Moving From Child Advocacy to Evidence-Based Care for Digital Natives

Pediatricians,^1,2 psychologists,³ and other health professionals⁴ have long cautioned about the physical and mental health effects of children’s media use. Parents have also been concerned; however, on the whole, they have been slow to respond to potential risks. The immediate practical advantages and believed educational benefits of entertaining children with screen media often override any long-term harm that many feel does not apply to their children.

Parents rely on the expertise of child development and health professionals to guide their child-rearing decisions. Pediatricians deserve credit for voicing early concern about media influences; however, in our zeal to advocate for children, we have largely ignored the positive effects of using media, mismanaged the public discourse, and lost the ear of many whom we serve. With the rapid spread of television in the 1950s, Congress solicited testimony⁵ on television’s effects on children from health professionals and media producers, balancing clinicians’ empirical observations against the perspectives of a major growth industry—entertainment. Without scientific evidence supporting reasons for concern, the discourse was framed as differing opinions and the First Amendment prevailed. A values-based polarization between those concerned for the physical, mental, and social health of our children and those protecting our freedom of expression has persisted to this day. In light of the behavioral and social evolution wrought by the digital revolution, it is time to reexamine this paradigm.

Over the intervening 6 decades, research conducted in more than a dozen disciplines⁶ has built a large and growing body of scientific evidence⁷ that media exposure can influence leading causes of morbidity and mortality among children and adolescents including obesity,⁸ substance use,^9,10 aggression,¹¹ and risk-taking behaviors.^12,13 Unfortunately, child advocates have sometimes overreached the data, making extreme cautionary recommendations vulnerable to being dismissed as moral panic by industry apologists and academics building careers on contrarianism. Because the popular press tries to balance reporting, the public may perceive that experts are divided. Important discussions on how media affect children, occurring from living rooms to congressional hearing rooms, are stalemated.

Children now spend more time with media than they do with parents, teachers, or any other influence.¹⁴ We can no longer afford to guide children’s media use based on values or opinions. Evidence-based decision making, which we practice in medicine and encourage in parenting, must be brought to bear on choices about the media that children use and the way that they use them.

Findings reported in this issue can help pediatricians, parents, educators, and others who care for children to move beyond opinion to consciously guide children’s media use toward healthy outcomes. The remarkable consistency of findings from Australia, China, Singapore, 8 different European countries, and the United States demonstrates that links between media exposure and children’s developmental and health outcomes are universal; media have globalized the psychosocial environments in which children are growing up. Testing long-standing empirical concerns among a cohort of European children, Hinkley et al¹⁵ found that greater durations of television viewing were associated with poorer psychological and social outcomes. Gilbert-Diamond et al¹⁶ moved beyond established correlations between television viewing and body weight to find that a television in a child’s bedroom increased the risk for childhood obesity, over and above their total screen time. Bernhardt et al¹⁷ found deceptive advertising of fast food to children that calls into question the reliability of public regulation.

Sleep, which is so important to healthy growth and development, was studied longitudinally by research groups in Spain and Australia. Even without data on televisions in bedrooms, Marinelli et al¹⁸ found a clear displacement effect of television watching, both cross-sectionally and over time, with children’s sleep durations varying inversely with their hours of television watching. In a 3-wave panel study of children at 4, 6, and 8 years of age, Magee et al¹⁹ found cross-sectional and longitudinal associations between durations of screen media use and sleep, such that increased screen time at younger ages predicted decreased sleep at older ages and decreased sleep at younger ages predicted increased media use at later ages. Like the circular relationship proposed for violent media and aggressive behavior,²⁰ it makes sense that children who sleep less because they have stimulated themselves with screen media might fill their sleepless hours in later years with more screen media.

A meta-analysis from van Geel et al²¹ investigated the research between 1910 and 2013, finding a significant association between peer victimization and subsequent suicidality. Cyberbullying, a phenomenon of the digital age, was a stronger predictor of suicidal ideation than traditional bullying. Gentile et al²² followed up more than 3000 schoolchildren in Singapore for more than 3 years, finding that those who played violent video games for greater time at wave 1 had increased aggressive cognitions at wave 2 and were more physically aggressive at wave 3, even when controlling for sex, age, and baseline level of aggression. Consistent with social cognitive theory,²³ these results suggest that violent game play teaches violent thinking, which, in turn, increases the likelihood of violent behavior.

Demonstrating that parental oversight of children’s media use can be protective, Tiberio et al²⁴ found maternal monitoring of media use to be associated with lower weight and rates of weight gain among school-aged children. Gentile et al²⁵ showed that active parental monitoring reduced not only total screen time and media violence exposure, but was associated with improved child health outcomes such as reduced aggressive behavior and improved sleep, school performance, and prosocial behavior.

Interactive screen media have significant potential for implementing interventions and building health literacy but must be used with caution. Addressing obesity using a popular entertainment technology that already has children’s interest and engagement, Trost et al²⁶ found significant increases in physical activity and greater reductions in overweight among children who were provided with active video games controlled by their body movement. Jiang et al²⁷ showed that sending short message service texts about healthy infant nutrition to first-time mothers resulted in longer durations of breastfeeding and later introduction of solid foods compared with peers who did not receive the texts. However, when Lewis et al²⁸ assessed the accuracy of information about deliberate self-harm that adolescents most commonly accessed online, they found that even health-information websites lacked credibility, with all of the sites propagating at least 1 inaccurate myth.

The diversity and rigor of these research articles will advance the discourse on how media affect children’s health and development—that is if clinicians, parents, and others who work with children are able to assess and apply their findings with the same critical perspectives we bring to other values-laden and controversial pediatric issues from circumcision to pain control. The prioritization of children, adolescents, and media in the American Academy of Pediatrics’ Agenda for Children offers an opportunity to evolve our efforts to understand and respond to media effects on children’s physical, mental, and social health. Parents have concerns about their children’s media use but know that media are not all bad. Screens are ever present in children’s lives. Media are neutral; it is what we do with them that helps or harms us. Media will not be censored by society or broadly restricted in most homes; however, we can use evidence to guide children’s media use to optimize their brain development and health and to shape their future society to be more aware, compassionate, and connected in meaningful ways.

To do so, we must implement more innovative methods²⁹ to studying what media children and adolescents use and the contexts and ways in which they use them. The media environment has changed and will continue to do so; we can no longer base research on self-reported television viewing. The effects of media multitasking, foreground-background exposures, and using mobile media are still largely unknown. We must approach media effects on health with less-biased research questions, investigating how media users are affected, positively as well as negatively, rather than focusing exclusively on harm. In this way, we can provide families more palatable (and adhered to) anticipatory guidance toward uses of media that are beneficial. We must standardize measures and accelerate the pace of research, reporting findings useful for parents making risk-benefit decisions about current media devices and content. For example, while arguments over what constitutes aggressive behavior can occupy scholars for decades, such academic minutiae matter little to mothers and fathers who need practical advice to raise healthy, happy, and productive children. Finally, we must accept that parents and society will apply scientific evidence in a variety of ways. Some will do anything to avoid increased risk, some may choose short-term benefit over long-term risk, and others will wait for incontrovertible proof of danger to change behavior. Most will fall somewhere along this risk-benefit continuum. As child health professionals, we must acquire accurate information on how media influence children; provide it to parents in nonjudgmental ways; and accept that, with our trusted advice, they will do the best that they can.