Screen time association with inattention in children

 

Brief description of patient problem/setting

An 11-year-old female with Hx of ADHD is brought to the clinic by her mother for routine wellness check. The mother asks the provider why her daughter has trouble concentrating/paying attention; she wonders if it is due to the long amount of time the child spends on her iPad, and asks if reducing screen time for her younger 3-year-old daughter will decrease risk of developing ADHD or inattention later.

 

Search Question: Does increased screen time negatively affect attention in children?

 

PICO search terms:

P	I	C	O
Children	Increased screen time	Recommended screen time	Inattention
Patients <18 years old	Increased screen exposure	2 hours or less daily screen time	Attention deficit
	High digital screen time		Risk of ADHD
	High digital media time
	>2 hours screen time

 

Search tools and strategy used:

Filters/limits use for all 3 search tools: last 5 years, MEDLINE, English, free full article/text

 

PubMed: (terms = screen time AND attention deficit) + filters above 896 results

Cochrane: (screen time AND (ADHD or attention)) + filters above 2 Cochrane reviews, 172 trials

NEJM: (screen time AND (ADHD or attention)) + filters above 0 results

Google Scholar: (screen time AND (ADHD or attention)) + filters above 4,120 results

JAMA: (“screen time” AND attention deficit) + filters above + research filter 5 results

ScienceDirect: (“screen time” AND (ADHD or attention)) + filters above 262 results

 

How I narrowed my choices:

I would usually look for randomized control trials after systematic reviews and meta-analyses; however, because of the nature of this research question, I am not expecting to find enough RCTs as I assume parents and researchers would not want to intentionally put children at increased risk of having attention deficits and issues with executive functioning. Therefore, for this assignment I will consider observational studies like cohort and cross-sectional studies. Ideally, the cohort studies (either prospective or retrospective) will take a group of children who have long daily screen times and a group of children with acceptable/short screen time and follow them overtime to compare the prevalence of inattention between the groups. 

After using the filters mentioned above, I had difficulty finding literature that specifically addressed whether high digital screen time was associated with increased risk of attention deficit; therefore, I did not have to narrow my choices down much. While PubMed and Google Scholar provided many results with my search, a majority of the articles were unrelated in that they did not touch on screen time enough or at all, and many results were not research articles; also, many focused on other aspects of screen time in those that already have ADHD and were not helpful in answering my research question. NEJM did not produce any results relevant enough to my specific topic with the search tools/filters used. My search on Cochrane produced articles that were not concentrated enough on my question, and other articles were not relevant enough to select for this assignment. For the few studies that did address digital screen time and attention, I narrowed my choices down to those that focused on children.

 

Results found:

1. “Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systematic Review and Meta-analysis”

https://jamanetwork-com.york.ezproxy.cuny.edu/journals/jamapsychiatry/fullarticle/2790338

 

Eirich R, McArthur BA, Anhorn C, McGuinness C, Christakis DA, Madigan S. Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022;79(5):393–405. doi:10.1001/jamapsychiatry.2022.0155

 

PDF: 1. jamapsychiatry

 

Abstract

Importance  Currently, there is a lack of consensus in the literature on the association between screen time (eg, television, video games) and children’s behavior problems.

Objective  To assess the association between the duration of screen time and externalizing and internalizing behavior problems among children 12 years or younger. 

Data Sources  For this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO databases were searched for articles published from January 1960 to May 2021. Reference lists were manually searched for additional studies.

Study Selection  Included studies measured screen time (ie, duration) and externalizing or internalizing behavior problems in children 12 years or younger, were observational or experimental (with baseline data), were available in English, and had data that could be transformed into an effect size. Studies conducted during the COVID-19 pandemic were excluded. Of 25 196 nonduplicate articles identified and screened for inclusion, 595 met the selection criteria.

Data Extraction and Synthesis  The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Extracted variables were child age, sex, and socioeconomic status; informants and measurement type for screen time and behavior problems; study publication year; and study design and quality. Data were extracted by 2 independent coders and were pooled using a random-effects model.

Main Outcomes and Measures  The primary outcome was the association of screen time duration with externalizing (eg, aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, depression, anxiety) behaviors or diagnoses.

Results  Of the 595 full-text articles assessed for eligibility, 87 studies met all inclusion criteria, comprising 98 independent samples and 159 425 participants (mean [SD] age, 6.07 [2.89] years; 83 246 [51.30%] male). Increased duration of screen time had a small but significant correlation with more externalizing problems (90 samples; r, 0.11; 95% CI, 0.10-0.12) and internalizing problems (43 samples; r, 0.07; 95% CI, 0.05-0.08) in children. Several methodological moderators explained between-study heterogeneity. There was evidence of significant between study heterogeneity (I2 = 87.80).

Conclusions and Relevance  This systematic review and meta-analysis found small but significant correlations between screen time and children’s behavior problems. Methodological differences across studies likely contributed to the mixed findings in the literature.

 

 

2. “Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469768/

 

Tamana SK, Ezeugwu V, Chikuma J, Lefebvre DL, Azad MB, Moraes TJ, Subbarao P, Becker AB, Turvey SE, Sears MR, Dick BD, Carson V, Rasmussen C; CHILD study Investigators, Pei J, Mandhane PJ. Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study. PLoS One. 2019 Apr 17;14(4):e0213995. doi: 10.1371/journal.pone.0213995. PMID: 30995220; PMCID: PMC6469768.

 

PDF:2. pubmed

 

Abstract

Background

Pre-school children spend an average of two-hours daily using screens. We examined associations between screen-time on pre-school behavior using data from the Canadian Healthy Infant Longitudinal Development (CHILD) study.

Methods

CHILD participant parents completed the Child Behavior Checklist (CBCL) at five-years of age. Parents reported their child’s total screen-time including gaming and mobile devices. Screen-time was categorized using the recommended threshold of two-hours/day for five-years or one-hour/day for three-years. Multiple linear regression examined associations between screen-time and externalizing behavior (e.g. inattention and aggression). Multiple logistic regression identified characteristics of children at risk for clinically significant externalizing problems (CBCL T-score≥65).

Results

Screen-time was available for over 95% of children (2,322/2,427) with CBCL data. Mean screen-time was 1·4 hours/day (95%CI 1·4, 1·5) at five-years and 1·5 hours/day (95%CI: 1·5, 1·6) at three-years. Compared to children with less than 30-minutes/day screen-time, those watching more than two-hours/day (13·7%) had a 2·2-point increase in externalizing T-score (95%CI: 0·9, 3·5, p≤0·001); a five-fold increased odd for reporting clinically significant externalizing problems (95%CI: 1·0, 25·0, p = 0·05); and were 5·9 times more likely to report clinically significant inattention problems (95%CI: 1·6, 21·5, p = 0·01). Children with a DSM-5 ADHD T-score above the 65 clinical cut-off were considered to have significant ADHD type symptoms (n = 24). Children with more than 2-hours of screen-time/day had a 7·7-fold increased risk of meeting criteria for ADHD (95%CI: 1·6, 38·1, p = 0·01). There was no significant association between screen-time and aggressive behaviors (p>0.05).

Conclusion

Increased screen-time in pre-school is associated with worse inattention problems.

 

 

3. “Screen Time and ADHD Behaviors in Chinese Children: Findings From Longitudinal and Cross-Sectional Data”

https://journals.sagepub.com/doi/pdf/10.1177/10870547221098181

 

Tan, T. X., & Zhou, Y. (2022). Screen Time and ADHD Behaviors in Chinese Children: Findings From Longitudinal and Cross-Sectional Data. Journal of Attention Disorders. https://doi.org/10.1177/10870547221098181

 

PDF: 3. journal of attention disorders

 

Abstract:

Objective:

Research suggests that screen exposure presents a risk for ADHD behaviors in young children. However, the operationalization of screen exposure remains murky and longitudinal data is scarce. In this paper, we examined the relations between better operationalized daily screen time and behaviors of inattention and behaviors of hyperactivity/impulsivity in three cohorts of community samples of young Chinese children.

Method:

Study 1 was longitudinal and included 111 children who were 3.6 years old (Range = 2.4–4.9; SD = 0.4) at Baseline and 4.8 years old (Range = 3.9–6.0; SD = 0.4) at Follow-Up. Study 2 was cross-sectional and included 172 children aged 4.9 years (Range = 3.0–7.1; SD = 1.0). Study 3 was also cross-sectional and included 313 children who were 6.9 years old (Range = 5.7–8.3; SD = 0.4). In each study, the parents reported how much time that their children spent daily on iPad/tablet, smart phone, and online games and watching TV in the previous week, and their children’s behaviors of inattention (I/A) and hyperactivity/impulsivity (H/I).

Results:

Regression analysis revealed that in Study 1, controlling for child demographics, mother’s education, family SES, and corresponding I/A or H/I scores at Baseline, screen time at Baseline predicted I/A scores (β = .27, p < .01) and H/I scores (β = .32, p < .001) at Follow-Up. Similarly, controlling for covariates, screen time predicted I/A scores (β = .25, p < .01) and H/I scores (β = .25, p < .01) in Study 2; I/A scores (β = 0.16, p < .01) and H/I scores (β = .15, p < .05) in Study 3.

Conclusion:

Screen exposure was a risk for inattention and hyperactivity/impulsivity behaviors in urban Chinese children.

 

4. “Screen-exposure and altered brain activation related to attention in preschool children: An EEG study”

https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S2211949319300213

 

Michal Zivan, Sapir Bar, Xiang Jing, John Hutton, Rola Farah, Tzipi Horowitz-Kraus,

Screen-exposure and altered brain activation related to attention in preschool children: An EEG study,

Trends in Neuroscience and Education, Volume 17, 2019, 100117, ISSN 2211-9493, https://doi.org/10.1016/j.tine.2019.100117.

 

PDF: 4. science direct

 

Abstract:

Exposure to screens has been shown to reduce attention span in children. Increased slow-wave (theta band) and decreased fast-wave (beta and gamma bands) generated from EEG, as well as increased theta/beta ratio, have been observed in children with Attention-Deficit-Hyperactivity-Disorder (ADHD). This study examined the relationship between 6-weeks screen exposure and attention abilities in typically developing preschoolers using EEG during rest. Theta and beta bands were compared, and visual attention and parental reports for attention abilities were controlled. Results suggested that the active control group showed improved visual-attention abilities following the exposure to stories, whereas the screen group did not show improved visual attention. EEG results suggested a higher connectivity in theta vs. beta bands in the screen group, but not in the control group. Results support the negative relationship between screen exposure and attention-related patterns generated from EEG in typically developing preschool children.

 

 

5. “Screen exposure exacerbates ADHD symptoms indirectly through increased sleep disturbance”

https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S1389945721001714

 

Eddy Cavalli, Royce Anders, Louise Chaussoy, Vania Herbillon, Patricia Franco, Benjamin Putois,

Screen exposure exacerbates ADHD symptoms indirectly through increased sleep disturbance,

Sleep Medicine, Volume 83, 2021, Pages 241-247, ISSN 1389-9457, https://doi.org/10.1016/j.sleep.2021.03.010.

 

PDF: 5.sleep, sciencedirect

 

Abstract:

Objectives

The aim of this study was twofold. First, to confirm the deleterious aspect of evening screen exposure in school-aged children, in particular the effect of screens in the bedroom. Second, to explore the three-way association between degree of screen exposure, sleep disturbance, and ADHD symptoms. Solid evidence exists on the link between sleep disturbance and ADHD symptoms, and screen exposure and sleep disturbance. However, no studies have formally assessed the impact of screen exposure on ADHD symptoms in children, as a function of sleep disturbance.

Methods

Parents of 374 French children (201 girls, 173 boys, mean age of 10.8 ± 2.8 years old) completed the Sleep Disturbance Scale for Children (SDSC), the Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale, and a questionnaire about their children’s screen habits (total hours in the morning, afternoon, and evening per day). Correlational analyses between evening screen exposure, sleep quality and behavioral problems were conducted. Then, formal mediation analyses were run in order to quantify the relationship between variables.

Results

School-aged children with screens in their bedrooms demonstrated more sleep and behavioral problems. Evening TV exposure was associated with higher SDSC and ADHD scores. Furthermore, the Structural Equation Modelling approach confirmed that evening screen exposure is directly associated with more disrupted sleep, which in turn is directly associated with behavioral problems.

Conclusions

These findings encourage families to avoid putting screens in their children’s bedrooms, and limit evening screen exposure. They furthermore demonstrate the importance of taking into account screen exposure time (morning, afternoon, evening) and location (bedroom or elsewhere) in future studies.

 

6. “The Association between Screen Time and Attention in Children: A Systematic Review”

https://www.tandfonline.com/doi/10.1080/87565641.2022.2064863

 

Renata Maria Silva Santos, Camila Guimarães Mendes, Débora Marques Miranda & Marco Aurélio Romano-Silva (2022) The Association between Screen Time and Attention in Children: A Systematic Review, Developmental Neuropsychology, 47:4, 175-192, DOI: 10.1080/87565641.2022.2064863

 

PDF: 6. The Association between Screen Time and Attention in Children A Systematic Review

 

Abstract:

Electronic media pervade modern life. Childhood is a crucial period for attentional development and the screen exposure time is increasing. This review aimed to understand the association between screen time and attention of children with typical development. A systematic review was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyzes PRISMA being registered at Prospero under number CRD42021228721. A search was performed in January 2021 with the following keywords: “screen time,” “children,” and “attention,” combined with the operator AND, on databases PubMed, and PsycINFO. Four hundred and ninety-eight articles were identified, and 41 papers were fully read, of which 11 were included in this review. Most studies found associations between screen time and attention in children. Only one study reported that children with more screen time performed better in an attention task. The findings suggest that exposure to excessive screen time in children can be associated with attention problems. Parents and teachers may be involved in controlling screen exposure, especially after the extensive exposition to online classes, due to the pandemic. Further studies are needed to assess the influence of this overexposure on care over time.

 

 

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Eirich R, McArthur BA, Anhorn C, McGuinness C, Christakis DA, Madigan S. (2022)	Systematic Review & Meta-analysis	159,425 participants Children <12 y/o 87 total studies (longitudinal and cross-sectional) Excluded studies done during the COVID pandemic (due to already increased screen time and mental distress)	Primary outcome: association of screen time duration with externalizing (eg, aggression, ADHD sx) and internalizing (eg, depression, anxiety) behaviors or diagnoses.	There was a small, but significant relationship between high screen time duration and increased attention deficit/hyperactivity disorder symptoms. (25 samples; r, 0.09; 95% CI, 0.06-0.11) Other conclusions (unrelated to my research question): Violence and aggressive behaviors in children were more strongly associated with screen time.	Effect sizes are correlational, not causal.  Correlations of screen time with externalizing behavior problems were stronger in the Middle East compared with any other geographic location; however, sample sizes in the Middle Eastern studies were small, and 95% CIs were wide, limiting the conclusions. Not all screen time is equal in content.   Significant heterogeneity for internalizing problems, only 1 of the moderator analyses had significant results. Unexamined moderators (genetic susceptibility, sleep) may have a significant role in associations.
Tamana SK, Ezeugwu V, Chikuma J, Lefebvre DL, Azad MB, Moraes TJ, Subbarao P, Becker AB, Turvey SE, Sears MR, Dick BD, Carson V, Rasmussen C. (2019)	Observational cohort study	2,322 participants.  3- and 5-year-olds.  Data is based on cohort study done in Canada. Children with reported developmental or genetic disorders, such as autism, were excluded.	Primary outcome: internalizing problems (e.g. anxious/depressed, withdrawal, somatic, emotionally reactive). Secondary outcomes: externalizing problems (e.g. inattention, aggressiveness) and total problems (internalizing, externalizing, sleep issues, and other problems).	Compared to children with <30 min/day of screen time, those with >2 hrs/day were 5-9 times more likely have clinically significant inattention problems. Children with >2 hrs/day screen time were 7x more likely to meet DSM-5 criteria for ADHD. Boys were more likely than girls to have externalized behavior problems.  Children who spent >2hrs per week in organized physical activity showed a reduction in externalized behavior problems.  Screen time seemed to have more of a statistically significant effect on behavior problems than other risk factors like sleep duration, parenting stress, and socio-economic factors.	Screen-time, sleep, and physical activity, were parent-reported and not validated against objective measures. Unable to determine if the media content (e.g. educational, video gaming, social media), or screen type (television, computer, tablet) were important predictors of behaviors. Most children were Caucasian and from mothers of older maternal age. About 84% of participants met the recommended 10-13 hrs of sleep. Findings may not be applicable to other populations.
Tan, T. X., & Zhou, Y. (2022)	Systematic Review	596 children.  3 studies (1 longitudinal, 2 cross sectional)	Children’s behaviors of inattention (I/A) and hyperactivity/impulsivity(H/I) as reported by parents via online survey.	More screen time alone significantly predicted higher inattention and hyperactivity/impulsivity scores, even after controlling for other factors such as age, sex, mother’s age, education level, number of children in the home, etc.  Even after controlling for baseline inattention and hyperactivity/impulsivity scores, more screen time positively predicted these scores to be higher even after 13 months.  Boys had higher inattention scores than girls in 2 out of the 3 studies.	Study was performed on Chinese children, so results may not be applicable to local, US population. Studies were also conducted in affluent cities in China, so data on children who may live in different conditions (rural) was lacking.  Parents were the ones reporting data on screen time and inattention behaviors.
Michal Zivan, Sapir Bar, Xiang Jing, John Hutton, Rola Farah, Tzipi Horowitz-Kraus. (2019)	Randomized Control Trial	30 children, ages 4–6 years, from a middle-class background, with normal developmental history, and without a history of attention difficulties	Behavioral measures: 1) verbal abilities using the Naming subtest from the WPPSI, 2) non-verbal abilities using the Matrix task, from the WPPSI, and 3) attention abilities using visual and auditory attention subtests Attention assessment based on parental questionnaire.  Encephalogram (EEG) recordings.	After 6 weeks, the human-based storytelling group showed improved visual attention after the intervention while the screen group did not improve in visual attention after the intervention. The children exposed to screens demonstrated higher functional connectivity in EEG frequencies related to attention difficulties, compared to the storytelling group. Meaning the screen group had EEG results more similar to those of children diagnosed with ADHD.	Small sample size. EEG data was not collected prior to intervention, so could not compare intervention effects on EEG.
Eddy Cavalli, Royce Anders, Louise Chaussoy, Vania Herbillon, Patricia Franco, Benjamin Putois. (2021)	Cross-sectional study	374 French children (201 girls, 173 boys) aged 6-16 years old.	Outcomes were measured by surveys completed by parents. Outcomes included sleep disturbance (assessed with Sleep Disorder Scale for Children) and ADHD symptoms (assessed with ADHD Rating Scale IV)	Evening screen time significantly modulated sleep disturbance, whereas daily (or morning) screen time did not.   Evening screen exposure, and especially the presence of a screen in children’s bedroom, is associated with sleep disturbances and ADHD symptoms as described by parents.	The correlation between ADHD, sleep and screen time does not necessarily equal causal links. The fact that the DSM-IV TR ADHD was filled by the parents can introduce a bias. Media content or type of screen used were not distinguished.  Results based on French children, so may not be applicable to local population of US children.
Renata Maria Silva Santos, Camila Guimarães Mendes, Débora Marques Miranda & Marco Aurélio Romano-Silva. (2022)	Systematic Review	8,637 children and adolescents aged between 18 months and 18 years old. 11 studies included (3 RCTs, 2 longitudinal, 2 prospective, 4 cross-sectional)	Attention behavioral changes	Most studies have observed associations between screen time and children’s attention. Younger children and preschoolers: screen time was predictive of attention problems later in life.  Time using touch screen devices was related to an increase in propensity for attention problems in young children. Children exceeding daily recommendation for TV exposure or use of tech  toys (>2 hrs) seem more likely to have more attention problems than average.  Dialogic reading and storytelling interventions showed improvement in visual attention, compared to the control group(screen-based exposure).	Screen time reported by parents/children may be inaccurate.  The heterogeneity in measures and outcomes, such as samples at different stages of child development, contexts, and methods made it difficult to generalize the results.

 

Conclusion(s):

Article 1: Eirich, R, et al. (2022). There was a small, but significant relationship between high screen time duration and increased attention deficit/hyperactivity disorder symptoms. (25 samples; r, 0.09; 95% CI, 0.06-0.11). Other conclusions (unrelated to my research question): Violence and aggressive behaviors in children were more strongly associated with screen time.

Article 2: Tamana, SK, et al. (2019). Compared to children with <30 min/day of screen time, those with >2 hrs/day were 5-9 times more likely have clinically significant inattention problems. Children with >2 hrs/day screen time were 7x more likely to meet DSM-5 criteria for ADHD. Boys were more likely than girls to have externalized behavior problems. Children who spent >2hrs per week in organized physical activity showed a reduction in externalized behavior problems. Screen time seemed to have more of a statistically significant effect on behavior problems than other risk factors like sleep duration, parenting stress, and socio-economic factors.

Article 3: Tan, T. X., & Zhou, Y. (2022). More screen time alone significantly predicted higher inattention and hyperactivity/impulsivity scores, even after controlling for other factors such as age, sex, mother’s age, education level, number of children in the home, etc. Even after controlling for baseline inattention and hyperactivity/impulsivity scores, more screen time positively predicted these scores to be higher even after 13 months. Boys had higher inattention scores than girls in 2 out of the 3 studies. 

Article 4: Zivan, M, et al. (2019). After 6 weeks, the human-based storytelling group showed improved visual attention after the intervention while the screen group did not improve in visual attention after the intervention.The children exposed to screens demonstrated higher functional connectivity in EEG frequencies related to attention difficulties, compared to the storytelling group. Meaning the screen group had EEG results more similar to those of children diagnosed with ADHD.

Article 5: Cavalli, E, et al. (2021). Evening screen time significantly modulated sleep disturbance, whereas daily (or morning) screen time did not. Evening screen exposure, and especially the presence of a screen in children’s bedrooms, is associated with sleep disturbances and ADHD symptoms as described by parents.

Article 6: Santos, R, et al. (2022). Most studies found associations between screen time and children’s attention. In younger children, screen time was predictive of attention problems later in life. Time using touch screen devices was related to increased attention problems in young children. Children exceeding daily recommendations (>2 hrs) for TV exposure or use of technological toys seem more likely to have more attention problems than average. Dialogic reading and storytelling interventions showed improvement in visual attention, compared to the control group (screen-based exposure).

 

Overarching conclusion: Based on my extensive database search efforts and the studies I’ve gathered above, it seems that recent literature on whether screen time has a significant effect on children’s attention or development of ADHD is lacking. While data derived from the articles I chose suggests that increased screen time may be associated with increased attention deficit, the clinical bottom line here is that strong conclusions regarding the direct effect of screen time on the attention of children cannot be made. We can say that there may be a causal relationship, but the media-ADHD connection cannot be definitively defined without stronger research.

 

 

Clinical Bottom Line:

Weight of the evidence(in order from highest to lowest) and explanations: 

Santos, R, et al. (2022)(Article 6). I considered this article to be the strongest in weight of evidence for various reasons. This is a systematic review published only a few months ago this year. It included a large sample size of over 8,000 children, aged 18 months – 18 years old. It included 11 studies, although some of those studies included some of the other articles I’ve included in this paper, so some of the data was redundant. I also appreciated that it only focused on the outcome of attention. It also found data specific to a type of device (touch screens) and data with a specific amount of screen time (>2 hours). One flaw, however, was that most of the data analyzed here was parent reported. 

Eirich, R, et al. (2022)(Article 1). This was a systematic review and meta-analysis with the largest sample size and the most number of studies, and it was only published this year. However, only a portion of the study was dedicated to finding a correlation of screen time with ADHD symptoms.

Tan, T. X., & Zhou, Y. (2022)(Article 3). This is also another systematic review published this year, but I ranked it lower than the above because it only included 3 studies and data was parent-reported on 596 children in urban areas of China (international data). This still ranked higher than other studies however, because data analyses controlled for some outside factors like demographics, mother’s education, and baseline inattention scores. Therefore, it was more focused on screen time effect on inattention. 

Cavalli, E, et al. (2021)(Article 5). I ranked this article a bit lower because this is a cross sectional study of only 374 French children (international data). Another weakness is that the data was based on surveys filled out by parents. Some strengths, however, was that data was distinguished by evening and daily screen time, and other specific details like whether the child had a screen in their bedroom. It also measured sleep disturbance as an outcome and related that to ADHD symptoms. Sleep disturbances caused by screen time and its potential influence on ADHD symptoms was an interesting aspect that I believe is important to consider in the clinical bottom line.

Zivan, M, et al. (2019)(Article 4). I ranked this article pretty low in weight of evidence because it had a very small sample size of only 30 children. I did not rank it last, however, because this is a randomized control trial, so the data may be relied on more. The difference between this study versus the others is that this one focuses on how screen time may affect the attention of children on a neurobiological level by use of EEG recordings. This provides a more concrete way of measuring how screen time may affect children. Researchers here compared EEG recordings of two groups of children: one with 6 weeks of screen-based stories, and the other with 6 weeks of storytelling by a human. Because the EEG patterns of children with attention deficit have been already established, I thought this would be an interesting and valuable study to include. Another strength is that the two groups were divided and matched based on factors like age, verbal abilities, baseline attention, and parental attention and hyperactivity report.

Tamana, SK, et al. (2019)(Article 2). I ranked this study last for several reasons. It was an observational cohort study based in Canada (international data). Another weakness is that it only included data on 3- and 5-year olds. Data was also all parent reported, so the risk of bias is there. Lastly, the media content and screen type were not distinguished. A strength, however, was a larger sample size (compared to the other articles above) of 2322 children. And I also included this article in my research because it had a distinguished threshold for screen time and categorized screen time that way; this classification is valuable for guiding recommendations. 

 

 

Clinical bottom line, magnitude of effects, clinical significance, other important considerations in guiding practice: 

The original aim of my research question was to find whether increased screen time had an effect on the attention of children. With this in mind, it would have been ideal to find studies that perhaps divided participating children into groups of specific amounts of screen time (such as <1 hour, 1-2 hours, >2 hours), so that we can see the difference in the attention behaviors between these groups. This would have helped with making more concrete descriptions instead of just saying “extended screen time.” 

There was also much heterogeneity between the studies collected and several factors such as international data which may have a cultural effect on conclusions should be kept in mind. It also important to note that much of the data presented by several of these studies was obtained by parents (screen time and severity of inattention behaviors); therefore, a question of reliability given likely bias or inaccurate data must be kept in mind. Further studies using uniform and more concrete methods of experimental factors of measuring screen time and inattention behaviors should be done. One suggestion of a future RCT would be to see if limiting children’s screen time to healthy/recommended time has an effect on attention problems, and having the children being objectively assessed by professional providers who can diagnose attention deficits and ADHD. The bit of evidence presented here which suggests a correlation between increased screen time and increased risk of inattention in children, although weak, may provide motivation for more robust studies to be done, especially those of higher-level evidence. With the age of technology advancing, tablets/phones are becoming more accessible and used in the pediatric population; therefore, identifying screen time as a potential risk factor for ADHD or other attention deficits is important.

It is also important to consider that not all screen time is equivalent. Most of the data collected here was based on screen time in general and grouped various forms (TV, video games, phones, etc). The type of screen and the actual content being watched by these children may have various effects. For example, the attention of a child is playing violent video games versus that of another child watching educational, interactive videos may be affected differently. The findings of most of the Further studies should not define screen time as a single, broad factor, but instead dissect the type of screen and the content that children are exposed to. This data may help with guiding practice by helping providers suggest one form of digital media over others.   

We must also keep in mind the way screen time may affect attention indirectly. For example, article 5 highlights the way that more screen time may lead to sleep disturbances, which have been shown to play a part in attention deficits. 

Another important consideration in interpreting this data is that parents of children who already have ADHD, attention deficits, insomnia, or other behavioral problems, may already be more likely to allow these children to have more screen time. Perhaps digital media is their way of controlling certain behaviors, so the attention deficit may have been there before the extended screen time was present. 

Regarding my patient scenario and a clinical bottom line, I would tell this parent and other parents with similar concerns, that while there is some evidence suggesting that increased screen exposure may be associated with impaired attention in children, the research is scarce. However, I would still advise against more than 1 hour on school day and 3 hours on the weekend for children 2-5 (based on 2020 recommendations from American Academy of Child & Adolescent Psychiatry) as there is abundant evidence which exhibits other negative effects of high screen time, such as sleep problems, poor academic performance, obesity, and mood problems amongst others. I would particularly advise against putting screens in children’s bedrooms and limiting screen exposure specifically in the evening, as these have been shown to be correlated with increased sleep disturbances, which may have an effect in attention deficits (article 5). I would also educate the parent with stating that the exact cause of ADHD is unknown, but it is proposed to be primarily genetic and maybe with some environmental factors (such as diet, sleep habits, smoke exposure, etc) which are still being investigated (UpToDate: Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis).