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Abstract

Background:

Excessive screen time is associated with a negative impact on the growth and development of young children. We aimed to assess parent-reported multimedia usage among children in Northern India and to study the factors associated with excessive screen time in young children.

Methods:

A cross-sectional observational study conducted from mid-2020 to early 2021 in the Northern part of India among healthy children with normal neurodevelopment aged 6 months to 5 years. A total of 256 children were included from the pediatric outpatient department of a government tertiary care hospital, and their parents were interviewed using a structured, predesigned questionnaire.

Results:

The average reported screen time was 70 minutes per day, which exceeded World Health Organization (WHO) recommendations. Sixty-one percent of children had their first screen exposure before 2 years of age. Multiple linear regression analysis found a positive association between screen time and age (P = .00; r = 0.38), between mother’s screen time and child’s screen time (P = .04; r = 0.22), and between parental attitude toward multimedia usage time with children of indifferent parents having higher screen time (P = .006; r = 0.17).

Conclusions:

The study draws attention to screen time and the factors affecting it among young children in Northern India. Targeted interventions to increase media literacy among parents and emphasize more active lifestyles in young children are required to further decrease screen time.

Keywords

Screen time digital behavior screen behavior children

Introduction

With technological advancement, the last few decades have seen an explosion of multimedia devices in the market. Due to the changes in lifestyle and easy access, these devices have become an essential element in everybody’s life, including those belonging to the lower strata of society. This might have eased life in many ways, but it has led to increased screen time in adults as well as young children.

Extensive literature worldwide indicates that excessive screen exposure in children is associated with increased risk of various health issues, including behavioral problems and poorer developmental outcomes.^1,2 Statutory organizations such as the World Health Organization (WHO) and the Indian Academy of Pediatrics (IAP) have given clear recommendations about screen time in young children.^3,4 According to IAP, children younger than 2 years should not be exposed to screen time; those aged 24-59 months should have less than 1 hour per day; and those aged 5-10 years should have less than 2 hours per day. However, this is seldom followed, due to a lack of awareness as well as motivation among parents.

After the commencement of COVID, children were compelled to stay indoors, resulting in a sedentary lifestyle. Social distancing and quarantine led many parents to work from home while taking care of their offspring. The education system modified itself to online learning as an alternative way of teaching. These major life changes drastically altered the screen-viewing patterns among the masses. During pre-COVID times, most of the studies done on assessing screen time in children were performed in older children, and studies done during COVID had included online schooling while considering total daily screen time. Various studies all over the world support the finding of higher screen viewing during COVID-19 times as compared to the pre-COVID era among children.⁵ There is a notable gap in the literature regarding screen-viewing patterns among children under 5 years of age, particularly in the Indian context. Furthermore, the influence of socio-demographic variables such as parental screen time, education, family structure, and socioeconomic status on early childhood screen use has not been comprehensively studied in this population.

This study was therefore conceptualized to assess multimedia screen use patterns in young children aged 6 months to 5 years residing in North India. It aims to explore the variation in screen viewing time based on age, gender, socioeconomic status, parental screen habits, and other demographic factors. By identifying patterns and associated influences, the study seeks to generate region-specific evidence that can guide clinicians, educators, and policymakers in promoting healthy screen habits during early childhood.

Materials and Methods

This cross-sectional descriptive study was conducted from June 2020 to January 2021 in a tertiary care medical college-affiliated hospital in North India after obtaining Institutional Ethics Committee clearance (F1. IEC/MAMC/ 70/05/2019/No 534). Healthy children aged 6 months to 5 years, accompanied by their parents, were recruited from the pediatric outpatient department. Children with known neuro-developmental disorders, delayed development as assessed by the Trivandrum developmental screening chart, children engaged in online classes, chronic systemic illness, or those not accompanied by their parents were excluded. The estimated sample size was 256, using the formula n = (2s/d)² and where s = (1.36 hours) was the standard deviation of screen time among young children and d = (0.17 hours) was the precision.⁶ Children were stratified into 2 age groups: 6 months to 2 years and 2-5 years. This stratification was done in accordance with the WHO recommendations for screen time, where there should be no screen time for children below 2 years, and less than 1 hour per day for children aged 24-59 months.^3,4 After obtaining informed written consent, all the eligible participants underwent a standard evaluation consisting of relevant history about socio-demographic details and history suggesting any systemic disorders. A pre-structured interviewer-administered questionnaire was filled which documented the details about the device-specific screen viewing time, parental screen time, and parental attitude and knowledge about multimedia screen time in their children. Multimedia screen time was defined as the time spent on gadgets such as television, mobile phones, tablets, and computers, including laptops. The parents were asked about the child’s time spent watching the multimedia screen on 2 typical weekdays and 2 typical weekend days during the week before the day of the interview. Parents were questioned about their multimedia screen time on a typical weekday and a typical weekend. The information was corroborated by the children in the higher age groups. The average of the 2 weekday and weekend screen times was taken separately. The mean screen time was calculated by dividing the sum of 2 times the weekend screen time and 5 times the weekday screen time by seven. Following this, a thorough clinical examination was performed by the researcher, including systemic examination and anthro-pometric assessment, that is, weight and height, using standard methodology. The anthropometric parameters were plotted on WHO growth charts and expressed as age and sex-adjusted centiles.

The collected data were coded, tabulated, and statistically analyzed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp; Armonk, NY; 2017). Descriptive statistics were used. Linear regression was applied to assess the association between various factors and screen viewing in children, and the factors found to have a significant association were further subjected to multiple linear regression analysis. Pearson correlation was used to assess correlation. A P value of less than .05 was considered statistically significant.

Results

The study sample comprised 256 children with a mean age of 2.4 years. Children <2 years comprised 45% of the study population, and the male-to-female ratio was 1.6:1. The socioeconomic profile was comparable between the two groups, 40% being the lower middle socioeconomic stratum, and around 35% belonging to the lower class. The children living in nuclear (48%) and joint families (52%) were comparable, and most of the children (67%) had one or more siblings. Most of the parents were educated till high school (65% of fathers and 64% of mothers), with illiteracy in 11% of fathers and 17% of mothers. Only about 20% of parents had attained higher education (graduation/post-graduation). Approximately 92% of mothers were unemployed (housewives) as compared to 2% of unemployed fathers. All the demographic characteristics are collectively demonstrated in Table 1.

Table 1.

Socio-demographic Characteristics of Enrolled Children and their P Values.

Characteristic	Number (%)	P Value
Age
≤ 2 years	115 (44.9)
2-5 years	141 (55.1)
Gender		.20
Males	158 (61.7)
Females	98 (38.3)
Socioeconomic status (Kuppuswamy scale)Upper class/ upper middle classLower middle classUpper lower class/ lower class	67 (26.2)101 (39.4)88 (34.4)	.64
Number of siblings		.60
0	87 (33.98)
1	108 (42.19)
2	43 (16.80)
≥ 3	18 (7.03)
Father’s occupational status		.63
Unemployed	5 (1.9)
Unskilled/semi-skilled/skilled worker	183 (71.5)
Clerical, shop owner/farm	31 (12.1)
Semi-professional/professional	37 (14.4)
Father’s educational level		.42
Graduate/postgraduate/ professional degree	59 (23.0)
Schooling	167 (65.2)
Illiterate	30 (11.7)
Mother’s occupational status		.64
Working	21 (8.2)
Housewife	235 (91.8)
Mother’s educational level		.75
Graduate/postgraduate/ professional degree	49 (19.1)
Schooling	164 (64.1)
Illiterate	43 (16.8)

Anthropometric parameters suggested that 96.5% of the enrolled children had normal anthropometric parameters. Of the children, 1.9% were severely wasted, and 1.2% were severely stunted. A total of 2.3% children were severely malnourished, and 1.6% were overweight (Table 2).

Table 2.

Anthropometric Characteristics of Enrolled Children Based on Standard Deviation.

Parameter	≤−3 SD n (%)	>−3 and <+2 SD n (%)	≥+2 SD n (%)	Mean SD of Cohort (up to 2 yrs)	Mean SD of Cohort (2-5 yrs)
Weight for age	5 (1.9)	247 (96.5)	4 (1.6)	−0.63	−1.5
Height or length for age	3 (1.2)	250 (97.6)	3 (1.2)	−0.59	−0.98
Weight for height	6 (2.3)	247 (96.5)	3 (1.2)	−0.50	−0.68
BMI for age	4 (1.6)	248 (96.9)	4 (1.6)	−0.69	−0.33

Most of the households (62%) had up to 3 multimedia devices, with approximately 1 device per family member. Around 17% of households had ≥7 devices with access to ≥1 device per person. Among the individual devices, smartphones topped the list as the most frequent device available (98%), followed by television (74%), with the availability of laptops and tablets in only 5% of households. None of the children had access to the game consoles or video games (e.g., playStation, etc). The mean screen time of children in the study was found to be 70 minutes (SD 86 minutes), with approximately 70% of children <2 years and 49% in the 2-5 years age group exposed to screen time more than the WHO recommendations. The mean screen time of children <2 years was 30 minutes, and that of children aged 2-5 years was 95 minutes. Around 32% of the study population was exposed to screens before 1 year of age, while only 14% were exposed to screens after attaining 2 years of age as per WHO recommendations (Table 3). The average time spent on smartphones was double the time spent on television (47.6 minutes vs. 23 minutes). The screen time in children had a direct correlation with age (coefficient of correlation, 0.38; P = .00) and maternal screen time (coefficient of correlation, 0.22; P = −.04). Also, there was a significant influence of parental attitude, with higher screen time in children whose parents showed apparent indifference (coefficient of correlation, 0.17; P = −.006) (Table 4). An association of screen time with sleep duration was also assessed in the present study, and it was seen that screen viewing time was negatively associated with sleep duration, indicating that the duration of sleep decreased as the multimedia screen viewing time increased (Figure 1).

Table 3.

Distribution of Children According to Their Multimedia Screen Viewing Characteristics.

Number of Devices Available per Person	N = 256 (%)
0-1.00	221 (86.3)
≥1.00	35 (13.7)
Multimedia screen time
Nil	39 (15.2)
≤1 hour	127 (49.8)
1-2 hours	46 (17.8)
>2 hours	43 (16.8)
Age at first exposure
≤1 year	82 (32.0)
1-2 years	74 (28.9)
> 2 years	64 (25.0)

Table 4.

Association of Screen Time with Various Socio-demographic Factors.

Risk Factor	P Value	Coefficient of Correlation
Number of devices available per person	.07	0.09
Paternal screen time	.77	0.08
Maternal screen time	.04	0.22
Parents’ attitude/belief	.006	0.17

Figure 1.

Scatterplot of Total Sleep Time (Hours) Versus Average Screen Time (Minutes).

There was no significant relationship identified between parental screen time and parental education (P = −.47 for father’s education; P = −.30 for mother’s education) or socioeconomic status (P = .343) and children’s screen time with other socio-demographic factors such as gender, socioeconomic status, and type of family, or physical factors such as weight and BMI, and developmental status of the child.

Discussion

This study, conducted in a tertiary care hospital in India, examined the screen viewing behaviors of young children aged 6 months to 5 years who were not assigned online schooling during the COVID-19 pandemic. Most of the schools were conducting online classes for older children who were >5 years of age and students of class 1 and above during the COVID lockdown. In our study, we enrolled 256 healthy young children, and it was found that their mean screen time was 70 minutes per day. A significant association was found between screen time and age, the mother’s screen time, and parental attitude toward multimedia usage time.

However, when compared to a similar study conducted in Western India in the pre-COVID era, where the average daily screen time in children aged 2-6 years was found to be 2.7 hours (SD = 1.7), the present study found a mean screen time of 70 minutes per day only, which was lesser than the previously reported data.⁷ However, similar studies in other countries, including the USA, China, France, Germany, and the Netherlands, have revealed an increase in children’s screen time compared to pre-COVID times.^8-12 However, most of these studies were conducted in children older than 4 years of age, and there is a paucity of such studies in younger children. The reasons why older children have more screen time seem to stem from the development of cognitive behavior, fine motor skills to operate devices, an explorative nature, and improvement in understanding. In contrast, younger children rely on adults to choose and operate devices. Additionally, adults fear that their devices may get harmed by young children, leading them to keep continuous checks on them, which may restrict their screen time.¹³

Another key finding of the present study supports the role of parental knowledge and concern as an important determinant of a child’s screen time. This supports the results from previous studies.^14,15 Our study also showed similar results with higher viewing in children whose parents showed apparent indifference to their child’s screen time behaviors. It was also seen that maternal screen viewing, as compared to fathers, was an important contributor to a child’s screen time, which reiterates the fact that young children usually model the behaviors of their parents, more so of their mothers. Hence, it is important to educate the parents about the implications of their actions in sculpting young minds.

Excessive screen viewing in young children can have detrimental effects on their development and well-being. They may have delays in language, impaired social skills, poor cognition, impaired parent-child relations, and reduced creativity and imagination.^16,17 Apart from the effect on the behavior and developmental trajectory of the child, multimedia usage is associated with various physical problems such as obesity, vision problems, sleep issues, hypertension, and many more. The results of our study support the negative association between screen time and sleep duration in younger children. A similar study in young children showed lower sleep duration in those with higher screen time, particularly among users of portable multimedia devices (e.g., mobile phones and tablets).¹⁸

Through this study, we have tried to make some important conclusions regarding the screen time behaviors of young children. First, we encourage everyone to accept multimedia devices to be considered as lifestyle issues and work together to strike an optimum balance between a physical and virtual world. Fixed routines of children should be encouraged with a set time for digital media. Second, there is a need to educate parents and caregivers about the concept of role-modeling. Responsible adults would model digital well-being for the younger generation, which can be inculcated as a habit, thus limiting the harmful effects of screen time. Third, the concept and importance of screen hygiene should be a part of every pediatrician’s counseling. Setting screen time, taking breaks, and the ideal distance of the screen from the eyes are some of the important considerations.

The strength of our study lies in the fact that there are very few studies in India studying multimedia screen time in young children aged 6 months to 5 years. The first 5 years of life are a significant period in child development, and screen viewing behavior during this period may have a long-lasting impact on the well-being of children.

The limitation of our study was that this was a questionnaire-based study that relied on the information given by the parents. There is a possibility of a recall bias in our study. The potential benefits of multimedia exposure were not studied. In light of these limitations, future research should focus on prospective, longitudinal studies that objectively assess screen use and its developmental impact over time. There is also a need to explore the qualitative aspects of screen exposure, such as content type, context of use, and co-viewing with caregivers, to better understand their differential effects. Interventional studies designed to evaluate strategies for reducing excessive screen time and promoting healthy digital habits among parents and children would also be valuable.

Conclusion

The need for media literacy among parents is crucial, as their attitudes and behaviors significantly influence children’s screen viewing habits. Addressing excessive screen time in young children requires early, targeted interventions focused on both the child and the family environment. Promoting mindful media use through parental education is essential for developing healthy screen habits during early childhood.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Statement of Informed Consent and Ethical Approval

The study was accorded Ethical Committee Approval vide Ethics Committee No. F1. IEC/MAMC /70/05/2019/No 534 dated 1 November 2019. Written informed consent was taken from the parents or guardians of all the participants. The study was carried out in accordance with the principles as enunciated in the Declaration of Helsinki.

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