Digital Device Use Rampant Among Preschoolers

Pam Harrison

May 11, 2018

TORONTO — More than 90% of toddlers younger than 3 years interact with at least one digital device at home, new research shows.

Although the cumulative time spent with those devices over the course of a day has not been precisely determined, the duration of an individual session and the frequency of those sessions suggests that toddlers are spending far more time than is recommended by the American Academy of Pediatrics (AAP) for a healthy "media diet."

"In our clinics, we see a lot of children coming in with devices," said Ruth Milanaik, DO, director of the neonatal follow-up program at the Cohen Children's Medical Center in New York City.

We should ask whether the device is being used to keep a child occupied in a stressful situation, like a physician's office, or whether it is a regular occurrence, she told Medscape Medical News.

When she and her team asked parents how often children are using these devices and how many different devices are they using, "we found there was an alarming tendency for a cumulative digital device usage time far higher than current recommendations," Milanaik reported here at the Pediatric Academic Societies 2018 Meeting.

In 2016, the AAP revised its policy on a healthy media diet, recommending that no child younger than 18 months be exposed to any type of screen media other than video chatting, as reported by Medscape Medical News.

We found there was an alarming tendency for a cumulative digital device usage time far higher than current recommendations.

After that, parents are advised to introduce high-quality programming that they can "cowatch" with children 18 to 24 months of age. No specific time was set for this by the AAP, but Milanaik said she recommends that parents keep it under 30 minutes a day.

Children 2 to 5 years of age should be restricted to less than an hour a day of high-quality programming, again cowatched with a parent.

For their study, Milanaik and her colleagues distributed a survey on Amazon Mechanical Turk. They received anonymous responses from 637 parents of children younger than 3 years (mean age, 29.7 months).

The survey asked about the types of digital devices in the home, the types of devices used by the child, the frequency of use, and the duration of each session with a digital device.

Close to three-quarters of the respondents reported that their child watched television, and almost half of those watched TV multiple times a day.

And 71% of respondents reported tablet use, with about 30% reporting use multiple times a day.

About half of the children used a smartphone, and about one-quarter used it multiple times a day.

Only about 10% of children used a laptop or a desktop computer, and about 15% used a gaming system. However, a not inconsequential proportion of respondents reported use of these devices multiple times a day.

Although very few children used any device for more than 3 hours a day, 1 to 2 hours a day was relatively common.

Table. Duration of Session for Each Digital Device

Device 1–30 Minutes, % 30–60 Minutes, % 60–120 Minutes, % 120–180 Minutes, %
Television 15.9 30.0 28.8 13.8
Laptop 50.0 26.1 13.0 6.5
Desktop computer 40.0 20.9 16.3 16.3
Tablet 34.5 28.6 21.8 10.5
Smartphone 67.1 15.2 11.0 3.0
Gaming system 45.1 28.2 11.3 5.6


Proficiency of Use

"We also asked questions about their independence in using these devices," said investigator Heejin Lim, a medical student at the Cohen Children's Medical Center.

"We asked if the child could unlock the tablet, get to different apps. If they opened up a computer, we asked if they could get to their favorite websites by themselves and whether they could turn on the TV by themselves," she told Medscape Medical News.

The majority of children could do all of these things, Lim noted.

What parents and physicians really need to know is how much cumulative time the children are spending with digital devices, Milanaik pointed out.

"If a child watches a TV show for 25 minutes, plays a game on an iPad for another 25 minutes, and then watches more TV later, that all adds up. This is something that needs to be addressed by the AAP, because how it all adds up is our main concern," she explained.

The investigators would like any future AAP guidelines to specify what high-quality programming is, not just for TV, which is the focus of the current guidelines, but for programs that run on tablets, which are almost as common as TV shows, Lim explained.

"The AAP needs to elaborate on the kinds of apps and videos children can watch as well, and they need to emphasize that parents should limit the cumulative amount of time a child spends with digital devices," she added. And pediatricians should start talking to parents seriously about the possible adverse consequences that time spent with digital devices can have on a young child.

Not Good for Kids

Evidence to suggest that too much time spent interacting with digital devices is not good for children was also presented at the meeting.

Results from the first study of its kind designed to look at the effects that the presentation of a story has on functional brain networks in preschool-aged children were reported by John Hutton, MD, from the Cincinnati Children's Hospital Reading and Literacy Discovery Center.

The investigators presented three stories, in three different formats, by Robert Munsch — all narrated by the same person — while 27 children (mean age, 57 months) underwent functional MRI. All presentations were 5 minutes long.

During the audio presentation, the children listened through headphones but saw no visuals. During the illustrated presentation, the children saw pictures displayed on a mirror above them while they listened to the audio through headphones. During the animated presentation, the children were exposed to straight animation of a picture book on a digital device.

"This is the age when kids are not reading yet but they are being read to. We wanted to get a sense whether there are any differences in how their brains process the story through those different formats," Hutton told Medscape Medical News.

The investigators were aware that different story formats would likely influence different parts of the brain. These include the language network; the visual perception network, or the seeing part of the brain; the visual imagery network, which is a higher-order visual network that takes images from memory and imagines them in the mind's eye; and the default mode network, which is involved with self-referential processing. The cerebellum helps children learn all types of skills, including language skills.

Comprehension rates were similar when children were presented with the audio and illustrated formats (81% vs 70%). However, rates dropped to 50% with the animated presentation.

There were differences in the functional connectivity for the three formats, which is a measure of how well synchronized areas within these networks are and how well the networks connect with each other.

When the illustrated format was compared with the audio format, "there was this nice positive increased connectivity, which was statistically significant," Hutton reported.

Specifically, there was a 55% increase in functional connectivity between the visual perception network, the default mode network, and the imagery network, with the cerebellum helping out.

"Paradoxically, we observed decreased connectivity within the language network, which doesn't reflect less engagement of the language network, but rather the fact that the pictures are providing a scaffolding. Children are seeing the picture and then brain networks involved in imagery are activated to help bring that story to life in their mind, and that makes it easier for the language network to understand what's going on," Hutton explained. This is the reason children of this age like picture books — they need a visual anchor to help them understand what's going on.

In contrast, when the animated format was compared with the audio format, there was less visual integration. In fact, there was a 78% drop in functional connectivity between the visual perception and language networks.

"You don't get that nice integration of visual language networks that you get with illustration. It's almost like the networks stop talking to each other, so animation does not provide the same level of constructive scaffolding in the brain, where the child can do their own work to figure out what is going on in the story," Hutton pointed out.

When the effect of the animation format was compared with the illustrated format, there was a dramatic decrease in the connectivity of all of the networks with one another.

In other words, with the animated format, there is less integration of imagery with the default mode network and none of the same scaffolding for the language network, he said. In addition, the cerebellum does not help children figure out what's going on.

"It's almost like these networks pull apart," Hutton explained.

When the animated format was compared with the illustrated format, the decrease in functional connectivity was 33% (mean, 19% - 82%).

"We think this reflects less effective visual scaffolding in the animated state, compared with the illustrated state, so animation is more about processing the audio and visual stimuli — taking it all in — than about using the imagination to figure it all out," he explained.

If children are not getting practice using their imaginations — their visual imagery skills — then the networks involved will be less likely to integrate and grow. This means that "when children are transitioning from picture books to books without pictures, it's possible they may be less able to use their imagination to figure out what's going on in stories," he concluded.

It is no surprise that digital device use in the home is so ubiquitous among toddlers, said Suzy Tomopoulos, MD, from Hassenfeld Children's Hospital at NYU Langone in New York City.

"Recent data suggest that over 40% of children between 0 and 8 years of age have their own tablets, and older children are using their devices 6 to 8 hours a day," she told Medscape Medical News.

This is not optimal for healthy brain development. It is during their earliest years that significant pruning of the brain's synapses takes place and important connections are made.

"When everyone is on their devices, children lose out on the quality and quantity of interactions they have with their parents," Tomopoulos added.

They are also losing out on the verbal stimulation that children need to develop language skills and, later on, school readiness. Once developmentally delayed, children, for the most part, are going to stay developmentally delayed, especially if they are poor, she explained.

"What concerns me about the high prevalence of use of these devices in the home is that it's impacting day-to-day interactions — playing and reading and talking to your child — all of which are so important in the first few years of life," Tomopoulos said.

Milanaik, Lim, Hutton, and Tomopoulos have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2018 Meeting. Presented May 5 and May 6, 2018.

Follow Medscape Pediatrics on Twitter @MedscapePeds


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.