Interventions to control children's screen use and their effect on sleep: A systematic review and meta-analysis

Adolescent smartphone use, sleep, and physical activity: daily associations between sensor-based measures in the adolescent brain cognitive development (ABCD) study

PURPOSE

Potential health consequences of adolescent smartphone use are a growing public concern. Improving upon existing, largely self-report-based research, this study investigated relationships between adolescent smartphone use, sleep, and physical activity using passive sensor measures.

METHODS

Over three weeks, 791 Adolescent Brain Cognitive Development (ABCD) Study participants (Mage=14.12, 53 % female) provided smartphone application and keyboard use data via the Effortless Assessment Research System (EARS) application, and sleep and physical activity data via Fitbit device.

RESULTS

Mixed-effects models found that daytime/evening application use (6:00AM-7:59PM) predicted reduced exercise, more time sedentary, and fewer daily steps (Standardized β=-0.21-0.07, P<.001). Late-evening use (8:00PM-9:59PM) modestly predicted increased sedentary time and reduced steps (Standardized β=-0.05-0.02, P<.001). Late-night use (10:00PM-5:59AM) predicted reduced sleep, delayed sleep onset, delayed waking, increased sedentary time, and fewer daily steps (Standardized β=-0.16-0.27, P<.001). After disaggregating within and between-person smartphone use, within-person relationships remained significant, with associations of similar magnitude to the initial analyses (daytime/evening use: standardized ꞵ=-0.22-0.07, P<.001; late-evening use: standardized ꞵ=-0.05-0.02, P<.001; late-night use: standardized ꞵ=-0.16-0.24, P≤.002), indicating daily-level relationships unattributable to between-subject differences. Examining smartphone use effects by hour relative to sleep onset indicated that only use recorded after initial sleep onset significantly predicted sleep, while use recorded 3-12 hours before sleep onset significantly predicted step counts.

CONCLUSIONS

Using passive sensor data, we found significant associations between adolescent smartphone use, physical activity, and sleep which differed by time of day and remained significant within subjects. Experimental replication is recommended to strengthen tentative causal claims.

Effects of school-based interventions on all 24-hour movement behaviours in young people: a systematic review and meta-analysis of randomised controlled trials

Objective

This systematic review and meta-analysis examined the effects of school-based interventions on all 24-hour movement behaviours.

Design

Systematic review and meta-analysis.

Data sources

Studies published in English, French, and Spanish from four databases from inception to February 2024 were identified.

Eligibility criteria for selecting studies

Eligible articles were randomised controlled trials (RCTs) that targeted and assessed physical activity (PA), sedentary behaviour (SB) and sleep duration among school-aged youth (3-17 years). Risk of bias and quality assessment were assessed using the Risk of Bias Tool 2 and Quality Assessment of Controlled Intervention Studies tool, respectively. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool evaluated the certainty of evidence. The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) (ID: removed for peer review).

Results

Of the 5141 records initially identified, 41 studies remained for full-text review. After full reading, 7 RCTs, comprising 8234 participants (49% girls), were included. Results indicated no effect in PA-related outcomes (Hedge's g=0.12, -0.05 to 0.28), a small reduction in SB-related outcomes (g=-0.33, -0.51 to -0.16) and a small increase in sleep duration (g=0.30, 0.16 to 0.43) according to Hedges' g (small effects (0≤g ≤0.50)). The GRADE, risk of bias and quality assessment tools indicated that most of the studies have a low risk of bias and are of good quality.

Conclusions

More school-based interventions promoting all movement behaviours are needed to determine if schools are optimal for encouraging 24-hour movement behaviours among young people.

Social Media and Sleep Health

Social media interferes with pediatric sleep health with downstream consequences for mental health and other developmental outcomes. Based on the literature on screen use and sleep, social media likely affects sleep through the following proposed mechanisms: activity displacement, content-related arousal, alerting effects of light, and disruptions from noises and vibrations. Future research on this topic should improve measurement of both social media use and sleep health. Scalable, sustainable, and effective interventions should be developed and evaluated. We offer clinical recommendations for reducing the negative effects of social media on pediatric sleep health.

Interventions for Digital Addiction: Umbrella Review of Meta-Analyses

BACKGROUND

Numerous studies have explored interventions to reduce digital addiction outcomes, but inconclusive evidence makes it difficult for decision-makers, managers, and clinicians to become familiar with all available literature and find appropriate interventions.

OBJECTIVE

This study aims to summarize and assess the certainty of evidence of interventions proposed to decrease digital addiction from published meta-analyses.

METHODS

An umbrella review of published meta-analyses was performed. We searched PubMed, Cochrane Library, Web of Science, and Embase for meta-analyses published up to February 2024. Eligible studies evaluated interventions using randomized controlled trials, nonrandomized controlled trials, or quasi-experimental studies and were assessed for methodological quality using Assessment of Multiple Systematic Reviews version 2. A random effects model was used to analyze data, considering heterogeneity and publication bias. Grading of Recommendations, Assessment, Development, and Evaluations was applied to assess evidence with certainty.

RESULTS

A total of 5 studies assessing 21 associations were included in the umbrella review, of which 4 (80%) were high-quality meta-analyses. Weak evidence was observed in 19 associations, whereas null associations appeared in the remaining 2 associations. These associations pertained to 8 interventions (group counseling, integrated internet addiction [IA] prevention programs, psychosocial interventions, reality therapy, self-control training programs, cognitive behavioral therapy, interventions to reduce screen time in children, and exercise) and 9 outcomes (self-control, self-esteem, internet gaming disorder symptoms, time spent gaming, IA scores, screen use time, interpersonal sensitivity longlines, anxiety, and depression). Cognitive behavioral therapy reduces anxiety (standardized mean difference [SMD] 0.939, 95% CI 0.311 to 1.586), internet gaming disorder symptoms (SMD 1.394, 95% CI 0.664 to 2.214), time spent gaming (SMD 1.259, 95% CI, 0.311 to 2.206), and IA scores (SMD -2.097, 95% CI -2.814 to -1.381). Group counseling had a large effect on improving self-control (SMD 1.296, 95% CI 0.269 to 2.322) and reducing IA levels (SMD -1.417, 95% CI -1.836 to -0.997). Exercise intervention reduced IA scores (SMD -2.322, 95% CI -3.212 to -1.431), depression scores (SMD -1.421, 95% CI -2.046 to -797), and interpersonal sensitivity scores (SMD -1.433, 95% CI -2.239 to -0.627).

CONCLUSIONS

The evidence indicates that current interventions to reduce digital addiction are weak. Data from more and better-designed studies with larger sample sizes are needed to establish robust evidence.

TRIAL REGISTRATION

PROSPERO CRD42024528173; crd.york.ac.uk/PROSPERO/display_record.php?RecordID=528173.

Association between excessive screen time and falls, with additional risk from insufficient sleep duration in children and adolescents, a large cross-sectional study in China

Objective

Falls is a major global public health issue that occur in all age groups. However, the association between screen time, sleep duration and falls in children and adolescents remains unclear.

Methods

This study included children and adolescents who participated in the 2017 Nutrition and Health Surveillance of Children and Lactating Mothers in China. Screen time, sleep duration and falls in the past 12 months were assessed using baseline questionnaires completed by the participants. We utilized a multivariate logistic regression model to estimate the association between screen time, sleep duration, and falls in children and adolescents. Stratified analyses and sensitivity analyses were performed using the same modelling strategies.

Results

A total of 564 participants (5.7%) self-reported falls in the past 12 months. Multivariate logistic regression analysis revealed that high screen time (> 2 h per day) was associated with a higher incidence of falls (cOR:1.46, 95% CI: 1.22-1.74, p < 0.001). The combination of high screen time and low sleep duration was associated with an increased risk of falls compared to the recommended low screen time and high sleep duration group (cOR: 1.62, 95% CI: 1.25-2.09, p < 0.001). After adjusting for relevant covariates, the associations remained significant (aOR: 1.30, 95% CI: 1.08-1.56, p = 0.006; aOR: 1.43, 95% CI: 1.10-1.87, p = 0.008).

Conclusion

Our study demonstrates that both high screen time and the combination of high screen time and low sleep duration were associated with an increased risk of falls. Interventions to promote healthy physical development should commence in early childhood to decrease the incidence of fall injuries in children and adolescents.

Toddler Screen Use Before Bed and Its Effect on Sleep and Attention: A Randomized Clinical Trial

Importance

Toddler screen time has been associated with poorer sleep and differences in attention. Understanding the causal impact of screen time on early development is of the highest importance.

Objective

To test (1) the feasibility of the 7-week parent-administered screen time intervention (PASTI) in toddlers (aged 16-30 months) who have screen time in the hour before bed and (2) the impact of PASTI on toddlers' sleep and attention.

Design, Setting, and Participants

This assessor-blinded, UK-based randomized clinical trial was conducted between July 2022 and July 2023. This was a single-site study that enrolled families with a toddler aged between 16 and 30 months, living within 75 miles of the Babylab, and with 10 minutes or more of screen time in the hour before bed on 3 or more days a week. Exclusion criteria were (1) a genetic or neurological condition, (2) premature birth (<37 weeks), and (3) current participation in another study.

Interventions

Families were randomized (1:1:1) to (1) PASTI: caregivers removed toddler screen time in the hour before bed and used activities from a bedtime box instead (eg, reading, puzzles); (2) bedtime box (BB only): used matched before-bed activities, with no mention of screen time; or (3) no intervention (NI): continued as usual.

Main Outcomes and Measures

Feasibility outcomes: participation rate, intervention adherence, retention, family experiences, and assessment acceptability. Efficacy outcomes: screen use, actigraphy-measured sleep, and eye-tracking attention measures.

Results

A total of 427 families were screened, 164 were eligible (38.4%), and 105 families were randomized (mean [SD] age, 23.7 [4.6] months; 60 male [57%]). The trial was feasible, with 99% participant (104 of 105) retention and 94% of families (33 of 35) adhering to PASTI. PASTI showed reductions in parent-reported screen time (vs NI: Cohen d = -0.96; 95% CI, -1.32 to -0.60; vs BB only: Cohen d = -0.65; 95% CI, -1.03 to -0.27). PASTI showed small to medium improvements in objectively measured sleep efficiency (vs NI: Cohen d = 0.27; 95% CI, -0.11 to 0.66; vs BB only: Cohen d = 0.56; 95% CI, 0.17-0.96), night awakenings (vs NI: Cohen d = -0.28; 95% CI, -0.67 to 0.12; vs BB only: Cohen d = -0.31; 95% CI, -0.71 to 0.10), and reduced daytime sleep (vs NI: Cohen d = -0.30; 95% CI, -0.74 to 0.13) but no difference compared with BB only. There was no observable effect of PASTI on objective measures of attention. Compared with BB only, PASTI showed a difference on parent-reported effortful control (Cohen d = -0.40; 95% CI, -0.75 to -0.05) and inhibitory control (Cohen d = -0.48; 95% CI, -0.77 to -0.19), due to an increase in BB-only scores.

Conclusions and Relevance

Results of this randomized clinical trial show that, supporting pediatric recommendations, removing screen time before toddler bedtime was feasible and showed modest preliminary beneficial effects on sleep. A future full confirmatory trial is needed before PASTI's adoption by parents and pediatricians.

Trial Registration

ISRCTN.org Identifier: ISRCTN58249751.

The Overflow Effects of Movement Behaviour Change Interventions for Children and Adolescents: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Considering the finite time within a 24-h day, the distribution of time spent on movement behaviours has been found to be associated with health outcomes.

OBJECTIVES

This systematic review and meta-analysis aimed to summarise and evaluate the overflow effects of interventions targeting a single behaviour (physical activity, sedentary behaviour/screen time, or sleep) on other non-targeted behaviours among children and adolescents.

METHODS

Six databases (MEDLINE [Ovid], PsycINFO [ProQuest], EMBASE [Ovid], PubMed, Web of Science and SPORTDiscus [EBSCO]) were searched for relevant studies published before 13 May, 2024. Randomised controlled trials and clustered randomised controlled trials that targeted a single behaviour and also assessed the effects on non-targeted behaviours, comprised of healthy children under the age of 18 years, were included. Movement behaviours can be measured either objectively or subjectively. The revised Cochrane risk-of-bias tool for randomised trials was adopted to evaluate the risk of bias.

RESULTS

A total of 102 studies with 45,998 participants from 21 countries were identified, and 60 of them with 26,183 participants were incorporated into the meta-analysis. The meta-analysis demonstrated that physical activity interventions led to a reduction in the proportion of each day spent in sedentary behaviour (mean difference =  - 0.95% of wear time, 95% confidence interval - 1.44, - 0.45, I2 = 39%). Sedentary behaviour interventions resulted in increased standing time (mean difference = 3.87%, 95% confidence interval 1.99, 5.75, I2 = 0%). Interventions targeting screen time did not yield changes in physical activity or sleep. The findings on the effectiveness of sleep interventions on non-targeted behaviours and of physical activity interventions on sleep were inconclusive.

CONCLUSIONS

Overall, the findings suggested that interventions aimed at increasing physical activity or reducing sedentary behaviour had overflow effects on non-targeted behaviours, but the effect sizes were small. Additional evidence is needed to reach definitive conclusions regarding the impact of behaviour change interventions on sleep and of the overflow effects of sleep interventions.

The Effect of Prebedtime Behaviors on Sleep Duration and Quality in Children: Protocol for a Randomized Crossover Trial

BACKGROUND

It is recommended that children should avoid eating dinner, being physically active, or using screens in the hour before bed to ensure good sleep health. However, the evidence base behind these guidelines is weak and limited to cross-sectional studies using questionnaires.

OBJECTIVE

The aim of this randomized crossover trial was to use objective measures to experimentally determine whether recommendations to improve sleep by banning electronic media, physical activity, or food intake in the hour before bed, impact sleep quantity and quality in the youth.

METHODS

After a baseline week to assess usual behavior, 72 children (10-14.9 years old) will be randomized to four conditions, which are (1) avoid all 3 behaviors, (2) use screens for at least 30 minutes, (3) be physically active for at least 30 minutes, and (4) eat a large meal, during the hour before bed on days 5 to 7 of weeks 2 to 5. Families can choose which days of the week they undertake the intervention, but they must be the same days for each intervention week. Guidance on how to undertake each intervention will be provided. Interventions will only be undertaken during the school term to avoid known changes in sleep during school holidays. Intervention adherence and shuteye latency (time from getting into bed until attempting sleep) will be measured by wearable and stationary PatrolEyes video cameras (StuntCams). Sleep (total sleep time, sleep onset, and wake after sleep onset) will be measured using actigraphy (baseline, days 5 to 7 of each intervention week). Mixed effects regression models with a random effect for participants will be used to estimate mean differences (95% CI) for conditions 2 to 4 compared with condition 1.

RESULTS

Recruitment started in March 2024, and is anticipated to finish in April 2025. Following data analysis, we expect that results will be available later in 2026.

CONCLUSIONS

Using objective measures, we will be able to establish if causal relationships exist between prebedtime behaviors and sleep in children. Such information is critical to ensure appropriate and achievable sleep guidelines.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12624000206527; https://tinyurl.com/3kcjmfnj.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63692.

Parental views on their children's smartphone use during personal and relational activities

Given the negative outcomes associated with smartphone use during personal and relational activities (SUPRA), parents strive to regulate its use among their children. However, media parenting recommendations lack knowledge of parental views on SUPRA and their relative occurrence in youths. This study aimed to (i) estimate SUPRA frequency among children and adolescents, (ii) assess parental dislike (PD) of SUPRA, and (iii) identify predictors of PD of SUPRA. An online survey was completed by 826 parents (49% mothers, age 25-74, Median = 43 years), capturing PD of SUPRA, estimated frequency of SUPRA in their children (49% female, age 6-18, Median = 10 years), parenting styles (warmth and control), parental attitudes toward screen media, and sociodemographic characteristics. The rate of frequent SUPRA was significantly higher in adolescents (2.7-48.1%) compared to children (2.1-27.2%) with odds ratios ranging from 0.67 to 3.04, depending on the activity type. PD of SUPRA was high in parents of children (M = 4.04, SD = 0.66) and adolescents (M = 3.93, SD = 0.71). Linear regression identified being a mother, having higher levels of control and warmth, and less positive attitudes toward screen media as significant predictors of SUPRA dislike. Our study was the first to report the estimated occurrence and parental dislike of smartphone use (SU) during various personal and relational activities, enabling their direct comparison. Experts warn against SU while studying and at bedtime, which frequently occurred in 4-5% of children and 10-12% of adolescents. More attention should be paid to SU during relational (peer/family) activities due to its relatively high occurrence and parental dissatisfaction.

The impact of screen use on sleep health across the lifespan: A National Sleep Foundation consensus statement

OBJECTIVE

To achieve consensus on whether screen-based digital media (1) in general, (2) via prebedtime content, and (3) via prebedtime light impairs sleep health in (a) childhood, (b) adolescence, and (c) adulthood. Furthermore, to address whether employing behavioral strategies and interventions may reduce the potential negative effects of screens on sleep health.

METHODS

The National Sleep Foundation convened a 16-person multidisciplinary expert panel ("Panel"). Panelists met virtually 5 times throughout 2023, during which they followed a modified Delphi RAND/UCLA Appropriateness Method to reach consensus.

RESULTS

The Panel conducted a literature review starting with 2209 articles, narrowed down to 522 relevant empirical articles and 52 relevant review articles. The search was refined to include 35 experimental/intervention studies that examined whether there was a causal link between screen-based digital media and sleep. In addition, panelists reviewed 5 recent relevant systematic review articles. After reviewing the summarized current literature, panelists voted on 10 candidate statements about whether screen use impairs sleep health. The Panel met virtually to discuss the results of the first round of votes, which was then followed by a second round of voting, ultimately achieving consensus on 5 out of the 10 statements.

CONCLUSIONS

The Panel achieved consensus that (1) in general, screen use impairs sleep health among children and adolescents, (2) the content of screen use before sleep impairs sleep health of children and adolescents, and (3) behavioral strategies and interventions may attenuate the negative effects of screen use on sleep health.

Daily Activities in European Children and Adolescents During COVID-19 School Closure: A Longitudinal Study Exploring Physical Activity, Use of Screens, and Sleep Patterns

This longitudinal study aimed to analyze the evolution of patterns of daily activities (physical activity time, screen usage time, and sleep hours) in European youth during school closure due to the COVID-19 health crisis. Participants were 624 caregivers of children and adolescents aged 3-18 from Italy, Spain, and Portugal. Evaluations were online, and four time-points were considered: retrospective measurement of daily activities before confinement (T1), and two (T2), five (T3), and eight (T4) weeks after starting the lockdown. Generally accepted international guidelines on physical activity time, screen usage time, and hours of sleep by age group were used to determine whether the pattern might increase the risk for ill health or not. To estimate the evolution of daily activities, generalized estimating equations (GEE) were used. The percentage of children who practiced less than 60 min of daily exercise increased significantly from before home confinement (47.8%) to T2 (86.4%); it slightly decreased at T3 (79.8%), and remained stable at T4 (76.1%). The percentage of children who made excessive use of screens (according to their age group) significantly increased from T1 to T2 and remained stable and high in the rest of the evaluations. The percentage of children who slept fewer or more hours than recommended for their age group remained stable between T1 and T4, although there was a significant increase at T3. In general, results found unhealthier behaviors as confinement was extended. Results are discussed in order to find strategies for promoting healthy daily activities for future pandemics.

The role of sleep in prospective associations between parent reported youth screen media activity and behavioral health

BACKGROUND

Screen media activity (SMA) can negatively affect youth behavioral health. Sleep may mediate this association but has not been previously explored. We examined whether sleep mediated the association between SMA and youth behavioral health among a community sample.

METHOD

Parents completed questions about their child (N = 564) ages 3-17 at Wave 1, Wave 2 (4-8 months later), and Wave 3 (12 months later). Path analyses were conducted to examine links between Wave 1 SMA and Wave 3 behavioral health problems (i.e., internalizing, externalizing, attention, peer problems) through Wave 2 sleep disturbance and duration.

RESULTS

SMA was significantly associated with greater sleep disturbance, β = .11, 95% CI [.01, .21] and shorter sleep duration, β = -.16 [-.25, -.06], and greater sleep disturbance was associated with worse youth behavioral health across internalizing, β = .14 [.04, .24], externalizing, B = .23 [.12, .33], attention, β = .24 [.15, .34], and peer problems, β = .25 [.15, .35]. Longer sleep duration was associated with more externalizing, β = .13 [.04, .21], and attention problems, β = .12 [.02, .22], and fewer peer problems, β = -.09 [-.17, -.01], but not with internalizing problems. Lastly, there was a direct effect of SMA on peer problems, β = -.15 [-.23, -.06] such that higher SMA that does not impact sleep may have a positive impact on reducing peer problems.

CONCLUSIONS

Sleep (i.e., disturbances and shorter duration) may partially account for the small associations observed between SMA and worse behavioral health in youth. To continue expanding our understanding, future research should utilize more diverse representative samples, use objective measures of SMA and sleep, and examine other relevant aspects of SMA, including content, device type, and timing of use.

Managing Screen Use in the Under-Fives: Recommendations for Parenting Intervention Development

The impact of excessive screen use on children's health and development is a public health concern and many countries have published recommendations to limit and guide the use of screen media in childhood. Despite this, international studies report that the majority of parents and children do not adhere to screen use recommendations. Existing research aiming to understand children' screen use has largely focused on older children, and on demographic and structural aspects of the child's environment. Parents play a central role in determining young children's screen use and identify numerous barriers to developing healthy screen use practices with their children. However, no clear models exist that incorporate key parenting factors in understanding children's screen use, which presents an impediment to intervention development. Likewise, while some evidence exists for interventions to improve children's screen use behaviours, most are focused on older children and parental involvement has generally been limited. In this paper, we overview key factors associated with screen use in young children (< 5 years) and summarise the existing evidence base for interventions designed to support healthy screen use. This paper proposes a conceptual model linking aspects of parenting and the socio-ecological environment to young children's screen use. Our proposed model could be used to design longitudinal studies of screen use predictors and outcomes, and inform intervention development. Finally, the paper provides key recommendations for future research, intervention development and testing.

Media Parenting Scale for School-Aged Children (MEPA-20): Psychometric Properties of the Turkish Version

BACKGROUND AND PURPOSE

Media parenting refers to the strategies and behaviors parents use to interact with their children regarding the amount, content, and context of screen use. Children's media/screen use is a significant indicator of media parenting practices. Therefore, this study aimed to determine the psychometric properties of the Turkish version of the Media Parenting Scale for School-Aged Children (MEPA-20).

METHODS

This methodological study involved 524 parents with children aged 6-10 and was conducted between October 15, 2022, and February 15, 2023. In the data analysis, the Content Validity Index, Explanatory and Confirmatory Factor Analyses, Cronbach's alpha, Test-retest reliability, Hotelling T2 test, and item-total score correlation were used. The test-retest reliability analysis of the Turkish version of MEPA-20 was performed with 30 parents after 4 weeks.

RESULTS

MEPA-20 consists of 20 items and three sub-dimensions (active, restrictive, and over-protective mediation). The MEPA-20 Turkish version and its three factors were found to indicate acceptable levels of internal consistency and reliability. The three-factor construct validity of the MEPA-20 Turkish version determined with Explanatory Factor Analyses was successfully confirmed with Confirmatory Factor Analysis.

CONCLUSION

The MEPA-20 is a valid and reliable tool for assessing the media parenting practices of parents of children aged 6-10 years in the Turkish population.

PRACTICE IMPLICATIONS

Based on the impact of media parenting practices on child and family health, nurses should raise awareness and support parents regarding children's healthy screen use.

Screen time and health issues in Chinese school-aged children and adolescents: a systematic review and meta-analysis

BACKGROUNDS

Many literature reviews summarized relationships between screen time and child health, but they only included a few studies conducted in Chinese children and adolescents. The potential influence of screen time may vary by social context. The current systematic review and meta-analysis aimed to evaluate relationships between screen time and health issues among Chinese school-aged children and adolescents.

METHODS

Peer-reviewed articles written in Chinese and English were retrieved from CNKI, Wanfang, PubMed, Embase, and Web of Science from inception to June 2020. The Downs & Black checklist was applied to assess study quality. Meta analyses used random effect models and mixed effects model to calculate pooled adjusted odds ratios and 95% confidence intervals. Heterogeneity, sensitivity, and publication bias were assessed using Q and I2 statistics, "one-study removed" analysis, the funnel plot, trim and fill analysis, and classical fail-safe N, respectively.

RESULTS

In total, we identified 252 articles reporting 268 studies with unique samples. These studies investigated relationships between screen time and health issues of adiposity, myopia, psycho-behavioral problems, poor academic performance, cardiometabolic disease risks, sleep disorder, poor physical fitness, musculoskeletal injury, sub-health, and miscellaneous issues of height and pubertal growth, injury, sick leave, and respiratory symptoms. Proportions of studies reporting positive relationships with screen time were lowest in adiposity (50.6%) and higher in myopia (59.2%) and psycho-behavioral problems (81.8%). Other health issues were examined in 10 or less studies, all of which had more than half showing positive relationships. The pooled odds ratio from 19 studies comparing health risks with the screen time cutoff of 2 hours per day was 1.40 (95% CI: 1.31 to 1.50, I2 = 85.9%). The pooled effect size was 1.29 (95% CI: 1.20 to 1.39) after trimming 7 studies for publication bias adjustments.

CONCLUSIONS

Findings exclusively generated from Chinese school-aged children and adolescents resonate those mainly from western countries. Evidence suggests that higher levels of screen time are related with greater risks of various health issues, although the relationships appear to be weak and intertwined with other confounding factors. Future studies need to investigate health-specific dose effects and mechanisms of screen time.

Effect of screen time intervention on obesity among children and adolescent: A meta-analysis of randomized controlled studies

Several studies have investigated the effect of screen time interventions on obesity in children and adolescents, but the existing results were controversial. This study aimed to analyze the effect of screen time intervention on obesity in children and adolescents. PubMed, Cochrane, Web of Science, Embase databases were searched through December 2020 to identify publications meeting a priori inclusion criteria and references in the published articles were also reviewed. Finally, 14 randomized controlled trials and 1894 subjects were included in this meta-analysis. The results showed that interventions targeting screen time are effective in reducing total screen time (MD: -6.90 h/week, 95% CI: [-9.19 to -4.60], p < 0.001) and television time (MD: -6.17 h/week, 95% CI: [-10.70 to -1.65], p < 0.001) in children and adolescents. However, there was no significant difference between the intervention and control groups in body mass index and body mass index-z score. In conclusion, there is no evidence that screen time interventions alone can decrease obesity risk in children and adolescents, though they can effectively reduce screen time.

Feasibility of two screen media reduction interventions: Results from the SCREENS pilot trial

Background

Advancements in screen media devices has transformed the way families engage with screen media. Although these modern devices offer many opportunities, e.g. communication and research online, an in-depth understanding of how these devices affect our health, is lacking. Before a definite randomized controlled trial, the SCREENS pilot study was conducted to assess compliance to and feasibility of two interventions, a measurement protocol, and a survey-based recruitment strategy. Also, the potential of the interventions to impact leisure time spent non-sedentary in children six-to-ten years of age was explored.

Methods

Families (N = 12) were recruited through a population-based survey sent out in October of 2018 to adults (N = 1,675) in the Municipality of Middelfart, Denmark. Families were randomized to one of two two-week interventions; an Evening Restriction intervention (no screen media use after six pm) and a General Restrict intervention (limit entertainment-based screen media to three hours/week/person). Intervention compliance was assessed objectively by measuring household TV usage, smartphone and tablet activity via an application, and via screen media diaries. During baseline and follow-up, as part of larger protocol, family members wore two triaxial accelerometers for seven consecutive days. The potential of the interventions to impact non-sedentary time was explored based on means and standard errors (SEs).

Results

Despite almost 85% and 75% reductions in leisure screen media use 0% and 50% of families were compliant in the Evening Restrict group and General Restrict group, respectively, based on strict a priori criteria. Participant feedback indicated that the General Restrict intervention generally was feasibly. Compliance to the accelerometry wear protocol was high (median non-wear was <1 hour/week). Moreover, the recruitment strategy was implemented and was feasible. The General restrict intervention might increase children’s non-sedentary time (mean (SE): 36.6 (23) min/day, N = 6).

Conclusions

The General Restriction intervention, the accelerometer wear protocol and recruitment strategy, appeared feasible.

Trial registration

NCT03788525 at https://clinicaltrials.gov [Retrospectively registered; 27^th of December, 2018].

Identifying effective intervention strategies to reduce children's screen time: a systematic review and meta-analysis

BACKGROUND

Excessive screen time ([Formula: see text] 2 h per day) is associated with childhood overweight and obesity, physical inactivity, increased sedentary time, unfavorable dietary behaviors, and disrupted sleep. Previous reviews suggest intervening on screen time is associated with reductions in screen time and improvements in other obesogenic behaviors. However, it is unclear what study characteristics and behavior change techniques are potential mechanisms underlying the effectiveness of behavioral interventions. The purpose of this meta-analysis was to identify the behavior change techniques and study characteristics associated with effectiveness in behavioral interventions to reduce children's (0-18 years) screen time.

METHODS

A literature search of four databases (Ebscohost, Web of Science, EMBASE, and PubMed) was executed between January and February 2020 and updated during July 2021. Behavioral interventions targeting reductions in children's (0-18 years) screen time were included. Information on study characteristics (e.g., sample size, duration) and behavior change techniques (e.g., information, goal-setting) were extracted. Data on randomization, allocation concealment, and blinding was extracted and used to assess risk of bias. Meta-regressions were used to explore whether intervention effectiveness was associated with the presence of behavior change techniques and study characteristics.

RESULTS

The search identified 15,529 articles, of which 10,714 were screened for relevancy and 680 were retained for full-text screening. Of these, 204 studies provided quantitative data in the meta-analysis. The overall summary of random effects showed a small, beneficial impact of screen time interventions compared to controls (SDM = 0.116, 95CI 0.08 to 0.15). Inclusion of the Goals, Feedback, and Planning behavioral techniques were associated with a positive impact on intervention effectiveness (SDM = 0.145, 95CI 0.11 to 0.18). Interventions with smaller sample sizes (n < 95) delivered over short durations (< 52 weeks) were associated with larger effects compared to studies with larger sample sizes delivered over longer durations. In the presence of the Goals, Feedback, and Planning behavioral techniques, intervention effectiveness diminished as sample size increased.

CONCLUSIONS

Both intervention content and context are important to consider when designing interventions to reduce children's screen time. As interventions are scaled, determining the active ingredients to optimize interventions along the translational continuum will be crucial to maximize reductions in children's screen time.

Does physical activity moderate the association between screen time and psychosocial development in early childhood? Analysis of a longitudinal infant cohort study in Ireland

The objective of this study was to explore the extent to which the association between screen time and psychosocial development in preschool children differed between the sexes and according to their frequency of engagement in physical activity. Data are based on a prospective cohort of Irish children, collected between 2010 and 2013 when children were ages 3 (n=9786) and 5 years (n=9001). Children's screen time (h/day), psychosocial development (Strengths and Difficulties Questionnaire), and physical activity (bouts/week) were assessed via caregiver report. The magnitude of the association between screen time and changes in behavioural difficulties differed significantly between the sexes. For boys, the association between increased screen time and the onset of behavioural problems coincided directly with a reduction in their frequency of engagement in physical activity. The association between screen time and changes in behavioural difficulties was not moderated by girls' engagement in physical activity, however; and there was no difference in the association between screen time and prosocial behaviours at different frequencies of engagement in physical activity for either boys or girls.Conclusions: Results support recommendations to establish greater balance between physical activity and sedentary behaviours in token economy systems to minimise the negative effects of excessive screen time. What is Known: • Provision of screen time has become normalised as a behavioural reinforcer for use with young children. • Screen viewing above recommended guidelines is associated with behavioural problems that reflect poor self-regulation. What is New: • Boys' levels of engagement in physical activity moderated the relationship between screen time and changes in behavioural difficulties between the ages of 3 and 5 years. • Neither screen time nor physical activity was significantly associated with changes in prosocial behaviours between the ages of 3 and 5 years for either boys or girls.

SODA MAPS: A Framework for Understanding Caffeinated Sugary Drink Consumption Among Children

Excess sugary drink (SD) consumption is associated with childhood obesity and development of cardiometabolic disease. In addition to having high added sugar content, many SDs also contain caffeine, which may further encourage excess SD consumption among children. The objective of this study was to develop a conceptual framework of children's caffeinated SD consumption using group concept mapping, an applied social research multimethodology that collectively harnesses qualitative and quantitative data from participants to generate a visual representation of their ideas and input. Children, 8–14 years old, who reported consuming ≥12 ounces of caffeinated SDs (e.g., sodas, sweet teas) per day were recruited throughout Washington, D.C. and invited to participate. Concept mapping included three participant-driven activities: (1) brainstorming (n = 51), during which children reported reasons for their SD consumption, from which 58 unique reasons were identified; (2) sorting (n = 70), during which children sorted each of the reported reasons into categories and named each category; and (3) rating (n = 74), during which children rated the influence of each reason on their own caffeinated SD consumption. Similarity matrices, multidimensional scaling, and hierarchical cluster analysis were used to generate concept maps (hereafter “SODA MAPS”), which display the 58 reasons organized within eight overarching clusters. Among these eight clusters, Taste and Feel, Something to Do, and Energy were rated as particularly influential. Children's caffeinated SD consumption is encouraged not only by the palatable taste and reported preferences for these beverages (e.g., Taste and Feel), but also by psychological (e.g., Mood and Focus), biological (e.g., Energy), social (e.g., Something to Do) and environmental reasons (e.g., Nothing Better Available). Thus, the SODA MAPS can inform the development of tailored, multi-level SD reduction interventions that incorporate strategies to address important and currently overlooked reasons for caffeinated SD consumption among children.

Digital media, book reading, and aspects of sleep and sleep-related fears in preschoolers: the Ulm SPATZ Health Study

Background

High levels of digital media use with screen-based devices has been found to threaten several aspects of child and adolescent health. However, the rapid change in digital media use behavior in our society over the past decade has rendered much of the existing evidence outdated.

Materials and methods

The present work reports data ascertained from 2016 to 2019 on preschoolers’ digital media use and book reading among 4‑ to 6‑year-old children from the longitudinal Ulm SPATZ Health Study. These data are supplemented by exploring the association of child digital media use and book reading with aspects of children’s sleep and sleep-related fears.

Results

After data management, 581 children participated at the age of 4 years. At the ages of 5 and 6 years, data were available for 508 and 426 participants, respectively. Median age of the mothers was 33 years (range 21–54) and 70% had graduated from high school. Most time spent using digital media was represented by passive activities in front of a screen. Time spent using digital media increased with children’s age. An increased risk of the fear of sleeping alone (RR: 1.35, [95% CI: 1.07; 1.70]) and fear of the dark (1.47 [95% CI 1.16; 1.87]) was documented for exposure to “all media” higher than the median as compared to lower levels. Exposure to “books” above the median and compared to lower levels was tentatively associated with a relevant 18% reduction in the risk of both fear of sleeping alone and fear of the dark (0.82 [95% CI 0.65; 1.03] and 0.82 [95% CI 0.64; 1.05], respectively).

Conclusion

Our results suggest that reducing time spent using digital media and potentially substituting this time by reading books, which seem to be a safe alternative, is a valid solution to reduce some common aspects of poor sleep in preschoolers.

Perceived Determinants of Children's Inadequate Sleep Health. A Concept Mapping Study among Professionals

An increasing number of children experience inadequate sleep, which negatively effects their health. To promote healthy sleep among children, it is essential to understand the underlying determinants. This online concept mapping study therefore explores potential determinants of children’s inadequate sleep as perceived by professionals with expertise in the sleep health of children aged 4–12 years. Participants (n = 27) were divided in three groups: (1) doctors (n = 9); (2) nurses (n = 11); (3) sleep experts (n = 7). Participants generated potential determinants (i.e., ideas) of children’s inadequate sleep. Subsequently, they sorted all ideas by relatedness and rated their importance. These data were analysed using multidimensional scaling and hierarchical cluster analysis. The results of all three groups were combined and validated by an additional group of professionals (n = 16). A large variety of perceived determinants were identified. The most important determinants perceived by all groups belonged to the categories psychosocial determinants (i.e., worrying, a change in daily life), daytime and evening activities (i.e., screen use before bedtime, stimulating game play before bedtime, inadequate amount of daytime physical activity), and pedagogical determinants (i.e., inconsistent sleep schedule, lack of a bedtime routine). These perspectives are valuable for future longitudinal studies on the determinants of children’s sleep and the development of future healthy sleep interventions.