Parental Technology Use in a Child’s Presence and Health and Development in the Early Years

This systematic review and meta-analysis evaluates studies of associations between parental technology use in a child’s presence and such outcomes as motor development, cognitive development, psychosocial health, physical activity, screen time, and sleep in children younger than 5 years.

Key Points

Question

What is the association between parental technology use in a child’s presence and motor development, cognitive development, psychosocial health, physical activity, screen time, and sleep in children younger than 5 years?

Findings

This systematic review and meta-analysis found that parental technology use in their child’s presence was significantly associated with poorer cognition and prosocial behavior, lower attachment, higher levels of internalizing and externalizing problems, and higher levels of screen time.

Meaning

This phenomenon may negatively affect young children’s health and development, highlighting the need for more longitudinal and experimental studies targeting this modifiable factor.

Abstract

Importance

Parental technology use in a child’s presence (hereafter, PTU), often referred to as technoference, is a growing concern in family dynamics, and no studies have quantitatively synthesized associations with children’s health and development.

Objective

To systematically review and synthesize literature on associations between PTU in their child’s presence and motor development, cognitive development, psychosocial health, physical activity, screen time, and sleep in early childhood.

Data Sources

Peer-reviewed studies from MEDLINE, CINAHL, SPORTDiscus, PsycINFO, PsycArticles, Web of Science, Scopus, and ProQuest published from inception to July 2024.

Study Selection

A total of 6212 studies were initially identified. Studies were included if they examined associations between PTU in the presence of their apparently healthy children (birth to age 4.9 years) and motor development, cognitive development, psychosocial health, physical activity, screen time, or sleep.

Data Extraction and Synthesis

PRISMA guidelines were followed. Random-effect models were conducted to determine the pooled estimates of the associations and moderating effects of the type of exposure (distraction/interruption). The risk of bias was assessed using the JBI critical appraisal tools.

Main Outcomes and Measures

Association between PTU in the child’s presence and motor development, cognitive development, psychosocial health, physical activity, screen time, and sleep.

Results

Twenty-one studies involving 14 900 participants from 10 countries were included in the meta-analysis. Significant associations were found between parental technology use in the child’s presence and cognition (r = −0.14; 95% CI, −0.23 to −0.04), internalizing behavior and emotions (r = 0.13; 95% CI, 0.08 to 0.19), externalizing behavior (r = 0.15; 95% CI, 0.09 to 0.21), prosocial behavior (r = −0.08; 95% CI, −0.13 to −0.02), attachment (r = −0.10; 95% CI, −0.19 to −0.01), and screen time (r = 0.23; 95% CI, 0.13 to 0.32). No moderating effects of the type of PTU exposure on any associations were found. No study examined motor development, physical activity, or sleep.

Conclusions and Relevance

Parents’ use of technology in their child’s presence was negatively associated with cognitive and psychosocial outcomes and screen time among young children, although the effect sizes were small. Further research focusing on potential impacts on physical activity, sleep, and motor skills is needed. Understanding these associations is crucial for informing research and guidelines aimed at minimizing the potential negative effects of this phenomenon on early childhood development.

Introduction

The expectation that parents respond spontaneously to their child’s bids for attention is a fundamental aspect of early childhood interactions, emotional security, and children’s playful exploration of their surroundings.¹ When this responsiveness is lacking, children may be deprived of the benefits of sensitive and engaged parenting, which are important for promoting health and early development.^2,3,4 With the ubiquity of technological devices, parental technology use in the child’s presence (hereafter, PTU), often referred to as parental technoference⁵ or phubbing,⁶ has become prevalent with children exposed to PTU from an early age. Research indicates that more than 70% of parents engage with technology while playing or during mealtime with their children,⁷ and 89% report engaging in PTU at least once or more on a typical day.⁸

Devices can play a valuable role in helping parents navigate the complexities of modern life by providing access to information, fostering connections with peers, or offering relief from the demands of parenting.^9,10 However, when parent-child interactions are disrupted by their devices, it may foster a sense of being ignored or lead children to feel they must compete for their parent’s attention. Such intrusions may disrupt the natural flow of interactions, which is particularly important as young children are acquiring critical social and language skills (and in parallel, motor, psychosocial, and cognitive skills¹¹) and establishing their movement behavior patterns (eg, physical activity, sedentary screen time, and sleep).¹² Evidence of the effect of PTU on young children’s health and development has been summarized through scoping reviews,^13,14 narrative reviews,^15,16 and systematic reviews.^17,18,19,20 However, most have focused on psychosocial outcomes, the quality of parent-child interactions, and parental outcomes (eg, sensitivity and responsiveness). A systematic quantitative synthesis of associations between PTU and a broad range of health and developmental outcomes is therefore needed to elucidate the patterns of associations of this behavior on health and development during early childhood. Further, it has recently been proposed that PTU can be operationalized into distinct behavioral mechanisms,²¹ such as (1) distraction, where parents are distracted by using a device while their child is present; and (2) interruption, where a device abruptly interrupts an ongoing parent-child interaction through a call, message, email, or notification. However, the potential variations in these different mechanisms and their impacts on children are not yet well understood, representing an important area for further investigation.

Our systematic review and meta-analysis synthesized existing literature on the associations between PTU and motor development, cognitive development, psychosocial health, physical activity, screen time, and sleep in children younger than 5 years. A secondary aim of this study was to explore whether the observed associations differed based on the type of PTU exposure (ie, distraction vs interruption).

Methods

Search Strategy

This review was registered in PROSPERO (CRD42023418164) and reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines²² (eTable 1 in Supplement 1). Eight electronic databases (MEDLINE, CINAHL, SPORTDiscus, American Psychological Association [APA] PsycINFO, APA PsycArticles, Web of Science, Scopus, and ProQuest) were initially searched from inception to December 28, 2023, with no language restrictions. The search was subsequently updated to July 31, 2024. The search strategy was developed by referring to a previous review,¹⁴ discussions among research team members, and consultation with a research librarian. One reviewer (M.T.V.) also screened the reference lists of included studies and relevant reviews to identify additional records that were not captured through the database searches. The full search strategy can be found in the eMethods in Supplement 1.

Inclusion Criteria

Studies were included if they met the following criteria: (1) they explored a direct cross-sectional or longitudinal association between the frequency of PTU (parental technoference, media/technology use while parenting, or during routines or interactions) in any context and at least 1 outcome of interest (motor development, cognition, psychosocial health, physical activity, screen time, or sleep) in apparently healthy children aged from birth to 4.9 years; (2) they were published or accepted/in press by a peer-reviewed journal. Qualitative studies, dissertations, books, reviews, study protocols, gray literature, editorials, commentaries, and conference abstracts were excluded.

All search records were exported from databases and uploaded into Covidence (Veritas Health Innovation), where duplicates were identified and removed. Two reviewers (M.T.V., C.I.M.) independently screened the titles and abstracts of all retrieved studies against the eligibility criteria (97.3% agreement). Studies that met the initial screening were included in the full-text screening, and 2 reviewers (M.T.V., C.I.M.) independently assessed for final inclusion (95.8% agreement). Discrepancies were discussed, and if necessary, a third reviewer (K.H.C. or A.D.O.) was consulted for resolution.

Data Extraction

Two reviewers (M.T.V., C.I.M.) independently extracted data from each included study using Covidence. Data extracted included general study characteristics (eg, year of publication, country where the study was conducted, study design, sample size), measurement methods (eg, tools or instruments), outcomes examined, and study findings (eg, associations reported with statistical results). Disagreements were discussed or consulted with a third reviewer if needed (K.H.C. or A.D.O.). When required, corresponding authors were contacted to request additional or missing data.

Risk of Bias

The JBI critical appraisal tools²³ were used to assess the risk of bias of each included study. Each study was assessed twice independently among 4 reviewers (M.T.V., K.H.C., C.I.M., A.D.O.) using the checklist specific to the study design. Discrepancies were discussed to reach a consensus or resolved by a third reviewer. Each checklist item could be rated as yes, no, unclear, or not applicable (eMethods in Supplement 1). No studies were excluded based on their risk-of-bias assessment.

Statistical Analysis

Studies that provided a valid effect size (correlation coefficient) were included in the meta-analyses. Anticipating some degree of heterogeneity, a series of random-effects meta-analyses were conducted using the restricted maximum likelihood estimation. Pearson correlation coefficients (r) were extracted from the included studies to calculate the pooled effect size between PTU and each outcome. If they were unavailable, the first step was contacting the corresponding authors to request the information. Where no response was received, standardized β coefficients within the range of −0.50 and 0.50 were imputed to Pearson correlations.²⁴ If unstandardized coefficients (B) were reported from simple linear regression, we used the following equation to impute the Pearson correlation: r = B × standard deviation of PTU variable / standard deviation of the outcome variable. Spearman correlations were treated as estimates of Pearson correlations and included in the analyses (eMethods in Supplement 1).

Where a study provided more than 1 effect size for the same outcome, we conducted a multivariate random-effects meta-analysis with a 3-level approach. This method accounts for the potential bias introduced by the correlation of different measurements nested within the same study.²⁵ Correlations were converted into Fisher z-transformed correlations for analysis and then converted back for reporting. The pooled effect sizes were classified as very small (<0.1), small (0.1-0.29), moderate (0.3-0.49), and large (0.5-1).²⁶ A sensitivity analysis was performed to assess whether the use of associations adjusted for covariates led to considerable changes to the pooled estimates.

Heterogeneity among the included studies was assessed using the I² statistic (<25%, low; 25% to 75%, moderate; >75%, high).²⁷ The Egger test and funnel plots are not recommended for assessing publication bias when fewer than 10 studies are included in the meta-analysis.²⁸ However, to provide a visual insight into potential publication bias, we included both funnel plots and Egger test results for all outcomes in eFigures 1 through 7 in Supplement 1. These results should be interpreted cautiously given the limited number of studies, which reduces the power of Egger tests and the reliability of conclusions drawn from the funnel plots. For the analysis, outcomes were categorized into 7 groups (eTable 2 in Supplement 1). Meta-regression analyses were conducted to explore the moderating effect of type of PTU exposure (ie, distraction, interruption) on the association (eTable 3 in Supplement 1 for categorization and rationale), acknowledging that the results may be biased in analyses based on fewer than 10 studies. Analyses were conducted in R version 4.3.3 (R Foundation) using the metafor package.²⁹

Results

The initial search retrieved 6212 records. After removing duplicates, 4448 titles and abstracts were screened. Eighty-nine full-text articles were assessed for eligibility, of which 30 met the inclusion criteria for this review and 21 for the meta-analyses (Figure 1). The selected articles, published between 2017 and 2024, predominantly followed a cross-sectional design and included 16 383 participants from 12 countries, of which all but 4^30,31,32,33 were high income. Sample sizes ranged from 13 to 3483 participants. None of the included studies examined associations between PTU and physical activity or motor skills. Study characteristics and findings of all included studies are provided in eTable 4 in Supplement 1.

Figure 1. PRISMA Flow Diagram for Assessing Studies of Parental Technology Use (PTU).

According to the risk-of-bias assessment, observational studies lacked clear inclusion criteria, and most exposure measurements were not validated or reliability was not assessed. Experimental randomized studies failed to blind those delivering the interventions, and the experimental nonrandomized studies did not include a control group. The complete assessment is available in the eMethods in Supplement 1.

Narrative Synthesis

Among the studies not included in the meta-analysis (n = 9),^{34,35,36,37,38,39,40,41,42} 5 studies^{36,37,39,41,42} followed a similar protocol using a handheld device interrupting parent-child interactions. Two of them^36,37 showed that children displayed more social bids during the interruption with a phone compared with free play, likely in the attempt to regain their parent’s attention, while 3 of 4 studies^37,41,42 showed more negative affect. Three studies^37,39,42 reported that children displayed less positive affect. In 1 experimental study,⁴⁰ toddlers demonstrated more comprehension when teaching was uninterrupted. Other studies found no significant association between PTU and infants’ behaviors,³⁴ imitation learning,³⁵ and talks or positive emotions.³⁸

Meta-Analyses

Twenty-one studies involving 14 900 participants from 10 countries were included in the meta-analyses. The results of the meta-analyses are presented in Figure 2 with a forest plot summarizing all meta-analyses (individual forest plots are provided in eFigures 8-14 in Supplement 1). In most cases, the assessments of publication bias remained inconclusive because of the limited number of studies (eFigures 1-7 in Supplement 1). For internalizing behavior problems and emotions (n = 11), visual inspection of the funnel plot and the results of an Egger test (P = .44) did not suggest clear evidence of publication bias. The sensitivity analysis showed that the inclusion of adjusted effect sizes considerably reduced the number of eligible studies and increased the statistical heterogeneity in the estimates, leading to reduced significance in the pooled effect sizes. The increase in study-level heterogeneity was likely caused by discrepancies in covariates used for adjustments across studies (eAppendix in Supplement 1).

Figure 2. Findings From Meta-Analyses of the Association of Parental Technology Use in a Child’s Presence and Their Health and Development Outcomes.

NA indicates not applicable.

Cognition

The association between PTU and children’s cognition was investigated in 3 studies.^33,43,44 A small but statistically significant effect size was found (r = −0.14; 95% CI, −0.23 to −0.04; P = .006). Children whose parents reported a higher frequency of PTU had lower cognitive performance (eg, on assessments of attention, executive function, and cognitive self-regulation). The model presented moderate heterogeneity (I² = 64.4%).

Language

Three studies^43,45,46 reported associations between PTU and children’s language development, resulting in a nonsignificant pooled effect size of r = −0.09 (95% CI, −0.31 to 0.14; P = .46). There were moderate levels of heterogeneity (overall I² = 67.7%).

Internalizing Problems and Emotions

Eleven studies^{8,33,43,47,48,49,50,51,52,53,54} reported associations between PTU and children’s internalizing problems and emotions. Two studies analyzed the same dataset^41,50; the one with the smaller analytical sample size⁴¹ was excluded from the analysis. A small but statistically significant pooled effect size (r = 0.13; 95% CI, 0.08 to 0.19; P < .001) with high heterogeneity (I² = 80.9%) was found, indicating that a higher frequency of PTU was associated with more internalizing problems and negative emotionality.

Externalizing Problems

Five studies^{8,30,43,52,54} reported associations between PTU and children’s externalizing problems. A small but statistically significant pooled effect size was found (r = 0.15; 95% CI, 0.09 to 0.21; P < .001), indicating that a higher frequency of PTU was associated with more child externalizing behavior. Moderate heterogeneity was observed in the model (I² = 63.2%).

Prosocial Behavior

Three studies^31,43,52 were included in the analysis of children’s prosocial behavior. The results indicated that PTU was significantly associated with less prosocial behavior (r = −0.08; 95% CI, −0.13 to −0.02; P = .006). The model presented low heterogeneity (I² = 15.1%).

Attachment

Three studies^30,31,55 identified associations between PTU and children’s attachment. A small but statistically significant pooled effect size of −0.10 (95% CI, −0.19 to −0.01; P = .03) was found, indicating less secure parental attachment at higher levels of PTU. The model showed high heterogeneity (I² = 82.7%).

Screen Time

Nine studies^{8,32,33,44,45,54,56,57,58} examined the associations between PTU and children’s screen time. Frequency of PTU was significantly associated with child screen time (r = 0.23; 95% CI, 0.13 to 0.32; P < .001), such that more PTU was related to more children’s screen time. The model presented high heterogeneity (overall I² = 94.6%).

Moderating Effect of the Type of PTU Exposure

The influence of the type of PTU exposure (distraction and interruption) was examined across all associations. No statistically significant moderating effect was found, indicating that both forms of PTU had similar associations with the measured outcomes (eTable 5 in Supplement 1).

Discussion

This systematic review and meta-analysis examined the literature on the associations between PTU and various health and development outcomes in early childhood. The main findings revealed that PTU was associated with poorer cognition, prosocial behavior, and attachment and higher levels of internalizing problems, externalizing problems, and screen time. Effect sizes were classified as very small to small and were not moderated by whether PTU was a distraction or an interruption, suggesting that distractions or interruptions by technological devices may have an equal impact on the outcomes studied.

To our knowledge, this is the first meta-analysis to examine the effects of PTU on various health and development outcomes during early childhood. Our findings align with previous literature that identified detrimental associations of PTU with psychosocial and cognitive outcomes in children aged birth to 3 years,²⁰ birth to 5 years,¹⁹ birth to 10 years,¹⁷ and birth to 18 years,^14,15 one of which also reported detrimental associations with preschoolers’ screen time.¹⁴ Our results extend this by providing quantitative analyses and identifying additional outcomes that may be negatively impacted by PTU.

The negative association between PTU and children’s cognition may be attributable to a decrease in the quality of parent-child interactions and lack of contingent responding. High-quality, sustained, and reciprocal interactions, particularly within the home environment, where young children spend the most time, are essential for cognitive development in young children.⁵⁹ When parents frequently engage with screen-based devices in the presence of their children, the children’s efforts to interact or seek attention may be met with delayed, dismissive, shallow, or absent responses. This inconsistency in social feedback and responsiveness may lead to fewer opportunities for children to engage in mentally stimulating activities that foster the development of foundational cognitive skills, such as executive functions. The reverse is also possible; screen-based devices are often used as a temporary reprieve to address challenges in the home. While we do not anticipate this to be the primary chain of effect, evidence suggests that parental use of digital media to help manage children’s problematic emotions can contribute to exacerbating later problematic media use and emotional extremes.⁶⁰ Still, low social-cognitive reciprocity during PTU, which creates fewer opportunities for adult-child interaction and scaffolding and potentially leads children to expect and seek less interaction over time, can be expected to confer minimal, if any, benefit to children. Instead, this situation almost certainly represents missed developmental opportunities.

The unfavorable findings for psychosocial outcomes may also be explained by children feeling ignored in attempts to engage their parents.⁶¹ Parents are children’s first and most important teachers, and child frustration can arise from inconsistent responses, regardless of whether these inconsistencies are attributed to PTU.^62,63 Our meta-analysis suggests that PTU is negatively associated with children’s behaviors, emotions, and attachment to their parents. The specific mechanisms and pathways of this association need to be better understood (eg, through children’s interpretations of PTU, consequences for the parent-child relationship, behavioral adjustments by the child). Nonetheless, even in its absence, our findings suggest the importance of minimizing PTU during early childhood and promoting awareness and parental responsiveness.

The observed association between PTU and increased screen time may be attributable to several factors. For instance, parents might allow their children to use screens for entertainment while they are engaged with their own devices. Research has indicated that parents may use digital devices to escape and manage stress,^64,65 and additionally, they are likely to rely on these devices to calm their children during moments of distress.⁶⁶ During PTU, parents also model acceptable use for their child (whether intentionally or not), which may stimulate more requests for digital activity from the child.⁶⁷ Further, observing their parents engage in extensive periods of sedentary screen time may lead children to imitate this behavior and limit parents from engaging in shared activities that could facilitate opportunities for physical activity and enhance children’s motor skills. This association may also be influenced by parents who are not concerned about their own screen time and, consequently, may be less attentive to their children’s screen time. These findings have implications for public health attempts to reduce sedentary screen time in young children since most children younger than 5 years do not meet the screen time recommendations.⁶⁸

Meta-regression analyses revealed no significant moderating effect of the type of PTU exposure (distraction vs interruption) on any association examined. Regardless of whether parents are momentarily interrupted or actively distracted by technology, the impact on children appears to be equally negative. Future research should more precisely define and specify the devices and mechanisms involved to obtain more robust conclusions. Similarly, further research is needed to explore whether a similar pattern exists with motor development, physical activity, and sleep, considering their codependence with screen time.^69,70

Only 1 validated questionnaire was used in the included studies to measure PTU.⁷¹ A comprehensive and validated tool that accounts for the context and type of device is needed to assess this behavior more accurately. Future studies should examine the frequency of use (how much time is excessive), context (location and type of content/task), devices involved (handheld devices, laptops, television, video games), and duration of distractions/interruptions. Studying both the short- and long-term effects of PTU and developing interventional studies could provide valuable insights. Additionally, it is crucial to systematically examine other variables that could influence or explain the associations between PTU and children’s outcomes, such as parental mental health^7,64 or problematic device use.^7,72 We emphasize that these results do not imply that technological devices are inherently harmful; they can serve as valuable tools for parents.^10,73 However, regulating and controlling device use around children may help mitigate potential negative effects. Co-viewing/co-using devices may offer a strategy to alleviate this, as it is positively associated with cognitive outcomes in young children.^19,73

Strengths and Limitations

This is the first known study to review and quantify the association of PTU with a broad range of health and developmental outcomes in early childhood using a solid quantitative approach. We attempted a novel classification to understand the potential difference between being distracted or interrupted by a technological device. There are also some limitations. First, analyses included a small number of studies, mostly from high-income countries, limiting the statistical power and generalizability. Second, our study only included correlations, further limiting causal interpretations and direction. Third, the outcomes were categorized into broader domains, which may misrepresent the true association with specific outcomes.

Conclusions

This systematic review and meta-analysis found that PTU was negatively associated with cognition, diverse psychosocial outcomes, and screen time in children younger than 5 years. While correlational in nature, triangulation of these results is at least suggestive that PTU may be a factor influencing children’s health and development. This review highlights the lack of research on outcomes other than psychosocial health, such as physical activity, sedentary behavior, sleep, motor development, and additional cognitive outcomes. Given the ubiquity of handheld and other screen-based devices and the frequency at which PTU can and does occur, it is essential to further investigate this phenomenon using methods to measure PTU more precisely in different contexts.

Supplement 1.

eTable 1. PRISMA checklist

eMethods

eFigure 1. Funnel plot cognition

eFigure 2. Funnel plot language

eFigure 3. Funnel plot internalising problems and emotions

eFigure 4. Funnel plot externalising problems

eFigure 5. Funnel plot prosocial behaviour

eFigure 6. Funnel plot attachment

eFigure 7. Funnel plot screen time

eTable 2. Categorisation of outcomes for meta-analyses

eTable 3. Type of PTU exposure

eTable 4. Study characteristics and findings

eFigure 8. Forest plot cognition

eFigure 9. Forest plot language

eFigure 10. Forest plot internalising problems and emotions

eFigure 11. Forest plot externalising problems

eFigure 12. Forest plot prosocial behaviour

eFigure 13. Forest plot attachment

eFigure 14. Forest plot screen time

eAppendix. Sensitivity analyses

eTable 5. Moderator analysis for the type of exposure

eReferences

Supplement 2.

Data sharing statement