Screens Are Not the Enemy: Recommendations for Developing Healthy Digital Habits in Youth

Abstract

With the rapid and ever-evolving growth of both digital media platforms and mental health concerns in youth, parents and practitioners are faced with the challenge of critically evaluating the effects of digital media use on youth development.¹ Despite popular culture’s narrow focus on the risks, research has established both positive and negative effects of youth digital media use.^2,3 In contrast to interventions primarily focused on screen time limits, the goal of this article is to propose a framework for healthy digital habits rooted in a social-ecological model, called the Multisystemic Model of Digital Habits. This framework considers the intersection of the digital environment, family environment, and individual factors when examining digital media use by youth. Using this framework, practical recommendations are offered, including strategies to evaluate media use and guidance on encouraging healthy digital habits with consideration for unique family and individual needs.

The Current State of Youth Digital Media Use

Almost 90% of youth aged 11 or younger interact with digital media⁴, including television, radio, social media, mobile apps, video games, and streaming platforms.³ Youth aged eight to 12 spend around five and a half hours daily on digital media, while youth aged 13 to 18 spend about eight and a half hours.⁵ With ubiquitous digital media access among youth, approximately 60% of parents report concerns about how digital media use affects their children’s development.⁶ About 60% of parents of a child under the age 12 also seek parenting digital media advice from doctors or other parents.⁷

Digital Media Use and Youth Outcomes

Mainstream media predominantly focuses on sharing the negative effects of youth digital media use. Negative effects of youth digital media use include traumatic experiences from being exposed to inappropriate or explicit content, development of sleep problems, attention and cognitive difficulties, mental health problems, and poor academic performance.^8,9 While the potential negative effects should not be underestimated, several factors can moderate harmful developmental outcomes associated with digital media use. These factors include type of digital media exposure and engagement (active versus passive),⁸ quality of parent-child relationship,¹⁰ and excessive or problematic media use (PMU), with associated impairment in various areas of functioning.¹¹

Digital media is not exclusively linked to negative youth outcomes. Multiple positive effects have also been associated with youth digital media use including increased accessibility to novel information (e.g., current events), early learning opportunities (e.g., alphabet/counting apps, Sesame Street), social connections (e.g., forming social relationships with other students), and health information (e.g., access to information about medical conditions).⁵ A review of 131 articles indicated that other benefits of digital media use include positive cognitive and social-emotional development.¹² Further, digital interventions such as care via telehealth platforms have been leveraged to promote favorable reductions in symptoms of depression and anxiety for adolescents.¹³

Gaps in Current Recommendations

While parenting guidance has predominantly focused on screen time limits, a narrow focus on screen time alone overlooks the broader context of moderators of digital media harm.¹⁴ According to the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP), guidance on youth digital media use should prioritize the individual characteristics of the child and family, as well as digital media quality, rather than focusing primarily on screen time.¹⁵ Mitigators of harm may include factors such as decreasing access to distressing content, and promoters of benefit, such as fostering opportunities for social connection digitally. A new framework is needed that integrates digital media use within the context of the whole child, moving beyond screen time limitations.

A New Framework for Healthy Digital Habits

We propose a framework, called the Multisystemic Model of Digital Habits, that de-emphasizes screen time by providing context of youth outcomes associated with digital media. This social-ecological systems model acknowledges the interaction of factors at different levels—such as the digital environment at the macro-level, the family environment at the meso-level, and individual factors at the micro-level—in influencing outcomes. Within this framework, youth digital media use and its associated outcomes are considered (Figure 1). We offer recommendations pediatric providers can consider integrating into their professional practice outside and within their clinics at each level.

Figure 1.

The Multisystemic Model of Digital Habits

Macro-Level: Digital Media Environment

At the broadest level in the Multisystemic Model of Digital Habits framework, digital environments are designed by technology companies without sufficient consideration for the unique developmental needs of youth.¹⁶ Digital environments include autoplay, algorithmic content recommendations, and digital advertising to increase youth engagement.¹⁷ The more users engage on the platform, the more revenue companies generate. One design technique to prolong engagement is autoplay, which streaming platforms like Netflix and YouTube use to automatically play the next video after the initial video is complete, making consumers feel a loss of self-agency.¹⁸ Users feel a similar lack of self-agency with another design technique, algorithmic recommendations, which platforms like TikTok and Facebook use to suggest tailored content to increase the likelihood of prolonging engagement.¹⁹ These algorithms promote extreme, emotionally arousing, or high-pleasure trending content to increase users’ engagement. For these algorithms to work, platforms constantly collect data from their consumers through customer-created content and customers’ patterns of use.²⁰ Youth’s unique vulnerability to advertising means the collection of their data is of particular concern.¹⁶ Digital marketing embeds advertising in platforms that are trusted by youth, some of which can be harmful.¹⁶ The rapid uptake of digital media, including generative artificial intelligence (AI), is particularly concerning in a profit-centered digital environment that often overlooks the unique needs of youth, who are typically early adopters.

Recommendation 1: Advocate for Policy Change Aimed at the Digital Media Environment

Advocacy is essential to shift the digital media environment to a child-centered design as the default. Experts have already started advocating for such policy changes. For example, in June 2024, the US Surgeon General called for a warning label on social media platforms.²¹ This proposed measure was a plea for legislation to improve awareness and behavior change. Similarly, in 2023, the American Psychological Association issued the Health Advisory on Social Media Use in Adolescence, encouraging changes to the digital environment to protect youth from possible harms of social media platforms.²²

Continued advocacy efforts should focus on supporting federal regulations that require the technology industry to adapt apps to suit the developmental needs of youth. For example, apps and platforms should limit autoplay functions, advertising, promotion of inappropriate content, data collection, and other features that are linked to previously discussed adverse youth outcomes. Medical providers can participate in advocacy efforts by joining health care advocacy groups like those offered by the American Medical Association or staying up to date on legislative efforts by joining special interest groups such as the AAP’s Council on Communications and Media, which provide information about advocacy efforts at the national level. Additionally, providers can contact their regional and national representatives regarding specific legislation.

Recommendation 2: Encourage Families to Modify or Tailor Their Child’s Digital Environment

Router and device-level settings may be implemented to avoid some manipulative design features. Apple iOS and Android platforms provide screen time controls at the operating system level, allowing users to restrict access to specific websites or apps and limit usage time based on customized settings. Implementing these restrictions can create friction and slow down the automatic impulse to access digital media that captures users’ attention and prolongs engagement. Third-party monitoring options such as Circle and Boomerang have also been recommended by online safety experts and offer additional features like more robust content monitoring.²³ Reducing harmful content such as illegal or maladaptive behaviors may serve to change behavior and reduce risks based on individual vulnerabilities.²⁴ Websites, such as commonsensemedia.org and childrenandscreens.org, offer recommendations on router and device-level settings.

Meso-Level: Family Environment

In addition to the broader digital environment, mesosystem-level factors within the Multisystemic Model of Digital Habits framework include systemic disadvantages experienced by families, digital media-specific parenting practices, and parents’ own digital habits.

Sociodemographic characteristics like single parent households, belonging to a marginalized race or ethnic group, and parents with less education attainment have been associated with higher digital media exposure and digital media use.²⁵ Youth in families with lower income tend to have more access to devices in their bedroom.²⁵ Higher parent-reported stress and chaos (e.g., confusion, disorganization) within the home are associated with more time spent on devices.²⁶ These findings likely represent systemic disadvantages experienced by families, such as limited access to childcare and after-school activities, which may require a greater reliance on digital media to occupy youth.

The overall family digital media culture, including parent media use habits, affects youth digital media use.²¹ Higher levels of parent digital media use are associated with higher levels of youth digital media use.^28–30 In addition to total screen time usage, researchers have introduced the concept of “technoference,” defined as everyday interruptions in interpersonal interactions due to digital media.³¹ Such interruptions may occur during face-to-face conversations or during daily routines, such as meals, playtime, or bedtime. Interruptions may lead to feelings of intrusion when another person interacts with digital media during planned time together.³² Higher parent digital media use is associated with fewer parent-child interactions, lower responsivity to child bids, and parent hostility in response to children’s bids for attention,³² all of which affect youth social-emotional health and the quality of parent-child relationship. These parent-child interactions are likely bidirectional, as parents who have youth with more problem behaviors may become more stressed, which may lead to greater technoference, such as withdrawal from parenting duties with digital media use, which in turn may contribute to more child problem behaviors and parent-child relationship difficulties.³³ Consequently, this cycle of stress and withdrawal can exacerbate existing issues, creating a feedback loop that intensifies both the child’s and the parent’s problematic behaviors. This may also be why parents with problematic media use are almost 10 times more likely to have youth with problematic media use.³⁰

Poorer quality of parent-child relationships is associated with increased digital media use in youth.^28,29 Digital health recommendations for youth often include recommendations for parents to moderate their children’s access to digital media. Examples of digital media-specific parenting practices include setting digital media content restrictions and screen time. Digital media-specific parenting practices, whether strict and lenient, have shown inconsistent associations with healthy digital habits in youth.³⁴ The parenting style and quality of parent-child relationships, two key factors in child development outcomes, may mediate the impact of digital media-specific parenting practices.¹¹ For example, authoritative parenting, the style of parenting that combines warmth, sensitivity, and clear boundaries, is associated with healthy digital habits and positive parent-child relationships.^11,35

Recommendation 3: Encourage Families to Develop a Household Culture of Healthy Digital Media Habits

Family digital health guidance should shift from emphasizing youth’s screen time and content limitations to fostering open conversations about the family’s digital media culture. This includes examining parents’ own digital media use and the quality of parent-child relationship. The AAP’s Family Media Use Plan is a valuable tool for encouraging open conversations within families about media use.³⁶ Media plans should be reviewed frequently and adjusted based on factors such as age and developmental level of the child. It includes prompts tailored to different age groups, which can be customized with family responses. Prompts such as “Screen-Free Times or Zones,” “Communicating about Media,” and “Using Media Together” help foster communication and strengthen parent-child relationships around digital health. This tool enables families to thoughtfully shape their digital media culture in a way that aligns with their values. For instance, establishing family agreements on screen-free zones, such as the dinner table, and screen-free times, like before bed, can encourage face-to-face interactions to reduce technoference. This approach is more likely to be accepted if the entire family agrees with the household expectations.

Recommendation 4: Provide Guidance on the Effect of Parents’ Own Digital Media Use on Youth Outcomes and Digital Media Habits

Raising awareness about the impact of parents’ digital media use on youth outcomes and digital habits is crucial. Pediatric providers can facilitate this by discussing the topic as part of anticipatory guidance, starting as early as infant well-checks. Direct education about how parents’ digital habits can influence the quality of the relationship with their child and their child’s digital use is key.

Given that parents often turn to digital media to cope with parenting stress, recommendations to reduce parent digital media use should be accompanied by alternative strategies. For example, pediatric providers may help parents identify triggers of stress and alternative coping strategies such as talking with a friend or co-viewing digital media with their child. When parents use digital media in the presence of their children, the explanation of the purpose and context of their usage to their child can help youth learn appropriate digital media use and reduce feelings of being ignored. The parents’ explanations of their own digital media use can be foundational in building digital literacy skills or the understanding of healthy digital media use in their children. This transparency fosters a healthier digital media culture at home and promotes mutual understanding within the family.

Recommendation 5: Provide Education About Parenting Strategies Related to Healthy Digital Use

In response to parents’ questions on digital specific topics such as screen time limitations, pediatric providers may shift guidance to encourage high quality parent-child communication about digital media. Consistent with the AAP and research outcomes, providers could recommend that parents use digital media to connect, co-view, and create.³² Education on online etiquette, empathy, ethics, digital media safety, personal boundaries, and how to regulate digital media habits may be helpful in conversations with youth.^{32, 37}

Micro-Level: Individual Characteristics

Lastly, at the micro-system level within the Multisystemic Model of Healthy Digital Habits Framework, there are individual factors like PMU, pre-existing mental health diagnoses, and digital literacy that can be considered.

PMU, also known as problematic internet use or internet dependency, lacks a universal definition, but often is characterized by excessive, impulsive, or risky behavior.³⁸ PMU is positively linked to psychological outcomes such as depressed mood, anxiety, sleep disturbance, attention problems, and behavioral concerns.³⁹ The prevalence of PMU is estimated to be between 5% and 10% of youth using media.³⁹

Youth with mental health disorders, such as depression and attention-deficit/hyperactivity disorder (ADHD), are at increased risk of harm from digital media due to the higher prevalence of PMU among these individuals.³⁹ Youth with PMU engage in more risky, excessive, and impulsive social media engagement, increasing their risk of encountering distressing content,⁴⁰ which may result in emotional distress. Exposure to distressing content, particularly cyberbullying, has been associated with elevated levels of anxiety and depression.⁴¹ The ubiquity of access to digital media allows it to become an easy distraction during times of emotional distress, reinforcing social media engagement. A recent study found that most 11–17-year-olds “sometimes” or “often” use their phones to escape from negative emotions⁴² and many used media to relax before bed. However, using the digital media excessively to distract from emotional distress has been linked with worsening self-regulation abilities over time, as it may reduce youth’s opportunities to learn these skills.^{43, 44} Youth experiencing PMU, anxiety, or depression, are particularly vulnerable to diminished self-regulation skills.⁴⁴ In turn, lack of self-regulation strategies exacerbates feelings of anxiety and depression, creating a cycle of emotional distress.

Recommendation 6: Screen for Problematic Media Use

Pediatric providers can screen for PMU using validated tools such as the parent-report measure, Problematic Media Use Measure (PMUM),⁴⁵ or the youth-report measure, Problematic and Risky Internet Use Screening Scale (PRIUSS).⁴⁶ If screening indicates PMU, pediatric providers should initiate referrals for evidence-based treatment. Treatment may include psychological interventions like cognitive behavioral therapy aimed at directly addressing digital media use.⁴⁷ Given the high rate of mental health disorders associated with PMU, pediatric providers should also consider screening for mental health comorbidities such as ADHD, anxiety, and depression. Improving the co-morbid mental health disorders can improve PMU.⁴⁸

Recommendation 7: Promote Digital Literacy for all Youth

Digital literacy has been proposed as a tool to mitigate harm for vulnerable individuals. The American Library Association’s Digital Literacy Task Force asserts that digital literacy is “the ability to use information and communication technologies to find, evaluate, create, and communicate information, requiring both cognitive and technical skills.”⁴⁹ Digital literacy can be a protective factor when it comes to reducing negative impacts of digital media use. Encouraging engagement in joint critical thinking with children about viewed content is foundational to building digital literacy skills. Promoting youth digital literacy by teaching skills such as the use of security features and responsible online actions is critical.

Recommendation 8: Tailor Digital Media Use Recommendations to Youth’s Unique Needs

Pediatric providers should take a child-centered approach with digital media guidance which focuses on delivering recommendations and interventions to families, children, and adolescents based on the patient’s individual needs as opposed to taking a one-size fits all approach. Individual factors such as developmental needs and psychological vulnerabilities (e.g., mental health conditions) are specific nuances to consider when examining media use and healthy digital habits. The AAP’s Center of Excellence on Social Media and Youth Mental Health 5 C’s (Child, Content, Calm, Crowding Out, and Communication) framework may help providers customize guidance for the individual youth.⁵¹ This approach allows for focused attention on the individual child, the quality of the content, use of appropriate coping strategies, assessing if media use is “crowding out” other enjoyable family activities, and highlights the need for continued communication about this topic.⁵¹