Early Childhood Screen Use Contexts and Cognitive and Psychosocial Outcomes: A Systematic Review and Meta-analysis

Sumudu Mallawaarachchi; Jade Burley; Myrto Mavilidi; Steven J Howard; Leon Straker; Lisa Kervin; Sally Staton; Nicole Hayes; Amanda Machell; Marina Torjinski; Brodie Brady; George Thomas; Sharon Horwood; Sonia L J White; Juliana Zabatiero; Clara Rivera; Dylan Cliff

doi:10.1001/jamapediatrics.2024.2620

. 2024 Aug 5;178(10):1017–1026. doi: 10.1001/jamapediatrics.2024.2620

Early Childhood Screen Use Contexts and Cognitive and Psychosocial Outcomes

A Systematic Review and Meta-analysis

Sumudu Mallawaarachchi ^1,^2,^✉, Jade Burley ^1,², Myrto Mavilidi ^1,², Steven J Howard ^1,², Leon Straker ^2,³, Lisa Kervin ^1,², Sally Staton ^2,⁴, Nicole Hayes ^2,⁵, Amanda Machell ^2,⁶, Marina Torjinski ^2,⁷, Brodie Brady ^1,², George Thomas ^2,⁸, Sharon Horwood ^2,⁷, Sonia L J White ^2,⁵, Juliana Zabatiero ^2,³, Clara Rivera ^1,², Dylan Cliff ^1,²

¹School of Education, University of Wollongong, Wollongong, New South Wales, Australia

²Australian Research Council Centre of Excellence for the Digital Child, Brisbane, Queensland, Australia

³School of Allied Health, Curtin University, Perth, Western Australia, Australia

⁴Queensland Brain Institute, The University of Queensland, Brisbane, Queensland, Australia

⁵School of Early Childhood and Inclusive Education, Queensland University of Technology, Brisbane, Queensland, Australia

⁶College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia

⁷School of Psychology, Deakin University, Geelong, Victoria, Australia

⁸Health and Wellbeing Centre for Research Innovation, The University of Queensland, Brisbane, Queensland, Australia

Accepted for Publication: May 15, 2024.

Published Online: August 5, 2024. doi:10.1001/jamapediatrics.2024.2620

^✉

Corresponding Author: Sumudu Mallawaarachchi, PhD, School of Education, University of Wollongong, Northfields Avenue Wollongong, NSW 2522, Australia (sumudu@uow.edu.au).

Author Contributions: Dr Mallawaarachchi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mallawaarachchi and Burley are co–first authors.

Concept and design: Mallawaarachchi, Burley, Howard, Straker, Kervin, Staton, Horwood, Zabatiero, Cliff.

Acquisition, analysis, or interpretation of data: Mallawaarachchi, Burley, Mavilidi, Howard, Straker, Hayes, Machell, Torjinski, Brady, Thomas, Horwood, White, Zabatiero, Rivera, Cliff.

Drafting of the manuscript: Mallawaarachchi, Burley, Howard, Thomas, Rivera.

Critical review of the manuscript for important intellectual content: Burley, Mavilidi, Howard, Straker, Kervin, Staton, Hayes, Machell, Torjinski, Brady, Thomas, Horwood, White, Zabatiero, Cliff.

Statistical analysis: Mallawaarachchi, Mavilidi.

Obtained funding: Burley, Howard, Straker, Kervin, White.

Administrative, technical, or material support: Mallawaarachchi, Burley, Howard, Machell, Torjinski, Brady, Thomas, Horwood, White, Rivera, Cliff.

Supervision: Cliff.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research, including fellowships supporting Drs Mallawaarachchi, Burley, and Hayes, was funded by the Australian Research Council through the Australian Research Council Centre of Excellence for the Digital Child (CE200100022).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The authors would like to thank Rachel Lawson, Gdip-IM-Lib, University of Wollongong, and Christina Salopek, MA, University of Wollongong, for assistance with the literature search, Jessica Mantei, PhD, School of Education, University of Wollongong, for contributions to data extraction and Marijka Batterham, PhD, University of Wollongong, for statistical input. No compensation was provided.

^✉

Corresponding author.

PMCID: PMC12527480 PMID: 39102255

Key Points

Question

What are the associations of screen use contexts in early childhood with cognitive and psychosocial outcomes?

Findings

In this systematic review and meta-analysis, more program viewing and background television were associated with poorer cognitive outcomes while more program viewing, age-inappropriate content, and caregiver screen use were associated with poorer psychosocial outcomes. Co-use was positively associated with cognitive outcomes.

Meaning

Contexts of screen use (ie, type, content, co-use, and purpose of use) beyond screen time limits should be considered in global recommendations for families, clinicians, and educators.

This systematic review and meta-analysis evaluates associations between screen use contexts among children and cognitive and psychosocial outcomes.

Abstract

Importance

The multifaceted nature of screen use has been largely overlooked in favor of a simplistic unidimensional measure of overall screen time when evaluating the benefits and risks of screen use to early childhood development.

Objective

To conduct a systematic review and meta-analysis to examine associations of screen use contexts in early childhood with cognitive and psychosocial outcomes.

Data Sources

PsycINFO, Embase, MEDLINE Ovid, ProQuest, CINAHL, Web of Science, and Scopus were searched from inception to December 31, 2023.

Study Selection

A total of 7441 studies were initially identified. Studies were included if they examined associations between a contextual factor of screen use among children aged 0 to 5.99 years and cognitive or psychosocial development. Observational, experimental, and randomized clinical trial study designs were included.

Data Extraction and Synthesis

All studies were independently screened in duplicate following PRISMA guidelines. Effect sizes of associations (r) from observational studies were pooled using random-effects 3-level meta-analyses. The remaining study designs were narratively synthesized.

Main Outcomes and Measures

Screen use contexts included content (child directed and age inappropriate), type (program viewing and game or app use), co-use (or solo use), background television, caregiver screen use during child routines, and purpose. Outcomes were cognitive (executive functioning, language, and academic skills) or psychosocial (internalizing and externalizing behavior problems and socioemotional competence).

Results

Overall, 100 studies (176 742 participants) were included, and of these, 64 observational studies (pooled sample sizes ranging from 711 to 69 232) were included in meta-analyses. Program viewing (n = 14; k = 48; r, −0.16; 95% CI, −0.24 to −0.08) and background television (n = 8; k = 18; r, −0.10; 95% CI, −0.18 to −0.02) were negatively associated with cognitive outcomes, while program viewing (n = 6; k = 31; r, −0.04; 95% CI, −0.07 to −0.01), age-inappropriate content (n = 9; k = 36; r, −0.11; 95% CI, −0.17 to −0.04), and caregiver screen use during routines (n = 6; k = 14; r, −0.11; 95% CI, −0.20 to −0.03) were negatively associated with psychosocial outcomes. Co-use was positively associated with cognitive outcomes (n = 8; k = 28; r, 0.14; 95% CI, 0.03 to 0.25).

Conclusions and Relevance

Findings show small to moderate effect sizes that highlight the need to consider screen use contexts when making recommendations for families, clinicians, and educators beyond screen time limits; including encouraging intentional and productive screen use, age-appropriate content, and co-use with caregivers.

Introduction

The pervasiveness of screen media globally and the increasing uptake and use of screen media at increasingly younger ages^1,2 have fueled empirical and public debate around the benefits and risks of screen use for children’s well-being and development. In a recent public health poll conducted in Australia, screen time was identified as the number one health concern among parents,³ reflecting families’ concerns around the management of children’s screen use. Although numerous international recommendations aim to guide healthy screen use practices, several inconsistencies exist across the adopted approaches.⁴ Notably, the World Health Organization guidelines⁵ and the Australian⁶ and Canadian⁷ 24-hour Movement Guidelines focus solely on time limits for young children’s sedentary screen viewing. In contrast, recent guidelines from the Pediatric Societies of the UK⁸ and Canada⁹ emphasize screen use within family circumstances rather than universal time limits. The American Academy of Pediatrics guidelines¹⁰ include time limits but also offer guidance on aspects such as content quality, purpose of use (eg, video chat) and social contexts (eg, coviewing). Despite being largely based on evidence reviews and expert consensus, these guidelines lack meta-analytic evidence supporting recommendations on screen use contexts influencing child development beyond total screen time. Meta-analytic evidence could enhance evidence-based contextual recommendations while promoting greater consistency across international guidelines.

The current evidence base has predominantly focused on total screen time, which is a combination of traditional (ie, televisions, computers, and gaming consoles) and contemporary (ie, smartphones and tablets) screen media, in terms of their implications for children’s cognitive and psychosocial development.^11,12,13,14 However, given the versatile affordances of devices, such as interactivity, internet connectivity, and portability, screen use currently extends beyond recreational sedentary screen time (ie, television or program viewing) to include gaming or app use for educational or recreational purposes, co-use (or coviewing with others), and exposure to a range of content, such as educational, entertainment, and age-inappropriate content.

Recently, there have been increasing calls for consideration beyond the unidimensional and simplistic construct of screen time to consider other contextual components (eg, type, content, and purpose).^15,16,17,18 Further, recent meta-analyses on total screen time and child developmental outcomes^12,13 have warranted the investigation of discrete mechanisms involving the different contextual factors that may be underlying such associations between screen time and outcomes. To date, only 1 review¹³ has examined associations of screen use quality (ie, educational content, coviewing, and age of onset of exposure) in early childhood, reporting significant associations with language skills in addition to screen time. However, to our knowledge, no review has yet explored the associations between the contextual factors of early childhood screen use and cognitive or psychosocial developmental outcomes more broadly. Examining such nuances in early childhood, characterized by high neural plasticity and habit formation, would aid in disentangling healthy screen use from potentially problematic use. Accordingly, the present review aims to synthesize and meta-analyze the evidence on associations of early childhood screen use contexts with cognitive and psychosocial outcomes and to examine potential moderators.

Methods

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline (eTable 1 in Supplement 1). The study protocol was registered on the PROSPERO review protocol database (CRD42022352082). Deviations from the protocol are detailed in eTable 1 in Supplement 1.

Search Strategy

Systematic searches were conducted from database inception to December 31, 2023, across PsycINFO, Embase, Ovid MEDLINE, ProQuest, CINAHL, Web of Science, and Scopus databases. The search strategy combined concepts from screen use, cognitive or psychosocial development, and early childhood (birth to <6 years). A sample full search strategy is provided in eTable 2 in Supplement 1. Additional articles were identified by examining reference lists and citations of key articles.

Study Inclusion and Exclusion Criteria

The population, exposure, outcome, and study design framework¹⁹ were used to determine eligibility criteria. The population included typically developing children younger than 6 years. Exposure included contextual factors related to habitual screen use by children and families, assessed from birth to 5.99 years. Screen use was defined as using electronic devices (eTable 3 in Supplement 1) for video or on-demand streaming content, electronic applications (apps), electronic/console gaming, the internet, and social media. Definitions and descriptions of the predetermined contextual factors as described within studies are presented in Table 1.^{20,21,22,23,25,27,28,29,30,31,32,33,34,35,37,38} Outcome measures included cognitive development (language, executive function, and academic skills) and psychosocial development (prosocial behavior, social-emotional competence, and internalizing/externalizing behaviors); see study-specific examples of outcomes and classification in Table 2.^{20,23,27,29,30,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63} The study designs encompassed were randomized clinical trials, acute experiments, longitudinal, or cross-sectional. Studies were also required to be peer reviewed and published in English. See eTable 3 in Supplement 1 for a complete description of inclusion and exclusion criteria.

Table 1. Description of the Contextual Factors of Screen Use in Early Childhood.

Contextual factor	Definition and description	Examples of constructs
Content	The type of content during screen use	Child directed (intended for a child audience): Time spent on common children’s television shows¹¹ Total time spent on programs created for preschool audiences and younger (eg, PBS and Nickelodeon preschool programs, baby-directed videos, or Disney movies)²⁰ Educational: Duration of exposure (min/d) to programs with educational content for children aged 2-6 y, including live-action and animated programs with an educational intent²¹ Frequency of viewing child-directed informative programs, such as Sesame Street²² Number of programs and mean scene length for content with prosocial behaviors²³ Entertainment: Average daily time spent on content that did not have any educational value (eg, SpongeBob SquarePants)²⁴ Frequency of watching children’s fast-paced cartoons (eg, Phineas and Ferb) or situation comedies for children (eg, Good Luck Charlie)²⁵ Random assignment to condition to watch an episode of fantastical cartoon (animated sponge that lives under the sea)²⁶
Content	The type of content during screen use	Age-inappropriate (intended for a general or adult audience) Time spent on daily exposure to unsuitable or age-inappropriate programs²⁷ Violence/action: Frequency of viewing films or television shows with “lots of violence in them”²⁸ Frequency of watching action cartoons and live action programs (eg, Power Rangers)²⁵
Digital media type	The type of screen use	Program viewing: Average daily program viewing on traditional devices (eg, TVs and DVD players) or nontraditional devices (eg, tablets and laptops) in a typical week²⁹ Weekday and weekend time spent on television³⁰ Average daily time spent watching TV, online videos, or movies in the past 7 d³¹
Digital media type	The type of screen use	Apps and electronic game use: Average daily use of apps on portable handheld devices (eg, smartphones and tablets) or games on gaming consoles in a typical week²⁹ Average daily time spent on non–school-related activities on a computer or gaming console in the past 7 d³¹
Co-use	Screen use in the presence of and/or with the involvement of another person	Coviewing/supervision of use: Joint media engagement with parent or adult (eg, discussing the content with child)³² Social coviewing (eg, parents and children watch together)³²
Co-use		Solitary viewing/solo use: Unattended viewing³³ Limited/lack of coviewing (ie, inconsistently supervised screen time)³⁴
Background exposure	Background exposure to technology during other activities or routines	Background TV exposure: Total number of hours spent in non–media-based activities or routines where a television was on in the background³⁵
Caregiver screen use/family exposure	Screen use by caregivers or family during interactions with the child or routines	Caregiver use of media during child routines or interactions: Parent use of digital media during child routines such as play or socializing³² Parent-child technology interference (technoference)³⁶
Purpose of use	Screen use for a specific purpose	Parent use of mobile devices for calming purposes³⁷ or to regulate child’s distress³⁸

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Table 2. Description of the Cognitive and Psychosocial Outcomes Included in the Review.

Global outcome for meta-analysis	Specific outcome	Example measures (cited examples of studies in the review using the measures)
Cognitive
Higher-order cognition	Executive function	O: Early Years Toolbox,²⁹ Preschool Executive Task Assessment³⁹; PQ: Behavior Rating Inventory of Executive Function⁴⁰
	Inhibition	O: Stroop Task,⁴¹ Head Toe Knees Shoulders Task,⁴² Day-Night Task⁴³
	Working memory	O: Backward Digit Span Task,⁴⁴ Spin the Pots Task⁴⁵
	Planning	O: Tower of Hanoi⁴¹
	Cognitive flexibility	O: Dimensional Change Card Sorting Task⁴⁶
	Nonverbal reasoning	O: Picture Similarities Task⁴⁷
	Self-regulation (eg, delay of gratification)	O: Snack Delay Test,⁴² Gift Delay Test⁴⁵
	Cognitive development	PQ: Bayley Scales of Infant Development⁴⁸
	Attention	O: Navon Test response accuracy,⁴⁹ Looking Time⁵⁰
	Intelligence	O: Weschler Preschool and Primary Scale of Intelligence²⁰
	Vocabulary/expressive/receptive language	O: Peabody Picture Vocabulary Test⁵¹; PQ: McArthur Bates Communicative Development Inventory⁵²
	Communication	PQ: Communication subscale of the Ages and Stages Questionnaire-3⁵³
	Literacy skills	O: Phonological Awareness Literacy Screening for Preschoolers Test³⁴
Academic skills and achievement	School readiness	O: Metropolitan Readiness Test⁵⁴; PQ: Bracken Basic Concepts Scales⁵⁵
	Academic skills/adjustment	O: Woodcock-Johnson III Test of Achievement⁵⁶
	Math achievement/skills	O: Test of Children Mathematics Achievement⁵¹
	Science knowledge	O: Life Science Assessment and Earth and Physical Science Assessment⁵¹
Psychosocial
Behavioral problems	Behavioral problems/difficulties	PQ: Strengths and Difficulties Questionnaire^29,57
	Behavioral regulation	PQ: Child Behavior Questionnaire⁵⁸
	Internalizing problems	PQ: Child Behavior Checklist: 1 1/2-5⁵⁹
	Child affect	O: Coded videotaped interactions⁶⁰
	Externalizing problems	PQ: Child Behavior Checklist 1 ½-5²⁷
	Inattention/hyperactivity	PQ: Behavior Assessment System for Children⁶¹
Socioemotional competence	Social skills	PQ: Ages and Stages Questionnaire,⁵³ Social Skills Improvement System⁵¹
	Social functioning	PQ: KINDL³⁰
	Prosocial behavior	O: Infant distress paradigm²³; PQ: Preschool Social Behavior Survey⁶²
	Social competence and adjustment	TQ: Social Competence and Behavior Evaluation⁵⁸; PQ: Modified Infant-Toddler Social and Emotional Assessment⁶³

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Abbreviations: PQ, parent-reported questionnaire; O, observation/direct assessment; TQ, teacher-reported questionnaire.

Titles and abstracts of all identified studies were reviewed independently by 2 authors using Research Screener, a web application with machine learning.⁶⁴ Two reviewers also independently reviewed all eligible full-text articles. Discrepancies were resolved by discussion or with a third independent reviewer, if needed, until consensus was reached.

Data Extraction

Data were extracted by one author and verified by another. A structured template was used that included information about study characteristics, sample characteristics, exposure, developmental outcome, analysis, and results, including effect sizes.

Quality Assessment

Risk of bias was evaluated using the National Collaborating Centre for Methods and Tools Assessment Tool for Quantitative Studies.⁶⁵ See eTable 4 in Supplement 1 for details of components and ratings. Eight articles were initially independently assessed by 2 reviewers to ensure substantial agreement (0.86); remaining studies were then independently assessed by 1 reviewer.

Data Synthesis

Only observational studies were included in the meta-analyses given substantial heterogeneity across experimental and comparative designs. Pooled summary estimates for the studies were included as Pearson correlation coefficients (r). β coefficients (between −0.5 and 0.5) and odds ratios were converted to r using established methods.^66,67 Where multiple effect sizes were available for multiple cognitive (eg, working memory, inhibition, and shifting) or psychosocial outcomes (eg, attention problems, aggressive behavior, and hyperactivity) within the same study, each effect size was extracted and treated individually (nested within the study). If a single study assessed multiple contextual factors (eg, coviewing and content), all relevant effect sizes were extracted as they were examined within separate meta-analyses. Effect sizes adjusted for confounders were selected over unadjusted effect sizes whenever available. If multiple time points were available within the same study, the effect size of the most temporally distant association was selected. The studies that were not eligible for the meta-analysis were narratively synthesized.

Statistical Analysis

Pooled effect sizes (r) were converted to Fisher z and combined using a 3-level meta-analysis approach.⁶⁸ Calculations were based on a random-effects model using the restricted maximum likelihood estimation method. Adopting such a 3-level approach allows multiple effect sizes from a single study to be included.^68,69 This approach is not limited by the assumption that effect sizes are independent of each other as they are nested within studies. It further allows examining heterogeneity within studies as well as between studies (using Q, I², and τ² statistics). Potential outliers or influential cases were determined,⁷⁰ and sensitivity analyses were conducted by removing such cases, when relevant. Pooled effect sizes were interpreted as very small (0.05 < r ≤ 0.1), small (0.1 < r ≤ 0.2), medium (0.2 < r ≤ 0.3), and large (0.3 < r ≤ 0.4).⁷¹ Publication bias was examined using funnel plots and Egger regression asymmetry tests. The analyses were carried out in R version 4.2.3 (R Foundation) using the metafor package.

A series of meta-analyses were conducted examining associations for the 7 distinct screen use contexts with cognitive and psychosocial outcomes where there were 3 or more relevant studies.⁶⁷ Moderator analyses were conducted using random-effects (ie, each included effect size weighted by its variance) meta-regressions in meta-analyses with high heterogeneity⁷² (eTable 5 in Supplement 1).

Results

Study Selection

The search yielded 7441 records for screening and 226 full-text articles were reviewed. A final sample of 100 studies comprising 176 742 participants who met the inclusion criteria and were included in the review. Of these, 64 were included in meta-analyses. The Figure provides the PRISMA study flow diagram.

Study and Sample Characteristics

A summary of study characteristics is presented in eAppendix 2 in Supplement 1. There were 22 acute experimental studies, 4 randomized clinical trials, 37 cross-sectional studies, and 37 longitudinal studies included. Most studies were rated weak on study quality (n = 65), while 27 and 8 studies were rated moderate and strong, respectively (eTable 11 in Supplement 1 for detailed study quality assessment).

Meta-Analytic and Systematic Review Results

The results of the meta-analyses are presented in Table 3 (see eFigures 1-14 in Supplement 1 for forest plots). Unless otherwise specified, the tested moderators were not significant within the significant meta-analyses (eTables 12-24 in Supplement 1). All significant associations remained significant following sensitivity analyses omitting potential outliers (eTable 25 in the Supplement 1). No considerable publication bias was detected for any of the significant meta-analyses (see eFigures 15-28 in Supplement 1 for funnel plots). The narrative synthesis of the experimental and randomized clinical studies is presented below. The nonsignificant findings of the meta-analyses (and associated moderator analyses) along with the narrative synthesis of observational studies ineligible for the meta-analyses are described in eAppendix 2 in Supplement 1. A summary of the systematic review findings is presented in eTable 26 in Supplement 1.

Table 3. Summary of Findings From Meta-Analyses for Overall Cognitive and Psychosocial Outcomes.

Exposure	Outcome	No. of studies	No. of effect sizes	Pooled effect size, r (95% CI)	I² within study	I² between study	σ^2.1 (between-study variance)	σ^2.2 (within-study variance)
Content
Child directed	Cognitive	19	70	0.01 (−0.05 to 0.07)	19.21	65.0	0.001	0.001
Child directed	Psychosocial	11	49	0.05 (−0.09 to 0.19)	28.97	70.41	0.018	0.044
Age inappropriate	Cognitive	16	48	−0.05 (−0.13 to 0.02)	10.23	77.10	0.002	0.016
Age inappropriate	Psychosocial	9	36	−0.11 (−0.17 to −0.04)^a	47.02	48.01	0.006	0.006
Digital media type
Program viewing	Cognitive	14	48	−0.16 (−0.24 to −0.08)^b	2.21	96.52	0.000	0.018
Program viewing	Psychosocial	6	31	−0.04 (−0.07 to −0.01)^a	58.30	24.00	0.001	0.000
Gaming or app use	Cognitive	9	34	−0.01 (−0.12 to 0.11)	0.00	87.55	0.000	0.024
Gaming or app use	Psychosocial	5	28	−0.01 (−0.04 to 0.02)	91.87	0.00	0.004	0.000
Co-use or supervision
Co-use	Cognitive	8	28	0.14 (0.03 to 0.25)^c	5.22	71.58	0.001	0.019
Co-use	Psychosocial	5	14	−0.05 (−0.16 to 0.06)	4.76	77.87	0.001	0.012
Solo/unsupervised use	Cognitive	7	23	−0.14 (−0.32 to 0.03)	22.93	72.15	0.013	0.042
Family/background exposure
Background TV exposure	Cognitive	8	18	−0.10 (−0.18 to −0.02)^c	65.63	18.91	0.009	0.003
Caregiver screen use during routines	Psychosocial	6	14	−0.11 (−0.20 to −0.03)^c	25.04	49.47	0.003	0.005
Purpose of use
As a calming tool	Psychosocial	3	6	−0.07 (−0.18 to 0.05)	73.00	0.00	0.009	0.000

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^{^a}

P < .01.

^{^b}

P < .001.

^{^c}

P < .05.

Content

Content was the most studied contextual factor within 3 randomized clinical trials, 14 acute experiments, and 20 longitudinal and 19 cross-sectional studies, across 53 169 participants. Greater exposure to age-inappropriate content (ie, violent, action, or intended for a mature audience) was associated with poorer psychosocial outcomes (r, −0.11; 95% CI, −0.17 to −0.04; n = 27 629). Moderate heterogeneity was evident (I² within studies = 47.0%; I² between studies = 48.0%). Randomized clinical trial findings strongly supported the benefits of educational and prosocial content for enhanced literacy⁷³ and socioemotional competence.⁷⁴ Specifically, the finding of improved socioemotional and behavior scores following the replacement of age-inappropriate and violent content with more age-appropriate prosocial content⁷⁴ aligns with the meta-analytic findings. Fast pacing of content was examined in 6 acute experiments^{26,49,75,76,77,78} demonstrating mixed findings (10 negative, 2 positive, and 25 null of 37 reported findings). Fantastical content was also a key focus of 4 acute experiments,^43,46,79,80 with 11 negative and 10 null findings reported for cognitive outcomes from 21 findings.

Digital Media Type

Digital media type was the second most studied contextual factor examined across 129 306 participants within 2 acute experiments and 10 longitudinal and 16 cross-sectional studies. More program viewing (ie, watching television, videos, DVDs, or movies) was associated with poorer cognitive (r, −0.16; 95% CI, −0.24 to −0.08; n = 69 232) and psychosocial (r, −0.04; 95% CI, −0.07 to −0.01; n = 63 632) outcomes. Considerable between-study heterogeneity was evident for cognitive outcomes (I² = 96.44%). Study design was a significant moderator, such that cross-sectional studies comprised more negative associations with cognitive outcomes (r, −0.22; 95% CI, −0.29 to −0.15) compared to longitudinal designs. Sixteen studies compared program viewing to gaming or app use, while 9 studies included program viewing or game or app use (n = 3) exclusively. One acute experiment⁴⁵ indicated that children performed significantly better on executive function tasks following app play compared to following program viewing, while no differences were present for cognitive flexibility–related tasks.^45,46

Co-Use

Co-use was assessed within 1 randomized clinical trial and 6 longitudinal and 17 cross-sectional studies across 9437 participants. Co-use with others (eg, parents and siblings) was associated with better cognitive outcomes (r, 0.14; 95% CI, 0.03 to 0.25; n = 1592). Considerable between-study heterogeneity was evident (I² = 71.6%). The randomized clinical trial finding demonstrated better learning outcomes for infants when co-using with another infant,⁸¹ aligning with the meta-analytic finding.

Background Television

Background TV exposure was associated with poorer cognitive outcomes (r, −0.10; 95% CI, −0.18 to −0.02; n = 2817). Minimal between-study heterogeneity was evident (I² = 18.9%). Background TV was studied in 1 acute experiment,⁸² which demonstrated significantly fewer episodes of focused attention in infants when TV was on in the background than when it was off. Overall, the limited studies on psychosocial outcomes also presented predominant evidence of associations between background TV and poorer behavioral regulation^24,58 (3 negative of 4 reported associations), comparable to cognitive outcomes.

Caregiver Screen Use

Caregiver screen use during parent-child interactions or child routines (eg, play and mealtimes) was associated with poorer psychosocial outcomes (r, −0.11; 95% CI, −0.20 to −0.03; n = 3333), with moderate between-study heterogeneity (I² = 49.5%). Three acute experiments examined effects of technology-related interruptions during parent-child interactions, 2 of which showed only significantly negative findings for cognitive⁸³ and psychosocial⁸⁴ outcomes. One experiment⁸⁵ reported 2 null (of 2) findings between texting interruptions by parents during interactions and infants’ learning.

Discussion

In this systematic review and meta-analysis, extending beyond the simplistic measurement of total screen time, our results reveal the importance of early childhood screen use contexts for cognitive and psychosocial development. The results indicate 3 key findings. First, program viewing was negatively associated with cognitive and psychosocial outcomes while age-inappropriate content was negatively associated with psychosocial outcomes. Second, caregiver screen use and background television exposure during child routines and interactions were negatively associated with psychosocial and cognitive outcomes, respectively. Third, co-use of screen media was positively associated with cognitive outcomes.

More program viewing was associated with poorer cognitive and psychosocial outcomes, while age-inappropriate content was associated with poorer psychosocial outcomes. These findings are consistent with previous meta-analyses including older children (eg, 4-18 years,⁸⁶ 0-18 years,⁸⁷ 0-12 years¹³). However, this finding should be interpreted cautiously given predominant past evidence of negative cross-sectional associations of screen time estimates (weighted toward program viewing) with children’s development,^87,88,89,90 which may have unevenly contributed to the meta-analyses. In contrast, a recent meta-analysis indicated program viewing was not associated with executive functioning.⁹¹ Digital media type (ie, how children engage with content) and content (ie, what they may be learning or decoding) in combination (rather than exploring in isolation) may variably influence developmental outcomes, proving a possible explanation for these divergent findings. Nonetheless, it remains prudent to encourage intentional program viewing, particularly age-appropriate content for early childhood.

The negative findings relating to family and background exposure to screens during daily routines and interactions present timely evidence to limit this type of exposure in early childhood. To our knowledge, this is the first meta-analysis to indicate potential detriment of caregiver screen use to early childhood psychosocial outcomes. Similarly, a scoping review⁹² indicated negative associations between parent technoference (ie, parental technological immersion affecting parent-child interactions³⁶) and behavioral outcomes in childhood and socioemotional outcomes in adolescents.^93,94 Children may be engaging in more attention-seeking behaviors during technological interruptions³⁶ or psychosocial difficulties and dysregulation may be a function of poorer quality interactions with caregivers over time⁹⁵ or caregivers using devices as means of avoidance and coping with stresses.³⁶ This finding reiterates the importance of parents modeling healthy screen use habits to young children while also interacting with the child during routines. Additionally, present findings concur with and extend on previous meta-analysis findings on language¹³ to also include the negative association of background television exposure with higher-level cognitive outcomes. Given the developing attention orientation systems in young children,⁹⁶ they can be distracted and oriented toward more salient and changing stimuli, such as a television being on in the background during play. This background stimulation is also likely to interfere with parent-child interactions during routines.⁹⁷

Benefits of co-use for cognitive development were identified in the present review, extending on previous positive findings regarding language¹³ and literacy.⁸⁷ In addition to co-use promoting interactions⁹⁸ and vocabulary development,¹³ co-use also creates learning opportunities for cognitive skills via caregiver scaffolding. Advantages of co-use are likely dependent on the extent of parent-child interactions and discussions about content.^98,99 For instance, questions about the content (eg, what if and why), explanations and connections to the child’s experience possibly support development of critical thinking and problem-solving skills in young children. Nonetheless, it is important to acknowledge that the co-use evidence base has focused largely on television coviewing. Co-use on handheld mobile devices, as well as the extent of co-use interactions that may be beneficial for children’s development, need further investigation.

Collectively, our findings support the need for a more nuanced approach beyond screen time limits by providing consistent underlying principles that families may use to make informed evidence-based decisions, to encourage healthy digital media use.⁴ The meta-analytic evidence supports American Academy of Pediatrics recommendations¹⁰ for parent-child coviewing and discouraging age-inappropriate content as well as background TV exposure, while also introducing novel recommendations, such as encouraging intentional and productive viewing while discouraging caregiver screen use during interactions and routines with children.

However, it is important to acknowledge the effect sizes were small (0.03-0.16). Nevertheless, effect sizes were comparable to previous reviews of screen time with language skills (0.13-0.19),¹³ academic performance (0.15-0.29),⁸⁶ executive functioning (0.05),⁹¹ and behavioral problems (0.07-0.11),¹² as well as a recent umbrella review on benefits and risks of electronic screens in youth (0.14-0.33).⁸⁷ The magnitude of associations may reflect that screen use may just be 1 predictor nested within multiple organizational layers (eg, family and community) among a multitude of interactive ecological forces (eg, parenting, family environment, and socioeconomic status) that may shape a child’s cognitive and psychosocial development.¹⁰⁰ Nevertheless, these associations may still have wider public health implications from a population-level perspective¹⁰⁰ for a highly sensitive developmental period such as early childhood.¹⁰¹

It should be noted that moderator analysis results were not consistent across meta-analyses. For instance, child’s age, study design (ie, cross-sectional or longitudinal), and type of content (ie, educational vs entertainment) were significant moderators within different meta-analyses (eAppendix 2 in Supplement 1), reflecting that moderation may be exposure- or outcome-specific. Further, when adjustment for socioeconomic covariates was accounted for as a moderator, there was minimal evidence (1 of 6 analyses) of differences in associations between studies that adjusted compared to those that did not. This may be explained by the heterogeneity in exposure or outcomes, study design, risk of bias, and covariates accounted for within individual studies.

Strengths and Limitations

The present review has several strengths, including the comprehensive focus on contextual factors to provide nuance to the screen time debate, consideration of a diversity of development outcomes, and application of a multilevel meta-analytic approach to include all study effect sizes, maximizing statistical power. However, it should be interpreted in light of the limitations that exist within current literature. First, heterogeneity in the operationalization of screen use contexts, for instance, variation in the definition of educational content or co-use across studies, as well as heterogeneity in the measurement of developmental outcomes (eg, direct assessment vs parent questionnaires), pose challenges in meaningful interpretation of pooled estimates. Second, although adjusted effect sizes were selected over unadjusted effect sizes, variability in included covariates may result in differences in observed meta-analytic associations. Further, the present research may be constrained in its generalizability to multiple races and ethnicities (which may influence children’s screen use^102,103) given the limited reporting of relevant information on sample racial or ethnic backgrounds within studies (43% reported sample race and ethnicity). Third, much of the meta-analytic evidence was cross-sectional with a high risk of bias, limiting causal inferences. Higher quality longitudinal, experimental, and randomized clinical trial evidence is required to make stronger meta-analytic inferences.

Conclusions

This systematic review and meta-analysis indicates that in children younger than 6 years, program viewing and background TV exposure were associated with poorer cognitive outcomes, and program viewing, age-inappropriate content, and caregiver screen use during child routines were associated with poorer psychosocial outcomes. Co-use was positively associated with cognitive outcomes. Future research should further evaluate elements within those contexts that may be associated with children’s development (eg, what elements of co-use interactions may be beneficial beyond coviewing?). The consideration of a broad scope of screen use contexts and outcomes presents new opportunities and actionable targets for intervention and public health messaging.

Supplement 1.

eTable 1. PRISMA checklist

eTable 2. Full search strategy

eTable 3. Description of inclusion and exclusion criteria

eTable 4. Criteria for assessing study quality and risk of bias

eAppendix 1. Description of moderator analyses

eAppendix 2. Summary of Findings of All Studies Extracted within the Systematic Review

eTable 5. Summary of characteristics of all included studies in the review

eTable 6. Summary of findings for digital media content

eTable 7. Summary of findings for digital media type

eTable 8. Summary of findings for digital media co-use

eTable 9. Summary of findings for digital media purpose of use

eTable 10. Summary of findings for background or family digital technology use

eTable 11. Study quality and risk of bias assessment

eTable 12. Moderator analysis for child-directed content and cognitive outcomes

eTable 13. Moderator analysis for child-directed content and psychosocial outcomes

eTable 14. Moderator analysis for age-inappropriate content and cognitive outcomes

eTable 15. Moderator analysis for age-inappropriate content and psychosocial outcomes

eTable 16. Moderator analyses for program viewing and cognitive outcomes

eTable 17. Moderator analysis for program viewing and psychosocial outcomes

eTable 18. Moderator analysis for game or app play and cognitive outcomes

eTable 19. Moderator analysis for game or app play and psychosocial outcomes

eTable 20. Moderator analysis for co-use and cognitive outcomes

eTable 21. Moderator analysis for co-use and psychosocial outcomes

eTable 22. Moderator analysis for solo use and cognitive outcomes

eTable 23. Moderator analysis for background TV and cognitive outcomes

eTable 24. Moderator analysis for caregiver screen use and psychosocial outcomes

eTable 25. Results of sensitivity analyses

eTable 26. Summary of review associations

eFigure 1. Forest plot for child-directed content and cognitive outcomes

eFigure 2. Forest plot for age-inappropriate content and cognitive outcomes

eFigure 3. Forest plot for child-directed content and psychosocial outcomes

eFigure 4. Forest plot for age-inappropriate content and psychosocial outcomes

eFigure 5. Forest plot for program viewing and cognitive outcomes

eFigure 6. Forest plot for program viewing and psychosocial outcomes

eFigure 7. Forest plot for game or app use and cognitive outcomes

eFigure 8. Forest plot for game or app use and psychosocial outcomes

eFigure 9. Forest plot for co-use and cognitive outcomes

eFigure 10. Forest plot for solo use and cognitive outcomes

eFigure 11. Forest plot for co-use and psychosocial outcomes

eFigure 12. Forest plot for background TV and cognitive outcomes

eFigure 13. Forest plot for caregiver screen use and psychosocial outcomes

eFigure 14. Forest plot for use as calming tool and psychosocial outcomes

eFigure 15. Funnel plot for child-directed content and cognitive outcomes

eFigure 16. Funnel plot for child-directed content and psychosocial outcomes

eFigure 17. Funnel plot for age-inappropriate content and cognitive outcomes

eFigure 18. Funnel plot for age-inappropriate content and psychosocial outcomes

eFigure 19. Funnel plot for program viewing and cognitive outcomes

eFigure 20. Funnel plot for program viewing and psychosocial outcomes

eFigure 21. Funnel plot for game or app use and cognitive outcomes

eFigure 22. Funnel plot for game or app use and psychosocial outcomes

eFigure 23. Funnel plot for co-use and cognitive outcomes

eFigure 24. Funnel plot for co-use and psychosocial outcomes

eFigure 25. Funnel plot for solo use and cognitive outcomes

eFigure 26. Funnel plot for background TV and cognitive outcomes

eFigure 27. Funnel plot for caregiver screen use and psychosocial outcomes

eFigure 28. Funnel plot for screen use as a calming tool and psychosocial outcomes

jamapediatr-e242620-s001.pdf^{(5.3MB, pdf)}

Supplement 2.

Data sharing statement

jamapediatr-e242620-s002.pdf^{(17.1KB, pdf)}

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