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FROM THE AMERICAN ACADEMY OF PEDIATRICSPEDIATRICS Volume 138 , number 5 , November 2016 :e 20162591
Media and Young Minds COUNCIL ON COMMUNICATIONS AND MEDIA
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.
DOI: 10.1542/peds.2016-2591
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they do not have a fi nancial relationship relevant to this article to
disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to
disclose.
abstractInfants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they
are adopting at increasing rates. Although there has been much hope
for the educational potential of interactive media for young children,
accompanied by fears about their overuse during this crucial period of rapid
brain development, research in this area still remains limited. This policy
statement reviews the existing literature on television, videos, and mobile/
interactive technologies; their potential for educational benefi t; and related
health concerns for young children (0 to 5 years of age). The statement also
highlights areas in which pediatric providers can offer specifi c guidance
to families in managing their young children’s media use, not only in terms
of content or time limits, but also emphasizing the importance of parent–
child shared media use and allowing the child time to take part in other
developmentally healthy activities.
INTRODUCTION
Technologic innovation has transformed media and its role in the lives
of infants and young children. More children, even in economically
challenged households, are using newer digital technologies, such
as interactive and mobile media, on a daily basis 1 and continue to be
the target of intense marketing. 2 This policy statement addresses the
influence of media on the health and development of children from 0
to 5 years of age, a time of critical brain development, building secure
relationships, and establishing health behaviors.
INFANTS AND TODDLERS
Children younger than 2 years need hands-on exploration and social
interaction with trusted caregivers to develop their cognitive, language,
motor, and social-emotional skills. Because of their immature symbolic,
memory, and attentional skills, infants and toddlers cannot learn from
traditional digital media as they do from interactions with caregivers, 3
and they have difficulty transferring that knowledge to their
3-dimensional experience. 4 The chief factor that facilitates toddlers’
POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children
To cite: AAP COUNCIL ON COMMUNICATIONS AND MEDIA. Media and Young Minds. Pediatrics. 2016;138(5):e20162591
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
learning from commercial media
(starting around 15 months of age)
is parents watching with them and
reteaching the content. 5, 6
The interactivity of touchscreens
enables applications (apps) to
identify when a child responds
accurately and then tailor its
responses, thereby supporting
children at their levels of
competence. Emerging evidence
shows that at 24 months of age,
children can learn words from live
video-chatting with a responsive
adult 7 or from an interactive
touchscreen interface that scaffolds
the child to choose the relevant
answers. 8 Starting at 15 months of
age, toddlers can learn novel words
from touchscreens in laboratory-
based studies but have trouble
transferring this knowledge to the
3-dimensional world. 9 However,
it should be noted that these
experiments used specially designed
apps that are not commercially
available.
Many parents now use video-chat (eg,
Skype, FaceTime) as an interactive
media form that facilitates social
connection with distant relatives.
New evidence shows that infants and
toddlers regularly engage in video-
chatting, 10 but the same principles
regarding need for parental support
would apply in order for infants and
toddlers to understand what they are
seeing.
In summary, for children younger
than 2 years, evidence for benefits
of media is still limited, adult
interaction with the child during
media use is crucial, and there
continues to be evidence of harm
from excessive digital media use, as
described later in this statement.
PRESCHOOL MEDIA AND LEARNING
Well-designed television programs,
such as Sesame Street, can
improve cognitive, literacy, and
social outcomes for children 3 to
5 years of age 11, 12 and continue
to create programming that
addresses evolving child health and
developmental needs (eg, obesity
prevention, resilience). Evaluations
of apps from Sesame Workshop and
the Public Broadcasting Service (PBS)
also have shown efficacy in teaching
literacy skills to preschoolers. 2
Unfortunately, most apps parents
find under the “educational”
category in app stores have no such
evidence of efficacy, target only rote
academic skills, are not based on
established curricula, and use little
or no input from developmental
specialists or educators. 2, 13 Most
apps also generally are not designed
for a dual audience (ie, both parent
and child). 2, 14 It is important to
emphasize to parents that the higher-
order thinking skills and executive
functions essential for school
success, such as task persistence,
impulse control, emotion regulation,
and creative, flexible thinking, are
best taught through unstructured
and social (not digital) play, 15 as
well as responsive parent–child
interactions. 16
Digital books (also called “eBooks, ”
books that can be read on a screen)
often come with interactive
enhancements that, research
suggests, may decrease child
comprehension of content or parent
dialogic reading interactions when
visual effects are distracting. 17
Parents should, therefore, be
instructed to interact with children
during eBook reading, as they would
a print book.
HEALTH AND DEVELOPMENTAL CONCERNS
Obesity
Heavy media use during preschool
years is associated with small but
significant increases in BMI, 18 may
explain disparities in obesity risk
in minority children, 19 and sets
the stage for weight gain later
in childhood. 20 Although many
studies have used a 2-hour cutoff
to examine obesity risk, a recent
study of 2-year-olds found that BMI
increased for every hour per week
of media consumed. 21 It is believed
that exposure to food advertising22
and watching television while
eating (which diminishes attention
to satiety cues) 23 drives these
associations.
Sleep
Increased duration of media
exposure and the presence of a
television, computer, or mobile
device in the bedroom in early
childhood have been associated with
fewer minutes of sleep per night. 24
Even infants exposed to screen
media in the evening hours show
significantly shorter night-time sleep
duration than those with no evening
screen exposure. 25 Mechanisms
underlying this association include
arousing content 26 and suppression
of endogenous melatonin by blue
light emitted from screens. 27
Child Development
Population-based studies continue to
show associations between excessive
television viewing in early childhood
and cognitive, 28 – 30 language, 31, 32 and
social/emotional delays, 33 – 36 likely
secondary to decreases in parent–
child interaction when the television
is on37 and poorer family functioning
in households with high media use. 37
An earlier age of media use onset,
greater cumulative hours of media
use, and non-PBS content all are
significant independent predictors
of poor executive functioning in
preschoolers. 38 Content is crucial:
experimental evidence shows that
switching from violent content
to educational/prosocial content
results in significant improvement
in behavioral symptoms, particularly
for low-income boys. 12 Notably,
the quality of parenting can modify
associations between media use
and child development: one study
found that inappropriate content
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PEDIATRICS Volume 138 , number 5 , November 2016
and inconsistent parenting had
cumulative negative effects on low-
income preschoolers’ executive
function, whereas warm parenting
and educational content interacted to
produce additive benefits. 39
Child characteristics also may
influence how much media children
consume: excessive television
viewing is more likely in infants
and toddlers with a difficult
temperament 40, 41 or self-regulation
problems, 42 and toddlers with social-
emotional delays are more likely
to be given a mobile device to calm
them down. 43
Parental Media Use
Parents’ background television
use distracts from parent–child
interactions 44 and child play. 45
Heavy parent use of mobile devices
is associated with fewer verbal and
nonverbal interactions between
parents and children 46 and may be
associated with more parent-child
conflict. 47 Because parent media use
is a strong predictor of child media
habits, 48 reducing parental media
use and enhancing parent–child
interactions may be an important
area of behavior change.
CONCLUSIONS: CLINICAL IMPLICATIONS
In summary, multiple developmental
and health concerns continue to exist
for young children using all forms
of digital media to excess. Evidence
is sufficient to recommend time
limitations on digital media use for
children 2 to 5 years to no more than
1 hour per day to allow children
ample time to engage in other
activities important to their health
and development and to establish
media viewing habits associated
with lower risk of obesity later
in life. 49 In addition, encouraging
parents to change to educational and
prosocial content and engage with
their children around technology
will allow children to reap the most
benefit from what they view.
As digital technologies become more
ubiquitous, pediatric providers
must guide parents not only on the
duration and content of media their
child uses, but also on (1) creating
unplugged spaces and times in their
homes, because devices can now
be taken anywhere; (2) the ability
of new technologies to be used in
social and creative ways; and (3)
the importance of not displacing
sleep, exercise, play, reading aloud,
and social interactions. Realistically,
pediatric providers will need to know
how to help parents find resources
finding appropriate content, tools
for monitoring or limiting child use,
ideas for play or activities in which
to engage rather than digital play,
and how parents can limit their own
media use (see HealthyChildren.
org for examples); each of these can
be built into the Family Media Use
Plan (see the American Academy
of Pediatrics guide to developing a
plan at www. healthychildren. org/
MediaUsePlan).
RECOMMENDATIONS
Pediatricians
• Start the conversation early. Ask parents of infants and young
children about family media use,
their children’s use habits, and
media use locations.
• Help families develop a Family Media Use Plan
(www. healthychildren. org/
MediaUsePlan) with specific
guidelines for each child and
parent.
• Educate parents about brain development in the early years
and the importance of hands-on,
unstructured, and social play to
build language, cognitive, and
social-emotional skills.
• For children younger than 18 months, discourage use of screen
media other than video-chatting.
• For parents of children 18 to 24 months of age who want to
introduce digital media, advise
that they choose high-quality
programming/apps and use them
together with children, because
this is how toddlers learn best.
Letting children use media by
themselves should be avoided.
• Guide parents to resources for finding quality products (eg,
Common Sense Media, PBS Kids,
Sesame Workshop).
• In children older than 2 years, limit media to 1 hour or less per
day of high-quality programming.
Recommend shared use between
parent and child to promote
enhanced learning, greater
interaction, and limit setting.
• Recommend no screens during meals and for 1 hour before
bedtime.
• Problem-solve with parents facing challenges, such as setting limits,
finding alternate activities, and
calming children.
Families
• Avoid digital media use (except video-chatting) in children younger
than 18 to 24 months.
• For children ages 18 to 24 months of age, if you want to introduce
digital media, choose high-quality
programming and use media
together with your child. Avoid
solo media use in this age group.
• Do not feel pressured to introduce technology early; interfaces are so
intuitive that children will figure
them out quickly once they start
using them at home or in school.
• For children 2 to 5 years of age, limit screen use to 1 hour per day
of high-quality programming,
coview with your children, help
children understand what they are
seeing, and help them apply what
they learn to the world around
them.
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
• Avoid fast-paced programs (young children do not understand
them as well), apps with lots of
distracting content, and any violent
content.
• Turn off televisions and other devices when not in use.
• Avoid using media as the only way to calm your child. Although there
are intermittent times (eg, medical
procedures, airplane flights) when
media is useful as a soothing
strategy, there is concern that
using media as strategy to calm
could lead to problems with limit
setting or the inability of children
to develop their own emotion
regulation. Ask your pediatrician
for help if needed.
• Monitor children’s media content and what apps are used or
downloaded. Test apps before the
child uses them, play together, and
ask the child what he or she thinks
about the app.
• Keep bedrooms, mealtimes, and parent–child playtimes screen free
for children and parents. Parents
can set a “do not disturb” option on
their phones during these times.
• No screens 1 hour before bedtime, and remove devices from
bedrooms before bed.
• Consult the American Academy of Pediatrics Family Media Use Plan,
available at: www. healthychildren.
org/ MediaUsePlan.
Industry
• Work with developmental psychologists and educators to
create design interfaces that are
appropriate to child developmental
abilities, that are not distracting,
and that promote shared parent–
child media use and application
of skills to the real world. Cease
making apps for children younger
than 18 months until evidence of
benefit is demonstrated.
• Formally and scientifically evaluate products before making
educational claims.
• Make high-quality products accessible and affordable to low-
income families and in multiple
languages.
• Eliminate advertising and unhealthy messages on
apps. Children at this age
cannot differentiate between
advertisements and factual
information, and therefore,
advertising to them is
unethical.
• Help parents to set limits by stopping auto-advance of videos
as the default setting. Develop
systems embedded in devices that
can help parents monitor and limit
media use.
LEAD AUTHORS
Jenny Radesky, MD, FAAP
Dimitri Christakis, MD, MPH, FAAP
COUNCIL ON COMMUNICATIONS AND MEDIA EXECUTIVE COMMITTEE, 2016-2017
David Hill, MD, FAAP, Chairperson
Nusheen Ameenuddin, MD, MPH, FAAP
Yolanda (Linda) Reid Chassiakos, MD, FAAP
Corinn Cross, MD, FAAP
Jenny Radesky, MD, FAAP
Jeffrey Hutchinson, MD, FAAP
Rhea Boyd, MD, FAAP
Robert Mendelson, MD, FAAP
Megan A. Moreno, MD, MSEd, MPH, FAAP
Justin Smith, MD, FAAP
Wendy Sue Swanson, MD, MBE, FAAP
LIAISONS
Kris Kaliebe, MD – American Academy of Child
and Adolescent Psychiatry
Jennifer Pomeranz, JD, MPH – American Public
Health Association
Brian Wilcox, PhD – American Psychological
Association
STAFF
Thomas McPheron
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