doi:10.1111/jpc.13462 REVIEW ARTICLE Clinical and psychological effects of excessive screen time on children Sophie Domingues-Montanari Longdom Publishing and Qustodio Technologies, Barcelona, Spain Abstract: Over recent years, screen time has become a more complicated concept, with an ever-expanding variety of electronic media devices available throughout the world. Television remains the predominant type of screen-based activity among children. However, computer use, video games and ownership of devices, such as tablets and smart phones, are occurring from an increasingly young age. Screen time, in particular, television viewing, has been negatively associated with the development of physical and cognitive abilities, and positively associated with obesity, sleep problems, depression and anxiety. The physiological mechanisms that underlie the adverse health outcomes related to screen time and the relative contributions of different types of screen and media content to specific health outcomes are unclear. This review discusses the positive and negative effects of screen time on the physiological and psychological development of children. Furthermore, recommendations are offered to parents and clinicians. Key words: children; electronic media; health policy; screen time; television. Introduction There is a general consensus among health authorities that excessive screen time has an adverse impact on childhood development. The current American Academy of Pediatrics (AAP) guidelines recommend that children under 2 years of age should not spend any time using electronic media, while children over 2 years of age should be restricted to less than 2 h per day.1,2 The Australian Department of Health has stricter criteria, recommending less than 1 h of screen time per day for children aged between 2 and 5 years. However, data collected from the International Children’s Accelerometry Database between 1997 and 2009 indicated that approximately two-thirds of children did not meet guidelines for screen time.3 Key Points 1 Television viewing negatively affects locomotive skills, physical strength, dietary habits and adiposity. 2 Television viewing negatively affects the cognitive and socioemotional development of children, and excessive screen time is associated with poorer mental health during adolescence. 3 Physical activity does not compensate for the adverse effects of screen time. Correspondence: Dr Sophie Domingues-Montanari, Gladiols 26, P4, 43850 Cambrils, Barcelona, Spain; email: sophiedomingues@gmail.com Conflict of interest: None declared. Accepted for publication 11 November 2016. Journal of Paediatrics and Child Health 53 (2017) 333–338 © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) The explosion of new technological devices over the last few years has led to electronic media becoming an integral part of life. As such, it may be presumed that adherence to screen time guidelines has further declined. Exposure to screens tends to start from very early infancy.4–6 Studies estimate that children spend a substantial proportion of their daily waking hours on screen-based activities, about 8 h in many cases.7–9 This was reflected in an AAP newsletter published in late 2015, which suggested that guidelines on screen time for children are outdated and need revision. Indeed, approximately 90% of parents appear to ignore the AAP’s advice.10,11 Many parents continue their current behaviours because they believe that media content is educational. One survey found that 29% of the 1000 parents interviewed allowed their children younger than 2 years to watch television (TV) because it is ‘good for their brains’.12 Other parents admitted to not limiting their children’s screen time to avoid conflict and social isolation or to entertain or distract children.13 For example, one study of mothers confirmed that TV viewing by their children was useful in accomplishing household tasks, while another study found that parents commonly utilised mobile media to occupy their children when eating out.14,15 The use of screen time as an entertainer means that parents do not need to dedicate monetary resources that may not be available.13 In fact, parents from a low socio-education background were significantly less likely to agree to the statement ‘I feel confident that I can keep my child busy with activities that do not include exposure to TV’ compared with parents from a higher household income or higher education level.16 Thus, there is disparity between the reality of ‘screen culture’ and reducing screen usage as a health policy. This review summarises the most recent evidence on the effects of screen time on the physiological and psychological 333 development of children. Based on the published evidence, recommendations for parents and clinicians to reduce children’s screen time will be proposed. Physiological Development Physical strength and general health complaints Regular physical activity is associated with improved health outcomes in children.17 During early childhood, locomotive skills are gained through learning to crawl and walk, and playing; whereas in later childhood and adolescence, team sports and fitness classes play a role in the development of physical strength and co-ordination. The World Health Organization recommends that individuals aged between 5 and 17 years participate in at least 1 h of moderate-to-vigorous physical activity per day. Any additional time being physically active has accumulative health benefits. However, research indicates that higher levels of physical activity do not compensate for the negative effects of screen time.9 This is exemplified by the National Health and Nutritional Examination Surveys (NHANES) study conducted in over 1000 children from USA aged 6–15 years. The NHANES study evaluated the relationship between physical strength – assessed by grip, leg extension, modified pull-ups and plank – and screen time.17 After controlling for gender, body mass index and days per week with at least 1 h of physical activity, TV viewing, but not computer use and video gaming, was inversely associated with physical strength. This study demonstrated that higher TV viewing was associated with lower physical strength, irrespective of physical activity. It also highlighted the idea that not all types of screen use are equal with respect to health effects. The negative impact of TV viewing on physical development has been shown in children under 6 years of age. A prospective, longitudinal study that evaluated the relationship between TV watching at 29 months old and physical strength at 65 months of age in 1997 Canadian children reported that gross motor skills were reduced by high screen time.18 During early adolescence, time spent on screen-based activities contributes to the chance of reporting general physical complaints, in particular, headache and backache. Differences in symptoms according to screen type have been documented. For example, headaches were more frequent during TV viewing for more than 3 h, whereas backache and headache were more likely during computer use or video gaming for more than 3 h.19 Furthermore, headache and backache associated with screen time do not appear to be ameliorated by physical activity.20 The threshold for a suitable level of screen usage is difficult to set because the effects of different types of screen time on physical problems are accumulative. Diet and obesity Due to the rapid increase in screen use by children, promoted by the vast array of electronic media devices that has become available, screen time has emerged as an important modifiable risk factor for childhood obesity. Data from the most recent NHANES study conducted between 2009 and 2012 demonstrated that children aged 2–4 years who exceeded 2 h of TV viewing per day were more likely to be obese.21 334 S Domingues-Montanari Results from a meta-analysis of 14 cross-sectional studies revealed a linear dose–response relationship between TV watching and obesity. A 13% incremental increase in obesity risk was reported for each hour per day of TV watching for both boys and girls.22 The relationship between diet and screen time was evaluated by the World Health Organization Childhood Obesity Surveillance Initiative, a cross-sectional study in over 10 000 children aged 6–9 years from five European countries.23 Each additional hour of screen time (watching TV or digital video discs (DVDs) and using a computer except for homework) was associated with increased consumption of high-fat/high-sugar foods – including sugar-sweetened drinks, candy bars or chocolate, and pizza, chips or hamburgers – and decreased consumption of vegetables and fresh fruits. Another large-scale study in children aged 2–9 years from eight European countries assessed the dietary impact of TV-viewing habits, defined as time spent watching TV, watching TV during a meal and having a TV in the bedroom.24,25 High-risk TV behaviours were associated with an increased chance of being overweight and increased consumption of highfat/high-sugar foods. Interestingly, food choice did not appear to be mediated by taste preference, perhaps by passive over-consumption. In a population-representative Dutch cohort of over 1000 children aged 10–14 years, children who had at least 20 h of screen time per week, equating to an average of 2–3 h per day, consumed more snacks.26 Screen time was directly associated with adiposity, but this relationship was independent of snacking. A study in adult females suggested that TV viewing affects several processes that normally assist the voluntary regulation of food intake, and food intake was dependent on the level of interest in TV content.27 One of the most compelling arguments for the link between electronic media use and food consumption is commercial advertising. In particular, a meta-analysis of 22 studies demonstrated that acute exposure to advertising of unhealthy foods increases energy intake in children, but not adults.28 In a study of approximately 400 Australian children between 10 and 16 years old, there was strong evidence of an increase in unhealthy food and drink intake in parallel with commercial TV viewing.29 The link between TV viewing and poor diet was strongest for children who watched the most commercial TV and those who were exposed to advertisements embedded within programmes. These findings emphasise the vulnerability of children to advertising ploys. Policy-makers should consider the effects that this may have on dietary habit-forming for life. Sleep Screen usage has been widely reported to diminish sleep duration and/or efficiency. In a Spanish study of 1000 children aged between 2 and 6 years, at least 1.5 h per day of TV viewing correlated with shorter sleep duration.30 Longitudinal analysis of the same cohort revealed that increases in TV viewing from less than 1.5 h to at least 1.5 h led to reduced sleep duration at follow-up visits 2–3 years later. Another study in over 2000 children aged 8–12 years old indicated that TV/DVD watching and video or computer game playing were associated with shorter sleep duration and perceived insufficient rest or sleep.31 In Slovak adolescents between 11 and 15 years old, working on a computer or playing computer games for more than 3 h was associated with Journal of Paediatrics and Child Health 53 (2017) 333–338 © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) 14401754, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jpc.13462 by Texas A&M Univ – Central Texas University Library, Wiley Online Library on [13/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Effects of screen time on children sleep difficulties. In contrast, TV viewing for more than 3 h was not associated with sleep difficulties.19 Adding to the complexity of analysing the impact of screen usage, a related issue is the presence of screens in children’s bedrooms. The effect of the number and type of electronic screens available in bedrooms was assessed in 502 Canadian children aged 9–11 years.32 Notably, children having a TV in their bedroom had higher adiposity than those having no screen at all. In contrast, the presence of a computer was not associated with higher adiposity compared with no screens in the bedroom. The presence of at least two screens per room was related to sleep efficiency, but not sleep duration.32 Another study found that screen time was associated with poor weight status and having either a TV or a computer in the bedroom.8 The regulation of metabolism and sleep occurs through interconnected pathways.33 Therefore, the effects of screen time on metabolism may indirectly alter sleep quality and vice versa, making it difficult to determine causality. Psychological Development Cognitive ability A recent review discussed the importance of social rather than screen interaction for children under 2 years of age, and its necessity for the development of facial recognition and communication skills.34 In particular, it was highlighted that the response of the developing brain to parental attention is different to that evoked by the use of electronic devices. Although few data are available on the relationship between cognitive development and computer use/video gaming, these concepts are supported by psychological studies evaluating the effect of TV viewing. Research in Korean children from 24 to 30 months of age demonstrated that the risk of language delay increased proportionately with time spent in front of the TV.35 Toddlers with 2–3 h of daily TV viewing had a 2.7-fold higher risk of language delay than those with less than 1 h, while toddlers with over 3 h per day had about a three-fold increase in the relative risk of language delay. Similarly, a longitudinal study reported that children with higher TV viewing at 29 months of age exhibited less school readiness at 65 months of age. This manifested as decreased vocabulary and number knowledge scores as well as lower classroom engagement.18 The anatomical features that underlie changes in cognitive development related to TV viewing have been scarcely investigated. This was addressed by a recent study that examined the association between duration of TV viewing and regional grey/ white matter volume in Japanese children.36 In both crosssectional and longitudinal analyses, TV viewing was positively correlated with changes in the frontopolar and medial prefrontal regions, the former of which contributes to intellectual functioning. Furthermore, a negative correlation between TV viewing and intelligent quotient was confirmed. However, some studies have suggested that cognitive development in relation to media use is highly content dependent. For example, playing video games has been shown to improve visual attention skills, but this effect was positive only for those games that were action-based, and playing prosocial video games, in Journal of Paediatrics and Child Health 53 (2017) 333–338 © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) Effects of screen time on children which game characters help and support each other, led to increases in prosocial behaviour.37–39 Moreover, some TV shows can help children learn numbers and letters. Several studies demonstrated that the viewing of specific TV programmes can have positive effects on language development in children aged 3–5 years.40,41 In one study, the viewing of ‘Dora the Explorer’ resulted in 13.30 more vocabulary words acquired at the age of 30 months compared with non-viewers, in comparison with the viewing of ‘Teletubbies’, which was negatively related to vocabulary acquisition.42 A similar study found the viewing of ‘Sesame Street’ to be educational for children at a certain age, yet it was associated with delayed language acquisition for younger children.42 The potential cognitive benefits are believed to originate from high-quality media contents that use strategies known to support language development, including the labelling of objects, characters speaking directly to the child and allowing opportunities for the child to respond. What’s more, co-viewing with an adult has been shown to increase the cognitive development benefits of suitable media content.43–46 For example, when pre-schoolers viewed ‘Barney & Friends’ with an adult, they acquired 3.5 words, compared with an average of just one word when the programme was viewed alone.41 Co-viewing increases parent–child interactions and offers opportunities for the adult to enhance the media content. Nevertheless, a comprehensive review found that the majority of positive cognitive development claims made by the manufacturers of media products aimed at children were unsubstantiated.47 Socio-emotional and mental health Excessive screen time is thought to have an impact on socioemotional functioning, although some confounding factors exist (e.g. poor mental health may trigger the desire to spend time alone using screens). A variety of environmental factors may also contribute to screen time and emotional health. For example, TV watching has been reported to be higher in offspring with a depressed mother.4 Nevertheless, studies in very young children suggest that screen usage is an independent risk factor for reduced psychological well-being. An analysis of Thai infants showed that increasing TV exposure from 6 to 18 months of age was associated with emotional reactivity, aggression and externalisation behaviours.6 It has also been repeatedly documented that high TV viewing at 2–3 years old leads to an increased risk of peer victimisation during early school years.18,48 This concerning finding prompts the assumption that children who experience victimisation by classmates have a higher risk of developing mental health problems. Among over 8000 Australian youths aged 10–16 years, those who met screen time guidelines were less likely to report depression. Notably, this relationship was stronger for younger children.49 Moreover, in adolescents, screen time has been inversely correlated with mental health, academic achievement, school disconnectedness and self-esteem, with the latter two being more frequent in males.3,49 This correlation was independent of physical activity.3,49 Data from almost 2500 Canadian students aged 12–18 years demonstrated that the duration of screen time was associated with the severity of depression and anxiety.50 335 14401754, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jpc.13462 by Texas A&M Univ – Central Texas University Library, Wiley Online Library on [13/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License S Domingues-Montanari With respect to the type of screen, computer use and video gaming, but not TV viewing, correlated with more severe depressive symptoms. Meanwhile, video gaming correlated with the severity of anxiety. Taken together, these results are in accordance with studies demonstrating that the effects of high screen time accumulate with age, with more obvious symptoms from early adolescence onwards.51 Nevertheless, a recent report from the AAP suggests that the use of social media may have some positive social effects.52 In particular for teenagers, participation through social media can help individuals make friends, particularly with others from diverse backgrounds, be creative, exchange ideas and improve interpersonal skills including empathy,52,53 with 19% of the 1030 teenagers aged 13–17 interviewed in a recent survey stating that the use of social networking sites made them more sympathetic to others.54 Moreover, many schools are successfully using blogs as educative tools to improve written English, and the internet grants access to health resources, including information on sexually transmitted infections and mental health.52,55 Recommendations In the context of the AAP newsletter suggesting that the strict guidelines on screen use are antiquated, an important theme appears to be that young children in particular and children from potentially marginalised social groups are the most susceptible to the effects of excessive screen time. For example, several studies have identified that White children spend less time on average watching TV than Hispanic and African American children, and children from lower-income families are exposed to longer screen times and less likely to view educational TV shows or electronic content on mobile devices than children from higher-income families or those with more highly educated mothers.3,56,57 This would suggest that children from social groups generally associated with poorer health outcomes – such as ethnic minority groups and low-income families – are the most at risk of excessive screen times. Clinicians should take into account the child’s socio-economic background when identifying at-risk children. Also, the general health complaints and psychological issues become more prominent throughout childhood into adolescence. Making efforts to limit screen time during mealtimes is important to promote a time for families to spend together and to encourage healthy eating behaviours.58 Furthermore, there is considerable evidence that children with a TV in their bedroom are at increased risk of obesity, poor sleep habits, substance use and exposure to sexual content.1,59 Media devices are best placed in common areas where their use can be monitored. A growing body of evidence supports the role of health services in developing recommendations to limit screen time. The recommendations should be aimed at encouraging parents to set consistent limitations on screen time because studies have shown that the children of parents who control the length of screen time were more likely to engage in physical activities and time spent reading.60,61 The recommendations should also encourage the parents of young children to co-view suitable media content to promote learning. Co-viewing allows parents to optimise the key messages by parent–child interaction and question asking, and the use of interactive media together with a parent or adult enhances its educational value.62 336 S Domingues-Montanari Box NaN Box 1: Practical suggestions for clinicians 1 Ask parents questions related to their children’s media use, including: i. How long does your child spend with electronic media a day? ii. Do your children have a TV or computer in their bedroom? iii. Do your children use electronic media during mealtimes? 2 Encourage parents to set consistent and age-appropriate limitations on screen time. 3 Encourage parents to limit screen time during mealtimes. 4 Discourage parents from allowing their children to have a TV in their bedroom. 5 Encourage the parents of young children to co-view suitable media content. Such a widespread public campaign is of particular importance among parents of a lower socio-economic background whose children are more likely to require the attention of health services due to the negative clinical and psychological effects of excessive screen time (Box 1). Future Directions Further research is urgently required to more accurately determine the age-related clinical and psychological effects on health outcomes associated with excessive screen time. However, future studies should change their research strategy towards the use of large multi-centred and cross-cultural cohorts. The lack of such international collaboration is currently an obstacle for research studies in this area, as is the need to differentiate between the different types of media use – including TV/DVDs, mobile phones and other hand-held devices, computers and video gaming – because not all screen time may cause the same effects. One particular challenge for researchers will be distinguishing the type of content viewed on devices, which is important in order to delineate the effects of media use on the changes in brain structure. Multiple Choice Questions 1 How many hours of screen time per day is recommendable for children less than 2 years of age according to the APA guidelines? a) None b) Less than 1 h c) Less than 2 h d) Between 2 and 8 h e) Unlimited Answer: a. The youngest children are the most susceptible to the adverse effects of screen time. (b) is incorrect. TV exposure at age 6–18 months has been demonstrated to have a negative impact on the behaviour of infants. (c) is incorrect. In the APA guidelines, children over 2 years of age may be permitted up to 2 h of screen time per day. In the stricter Australian guidelines, children over 5 years may be permitted up to 2 h of screen time per day. (d) is Journal of Paediatrics and Child Health 53 (2017) 333–338 © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) 14401754, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jpc.13462 by Texas A&M Univ – Central Texas University Library, Wiley Online Library on [13/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Effects of screen time on children incorrect. Although daily screen time tends to increase throughout childhood into adolescence, more than 2 h of leisure screen time is not recommended for children of any age. (e) is incorrect. Unlimited screen time is not recommended for children or adults. 2 What are the effects of TV watching on children’s dietary habits? a) Reduced consumption of all types of foods b) Reduced consumption of all types of drinks c) Increased consumption of a variety of fruit and vegetables d) Increased consumption of high-fat/high-sugar foods and drinks e) Less snacking in-between meals Answer: d. Time spent watching TV is associated with an increased likelihood of consuming high-fat/high-sugar foods and drinks. The susceptibility of young children to commercial advertising is considered to be one of the main causes of this phenomenon. (a) is incorrect. TV watching tends to increase calorie intake. (b) is incorrect. Time spent watching TV is associated with increased consumption of sugar-sweetened drinks, but not an increase in overall liquid intake. (c) is incorrect. Time spent watching TV is associated with a reduced likelihood of eating fruit and vegetables. (e) is incorrect. Studies suggest that snacking is more frequent in children who exceed 2 h of TV watching per day. 3 What are the effects of TV viewing and other types of screen time on children’s cognitive and socio-emotional development? a) Earlier development of language skills b) An increased risk of peer victimisation during early school years c) Better classroom engagement and greater academic achievement d) A higher intelligent quotient score e) A lower likelihood of developing depression Answer: b. TV viewing at about 2 years of age, but not other types of screen time, is associated with a higher risk of peer victimisation during early school years. (a) is incorrect. TV viewing at about 2 years of age, but not other types of screen time, is associated with delayed language development, as well as lower school readiness with a reduced vocabulary and numerical ability. (c) is incorrect. Screen time is associated with lower school disconnectedness, academic achievement and self-esteem, particularly in males. (d) is incorrect. TV viewing, but not other types of screen time, has been confirmed to negatively affect children’s intelligent quotient score. (e) is incorrect. Children who do not meet screen time guidelines have an increased chance of reporting depression. References 1 American Academy of Pediatrics. Policy statement: Children, adolescents, and the media. Pediatrics 2013; 132: 958–61. 2 Mulligan DA, Altmann TR, Brown A et al. Media use by children younger than 2 years. Pediatrics 2011; 128: 1040–5. 3 Atkin AJ, Sharp SJ, Corder K, van Sluijs EM; International Children’s Accelerometry Database (ICAD) Collaborators. Prevalence and correlates of screen time in youth: An international perspective. Am. J. Prev. Med. 2014; 47: 803–7. 4 Anand V, Downs SM, Bauer NS, Carroll AE. Prevalence of infant television viewing and maternal depression symptoms. J. Dev. Behav. 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Journal of Paediatrics and Child Health 53 (2017) 333–338 © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) 14401754, 2017, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jpc.13462 by Texas A&M Univ – Central Texas University Library, Wiley Online Library on [13/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Effects of screen time on children Developmental Neuropsychology ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hdvn20 Association Between Screen Time of Mobile Devices and TV and School Readiness in Preschool Children: A Cross-Sectional Study Uğur Tekin & Ömer Alpgan To cite this article: Uğur Tekin & Ömer Alpgan (2023) Association Between Screen Time of Mobile Devices and TV and School Readiness in Preschool Children: A Cross-Sectional Study, Developmental Neuropsychology, 48:2, 47-55, DOI: 10.1080/87565641.2023.2183957 To link to this article: https://doi.org/10.1080/87565641.2023.2183957 Published online: 27 Feb 2023. Submit your article to this journal Article views: 292 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=hdvn20 DEVELOPMENTAL NEUROPSYCHOLOGY 2023, VOL. 48, NO. 2, 47–55 https://doi.org/10.1080/87565641.2023.2183957 Association Between Screen Time of Mobile Devices and TV and School Readiness in Preschool Children: A Cross-Sectional Study Uğur Tekin and Ömer Alpgan University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Clinic of Child and Adolescent Psychiatry, Istanbul, Turkey ABSTRACT ARTICLE HISTORY We aimed to investigate the relationship between screen time and school readiness. A total of 80 ppreschool children were included. Parents were interviewed about their children’s daily screen time. The Metropolitan Readiness Test was utilized. Results showed that the school readiness of those with a total screen time of 3 hours or less was significantly higher. TV time was inversely associated with reading readiness (B=− 2.30,p < .001), whereas mobile device time was inversely associated with both reading (B = −0.96,p = .04) and numbers readiness (B = −0.98,p = .02). This study point to the importance of supervising children’s screen use, and of awareness of parents and professionals. Received 14 September 2022 Revised 20 November 2022 Accepted 19 February 2023 Introduction The use of screen devices has been increasing rapidly in the last few decades. In addition to watching TV, mobile devices (smartphones, tablets, laptops, video games, etc.) play a major role in this increase (Marshall, Gorely, & Biddle, 2006). Nowadays, children spend a significant part of their free time in front of screen devices (Thomas, Bennie, De Cocker, Castro, & Biddle, 2020). While screen devices provide many advantages and benefits, their intensive use also has some risks. Studies are reporting with increasing frequency the negative health consequences of inappropriate and excessive screen use (Lissak, 2018). Due to its transforming nature under the influence of rapidly developing technology, the consequences of screen exposure are not fully understood. It is known that intense screen exposure in children has consequences on academic achievement (Adelantado-Renau et al., 2019; Pagani, Fitzpatrick, & Barnett, 2013). However, studies report different results. While some studies have revealed negative consequences (Steinberg, 2017; Syväoja et al., 2013), some others have reported positive effects (Skoric, Teo, & Neo, 2009). Many factors related to the use of screen devices such as screen time, media content, or context can affect the results associated with this activity. Among these, one of the most frequently researched topics is screen time. Screen time refers to the time spent on screen-based activities (LeBlanc et al., 2017). A recent systematic review reports that screen time is negatively associated with physical and mental health indicators (Stiglic & Viner, 2019). Another review reported that screen time, particularly TV time, was inversely related to academic performance. However, in the meta-analysis part of the same study, no relationship was found between total screen time and the academic performance of children (Adelantado-Renau et al., 2019). Based on the findings, the authors conclude that it would be more accurate and consistent to evaluate different screen types separately. There is no clear consensus on the limits of screen time. The World Health Organization (WHO) and The American Academy of Pediatrics (AAP) recommend no screen time for children under the CONTACT Uğur Tekin drutekin@gmail.com University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Clinic of Child and Adolescent Psychiatry, Istanbul, Turkey © 2023 Taylor & Francis Group, LLC 48 U. TEKIN AND Ö. ALPGAN age of 2, and a 1-hour limit for children 2–5 (Organization, 2019; Reid Chassiakos et al., 2016). The American Academy of Child and Adolescent Psychiatry (AACAP) limits non-educational screen time to 1 hour on weekdays and 3 hours on weekends for children aged 2–5 (Screen Time and Children, 2020). However, studies show screen time of children is above these limits. In a study (USA-2017), the average daily screen time was reported to be 2–3 hours between the ages of 2–4 (Rideout & Robb, 2017). In addition, the accessibility and diversity of screen media are developing rapidly. While many previous studies have investigated only TV time as the most common screen time, it has been reported that mobile devices are found in 98% of all homes, increasing steadily since 2013 across the world (Silver, 2019). There are also no specific limits on educational screen time. Furthermore, distance education via screens has become widespread everywhere as a result of the COVID-19 pandemic in 2020 (Kim, 2020). It is likely that remote learning will become a more important part of the education culture which increases the need for research on this subject. School readiness refers to the range of skills and knowledge that are necessary to respond adequately to school requirements (Carlton & Winsler, 1999). The development of cognitive, sensorymotor, and socio-emotional characteristics and the skills acquired by preschool children are associated with adaptation and success in the school period (High, 2008). Children with good school readiness are expected to be good at the ability to meet the school curriculum (Shonkoff, 2011). In the preschool period, brain plasticity is very high and development is rapid. Moreover, this period may also include many undiagnosed developing psychiatric syndromes (Bufferd, Dougherty, Carlson, Rose, & Klein, 2012) that are related to exposed environmental risk factors associated with the development of chronic problems such as ADHD (Pauli-Pott & Becker, 2011). This situation also increases the impact of the relationship of this developmental period with academic achievement. On the other hand, the option of online learning in the preschool period has been one of the topics debated. While using digital technologies to learn online in the early years is considered risky by some researchers (House, 2012), others suggest that digital learning can help young children understand abstract concepts and engage in learning, reasoning, and problem-solving activities (Clements & Sarama, 2005). As men­ tioned above, the effects of screen time on various academic fields need to be investigated on different types of devices and in different age groups. In this context, it was shown that TV time in the preschool period was negatively related to school readiness (Pagani, Fitzpatrick, & Barnett, 2013). Another study reported that those who watch general audience programs on TV more frequently perform worse in terms of school readiness (Wright et al., 2001). In the preschool period, the effect of mobile devices on the relationship between screen time and school readiness has not been sufficiently investigated. In this cross-sectional study, we aimed to investigate the relationship between the screen time of preschool children and their school readiness. In this context, by evaluating TV and mobile devices’ time separately, we investigated their contributions to the effects of screen use on school readiness. Material and methods This cross-sectional study was conducted on children aged 5.5–6 years. The inclusion criteria of the study were as follows: the child and the family’s willingness to participate, clinically having a normal developmental stage, and living with both parents. The study’s exclusion criteria were the presence of any chronic illnesses, clinically abnormal development, mental retardation or autism spectrum dis­ order, and insufficient literacy of the parents. Written informed consent was obtained from the parents. Ethical permission and approval for this study were obtained. A total of 105 participants were evaluated for inclusion in the study. Participants were evaluated by a child psychiatrist and the Denver II developmental screening test was applied by a child development specialist (Frankenburg, Dodds, Archer, Shapiro, & Bresnick, 1992). Among those evaluated, 8 children with developmental delay, 5 children with autism spectrum symptoms, and 5 children with chronic neurological or organic diseases were excluded from the study. Besides, 7 children whose parents were divorced or who were living with grandparents were excluded to avoid the possible DEVELOPMENTAL NEUROPSYCHOLOGY 49 confounding effect of this situation on school readiness. The study group was formed from the remaining 80 children and their parents. Measures: The socio-demographic data questionnaire created by the researchers surveyed each subject’s socio-demographic characteristics including age, gender, duration of preschool education, parental age, parental education and employment status, family structure, number of siblings, and socio-economic status (SES). The SES was classified according to the official poverty limits. Parents were interviewed about the daily screen-based activities of their children. To obtain more accurate and consistent information, and to examine TV and mobile devices separately, information about screen time was queried in two separate parts TV and mobile devices (smartphone, tablet, laptop). Metropolitan Readiness Test (MRT): It was developed to determine the readiness of children for primary school. The test has a total of 100 items and 6 sub-dimensions. These are 1- word compre­ hension (19 items), 2-sentence comprehension (14 items), 3- general knowledge (14 items), 4matching (19 items), 5-numbers (24 items), and 6- copying (10 items). For each correct answer, 1 point is obtained and wrong answers are not scored. The first 4 sub-dimensions give the reading readiness score, the 5th sub-dimension gives the numbers readiness score, and the total of all six subdimensions gives the overall readiness score. The high score indicates that the child’s school readiness level is high. Statistical Methods: Statistical analyses were performed using the IBM Statistical Package for the Social Sciences Statistics 22 statistical software package program. The statistical data was expressed using the mean and standard deviation. MRT scores of the groups formed according to screen time, showing normal distribution and continuous data, were compared using the independent t-test. The correlation between the MRT scores and screen times was analyzed using the partial correlation test. Multiple regression analysis was performed to determine predictors of the overall, reading, and numbers readiness on MRT using the variables that show significant correlations, and are likely to covary with both screen use and school readiness. A value of p < .05 was considered statistically significant. Results A total of 80 children, 36 (45%) girls, and 44 (55%) boys were included. The mean age was 5.72 (± 0.14) years. The average daily screen time was 3.83 (± 1.68) hours, of which 1.95 (± 1.08) were TV and 1.87 (± 1.21) mobile devices. The socio-demographic characteristics of the sample are summarized in Table 1. The AACAP recommends up to 3 hours limit of screen time per weekend day, while it has been reported in a recent review that among children screen time was exceeding guidelines of 2 h/day in 52.3% of participants, and the average total screen time was 3.6 h/day (Thomas, Bennie, De Cocker, Castro, & Biddle, 2020). Taking these into consideration, among the children in our sample, those with a total screen time of 3 hours or less (n = 35) and those with more (n = 45) were compared in terms of MRT scores. The MRT scores (reading, numbers, and overall) of those with a total screen time of 3 hours or less were found to be significantly higher (Table 2). The relationship between screen time and MRT scores was examined by partial correlation analysis. Controlled variables were age, gender, attendance of preschool education, parent age and education, SES, and maternal employment. Reading readiness score showed a moderate negative correlation with TV time and a low-level negative correlation with mobile device time. Numbers readiness score did not show a significant correlation with TV time but showed a low-level negative correlation with mobile device time. Overall MRT score showed a moderate negative correlation with both screen time. Total screen time showed moderate negative correlations with all MRT scores (Table 3). We examined the relative contribution of TV time, mobile devices time, duration of preschool education, mother employment, number of siblings, maternal education, paternal education, and SES to the explanation of the variability in children’s school readiness, using multiple regression analysis (Table 4). Results showed that TV time, mobile device time, and maternal and paternal education were 50 U. TEKIN AND Ö. ALPGAN Table 1. Data of MRT, Screen Time, and Sociodemographic Variables. n (%) Sex Male Female Age (mean ± SD) (y) Preschool education Attendance Duration (mean ± SD) (y) MRT scores (mean ± SD) Reading readiness Numbers readiness Overall readiness Screen time (mean ± SD) (h) TV Mobile device Total SES Low Middle High Maternal Age (mean ± SD) (y) University Education* Employment** Paternal Age (mean ± SD) (y) University Education* Employment** Number of siblings 44 (55%) 36 (45%) 5.72 ± 0.14 64 (80%) 1.31 ± 0.96 44.97 ± 6.14 13.25 ± 5.36 63.15 ± 11.87 1.95 ± 1.08 1.87 ± 1.21 3.83 ± 1.68 35 (43.8%) 16 (20%) 29 (36.3%) 35.1 ± 4.78 20 (25%) 26 (32.5%) 38.7 ± 4.73 20 (25%) 80 (100%) 0.92 ± 0.74 SES, socioeconomic status; SD, standard deviation; y, years; h, hours. *, number of parents with university or higher education. **, number of employed parents. Table 2. Comparison of the MRT scores of those with a total screen time of 3 hours or less and those with more. Group 1 (n = 35) Reading Numbers Overall Mean 48.00 15.23 69.29 SD 5.40 5.18 10.77 Group 2 (n = 45) Mean 42.62 11.71 58.38 SD 5.68 5.05 10.51 p
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