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ADC Online First, published on March 25, 2013 as 10.1136/archdischild-2011-301508 Original article

Do television and electronic games predict children’s psychosocial adjustment? Longitudinal research using the UK Millennium Cohort Study
Alison Parkes, Helen Sweeting, Daniel Wight, Marion Henderson
Medical Research Council/ CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK Correspondence to Dr Alison Parkes, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK; Alison-p@sphsu.mrc.ac.uk Received 7 December 2011 Revised 15 October 2012 Accepted 7 December 2012

ABSTRACT Background Screen entertainment for young children has been associated with several aspects of psychosocial adjustment. Most research is from North America and focuses on television. Few longitudinal studies have compared the effects of TV and electronic games, or have investigated gender differences. Purpose To explore how time watching TV and playing electronic games at age 5 years each predicts change in psychosocial adjustment in a representative sample of 7 year-olds from the UK. Methods Typical daily hours viewing television and playing electronic games at age 5 years were reported by mothers of 11 014 children from the UK Millennium Cohort Study. Conduct problems, emotional symptoms, peer relationship problems, hyperactivity/inattention and prosocial behaviour were reported by mothers using the Strengths and Difficulties Questionnaire. Change in adjustment from age 5 years to 7 years was regressed on screen exposures; adjusting for family characteristics and functioning, and child characteristics. Results Watching TV for 3 h or more at 5 years predicted a 0.13 point increase (95% CI 0.03 to 0.24) in conduct problems by 7 years, compared with watching for under an hour, but playing electronic games was not associated with conduct problems. No associations were found between either type of screen time and emotional symptoms, hyperactivity/inattention, peer relationship problems or prosocial behaviour. There was no evidence of gender differences in the effect of screen time. Conclusions TV but not electronic games predicted a small increase in conduct problems. Screen time did not predict other aspects of psychosocial adjustment. Further work is required to establish causal mechanisms.

What is already known on this topic
▸ High screen time has been linked with behavioural and emotional problems in children, although findings have not all been consistent. ▸ Most longitudinal studies have focused on television and almost all have been conducted in North America. ▸ Few studies have examined TV and electronic games separately to see whether they have similar effects.

What this study adds
▸ Watching TV for 3 h or more daily at 5 years predicted increasing conduct problems between the ages of 5 years and 7 years. ▸ No effects of TV at 5 years were found on hyperactivity/inattention, emotional symptoms, peer relationship problems or prosocial behaviour. ▸ Playing electronic games at 5 years was not associated with increased risk of problems.

INTRODUCTION
Television and electronic games are prominent features of children’s home environments in many high-income countries. However, children’s heavy screen time has been linked with obesity, sleep problems, lower cognitive skills and poor academic adjustment.1–3 High screen time may also predict behavioural and emotional problems in children, including aggression,4 5 anxiety and depression,5–7 victimisation,3 social isolation,8 reduced prosocial behaviour4 9 and attentional problems.4 10 11 Heavy screen time might impair children’s mental health in various ways, particularly if it involves viewing material not primarily designed for children and/or with less adult supervision. Screen entertainment’s rapid pace, frequent changes of image and capacity to excite may shorten concentration span12 and reduce time

To cite: Parkes A, Sweeting H, Wight D, et al. Arch Dis Child Published Online First: [ please include Day Month Year] doi:10.1136/archdischild2011-301508

spent on other key developmental activities, including interpersonal interactions.13 Violent content may ‘prime’ children for aggression and prompt them to imitate aggressive behaviour they have just seen. Longer term effects may include desensitisation to violence, and development of attitudes supporting the use of aggression.5 14 Violent content may also increase children’s perceptions that the world is a ‘scary place’, resulting in trauma symptoms including depression and anxiety.6 It is thought that many psychological processes associated with exposure to TV and electronic games are similar, particularly those regarding the development of attentional problems and aggressive behaviour.15 However, games may have more powerful effects due to active user engagement, identification with characters and repeated rehearsal and reinforcement.16 Gaming’s interactive and absorbing qualities may substitute for interpersonal relationships and increase social isolation.17 Such isolation may provoke anxiety and depression,18 or, if coupled with reduced empathy (from exposure to violent games) may depress prosocial

Parkes A, Article author (or their employer) 2013. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence. 1 Copyright et al. Arch Dis Child 2013;0:1–8. doi:10.1136/archdischild-2011-301508

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Original article behaviour.19 Few studies have examined young children’s use of electronic games, although a recent study found negative effects of television and video game exposure on attentional problems in middle childhood.11 There are, however, a number of alternative explanations for associations observed between screen time and psychosocial adjustment. Family circumstances and functioning may underpin variation in children’s screen time and poor adjustment.20 Links between screen time and mental health may be indirect, rather than direct, for example, via increased sedentary behaviour, sleeping difficulties and language development.21–23 Lastly, the child’s own temperament may predict screen time.24 Longitudinal studies of early screen exposure on children’s mental health must take account of these alternative possibilities, in order to demonstrate direct associations between screen time and children’s mental health. More research would be valuable to supplement existing longitudinal studies on young children that do allow for a range of confounders.3 9 10 25 26 All but one9 of these studies come from North America and findings are inconsistent with regard to attentional problems4 10 25 and aggression.3 26 There are also limitations in scope. Only two examined prosocial behaviour.9 26 Only one recent study has distinguished between TV and video game exposure,11 but did not allow for many potential confounders. None of these studies examined gender differences, although psychosocial adjustment and screen use are patterned by gender.27–31 This study explores associations between children’s screen exposure at age 5 years and change in adjustment from ages 5 years to 7 years, using a nationally representative sample from the UK. In the UK, watching television, videos or DVDs and electronic gaming using a games console or computer are the most common ‘media activities’ for 5–7-year-olds, and average 2011 weekly exposure times were 15 h TV compared with 6½ h gaming.32 We explore TV/video/DVD watching separately from gaming, to see whether passive and interactive forms of screen time have similar or different effects. We examine gender differences and take account of a wide range of confounders, to assess whether screen exposure may be an independent predictor of children’s mental health.

Outcome measures
Psychosocial adjustment was reported by mothers at ages 5 years and 7 years using the Strengths and Difficulties Questionnaire (SDQ),38 a widely-used survey instrument with high validity and reliability. The SDQ contains five scales, measuring conduct problems, emotional symptoms, inattention/ hyperactivity, peer relationship problems and prosocial behaviour. Each scale contains five items scored from 0 to 2, giving a scale range of 0 to 10. Change scores were calculated by subtracting age 5 years from age 7 years scores, to give measures ranging from −10 to +10.

Screen time
Television/video/DVD viewing (referred to as ‘TV’ here) and playing computer or other electronic games (referred to as ‘electronic games’) were reported by mothers when children were age 5 years. For both types of screen time, typical weekday term-time hours of exposure outside school were measured on a 6-point scale: none,