European Journal of Cardiovascular Medicine

Digital screen time is the time spent by doing activities in front of a screen like watching Television, using mobile phones, laptops and other devices. Increased digitization is leading to increased screen time. Digital media is rapidly penetrating the lives of young children owing to increased accessibility resulting in increased screen time ¹. The Covid-19 pandemic has resulted in continuous lockdowns that forced young children to stay indoors and had to continue their education by digital mode accelerating the process of digitization which invariably resulted in increased screen time of children.²

According to WHO guidelines and pediatric association guidelines of various nations, the recommended daily screen time for the ages 2 to 5 years is not more than an hour a day and discourage screen time for children less than 2 years ³. Despite the recommendations, the screen time is increasing at an unprecedented rate. Mounting evidence has documented that many children start using screen media devices in infancy and the usage increases as the age of the children increases.⁴ International statistics from 40 countries in Europe and North America show that more than 60% of children watch television for more than 2 hours per day⁵. A survey of children aged 3 to 6 in 35 kindergartens in China revealed that 57.3% of the children were exposed to electronic screens for more than 2 hours per day ⁶.

The first 5 years of life are crucial for brain development, and forms the foundation for the socio-emotional relationships and formation of habits ⁷. Excessive screen usage has a negative impact on the various domains of development and behavioral problems among preschoolers as well as school going children which may persist as the child gets older ⁸. Prolonged screen time can be attributed to risk of reduced prosocial behavior and increased risk of antisocial behavior ⁹.

Most of the studies conducted in this domain are mainly focused on adolescents and young adults. Very few studies have been targeting the under 5 population and there is a lack of adequate information regarding problematic device usage and behavioral changes in children 2 to 5 years in the Indian scenario. This study was conducted to assess the problematic device usage and its association with behavioral changes in children of 2 to 5 years age.

A community-based cross-sectional study was conducted in 2 to 5 years age group children both male and female residing in Balaji Nagar which is an Urban field practice area of Government Medical College, Ongole, for a period of 2 months from February 2023 to April 2023. Information was obtained from Parents of 2-5 years age in the study, and in the absence of Parents, Grand Parents/Guardians were given the details. Parents who are not willing to participate, Children with Mental retardation, Children diagnosed with behavioral disorders were excluded from the study and also Children who are being taken care by a relative or a professional caretaker were also excluded.

House to house survey was conducted and face to face interview was taken with the help of local ASHAs. A semi-structured questionnaire based on PMUM-SF scale¹⁰was used to assess the problematic device usage and SDQ questionnaire was used to assess the behavioral problems in the children¹¹. It consists of Sociodemographic information, device details and usage, Screen addiction as per Problematic Media Use Measure Short Form (PMUM-SF scale), SDQ questionnaire.  Purposive sampling method with simple random technique was used for inclusion of participants in the study. All eligible individuals in the visited house were included in the study. Permission was obtained from Institutional Authorities and the study was approved by the Institutional Ethics Committee and Informed consent was taken from the parents.

The questionnaire used in the study consists of four sections. The first section had questions related to socio-demographic details like age, gender, total members in the family, type of family, parent’s education and occupation were collected. The Second section had questions regarding different devices and their usage. In this section, questions were asked regarding the age of initiation for the devices, devices that the child has access to, average screen time in each sitting, average duration of total screen time for all the devices during weekdays and weekends, and the type of programs the child watches. The Third section had questions related to Screen Addiction as per PMUM-SF scale. PMUM-SF Scale refers to Problematic Media Use Measure- Short Form Scale was created by Domoff et all ¹². The short form scale consists of 9 questions which were based on internet gaming disorder of DSM-5 It is a Five-point Likert scale having a score from 1 to 5. A score of 3 or more in 5 or more questions is considered as the child is having problematic media usage. The Fourth section had questions regarding SDQ Questionnaire i: e Strengths and Difficulties Questionnaire. The SDQ questionnaire was prepared by Robert.N.Goodman. The questionnaire assesses Emotional, Physical and Psychological problems in children and Adolescents. The questionnaire is a 3-point Likert scale with zero, one and two as scores. Zero stands for not at all/only a little, one stands for a medium amount and Two stands for often/ a great deal.

The questionnaire consists of 5 components and 25 questions

1. Emotional symptoms
2. Conduct problems
3. Hyperactivity/inattention
4. Peer relationship problems
5. Prosocial behavior

The SDQ Questionnaire is valid in children aged 2 to 17 years. Grading is separate for 2-4 years and 4-17 years of age. Separate scoring bands were applied for 2 to 4 years old and above 4 years children as per SDQ guidelines and an overall scoring is calculated which determines the level of behavioral problems faced by the children.

STATISTICAL ANALYSIS:

After the data collection, the data was entered into Microsoft Excel and checked for the errors. Statistical analysis was done by using MS Excel and trial version of SPSS. Descriptive statistics was calculated for the devices, duration of usage, excess screen time, reasons for usage and problematic usage of device in terms of frequencies and percentages mean and standard deviation. Analytical statistics applied to find out the association between the problematic device usage and behavioral change. Multivariate logistic analysis was applied to find out the correlation between problematic device usage and behavioral problems. Chi square test applied to assess the relationship between Sociodemographic factors and problematic device usage.

Out of 116 children, 66 (56.9%) were males and 50 (43.1%) were females and the mean age of the children was 3.5 ± 1.2 years. 39(33.62%) of the children have both parents who were working either part-time or full time and 77(66.38%) of the children have at least one parent who were working either part-time or full time and 42(36.20%) of the children have a working mother and fathers of the all the children were employed. As per the responses given by the parents to PMUM-SF scale, 64 children (53.44%) have problematic media usage/device usage. Of the 64 children, 30 children are in the age group of 2-4 years and 34 children are in the age group of 4-5 years. The association between Age, mother’s Education, Mother’s occupation, father education, working parents with PMUM present found to be significant (P<0.05) (Table-1).

Table-1: Association between Sociodemographic Profile and Problematic Media usage

It was seen that 95.6% children were watched television, 98.3% were using mobile phones and only 11% were seeing desktop computers. It was observed that 32.8% children were using these devices in bed room. 55% children were watching television for 2 hours or more in week rime and 77.5% weekend time. 63.2% children were involved with mobile phone for 2 hours or more in week rime and 81.6% weekend time. Mean screen time was found to be 102.46 ± 14.7 minutes and 17.2% children started using digital devices below 1 year, 46.6% between 1 to 2 years and 56.9% children were continuously sitting for more than 20 minutes with digital devices (Table-2)

Table-2: Digital Device Usage and Screen Time among children 2 to 5 Years

58.6% (3 Points) parents expressed that it is hard for my child to stop using screen media, and it is the only thing that seems to motivate (43.9% with 2 points) the child. 54.3% (2 points) viewed that screen media all that my child to think about and screen time interfering with 54.3% (2 points) of family activities. Children screen media causes problem to the family (52.6% with 2 points).57.7% (3 points) children were frustrated when they cannot use screen media. The time period child wants to use screen media is increasing (37.9% with 3 Points) and 53.4% (3 points) children sneaks for using digital devices. When children had a bad day, screen media seems to be only thing (59.5% with 3 points) that helps them feels better (Table-3).

Tabl-3: Screen Addiction (As per PMUM-SF) and 5-point Likert scale (1 to 5)

It was found that 82 (71%) of the parents reported co-viewing with their children. 18% of the parents were always co-viewed with the Children, where as 53% parents were partly co-viewed and 29% parents were never co-viewed in watching electronic devices. (Graph-1)

Graph-1:  Status on Co-viewing of Parents with their Children

Screen time more than 1 hour was noticed higher side among both males (45.7%) and Females (39.1%), similarly it was 43.1% in <4 years and 34.5% in above 4 years. PMUM presence seen with screening time more than 1 hour among 50% of Children and its association found to be significant (P<0.05) (Table-4).

Table -4: Relationship between average screen time and sociodemographic characteristics

According to SDQ scale there is a positive association between Problematic Media usage and Conduct problems (P<0.00006), Hyperactivity (P<0.0066) and Peer problems (P<0.0096) in children 2-4 years. But there is a negative association between Problematic Media usage and emotional symptoms. Over all Positive association (P<0.0000017) is there between Problematic media and SDQ scale total score (Table No.5).

Table No-5:  Problematic Media Usage according various domains of SDQ in 2-4 years Children (N=64)

As per SDQ scale there was a positive association between Problematic Media usage and Conduct problems (P=0.011) and Peer problems (P=0.014) in children 4-5 years. But there was a negative association between Problematic Media usage and emotional symptoms, hyperactivity. Over all Positive association (P<0.000036) was there between Problematic media and SDQ scale total score (Table-6).

Table No:6 Problematic Media Usage according various domains of SDQ in 4-5 years Children (N=52)

As per the rating given to the questions in PMUM-SF scale by the parents, 62 children (53.4%) have problematic media usage/ problematic device usage and 47.4% were used without help and the association was found to be significant (P<0.05) (Table-7). 

Table-7: Association Between the Ability to Operate the Devices independently and PMUM

The highest correlation value with screen time noticed for SDQ component of Total difficulties (0.713), followed by Peer problems (0.555), hyperactivity (0.496) then conducts problem (0.487), and emotional problems (0.382) (Table-8)

Table-8: Spearman correlation of screentime with SDQ scores

Problematic device usage and behavioral problems were found to be moderate to strongly positive (high positive correlation) ,  with r (114) =0.6825 and P value <0.001. (Graph-2)

Graph-2: Correlation between problematic media usage and behavioral problems

The present study shows a screentime of   102.46 ± 14.7 minutes which is very less compared to many studies like Anitha et al ¹⁰(170 ± 46 minutes). This might be due to the relatively younger age of the study group in our study. In a study conducted by Kaur et al¹³with a similar age group to our study, the mean screen time during weekdays is similar to that of the present study.The mean age of initiation of screen exposure is 18 months± 10 months which is around the similar age as compared to Anitha et al¹⁰ 95.6% children were watched television , 98.3% were using  mobile phones , 55% children were watching television for 2 hours or more in week rime and 77.5% weekend time. 63.2% children were involved with mobile phone for 2 hours or more in week rime and 81.6% weekend time in our study.

As per Donthu etal study,the smartphone has the highest accessibility (77.9%), followed by conventional television (TV) (51.4%) and kids used digital applications and social media is less than 30 minutes during weekdays, which increases by at least half to one hour during the weekend ¹⁴.  Goode J.A etal study found that the usage of video games, video calls, increases to 2 hours during the weekend from less than 1 hour during weekdays.  A 2019 study in the U.S. reports that in the past two decades, children’s media usage time increased by 32% ¹⁵. Chen, W etal research showed that total screen time in children aged 0–2 years increased from 1.32 hours to 3.05 hours a day and 3–5 years from 2.47 hours to 2.56 hours a day between 1997 and 2014 ¹⁶.

As per PMUM-SF and Likert scale 58.6% (3 Points) parents expressed that it is hard for my child to stop using screen media, and it is the only thing that seems to motivate (43.9% with 2 points) the child. 54.3% (2 points) viewed that screen media all that my child to think about and screen time interfering with 54.3% (2 points) of family activities in our study. Raju V etal study viewed that toddlers are 40% more likely to develop problematic media habits at age 2, with more than 2 hours of their day in front of a screen ¹⁷. Mustuloğlu, Ş etal study found that Twelve (7.8%) children, who gained a PMUM-SF score of 1 which indicated absence of PMU. ¹⁸

PMUM and behavioral problems were found to be moderate to strongly positive (high positive correlation), with r(114) =0.6825 in our study. Dwairej et al ¹⁹-study showed that the Arabic version of the PMUM had good reliability (Cronbach’s alpha = 0.90) and good convergent and predictive validity.  Domínguez et al. ²⁰ study in children between 4 to 14 years found that the scale fit a unidimensional model and had high-reliability values with McDonald’s Omega value of 0.96 for the full scale and 0.90 for the reduced scale. 18% of the parents were always co-viewed with the Children and 53% parents were partly co-viewed in our study and as per Muppalla S etal study 82 (71%) of the parents reported co-viewing with their children in this study. ²¹

In the present study, 62 children (53.44%) have problematic media usage/   problematic device usage which is significantly higher than Anitha et al (28%), ¹⁰ owing to the younger age of the study participants and most of the study subjects have not yet begun their schooling.  The present study shows a significant association between problematic device usage and working parents which is similar to studies like Anitha etal ¹⁰., Prashanth Bhushan Kulkarni et al ^22, Kaur et al ¹³. The present study shows no significant association between age, gender and socioeconomic status and problematic media usage which is similar to Cao et al ^[2].

The present study shows that there is no significant association between increased screen time to gender and age which is different from studies like Xie et al ²³, that shows that gender and age are significant factors associated with increased screen time. A study conducted by Priya P R et al²⁴., showed there is a statistical significance between longer duration of screentime to various behavioral problems (p=0.0008). The present study also shows a statistical significance to the same(p=0.0001).  In a study conducted by Liu et al²⁵ age is not associated with behavioral problems in any domain. But in the present study, there is association between 2-4 years age and emotional, conduct and hyperactivity domains.

In our study, the association between increased screen time and various subcategories of SDQ scoring is statistically significant which is similar to Priya P R et al.²⁴.A study conducted by  Wu et al ^[6] reported that there is a strong correlation between the total SDQ score and screen time I.e., a higher screen time essentially correlated to a higher SDQ score and there is a high degree of correlation between raised scores in each domain with increased screen time.The present study also shows that there is a strong correlation between total SDQ score and duration of screentime. It implies that greater duration of screen time can lead to behavioral problems in children less than 5 years. There is a strong correlation with a statistical significance between Problematic media usage and Higher SDQ scores which has not been demonstrated in any studies as there were no studies correlating the two factors previously.

Screen time among young children is increasing rapidly. The early exposure to devices leads to prolonged duration of exposure leading to delayed development and reduced prosocial behavior and increased hyperactivity and antisocial behavior. The findings of this study will be utilized for better understanding of the relationship between screen time and behavioral changes and to provide effective community-based awareness interventions.

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