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Infant Media Exposure and Toddler Development Suzy Tomopoulos, MD; Benard P. Dreyer, MD; Samantha Berkule, PhD; Arthur H. Fierman, MD; Carolyn Brockmeyer, PhD; Alan L. Mendelsohn, MD

Objective: To determine whether duration and con- tent of media exposure in 6-month-old infants are asso- ciated with development at age 14 months.

Design: Longitudinal analysis of 259 mother-infant dy- ads participating in a long-term study related to early child development, from November 23, 2005, through January 14, 2008.

Setting: An urban public hospital.

Participants: Mothers with low socioeconomic status and their infants.

Main Exposure: Duration and content of media expo- sure at age 6 months.

Main Outcome Measures: Cognitive and language de- velopment at age 14 months.

Results: Of 259 infants, 249 (96.1%) were exposed to me- dia at age 6 months, with mean (SD) total exposure of 152.7

(124.5) min/d. In unadjusted and adjusted analyses, du- ration of media exposure at age 6 months was associated with lower cognitive development at age 14 months (un- adjusted: r = −0.17, P � .01; adjusted: � = −0.15, P = .02) and lower language development (r = −0.16, P � .01; � = −0.16, P � .01). Of 3 types of content assessed, only 1 (older child/ adult–oriented) was associated with lower cognitive and language development at age 14 months. No significant as- sociations were seen with exposure to young child– oriented educational or noneducational content.

Conclusions: This study is the first, to our knowledge, to have longitudinally assessed associations between me- dia exposure in infancy and subsequent developmental outcomes in children from families with low socioeco- nomic status in the United States. Findings provide strong evidence in support of the American Academy of Pedi- atrics recommendations of no media exposure prior to age 2 years, although further research is needed.

Arch Pediatr Adolesc Med. 2010;164(12):1105-1111

M EDIA EXPOSURE PLAYS

an increasing role in the lives of infants and toddlers,1-3 despite the American Academy of

Pediatrics recommendation that children younger than 2 years should have no me- dia exposure.4,5 In part, the increasing ex- posure of infants and toddlers to various types of media has resulted from the emer- gence of media content specifically geared toward infants and toddlers and mar- keted as educational.6,7 Children from fami- lies with low socioeconomic status (SES) are likely to be most vulnerable to any ad- verse effects of media exposure on early child development because they have been documented to have the greatest expo- sure to media8-10 and are at increased risk in general for disparities in early develop- ment, school readiness, and educational achievement.11

A substantial body of literature12-14 has documented adverse effects of noneduca- tional media in preschool and school-

aged children on later outcomes, includ- ing cognition, achievement, and behavior. Emerging research strongly suggests the potential for adverse effects of media be- ginning in infancy.10,15 However, many of the studies have been performed with fami- lies that are not economically disadvan- taged; also, these studies have not been prospective or have not included de- tailed information regarding content. In particular, to our knowledge, there has been no prior longitudinal study per- formed in the United States concerning the effect of media exposure on the develop- ment of infants from families with low SES.

In this study, we sought to assess whether duration and content of media ex- posure at age 6 months were related to later developmental outcomes at age 14 months. We had 2 hypotheses: first, that total du- ration of media exposure in infancy would be adversely related to developmental out- comes, and second, that associations be- tween media exposure and developmen- tal outcomes would vary depending on

Author Affiliations: Department of Pediatrics, New York University School of Medicine–Bellevue Hospital Center (Drs Tomopoulos, Dreyer, Berkule, Fierman, Brockmeyer, and Mendelsohn), and Department of Psychology, Manhattanville College, Purchase (Dr Berkule), New York.

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content, with the greatest adverse effects seen for non- educational content.

METHODS

STUDY DESIGN

We performed a longitudinal analysis of mother-infant dyads par- ticipating in the Bellevue Project for Early Language, Literacy, and Education Success, a study assessing the role of primary care interventions in promoting child development through en- hanced shared reading and play. Two interventions, the Video Interaction Project16,17 and Building Blocks,18 were studied in the larger project; each was designed to enhance shared reading and play. This analysis included mothers and infants who had been enrolled from November 23, 2005, through January 14, 2008.

STUDY SAMPLE

Enrollment of consecutive eligible mother-infant dyads was per- formed in the postpartum unit of Bellevue Hospital Center, New York, New York, an urban public hospital serving at-risk fami- lies. Inclusion criteria were intention to receive pediatric pri- mary care at our institution for at least 3 years, English or Span- ish as the primary language, uncomplicated full-term delivery, no early intervention eligibility, the mother as the primary care- giver, ability to contact the mother, mother’s age being at least 18 years, and no significant maternal medical problems, as de- scribed previously.10

We obtained written informed consent from parents be- fore participation. Approval for studies involving human co- hort individuals was obtained from the New York University School of Medicine Institutional Review Board and Bellevue Hos- pital Center Research Committee.

STUDY VARIABLES AND ASSESSMENTS

The independent variables were total duration and content of media exposure at age 6 months. The dependent variables were cognitive and language development at age 14 months. We also assessed potential confounders, including home environmen- tal factors, and family sociodemographic characteristics.

MEDIA EXPOSURE

We assessed electronic media exposure in the home with a widely used method, namely, a 24-hour recall diary based on an interview with the mother.19-21 We asked the mother to provide information about all electronic media (television, videos/DVDs, movies, and games) to which the infant had been exposed on the most recent typical day, including name and duration (in minutes) of each pro- gram. We asked the mother to include all programs for which the infant was present and awake, from the infant’s awakening in the morning until going to sleep for the night. Information from the diary was then used to calculate our 2 study variables:

1. Total duration of exposure (in minutes): We calculated total daily duration by adding together the duration of each ex- posure for the child during the 24-hour period.

2. Content of exposure (in minutes): We assessed pro- gram content using information obtained from industry rat- ing systems and a consumer media Web site (TV Parental Guide- lines,22 TV Guide,23 and the Motion Picture Association of America).24 Media content was categorized while masked to out- comes, using a classification system developed by some of us10,21:

Educational young child–oriented programs consisted primar- ily of those with educational content intended for children 2 to

6 years old, including live action and animated programs (eg, Sesame Street and Blue’s Clues). In addition, media marketed as infant-directed and educational (eg, Baby Einstein and Brainy Baby) was also included in this category; however, there was a limited number of exposures to this type of media.

Noneducational young child–oriented programs consisted of those without educational content intended for children 2 to 6 years old. Examples include action cartoons such as Sponge- Bob SquarePants that are intended for young children and con- tain little or no violence.

Older child/adult–oriented programs consisted of those con- sidered appropriate for school-aged children (7 years and older) and teenagers but not for younger children on the basis of vio- lence and other such content. Examples of older child–oriented programs include Xiaolin Showdown. Adult-oriented programs con- sisted of those not oriented toward children but adults, of genres including news, sports, game, talk, variety, soap opera, drama, and comedy. Examples include Good Morning America (talk show), La Fea Más Bella (soap opera), and Law & Order (drama).

Unknown programs consisted of those we were unable to cat- egorize owing to incomplete information.

COGNITIVE AND LANGUAGE DEVELOPMENT

We assessed cognitive development at age 14 months using the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III), Cognitive Scale.25 We assessed language develop- ment using the Preschool Language Scale–4 (PLS-4). The PLS-4 consists of a total score and 2 subscales: auditory comprehen- sion and expressive communication.26

CONTROL VARIABLES

We collected sociodemographic data from maternal inter- views conducted during the postpartum period, including moth- er’s educational level, age, primary language spoken, ethnic- ity, country of origin, and marital status, and child’s sex and position in the birth order. We also assessed maternal depres- sive symptoms using the Patient Health Questionnaire–9.27 To define the presence of symptoms, a cutoff score of 5 was used, corresponding to mild depression. We assessed the cognitive home environment using StimQ (http://pediatrics.med.nyu .edu/patient-care/for-healthcare-providers/stimq-cognitive -home-environment), an office-based questionnaire that is re- liable and valid in families with low SES and correlates with the Home Observation for Measurement of the Environment inventory.28

STATISTICAL ANALYSIS

Associations between media exposure at age 6 months and cog- nitive and language development at age 14 months were ana- lyzed. In unadjusted analyses, we used Pearson correlations. In adjusted analyses, we used multiple linear regressions ad- justing for all control variables and exposure status with re- spect to the primary care interventions being carried out within the larger study. Separate multiple regressions were per- formed for total duration of media exposure and for each cat- egory of content. To assess the independent effect of each cat- egory of content, additional regressions were performed, including all 3 content categories in a single model, while ad- justing for the same control variables. In each of these models, � (standardized regression coefficients) and B (unstandard- ized regression coefficients) were calculated. Because the dis- tribution of media exposure was significantly different than nor- mal (Kolmogorov-Smirnov Z = 2.8, P � .001) with positive skew (skewness = 2.3, SE = 0.1; Figure 1), analyses of media dura-

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tion and content were performed using log transformations; these transformations were performed adding a constant of 1 to each value to account for values of 0.29 This analytic approach was also consistent with theoretical concerns because effects of me- dia exposure are likely to be nonlinear. This has been found in a number of studies of negative effects of exposure30-32 and of learning in relation to educational exposure.33

RESULTS

STUDY SAMPLE

From November 23, 2005, through January 14, 2008, a total of 516 mother-infant dyads were enrolled, of which 377 infants (73.1%) were evaluated at age 6 months. Of these, 259 (68.7%) also had an evaluation at age 14 months and constitute the sample analyzed in this study. Families assessed and not assessed when infants were aged 14 months showed similar data for media exposure and all sociodemographic characteristics except for mater- nal primary language spoken. Assessed families were more likely to speak Spanish as the primary language (P = .001).

Descriptive data are shown in Table 1. Mean (SD) me- dia exposure was 152.7 (124.5) minutes, with a median of 120.0 minutes. As seen in Figure 1, 15.8% (41 of 259) had less than 60 minutes of exposure, including 3.9% (10 of 259) who had no exposure to media. Of the total me- dia exposure, 23.0 (38.7) minutes were categorized as young child–oriented educational, 6.6 (19.1) minutes as young child–oriented noneducational, 91.5 (86.8) min- utes as older child/adult–oriented, and 31.6 (80.2) min- utes as unknown (data are given as mean [SD]).

MEDIA EXPOSURE AND COGNITIVE/ LANGUAGE DEVELOPMENT

Total Duration of Media Exposure

Longer daily duration of media exposure at age 6 months predicted lower cognitive development (Bayley-III) and language development (PLS-4 Total Language Score) at age 14 months in unadjusted and adjusted analyses (Table 2). For language subscales, associations were present for auditory comprehension and expressive com-

munication but somewhat stronger for the auditory subscale.

In multiple linear regression analyses adjusting for all potential confounders, statistically significant associa- tions were found for duration of total and older child/ adult–oriented media exposure with each of the develop- mental measures (Table 2 and Table 3). For example, the coefficient for the association between total daily du- ration of media exposure and PLS-4 Total Language Score was −1.2 (P = .005). Because media exposure was log trans- formed, this finding can be interpreted to mean that a 50.0% increase in media exposure was associated with approxi- mately a 0.5-point decrease in PLS-4 Total Language Score. Similar effects are seen with PLS-4 Total Language Score and older child/adult–oriented content. However, no as- sociations were found for educational young child– oriented or noneducational young child–oriented content.

Figure 2 shows predicted developmental scores for dif- ferent levels of media exposure based on the multiple lin- ear regression models adjusting for all potential confound- ers described herein. As shown in Figure 2 regarding predicted cognition scores, infants exposed to 0 minutes of media had an adjusted mean Bayley-III score of 102.1, but those with 60 minutes of exposure had an adjusted mean Bayley-III score of 95.9 (0.4 SD lower). Media exposure be- yond 60 minutes was associated with further decrements in Bayley-III score; infants with 360 minutes of exposure had an adjusted mean Bayley-III score of 93.2 (0.59 SD lower than those with 0 minutes). Regarding predicted lan- guage scores, infants exposed to 0 minutes of media had an adjusted PLS-4 Total Language Score of 103.0, whereas infants with 60 minutes of exposure had an adjusted mean PLS-4 score of 98.2 (0.32 SD lower than those with 0 min- utes of exposure); similarly, infants with 360 minutes of exposure had an adjusted PLS-4 score of 96.0 (0.47 SD lower than those with 0 minutes of exposure).

Content of Media Exposure

Exposure to older child/adult–oriented content at age 6 months predicted lower cognitive (Bayley-III) and lan- guage (PLS-4 Total Language) scores at age 14 months

0 0 1-59 60-119 120-179 180-239 240-299 300-359 ≥360

Media Exposure, min/d

Co ho

rt In

fa nt

s, N

Figure 1. Total duration of media exposure at age 6 months.

Table 1. Cohort Descriptive Data a

Characteristic No. (%)

Mother Age, mean (SD), y 27.8 (5.4) High school graduate 106 (40.9) Non–US-born 237 (91.5) Married or living with partner 220 (84.9) Spanish as primary language 223 (86.1) Depressive symptoms 62 (23.9)

Child Female sex 137 (52.9) Firstborn 101 (39.0) Cognitive (Bayley-III) score, mean (SD) 95.5 (11.7) Total Language (PLS-4) score, mean (SD) 97.0 (8.5)

Abbreviations: Bayley-III, Bayley Scales of Infant and Toddler Development, 3rd edition; PLS-4, Preschool Language Scale–4; US, United States.

a n = 259 mother-infant dyads.

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(Table 3). As with total duration, associations were present for auditory comprehension and expressive communi- cation but were stronger for the auditory subscale. In these analyses, educational and noneducational media with young child–directed content were not associated with cognitive and language scores.

To determine whether any single content category in- dependently predicted development and would account for the results from other categories, simultaneous regression models including all 3 types of media content (educa- tional, noneducational, and older child/adult–oriented content) were performed, adjusting for all potential con- founders. In a model in which cognitive development (Bay- ley-III score) was the outcome variable, older child/adult– oriented content was an independent predictor (� = −.19, P �.01) after adjusting for educational and noneduca- tional young child–oriented media. In a model in which overall language development (PLS-4 Total Language Score) was the outcome variable, older child/adult–oriented con- tent was an independent predictor (� = −.22, P �.001), whereas a trend (nonsignificant) was seen for exposure to educational young child–oriented content (�=−.11, P =.06).

COMMENT

This study is the first, to our knowledge, to have longitu- dinally assessed associations between media exposure in infancy and subsequent developmental outcomes in chil- dren from US families with low SES. Regarding our first hypothesis, total duration of media exposure at age 6 months predicted lower cognitive and language develop- ment at age 14 months. More important, children with 60 minutes of media exposure had approximately one-third SD lower developmental scores in both domains com- pared with those who had no exposure. Although chil- dren with the longest durations of media exposure had ad- justed developmental scores in the normal range, the differences found are likely to be important at the popu- lation level.34,35 Regarding our second hypothesis, expo- sure to media with older child/adult–oriented content at age 6 months was associated with adverse developmental

Table 2. Duration of Media Exposure at Age 6 Months and Cognitive and Language Development at Age 14 Months

Measure

Total Daily Duration, min

Unadjusted Adjusted a

r P

Value � P

Value B (95% CI)

Bayley-III Cognitive b −.17 .008 −.15 .02 −1.5 (−2.7 to −0.3) PLS-4

Total Language c −.16 .009 −.16 .005 −1.2 (−2.0 to −0.4) Auditory

comprehension −.16 .01 −.14 .02 −1.1 (−2.0 to −0.2)

Expressive communication

−.12 .06 −.13 .02 −1.0 (−1.9 to −0.1)

Abbreviations: Bayley-III Cognitive, Bayley Scales of Infant and Toddler Development, 3rd edition, Cognitive Scale; CI, confidence interval; PLS-4, Preschool Language Scale–4.

a Adjusted analyses based on multiple regression models including as covariates for child: sex and position in birth order; for mother: age, educational level, country of origin, primary language, marital status, depressive symptoms, and cognitive home environment; and intervention status.

b n = 257 for unadjusted and n = 253 for adjusted analyses. c n = 259 for unadjusted and n = 255 for adjusted analyses.

Table 3. Content of Media Exposure at Age 6 Months and Cognitive and Language Development at Age 14 Months

Content Time (min)

Unadjusted Adjusted a

r P

Value � b P

Value B (95% CI) b

Educational Young Child–Oriented Bayley-III Cognitive c .01 .86 .01 .94 0.03 (−0.7 to 0.8) PLS-4

Total Language a −.05 .47 −.06 .33 −0.3 (−0.8 to 0.3) Auditory

comprehension −.04 .52 −.04 .55 −0.2 (−0.7 to 0.4)

Expressive communication

−.04 .50 −.07 .27 −0.3 (−0.9 to 0.2)

Noneducational Young Child–Oriented Bayley-III Cognitive c .03 .56 .04 .49 0.4 (−0.7 to 1.5) PLS-4

Total Language a −.03 .62 .003 .96 0.02 (−0.7 to 0.8) Auditory

comprehension .02 .80 .05 .42 0.4 (−0.5 to 1.2)

Expressive communication

−.07 .23 −.05 .41 −0.3 (−1.2 to 0.5)

Older Child/Adult–Oriented Bayley-III Cognitive c −.20 .002 −.18 .006 −1.0 (−1.7 to −0.3) PLS-4

Total Language a −.18 .003 −.19 .001 −0.8 (−1.3 to −0.3) Auditory

comprehension −.18 .005 −.17 .005 −0.8 (−1.3 to −0.2)

Expressive communication

−.13 .04 −.14 .02 −0.6 (−1.1 to −0.1)

Abbreviations: See Table 2. a n = 259 for unadjusted and n = 255 for adjusted analyses. b n = 259; Adjusted analyses based on multiple regression models

including as covariates for child: sex and position in birth order; for mother: educational level, country of origin, primary language, marital status, depressive symptoms, and cognitive home environment; and intervention status.

c n = 257 for unadjusted and n = 253 for adjusted analyses.

107

103

105

101

91 0 30 60 120 180 240 360

Media Exposure, min/d

Ad ju

st ed

M ea

n, S

co re

Adjusted mean PLS-4 Total Language score Adjusted mean Bayley-III Cognitive score

Figure 2. Relationship between total duration of media exposure at age 6 months and predicted development scores at age 14 months. Bayley-III Cognitive indicates Bayley Scales of Infant and Toddler Development, 3rd edition, Cognitive; PLS-4, Preschool Language Scale–4.

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outcomes at age 14 months. In contrast, significant asso- ciations in either direction were not found for exposure to educational and noneducational young child–oriented content. Taken together, our findings provide strong evi- dence in support of the American Academy of Pediatrics recommendations of no media exposure prior to age 2 years. In demonstrating adverse effects of older child/adult– oriented media, these findings suggest that even media likely not focused on by very young children36,37 may have ad- verse effects, possibly owing to interference with interac- tions and play.38,39 In demonstrating lack of benefit re- lated to educational media exposure in infancy, these findings contradict industry claims40 and provide further support for these recommendations.

In documenting adverse associations between overall media exposure in infancy and development at age 14 months, this study has provided an important addition to the existing literature. Two studies performed in Thai- land have investigated the effect of media exposure in in- fancy on the development of toddlers from families with low SES, with only 1 finding positive results. Chonchaiya and Pruksananonda41 performed a case-control study that found that children exposed to 2 hours or more of televi- sion daily prior to age 12 months were 6 times more likely to have language delay. Ruangdaraganon et al42 per- formed a longitudinal study that did not find associations between media exposure and development; however, only 8% of the sample had developmental delay, limiting the authors’ power to find associations. In addition, 3 longi- tudinal studies of associations between media and devel- opment in US populations that are not economically dis- advantaged have been published. In an analysis of National Longitudinal Study of Youth data, Zimmerman and Chris- takis13 found that average viewing prior to age 3 years was negatively associated with cognitive outcomes at age 6 years. In a US longitudinal analysis of predominantly white, Mid- western families with relatively high levels of education and income, cumulative prior media exposure was asso- ciated with reduced vocabulary at 30 months.43 However, in a longitudinal analysis of families in Massachusetts with similar sociodemographic characteristics who are not eco- nomically disadvantaged, no associations were found be- tween media exposure prior to age 2 years and language development at 36 months.44 Our study, the first to lon- gitudinally study effects of media exposure on develop- ment in the United States, suggests real possibility for harm in the vulnerable population of families with low SES.

A strength of our present study was the use of de- tailed media diaries to quantify duration based on con- tent. Based on these diaries, exposure in infancy to older child/adult–oriented content not appropriate for young children was specifically associated with adverse devel- opmental outcomes. Previous studies in older children have shown adverse effects in association with develop- mentally inappropriate content, including associations between media violence exposure in elementary school and aggressive behavior12 and associations between older child/adult–oriented media content and externalizing be- haviors21 in older toddlers. Our present findings extend these associations to very young infants.

Regarding educational content, we found limited as- sociations (positive or negative) with developmental out-

comes. Our single finding, a nonsignificant trend, sug- gested the possibility of an adverse association between educational media exposure and overall language devel- opment after adjusting for exposure to other content. Al- though exposure to educational content at the age of school entry has been shown to have potentially benefi- cial effects,20,45 two prior studies of infants and toddlers from families that are not economically disadvantaged have suggested the possibility of adverse effects. In a cross- sectional study, Zimmerman et al46 found exposure to edu- cational DVDs for infants such as Baby Einstein to be as- sociated with decreased concurrent vocabulary in 8- to 16-month-old children. In a longitudinal study, Line- barger and Walker43 found that exposure beginning in infancy to some educational programs (Teletubbies, Sesame Street, and Barney and Friends) was associated with re- duced later vocabulary at age 30 months, whereas other programs (Dora the Explorer, Blue’s Clues, and Dragon Tales) were associated with enhanced vocabulary. In con- trast, experimental studies36,47-50 have consistently shown reduced learning from video compared with live mod- els, which may be owing to formal characteristics that elicit attention but are difficult for infants to under- stand.51 In finding lack of positive effects resulting from exposure to educational content, our study does not sup- port development of even educational media for in- fants.

There are 3 potential mechanisms for media-asso- ciated adverse effects on very young children’s develop- ment. First, a number of studies have shown reductions in parent-child interactions in association with increased media, including reduced audible language,15 conversa- tion,10 and engagement with the child.38 Other studies have suggested potential displacement of parent-child shared reading and playing together with toys,39,52 activities criti- cal to young children’s development. Second, exposure to media in very young children has been shown to inter- fere with children’s play activities.39 Third, specific char- acteristics of media exposure such as rapid scene changes have been hypothesized to have direct, adverse effects on the developing brain.7,36 The first of these mechanisms, re- duced interactions, is likely to be especially important in families with low SES, in which children are at increased risk of developmental delay in association with less pa- rental language being directed at them.11

Another important finding relates to characteriza- tion of media exposure in children from families with low SES. Our findings are consistent with prior population- based studies in infancy, which have shown substantial exposure as early as age 6 months,53 with increased ex- posure related to low maternal education.8 However, our finding that the greatest media exposure for infants from families with low SES is to older child/adult–oriented con- tent contrasts with prior studies showing educational con- tent to make up the majority of exposure in infancy.53

Our findings underscore the increased risks experi- enced by children from families with low SES related to early development in the context of greater overall ex- posure to media and exposure to media less likely to have educational content. Even small effect sizes as noted in this study, with a 50.0% increase in media exposure as- sociated with a 0.5-point decrease in PLS-4 total score,

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are likely to be important regarding families with low SES, who are already at risk.34,35

This study has some limitations. First, although the use of media diaries allowed the collection of detailed infor- mation regarding content, we must acknowledge the pos- sibility that data collected via this assessment tool may un- derestimate quantity of media in the home and only covers 1 typical day.54 Second, there was limited exposure to young child–oriented noneducational media in this sample, which reduced our ability to draw conclusions about its effect. Regarding young child–oriented educational media, most of the exposure was to preschool-oriented educational media, and there was limited exposure to infant-directed media such as Baby Einstein, which prevented us from ana- lyzing this exposure separately. Third, lower effects on ex- pressive compared with receptive language tests may re- flect limited expressive language at age 14 months; it is possible that greater effects on expressive language might be seen for older children. Fourth, our results apply to ex- posure in infants from families with low SES, primarily from a Latino immigrant background, and may not be gener- alizable to children in families with greater economic re- sources. Finally, our results may be specific for the infant– early toddler period studied, given rapid changes in development and changes in content of exposure over time, with educational television representing a greater propor- tion of exposure.53

In conclusion, overall exposure and exposure to older child/adult–oriented content were associated with lower lev- els of cognitive and language development at age 14 months. Findings from this study provide strong support for the American Academy of Pediatrics recommendation of no media exposure before age 2 years. These findings also cast doubt on the potential for benefit from educational pro- gramming in infancy. However, more research is needed regarding what would constitute educational program- ming during early childhood before definite conclusions can be reached. Given the substantial amount of exposure beginning in early infancy in families with low SES, whose children are at greatest risk for adverse developmental out- comes, these findings suggest that media exposure repre- sents a substantial public health problem. Advocacy ef- forts and public health interventions will be necessary to reduce exposure and optimize developmental outcomes.

Accepted for Publication: April 27, 2010. Correspondence: Suzy Tomopoulos, MD, Department of Pediatrics, New York University School of Medicine– Bellevue Hospital Center, 550 First Ave, New York, NY 10016 ([email protected]). Author Contributions: Drs Tomopoulos, Dreyer, Berkule, Fierman, Brockmeyer, and Mendelsohn had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analy- sis. Study concept and design: Tomopoulos, Dreyer, Berkule, Brockmeyer, and Mendelsohn. Acquisition of data: To- mopoulos, Berkule, Brockmeyer, and Mendelsohn. Analy- sis and interpretation of data: Tomopoulos, Fierman, Brock- meyer, and Mendelsohn. Drafting of the manuscript: Tomopoulos, Dreyer, Berkule, Brockmeyer, and Men- delsohn. Critical revision of the manuscript for important intellectual content: Tomopoulos, Dreyer, Berkule, Fier-

man, Brockmeyer, and Mendelsohn. Statistical analysis: Tomopoulos, Dreyer, Fierman, Brockmeyer, and Men- delsohn. Obtained funding: Berkule, Brockmeyer, and Men- delsohn. Administrative, technical, and material support: Tomopoulos, Dreyer, Berkule, Brockmeyer, and Men- delsohn. Study supervision: Tomopoulos, Dreyer, Fier- man, and Mendelsohn. Funding/Support: This study was supported by grant R01 HD047740-05 from the National Institutes of Health/ National Institute of Child Health and Human Develop- ment and by the Tiger Foundation, the Marks Family Foundation, the Rhodebeck Charitable Trust, and Chil- dren of Bellevue, Inc. Financial Disclosure: None reported. Previous Presentation: This study was presented in part at the Pediatric Academic Societies Annual Meeting, “In- fant Media Exposure: Adverse Effects on Toddler Devel- opment”; May 2, 2009; Baltimore, Maryland. Additional Contributions: We thank many colleagues for their guidance and support, including J. Lawrence Aber, PhD, Clancy Blair, PhD, David Dickinson, EdD, Vir- ginia Flynn, MS, Gilbert Foley, EdD, Emily Forrest, MD, Harris Huberman, MD, Matthew Johnson, PhD, Perri Klass, MD, Mary Jo Messito, MD, Lesley Morrow, PhD, Erin O’Connor, EdD, Cybele Raver, PhD, Catherine Tamis- Lemonda, PhD, Wendy Tineo, PhD, Purnima Valdez, MD, Linda van Schaick, MSEd, and Hiro Yoshikawa, PhD. Fi- nally, we are grateful to many additional individuals who contributed to this project, including Melissa Acevedo, MD, Jenny Arevalo, BA, Nina Burtchen, MD, Daniela Rom- ero, BS, Jessica Urgelles, MA, Linda Votruba, BA, Mar- garet Wolff, BA, and Brenda Woodford, MA.

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Few things are more satisfying than seeing your children have teenagers of their own.

—Doug Larson

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