ARTICLE IN PRESS

ARTICLE

Screen Media Overuse and

Associated Physical,
Cognitive, and Emotional/
Behavioral Outcomes in
Children and Adolescents:
An Integrative Review
Jianghong Liu, PhD, RN, FAAN, Susan Riesch, PhD, RN, FAAN,
Joyce Tien, BA, Terri Lipman, PhD, CRNP, FAAN,
Jennifer Pinto-Martin, PhD, MPH, & Ann O’Sullivan, PhD, FAAN, CRNP

Introduction: Screen media overuse is seen as a public health con-

cern because of its negative effects on child and adolescent health.
This integrative literature review examines recent empirical evi-
Jianghong Liu, PhD, RN, FAAN, Professor of Nursing, Department
dence on the relationship between screen media overuse and physi-
of Family and Community Health, University of Pennsylvania
School of Nursing, Philadelphia, PA.
cal, cognitive, and emotional/behavioral outcomes in children and
adolescents.
Susan Riesch, Professor Emeritus, School of Nursing, University Methods: Empirical research of experimental design, observa-
of Wisconsin-Madison, Madison, WI. tional studies, and systematic reviews from several data sources
Joyce Tien, BA, University of Massachusetts Medical School, was reviewed and synthesized to form the basis of this integrative
Worcester, MA. review.
Terri Lipman, PhD, CRNP, FAAN, Professor of Nursing, Results: Screen media overuse is associated with poor sleep qual-
Department of Family and Community Health, University of ity, shorter sleep duration, greater likelihood for overweight/obe-
Pennsylvania School of Nursing, Philadelphia, PA. sity, lower executive functioning, poorer academic performance,
and increased internalizing and externalizing problems. Bidirec-
Jennifer Pinto-Martin, PhD, MPH, Proessor of Nursing,
tional associations may exist.
Department of Family and Community Health, University of
Pennsylvania School of Nursing, Philadelphia, PA. Discussion: Findings support the importance of understanding
the impact of screen media use on health and wellbeing. Generating
Ann O’Sullivan, PhD, FAAN, CRNP, Professor of Nursing, screen time guidelines and developing effective prevention/inter-
Department of Family and Community Health, University of
vention strategies are critical to mitigating screen media overuse
Pennsylvania School of Nursing, Philadelphia, PA.
and its adverse outcomes in children and families. J Pediatr Health
Conflicts of interest: None to report. Care. (2021) XX, 1−11
Correspondence: Jianghong Liu, PhD, RN, FAAN, Department of
Family and Community Health, University of Pennsylvania School KEY WORDS
of Nursing, Claire M. Fagin Hall Room 426, 418 Curie Blvd., Screen media overuse, sleep, obesity, cognition, internalizing/exter-
Philadelphia, PA, 19104; e-mail: jhliu@nursing.upenn.edu. nalizing, children/adolescents
J Pediatr Health Care. (2021) 00, 1−11
0891-5245/$36.00
Copyright © 2021 Published by Elsevier Inc. on behalf of National INTRODUCTION
Association of Pediatric Nurse Practitioners. In today’s digital age, the rising prevalence of screen media
https://doi.org/10.1016/j.pedhc.2021.06.003 use in the daily lives of children and adolescents is an

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increasingly important public health concern, with exposure METHODS

beginning as early as infancy (Kabali et al., 2015; Riesch EBSCO, Web of Science, PubMed, Google Scholar, and
et al., 2019; Trinh et al., 2020). The interactive ability, enter- Scopus databases were used to search for studies examining
tainment value, and increasing mobility of using devices the association between screen media overuse and physical,
such as television, phones, tablets, laptops, and computers, cognitive, and emotional/behavioral problems, using key-
have led to their rapid integration into the day-to-day lives words “screen media use” in combination with “sleep,”
of youth. In the past two decades, screen time among chil- “overweight/obesity,” “executive functioning,” and “inter-
dren aged 0−2 years have doubled (Chen & Adler, 2019). nalizing/externalizing.” All relevant articles, including exper-
Furthermore, 95% of adolescents report having access to imental research, cross-sectional and longitudinal
smartphones, a 22% increase in 3 years (Anderson & epidemiological studies, and systematic reviews, were
Jiang, 2018). Concerningly, 39% of children in the U.S. reviewed and synthesized in this integrative review.
report feeling addicted to their mobile devices, and 58% feel
distracted by their mobile devices at least once per day Association Between Screen Media Overuse and
(Robb, 2019). Although electronic devices have revolution- Associated Outcomes
ized learning, communication, and the dissemination of This section reviews empirical evidence on the association
information, recent data have suggested that screen media between screen media overuse and various associated out-
use may have significant negative repercussions on child and comes. A summary of key findings is reported in Table 1.
adolescent health in both the short and long term, rendering
this a pressing public health issue (Riesch et al., 2019). Nev-
Screen media overuse
ertheless, research on the effects of screen media overuse
Currently, there exists much debate surrounding the defini-
continues to lag behind the rate at which they are being
tion of screen media overuse. Most studies examine hours
adopted (Kabali et al., 2015; Radesky, Schumacher, & Zuck-
of use, with large variation in the conceptualization of “over-
erman, 2015; Liu et al., 2019).
use.” For example, some studies characterize “overuse” as 4
Given the adverse public health consequences linked
−6 hr/day for pre-adolescents and over 10 hr/day for ado-
with screen media overuse, understanding these associations
lescents (Parent, Sanders, & Forehand, 2016), whereas
is critical for the development of evidence-based guidelines
others have suggested 3 hr or more of electronic gaming
on creating a safe and healthy digital environmental for chil-
daily in children (Przybylski, 2014). Apart from duration of
dren and adolescents. The current literature review aims to
use, recent research is also investigating other measures of
comprehensively examine the empirical evidence on the rela-
overuse, including parental use (Robb, 2019), the number of
tionship between screen media overuse and its associations
electronic devices in the household (Chaput et al., 2014),
with physical (sleep problems and obesity), cognitive (execu-
and environment/timing/frequency of use (Huber, High-
tive functioning and academic performance), and emo-
field, & Kaufman, 2018; Moorman, Morgan, & Adams,
tional/behavioral factors (internalizing/externalizing
2019). Furthermore, the debate regarding screen media
problems) outcomes (Figure), as well as their potential
overuse may be more nuanced than simply examining the
mechanisms of action. Specific strategies and recommenda-
variables used to measure “overuse.” For example, the Royal
tions for research, policy, and practice to prevent screen
College of Paediatrics and Child Health’s recent screen time
media overuse problems in children and adolescents will
guidelines emphasize that the amount of use is not the issue;
also be addressed.
rather, it is the activities, such as sleep, exercise, and

FIGURE. Screen media overuse and associated outcomes.

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TABLE 1. Summary of key research findings on-screen media overuse and adverse outcomes
Physical Health Cognition Emotion/Behavior

Sleep Problems Overweight and Obesity Executive Functioning Academic Performance Internalizing Behavior Externalizing Behavior
SMO In infancy, SMO is associ- Screen time has strong, In childhood, SMO is In early childhood, SMO has In adolescents, SMO is Human studies have
ated with shorter sleep graded associated with negatively associated a lasting adverse impact linked to depression revealed mixed

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duration and increased adiposity and preva- with language devel- on classroom engage- and anxiety symptoms results regarding the
daytime sleepiness lence of overweight in opment and overall ment and academic SMO is also associ- association between
In childhood and adoles- childhood and adoles- executive functioning achievement ated with feelings of SMO and externaliz-
cence, SMO is associated cence In adolescence, SMO In adolescence, SMO is loneliness, lowered ing behaviors
with lowered sleep quan- Children who reduced is negatively associ- inversely associated with self-esteem, and wors- Preliminary animal
tity and quality their screen media use ated with working overall academic perfor- ened interpersonal studies have demon-
SMO and sleep problems saw significant reduc- memory, inhibition, mance relationships strated that SMO
may share a bidirectional tions in sedentary and task-shifting ability In young adulthood, SMO SMO and internalizing models produce
relationship, with shorter behavior as well as SMO and executive has inverse associations behavior may share a ADHD-like sympto-
sleep duration linked with slower increases in BMI functioning may share with college test perfor- bidirectional relation- mology
increased subsequent SMO and overweight/ a bidirectional relation- mance and GPA ship, with depression SMO and externaliz-
screen media use obesity may share a ship, with lower self- and anxiety linked with ing behavior may
bidirectional relationship, regulation/overall increased subsequent share a bidirectional
with obese children executive functioning screen media use relationship, with
more likely to engage in linked with increased impulsivity and atten-
greater screen media subsequent screen tion problems linked
use media use with increased sub-
sequent screen
media use

Note: SMO, screen media oversee; BMI, body mass index; GPA, grade point average; ADHD, attention deficit hyperactivity disorder.
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socializing, displaced by screen media use that is the cause global child and adolescent obesity epidemic (Communica-
for concern and should be further investigated. Taken tions & Media, 2011). In addition, epidemiological studies
together, the variability in the conceptualization of media have consistently demonstrated significant positive associa-
overuse suggests the lack of consensus on safe practices tions between screen media use and obesity. For example, a
with regard to screen media use. Given the wide range of recent United Kingdom cross-sectional study (N = 4,495)
measures, overuse is operationally defined in this review as using child self-report measures and objective measures of
screen media use that interferes with an individual’s daily physical activity, fasting cardiometabolic risk marker assess-
functioning and wellbeing as determined by physical, cogni- ments, and anthropometry measurements found strong,
tive, and emotional/behavioral problems. graded associations between screen time and adiposity
(Nightingale et al., 2017). This finding was consistent with
Physical Health Outcomes several previous cross-sectional studies in children from
Australia (Hesketh, Wake, Graham, & Waters, 2007;
Sleep problems Robinson, Daly, Ridgers, & Salmon, 2015), Denmark, Esto-
Adequate sleep is critical for children’s and adolescents’ nia, and Portugal (Ekelund et al., 2006). Longitudinal cohort
physical and psychosocial development (Liu, Glenn, Cui, & studies revealed similar results, indicating a strong, dose
Raine, 2021). However, according to the Centers for Disease −response relationship between television viewing time per
Control and Prevention, 57.8% and 72.7% of middle and day and the prevalence of overweight in children aged 10
high school students, respectively, in the U.S. report short −15 years (Robinson et al., 2017). However, several of these
sleep duration (Wheaton, Jones, Cooper, & Croft, 2018), studies did not adjust for race/ethnicity or socioeconomic
rendering insufficient sleep and other sleep problems a sig- status, key roles in overweight/obesity, potentially leading to
nificant public health issue. Screen media use is one vital fac- uncontrolled confounding (Wang & Zhang, 2006; Whitaker
tor that has long been associated with reduced sleep & Orzol, 2006).
duration and poor sleep quality (Riesch et al., 2019). These A few randomized controlled trials have found direct
effects have been broadly studied with consideration for the causal effects of reducing screen time in community settings
type, timing, content, environment, and duration of screen on reducing weight gain in children. For example, in a ran-
media use across infancy, childhood, and adolescence. A domized controlled school-based trial of elementary school
cross-sectional study of 715 infants and toddlers from the children, students in the intervention group received class-
United Kingdom reported that increased frequency of por- room lessons on reducing TV and video game over 6
table touchscreen device use was associated with reduced months. Although body mass index (BMI) increases were
sleep duration, longer sleep onset, and increased daytime observed in both groups over the school year, there were
sleepiness; with every hour of screen media use, nearly statistically significant decreases in TV viewing and signifi-
16 min of total sleep was lost per day (Cheung, Bedford, cantly slower relative increases in BMI in the intervention
Saez De Urabain, Karmiloff-Smith, & Smith, 2017). Longi- group (Robinson, 1999). A later study found that children
tudinal analyses of United States (Cespedes et al., 2014) and and families receiving screen time reduction interventions
Thai (Vijakkhana, Wilaisakditipakorn, Ruedeekhajorn, Pruk- demonstrated significant decreases in television viewing/
sananonda, & Chonchaiya, 2015) infants demonstrated simi- computer use and BMI compared with controls. These
lar results, with greater screen media exposure predictive of changes persisted for 2 years and were mediated by reduc-
7 and 28 min fewer total sleep per day, respectively. Among tions in dietary energy intake. Interestingly, TV viewing is
children and adolescents, a strong and consistently reported most consistently associated with increased BMI
association exists between screen media use and sleep prob- (Bickham, Blood, Walls, Shrier, & Rich, 2013; Falbe et al.,
lems, with even higher usage times and prevalences 2013), possibly because of the influence of TV commercials
(Calamaro, Mason, & Ratcliffe, 2009). that advertise energy-dense, micronutrient-poor foods, and
Although most research has focused on the potential excessive snacking while watching TV.
negative impact of screen media use on sleep, the relation-
ship may be bidirectional. In a longitudinal study of Austra- Adverse Cognitive Outcomes
lian children, Magee, Lee, & Vella (2014) found that not only For children’s and adolescents’ cognitive outcomes, screen
does increased screen media use predict shorter sleep dura- media use may have both positive and negative consequen-
tion, but also shorter sleep duration was associated with ces. Screen media devices have the potential to create a posi-
increased subsequent screen time, especially for television tive impact on learning and education. For example,
(TV) viewing. This reciprocal relationship may be due to promising research has indicated that digital educational
shorter sleep, leading to tiredness, fatigue, and reduced games, learn-to-read apps, and electronic books may
energy, and promoting engagement in sedentary behaviors, enhance children’s early literacy skills (Kucirkova, 2014;
including screen media use. Neumann, 2014; M. Neumann & D. Neumann, 2014) and
creative thinking abilities (Doron, 2017). Emerging data sug-
Overweight and obesity gest that these positive cognitive benefits may be influenced
According to the American Academy of Pediatrics (AAP), by several factors, including the age of the child
screen media use plays an important role in the current (Anderson, Subrahmanyam, & Cognitive Impacts of Digital

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Media Workgroup, 2017), quality and kind of interactive the 1990s revealed a stark increase in depressive symptoms
media, and type of guidance provided by parents and/or and suicide-related outcomes (Twenge, Joiner, Rogers and
teachers (M. Neumann & D. Neumann, 2014). Martin, 2018) because of the rise in media use and the sub-
In contrast, studies have also supported adverse conse- sequent decline in engagement in nonmedia-related activi-
quences of screen media use on several cognitive domains, ties. More recently, a sample of 11,831 adolescents from the
including sensorimotor development, executive functioning, Shandong Adolescent Behavioral and Health Cohort
and academic outcomes (Suggate & Martzog, 2021; Liu (Liu et al. 2019) found that mobile phone use of over
et al., 2020). A study found that young children who 2 hr/day on weekdays and 5 hr/day on weekends were asso-
watched fast-paced, fantastical shows intended to be educa- ciated with depressive symptoms. However, these associa-
tional had lower executive functioning than children in a tions were partially mediated by short sleep duration and
control group who either played or watched a slow, realistic insomnia, suggesting that the effects of mobile screen media
show (Lillard, Drell, Richey, Boguszewski, & Smith, 2015). use on mental health may result, at least in part, from the
In adolescents, frequent media multitasking was found to be direct effect of sleep disturbances. Thus, there is a need for
negatively associated with executive functioning, specifically further research examining the dynamics between screen
working memory, inhibition, and the ability to shift between media use, mental health disorders, and sleep.
tasks (Baumgartner, Weeda, van der Heijden, & Huizinga, In addition to its effects on depression and anxiety, recent
2014). research has demonstrated the positive association between
Addressing academic outcomes, studies across several the use of screen media and loneliness (Caplan, 2007;
age groups have demonstrated negative effects of screen Kim, LaRose, & Peng, 2009). A study conducted on Chinese
media use. During infancy, the Quebec Longitudinal Study students demonstrated that those who scored higher in lone-
of Child Development cohort study found that each 1-hr liness on the UCLA Loneliness Scale were more likely to
increase of TV exposure at 2 years of age corresponded to a demonstrate addictive use of their smartphones (Bian &
7% unit decrease in classroom engagement and a 6% unit Leung, 2015). Moreover, this compensatory use of media
decrease in math achievement (Pagani, Fitzpatrick, Barnett, only serves to exacerbate these feelings of loneliness by
& Dubow, 2010) in the fourth grade, indicating a lasting increasing isolation and negatively reinforcing the behavior
association between early screen media exposure and cogni- (Kim et al., 2009). Thus, the relationship between screen
tive abilities. In adolescence, a Spanish study found academic media use and loneliness is likely bidirectional.
performance to be inversely related to screen media use Similarly, self-esteem may be negatively impacted by
(Peir

o-Velert et al., 2014), and a U.S. study similarly found extensive screen media use (Ha, Chin, Park, Ryu, & Yu,
greater media multitasking was linked to statistically signifi- 2008). A large cross-sectional study conducted on Taiwanese
cant poorer performance on standardized test scores mea- adolescents revealed a relationship between mobile phone
suring academic performance in math and English use and low self-esteem (Yang, Yen, Ko, Cheng, & Yen,
(Cain, Leonard, Gabrieli, & Finn, 2016). During young 2010). Conversely, students reporting low self-esteem were
adulthood, several studies have found a negative relationship more likely to spend time using mobile phones and become
between screen media use and college students’ test perfor- addicted than those reporting high self-esteem
mance and grade point average (Jacobsen & Forste, 2011; (Ehrenberg, Juckes, White, & Walsh, 2008). Therefore, the
Walsh, Fielder, Carey, & Carey, 2013); however, adverse aca- directionality of the association between self-esteem and
demic outcomes may be confounded by the poorer attention screen media use is unclear, and further research is needed
and focus from multitasking behaviors rather than solely to determine the mechanism behind this relationship.
from screen media overuse, and more research is necessary
to tease out this relationship. Thus, there are significant, Externalizing behavior
albeit indirect, effects of screen media use on academic out- Many studies have investigated the impact of screen media
comes. use on externalizing behavior across childhood, including
attentional deficits, hyperactivity, aggression, and delin-
Emotional/Behavioral Problems quency. In a longitudinal study of U.S. toddlers, increased
TV exposure before the age of 3 years was associated with
Internalizing behavior attentional problems at school age, with a one standard devi-
A growing body of research has demonstrated the relation- ation increase in TV viewing time associated with a 28%
ship between screen use and internalizing behavior prob- increase in the probability of attentional problems at age
lems, including depression, anxiety, suicidal thoughts and 7 years (Christakis, Zimmerman, DiGiuseppe, & McCarty,
behaviors, feelings of loneliness, and low self-esteem. Multi- 2004). A longitudinal cohort study of Latino toddlers yielded
ple studies with high school students have shown positive similar results, with screen media use at 21 months signifi-
associations between depression and anxiety symptoms and cantly associated with aggressive behavior and overall exter-
increased use of both mobile phones (Demirci, Akg€ on€ul, & nalizing problems at 33 months (Tomopoulos et al., 2007).
Akpinar, 2015) and the Internet (Jenaro, Flores, G
omez- These effects have also been observed during adolescence,
Vela, Gonz
alez-Gil, & Caballo, 2007). Data from two in which screen media use is linked with conduct disorders
nationally representative surveys on U.S. adolescents since (Galica, Vannucci, Flannery, & Ohannessian, 2017),

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attention deficit hyperactivity disorder symptoms, aggres- Marquis, & Green, 1999). It proposes that screen media use,
sion, and delinquency (Holtz & Appel, 2011). Nevertheless, a highly reinforcing activity that is low in cognitive complex-
other researchers have found inconsistent results between ity, displaces academic behaviors, such as studying, material
screen media use and externalizing behavior. Among a preparation, and class attendance. Furthermore, screen
cohort of 6,595 U.S. adolescents, Riehm et al. (2019) found media activities like video gaming may generate physiological
that although social media use is associated with increased arousal that produces alterations in the processing and shap-
risk of comorbid internalizing and externalizing problems, it ing of child and adolescent neural networks (Green, Li, &
shares no association with externalizing symptoms alone. Bavelier, 2010).
These mixed results demonstrate the need for more exten- Increasingly, literature has found sleep to be a significant
sive research on the long-term effects of screen media use mediator of the relationship between internalizing and exter-
on externalizing behaviors. nalizing behavior and screen media use. Because sleep is sig-
Although numerous studies have demonstrated the nega- nificantly related to mood regulation, children and
tive impact of screen media overuse on externalizing behav- adolescents with sleep disruptions because of screen media
ior, a considerable number have not adjusted for violent use may face a greater likelihood of anxious, depressive,
content as a potential confounder, making it possible that it withdrawn, aggressive, and oppositional behavior (Palmer &
is the content being viewed, rather than overuse itself, that is Alfano, 2017). Apart from biological mechanisms, the type
associated with externalizing symptomology in children. For of content (prosocial/educational content vs. violent con-
example, in a randomized controlled trial of preschool-aged tent) may also contribute to the development of emotional/
children in which aggression-laden programming was substi- behavioral problems (Christakis et al., 2013). More research
tuted with high-quality, prosocial, and educational program- is necessary to elucidate the psychological and neural mecha-
ing without reducing total screen media use time, nisms that underly the relationships between screen media
investigators found that children demonstrated better scores use and its wide array of adverse physical, cognitive, and
on the Social Competence and Behavior Evaluation by 2.11 behavioral/emotional outcomes, as well as their possible
points 6 months postintervention, as well as significantly shared complex, interconnected mechanistic relationships.
lowered angry, aggressive, and oppositional behavior
(Christakis et al., 2013). By focusing on content rather than Directionality: Potential Converse Associations
quantity, the results of this study indicate that violent content Screen media overuse and its associated adverse outcomes
may mediate the adverse relationship between screen media are the focus of this review. However, one important caveat
use and externalizing behavior, warranting a need for future that should be considered is the possibility of potential con-
studies to further elucidate these interactions. verse associations, depicted as dashed arrows in the Figure.
Emerging research has demonstrated bidirectional associa-
Potential Mechanisms tions between several variables, including sleep, obesity
To date, the specific mechanisms of action through which (Hashem et al., 2019), executive functioning, internalizing/
screen media overuse acts on physical, cognitive, and behav- externalizing behaviors, and screen media overuse. Several
ioral consequences in children and adolescents are not well studies have found that children/adolescents with decreased
understood; however, several potential mechanisms have sleep quality/quantity (Magee et al., 2014), lowered self-reg-
been proposed. In terms of sleep changes, screen media use ulation/overall executive functioning (Cliff, Howard, Rade-
near bedtime may act as a direct displacement of sleep, cause sky, McNeill, & Vella, 2018), symptoms of depression,
physiological arousals that make it more difficult for children anxiety (Houghton et al., 2018), and loneliness (Kim et al.,
and adolescents to relax and suppress melatonin production 2009), decreased self-esteem (Ehrenberg et al., 2008), inter-
by blue light emission from electronic devices that leads to personal skills (Poulain et al., 2018), and increased impulsiv-
subsequent circadian rhythm delay (Hersh, Sisti, Richiutti, & ity/attention problems (Gentile, Swing, Lim, & Khoo, 2012)
Schernhammer, 2015). In turn, these problems lead to may spend more time on-screen media devices, which sub-
reduced total sleep time, longer sleep latency, later bedtimes, sequently further exacerbates existing problems. Thus,
and altered sleep architecture, thereby contributing to overall future research using longitudinal or randomized control
poor sleep quantity and quality. With respect to obesity, the trial study designs are critically needed to tease out the direc-
displacement of physical activity by increased screen-based tionality of these associations.
sedentary lifestyle (LeBlanc et al., 2015), increased caloric
intake via cravings for unhealthy snack foods and sweetened IMPLICATIONS
drinks during TV watching and video game playing The use of screen media has rapidly improved the availability
(Borgogna et al., 2015), and exposure to advertisements of of information and increased the convenience of communi-
calorie-dense foods with low nutritional value cation. Despite these positive effects on society, screen
(Robinson et al., 2017) have all been suggested as potential media overuse has repeatedly been shown to negatively
mechanisms. impact health outcomes, especially among children and ado-
The displacement hypothesis suggests the mechanism lescents. Although children and adolescents are most sus-
through which excessive media exposure may influence ceptible to the harmful effects of screen media, the physical,
learning and thereby affect cognition (Huston, Wright, cognitive, and behavioral outcomes potentially caused by

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TABLE 2. Strategies and recommendations for preventing screen media overuse in children/
adolescents
Intervention Target Strategies and Recommendations
Research
 Implement robust design designs by (1) performing comprehensive assessments of
screen use type, content, context, environment, parental mediation, and timing and (2)
use measurement methods such as direct observation, usage monitoring programs,
and reports from multiple sources (youths, parents, teachers, etc.)
 Use large, population-based longitudinal studies to tease out directionality
 Design randomized controlled trials examining effective intervention methods to reduce
screen media overuse and promote sustained positive behavioral change in children/
families
 Control for potential confounders, including parent/family/peer network use of screen
media, level of in-person social interaction, diet, exercise, and other activities of daily
living
Policy and Children and
practice adolescents  Reduce engagement in recreational sedentary screen time, and engage in alternate
hobbies and activities such as exercise, reading, arts and crafts, and listening to music
 Reduce media multitasking behaviors and use of social networking sites
 Limit the use of screen media while in class, studying, or doing homework
 Develop self-regulated rules/routines for screen media use that balance schoolwork
with entertainment
Parents and
caregivers  Develop and follow family media use plan (http://www.healthychildren.org/MediaUse
Plan), placing consistent limits on the duration of screen media use and considering
appropriate usage for each individual child
 Designate media-free times (e.g., mealtimes, parent−child playtimes, an hour before
bedtime)
 Remove screen media devices, including TVs, computers, tablets, and smartphones,
from children/adolescents’ bedrooms
 Work with adolescents to develop consistent routines that limit screen media use and
help them develop the ability, responsibility, and autonomy to self-regulate screen
media use
 Model healthy screen use by limiting parental screen media use
 Foster increased physical activity and reduced sedentary behavior in the home
Institutions Health care
 Ask parents/caregivers about their family’s screen media use, provide information
about benefits and health risks of screen media use, and educate families on recom-
mended use guidelines
 Help parents/caregivers create screen media use guidelines to meet the individualized
needs of each family
 Assess children and adolescents for the duration, content, timing, and environment of
screen media use during well-child visits, using standardized instruments
 Develop research-informed updated screen media use guidelines, and disseminate
information to educators/legislators
Schools
 Monitor and guide their students’ technology use in the classroom
 Receive professional development and training to successfully implement technology
use in the classroom
 Designate media-free zones at schools, such as cafeterias and classrooms
 Advocate for schools to sponsor screen-free days throughout the school year and
develop media education programs
 Collaborate with parent−teacher associations to encourage at-home guidance of
appropriate screen media use
Industry
 Collaborate with educators, pediatricians, and developmental psychologists to create
educational, high-quality, and age-appropriate content
 Develop electronic monitoring programs and systems in screen media devices to help
parents/caregivers limit children’s usage
Government
 Allocate federal and private funding for screen media use research
 Fund intervention strategies and public health campaigns for children, families, and
communities to promote healthy screen media use guidelines
 Collaborate with the Department of Education for the development of media education
curriculum in school settings

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screen media use can have far-reaching effects carrying into hour before bedtime; removing screen media devices from
adulthood and later life, underscoring the need for strategies children/adolescents’ bedrooms (Council on Communica-
to prevent screen media overuse and its associated detri- tions and Media, 2016b); working with adolescents to
mental effects. Table 2 summarizes the key strategies and develop consistent routines that limit screen media use and
recommendations for preventing screen media overuse in help them develop the ability, responsibility, and autonomy
children and adolescents. to self-regulate screen media use; modeling healthy screen
Given the wide array of methodological limitations that use by limiting parental screen media use (Canadian Paediat-
exist in screen media research to date, future research should ric Society & Digital Health Task Force, 2019); and fostering
seek to address these shortcomings. Specifically, consider- increased physical activity and reduced sedentary behavior
able research currently relies on parental or youth self- in the home (Carlson et al., 2010).
report, but seldom by both parents and youth, or by other Moreover, health care providers should ask parents/care-
sources such as teachers, rendering the data susceptible to givers about their family’s screen media use; provide infor-
substantial inaccuracies and biases (Marshall, Gorely, & Bid- mation about benefits and health risks of screen media use
dle, 2006). Future studies should use rigorous screen media and educate families on recommended use guidelines during
use measurement methods, such as direct observation or well-child visits (Radesky, Schumacher, & Zuckerman et al.,
usage monitoring programs installed within screen media 2015); help parents/caregivers create screen media use
devices, as well as multiple reports from youth, parents, and guidelines to meet the individualized needs of each family;
teachers, to obtain comprehensive, accurate data and assess children and adolescents for the duration, con-
(Segev et al., 2015). Another limitation widely existing in cur- tent, timing, and environment of screen media use during
rent research is the use of cross-sectional, survey, correla- well-child visits using standardized instruments. Health care
tional, and observational study designs, raising issues of providers should also help develop research-informed uni-
duration of findings and temporal precedence. Large, popu- form guidelines for screen media use practices that protect
lation-based randomized controlled trials are necessary to children and adolescents’ health and wellbeing. School
establish causality and elucidate the potential mechanisms nurses are in particularly good positions to help children,
involved in the pathways between screen media overuse and adolescents, and families understand the potentially detri-
adverse physical, cognitive, and emotional/behavioral out- mental effects of screen media use and develop appropriate
comes. In addition, confounders, including parent/family/ usage guidelines, working on individual and community lev-
peer network use of screen media (Ferguson, 2017), level of els to promote healthy screen media use. At the individual
in-person social interaction (Twenge, Martin and Campbell, level, nurses can meet with students regularly to screen for
2018), diet, exercise, behavioral/emotional problems, and overuse and educate them about the adverse effects of over-
other activities of daily living, should be controlled in future use. In addition, nurses can help develop community-wide
research to enhance the accuracy and validity of findings. education programs by collaborating with other health pro-
Researchers should also perform comprehensive assess- fessionals, schools, and families (Puskar & Bernardo, 2007).
ments of screen use type, content, context, environment, Currently, the guidelines for screen media use conflict. For
parental mediation, and timing (Straker, Zabatiero, Danby, example, the AAP states that parents should place limits on
Thorpe, & Edwards, 2018), as well as examine effective time spent on-screen media use to ensure it does not dis-
implementation methods to promote sustained positive place time for adequate sleep and physical activity for chil-
behavioral change in reducing screen media overuse. dren aged > 6 years (Pediatrics); the Australian 24-hr
In addition to implications for future research, several Movement Guidelines, meanwhile, state screen time should
strategies may also be implemented regarding policy and be limited to no more than 2 hr/day. The establishment of
practice. Children and adolescents can prevent screen media consistent, authoritative, evidence-based guidelines through
overuse by reducing engagement in recreational sedentary investigation of short-term and long-term effects of screen
screen time and engage in alternate hobbies and activities media use is crucial.
such as exercise, reading, arts and crafts, and listening to In addition, teachers and educators should monitor and
music (Jongenelis, Scully, Morley, Pratt, & Slevin, 2018); guide their students’ technology use in the classroom;
reducing media multitasking behaviors and use of social net- receive professional development and training to success-
working sites; limiting use of screen media while in class, fully implement technology use in the classroom; designate
studying, or doing homework (Jacobsen & Forste, 2011; media-free zones at school, such as cafeterias and class-
May & Elder, 2018); and developing self-regulated rules/ rooms; advocate for schools to sponsor screen-free days
routines for screen media use that balance school work with throughout the school year and develop media education
entertainment. Parents and caregivers should also play a role programs; and collaborate with parent−teacher associations
by following the AAP family media use plan (http://www. to encourage at-home guidance of appropriate screen media
healthychildren.org/MediaUsePlan), considering the appro- us (Hale et al., 2018; Riesch et al., 2019). Furthermore, the
priate screen media types and behaviors for each child industry should collaborate with educators, pediatricians,
(Reid Chassiakos et al., 2016); placing consistent limits on and developmental psychologists to create educational, high-
the duration of screen media use; designating media-free quality, and age-appropriate content and develop electronic
times, including mealtimes, parent−child playtimes, and an monitoring programs and systems in screen media devices

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to help parents/caregivers limit children’s usage (Council on Bickham, D. S., Blood, E. A., Walls, C. E., Shrier, L. A., &
Communications and Media, 2016a). Rich, M. (2013). Characteristics of screen media use associ-
Finally, governmental institutions should allocate federal ated with higher BMI in young adolescents. Pediatrics, 131,
935–941.
and private funding for screen media use research. Although Borgogna, N., Lockhart, G., Grenard, J. L., Barrett, T., Shiffman, S.,
there may exist a critical period during development in & Reynolds, K. D. (2015). Ecological momentary assessment
which screen media-related adverse outcomes are estab- of urban adolescents ’ technology use and cravings for
lished (Tamana et al., 2019), current evidence-based screen unhealthy snacks and drinks: Differences by ethnicity and sex.
Journal of the Academy of Nutrition and Dietetics, 115, 759–
media guidelines vary widely; thus, the funding of research
766.
in this area is critical. Furthermore, governmental agencies Cain, M. S., Leonard, J. A., Gabrieli, J. D., & Finn, A. S. (2016). Media
should fund intervention strategies and public health cam- multitasking in adolescence. Psychonomic Bulletin & Review,
paigns for children, families, and communities to promote 23, 1932–1941.
healthy screen media use guidelines, as well as collaborate Calamaro, C. J., Mason, T. B., & Ratcliffe, S. J. (2009). Adolescents
with the Department of Education for the development of living the 24/7 lifestyle: Effects of caffeine and technology on
sleep duration and daytime functioning. Pediatrics, 123,
media education curriculum in school settings (Riesch et al., e1005–e1010.
2019). Canadian Paediatric Society, & Digital Health Task Force, Ottawa,
Given that technology has become embedded within the Ontario. (2019). Digital media: Promoting healthy screen use in
lives of children and adolescents, it is vital to understand its school-aged children and adolescents. Paediatrics & Child
impact on health and wellbeing. Although screen media use Health, 24, 402–417.
Caplan, S. E. (2007). Relations among loneliness, social anxiety, and
has positive benefits to the learning environment, growing problematic Internet use. Cyberpsychology and Behavior, 10,
evidence also suggests that overuse has adverse effects on a 234–242.
wide range of physical, cognitive, and emotional/behavioral Carlson, S. A., Fulton, J. E., Lee, S. M., Foley, J. T., Heitzler, C., &
problems. Childhood and adolescence are critical windows Huhman, M. (2010). Influence of limit-setting and participation
in physical activity on youth screen time. Pediatrics, 126, e89–
of development during which youth may be particularly sus-
e96.
ceptible to the negative social, psychological, and biological Cespedes, E. M., Gillman, M. W., Kleinman, K., Rifas-Shiman, S. L.,
effects of screen media use, thus rendering more research in Redline, S., & Taveras, E. M. (2014). Television viewing, bed-
this area essential. Specifically, although research studies room television, and sleep duration from infancy to mid-child-
have extensively investigated the effects of screen media hood. Pediatrics, 133, e1163–e1171.
Chaput, J. P., Leduc, G., Boyer, C., Be
langer, P., LeBlanc, A. G.,
overuse on sleep disturbances, there continues to be con-
Borghese, M. M., & Tremblay, M. S. (2014). Electronic screens
flicting data with regard to externalizing behavior, as well as in children’s bedrooms and adiposity, physical activity and
potential bidirectional relationships shared with the adverse sleep: Do the number and type of electronic devices matter?
outcomes discussed in this review. Understanding its Canadian Journal of Public Health, 105, e273–e279.
impacts and mechanisms are critical to generating screen Chen, W., & Adler, J. L. (2019). Assessment of screen exposure in
young children, 1997 to 2014. JAMA Pediatrics, 173, 391–
time guidelines by practitioners and developing effective pre-
393.
vention/intervention strategies to mitigate screen media Cheung, C. H., Bedford, R., Saez De Urabain, I. R.,
overuse and its adverse outcomes in children and adoles- Karmiloff-Smith, A., & Smith, T. J. (2017). Daily touchscreen
cents. use in infants and toddlers is associated with reduced sleep
and delayed sleep onset. Scientific Reports, 7, 46104.
Funding/support Christakis, D. A., Garrison, M. M., Herrenkohl, T., Haggerty, K.,
Rivara, F. P., Zhou, C., & Liekweg, K. (2013). Modifying media
This work was supported by the National Institutes of content for preschool children: A randomized controlled trial.
Health: the National Institute of Environmental Health Pediatrics, 131, 431–438.
Sciences (R01-ES-018858, K02-ES-019878, K01- Christakis, D. A., Zimmerman, F. J., DiGiuseppe, D. L., &
ES015877 and P30-ES013508) and Eunice Kennedy Shriver McCarty, C. A. (2004). Early television exposure and subse-
National Institute of Child Health and Human quent attentional problems in children. Pediatrics, 113, 708–
713.
Development (R01-HD087485). Cliff, D. P., Howard, S. J., Radesky, J. S., McNeill, J., &
Vella, S. A. (2018). Early childhood media exposure and self-
regulation: Bidirectional longitudinal associations. Academic
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