Excessive Screen Time in Children and Young People – Should We Be Worried?

Levelling up hooks gamers to their screens, whilst each TikTok video viewers watch keeps them scrolling more. Subconsciously, these digital consumers become addicted to entering new virtual worlds, losing track of time, all while accumulating more screen time.

Screen time (i.e. time spent on any digital or electronic screens) – including television, computers, smart phones, tablets and video games – has become an integral part of modern life. This is especially the case for children and young people who, having grown up surrounded by digital media, online learning and screen entertainment, are often described as 'digital natives' [1, 2]. Screen time is a broad concept and can be categorised into passive (e.g., TV viewing), educational (e.g., computers for homework) and interactive/social (e.g., video games and social media) [3,4]. TV viewing remains the most common screen-based activity among children [5]. However, as technology has advanced, a growing range of electronic media devices have become available. We have seen an increase in children’s ownership and use of such devices over the past decade beginning at an increasingly young age. [1, 5]. Much of screen time in children is for leisure and entertainment purposes, but in developed countries, digital technology has been extensively integrated into mainstream schooling and education.

In this article, the benefits and risks of screen time from the current evidence base will be presented across various domains, including psychosocial, educational, and the physical and mental health effects. Influencing factors to these effects will also be described, alongside recommendations for controlling screen time in children and young people. The current scientific thinking will be discussed, and conclusions drawn from the evaluated evidence, to increase awareness among young people of the potential health risks of excessive screen time to enable them to make informed decisions on their screen time use. The findings will also enable parents, educators, and policy makers to make informed decisions on managing and moderating screen time in children. This topic directly relates to the UN Sustainable Development Goal 3 (UN SDG 3): Good Health and Wellbeing.

So, what do we know so far about the health and wellbeing effects of screen time exposure in children?

Screen Time Exposure Levels in Children

It has been reported that children spend more time with electronic media (TV, video games and Internet) than with any other activity [6]. On a typical day, UK children and young people reported spending an average of 2.5 hours on a computer/laptop/tablet, 3 hours on their phone and 2 hours watching TV [1]. Other studies have reported that children spend around 8 hours of their daily waking hours on screen-based activities [5, 7, 8]. Even though this number may seem alarming, many parents encourage these activities.

Parental Influence

Many parents believe that digital media content has positive educational benefits for their children [5]. In one study, 29% of parents allowed their children under 2 years old to watch television, believing it would be beneficial to their brain development [9]. That study also found that parents were less likely to control their children’s screen time because it distracted and entertained them, as well as preventing family conflict and social isolation [10].

TV has been described as an “electronic babysitter” [3] and parents have admitted to using TV viewing and electronic devices to keep their children busy in restaurants [11], social situations and to free up their time to undertake household chores [5, 12]. TV is often used as an entertainment source for children of families of lower socio-education backgrounds, due to limited monetary resources [13].

Reducing screen time in children and young people has been found to be heavily influenced by parents who decrease their own screen time [14]. This positive parental influence has a similar effect on other activities such as sedentary behaviour and exercise [14]. Electronic/digital media is associated with some benefits so it’s important to explore them in more detail.

Benefits of Electronic/Digital Media

Social and Educational

Digital technology has revolutionised education, bringing new methods of teaching and learning. As a result, children are able to navigate the internet from a much younger age [5]. Educational screen time has been associated with positive educational outcomes and greater persistence, although the magnitude of the effect was small [15]. Other benefits of electronic and digital technology include greater access to support networks for those with disabilities or health conditions, exposure to vast amounts of knowledge and new ideas, social contact with friends or family members who are separated geographically, health promotion, and awareness of current affairs [3]. It has been reported that the rise of social media has improved inclusion in society, as people can make connections with others who have shared similar experiences and receive support through this [3].

While the social and educational benefits of digital media are widely acknowledged as above, there is no consistent evidence of any health benefits from screen time [2, 3]. However, harmful health associations of excessive use have been observed affecting psychosocial, physical and mental wellbeing. The following section summarises the literature and evidence base for this.

Adverse Effects

Psychosocial Effects

As young people become more exposed to technology and the internet, they also become more vulnerable to harmful content, including online bullying, age-inappropriate material, inaccurate or unsafe content and exploitation [16]. Unsupervised access to social media can also compromise their privacy and confidentiality and potentially contribute to the development of eating disorders [3, 17]. It is imperative that the importance of protecting young people is not underestimated and robust safeguarding measures are implemented.

Sedentary Effects and Neglecting Other Beneficial Activities

Increased screen time in young people can result in neglect of other beneficial activities, such as exercise, sleep, nutrition and socialising [1, 16]. Most digital media-related activities are also sedentary. Along with obesity, sedentary behaviour can increase a child’s risk of high blood pressure and high cholesterol levels [18]. If screen time is not managed in youth, poor habits and overuse may carry on to adulthood [19] which could result in significant health conditions.

Excessive sedentary screen time in adulthood is strongly associated with all-cause mortality, type 2 diabetes, cardiovascular disease and metabolic syndrome, as well as being moderately associated with ovarian, colon and endometrial cancers [18].

Physical and Mental Health Effects

Various studies have been published in the literature examining both physical and mental health effects of screen time. There is evidence that higher levels of screen time are associated with a variety of health risks for children and young people.

The strongest evidence is for obesity and unhealthy diet , depressive symptoms and health-related quality of life [2, 3, 5, 20,-24]. There is also some emerging evidence of an adverse impact on cognitive development in infants and sleep [1-3, 5, 27-30].

Obesity and Unhealthy Diet

For obesity and unhealthy diets, the most significant risks are associated with TV viewing. Children aged 2–4 years who exceeded 2 hours of TV viewing per day were more likely to be obese [31]. A meta-analysis revealed a linear dose–response relationship (where increasing levels of exposure are associated with increasing risk of the outcome) between TV watching and obesity. For both boys and girls, a 13% incremental increase in obesity risk was reported for each hour per day of TV watching [32].

A large international study of 300,000 children and adolescents found that daily TV viewing of between 1-3 hours led to a 10% to 27% increase in risk of obesity [33].

Suggested mechanisms for the association of screen time with obesity include an increase in energy intake and unhealthy eating habits, the displacement of time available for physical activity or more directly, through reduction in metabolic rate [16, 20].

Suggested explanations for the relationship between screen time and unhealthy diet include distraction, interruption of physiological food regulation, screen time as a conditioned cue to eat, disruption of memory formation, and the effects of the stress-induced reward system [1, 34].

Depressive Symptoms

Strong positive associations of screen time with depressive symptoms have been reported and higher depressive symptoms were associated with engaging with at least two hours of screen time daily [2, 21, 22]. There is evidence for an association between social media screen time and depression [3]. Studies illustrate that, beyond the number of hours spent on social media, the manner in which individuals use social media is a key factor [3].

Proposed explanations for the relationship between screen time and depressive symptoms include peer disapproval on social media, low self-confidence caused by resultant obesity, and exposure to inappropriate content [2, 16]. Another factor implicated is the infringement on time that could be spent taking part in beneficial activities. Rather than socialising, playing sports and getting adequate sleep, young people are increasingly devoting their time to screen-based media or watching television [2, 16]. However, this association with depressive symptoms should be considered in the context of a general rise of mental health issues in children and young people in the 25 years before the rapid increase in screen time [16].

Health-Related Quality of Life

Greater screen time has been associated with lower measured health-related quality of life (a multidimensional construct that covers physical, psychological, and social health and hence represents overall health of an individual) [24]. Notably, individuals who engage with ≥2–2.5 hours of screen time per day experience significantly lower health-related quality of life than those with <2–2.5 hours/day [24].

Cognitive Development In Infants

Evidence is beginning to emerge that increased screen time in younger infants could have adverse effects on cognitive and social development. In a Korean study, children under 30 months with 2–3 hours of daily TV viewing had a 2.7-fold higher risk of language delay than those with less than 1 hour, while toddlers with over 3 hours per day had about a three-fold increase in the relative risk of language delay [25].

In a different study, higher levels of screen time at 24 and 36 months were significantly associated with poorer performance on developmental screening tests at 36 months and 60 months [26]. Other studies have observed that the content of the media use is an important influencing factor in both positive and negative cognitive development [5].

Sleep

There is a growing body of evidence that media use negatively affects sleep [28, 30]. The presence of a TV, computer, or mobile device in the bedroom and increased duration of exposure to media has been associated with fewer minutes of sleep per night [28, 29]. Later bedtimes after evening media use, violent content in the media and suppression of endogenous melatonin by blue light emitted from screens may also be contributing factors [30, 35]. Studies involving older children have shown that increased social media usage or those who sleep with media devices in the bedroom [27, 36, 37] were at higher risk of sleep disturbance. Children of ethnic minority groups are more likely to have a TV in their bedroom and are therefore a high-risk group for sleep disturbance [29]. A UK study investigated children’s views on screen time and found that 88% of the children stated that screen time had a negative impact on their sleep [1]. The average time spent on screens before falling asleep was 1.5 hours [1].

It is important however, that the various associations described above are not confused with causation. To date, there is no evidence of a direct adverse effect of screen time on physical or mental health. The general consensus from the literature above is that screen time alters behaviour, which in turn leads to negative outcomes [2, 16].

There is no or insufficient evidence for an association between screen time and eating disorders, suicidal ideation, individual cardiovascular risk, asthma prevalence or pain [2]. What has emerged from studies so far is that different types of screen time have been associated with different effects.

Effects of Specific Types of Screen Time

Distinguishing between passive (e.g., TV viewing), educational (e.g., computers for homework) and interactive (e.g., video games) screen time is important as health effects are influenced by the type of screen time children are exposed to [4, 15].

• Educational screen time (e.g. homework on electronic devices) is considered a beneficial form of screen time with positive effects on educational outcomes and persistence [4] . Research has not identified negative effects on any other factors, including psychological and health outcomes [4].

• Passive screen time (e.g., TV viewing) is associated with worse psychological outcomes, poorer health outcomes, lower educational outcomes and increased sedentary time [4, 15, 38].

• Interactive screen time (e.g., video games) is associated with unfavourable temperament outcomes, worse socio-emotional outcomes, lower health-related quality of life and poorer health outcomes [4]. In one study, it had positive associations with educational outcomes but associations were small [15].

Some scientists have argued that the harms of screen time are overstated citing the absence of a sufficient body of research and evidence [2, 16, 39]. They highlight the need for more long-term follow-up studies and more robust controlling for confounding variables before any conclusions are drawn.

Studies have not been able to identify a threshold for safe screen use, although there is weak evidence for a threshold of 2 hours daily screen time for the associations with depressive symptoms and health-related quality of life [2].

Recommendations for Controlling Screen Time

In light of the exponential increase in screen time in young people and the harmful associations observed in recent research studies, expert groups have advocated limiting screen time usage for children. A number of Paediatric Organisations in various countries have published specific guidelines to address this. The revised 2016 American Academy of Paediatrics (AAP) guidelines essentially recommend no screen time for children <2 years, a 1-hour daily limit (of high-quality programmes) for 2-5-year olds and placing consistent limits on the time spent using media and the types of media for children age 6 and older [40]. They also advise that media should not take the place of adequate sleep, physical activity and other health-promoting behaviours [3, 40]. However, there is evidence that the majority (approx. 90%) of US parents ignore the AAP’s advice [5, 41]. The Canadian Paediatric Society and the Australian Department of Health have issued similar guidelines, the latter going further and recommending no more than two hours of sedentary recreational screen time per day for children and young people aged 5–17 years (not including schoolwork) [19, 42].

The UK Royal College of Paediatrics and Child Health (RCPCH) 2019 guidance acknowledged that evidence for an absolute screen time limit is weak and that the adverse effects of screen time can often be attributed to loss of other positive activities, such as exercise, social contact with friends, and good sleep hygiene. They recommend the amount of time a child or young person spends on devices should be tailored to the individual, with special attention when introducing technology to younger infants or toddlers. They advise that thresholds may be an appropriate part of a family’s media planning, but they do not set any specific limits [1].

Children of parents who control the length of screen time are more likely to engage in physical activities and time spent reading [5]. Furthermore, given that not all screen time may cause the same effects, studies have highlighted that parents should consider the type of their children’s screen time (TV/DVDs, mobile phones and other hand-held devices, computers and video gaming) rather than just duration [4]. This article should bring awareness to young people of the potential adverse issues they could face and they should monitor and decrease their screen time if excessive, especially if it is not for educational use.

Summary

In summary, electronic and digital media is now a significant and integral part of our lives and children and young people are becoming exposed to screen time from a much younger age, both at home and at school.

While there is no evidence that increased screen time ‘directly causes’ harmful health effects, there is a growing body of evidence linking it to negative health outcomes (due to altered behaviours) and an adverse impact on childhood development. This topic area is highly relevant to UN SDG 3 which highlights the importance of good health and wellbeing.

Lack of a sufficient evidence base to draw definitive conclusions has been reported. Gaps in the existing evidence base have been highlighted, particularly a lack of robust research accounting for confounders (e.g., failure to separate screen time from non-screen sedentary behaviours and the sedentary elements of screen time from the content watched on screens), inadequate follow-up periods and a lack of international studies of large multi-centred and cross-cultural cohorts.

A significant proportion of research to date has focused on the quantity of screen time rather than investigating the contexts of screen use and the content watched. This is particularly important with newer digital and electronic devices becoming available. A key issue therefore is whether these findings can be applied to all forms of screen time (including more modern forms, such as social media and mobile screen use) and the degree to which the effects of screen time relate to time spent on screen, the content watched or context of screen use.

Therefore, the current evidence does support a case for recommending that young people moderate their screen time and parents set consistent screen time limitations for their children, although consensus is still lacking regarding a safe level of screen time. Setting a blanket threshold for total screen time has also been questioned, given that some types of screen time for example educational screen time (e.g., homework on electronic devices) are beneficial.

Further research is needed to understand the impact of both the contexts and content of screen use on children and young people’s health and well-being, particularly in relation to mobile digital devices (e.g., smartphones, tablets and video games) and for new content areas such as social media (e.g., YouTube, TikTok, Instagram, Snapchat).

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