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Prevalence of excessive screen time and its association with developmental delay in children aged <5 years: A population-based cross-sectional study in India

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The global growth of electronic media usage among children has caused concerns regarding screen time (ST) impact on child development. No previous population-based studies have evaluated ST and child development in India. This study aimed to determine the burden of ST, associated sociodemographic factors, and its impact on domains of child development. A population-based cross-sectional study was conducted in the field practice area of rural and urban health centers in Tamil Nadu, India. A total of 718 children (396 rural and 322 urban) were selected, using a cluster random sampling method. ST estimates were obtained from parents/guardian after a 7-day observation period. The Communication DEALL Developmental Checklist was used to assess child development. The mean ST was 2.39 hours/day (95% confidence interval [CI]: 2.23-2.54), and the prevalence of excessive ST was 73% (95% CI: 69.2-76.8). Excessive ST was significantly associated with the moth-ers' ST, screen usage at bedtime, birth order (in children < 2 years), and attending school (in children � 2 years). Increased ST was significantly associated with developmental delay, in particular, in the domains of language acquisition and communication. In children aged � 2 years, a delay in � 3 domains was associated with ST (adjusted odds ratio [AOR] = 17.75, 95% CI: 5.04-62.49, p < 0.001), as was language delay (AOR = 52.92, 95% CI: 12.33-227.21, p < 0.001). In children aged < 2 years, a delay in � 2 domains was associated with ST (AOR = 16.79, 95% CI: 2.26-124.4, p < 0.001), as was language delay (AOR = 20.93, 95% CI: 2.68-163.32, p < 0.01). A very high prevalence of excessive ST was identified, with a significant association with developmental delay in children. There is an urgent need to include education on ST limits at the primary healthcare level.
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RESEARCH ARTICLE
Prevalence of excessive screen time and its
association with developmental delay in
children aged <5 years: A population-based
cross-sectional study in India
Samya VaradarajanID
1
, Akila Govindarajan Venguidesvarane
1
*, Karthik
Narayanan Ramaswamy
2‡
, Muthukumar Rajamohan
1‡
, Murugesan Krupa
3‡
,
Sathiasekaran Bernard Winfred Christadoss
1
1Department of Community Medicine, Sri Ramachandra Institute of Higher Education and Research,
SRIHER, Chennai, India, 2Department of Pediatric Critical Care, Rainbow Children’s Hospital, Chennai,
India, 3Department of Speech, Language and Hearing, Sri Ramachandra Institute of Higher Education and
Research, SRIHER, Chennai, India
These authors contributed equally to this work.
‡ These authors also contributed equally to this works.
*aki_ravi24@yahoo.co.in
Abstract
The global growth of electronic media usage among children has caused concerns regard-
ing screen time (ST) impact on child development. No previous population-based studies
have evaluated ST and child development in India. This study aimed to determine the bur-
den of ST, associated sociodemographic factors, and its impact on domains of child devel-
opment. A population-based cross-sectional study was conducted in the field practice area
of rural and urban health centers in Tamil Nadu, India. A total of 718 children (396 rural and
322 urban) were selected, using a cluster random sampling method. ST estimates were
obtained from parents/guardian after a 7-day observation period. The Communication
DEALL Developmental Checklist was used to assess child development. The mean ST was
2.39 hours/day (95% confidence interval [CI]: 2.23–2.54), and the prevalence of excessive
ST was 73% (95% CI: 69.2–76.8). Excessive ST was significantly associated with the moth-
ers’ ST, screen usage at bedtime, birth order (in children <2 years), and attending school (in
children 2 years). Increased ST was significantly associated with developmental delay, in
particular, in the domains of language acquisition and communication. In children aged 2
years, a delay in 3 domains was associated with ST (adjusted odds ratio [AOR] = 17.75,
95% CI: 5.04–62.49, p <0.001), as was language delay (AOR = 52.92, 95% CI: 12.33–
227.21, p <0.001). In children aged <2 years, a delay in 2 domains was associated with
ST (AOR = 16.79, 95% CI: 2.26–124.4, p <0.001), as was language delay (AOR = 20.93,
95% CI: 2.68–163.32, p <0.01). A very high prevalence of excessive ST was identified, with
a significant association with developmental delay in children. There is an urgent need to
include education on ST limits at the primary healthcare level.
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OPEN ACCESS
Citation: Varadarajan S, Govindarajan
Venguidesvarane A, Ramaswamy KN, Rajamohan
M, Krupa M, Winfred Christadoss SB (2021)
Prevalence of excessive screen time and its
association with developmental delay in children
aged <5 years: A population-based cross-sectional
study in India. PLoS ONE 16(7): e0254102. https://
doi.org/10.1371/journal.pone.0254102
Editor: Vijayaprasad Gopichandran, ESIC Medical
College & PGIMSR, INDIA
Received: March 17, 2021
Accepted: June 15, 2021
Published: July 6, 2021
Copyright: ©2021 Varadarajan et al. This is an
open access article distributed under the terms of
the Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
Introduction
Electronic media usage has seen explosive growth globally. Children today are exposed to screen-
based entertainment and information, which has become an integral part of their lives. In the
United States, children between the ages of 0–8 years spend more than 2 hours per day on screens
[1]; in western India, the mean screen time (ST) is 2.7 hours among children aged 2–6 years [2].
Due to the malleability of children’s social and intellectual development in the early years, it
is critical to evaluate the impact of ST during this period [3]. Excessive ST has been associated
with language and motor skill developmental delay, [3,4] in addition to its psychosocial impact
[5]. According to the American Association of Pediatrics guidelines, children aged <2 years
should not have any ST, and those aged 2–5 years should be limited to 1 hour of high-quality
education programs per day, monitored by their caregivers [6]. The Canadian Pediatric Soci-
ety issued similar guidelines in 2017 [7], as did the World Health Organization (WHO) in
2019, proposing ST limits in children aged <5 years [8]. However, these guidelines have been
criticized as not being evidence-based [9], and the findings on ST impact have been inconsis-
tent in systematic reviews.
While some evidence on the impact of ST on development is available from high-income
Western countries, that from low-and middle-income countries is lacking [10]. The assess-
ment of ST in the existing studies is mostly based on caregivers’ recollection, which is subject
to bias. In addition, most research on ST is based on data from hospital, clinic/well-child
immunization and pre-school records, without any population-based studies assessing child
development at home. The coronavirus disease 2019 pandemic has led to global school clo-
sures and a shift to online education. Studies are required for evidence-based guidelines,
aimed at establishing healthy ST limits for children [11].
This study aimed to determine the prevalence of excessive ST, associated sociodemographic
factors, and its effects on various domains of child development among the population in India.
Materials and methods
Study design and population
A population-based cross-sectional study was conducted in the field practice and demonstra-
tion areas of rural and urban health and training centers of the Medical College and Research
Institute in South India. Based on a previous study [2], a minimum sample size of 360 was
required for a mean ST of 2.7 ±1.7 hours, and a relative precision of 6.5. The design effect of 2
was considered, and the final sample size was set at 720. The sampling frame of the Rural
Health and Training Center consists of 1218 children aged <5 years, distributed in 9 pan-
chayats (divisions). In comparison, the Urban Health and Training Center area has 1356 chil-
dren in 19 divisions. A cumulative list of the population aged <5 years was created and the
villages of the panchayats were identified as clusters in rural areas, as well as the sub-divisional
regions in urban areas, with a probability proportional to size. From each cluster, 30 children
were selected. Children aged <6 months, parents who refused consent, children with known
intellectual disabilities, congenital anomalies, and genetic conditions such as trisomy 21 were
excluded. In households with multiple children fitting the criteria, only one child was ran-
domly included in this study.
Study variables and measurements
After obtaining written informed consent from the child’s mother/guardian data on back-
ground demographic characteristics, living conditions, socioeconomic status [12], and parents’
education were obtained.
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Screen time. ST was estimated by requesting the mother/primary caregiver to observe the
child over a period of 7 days and record their ST in a diary, which was later collected through re-
visitation. Health inspectors and public health nurses were instructed to follow up with the
parents/caregivers over the telephone to ensure that ST was documented daily. For children attend-
ing playschool/balwadi/daycare, we sent a letter to the teachers through the parents requesting
them to document the children’s ST. The mean amount of time spent on screens (in hours) during
the 7-day observation period was considered as the ST of the child. Details of the type of screen
used, age at first exposure, and weekday/weekend frequency of screen use were also collected.
Excessive ST for children aged between 6 months to 2 years was defined as any ST per day; for
those aged 2–5 years, it was defined as >1 hour of ST per day, as per the 2019 WHO guidelines [9].
Developmental assessment. Child development was assessed through the Communication
DEALL Developmental Checklist [13,14], which is a validated tool for child assessment in India.
This tool covers eight domains including gross motor, fine motor, receptive language, expressive
language, activities of daily living, cognitive skills, and social and emotional development. Each
domain includes 36 items, which makes a total of 288 items. Children aged 0–72 months were
categorized into a developmental hierarchy at 6-month intervals, thereby creating 12 groups.
Each group contained three skills on the checklist and each skill was scored on a 5-point scale.
0. Not acquired
1. Acquired but lost
2. Acquired but inconsistently present
3. Acquired and consistently present, but only in specific situations
4. Acquired and consistently present in all situations
A child was classified as having a developmental delay in a domain if two or more skills
were not acquired in the child’s developmental hierarchy. Developmental delay was catego-
rized as delay in any one domain, in two or more, or three or more domains. A separate analy-
sis was conducted for receptive or expressive language delay, language or social interaction
delay, and communication skills delay.
Data collection and quality control measures
Data were collected from January to May 2019. A team of two members, a speech-language pathol-
ogist, and the principal or co-investigator visited each house. Since ST details were not collected on
the same day, the speech-language pathologist was blinded to the ST estimates of the child.
Ethical approval
Institutional Ethics Committee approval was obtained before the commencement of this
study. The Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education
and Research, Chennai, India, approved all experimental protocols (Ref No: IEC-NI/18/SEP/
66/53). This study was conducted in accordance with the relevant guidelines and regulations
from the ethics committee and the Declaration of Helsinki. Children who were identified as
having significant developmental delay were referred for further evaluation and management.
Consent to participate
Because this study included minors, written informed consent was obtained from the parents/
guardians. Informed consent was translated into the local language and validated by language
experts.
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Statistical analysis
Statistical Package for the Social Sciences (SPSS), version 16 (IBM Corporation, Somers, NY,
USA), was used for data entry and analysis. The background variables were expressed as fre-
quencies and percentages. The prevalence of excessive ST and 95% confidence intervals (CIs)
were calculated. Factors associated with excessive ST were examined, using the chi-square test;
the corresponding odds ratios (ORs) and 95% CIs were calculated. Statistical significance was
set at a two-sided p-value of <0.05. A logistic regression model using the enter method was
created for children in two groups (6–23 months and 24–60 months) with ST as an indepen-
dent variable and development in each domain as a dependent variable; adjusted odds ratios
(AORs) were calculated to account for the impact of probable confounders.
Results and discussion
A total of 718 children were included in this study, including 396 and 322 children from urban
and rural areas, respectively. Approximately half of the children were male (49.7%), and the
mean age was 34.7 ±15.8 months. Most children (61.3%) were a part of a nuclear family. The
sociodemographic characteristics of the study population are shown in Table 1.
The mean overall ST was 2.39 hours per day (95% CI: 2.23–2.54). The children were mostly
exposed to smartphones and televisions (Table 2).
Most children (72.8%) had similar ST on weekdays and weekends; a total of 24.2% and
2.7% of the children had increased and decreased exposure during the weekends, respectively.
The screen was accessible in the bedroom in 21.6% of cases. Only 4.9% of parents (n = 35) had
implemented ST rules for their children. Among them, 5.9% did not allow any ST, 76.5% and
17.6% allowed for 1 and 2 hours of ST per day, respectively. Regarding the implementation of
these rules, 34.3% of parents declared they were always able to implement them, 45.7% imple-
mented them sometimes, and 20.0% could not implement them at all.
The rates of excessive ST among children aged <2 years and those aged 2 years were
73.3% (95% CI: 67.1–79.5) and 73.0% (95% CI: 69.2–76.8), respectively. Excessive ST was not
associated with residence area (rural/urban), socioeconomic status, family type, or education
level of the mother or caregiver. However, a statistically significant association was found
between excessive ST and children attending balwadi for children aged >2 years (p <0.05), as
well as the birth order of children aged <2 years (p <0.05). Excessive ST was significantly
associated with screen use at bedtime and the ST of the mothers among children of all age
groups (Table 3).
Child development
Among the children aged <2 years, 1.5% (n = 3) had a delay in gross motor development,
2.1% (n = 4) in fine motor development, 3.6% (n = 7) in activities of daily living, 11.8%
(n = 23) in expressive language, 6.2% (n = 12) in receptive language, 4.6% (n = 9) in social
interaction, and 3.6% (n = 7) in emotional development. Among children aged 2 years, the
corresponding rates were 1.5% (n = 8), 3.6% (n = 19), 3.4% (n = 18), 24.5% (n = 128), 14.1%
(n = 74), 8.6% (n = 45), and 2.9% (n = 15), respectively. In addition, 7.1% (n = 37) of children
aged >2 years had cognitive delay.
Bivariate analysis of child development in any domain and background variables showed
that excessive ST was significantly associated with developmental delay (Table 4). This analysis
was performed separately for two age groups, as the definition of excessive ST differed between
them. A logistic regression model using the enter method was performed, and the ORs were
adjusted for the following confounders: residence location, sex, birth order, family type, socio-
economic status, and mother’s education. The AORs were 7.64 (95% CI: 1.67–34.85) and 19.28
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Table 1. Sociodemographic characteristics and screen time details of study participants.
S No Background variables N %
1Sex
Males 358 49.7
Females 360 50.3
2Age
<18 months 118 16.4
18–23 months 77 10.7
24 months and older 523 72.8
3Type of Family
Nuclear 440 61.3
Extended nuclear 228 31.8
Joint 46 6.4
Others 4 0.6
4Modified Prasad’s Socio-economic status [12]
Class 1 131 18.2
Class 2 228 31.8
Class 3 231 32.2
Class 4 123 17.1
Class 5 5 0.7
5Mothers education
Postgraduate 76 10.6
Graduate/diploma 190 26.5
Higher Secondary school 136 18.9
High School 204 28.4
Middle School 88 12.3
Primary School 16 2.2
Illiterate 8 1.1
6Mothers occupation
Homemaker 609 84.8
Employed 108 15.2
7Mother’s/caregiver’s ST
<2 hours 282 39.3
>2 hours 436 60.7
8Whether the child going to playschool/balwadi/daycare (N = 523)
Yes 333 63.8
No 190 36.2
9Age at first exposure to screen
Not exposed 23 3.2
<6 months 61 8.5
7–12 months 435 60.8
13–18 months 42 5.9
19–23 months 99 13.8
More than 24 months 56 7.8
10 Screen time on weekends
Increases 173 24.2
Decreases 19 2.7
Is the same as on weekdays 523 72.8
(Continued )
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(95% CI: 6.65–55.59) for children aged <2 years and for those aged 2 years, respectively.
Excessive ST was the only factor associated with developmental delay.
ST and child development
Tables 5and 6present the association between ST and child development domains. Increasing
ST was associated with increased odds of development delay, in particular, in the language and
communication domains. For children aged <2 years, an ST usage was significantly associated
with any one domain of developmental delay (Table 4). When ST was more than 1 hour, there
was significant delay in language domains. Similar results were observed in children aged 2
years when ST was more than 1 hour. In binary logistic regression analysis, the OR was
adjusted for probable confounders such as socioeconomic status, mother’s education level and
occupation, sex of the child, and place of residence. AORs were higher for both age groups.
The wide CI was likely due to the small number of children with ST of <1 hour in
the 2-year age group and no ST in the <2 years group with developmental delay.
This study, conducted in a rural and urban field practice area at a medical college, aimed to
identify the impact of ST on child development. The mean ST in children under 5 years of age
was 2.39 ±2.18 hours per day (95% CI: 2.23–2.54). Excessive ST was significantly associated
with attending school (in children aged 2 years), birth order (in children aged <2 years),
screen availability at bedtime, and ST of the mothers. Increased ST was significantly associated
with developmental delay, in particular, in the language and communication domains.
In our study, the narrow CI of the mean ST indicates good internal validity and sufficient
sample size. The mean ST for children aged <2years and those aged 2–5 years was 1.26 hours
and 2.8 hours, respectively. Similar findings were observed in a study conducted in Western
India, which reported the mean ST of 2.7 hours among children aged 2–5 years [2]; in addi-
tion, Ruangdaraganon et al. reported 1.21 hours for 1-year-olds and 1.69 hours for 2-year-olds
[15]. However, studies conducted in Melbourne [16,17], Europe [18], and Korea [3] had lower
Table 1. (Continued )
S No Background variables N %
11. A circumstance when the screen is given to the child
While feeding/eating 529 74.4
Parents are at household chores 412 57.9
As a reward 108 15.2
To calm the child 280 39.3
Distract the child 205 28.8
At outdoor (restaurants, functions, etc) 40 5.6
Traveling by bus, car, train, etc 34 4.8
During illness 23 3.2
At bedtime 222 31.2
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Table 2. Details of screen time.
Screen type 6–23 months 24–60 months Total
Mean (95% CI) (hours) SD (hours) Mean (95% CI) (hours) SD (hours) Mean (95% CI) (hours) SD (hours)
Smart phone 0.74 (0.61–0.87) 0.96 1.35 (1.23–1.47) 1.45 1.2 (1.1–1.3) 1.37
TV 0.72 (0.58–0.86) 1 1.59 (1.47–1.71) 1.43 1.36 (1.26–1.46) 1.39
Total ST 1.26 (1.04–1.48) 1.55 2.8 (2.6–2.9) 2.23 2.39 (2.23–2.54) 2.18
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mean ST estimates (1.8 hours, 1.32 hours, 1.21 hours, respectively). These differences could be
attributed to the different study locations as well as better parental control. An extensive litera-
ture review revealed a lack of studies on ST per device, although ST estimates for mobile
phone [1921], television, and computer usage have been reported [17,2226]. Our study has
documented the separate mean usage of television and smartphones, which were 1.36 hours
and 1.2 hours, respectively.
Our results revealed that 89% of the children were exposed to at least one type of screen
before the recommended age of 24 months, whereas a study in Korea by Chang et al. reported
that only 65% and 31.3% of children were exposed to television and smartphones, respectively
[27]. This evidence shows that children in India are exposed to screens early, which requires
further observation. Most caregivers (72.8%) reported no difference in ST duration between
weekdays and weekends. This finding is in contrast to those in studies conducted by Chang
[27], Jago [20], and Georgia et al. [18], which showed increased ST on weekends. These differ-
ences may be associated with study settings, as well as sociocultural differences.
Excessive ST in children was not correlated with socioeconomic status, place of residence,
or the mother’s education level in our study. In comparison, Cheng [28] and Fulton et al. [25]
Table 3. Factors associated with screen time.
Children aged 24–60 months Children aged 6–23 months
S no Background variable Excess ST N (%) Normal ST N (%) OR 95% CI p Excess ST N (%) Nil ST N (%) OR 95% CI p
1Place of residence
Rural 158(69) 71 (31) 0.69 0.47–1.02 0.66 28 (30.1) 65 (69.9) 0.83 0.45–1.51 0.53
Urban 224 (76.2) 70 (23.8) 35 (34.3) 67 (65.7)
2Gender
Male 194 (74.6) 66 (25.4) 1.17 0.8–1.73 0.42 30 (30.6) 68 (69.4) 0.86 0.47–1.56 0.611
Female 188 (71.5) 75 (23.8) 33 (34) 64 (66)
3Birth order
1 222 (72.5) 84 (27.5) 0.94 0.64–1.3 0.764 43 (38.7) 68 (61.3) 2.02 1.08–3.8 0.029
2 or more 160 (73.7) 57 (26.3) 20 (23.8) 64 (76.2)
4Going to balwadi/playschool
Yes 256 (76.9) 77 (23.1) 1.69 1.1–2.5 0.009
No 126 (66.3) 64 (33.7)
5Type of family
Nuclear 245 (73.1) 90 (26.9) 1.01 0.68–1.52 0.94 36 (34.3) 69 (65.7) 1.22 0.67–2.23 0.523
Extended/joint 137 (72.9) 51 (27.1) 27 (30) 63 (70)
6Modified BG prasad’s SES
Class 1 69 (69.7) 30 (30.3) 0.49 13 (40.6) 19 (59.4) 0.55
Class 2 127 (76) 40 (24) 21 (34.4) 40 (65.6)
Class 3 120 (74.5) 41 (25.5) 21 (30) 49 (70)
Class 4 &5 66 (68.8) 30 (31.2) 8 (25) 24 (75)
7Mother’s education
Middle school and above 365 (72.6) 138 (27.4) 0.47 0.14–1.62 0.21 63 (33) 128 (67) 0.67 0.61–0.74 0.163
Primary or below 17 (85) 3 (15) 0 (0) 4 (100)
8Mothers screen time
>2 hours 273 (83) 56 (170) 2.45 1.83–3.28 0.000 74 (69.2) 33 (30.8) 1.62 1.14–2.31 0.006
<2 hours 113 (58.2) 81 (41.8) 44 (50) 44 (50)
8Screens used at bedtime
Yes 150 (96.2) 6 (3.8) 14.5 6.3–33.8 0.000 1 (25) 3 (75) 0.69 0.07–6.80 0.044
No 232 (63.2) 135 (36.8) 5 62 (32.5) 129 (67.5)
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found an inverse association between ST and socioeconomic status, and Cheng [28] and
Emond et al. [24] found an association between excessive ST and parent/caregiver educational
levels. Mothers’ ST was found to be associated with high ST in children in our study. Primary
healthcare providers should inform parents/caregivers about the impact of their ST on that of
the children in their care.
Moreover, an increase in ST was significantly associated with a delay in the development of
language, communication, and social interaction among children; these findings are consistent
with those of a study conducted by Madigan et al. [26], where excessive ST was associated with
child developmental delay. Lin [3] and Wu et al. [19] also found positive associations between ST
and delays in cognitive, functional, language, and motor development; meanwhile, van den Heu-
vel et al. [29] showed a significant association between cell phone use and expressive speech
delay. The first 5 years are critical to a child’s development, and a healthy environment is crucial
to their upbringing. In this study, screens were mostly introduced to children during meals or
when the caregiver was doing chores, suggesting that the purpose of ST is not always educational,
and that parental monitoring may be ineffective. Such use of devices leads to reduced social
interaction with caregivers [3032] and developmental delay in terms of communication skills.
Table 4. Developmental delay domains and their associated factors.
Children aged 24–60 months Children aged 6–23 months
S
no
Background variable Delay 1 or more
domains N
Normal
development N
OR 95% CI p Delay 1 or more
domains N
Normal
development N
OR 95% CI p
1Place of residence
Rural 65 164 0.88 0.61–
1.29
0.52 16 77 0.97 0.46–
2.03
0.935
Urban 91 203 18 84
2Gender
Male 83 177 1.22 0.84–
1.78
0.29 76 22 0.48 0.23–
1.05
0.06
Female 73 190 85 12
3Birth order
2 or more 140 227 5.22 3.58–
7.62
<0.0001 10 74 0.49 0.22–
1.09
0.08
1 79 77 24 87
4Going to balwadi/
playschool
Yes 93 240 0.78 0.53–
1.15
0.21
No 63 127
5Type of family
Nuclear 103 135 1.13 0.76–
1.15
0.54 14 91 0.53 0.25–
1.14
0.11
Extended/joint 53 232 20 70
6Modified BG
Prasad’s SES
Class 1 34 65 0.748 4 28 0.714
Class 2 48 119 13 48
Class 3 47 114 11 59
Class 4 &5 27 69 6 26
7Mother’s education
Middle school and
above
150 353 0.99 0.37–
2.62
0.98 34 157 1.97 0.1–
37.48
0.65
Primary or below 6 14 0 4
8Screen time excess
Yes 151 231 17.78 7.11–
44.23
<0.0001 32 111 7.21 1.66–
21.25
0.008
No 5 136 2 50
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Limitations
The causal relationship between ST and developmental delay could not be established due to
the study’s cross-sectional nature. Since the ST details were collected prospectively, the
parents/caregivers could have modified the children’s screen exposure, reducing the mean ST.
This study was conducted in a small part of India, within rural and urban areas in Tamil Nadu.
Therefore, the mean values of ST may not be representative of those observed elsewhere in the
Table 5. Association between screen time in hours (STh) and child development among children aged 24–60 months.
S NO DOMAIN STh DELAY N NORMAL N OR 95% CI AOR 95% CI
1 Any one domain >2 123 104 32.4312.8–82.18 37.6114.48–97.69
1–2 28 127 5.992.25–16.01 6.62.44–17.86
<1 5 136
2 2 or more domains >2 82 104 35.7410.98–116.33 39.9712.05–132
1–2 18 127 6.431.85–22.34 6.631.89–23.27
<1 3 136
3 3 or more domains >2 30 104 13.083.88–44.03 17.755.04–62.497
1–2 9 127 3.21 0.85–12.13 3.49 0.91–13.296
<1 3 136
4 Receptive or expressive language delay >2 72 104 47.0811.29–196.33 52.9212.33–227.21
1–2 14 127 27.51.67–33.64 8.221.798–37.598
<1 2 136
5 Language or social interaction delay >2 82 104 53.6212.89–223.09 61.6914.38–264.61
1–2 14 127 7.51.67–33.64 8.331.82–38.12
<1 2 136
6 Any communication skill delay >2 101 104 33.0211.77–92.61 38.0213.22–109.37
1–2 19 127 5.091.69–15.36 5.621.83–17.22
4 136
p<0.05.
https://doi.org/10.1371/journal.pone.0254102.t005
Table 6. Association between screen time in hours (STh) and child development among children aged 6–23 months.
S NO DOMAIN STh DELAY N NORMAL N OR 95% CI AOR 95% CI
1 Any one domain >1 25 43 14.533.25–64.94 35.745.74–222.67
0–1 7 68 2.57 0.51–12.92 3.93 0.614–251.17
0 2 50
2 2 or more domains >1 11 43 6.3951.34–30.46 16.792.26–124.44
0–1 4 68 1.47 0.26–8.34 2.79 0.36–21.89
0 2 50
3 3 or more domains >1 5 43 5.81 0.65–51.71 9.61 0.85–108.58
0–1 3 68 2.21 0.22–21.84 4.04 0.32–50.798
0 1 50
4 Any communication skill delay >1 20 43 23.262.99–180.53 135.586.26–2935.47
0–1 5 68 3.68 0.42–32.46 8.64 0.45–167.52
0 1 50
5 Language or social interaction delay >1 18 43 20.932.68–163.32
0–1 2 68 1.47 0.13–16.67
0 1 50
p<0.05.
https://doi.org/10.1371/journal.pone.0254102.t006
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Screen time and developmental delay in children less than 5 years of age
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state or country and cannot be generalized due to differences in ethnicity, culture, and language
(mother tongue). The tool used for child development assessment has only been validated as a
screening method in the Indian setting and may not be used for diagnosis. However, since there
is a significant association between ST and developmental delay, it is important to limit chil-
dren’s ST. This study only evaluated the negative effects of ST on child development. Although
high-quality educational videos may benefit fine motor skill [33], and language [34] and vocab-
ulary acquisition [35], in particular, when combined with parental interaction, the overall evi-
dence suggests that the damage caused by screens outweighs the benefits [36].
Strengths
This is the first population-based study in India to assess the association between ST and the
development of children aged <5 years. The assessment was performed by a speech-language
pathologist in the comfortable environment of the child’s home, which ensured better cooper-
ation and assessment. All domains of child development were examined to ensure a better
understanding of the association between ST and each domain. Recall bias was reduced as the
data regarding ST were collected prospectively after observing the child for a week.
Conclusions
This study found a significant association between ST and child development. Since the preva-
lence of excessive ST is extremely high, limiting ST in children is essential to ensure healthy
development. Even though high-quality videos may support skill acquisition, it is difficult to
ensure supervised ST; parents should be advised to prevent leaving their children unsupervised
with screens. The WHO ST limits should be considered when implementing reproductive and
child health programs as an essential part of childcare services. This aim can be achieved by
involving primary care physicians and paramedical workers in rural and urban primary
healthcare centers to educate parents and caregivers on limiting ST. Future studies should
focus on effective methods to reduce and maintain low ST in children.
Supporting information
S1 File. Screen time data file.
(XLSX)
Acknowledgments
a. Mr Ranganathan, Health Inspector, Rural Health and Training Center, SRIHER, Chennai,
India
b. Mr Sampathkumar K, Health Inspector, Urban Health and training Center, SRIHER,
Chennai India
c. Mr Rajasekar N K, health inspector, Rural Health and Training Center, SRIHER, Chennai,
India
d. Ms Kumutha, Public Health Nurse, Rural Health and Training Center, SRIHER, Chennai,
India
Author Contributions
Conceptualization: Samya Varadarajan, Akila Govindarajan Venguidesvarane, Karthik Nar-
ayanan Ramaswamy, Muthukumar Rajamohan.
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Screen time and developmental delay in children less than 5 years of age
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Data curation: Akila Govindarajan Venguidesvarane, Murugesan Krupa.
Formal analysis: Samya Varadarajan, Akila Govindarajan Venguidesvarane, Karthik Naraya-
nan Ramaswamy, Sathiasekaran Bernard Winfred Christadoss.
Investigation: Samya Varadarajan, Akila Govindarajan Venguidesvarane, Muthukumar Raja-
mohan, Murugesan Krupa.
Methodology: Samya Varadarajan, Akila Govindarajan Venguidesvarane, Muthukumar Raja-
mohan, Murugesan Krupa, Sathiasekaran Bernard Winfred Christadoss.
Supervision: Sathiasekaran Bernard Winfred Christadoss.
Writing – original draft: Samya Varadarajan, Akila Govindarajan Venguidesvarane.
Writing – review & editing: Karthik Narayanan Ramaswamy, Sathiasekaran Bernard Winfred
Christadoss.
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... Although excessive screen time is more prevalent among children from developed countries than developing countries, the subject will need to be interpreted with caution due to the scarcity of studies in the latter. Nonetheless, findings from a population-based study in India revealed that the prevalence of screen time among children below five was indeed high at 73% [10]. In Malaysia, the National Health and Morbidity Survey (NHMS) conducted in 2016 using the older American Academy of Pediatrics (1999) guidelines revealed that 52.2% of children below five years old exceeded the two-hour screen-time limit, with 74% of them aged below two years and 32.6% aged between two to below five years [11]. ...
... This phenomenon has been largely exacerbated with the recent Coronavirus pandemic and multiple lockdowns imposed by the country. Excessive screen time has been associated with higher risks of developmental delay, particularly language delay, reduced physical activity, childhood obesity, hyperactivity-inattention, irritability, low mood and disrupted cognitive and socioemotional development, leading to poor educational performance, as well as limiting children using their imagination or exploring the world around them [10,[12][13][14]. ...
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Objectives To systematically examine the evidence of harms and benefits relating to time spent on screens for children and young people’s (CYP) health and well-being, to inform policy. Methods Systematic review of reviews undertaken to answer the question ‘What is the evidence for health and well-being effects of screentime in children and adolescents (CYP)?’ Electronic databases were searched for systematic reviews in February 2018. Eligible reviews reported associations between time on screens (screentime; any type) and any health/well-being outcome in CYP. Quality of reviews was assessed and strength of evidence across reviews evaluated. Results 13 reviews were identified (1 high quality, 9 medium and 3 low quality). 6 addressed body composition; 3 diet/energy intake; 7 mental health; 4 cardiovascular risk; 4 for fitness; 3 for sleep; 1 pain; 1 asthma. We found moderately strong evidence for associations between screentime and greater obesity/adiposity and higher depressive symptoms; moderate evidence for an association between screentime and higher energy intake, less healthy diet quality and poorer quality of life. There was weak evidence for associations of screentime with behaviour problems, anxiety, hyperactivity and inattention, poorer self-esteem, poorer well-being and poorer psychosocial health, metabolic syndrome, poorer cardiorespiratory fitness, poorer cognitive development and lower educational attainments and poor sleep outcomes. There was no or insufficient evidence for an association of screentime with eating disorders or suicidal ideation, individual cardiovascular risk factors, asthma prevalence or pain. Evidence for threshold effects was weak. We found weak evidence that small amounts of daily screen use is not harmful and may have some benefits. Conclusions There is evidence that higher levels of screentime is associated with a variety of health harms for CYP, with evidence strongest for adiposity, unhealthy diet, depressive symptoms and quality of life. Evidence to guide policy on safe CYP screentime exposure is limited. PROSPERO registration number CRD42018089483.
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Background Excess screen media use is a robust predictor of childhood obesity. Understanding how household factors may affect children’s screen use is needed to tailor effective intervention efforts. The preschool years are a critical time for obesity prevention, and while it is likely that greater household disorder influences preschool-aged children’s screen use, data on that relationship are absent. In this study, our goal was to quantify the relationships between household chaos and screen use in preschool-aged children. Methods A cross-sectional, online survey was administered to 385 parents of 2–5 year-olds recruited in 2017. Household chaos was measured with the Confusion, Hubbub and Order Scale (i.e., the chaos scale), a validated, parent-reported scale. The scale consists of 15 items, each scored on a 4-point Likert scale. Final scores were the sum across the 15 items and modeled as quartiles for analyses. Parents reported their children’s screen use for nine electronic media activities. Adjusted linear and Poisson regression were used to model associations between household chaos and children’s total weekly screen use, screen use within one hour of bedtime and screen use in the bedroom. Results Children averaged 31.0 (SD = 23.8) hours per week with screens, 49.6% used screens within one hour of bedtime and 41.0% used screens in their bedrooms. In adjusted regression models, greater household chaos was positively associated with weekly screen use (P = 0.03) and use of screens within one hour of bedtime (P < 0.01) in a dose-dependent manner. Children in the fourth versus the first quartile of household chaos were more likely to use screens in their bedroom (P = 0.03). Conclusions Greater household chaos was associated with increased total screen use as well as screen use behaviors that are related to disrupted nighttime sleep. Findings suggest that household chaos may be an obesity risk factor during the preschool years because of such effects on screen use, and highlight the need to consider household chaos when implementing home-based obesity prevention programs for young children.
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Objective: These days, young children are exposed to a wide range of smart devices and their usage of smart devices is rapidly increasing worldwide. However, the use of smart devices by young children has not been studied in detail yet because smart device is relatively recent. The purpose of this study was to investigate the exposure status of smart devices among 2-5 years old children in Korea. Methods: Four hundred parents of 2- to 5-year-old children were invited to enroll. Data on demographic information and the frequency of media use, time of media use, age at first use of media was self-reported. Results: Among 390 toddlers, 39.3% watched TV almost every day, while 12.0% of children used smartphone on a daily basis. During weekdays, 48% of the children watched TV for over an hour. On weekends, 63.1% of the children watched TV for over an hour. On weekends, 23.4% of children use their smartphones for over an hour. Children using smartphones before 24 months of age were 31.3%. Conclusion: Research has shown that TV and smartphones are the most popular digital devices used by toddlers. Most toddlers began using smart devices at 12-24 months. This study provides comprehensive information on children's contemporary use of media.
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Objective The objective was to examine the association between mobile media device use and communication delays in 18-month-old children. Methods A cross-sectional study was conducted from September 2011 and December 2015 within the TARGet Kids! primary care research network. Children were included if parents reported their child's mobile media device use and completed a validated questionnaire for communication delay at the 18-month well child visit. Mobile media device use was measured using a parent-reported survey instrument. Daily mobile media device use was calculated as a weighted average of typical weekday and weekend day mobile media device use. Two communication outcomes were investigated: (1) expressive speech delay and (2) other communication delays, as measured by the Infant Toddler Checklist. Results The study sample included 893 children (mean age 18.7 months, 54.1% male). Most parents reported 0 minutes per day of mobile media device use in their children (n = 693, 77.6%). Among children whose parents reported any mobile media device use (n = 200, 22.4%), the median daily mobile media device use was 15.7 minutes (range 1.4–300). The prevalence of parent-reported expressive speech delay was 6.6%, and the prevalence of other parent-reported communication delays was 8.8%. For children who used a mobile media device, each additional 30-minute increase in daily mobile media device use was associated with increased odds of parent-reported expressive speech delay (ORa = 2.33, 95% confidence interval, 1.25–4.82). No relationship was observed between mobile media device use and other parent-reported communication delays. Conclusion Our study demonstrated a significant association between mobile media device use and parent-reported expressive speech delay in 18-month-old children.