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Preventing adverse health outcomes among children and adolescents by addressing screen media practices concomitant to sleep disturbance

      Executive Summary

      In today's digital age, screen media use is prevalent in the daily life and functioning of children and adolescents. Sleep disturbance and adverse health outcomes related to screen media practices are on the rise affecting physical, cognitive, and behavioral health outcomes. Mounting evidence from studies worldwide support the following recommendations addressing practice, research, and policy: (a) All practitioners are encouraged to assess youth and their families at each health encounter for screen media practices, sleep disruption and daytime sleepiness, and be able to refer to specialists or be trained on interventions to address problems; (b) Children and families are encouraged to seek information about and take responsibility for screen media use practices, effective sleep habits, and signs and symptoms of adverse health outcomes; (c) Policy makers are encouraged to promote public awareness and provide funding for further research into screen media practices, sleep disturbance, and adverse health outcomes. The American Academy of Nursing (Academy) supports individual, family, community, and population-based initiatives to inform screen media practices among children and adolescents, to assess for and treat adverse health outcomes linked to screen media use, and to help families adopt sleep-friendly practices.

      Background

      Social media is a ubiquitous part of children and adolescents’ daily lives. Social media activities along with the use of mobile devices, computers, gaming platforms, and televisions increase screen use and saturate our culture. Infants and young children use screens; 75% of 0 to 8 year olds (
      • Lup K.
      • Trub L.
      • Rosenthal L.
      Instagram #Instasad?: Exploring associations among Instagram use, depressive symptoms, negative social comparison, and strangers followed.
      ) and 97% of 0 to 4 year olds have used a mobile device (
      • Lenhart A.
      Teens, Social Media, & Technology Overview.
      ). Among teens, over 89% own a smartphone, 39% report feeling “addicted to their phones,” and 68% keep their phone in their bed or within reach during the night (
      • Robb M.R.
      The new normal: Parents, teens, screens, and sleep in the United States.
      ). Youth screen media use is highly influenced by adult use and parental attitudes (
      • Lauricella A.R.
      • Wartella E.
      • Rideout V.J.
      Young children's screen time: The complex role of parent and child factors.
      ).
      Screen media practices include content (
      • Murray J.P.
      • Liotti M.
      • Ingmundsaon P.T.
      • Mayberg H.S.
      • Yonglin P.
      • Zamarripa F.
      • ...
      • Fox P.T.
      Children's brain activation while viewing televised violence revealed by fmri.
      ), usage time and tasks performed (
      • Ferguson C.J.
      Everything in moderation: Moderate use of screens unassociated with child behavior problems.
      ), the level of interference with other activities (
      • Laurson K.
      • Lee J.
      • Eisenmann J.
      The cumulative impact of physical activity, sleep duration, and television time on adolescent obesity: 2011 youth risk behavior survey.
      ), time of day of use and simultaneous use of multiple screens (
      • Hysing M.
      • Pallesen S.
      • Stormack K.M.
      • Jakobsen R.
      • Lundervold A.J.
      • Severtsen B.
      Sleep and use of electronic devices in adolescence: Results from a large population-based study.
      ), degree of social interaction and comparison (
      • Lup K.
      • Trub L.
      • Rosenthal L.
      Instagram #Instasad?: Exploring associations among Instagram use, depressive symptoms, negative social comparison, and strangers followed.
      ), and the type of screen used (
      • Hale L.
      • Guan S.
      Screen time and sleep among school aged children and adolescents: A systematic literature review.
      ). While such devices have revolutionized information and communication in many ways, their negative effects are numerous and significant. Screen media practices are associated with sleep disturbances, peer problems (
      • Parent J.
      • Sanders W.
      • Forehand R.
      Youth screen time and behavioral health problems: The role of sleep duration and disturbances.
      ), high likelihood of self-injury (
      • Oshima N.
      • Nishida A.
      • Shimodera S.
      • Tochigi M.
      • Ando S.
      • Yamasaki S.
      • ...
      • Sasaki T.
      The suicidal feelings, self-injury, and mobile phone use after lights out in adolescents.
      ), and high levels of internalizing as well as externalizing behavior (
      • Przybylski A.K.
      Electronic gaming and psychosocial adjustment.
      ,
      • Tamana S.K.
      • Ezeugwu V.
      • Chlkuma J.
      • Lefebvre D.L.
      • Azad M.B.
      • Moraes T.J.
      • ...
      • Mandhane P.J.
      Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study.
      ) that, in turn, influence a wide range of physical, cognitive, and behavioral health outcomes. National rates of internalizing behavior (depression, thoughts of suicide, anxiety, and poor peer relations) and externalizing behavior (aggression, conduct problems, and violence) have been rising (
      • Kann L.
      • McManus T.
      • Harris W.A.
      • Shanklin S.L.
      • Flint K.H.
      • Queen B.
      • ...
      • Ethier K.A.
      Youth Risk Behavior Surveillance — United States, 2017.
      ) along with screen media use and merit serious attention .
      The interactions between screen media practices, sleep, and adverse health outcomes are multifaceted, and in several cases, bidirectional. First, screen media practices act as a psychosocial risk factor for child and adolescent adverse outcomes. For example, watching violent entertainment from ages 2 to 4 is associated with significantly increased risk for antisocial behavior for boys when they are ages 7 to 9 (
      • Christakis D.A.
      • Zimmerman F.J.
      Violent television viewing during preschool is associated with antisocial behavior during school age.
      ). Playing digital games that include violence is associated with direct aggression among boys at age 10 and negative interpersonal behaviors such as shunning and revenge-seeking among 13-year-old children (
      • Wallenius M.
      • Punamaki R.L.
      • Rimpela A.
      Digital game playing and direct and indirect aggression in early adolescence: The roles of age, social intelligence, and parent-child communication.
      ). Second, screen media practices affect sleep health. The use of screen media at bedtime is highly prevalent; on average adolescents engage in up to four activities involving screens after 9 PM (
      • Calamaro C.J.
      • Mason T.B.A.
      • Ratcliffe S.J.
      Adolescents living the 24/7 lifestyle: Effects of caffeine and technology on sleep duration and daytime functioning.
      ). A strong and consistently reported association exists between bedtime screen media use and inadequate sleep quantity, quality, and excessive daytime sleepiness (
      • Garmy P.
      • Ward T.M.
      Sleep habits and nighttime texting among adolescents.
      ). Among the reasons for this association are suppression of melatonin production and physiological as well as psychosocial arousal caused by viewing social media content (
      • Carter B.
      • Rees P.
      • Hale L.
      • Bhattacharjee D.
      • Paradkar M.
      A meta-analysis of the effect of media devices on sleep outcomes.
      ).
      The indirect effect between screen media practices and adverse health outcomes may lead to less and poorer quality sleep (
      • Reid Chassiakos Y.
      • Radesky J.
      • Christakis D.
      • Moreno M.
      • Cross C.
      Children and adolescents and digital media.
      ). Screen media practices are associated with reduced sleep duration in children ages 3 through 12 years and sleep disturbance at all ages that, in turn, share a reciprocal relationship with externalizing behaviors (
      • Quach J.L.
      • Nguyen C.D.
      • Williams K.E.
      • Sciberras E.
      Bidirectional associations between child sleep problems and internalizing and externalizing difficulties from preschool to early adolescence.
      ). The consequences of sleep-related externalizing behaviors extend to criminal behavior in adulthood. In contrast to teens who did not report being sleepy during the afternoon at age 15, those who did were 4.5 times more likely to become convicted criminals by age 29 (
      • Raine A.
      • Venables P.H.
      Adolescent daytime sleepiness as a risk factor for adult crime.
      ). Sleep disturbances were also associated with other adverse outcomes such as being fearful, worried, self-conscious, argumentative, destructive or disobedient, having disturbed interpersonal relationships with peers (
      • Parent J.
      • Sanders W.
      • Forehand R.
      Youth screen time and behavioral health problems: The role of sleep duration and disturbances.
      ), poor mental health, suicidal thoughts, and self-injury (
      • Oshima N.
      • Nishida A.
      • Shimodera S.
      • Tochigi M.
      • Ando S.
      • Yamasaki S.
      • ...
      • Sasaki T.
      The suicidal feelings, self-injury, and mobile phone use after lights out in adolescents.
      ). These outcomes demonstrate that early life habits have long-lasting consequences.
      The interaction between biological factors such as sleep and psychosocial factors such as screen media practices provides a framework to understand the development of aggressive behavior and violence, as well as, predicting and preventing it (
      • Liu J.
      Early health risk factors for violence: Conceptualization, review of the evidence, and implications.
      ). With sleep as a potential mediating factor between screen media practices and adverse outcomes, addressing risk factors that contribute to poor sleep has significant potential societal and public health benefit.

      Responses and Policy Options

      To date, systematic literature reviews (
      • Hale L.
      • Guan S.
      Screen time and sleep among school aged children and adolescents: A systematic literature review.
      ,
      • Stiglic N.
      • Viner R.M.
      Effects of screentime on the health and well-being of children and adolescents: a systematic review of reviews.
      ) and meta-analyses (
      • Carter B.
      • Rees P.
      • Hale L.
      • Bhattacharjee D.
      • Paradkar M.
      A meta-analysis of the effect of media devices on sleep outcomes.
      ) have explored the relationship between screen media practices, sleep, and adverse health outcomes. Few randomized controlled studies and no population level programs of research have been conducted. In response to the needs of parents, children, and health, social, and education professionals, however, statements and guidelines have been developed by the American Academy of Pediatrics (https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Children-and-Media-Tips.aspx), the American Academy of Family Physicians (https://www.aafp.org/afp/2017/0701/p56.html), the National Sleep Foundation (https://www.sleepfoundation.org/articles/electronics-bedroom-why-its-necessary-turn-you-tuck), and the World Health Organization (http://www.who.int/iris/handle/10665/311664). Strategies to promote sleep friendly practices (
      • Hiscock H.
      • Sciberras E.
      • Mensah F.
      • Gerner B.
      • Efron D.
      • Khano S.
      • Oberklaid F.
      Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: Randomised controlled trial.
      ) and safe screen media practices (
      • Sanders W.
      • Parent J.
      • Forehand R.
      Parenting to reduce screen time: A feasibility pilot study.
      ) have been tested and published.
      The 116th United States Congress re-introduced the bi-partisan Children and Media Research Advancement Act (CAMRA, H.R. 1367 and S. 558). It calls for the directors of the National Institutes of Health and other leaders to develop a research agenda concerning the cognitive, physical, and socio-emotional health and developmental effects of exposure to screen media with a progress report due to Congress one year after the law is enacted. The bill proposes an important step to develop evidence for guidelines, recommendations, and interventions. Appropriations proposed are $15 million for each of fiscal years 2020 through 2022 and $25 million for each of fiscal years 2023 and 2024. If enacted and funds appropriated, funds would need to grow over time to effectively address the issues systematically.
      Corporations that develop and manufacture devices have a role guiding families, schools, and communities in screen media practices. Jim Steyer (Common Sense Media) proposed that companies “practicing institutional manipulation of screen media use should be accountable” and Tim Cook (Apple CEO) stated if device use is harmful, “we should do something to make (them) more productive”(

      Sloan, D. (Writer). (2019, May 3). Screen Time: Diane Sawyer Reporting. ABC.

      ).

      The American Academy of Nursing's Position

      The Academy supports individual, family, community, and population-based initiatives to inform screen media practices among children and adolescents, to assess for and treat adverse health outcomes linked to screen media practices, and to help families adopt sleep-friendly habits. These initiatives include funding for research to create high quality evidence to develop and test interventions and train nurses and other healthcare professionals to deliver these interventions. The Academy supports raising awareness about the potential serious public health consequences of screen media practices, their influence on sleep disturbance, and impact on adverse health outcomes.

      Recommendations

      Clinical and Practice Recommendations

      1. To encourage all health professionals to assess duration, content, and timing of screen media use; sleep quality, behavior, and duration; and daytime sleepiness at each health encounter. Practice guidelines need to include pertinent health history items.
      Standardized instruments are available to identify those in need of screen media practices modification and sleep health education. The Modern Digital Use Questionnaire (
      • Ra C.K.
      • Cho J.
      • Stone M.D.
      • De La Cerda J.
      • Goldenson N.I.
      • Moroney E.
      • ...
      • Leventhal A.M.
      Association of digital media use with subsequent symptoms of Attention-Deficit/Hyperactivity Disorder among adolescents.
      ), the Adolescent Sleep, Caffeine Intake, and Technology Use, including a multi-tasking index (
      • Calamaro C.J.
      • Mason T.B.A.
      • Ratcliffe S.J.
      Adolescents living the 24/7 lifestyle: Effects of caffeine and technology on sleep duration and daytime functioning.
      ), the Insomnia Severity Index (
      • Lemola S.
      • Perkinson-Gloor N.
      • Brand S.
      • Dewald-Kaufmann J.F.
      • Grob A.
      Adolescents' electronic media use at night, sleep disturbance, and depressive symptoms in the smartphone age.
      ), the Pediatric Daytime Sleepiness Scale (
      • Drake C.
      • Nickel C.
      • Burduvali E.
      • Roth T.
      • Jefferson C.
      • Badia P.
      The Pediatric Daytime Sleepiness Scale (PDSS): Sleep habits and school outcomes in middle school children.
      ), and the Epworth Sleepiness Scale (
      • Janssen K.C.
      • Phillipson S.
      • O'Connor J.
      • Johns M.W.
      Validation of the Epworth Sleepiness Scale for children and adolescents using Rasch analysis.
      ) are examples. Additional recommendations include providing patient informational materials in clinical settings, such as pamphlets, reading material in waiting rooms, posters along hallways, and the like. Useful sources to obtain materials include: The National Heart Lung and Blood Institute (https://www.nhlbi.nih.gov/health/educational/wecan/tools-resources/tools-reduce-screen-time.htm); Common Sense Media (https://www.commonsensemedia.org/); and Nemours Children's Health System (https://healthykidshealthyfuture.org/wp-content/uploads/2015/02/Reducing-Screen-Time_FINAL.pdf).
      2. Evidence-based, sleep-friendly practices guidelines in the form of parent and youth education should be readily available for school nurses, clinicians, educators, and social service professionals in schools and primary care to help families achieve sleep-friendly practices and safe screen media practices.
      With the family, school, and community as the intended audience, school nurses, psychologists, and counselors should provide accessible and continually updated information on the use of screen media and its potential positive and negative effects. Evidence-based, sleep-friendly screen behavior recommendations for clinicians and educators include: teaching families about the importance of adequate sleep, building healthy sleep habits early, and emphasizing the negative effects of bedtime use of light-emitting screens on sleep; removing screen devices from bedrooms; and considering that children's mood, academic, or adverse health outcomes may be caused by excessive screen media use (
      • Hale L.
      • Kirschen G.W.
      • LeBourgeois M.K.
      • Gradisar M.
      • Garrison M.M.
      • Montgomery-Downs H.
      • ...
      • Orfeu M.B.
      Youth screen media habits and sleep.
      ). Examples of evidence-based sleep friendly screen practice tips include the Fact Box (
      • Carskadon M.A.
      Optimal sleep habits in adolescents.
      ) and Screen Friendly Recommendations for Parents (
      • Hale L.
      • Kirschen G.W.
      • LeBourgeois M.K.
      • Gradisar M.
      • Garrison M.M.
      • Montgomery-Downs H.
      • ...
      • Orfeu M.B.
      Youth screen media habits and sleep.
      ).
      Children and families need to take an active role and assume responsibility for understanding how screen media use affects their health. A Family Media Use Plan is available through the American Academy of Pediatrics (www.HealthyChildren.org/MediaUsePlan).
      3. Federal and private funding should be allocated to research the risks of screen media practices.
      There may be a “critical developmental period” during which screen media and sleep practices contributing to adverse health outcomes are established (
      • Tamana S.K.
      • Ezeugwu V.
      • Chlkuma J.
      • Lefebvre D.L.
      • Azad M.B.
      • Moraes T.J.
      • ...
      • Mandhane P.J.
      Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study.
      ), yet the evidence underlying universal recommendations may be flawed due to limitations of the research (
      • Ashton J.J.
      • Beattie R.M.
      Screen time in children and adolescents: Is there evidence to guide parents and policy?.
      ). Passage and funding of CAMRA and other sources of research funding is critical. Future studies need to: (a) include objective measures of sleep parameters such as sleep logs, actigraphy, and wakefulness testing (
      • Bhat S.
      • Pinto-Zipp G.
      • Upadhyay H.
      • Polos P.G.
      “To sleep, perchance to tweet”: In-bed electronic social media use and its associations with insomnia, daytime sleepiness, mood, and sleep duration in adults.
      ); (b) recruit samples that are racially, ethnically, and economically diverse; (c) focus on multiple reports of behavior including youth, parents, and teachers (
      • Przybylski A.K.
      Electronic gaming and psychosocial adjustment.
      ); (d) address confounders, such as screen media use outside the home, consideration that daytime sleepiness increases during puberty despite optimal sleep, parental beliefs about screen media use (
      • Thompson D.A.
      • Schmiege S.J.
      • Johnson S.L.
      • Vandewater E.A.
      • Boles R.E.
      • Zambrana R.E.
      • ...
      • Tschann J.M.
      Screen-related parenting practices in low-income Mexican American Families.
      ), and level of in-person social interaction (
      • Twenge J.M.
      • Martin G.N.
      • Campbell W.K.
      Decreases in psychological well-being among American adolescents after 2012 and links to screen time during the rise of smartphone technology.
      ); and (e) use longitudinal designs with large, randomly selected samples that contribute data at frequent intervals (
      • Quach J.L.
      • Nguyen C.D.
      • Williams K.E.
      • Sciberras E.
      Bidirectional associations between child sleep problems and internalizing and externalizing difficulties from preschool to early adolescence.
      ).
      Particularly necessary is research on how screen media is embedded in the social fabric of families and peer networks (
      • Ferguson C.J.
      Everything in moderation: Moderate use of screens unassociated with child behavior problems.
      ) that, in turn, may lead to excessive use. Ideas needing further study include youth actively using screen media as a sleeping aid or to counteract boredom, creating a self-perpetuating cycle of screen media use (
      • Hysing M.
      • Pallesen S.
      • Stormack K.M.
      • Jakobsen R.
      • Lundervold A.J.
      • Severtsen B.
      Sleep and use of electronic devices in adolescence: Results from a large population-based study.
      ) and that pre-existing psychopathology may lead to screen media use to avoid or escape distress (
      • Kaess M.
      • Durkee T.
      • Brunner R.
      • Carli V.
      • Parzer P.
      • Wasserman D.
      Pathological Internet use among European adolescents: Psychopathology and self-destructive behaviors.
      ). Research is needed on the mechanisms involved in the pathways of sleep disturbance and adverse health outcome as they may differ by youth developmental stage.
      4. Governmental agencies and private foundations should fund developmentally suitable prevention and intervention strategies aimed at the individual, family, community, and population levels to achieve youth sleep guidelines. Developers and manufacturers of screen media should consider support for professional training and literacy around screen device use.
      Public health campaigns conveying the hazards of screen media practices, sleep disturbance, and adverse health outcomes should be developed and evaluated through comparative effectiveness trials. Safe screen media and sleep friendly practices should be communicated to all American households.
      5. Future Healthy People frameworks, Youth Risk Behavior Surveillance Surveys (YRBSS), and World Health Organization (WHO) monitoring should include objectives and items to address sleep health and screen media practices.
      Healthy People 2020 includes an objective to reduce the proportion of early and middle childhood youth who have poor sleep quality. A similar objective should be included for adolescents. Since the use of screen media has increased at an unprecedented rate and is associated with sleep disturbances and adverse health outcomes, future Healthy People frameworks should use data available from the YRBSS to establish targets for screen media practices by children and adolescents. The WHO might consider inclusion of screen time in future monitoring and surveillance systems.
      Taken together these recommendations if widely disseminated and enacted will protect the health and development of children and adolescents worldwide.

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