, education, marketing and social and cognitive psychology, whose research is often funded by TV, software and technology industries, who have dominated research, public and professional understanding of, and policy considerations on, ST and child health. Few seem to have spotted the most salient point: their focus is not on child health, but as one leading institution advising successive British governments states, 'research focuses on children's and young people's interactions with [author's italics] electronic media, and on media education.'
Information Hygiene
Moreover, while medical journals, such as the BMJ group have instituted measures to identify competing interests and sources of funding, particularly regarding the pharmaceutical industry, in order to minimise such influence within their publications, thereby maintaining a high standard of information hygiene, the culture and standard of hygiene with respect to research on screen media and children is very different in media, psychology and education journals.
As the most valid impartial arbiter of child health, British and European paediatric medicine must in future be at the centre of research, public understanding and policy formation on ST.
In other areas of child health and development, when considering the potential effects of profound new developments, the paediatric health profession instinctively adopts a principle of precaution. Yet, to date, the increasingly excessive levels of child ST have been met with relative silence. While many questions remain regarding the precise nature of the association between ST and adverse outcomes, the advice from a growing number of both researchers and other medical associations and government health departments elsewhere is becoming unequivocal: reduce ST. Irrespective of whether this will endear paediatricians to the public or not, Britain and Europe's medical establishments, including the RCPCH, EAP and Department of Health, should now formally express some concern over ST.
A drop in viewing figures may be bad for TV executives' blood pressure, but may prove to be very good for child health.
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