Screen Use in Children and Impact on Development: What Has Changed?

Editor’s Note: This text is a transcript of the course, "Screen Use in Children and Impact on Development. What Has Changed" presented by Angie Neal, MS, CCC-SLP.

Learning Outcomes

After this course, participants will be able to:

• Identify the pros and cons of screen time use in young children.
• List key areas of development that are negatively impacted by excessive screen use.
• Describe strategies that help minimize negative consequences of excessive screen time.

Introduction

This course is an update to a presentation that I did for SpeechPathology.com in November of 2019, "Digital Diets and the Impact of Screen Time on Development." Since late 2019, there has been an increase in the amount of data collected about screen use in children, as well as an increase in screen time among children.  I wanted to provide an update because who would've thought that just a few months later in March of 2020 the whole world would make a tremendous shift in so many things that we do due to the pandemic?  That includes how we use technology, how much we use technology, and the impacts that we're seeing today.

One point that I didn't include in the slides that I want to give you a head’s up about is if you've not seen it on Netflix, there's a documentary film called, "The Social Dilemma" that takes much of what you're seeing here and builds upon it. That is good to watch from an adult's standpoint.

What’s Different

First, let's talk about what has changed. More precisely, what are teachers describing that has changed? In case you're not working in a school setting, teachers are the ones spending so much time with little ones.

In my state of South Carolina, beginning this 2021-2022 school year, students were fully back in the classroom after having been in a virtual classroom the year prior due to the pandemic. I hear from teacher after teacher that students are struggling significantly more than they ever have before.  Students in school are struggling with just listening to a book being read to them. They're struggling with following simple directions, such as "get in line" and "get your backpack." They're struggling with basic problem solving or picking up on cues from their peers, like looking around to see if the other students are putting on backpacks or lining up.

Teachers are observing significantly more learned helplessness than before. I actually had a teacher friend tell me that a student came up to her and said, "Hey, can you open this snack for me?" She said to the student, "You have scissors in your desk. You can go do this yourself." He said, "I know, but can you just open it?" When the teacher said, "No," he just walked away and threw it in the trash.

Teachers are saying that attention spans are shorter, and the wiggles are more frequent. Many students get bored after 10 minutes of play, even with blocks. We're also seeing that academic readiness isn't there, including that language foundation that is necessary for building those early literacy skills.

Students are struggling to interact with their peers or be in a group of peers. One teacher noted that the interrupting and shouting is the worst she has ever seen in first grade, and she's been teaching for seven-plus years. Teachers are also saying students have a shorter fuse, and we're going to talk a lot about that as it relates to self-regulation and emotional regulation. They are seeing impaired fine motor development and are starting the first day with, "These are crayons. Here's how you hold them. Be careful with them because they'll break. Here's how you hold scissors."

Of course, while the pandemic certainly has its fair share of the blame, these are difficulties that were there before.  They're just now more intensified. Now, instead of teaching curricular standards as a result of all of these changes, teachers are starting the school year by teaching or reteaching some basic academic readiness skills.

Pros and Cons of Technology

There certainly are some good things about technology. First is virtual school. Can you imagine what would've happened during the pandemic if we did not have the option of virtual school? Also, there are new ways to socialize. During the pandemic, my family actually had a "Virtual Tailgate." We're big tailgaters and football game goers for Clemson, our favorite team. But we couldn't do that during the pandemic. So, we had a "Virtual Tailgate".

There are also so many apps that connect family and friends. We are able to FaceTime loved ones who are far away. We also have access to additional, very cool educational content that extends the learning in powerful ways. For example, students can now take virtual field trips to the Great Barrier Reef or to NASA. If they read a book about Egypt, they can pull up drone footage about the pyramids, artifacts, tombs, and all kinds of information related to that.

They can discover new hobbies and new interests. They can learn how to do all sorts of things on YouTube, like "Make Ice Cream in a Ziploc Bag" or do cool science experiments with things around the house.  They can learn magic tricks. They could find out so much about their favorite things like horses or dogs or rocks or minerals or presidents. Literally, there's almost limitless information that you can access with just the touch of a button.

But there are also the obvious cons. First, the rate of obesity has increased because there is increased eating while they're using screens, which then leads to more calorie intake. Also, when children are seeing advertisements for high-calorie, low-nutrition foods and beverages, that influences their preferences.

Then, of course, there's the disruption in sleep. When children have poor sleep, it's not just because of the blue light from the screen that makes it difficult to fall asleep. When children are staying up well past their bedtimes on a device, that also impacts their sleep and it impacts the appetite-related hormones.

Finally, screen-time impacts behavior. Behaviors have certainly been negatively impacted.  Before I explain why I want to clarify some important differences between screens. 

What’s The Difference Between TV and Handheld Devices?

The research has extended what we already knew about television and is adding information about handheld screens like iPads, iPhones, and tablets. There are very important differences that do impact development. First, TV was usually experienced as a group, but handheld devices are meant to be experienced alone.  Let's think about this. With TVs, at least when I grew up, there was only one TV and when we watched it, it was together as a group.  We experienced shows together and talked about them even after the show was over. With handheld devices, they're watching shows alone. So, a discussion is not taking place about what has been watched.

Another big difference is that TVs are pretty much stuck to one location. They used to be a big, huge piece of furniture and now they hang on the wall. The difference is that smartphones and iPads can go everywhere and there are huge implications for this, which I will explain more throughout the presentation.  The general idea is that when children are attending to shows and activities online, they aren't attending to the people and the things going on around them. This leads to what I refer to as the “opportunity cost”. When technology no longer has to be plugged into a wall, conversations don't happen while they're riding in the car and they're on their tablet. Conversations in which we are pointing out new vocabulary in the grocery store, or even talking while waiting in line are not occurring. That's the opportunity cost of decreased vocabulary and background knowledge. Again, we're going to talk more about that later.

The other difference is downtime. Children today are no longer bored as they really don't have downtime.  They don't even know how to be bored and the result of not being bored is that you don't have that opportunity to wonder, to come up with novel thoughts, to be creative, to imagine and reflect.

American Academy of Pediatrics

The recommended amount of screen time has changed as well. The American Academy of Pediatrics updated its stance on screen time because of the pandemic, while also sharing what the significant concerns are. First, in no uncertain terms, they talk about how excessive screen time has negative effects, especially in the early developmental period. They are also very clear in saying that it does more harm than good and that there are links to poor academic achievement, links to obesity and sleep problems, as well as behavior deficits and attention problems, especially, when excessive screen use is occurring during those critical periods of development.

The American Academy of Pediatrics used to recommend specific amounts of time, but again, that has changed. And, to be honest, parents needed a little bit of grace. The world changed, and the previous recommendations were no longer feasible, especially with online school being the norm. This, obviously, does not mean to throw caution to the wind and let children have as much screen time as they want, rather the recommendation is for parents to have a plan for screen use and then stick to it.

Their first recommendation is no technology until 18 months of age, unless it is for video chatting with an adult like a parent or a grandparent. That type of use is still social. 

Then, for the ages of 18-24 months, screen time should be limited to one hour a day, and only for co-viewing of educational content. For children ages 2-5 years, there should be a limit on non-educational screen time.  Again, we're thinking about that educational piece to one hour on weekdays and 3 hours cumulative on weekend days. That does not mean 3 hours on Saturday and 3 hours on Sunday. Again, it’s cumulative.  For ages 6 and older, they encourage turning off all screens during meals and outings. For example, in the car, while you're standing in line, while you're going through the car wash, etc.

Parents should learn about and use the different parental controls that are actually part of these tools. Also, avoid using screens as pacifiers or babysitters, or to stop a tantrum, and turn off screens and remove them from bedrooms 30-60 minutes before bedtime.

The New Second Hand Smoke

To be clear, the negative impacts of screen time are not just a concern when children are on handheld devices. There’s a great article by Theresa Rodgers, who is ASHA's past president entitled, "Parents' Smartphone Use Could Be the New Secondhand Smoke." That article came out in 2020. What it's meant to imply is that secondhand screen time is similar to the dangers that we know all too well with regard to secondhand smoke. But with secondhand screen time, children are indirectly exposed to screens because someone close to them is using screens instead of engaging with or attending to them.

And the impacts are significant. Ninety-five percent of parents report that their tech use does interfere with their daily opportunities for talking, playing, and interacting with their child without distraction, at least a little bit.  So, we're aware that it's a problem, but are we aware of why this becomes problematic?

For that, we need to consider the term "continuous partial attention". Continuous partial attention interferes with our most primitive emotional cuing system, which is based on responsive communication. Temple University conducted an interesting study, testing the impact of parent cell phone use on their children's learning of language. They had mothers and their two-year-olds brought into a room, and the moms were instructed that they would need to teach their child two new words.  The mothers were also given a phone so that investigators could contact them from another room if they needed it. When the mothers were interrupted by a call, the children did not learn the words. But when the mother was not interrupted, the children did learn the new words.

We know there are certainly times that parents need a few minutes to shower, cook, or even just talk to another adult. But these are the times when children should be sent off to entertain themselves and be bored. This is a good thing because it builds independence and gives them an opportunity to be bored and to play.

Here is the difference.  With continuous partial attention, the parent is with the child and the parent is not paying attention to them. This lack of engagement with the child, who is physically in front of them, sends a message that they are less valuable than whatever's on that device. It's this weird combination of being physically present, but emotionally disconnected.  I'm betting many of us have experienced this with another adult. But we know the difference and we can say something and do something about it. But young children can't. 

When parents are attending to screens instead of children, there are fewer verbal and non-verbal interactions between the parent and children.  And this is significant. As I mentioned, it's this serve-and-return and this responsiveness between parents and children. That's how we develop verbal and nonverbal language.  Between birth and age 3, all learning takes place in a social context through our relationships with other humans. The younger the child is, the truer this is. This is how we are wired biologically to learn language, and it can't be replicated in any other way.

There's also less responsiveness to the child when he/she is trying to get their parents' attention. When this happens, it impacts that relationship as well as the child's self-esteem and other emotional aspects of development because there's that lack of connection to and with their parent. 

Sometimes, too, parents become angry at the child for trying to get their attention. When children are not able to get positive attention, what do they do? They resort to trying to get negative attention. As a result, we're seeing very different children entering school than we have in years past.

Myelin

I want to talk about the specific areas of brain development and how they're impacted because that helps us understand the changes we're seeing. First, I want to discuss myelin. Myelin is what gives the brain its white matter. That's the white coloring due to the relatively high lipid fat content of the myelin protein. Myelin is a fatty coating that forms a protective sheath, kind of like what plastic around an electrical cord does.  It provides that protective coating, and it does the same thing for synapses. It's what allows the synapses to become fast and even more efficient.

Brain research tells us that the brain cells that produce this cholesterol from myelination, are very easily damaged by head trauma, stress, toxins, certain drugs, as well as the wrong kind of stimulation and the wrong amount of stimulation. This includes overstimulation. Too much stimulation or the wrong kind of stimulation impacts the ability to grow the brain in such a way that makes it easy and efficient to do things like learn new words, understand complex sentences, focus our attention, or even engage in play.  The overstimulation stops those synapses from growing, and it stops creating the myelin that makes it easy to do what we already know how to do.

This is especially critical in the 0-5 age range because in the first 2 years of life the brain triples in size. This is unparalleled growth to any other point in time over our entire lives. By the age of 3, the brain is 85% complete. Although we're born with a lifetime of brain cells, that's not what's growing. What's growing are those synapses. That's what accounts for the growth. We start out with 2,500 synapses, and we increase to 15,000 synapses by age 3. But these synapses are based on early experiences and meaningful experiences, not repetitive experiences like you would find on an app.

So, again, the synapses need to become pruned and more refined because that's what makes what we're able to do faster and more efficient. Think about it in terms of how toddlers learn to walk. First, they're super clumsy and inefficient, and they fall all the time. But eventually, they get faster and more efficient. Eventually, you're running and chasing them down in the grocery store.

Here's the key point and connection between the white matter and the myelin. A toddler's brain starts realizing which synapses it's actually going to need, and which ones they do not need. Once they realize that there's a synapse they don't use often, it doesn't myelinate. That becomes a big problem and there is research that supports this from the Journal of the American Medical Association. The research showed that among healthy pre-kindergarten children ages 3-5, who had not started kindergarten, when they exceed the amount of screen time recommendations from the American Academy of Pediatrics guidelines, that resulted in lower measures of microstructural organization and myelination that support language and emergent literacy skills, as well as corresponding cognitive assessments.  In addition, it showed slower cognitive speed and increased difficulty even just learning simple things. So, the impacts on language, early literacy, cognition, and the ability to learn are evident. In other words, it's not if there is an impact, we know there's an impact.

A lot of people are probably asking, "Have they figured this out? How did they determine this?" The researchers administered the rapid object naming portion of the Comprehensive Test of Phonological Processing, the Expressive Vocabulary Test, and the "Get Ready to Read,” which looks at emergent literacy skills. They also used a special type of MRI called Diffusion Tensor Imaging to examine the white matter, that myelin. The imaging showed that if the child exceeded one hour over the recommended amount of screen time, they had lower white matter. While the brain can certainly change and learn at all ages, it's the most efficient in the first five years. This is why those early childhood experiences are so important. It's harder for children to catch up if they start behind.

The takeaway should be how important the right kind of stimulation is for a young child's brain. I've used the following example several times and you'll hear me use it again. I like to compare it to food. Positive, frequent, repetitive language interactions between a parent and child are equivalent to a healthy diet of healthy fruits and vegetables. But passive, meaningless, decontextualized interactions with screen content are more like eating potato chips and French fries as a steady diet. If you wouldn't feed your child a steady diet of potato chips and French fries, why feed their brain a steady diet of what is essentially just mental junk food?

Dopamine

Dopamine is another aspect of brain development that is negatively impacted. As a quick definition, dopamine is the same feel-good chemical that's released when people do cocaine, or when somebody likes their Instagram post. When people are triggered by some sort of external stimuli, there's a rush of dopamine that's released through the neural pathways to the reward system. That “rush” tells someone what they are doing feels good, and we should do more of it. There's ample evidence that screens trigger and release a significant amount of dopamine. This release wears down those pathways in the brain, which then increases the demand for more stimuli.

There is a new category in the DSM-5 called "Internet gaming addiction." The diagnosis criteria include the following, and I urge you to think about this related to children or students that you may be concerned about: preoccupation or obsession, withdrawal, loss of interest in other things, continued overuse, use as an escape from negative feelings, as well as functional impairments.

Let's think about what an addiction is. Basically, an addiction is something you do in the short term, that undermines your well-being in the long term. That’s anything that you do in a compulsive, habitual, and uncontrollable way. Digital addiction can begin in early childhood. In fact, infants are at the greatest risk because they're born wired to learn through the world, through cause and effect, because it explains how things happen. For example, if I drop a game off the high chair, you're going to go and get it for me.  That's learning cause and effect. But here's the difference. Apps and games on the iPad never stop. They violate that expectation of cause and effect.

Apps and games on devices also impact a child’s understanding of object permanence. With apps that are designed for young children that have different things popping out, that develops a novelty bias and makes it very difficult for a child to disengage from.

Dopamine is supposed to serve as a survival function. It's a reward to incentivize basic biological functions like eating. For example, after some effort delay, whether it's waiting for Mom to serve the food or cook the food, and then you eat the food, eventually, there is the reward of eating the food.  But technology is providing a shortcut to this reward process, is flooding the brain with dopamine, and is not serving any biological function. Consider how many dopamine hits a child is getting per game or per swipe, and then multiply that across the length of time they're on a device.

Evolutionarily speaking, humans haven't adapted to this. Our bodies don't know what to do with this flood of dopamine. Which means they're going to crave more dopamine while producing less dopamine naturally in order to self-regulate the surge of dopamine.  That, in turn, makes it harder to experience joy from the naturally occurring dopamine and producing experiences. The more time spent on screens, the more addicted to screens a child can become in order to get that dopamine rush.

Again, we are talking about addiction in children, and most technology is actually designed to increase dopamine by incentivizing play by having rewards for achieving certain levels, by receiving certain tokens, by getting a certain desired object, having random rewards, or decreasing the reward rate over time. For example, you start out getting lots of rewards, and then it takes longer and more effort to get them. Eventually, too, there's also punishment where they take away rewards for not playing every day or for having losing streaks. Then, when children have to stop playing a game or watching YouTube videos, what happens? The dopamine levels drop, and young children do not have enough ability to regulate these emotions in the first place in order to make that transition without some level of chaos.  This is why 93% of parents said that their child throws a tantrum, whines, or resists at least occasionally when screen time is removed.  Remember, this is not just a result of the reward center of the brain being overstimulated, but it's a consequence of the other areas being understimulated.

Executive Function Development

Executive function development is impacted because of the lack of opportunity. Again, this is the "opportunity cost" to develop and refine these skills through interactions with other humans. It explains many of these behaviors teachers are describing.

Executive function basically has four domains: cognition, action, emotion, and perception. Cognition includes cognitive flexibility, such as attempting to solve a problem in multiple ways. In other words, if you can't open your snack and the teacher won't open your snack, try and find another way.

Cognition also relates to theory of mind. This is the ability to think about your own thinking and the thinking and perspective of other people.  This is a hallmark of autism, and we're going to touch on that later. But you can't develop theory of mind, the ability to think about what other people are thinking, with a screen. Development of theory of mind begins early at around 3-18 months. It starts with following the direction of a gaze, turning a head and pointing or gesturing, attending to facial features, and following a line of regard. That's all based on your interaction with people.

Executive function also includes those controls for emotion. This is important because emotion sets the tone for perception, thoughts, and action.  In other words, we all know that your emotions tend to influence what you're thinking, what your actions are, and how you perceive things. Again, screens have that “opportunity cost” related to the development of executive function.

Let’s consider emotional regulation which is the ability to maintain a well-regulated emotional state, cope with stress, and be available for learning and interacting. It helps us to move from negative emotions to positive emotions. Emotional dysregulation is not being able to do all of that. It’s not being able to manage your emotions appropriately.

Consider this example. I had a student who was on a roller coaster of emotions.  Once, within a 10-minute span of time, he was compliant, then he ran out of the room, then when we caught up to him, he was aggressive and angry, then we brought him back in. There was a tremendous amount of emotional lability, tears, crying, regret, and then it was back to compliance. That was within 10 minutes. Think about that. How ready was he to learn or follow directions and read stories about Abraham Lincoln? Would you be able to do it if you were feeling like that?

How does emotional regulation develop then? First, it starts with babies expressing emotions that are responded to by their caregivers. During the first 3 years, that ability to label emotions begins.  By the age of 3, children should be able to intentionally modify the intensity of their emotions depending on the situation they're in. By the end of pre-school, they should be able to use some strategies for emotional regulation. They should be able to manage their frustration, inhibit some emotions and stay organized even when there are big emotional things happening. That's what they should be able to do. But that doesn’t happen if they've not had the opportunity to engage in situations where they observe that happening, where they learn how to do it, and where they get to practice these skills with other humans.

Emotional regulation is also closely related to self-regulation, which is the capacity to control your emotions. Self-regulation is modeled by adults in their environment when they talk to the child in a calm voice, when they hold them or rock them, and when they make children feel safe and comfortable again. But this does not happen if a screen is used in place of that. Let me explain that. I have had several pediatricians tell me that often when a young child is given a vaccine, instead of comforting the child, the parent gives them the phone. This is not teaching the child to self-regulate and by the age of 3 most toddlers should have learned some self-regulation skills, such as being able to wait for a short period of time for something they want, and to pay attention when someone is talking to them.  This all occurs as a result of observing, learning, and practicing these things with other humans.

Continuing on with executive function is action, which relates to inhibitory control, or the ability to control your impulses. It also relates to recognizing a distraction and ignoring it. 

I want to go into some detail about perception. The visual processing system begins developing before the age of 2, but it's not finished developing until around age 8 or 9. However, the faster the visual information comes in, the faster the brain needs to process it in order to keep up. But children, especially those with ADHD, often get in this state of hyper-focus because their brain is super busy processing all of this fast-changing visual information. Having this happen over and over again during critical stages of development can cause permanent changes in the processing pace of the brain. So, a two-year-old could potentially grow up feeling comfortable in that super-fast-paced environment of screen media overstimulation, and uncomfortable with the normal pace of everyday life. Again, what happens when you have to eventually pull them away from the screens? Chaos. Why? Because they were super focused, and now they're super unfocused. Until the brain readjusts to real life at a normal pace, which does take some time, they're likely to be bouncing off the walls in an attempt to find that same stimulation that's moving at the same pace as their brain.

The visual system is also closely related to the vestibular system that controls balance and your perception of where your body's in space. It also has an impact on mood. For example, linear acceleration is calming, such as rocking, swinging, walking, or even driving a cranky baby so that they fall asleep. On the other hand, rotational acceleration is arousing. Think of the spinning teacups at Disney World.  It's either going to arouse you or make you throw up.  The problem is that while the child's visual system is in super busy processing mode, it locks down the vestibular system, which then puts emotion on a really uneven keel. Then, once they're off the screen, the vestibular system is unfrozen and they're struggling to readjust and what we see is a dramatic shift in their mood.  To summarize, executive function skills may be impaired by excessive screen use, and lead to the difficulties and behaviors discussed above such as tolerance for frustration, task, persistence, and increased emotionality.

Attention

Brain plasticity is one of the most amazing things about the human body. Humans can be born missing whole sections of their brain or having damage to parts of their brain, but because of plasticity, other areas of the brain adapt and help take over these skills. However, in the case of screen use, the brain adapts to the environment that it's in and what it is asked to do within that environment.

What do you think the implications are of being in an environment that emphasizes speed, multitasking, and continuous partial attention? The average attention span is currently down by about half, and that has implications for learning and memory. We actually have whole generations that are now being trained to have shorter attention spans than a book requires. Books take cognitive patience, learning to read, and perseverance, and apps don't provide that. When apps get hard, you can just turn them off. Also, the amount of distraction for children and youth through about age 29, is 27 times per hour. This is one thing for adults who have fully developed reading brains, for those of us who already know how to read, and already have executive function skills. We can actively problem solve, identify, and eliminate these distractions. But it's an entirely different thing for children who haven't mastered these skills. If you're a reader who struggles with attention and recall of what you've read or reading stamina, what's the impact going to be on comprehension?

Think about this question. Have you ever gone through a book drought, meaning, you haven't picked up an actual book in about 3-6 months? You've been reading all kinds of material, but not anything of great length beyond a few paragraphs or anything that has any syntactic complexity. Then you pick up a book to read.  How does it feel?  For me, I find that I have to go back and reread. I struggle with the stamina to get through it. I struggle with the attention to process syntactically complex sentences.  I actually have to acclimate myself back to reading a book, as opposed to reading bits of information from Yahoo News, Twitter, or Facebook. While reading Facebook, Twitter, and online news does have a purpose, that purpose is not deep reading. It’s semi-reading because those shortened, less complex texts do not require any complexity of thought. Therefore, we're not going to have insight into and reflect on what we read.

You may not have realized it, but over the last 10 years, we've changed how we read, what we read, and why we read. The average person in the United States reads the same number of words found in a novel, but rarely is it continuous, sustained, or concentrated. We consume information as entertainment. We read an article about this, a Facebook post about that, etc.  But it's really just a diversion and we're really only reading at the very surface. We certainly aren't analyzing it critically, taking the time to reflect on the content to determine whether or not the author had bias, or if the information is factually accurate.

We're also confronted with too much information. Books and movies are now catering to and exacerbating shorter and shorter attention spans.  Scenes, movies, and TV shows are coming at us more frequently in order to hold our attention. We're seeing changes now every 7 seconds or less. Additionally, if you used a readability formula to look at current best-seller books versus classic literature, the average sentence length in current bestsellers is less than half the length average of mid-20th-century work per sentence. In other words, it's less dense. There's less author word choice, syntactic complexity, and figurative language.

Language

We've talked about language already, but I want to highlight more of the research. In 2015, children who started watching TV as early as 12 months and watched for more than two hours a day, were 6 times more likely to have language delays.

In 2017, Dr. Catherine Birken’s research revealed that for every 30-minute increase in handheld screen time, there was a 49% increased risk of expressive speech delay in children ages 6 months to 2 years of age. In other words, the more handheld screen time the parent reported, the more likely that child was to have an expressive speech delay. We know that delays in spoken language are related to delays in written language. In fact, the majority of poor readers, have an early history of spoken language deficits. And, of course, when children haven't engaged in conversation, the result is that they don't alert to hearing words that aren't familiar. They're not listening as carefully, and later on, they're just not as good at reading as they could be.

As I have mentioned, connection with parents, human interaction, and physical interaction with books before the age of 2 are the building blocks of creating the reading circuit for the brain. Sharing a book with a child is significantly different than having the child read a book on the iPad because book sharing is the only setting where parents typically talk with a child about things that are outside of their everyday routines. Think about it. It's a chance to talk about space, Africa, castles, and dragons because it's not constrained to the here and now. When that doesn't happen, there's an impact on background knowledge and vocabulary. In the early development, again, this happens through conversation. Later on, it's through books, but at the very beginning, it's through conversation.

Limited language-rich environments and conversations will impact not only vocabulary but phonemic and phonological awareness. This happens because the child is not being exposed to rhythm and rhyme and alliteration. Being read prepares us for complex grammar that's only found in books, and it provides a sense of narrative that stories have a beginning, middle, and end.

I mentioned phonological awareness, but just a point about phonemes in particular and the concerns about whether or not masks during this time have impacted development. If masks were to blame for poor articulation and phonological awareness, then children who are blind or visually impaired would have these types of documented deficits. But they don't.

In terms of play, this is the “opportunity cost” again because screens get in the way of development. Play is a child's work.  This is where they learn and acquire all kinds of cognitive skills and language skills, not just from the objects they play with, but from the peers they interact with as well.

Pretend play is where we start to experience emotional and social situations. It's where we start to learn to control our emotions, resolve conflicts, and negotiate rules with partners. Without those opportunities, there's an impact on development. Also, as it relates to the secondhand smoke mentioned earlier, the level of involvement in pretend play by preschoolers with their parents, in particular, is positively linked with their capacity for emotional regulation because of the guidance and the coaching that parents offer.

When we compare this to virtual reality, playing with another 2-year-old or 4-year-old is found to be “boring”. You have to share your stuff, you have to take turns with somebody who also wants to be the fireman, and your friends don't do everything you want them to do the very moment you want them to do that.  How can Candyland compete with that?

Autism

Let’s move on to autism and the changes we’re seeing. In 2014, 1 in 59 children had a diagnosis of autism. In 2020, it increased to 1 in 44. In schools, it's risen from 93,000 children in the 2000-2001 school year to 762,000 in 2021.

There's research being conducted that confirms what I believed back in 2019 about the rise in autism.  The hours spent on electronic devices are associated with autism-like features. As a matter of fact, research suggests that the hours spent using the electronic device were significantly associated with the daily hours spent on devices and a score on the Social Communication Questionnaire above 15, which suggests a deficit in social skill development and having autism spectrum disorder-like symptoms (Alrahli, 2021).

Another study found that screen time was positively correlated with the CARS score. Again, the longer the screen time, the more obvious the autistic-like symptoms. Why is this happening?  It’s that opportunity cost. Longer screen time means shorter play time, shorter companionship with the caregivers, shorter time for social interactions which results in worse behavior and more obvious autism-like symptoms. But to be clear, it's not technology that's causing autism spectrum, it is the disproportionate exposure and overstimulation during those critical periods that negatively impacts the development of social communication, social-emotional skills, and behaviors that look like autism.

Digital Diets

What can we do? A digital diet is meant to imply that what we put into our brain contributes to healthy brain development and what it needs to develop appropriate skills.  Make no mistake, most of what is on the screen is mental junk food. What children need the most is healthy, physical, emotional, intellectual, and social development through interaction with other humans and with the world around them. They need things like a rattle. They need hugs, they need dolls, they need pots and pans, and Tupperware. They need to be tickled. They need to stand at the bathroom sink and play with cups and spoons and soapy water. They need to play peekaboo. They need riding toys and blocks and balls and piggyback rides. They need to be looking out of their car window. But we need to let parents know that this is not going to get easier. It's much, much harder to take away an iPad from a 3-year-old than it is to take it away from a 12-year-old. But, again, the age of 3-5, is when they're developing habits they'll have for life. These habits can be good habits or not-so-good habits related to sleeping, eating, personal hygiene, and taking care of their personal belongings. Of course, they can learn them later, but it's going to be harder later, especially if the myelin has been compromised.

We also need to remember that at the ages of 0-2, parents are 100% in control of their child's screen use.  Until 18 months, again, screen use should only be for the purpose of interacting via FaceTime. At ages 2-5, parents are still 100% in control of the screen viewing and the best use of screen time is via co-viewing. After a child watches the program on a screen, replicate what they have watched so they can have a real-world experience to connect with the screen experience. For example, if it was a program about making a cake, go bake a cake. For preschool, that experience will be real, even if it was make-believe, as long as they are physically and socially involved in it.

Also, no technology before school. Children are the most alert and ready to engage with the world when they wake up in the morning.  Exposure to screens at that time will start the zoning out process, which makes it harder for them to concentrate and do their best. Most teachers will tell you that they can tell who's been on a screen that morning.

Physical activity goes back to that perception piece. After screen time, do a physical activity. Turn this into an automatic connection. After you put down those screens, do a physical activity such as go play hopscotch, go jump rope, go ride your bike, go jump on the trampoline, go run up and down the stairs three times.  That physical activity is going to reset that perceptive system, that vestibular system, that affects their mood.

Don't give them the charger. This is a really practical, physical way of setting limits and keeping the parent in charge. Point out that they only have a certain amount of time and only a certain amount of charge left until the device shuts off.  Then they are in charge of figuring out exactly what it is they want to accomplish during that period of time.

Create tech-free times and locations. For example, no tech in the car. A car ride is for conversations and observing the world around you.  No tech at the dinner table because that is also for conversation. I'll be honest, I think that is harder for adults than children. There should also be tech-free time right before bed, as the American Academy of Pediatrics recommends. Those are the best times to engage in conversation, and/or improve sleep.

Also, keep a bag of boredom busters for older children if they're going to be waiting for a long period of time whether that is standing in line or waiting at the doctor’s office.  Have a little bag with Legos, playdough, beads and a string, or dry noodles and string, pennies and a small box with a little slit so they can practice that fine motor skill of putting the coins in the bank.  Pipe cleaners can be used to make shapes.  The goal is to teach the child to actively sustain attention through something other than passive use of the screen.

Make use of apps that monitor and restrict the amount of time the technology is used. There are a bunch of them so I'm not going to list them. But another recommendation is to change the phone to grayscale. Don't keep it in color. That automatically makes it less overstimulating.

Think about all those things we used to do as a child. What did we do before technology?  We read books and we had game nights. The cool thing with game night is that's where you provide feedback: How do you win?  How do you lose? How do you take turns? You can have a play date with friends or with just your parents, and work on specific skills like compromise, complimenting, and social manners, like, "Please, thank you, and excuse me."

Also, train and practice delayed gratification. Being able to delay gratification means that you're able to function under stress.  Children are becoming less and less equipped to deal with even minor stresses, which becomes a huge obstacle to success in later life. Teach them to do the mundane monotonous chores, like folding laundry, cleaning their room, hanging up their clothes, unpacking the groceries, emptying the dishwasher, putting toys in the toy box, making their bed. Teach them to do those things.

Get them engaged in activities, especially outside the home. Golf is a personal favorite, not because I'm good at it, but because golf deals a lot with the social rules, being considerate, and playing with other players. Also, talk more. I like to recommend getting a sticky note and putting it on the dash of the car. All it has to say on it is, "I remember…" That reminds parents to talk about things as they drive that may inspire stories to tell their children about when they were little. There are many other things that will make a big difference.

In summary, I recognize that this is very difficult content. It's unsettling because technology is out already out there, and we can't close Pandora's box, figuratively speaking. But we can proceed by doing things more intentionally and knowing what the risks are.

Questions and Answers

Can you explain novelty bias?

Novelty bias is when you're constantly searching for novel stimulation. So instead of looking at the same things all the time, and that being okay, you're constantly searching for things that are new. 

What are your thoughts on eBooks and Kindle versus paper books?

There's a great deal of research out there on this. If you really want a great book that explains this in-depth, Dr. Marion Wolf has a book called "Reader come home," that goes into this in depth. But the gist of what you need to know about eBooks, Kindle and paper books, is you have to consider the context in which they're being used. If you're just reading a book for fun, for example, I'm on the beach and I'm using my Kindle to read whatever fiction book, that's a whole different purpose than reading to learn or reading to gain information.

If you think about it, even using a paper book, there's a physicality that actually helps you remember information. For example, "Oh, yeah, I remember that information was on the right-hand side of the page." Or "I remember that was a dog near that page." You can't do that with a Kindle. You can do highlighting, but you can't pull out some of those specific kinds of physical tasks where you're interacting with a book.

Is it possible that children who are late talkers are more attracted to screen time due to decrease communication demands of the activity? I feel this relationship could be bad directional.

I would agree, I would say also that it can be bad directional.

What are your thoughts on online independent learning programs for children in lieu of class time?

When you're talking about virtual school, it is all about a purpose.  There's a purpose for that instructional time that is via a virtual screen, there's a purpose for that. Mostly, what we're talking about, when we talk about the negative consequences, are the passive activities. So, yes, we are definitely in a time where we have to have virtual content and we have to have virtual screen time. But that is being actively engaged on a screen, as opposed to video games, YouTube, things like that. I do have one caveat for teachers, and that is to be especially mindful of the video content, even when they're in class.  For example, showing GoNoodle and having the children do those activities and then trying to get them back on track. If you're seeing your students can't handle it, there's a reason for that.

Is the brain damage due to screen time reversible in children over 5 years?

There's always that opportunity for the brain to develop. But again, we have to consider what might have happened in those critical stages of brain development, especially when we're talking about myelin. So, there's nothing that says they can't, but it certainly is much harder.

What is the best way to share this information with schools that I service in that community?

I think this is a topic that is an entire professional development course or in service. If you could provide this through a PTA night or something similar, that is a great way to share this information. But mostly, I like to share it one-on-one with parents, especially when I'm seeing these kinds of concerns in children. And I like to do that first by building trust. I don't want to immediately walk into a conversation and say, "Hey, your child's been on the screen too much." You need to start by developing trust around other things. Trust is developed in small moments with other people. So, share conversations about other things, “How are they doing with this?” “I remember their birthday party was coming up,” or “How did the surgery go?”  So, develop trust in those small moments, and then start bringing up those kinds of issues and concerns.

What is your opinion about YouTube channels for kids? Would you limit it?

Aha, yes. There are great educational videos for kids. But again, it's got to be a balance. Like I said, "If they're learning about how to bake a cake, then go bake a cake." Translate the screen time information they're getting with the real-world application.

What are your thoughts on playing interactive online games during speech therapy sessions?

It depends on what the purpose is for what you're trying to accomplish. For example, if you're playing an interactive game with a child through video or teletherapy, it depends on what the purpose is. Is the child mastering the content or are they getting distracted by the interactive game or app? It's not always as simple as a yes or no, you have to consider the context, and you have to consider the student's response to it.

I see high middle school students and I see serious technology addictions.

Yes, yes. I have a freshman in college and a junior in college, and I tell them the same thing. And I very much hit them hard with having phones at the table, even with my husband.  Yes, most definitely, it is a big concern. Again, remember, it's changing how they process what they're learning, even in college. It impacts how they learn, how well they can attend to what they're learning, and that cognitive perseverance to learn.

With high school kids, what can parents do?

Set and enforce limits, that's the hardest part. I can promise you that having children who are a freshman and junior college, it's very hard to set those limits. But you also have to talk to them about why? We should never enforce limits without telling them why this is not good for them. We do the same thing with smoking, we do the same thing with drugs and alcohol, and we need to do the same thing with screens.