Screen time's effect on adolescents mental health

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Screen time is the aggregate time spent using a device with a digital screen, which can include computers, smartphones, tablets, TV's, and video games. It is measured in hours per day. There are five different categories of screen time: social, passive, interactive, educational, and other[1], and all five categories in excess show negative psychological effects. Mental Health is defined by the World Health Organization as a state of well-being whereby individuals recognize their true abilities, are capable of coping with the normal stresses of life, and are capable of productively and joyfully contributing to their communities[2]. The effects of screen time on young users' mental health is an emerging area of research of the 21st century. Adolescents 18-29 comprise the highest proportion of smartphone users, making up 96% of the market share of mobile phone ownership [3]. The Academy of Pediatrics (AAP) recommends children over 5 years of age should be restricted to 2 hours of screen time per day, yet the majority of adolescents exceed this threshold.[4] Studies show that excessive mobile screen time is significantly associated with negative psychological symptoms[2] as well as physical ailments as a result of leading a more sedentary lifestyle[2]. The true extent to which screen time affects mental health is still being debated. Some experts believe any amount of screen time is harmful to mental health[5], but others have found evidence that there is an optimal amount of screen time that leaves adolescents better off[6]. These juxtaposing theories are known as the Less is Better approach and the Goldilocks Theory. In addition to debates over theories of use, there is also debate on who is responsible for regulating these children’s’ use of their information technologies. Experts are currently calling on parents, medical care providers, and the tech industry to make efforts to protect the adolescent population from harmful screen time effects[7].

Screen-time phone.png


Physical Activity

Screen time has been proven to have a negative linear relationship with physical activity, which is a key attribute in mental health because physical activity boosts confidence, lessens depression and anxiety, and improves sleep quality[8]. Children who watched TV for a long period of time demonstrated reduced participation in physical activities[2]. In a survey of Iranian students, those who were categorized as having high screen time usage of over 2 hours per day and a low level of physical activity of 1-2 days per week, self-reported psychological distress by reporting symptoms of depression, anger, insomnia, worthlessness, confusion, anxiety and worry[2]. In the same study, students with high physical activity and high screen time reported less psychological distress than students with high screen time and moderate physical activity, suggesting that physical activity can improve psychological well-being irrespective of screen time[2]. Inactivity is linked to psychological disorders, including anxiety and depression[9]. Overconsumption of screen time raises the chance of general physical ailments, most commonly headache and backache, as observed in adolescents who consumed more than 3 hours of daily screen time[10]. There is an indirect link between screen time and worse mental health due to the physical repercussions[10].


Screen time has an association with poor diet. High screen time increases the likelihood of engaging in unhealthy behaviors that harm the physical body, such as consuming fattening food, smoking, drinking alcohol, using tobacco, and leading a life of inactivity[10].High screen time is directly associated with adiposity, and the risk of obesity in adolescents increases 13% for each additional hour of daily screen time[4]. Each additional hour of screen time is also associated with increased consumption of high-fat and high-sugar foods and decreased consumption of fruits and vegetables[4]. Children who consume 3 hours of daily screen time consume more snacks throughout the day[4]. One explanation for the association between screen time and overeating is exposure to commercial advertisements that promote high-fat foods. Another explanation is passive over-consumption, varying on the level of interest in the digital entertainment[4].


Electronic Screen Syndrome (ESS)

Excess screen time in adolescents has been linked to a myriad of cognitive and mood disorder symptoms, including heightened depression and anxiety. The American child psychiatrist Dr. Victoria L. Dunckley, MD labeled the constellation of symptoms that arise in response to excessive screen time as the Electronic Screen Syndrome (ESS). [5]. ESS is caused by screen time which overstimulates the adolescents' nervous system and sends them into a fight-or-flight state of mind. In turn, the serotonin, melatonin, and dopamine levels in the brain are altered. Chronically existing in this state of mind leads to the dysregulation of modulating mood, attention, anxiety, and behavior[5]. Other typical symptoms of ESS include chronic stress, sleep deprivation, irritability, depression, mood swings, low frustration toleration, poor self-regulation, disorganized behavior, poor sportsmanship, social immaturity, poor eye contact, and poor short-term memory[5]. It also affects executive functions primarily carried out in the frontal lobe of the brain such as reasoning, judgement, planning, problem solving, and critical thinking. The dysregulatory symptoms can arise immediately, gradually, or latently.
The psychological processes of Electronic Screen Syndrome[5]

Certain factors put adolescents at a higher risk for ESS, such as preexisting psychiatric disorders, younger age, male gender, and family history of addiction[5]. Not all children exhibit all the symptoms because certain symptoms only appear in children with pre-existing conditions. For example, autistic symptoms would only be exemplified in children who have autism, and would not be mimicked by a neurotypical child. However ESS is known to mimic symptoms of ADHD in typically developing children as well as worsening ADHD symptoms in children with ADHD[5]. ESS mimics an array of neurological disorders including depression, bipolar, ADD and ADHD[5]. Due to the negative relationship between screen time and sleep, the combined effects can worsen the symptoms of diagnosed mental disorders[5].


Total screen time is linearly associated with unfavorable temperament outcomes, worse socio-emotional outcomes, lower health-related quality of life, and poorer health outcomes[1]. There are more varied effects for the different categories of screen time.


Social screen time encompasses all digital social interactions, including direct messaging, social media, and FaceTime calls. Social screen time has improved the happiness of some adolescent screen device users because forming social relationships is a key indicator of strong mental well-being and the digital technologies available in the information age can help connect people [1]. The American Academy of Pediatrics released a statement in 2017 that stated screen time can be used to enhance social support and connection, community participation, and civic engagement[7]. Social media apps could be used to foster community by serving as communication platforms for niche health groups, such as people with rare diseases or young people questioning their sexualities. [11] There was a notable increase in children’s social screen time between the ages of 12 and 14 as they developed more autonomy. However, children who spent the highest amounts of time on the internet tended to be the least happy. Social screen time was linearly associated with higher reactivity, and worse socio-emotional outcomes[1].


Passive screen time encompasses any digital activity in which the user is an observer of digital content. Some examples are watching TV and scrolling on social media. Of the five categories of screen usage, it has the most detrimental effects on adolescents' well-being[1]. It is associated with poorer pro-social behavior and lower persistence[1].


Interactive screen time encompasses digital activity that requires the user's input, such as video games. It shows similar effects as overall screen time, however it can have positive effects on education[1]. Interactive screen time is linked to ESS because it contributes to hyperarousal and provides immediate gratification which activate reward circuits and promotes compulsive, addictive use of screen devices[5]. Some studies demonstrate that interactive screen time is more dangerous than passive screen time[5]. A study comparing adolescents' sleep disturbances in response to playing video games and watching TV showed that the threshold for apparent sleep disturbances was much lower (30 minutes) in response to interactive screen time than in response to passive screen time (2 hours)[5].


Educational screen time encompasses any digital activity that involves learning. This implies it can be passive or interactive. Some examples are watching a documentary, reading a research paper, and completing an online course. Educational screen time has not been proven to produce any negative outcomes that are associated with overall screen time[1]. It does produce a positive association with educational outcomes and high persistence[1]. Educational TV programs have benefits in improving children's racial attitudes and imaginativeness[11]. Screen devices serve as channels for news updates. The majority (68%) of American adolescents receive their news from Facebook, Reddit, and Twitter[11].


Other screen time captures extraneous uses of screen time that can't be categorized into passive, social, educational, or interactive categories. There is no evidence that other screen time has any association with psychological outcomes[1].


In the modern information age, it is inconvenient to completely eliminate screen time[1]. There are nuanced effects of screen time, it's use in moderation, and it's different uses, such as the effects of interactive screen time that have both negative effects and positive effects on mental health, or educational screen time that aids in learning [1].

Goldilocks Theory

The Goldilocks theory proposes that there are thresholds of screen time in which it can be healthy and positively impact a person's wellbeing in a technologically connected world[6]. It postulates that a balancing point exists and can be achieved, thus it follows that screen time in moderation is not intrinsically harmful[6]. Like Goldilocks trying extremes of soup, too much technology deprives young people of physical activity, in-person social development, and cognitive growth by replacing meaningful activities. However, too little technology may result in missing out on important information and making connections in the digital medium[6].

A 2017 study on 15-year olds from the United Kingdom found that the relationship between digital-screen time and self-reported mental wellbeing had a statistically significant quadratic relationship. [6] The local extremum in these quadratic trends indicate positive associations between well being and screen time below the extremum, and negative trends between well being and screen time above the extremum[6]. These findings challenge the significance of observed negative effects of screen time on adolescents well being[6].
The mental well-being of U.K. adolescents in response to screen time (a) watching TV, (b) playing video games, (c) using computers and (d) using smartphones.

Investigations on the practical significance of statistically significant correlations between screen time and mental health reveal that the positive and negative impacts of screen time on mental health account for 1% of variability in adolescent psychosocial outcomes. (In other words, more than 99% of variability in adolescent mental health is unrelated to digital screen time) [12]. There is a lack of an empirical standard to judge at what point the effect of screen time on mental health becomes an urgent matter[12]. According to a study that analyzed caregiver perceptions of their child's well being in relation to their amount of screen time usage from the National Survey of Children’s Health, caregiver perceived a difference in their child's psychosocial functioning when the child engaged in over 4 hours of screen time per day[12]. The researchers consider this finding a possible benchmark on which to assess practically significant changes[12].

Less is Better

Another theory known as the "less is better" approach postulates minimum screen time is optimal[1]. It emerged from evidence that screen time is sedentary and passive, which leads to physical and mental detriments. [11] Regardless of content or purpose, the less is better theory proposes that any screen time is problematic. It even discourages the use of eReaders and computers for educational purposes due to the fact that electronic displays are visually hard due to fatiguing LCD screens, and they lack 3-D information--such as the weight of a long textbook--that would lessen the cognitive load, or the time and effort it takes to process information[5].

Electronic Fast

Child psychiatrist Dr. Victoria Dunckley administered electronic fasts to her patients and witnessed resolution of psychological dysfunction [5]. In 500 case studies of children, teens, and young adults who participated in a 3-week long strict electronic fast, the adolescents who had been diagnosed with psychiatric disorders showed a 50% reduction in their psychiatric symptoms. [5] The benefits of educational screen time have challenged the less is better approach[1].


Successful approaches to regulate screen time have included behavioral self-imposed limitations, using non-digital means for as many tasks as possible to avoid interacting with screens, and using digital platforms in a mindful way[1]. Mindful digital habits are possible and studies regarding self-control will need to be consulted to make a further prescription[1].


Research shows that parents can effectively deter their children from partaking in excessing screen time. Parents' efforts to modulate screen-time have proven to be more impactful on adolescents than efforts from school teachers[13]. Interventions are most likely to succeed when targeting children who are younger than 6 years old [11]. The American Academy of Pediatrics recommends parents avoid introducing children to digital media use until they are at least 2 years old, and even then limit their use to 1 hour per day[7]. Additionally, parents should strive to prevent their children from consuming fast-paced programs, apps with lots of distracting content, and any violent content[7]. Monitoring children's media content by testing the apps before the children are exposed to them, playing the apps with their children, and having frequent conversations about the child's thoughts and feelings about the app are suggested regulation methods [7]. Professor Manuel Jimenez, assistant professor in the Department of Pediatrics and director of Developmental and Behavioral Pediatrics Education at the Boggs Center on Developmental Disabilities at Rutgers Robert Wood Johnson Medical School recommended implementing a family media plan that places time limits on media usage, identifies what media behaviors are appropriate, and designates media-free hours and locations of the house.[14] According to the AAP, parents should prohibit screens during meals and 1 hour prior to bedtime to promote healthy eating and sleeping habits[7]. However, parents' influence on adolescents is subjective to the parents' screen usage. Parents with excessive leisure-related screen time usage were less likely to deter children from over-indulging in screen-time. Conversely, parents who modeled lower levels of screen-time are more likely to deter children from using TV or computer screens for more than 2 hours [13]. The importance of moderating screen time is not realized by some parents. Some view screen related activities as having educational benefits for the child[4]. Occupying children with screens has additional perceived benefits such as avoiding conflict with the child, allotting the parents time to complete other household tasks, and financial gains by displacement of other possibly costly activities[4]. Parents also experience guilt and anxiety at the notion of depriving their children from connection to their peers as a result of screen restrictions[5].

Medical Care Providers

The alarming correlation between screen-time and depression in adolescents has motivated researchers to turn to clinicians and medical providers to educate adolescents' on the dangers of excessive screen-time[15]. As a primary point of contact to the healthcare system, care providers and nurses should educate children and parents about the risks of screen time in regards to mental and physical health[15]. According to the AAP, medical care providers should emphasize the importance of hands-on, unstructured, and social play in brain development. Providers can share resources about finding quality, productive digital media products [7] As a new best practice, it is recommended that providers screen any adolescent for negative consequences from excessive screen-use who report a higher screen time than 2 hours per day, the recommended daily screen time usage administered by the American Academy of Pediatrics. Clear recommendations, behavioral contracts, and screen time interventions are needed to guide adolescents' use of their time effectively[7]. Behavioral contracts between individual adolescents and medical care providers regarding screen time grant the adolescent the autonomy to decide how many hours a day he/she would reduce their screen exposure[15]. Evidence suggests when adolescents participate in rule-making, they are more likely to adopt initial behavior changes[16]. The most updated criteria for assessing adolescent psychosocial health is HEADS4, which stands for Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, Safety, and--newly added--Screen-Time[16]. It has been helpful at opening a conversation between providers and patients regarding the addictiveness, risks, and repercussions of excessive screen-time use, specifically spent on social media[16]. It is not widely used because care providers have reported the HEADS4 assessment adds 20 minutes to each patient visit which is too long to maintain their busy patient schedules[16].


The tech industry shares in the responsibility for adolescents' mental health[7]. According to the AAP, they have the ethical obligation to not only make high-quality, accessible, and affordable products, but also to create products that are appropriate for child developmental abilities[7]. One way the tech industry can create ethical digital screen-based applications is to involve developmental psychologists and educators in the design process[7]. By having experts and stakeholders on adolescent mental health represented in the design process, researchers hope less distracting apps will be created[7]. The industry has also been instructed to eliminate advertising on children's apps because of children's undeveloped ability to discern advertisements and factual information[7]. Additionally, the AAP has prescribed that industry cease designing apps and technology for children younger than 18 months altogether until there is proof of benefits of screen usage for this age group[7]. The industry could help parents set screen time limits by developing systems embedded into devices that can help parents monitor and limit media usage[7]. Apple Screen Time was released in 2018 as part of iOS 12 which enabled users to view weekly and daily screen usage by screen activity, as well as set App limits and scheduled downtime[17]. The AAP also calls on the tech industry to scientifically evaluate products before making claims of having educational benefits[7].


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