The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
Despite the clarity of these recommendations, there is a large variance between AAP recommendations and what limits parents have actually placed on screen time for their children. Data suggest that children from 2 to 11 years old are spending an average of 4.5 hours/day on screens (TV, computer, tablets, or smart phones, not counting homework). By adolescence, that number balloons to over 7 hours of daily screen time. Up to three-quarters of surveyed adolescents describe themselves as “constantly connected” to the Internet (Pew Internet and American Life Project, 2015). The reasons are many: Screens, from TV’s to laptops and smartphones, are omnipresent and limiting access can feel simply impossible. Indeed, many parents may have difficulty limiting their own use. Children may (accurately) complain that their peers get easy access to phones and apps, and that limiting their access puts them at a social disadvantage. Many exhausted parents default to a screen as a babysitter or reward. Parents also recognize the power of technology to help cultivate independence (when they give a cellphone to their older child), to have a research library at their fingertips, or to build supportive social networks. Most families are eager for help in setting reasonable limits on screen time for their children. What can pediatricians recommend so that screen time fits into the family’s life in a manageable way that might promote healthy development and family cohesion?
The data about the potential risks to children and adolescents of unchecked time spent passively engaged in screen-based entertainment are growing, but it is important to note that these are challenging questions to answer, given the difficulty of separating causal links from simple associations. The youngest children should be learning about themselves and the world through joint engagement in activities with their parents. Passive engagement with a screen might impede the development of self-regulation of emotion and attention. Indeed, there is some evidence that the prevalence of attention-deficit/hyperactivity disorder in young children increases with increased time spent on screens, although this may reflect a predilection for screen-based activities among children with ADHD or their difficulty switching focus when engaged in engrossing activities. There is more robust evidence for a link between time spent in passive consumption of TV or Internet-based activities and obesity: Having a TV in the bedroom, spending more than 1.5 hours daily in media consumption, and snacking while watching TV all have been independently associated with the risk of obesity in childhood. Sleep also appears to be very sensitive to a child’s time spent engaged with media. Having a mobile device in the bedroom or simply being a heavy user of social media both predict inadequate sleep in children and teenagers. Exposure to back-lit screens directly suppresses melatonin release and can contribute to the drop in melatonin that is part of the hormonal trigger for the start of puberty. Combined with the added risk of obesity, excessive daily screen use can significantly increase the risk of early puberty. Finally, time spent on the Internet also appears to be habit forming for vulnerable youth: Up to 8.5% of children 8-18 years old meet criteria for Internet gaming disorder ( Psychological Science. 2009;20[5]:594-602 ).
What children are watching appears to also be critical to the degree of developmental risk. While young children may learn some fundamentals of reading or mathematics from the best educational video games, their efficacy is not as good as time spent with parents reading together or working jointly on a math problem. Exposure to violent content on TV or video games can potentially be traumatizing for children, causing sleep disruptions and anxiety symptoms. And it can take away from the time children would otherwise spend in unstructured play, meeting new friends in the neighborhood, or trying new physical skills outside. When children have inadequate time spent in self-directed activities, they are less likely to develop their creative potential and discover their genuine interests and abilities.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
