"Screen-time" for children and adolescents in COVID-19 times

The lockdown following the COVID-19 has changed the way a large proportion of people around the world go about their lives. Among the continued school closure and in a bid to adjust to this new way of life, the educational institutions resorted to the use of Internet-based technology to reach out and engage with the students.1 However, this meant that the children and adolescents accessed Internet and used Internet-enabled devices for a significantly greater duration of time. A similar disruption in the traditional education system due to COVID-19 followed by upscaling or shifting to alternative systems or models of education promoting distance learning has been adopted across several counties worldwide.2 For example, the Government of China resorted to an emergency homeschooling plan through creation and delivery of digital courses through television broadcast and Internet-mediated videoconferencing or streaming. Further, new virtual semesters have been started at some places in China to meet the gap in educational requirements of their children and adolescents during this and possible next wave of the pandemic.3 This has led to concerns being expressed about the potential harmful effects of excessive screen time among the children and adolescents in the popular media and scientific community.45 There are news reports about advisories against online classes for the preprimary school.6 Such suggestions have been made in view of the “potential harm of excessive screen time to the children.” In response to this, the Ministry of Human Resource Development, Government of India, has launched guidelines for digital education (“PRAGYATA”), which recommends states to limit daily screen time for online lectures or teaching to one session of 30 min for preprimary (0.5 h), two sessions of up to 45 min each for 1st to 8th standard (1.5 h), and four sessions of 30–45 min duration for 9th to 12th standard (3 h).7 It also describes resources for guiding school administrators, teachers, and parents in ensuring continued education of children during COVID-19 period and thereafter through various online (e.g. videoconferencing apps, social media networks, etc.) and offline (e.g. television, radio, etc.) digital platforms. The emphasis has been placed upon promoting physical as well mental health and well-being of students along with provision of digital education in a safe (cyber secure) and accessible learning environment. However, a detailed discussion about the challenges in providing digital education during COVID-19 in India and worldwide is beyond the purview of this paper. In this article, we present a case to revisit the concept of “screen time” in context of the current situation. While the need for this exercise stems from the situation in wake of COVID-19, it is likely to remain contextual going ahead. How much screen time is too much? The WHO recommends no sedentary screen time (such as watching TV or videos, playing computer games) for children <2 years and limits sedentary screen time to no more than 1 h (less is better) for children older than 2 years but younger than 5 years.8 The American Academy of Pediatrics (AAP) has also endorsed similar screen time restrictions.9 There are no screen-time cutoffs specifically recommended for older children or adolescents by either the WHO or any other government/country health guidelines. The concerns about the excessive screen time among children and adolescents pertain to two main health domains. First, an increase in screen time can have an adverse impact on physical health. This can result from a reduction in time spent on physical activity. In addition, prolonged continuous screen viewing can cause digital eye strain (e.g., dry eyes, itchy eyes, blurry vision, and headache). Watching or reading on screen at close distances can increase the risk of children developing myopia.10 The association between excessive screen time and obesity has also been reported.11 Further, several studies have reported increased screen time to be associated with poor sleep both qualitatively and quantitatively, with a recent systematic review and meta-analysis confirming poor sleep outcomes associated with screen time in very young children (0–2 years) as well.12 Several psychological and biological mechanisms have been proposed to explain the sleep disturbances associated with screen time, especially late-night use.13 For example, using mobile or any other screen near bedtime would simply displace sleep time. The combined effect of watching at a bright display screen along with emotionally arousing violent or fast-paced content in the form of movie or digital games can lead to psychophysiological arousal and cause sleep disruption. The after-dark time exposure to blue light or electromagnetic radiation emitted from several digital screens like smartphones has been shown to delay or suppress the melatonin production from the pineal gland and cause sleep problems due to circadian rhythm disturbances. These sleep disturbances in turn have been associated with physical health problems and poor psychosocial functioning including impaired academic performance.13 Second, excessive screen time can also lead to adverse psychological consequences. Use of screens while engaging in gaming, accessing social media, and watching online streaming services can be associated with behavioral addictions such as gaming disorder. Furthermore, excessive screen time has been found to be associated with an increased incidence of certain psychiatric disorders.11 However, a critical appraisal of the literature suggests that the relationship between psychological well-being and screen time among children and adolescents is at best inconsistent. The existing studies have reported either positive or no (and even negative) association between the two.141516 More importantly, the concept of screen time has multiple attributes besides the time spent looking at the screen. The studies that have explored the differential effects of screen time on psychological well-being have suggested that the type or purpose of activities engaged online and the broader life context in which they were engaged by these individuals are important determinants of the net outcome effects.17 Further, targeting a decrease in screen time as a stand-alone strategy did not directly translate into an increase in the physical activity among children.18 In fact, the recent studies conducted among representative samples of young children have even challenged the notion of excessive screen time among young children negatively affecting their physical health and psychological development at a later age.19 A study conducted among a representative sample of about 20,000 children ranging from 2 to 5 years old assessed the impact of screen-time use across different digital devices separately upon their mental well-being in terms of children's curiosity, resilience, attachment to caregivers, and positive affect.20 This study found no empirical support for screen-time limits recommended by the AAP or the WHO, after controlling for potential confounders such as age, gender, ethnicity, and socio-economic condition of the children. A U-shaped curve has been observed for the relation between digital screen time and mental well-being.1620 Need to revisit screen-time cutoff? The present scenario in wake of COVID-19 has brought to forefront the need to revisit the concept of screen time from a health perspective. This is important given the exclusive reliance on time spent looking at the screen as a measure to ensure healthy use of Internet and Internet-enabled devices. Interestingly, online social networking has been suggested as a way to connect with peers and relatives during the COVID-19 times by the WHO.21 A similar sentiment has also been echoed in the recent American Academy of Child and Adolescent Psychiatry position statement on media habits and sedentary screen time during COVID-19 quarantine among children and adolescents.22 The AAP guidelines also emphasize the importance of content and context of digital media use by children.9 A recent report prepared by the United Nations Children's Fund (UNICEF) has highlighted the children's and parents' views about the overall positive role played by the Internet and digital technology for educational purposes and leisure activities by children while acknowledging the concerns or potential risks with its use at the same time.23 Another report prepared by the UNICEF had pointed out the several gaps and methodological limitations in evidence-based literature supporting the validity and utility of having arbitrary screen-time cutoffs in today's digital world.18 It has also been argued that the activities and content children and adolescents engage in through digital technology are probably more relevant than the amount of screen time in determining the positive or negative outcomes experienced by them.4 The issue gathers a greater relevance in the context of exposure to screens for the purpose of learning. Currently, the teaching institutions have shifted to the online classroom to avoid the prolonged disruption in studies of students. This approach has increased the amount of time the students spend looking at a digital screen. However, based on the aforementioned discussion, there is a need to look beyond the absolute amount of time children and adolescents spend looking at the digital screens. Hence, it is important to have a well-thought approach on the role of Internet and digital devices in teaching and learning. Way forward for managing digital screen time in children and adolescents during COVID and post-COVID times First, there is a need to revise the existing recommendation on screen time for children and adolescents. It is important to incorporate the additional attributes of the screen time besides the amount of time spent looking at the screen. The most important of these shall be the activity being engaged in while using the screen. Use of screen for communicating with family and friends should be identified separately. Similarly, use of the digital screen for learning purposes should also be separated. Concerns of increased chances of developing problematic Internet use due to use of Internet and Internet-enabled devices for learning purposes are not grounded in unequivocal evidence. However, since the exposure to the digital screens can contribute to the adverse physical health consequences irrespective of the purpose of use, the necessary precautions should be taken to avoid the same. Second, there is a need to create an understanding among the children and adolescents on the purpose of access to Internet and Internet-enabled devices. They need to be educated about the use of these as tools in the learning process. There is a need to emphasize age- and context-appropriate access to Internet and Internet-enabled devices. The parents should discuss with their children about appropriate screen time on an individualized basis.2224 Co-viewing or co-sharing of digital content helps in strengthening the parent–child bond and provides opportunity to supervise the digital or media use habits and discuss about healthy pattern of digital technology use. Third, the Internet and Internet-enabled devices need to be approached as a lifestyle issue. With a growing access to Internet and Internet-enabled devices at an increasingly younger age, there is a need to focus on their safe and healthy use. There is a need to ensure the optimum balance between the offline and online life. The daily routine of children and adolescents should be maintained as much similar to their pre-COVID routine as possible, with fixed sleep, bathing, and meal times.21 In addition, they should be motivated to take up a hobby or activity that does not involve the use of digital screen to cut down on total screen time. They should also be encouraged to play nonscreen-based indoor games (e.g. board games, carrom, and chess) during leisure time.22 Fourth, we need to be cognizant of the potential threats (cyberbullying, exposure to undesirable content in the form of nudity, violence, or profanity) that children and adolescents might face while online. The early and/or prolonged exposure of children as young as 2 years to violent content over a digital medium like TV has been linked to risk of developing increased antisocial behavior and decreased prosocial behavior at a later age.25 Thus, parents should discuss freely and openly with their children regarding their experiences with the use of digital technology. Fifth, even when used for the learning purpose, the screen hygiene should be practiced. The children and adolescents should watch digital screens in a sufficiently lit room and take breaks in between to avoid eye strain. They should maintain appropriate posture while seated, for example, looking up from the screen or close-up work every 20 min and focus at least 20 feet away for 20 s. This 20-20-20 rule helps to relax the eyes and avoid digital eyestrain. Furthermore, the digital screen should be kept about 35–40 inches away from the face. In addition, the use of filters and glasses or screen protectors blocking blue light and reducing glare from digital screens is helpful in reducing the digital eye strain.26 The digital screen use during meal times and at least 1 h prior to the usual bedtime of children should be avoided.24 Finally, parents should follow healthy digital media use habits themselves, as research has showed that children model their parents' behaviors.27 In conclusion, there is a need to revisit the recommendations on the screen time for children and adolescents. The screen time is a complex concept and it is advisable to incorporate other attributes besides the total time spent looking at the screen while making the amendments. For example, the AAP screen-time guidelines apart from providing daily cutoffs also emphasize upon the content and context of digital media use by children, with recommending parents to choose age-appropriate quality content for the child and encourage them to co-share media use with them to improve parent–child interaction and relations. It also emphasize upon creating media-free routines (e.g., no screen time while eating, at least 30 min before bedtime) and ensuring that the child engages in other nonscreen-related behaviors associated with positive development of children (e.g., unstructured play, two-way communication with friends and family in the real world). Thus, a comprehensive approach that incorporates a wide array of activities and interventions with good evidence support for a positive effect on the overall health and well-being of children and adolescents should be promoted during the COVID-19 times and thereafter. There is a need for conducting future studies exploring the optimal cutoffs based on the type of screen time (e.g., active vs. passive), with a greater premium placed upon research that explores the content and context of screen-time use among children and adolescents at different developmental stages of life. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.