Screen time and sedentary behaviour in the early years (Part 3): Seven psychological health risks and academic outcomes thought to be related to screen time

Dr Breanne Kunstler (BBiomedSci, BHealthSci, MPhysio, PhD).

Last week I wrote about the physical health impacts of high screen time on children. This is the third post in a series of posts on children’s screen time and will involve examining some of the psychological health risks associated with screen time.

I did a quick search and found hundreds of studies on screen time and child health, dozens of which were review-level (some of the best evidence you can get). I looked at some of the highest quality review-level evidence to inform this post. Basically, if I found high-quality review-level evidence to support relationships between health and screen time then I was pretty confident that the relationships exist.

Let’s have a look at what the research I found has to say about the psychological health risks associated with screen time for kids. I will use a three-part system ('confident', 'hmm maybe' and 'unlikely') to indicate how confident I am in the findings of the studies I came across.

High sedentary time is related to lower health-related quality of life: Hmm maybe.

Health-related quality of life (HRQOL) is defined as “an individual’s perceived physical and mental health over time”. It focuses on the quality of one’s life, like how happy they are with various components of their health, ranging from physical issues like the presence or absence of joint pain to mental health concerns like the presence or absence of stress. A review found that increased sedentary time (not just screen time) in kids 3 to 18 years old is not only related to lower HRQOL, but there’s a dose response. This means as sedentary time (or time bumming around) gets higher and higher, HRQOL gets lower and lower. Although there is high quality evidence to support this finding, I simply haven’t found enough of it to make me confident that the relationship truly exists.

Image 1: This girl and her mum look pretty happy to me (credit: workingmother.com)

High screen time is related to poor sleep: Hmm maybe.

Children must sleep well to achieve good health. We have Australian guidelines that outline recommended sleep durations for children of different ages:

• Infants (birth to 1 year) should sleep for 14 to 17 hours (0 to 3 months old) and 12 to 16 hours (4 to 11 months old) across a 24-hour period;
• Toddlers (aged 1 to 2 years) should sleep for 11 to 14 hours across a 24-hour period, with consistent sleep and wake patterns; and
• Pre-schoolers (aged 3 to 5 years) should sleep for 10 to 13 hours across a 24-hour period (but primarily at night), with consistent sleep and wake patterns.

Furthermore, children are encouraged not to use screens 1 hr before bed and parents are encouraged to keep screens out of bedrooms to support good quality sleep. This is probably a good recommendation given half of Australian children use screens at bedtime and 25% report sleep problems. Although the use of screens close to bedtime is thought to negatively affect the ability to fall asleep, can we be sure that screen time is indeed impacting sleep?

Image 2: Forget the bed bugs, it's all about screens in the bed. Lucky they don't bite (credit: healthline.com)

High-quality, review level evidence suggests that screen time can impact sleep, such as sleep duration, in children under 5 years old (Chaput et al, 2017; Janssen et al, 2019). Older kids aged 6 to 19 years are at risk of inadequate sleep quality, quantity and daytime alertness if they use portable screens (e.g. smartphone) at bedtime. These findings are also supported by smaller studies and opinion pieces. So, there’s convincing evidence that screens can affect sleep quality and quantity, but we also need to keep in mind that researchers are still calling for more research in this area.

Some study authors have suggested that participating in physical activity and outdoor play can help to improve sleep, but it’s still unclear if kids can simply be extra active to make up for the damage screen time might be doing to sleep. It’s unlikely to be as easy as fixing one with the other.

Image 3: How can they learn if they're asleep? (credit: accuweather.com)

High screen time is related to poor academic outcomes: Hmm maybe.

This is an interesting one. Studies looking at the relationships between screen time and learning tend to distinguish between screen time used for academic pursuits and screen time used for leisure. 

Image 4: Dissecting a frog is so much cleaner on the iPad (credit: mashable.com)

High-quality, review-level evidence suggests that using mobile devices, like tablets, can positively impact the development of literacy, maths, science and problem solving skills of children. These positive associations might be explained by the content the child is interacting with and how that content is delivered (e.g. does the app design allow the child to effectively engage with the content and problem solve?). 

Once the type of screen changes to TV and others used for leisure (e.g. video games), suddenly screen time becomes potentially detrimental to cognitive abilities of children, impairing their learning and skill acquisition, academic achievement and overall school performance. One review also suggested that greater sedentary time, not just on screens, is related to poor academic achievement.

More research is needed in this area but it seems that the impact screens have on academic performance depends on how they are used and for what, not simply whether or not they are used.

High screen is related to poor mental health: Confident

We all hope that our kids are mentally healthy. We have become more and more focused on the importance of good mental health, as opposed to just good physical health, over the past several years and I strongly believe that this is a very positive thing.

Poor mental health has been found among adolescents who use screens for >2hr/day. There are several areas of mental health that I could explore in this post but I will focus on the areas where I have found some interesting work.

I found several high-quality studies exploring the relationship between high screen time and poor mental health outcomes, including:

1. Addictive behaviours (Neophytou et al, 2019; Wolf et al, 2018);
2. Anxiety (Domingues-Montanari, 2017; Saunders et al, 2017; Twenge et al, 2018);
3. Depressive symptoms (Domingues-Montanari, 2017; Hoare et al, 2016; Lissak, 2018; Liu et al, 2015; Rosen, 2019; Saunders et al, 2017; Twenge et al, 2018);
4. Emotional stability (Twenge et al, 2018);
5. Hyperactivity/inattention/self-control; (LeBlanc et al, 2017; Twenge et al, 2018);
6. Internalising problems (LeBlanc et al, 2017);
7. Low self-worth (LeBlanc et al, 2017);
8. Poor stress regulation (Lissak, 2018);
9. Prosocial behaviour (Carson et al, 2016; LeBlanc et al, 2017; Saunders et al, 2017);
10. Psychological distress (Hoare et al, 2016);
11. Self-esteem (Carson et al, 2016; Herodotou, 2017; Hoare et al, 2016; LeBlanc et al, 2017; Neophytou et al, 2019; Saunders et al; 2017);
12. Suicidal feelings (Lissak, 2018; Rosen, 2019); and
13. Wellbeing and quality of life (LeBlanc et al, 2017; Twenge et al, 2018).

I will specifically examine the outcomes that have the most research: self-esteem, depression and anxiety, and pro-social behaviour.

Self-esteem relates to your opinion of yourself, the confidence you have in yourself to tackle common challenges and make yourself happy. I found several high-quality reviews (see sources above) that suggest high screen time, especially for leisure (e.g. TV and video games) is related to low self-esteem in kids and adolescents. In contrast, I also found a review that reported that the use of mobile devices, like tablets, can have positive effects on self-efficacy (confidence in oneself to perform tasks) of 2 to 5 year-old kids. However, this relationship could be due to the type of content kids are interacting with and the way the apps and programs are designed to engage children in meaningful activities. So, I am confident that screen time can be related to poor self-esteem, but I also believe that the content children are interacting with has an important role to play in deciding whether the relationship is a positive or negative one.

The impact of screen time on symptoms of anxiety and depression in children and adolescents is widely researched. Several high-quality reviews and a huge population study (see sources above) found that screen time is related to symptoms of depression and anxiety in children and adolescents, where the more screen time the child gets, the greater their risk of them developing symptoms. Again, different types of screens and their content seemed to influence the likelihood of developing these symptoms (e.g. computer use, but not video game use, was related to depression risk in one study, whereas TV use was related to developing depression and anxiety in another study).

The risk of depression also can depend on the amount of time spent on screens. Depression risk is lowest at 1hr per day but is higher at less and more than this. Adolescents have been found to be 66% more likely to report more suicide-related outcomes as their daily screen time increased from 1 hr to ≥5hrs daily. Furthermore, depression risk differs depending on if screens are used for academic pursuits or leisure, with leisure use presenting a risk for depressive symptoms in adolescents. These findings suggest that some screen time (about 1 hr daily), especially when used for learning, might even be beneficial. However, the risk of experiencing depressive symptoms and suicidal feelings might increase again if screen time starts to impact sleep.

The impact screen time has on pro-social behaviour (e.g. positive interactions and altruism) also deserves some attention. Parents often worry about children socialising online compared to in-person, with the assumption that in-person socialising is ‘better for them’. However, just because the socialising is online doesn’t dictate the quality of interaction or relationships children are forming. Again, it’s the time spent on the device and what kids are doing that probably matters most, with more time spent playing video games, watching TV and using other screens being deleteriously related to pro-social behaviour in children and adolescents.

Image 5: That's pretty poor social behaviour. Maybe it's the influence of the xbox, or maybe you just deserve it? (credit: YouTube)

In summary

It is clear that there’s a relationship between screen time and psychological health. I am confident that screen time over and under 1 hr per day, with 1 hr being some kind of magic sweet spot, can have a detrimental relationship with depression, anxiety, self-esteem and pro-social behaviour. However, I strongly believe that screen type and content has an impact on these relationships. 

I am less confident that there’s a relationship between screen time and poor quality of life, sleep and academic outcomes. My lack of confidence isn’t because the studies haven’t found any relationships, but rather that authors of these studies are calling for more research to support their findings. So, let’s wait and see what the research says in another few years.

In my next post I will explore what parents think about screen time. Is it really that bad? Is screen time a necessity in modern times?

Happy reading!