Problematic screen media use in children and adolescents attending child and adolescent psychiatric services in a tertiary care center in North India : Indian Journal of Psychiatry

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ORIGINAL ARTICLE

Problematic screen media use in children and adolescents attending child and adolescent psychiatric services in a tertiary care center in North India

Raju, Venkatesh; Sharma, Akhilesh; Shah, Ruchita; Tangella, Ravikanth; Yumnam, Sana Devi; Singh, Jyoti; Yadav, Jaivinder; Grover, Sandeep

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Indian Journal of Psychiatry 65(1):p 83-89, January 2023. | DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_182_22
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Abstract

INTRODUCTION

Screen media includes all types of screen devices like television, computers, laptops, mobile phones, tablets, and other handheld devices. Screen media use in children is common and has been increasing over the years due to its easy availability with advances in technologies.[1] In today’s world, screen media exposure occurs as early as infancy.[2] Internet-enabled smart devices are helpful to children and adolescents in many ways, such as facilitating learning and building early literacy skills, serving as a distraction tool while administering medicines or performing medical procedures to infants and toddlers,[3] and retaining or strengthening familial connections when parents are away.[4] However, excessive use of screen media devices is associated with adverse health consequences like obesity, sedentary behavior, poor dietary habits, and poor sleep.[3,5] Excessive use of screen media at a tender age can also affect learning and cognition, language development, social interaction skills, and the overall social well-being of the child/adolescent. It also leads to a higher chance of experiencing negative emotional states and being exposed to unsafe content and contacts through cyberbullying, sexting, multiplayer games, and social media.[3,6,7] There is also evidence of structural brain changes with increased use of screen-based media.[8] Excessive screen media use in pre-kindergarten children (even after controlling for child age and household income) is associated with lower microstructural integrity of brain white matter tracts that support language, executive functions, and emergent literacy skills.[8] Given these negative consequences, the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) set up guidelines for screen time for children.[9,10] As per these guidelines, there should be no screen exposure other than video calling exposure with family members for children up to two years of age. However, children can co-watch high-quality educational content for <1 hour/day between 1.5 to 2 years. From two to four years of age, recommended screen time is <1 hour/day, and from five years of age and above, a maximum of 2 hours/day of recreational screen time is recommended.[9,10]

A systematic review evaluating the correlates of excessive mobile screen media use among children aged zero to eight years reported that higher use of screen media was associated with older children, children better skilled in using devices, children having increased access to the devices at home, and children whose parents had a higher use of said device. No association of higher screen media use was correlated with the parents’ age, sex, and education.[11]

Evidence also suggests that the excessive use of screen media in itself becomes “addictive.” It becomes a problem of concern for the parents, family members, and sometimes to the children and adolescents themselves. This has led to the development of the concept of problematic use of screen media or screen media addiction. This concept draws its roots from internet addiction, which first arose when Kimberly Young talked about the “addictive use of the Internet” as a pathological condition.[12] Young took the lead from the pathological gambling criterion of the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) and developed criteria for internet addiction.[12] These criteria have been applied to other types of behavioral addictions.[13] Internet gaming disorder (IGD) was included in section 3 of the DSM-5, requiring at least five out of nine criteria (preoccupation, tolerance, withdrawal, persistence, displacement, problem, deception, escape, and conflict) to be met.[14]

There are several surveys on-screen use among children and adolescents. A systematic scoping review of 30 surveillance studies since 2000 that synthesized the descriptive epidemiology of screen-based devices, incorporating newer forms of screens, among 5–18-year-olds found that television viewing (64.3%) was the most common measure of screen time, and on average 52.3% of participants (k = 19 studies) exceeded 2 hours/day of screen time and total screen time was 3.6 hours/day (1.3–7.9 hours/day).[15] However, there was no study on the problematic use of screen media or screen media addiction in children and adolescents attending the mental health services with various mental disorders. Accordingly, this study aimed to evaluate screen media use among children and adolescents attending the child and adolescent psychiatry (CAP) clinic of a tertiary care center in north India.

METHODOLOGY

A prospective, cross-sectional study was carried out at the child and adolescent psychiatry (CAP) outpatient department (OPD). The ethics committee of the institute approved the study, and informed consent and assent were obtained from the family members and patients. Family members of all the children and adolescents (both new and follow-up patients) attending the CAP OPD services between April 1 and July 31, 2019, were approached. Parents who could read Hindi or English and provided written consent were invited to complete the Problematic Media Use Measure-Short Form (PMUM-SF).[16] If the children and adolescents were brought to the OPD by persons other than their parents, they were excluded from the study.

The PMUM-SF is based on the DSM-5 criteria for internet gaming disorder (IGD).[16] It is a parent-rated questionnaire for children aged 4–13 years. It has a long-form that has 27 items, and a short form that has 9 items. Items are worded in such a way that any screen media addiction can be assessed by the nine-item short form, which corresponds to the DSM-5 criteria for IGD.[16] Item numbers 5, 8, 11, 12, 15, 16, 20, 26, and 27 of the PMUM long form constituted the short-form version and was used as a measure of screen media addiction. It has a Cronbach’s alpha of 0.93. A Hindi translated version was used in this study. The scores of the nine items were added; higher scores indicated a higher level of problematic media use. For the purpose of this study, those items, the responses of which were marked as “often” and “always” by the parent, were scored as positive to see how many children fulfilled the addiction criteria, similar to the DSM-5 criteria for IGD.

Screen time was calculated based on the information provided by the parents and the patients. In case there was a discrepancy, the higher reported duration was considered.

The sociodemographic and clinical data was recorded in a structured format. All the psychiatric diagnoses were made as per the International Classification of Diseases, tenth revision (ICD-10)[17] criteria by a qualified psychiatrist.

RESULTS

The study included 212 children and adolescents and their family members. The mean age of the children and adolescents whose parents participated in the survey was around 13 years (SD: 4; range: 0.8–18), with the majority (71.7%) of the sample aged more than 12 years. The majority of the children and adolescents were boys, Hindu by religion, and from nuclear families [Table 1]. The most common primary diagnosis was neurodevelopmental disorder (38.7%), followed by neurotic disorder (29.2%). A small proportion of the children and adolescents had an additional second diagnosis [Table 1].

T1
Table 1:
Sociodemographic and clinical profile of the children whose parents participated in the study

Screen media used

The most common screen-based media devices used by the children and adolescents were mobile phones (70.3%) followed by television (66%). When we specifically enquired about a child’s most commonly used screen media device, television was the common gadget, followed by mobile phone and video games [Table 2]. The children’s mean duration of screen media use per day was 3.14 (SD: 1.33) hours/day. No significant difference was seen between children <12 years of age and those aged ≥12 years in terms of preference for the type of gadget and the mean duration of screen media use per day. About two-thirds of the participants used screen media for a duration more than what was recommended for their age, with no significant difference in prevalence between those aged <12 years and those aged 12 or older [Table 2].

T2
Table 2:
Screen media devices used by children and adolescents

SCREEN MEDIA ADDICTION OR PROBLEMATIC USE

As is evident from Table 3, the affirmative response on various items suggesting “often” or “always” responses (i.e., a score >3 on multiple items of the PMUM-SF) varied from 13.7% to 48.1%. When the DSM-5 criteria of IGD was applied, with an affirmative response on each item as >3 (i.e., 4 [often] and 5 [always]) indicative of fulfillment of a particular criteria, 22.2% of children and adolescents met the criteria for addiction, with no significant difference in the prevalence of screen media addiction between those aged <12 and ≥12 years, although there was a trend for children aged 12 or older spending more time per day on various screen media [Table 3].

T3
Table 3:
PMUM-SF items with scores >3 (“often” and “always”)

Factors associated with screen media addiction

When those with and without screen media were compared, in the whole sample, those with screen media addiction were more often male, from joint or extended families, more often diagnosed with neurodevelopmental disorders and disruptive disorder, less frequently diagnosed with neurotic disorders, and were using the screen media for a longer duration every day [Table 4].

T4
Table 4:
Comparison of demographic and clinical profiles of those with and without addiction (whole sample)

When the factors associated with screen media addiction in children aged <12 years were assessed, those with screen media addiction had more than one diagnosis (P = 0.005**), more often had a neurodevelopmental disorder (P = 0.032*) and disruptive disorder (P = 0.001**), and were using the screen media for a longer duration every day (P < 0.001***).

When the same was assessed in children aged ≥12 years, those with screen media addiction were more often male (P = 0.039*), from joint or extended families (P = 0.023*), were more often diagnosed with neurodevelopmental disorders (P = 0.017*), were less often diagnosed with neurotic disorders (P = 0.007**), and were using the screen media for a longer duration every day (P < 0.001***).

DISCUSSION

The present study aimed to evaluate the prevalence of screen media use among children with mental disorders attending the CAP OPD of a tertiary care center. The most common primary diagnosis in the study sample was neurodevelopment disorder (38.7%), followed by neurotic disorder (29.2%) and mood disorder (14.2%). This diagnostic profile of the study sample is similar to that reported for patients attending the CAP services of the department.[18]

The mean screen time for the children and adolescents was 3.14 hours with a range of 0.5–7 hours, and about two-thirds of the children and adolescents were using the screen media for more than the recommended duration. These findings suggest that children and adolescents often use screen media for more than the recommended duration. There is a need to improve awareness regarding the recommended duration among parents of children with mental disorders. The high prevalence of more than the recommended duration also calls for evaluating the association of screen media use with the development of psychopathology and the severity of the psychopathology. However, we did not specifically look for these associations in the present study.

The most commonly used screen media among children and adolescents was television followed by mobile phones. This could be because televisions are present in most households, including families from a lower socioeconomic status. This allows easy access to television for children and adolescents of all age groups. Access to mobile phones can be understood from the current level of penetration of mobile phones in India.[19] Our study sample’s profile of screen media use is similar to that reported in existing literature.[15]

In the present study, more than one-fifth of the children (22.2%, n = 47) met the criteria for screen media addiction or problematic screen media use when the same was evaluated by using the cut-off for items as more than 3 (i.e., often and always). Screen media addiction was 13.3% (n = 8) and 25.7% (n = 39) in children <12 years of age and those aged ≥12 years, respectively, with a trend toward higher prevalence in the latter group. The prevalence figure of problematic use or screen media addiction in the present study is reported to be in the range of 14%–31%, according to a systematic review and meta-analysis of data from different countries across the globe.[20] A systematic review and meta-analysis that evaluated the prevalence of smartphone addiction in adolescents without mental disorders in India reported its prevalence to range from 39% to 44%.[21] Accordingly, it can be said that the prevalence findings of the present study are lower than those reported in previous studies from India. However, this difference could be attributed to differences in the methodology and age group of the study sample.

Regarding factors associated with screen media, those with screen media addiction were more often male, from joint or extended families, more often diagnosed with neurodevelopmental disorders and disruptive disorder, less frequently diagnosed with neurotic disorders, and were using the screen media for longer than the recommended duration every day. When the association was evaluated specifically in children aged <12 years, those with screen media addiction had more than one diagnosis, more often had a neurodevelopmental disorder, and were using the screen media for a longer duration every day. In children aged ≥12 years, those with screen media addiction were mostly male, from a joint or extended family, more often diagnosed with a neurodevelopmental disorder, were less often diagnosed with a neurotic disorder, and were using the screen media for longer than the recommended duration every day. A systematic review and meta-analysis that studied problematic smartphone use among children and adolescents found that problematic use was associated with increased odds of depression, anxiety, higher perceived stress, and poorer sleep quality.[20] A higher use of screen media in the joint family setup should be consdiered as a preliminary finding and this requires replication in future studies. At first glance, this appears counterintuitive. It is quite possible that in the joint family setup, more and more adults and older siblings act as role models for excessive screen media use, which possibly propels the children and adolescents to use screen media. Furthermore, it is also possible that in the joint family setting, the rules of parenting are not very firm, with some adult family members contradicting the rules laid by others and leading to indiscipline in the family environment and resultant excessive screen media use. This is further compounded when the child has a mental disorder. A significantly higher use of problematic screen media use in children and adolescents with neurodevelopmental disorders could be due to parents allowing these children to use screen media as a distraction to get rid of their other behavioral problems. Furthermore, parents may not enforce discipline as required, considering the mental illness in the child from the beginning. Additionally, considering the limited interest of the child with neurodevelopmental disorders, parents may be more accepting of the screen media use. Accordingly, it is important to understand the parenting style of children and adolescents with problematic screen media use.

Overall, it can be said that the factors associated with problematic screen media among children and adolescents with mental disorders are different than that reported for those enrolled from the community sample. Hence, there is a need to evaluate this further.

The present study has certain limitations. It did not evaluate the parents’ parental attributes and their time spent on screen media. Furthermore, the duration of screen media use for their children and adolescents was based on the subjective perception of the parents rather than any objective parameter. The sample sizes for different diagnostic groups were small and did not evaluate risk factors for problematic screen media use for each diagnostic group. Future studies need to overcome these limitations of the present study.

In conclusion, the present study suggests that about 22.2% of children and adolescents with mental disorders have screen media addiction or problematic screen media use. About two-thirds of them use screen media for more than the recommended duration for their age. The present study also suggests that those with screen media addiction are more often diagnosed with neurodevelopmental and disruptive disorders and less frequently diagnosed with neurotic disorders. Based on the findings of the present study, it can be recommended that children and adolescents should be routinely evaluated for excessive time spent on screen media and for problematic screen media use. The parents of these children and adolescents should be routinely made aware of the recommended duration, and they should be asked to implement the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent and assent forms. In the form, the patient(s) has/have given his/her/their consent for clinical information to be reported in the journal. The patients and thier parents understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

We thank all the participants of this study.

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Keywords:

Addiction; north India; problematic media use; screen media

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