24/11/24, 20:13 Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systemat…

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JAMA Psychiatry. 2022 Mar 16;79(5):393–405. doi: 10.1001/jamapsychiatry.2022.0155

Association of Screen Time With Internalizing and Externalizing

Behavior Problems in Children 12 Years or Younger
A Systematic Review and Meta-analysis

Rachel Eirich 1,2, Brae Anne McArthur 1,2, Ciana Anhorn 1, Claire McGuinness 1, Dimitri A Christakis 3,4,
Sheri Madigan 1,2,✉

Author information Article notes Copyright and License information

PMCID: PMC8928099 PMID: 35293954

This systematic review and meta-analysis examines the duration of screen time among children
12 years or younger and its association with externalizing and internalizing behavior problems.

Key Points

Question

Is there an association between screen time and children’s internalizing and externalizing
behavior problems in the extant screen time literature?

Findings

In this systematic review and meta-analysis of 87 studies (98 independent samples) including
159 425 children 12 years or younger, greater duration of screen time was weakly but

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significantly correlated with externalizing (eg, aggression, inattention) and internalizing (eg,
anxiety, depression) behavior problems. Results varied as a function of demographic (eg, sex)
and methodological factors (eg, informant and measurement method).

Meaning

The findings showed weak but significant correlations between screen time and children’s
behavior problems and suggest that methodological variability may have contributed to mixed
findings in the literature.

Abstract

Importance

Currently, there is a lack of consensus in the literature on the association between screen time
(eg, television, video games) and children’s behavior problems.

Objective

To assess the association between the duration of screen time and externalizing and
internalizing behavior problems among children 12 years or younger.

Data Sources

For this systematic review and meta-analysis, MEDLINE, Embase, and PsycINFO databases
were searched for articles published from January 1960 to May 2021. Reference lists were
manually searched for additional studies.

Study Selection

Included studies measured screen time (ie, duration) and externalizing or internalizing
behavior problems in children 12 years or younger, were observational or experimental (with
baseline data), were available in English, and had data that could be transformed into an effect
size. Studies conducted during the COVID-19 pandemic were excluded. Of 25 196 nonduplicate
articles identified and screened for inclusion, 595 met the selection criteria.

Data Extraction and Synthesis

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The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses
(PRISMA) reporting guideline. Extracted variables were child age, sex, and socioeconomic
status; informants and measurement type for screen time and behavior problems; study
publication year; and study design and quality. Data were extracted by 2 independent coders
and were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was the association of screen time duration with externalizing (eg,
aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg,
depression, anxiety) behaviors or diagnoses.

Results

Of the 595 full-text articles assessed for eligibility, 87 studies met all inclusion criteria,
comprising 98 independent samples and 159 425 participants (mean [SD] age, 6.07 [2.89] years;
83 246 [51.30%] male). Increased duration of screen time had a small but significant
correlation with more externalizing problems (90 samples; r, 0.11; 95% CI, 0.10-0.12) and
internalizing problems (43 samples; r, 0.07; 95% CI, 0.05-0.08) in children. Several
methodological moderators explained between-study heterogeneity. There was evidence of
significant between study heterogeneity (I2 = 87.80).

Conclusions and Relevance

This systematic review and meta-analysis found small but significant correlations between
screen time and children’s behavior problems. Methodological differences across studies likely
contributed to the mixed findings in the literature.

Introduction

The effects of screen time on children’s mental health has been rigorously debated.1,2 Some
literature suggests that screen time may be associated with risk of poor mental health
outcomes by displacing sleep and physical activities as well as social exchanges and learning
opportunities known to foster well-being.3,4 Screen media may also impede self-regulation
strategies and increase arousal levels owing to fast-paced and intense audiovisual effects, which
may be associated with inattention and aggressive behavior.5,6 However, it has been argued that
concern with regard to screen time and its effect on child mental health is not empirically
justified owing to conflicting research results and methodological shortcomings.7,8,9,10

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Meta-analyses can address discrepancies in the literature by providing greater statistical

precision through pooled results from multiple individual studies11 and can detect whether
variations in study findings are explained by moderators. In the screen time literature,
methodological differences have likely contributed to the conflicting findings: effect sizes may
differ based on the statistical analyses conducted,12 how variables are measured,13 and
whether data are cross-sectional or longtudinal.7 Effect sizes may also vary as a function of
child sex (eg, sex differences in the associations of screen time14,15 with behavior
problems),16,17,18 child age (eg, association of increased screen use with increasing age among
children),15,19 and socioeconomic risk (eg, association of increased screen use with behavior
problems in the context of low socioeconomic status).20,21 Identifying when and for whom
correlations are stronger or weaker may inform the ongoing screen time debate and help
develop targeted interventions for children most at risk for potential behavior problems
associated with screen time.

Owing to substantial research to date on duration of screen time and behavior problems, it
appeared timely to meta-analytically summarize this body of research. Given that the context
and nature of screen use changes from childhood to adolescence from mostly parent-mediated
and television-centric to less parent-mediated and weighted toward social media,19,22,23 this
systematic review and meta-analysis focused on children 12 years or younger. Because of their
different mechanisms,24,25 we conducted 2 separate meta-analyses for externalizing (eg,
aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, anxiety,
depression) behavior problems.25 In addition, we sought to identify sources of between-study
heterogeneity.

Methods

Search Strategy

In this systematic review and meta-analysis, searches were conducted in the MEDLINE,
Embase, and PsycINFO databases by a science librarian for articles published from January
1960 to May 2021. The concepts of screen time, internalizing and externalizing behavior, and
children were captured by searching database-specific subject headings and text word fields
(eTable 1 in the Supplement). Synonymous terms were combined with the Boolean “OR” and
then combined with the Boolean “AND.” The concept of children (12 years or younger) was
searched using the “age limits” database functions and via text word search. In all databases,
truncation symbols were used in text word searches to capture variations in phrasing and
spelling. No language limits were applied. Reference lists in included studies and review articles
were manually searched for additional studies. This study followed the Preferred Reporting
Items for Systematic Reviews and Meta-analyses (PRISMA ) reporting guideline.

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Study Inclusion and Exclusion Criteria

Studies were included if (1) the age range of included children was 12 years or less, (2) screen
time duration was measured (hours and/or minutes), (3) behavior problems (ie, internalizing,
externalizing) were measured, (4) the studies were observational or experimental (with
baseline data), (5) statistical data were available, and (6) the article was available in English.
Because child screen time and mental distress have increased during the COVID-19
pandemic,26,27 we excluded studies conducted during the pandemic. Inclusion and exclusion
criteria are detailed in eTable 2 in the Supplement. Studies were assessed for inclusion by 2
coders (R.E. and C.A.). Any study deemed to meet inclusion criteria by either coder was
considered for full-text review.

Data Extraction

Study Quality Assessment

Each study was evaluated by 2 independent coders (C.A. and C.M.) for quality based on an
adapted 16-item quality assessment tool28 (eTable 3 in the Supplement), with each item coded
as 0 (no) or 1 (yes) (eTable 4 in the Supplement). Intercoder agreement for the overall quality
score was good (intraclass correlation coefficient, 0.75). Discrepancies were resolved via
consensus.

Moderating Variables

Moderators extracted were (1) child sex (percentage of males in the study); (2) child age at
outcome measurement (in months); (3) screen time informant (child or parent); (4) screen time
measurement method (ie, activity log, questionnaire, or interview); (5) type of internalizing
(anxiety, depression, or somatization) or externalizing (aggression or attention
deficit/hyperactivity disorder symptoms) behavior problems; (6) informant (child, parent,
clinician or coder, peers, teacher, or combination); (7) measurement method (diagnostic and
structural interview, observer report, or questionnaire); (8) whether informants differed for
screen time and behavior problems; (9) clinical sample (diagnosis of a preexisting behavior
problem [yes or no]); (10) publication year; (11) study design (cross-sectional, longitudinal
with baseline outcome adjustment, or longitudinal with no baseline adjustment); (12)
sociodemographic risk (less than 80% vs 80% or more of the sample had at least 1 of the
following: low income, low caregiver educational level, or an adolescent parent); and (13)
geographic location. eTable 5 in the Supplement shows the data extraction document used. All
included studies were independently coded by 2 trained coders (C.A. and C.M.), with excellent
reliability29 for continuous moderators (intraclass correlation coefficient, 0.80-1.00). The mean
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percentage of agreement for categorical moderators was 92.5% (range, 85%-100%).

Discrepancies were resolved via consensus.

Data Synthesis

When multiple studies conducted analyses on the same sample, the study with the largest
sample size and most comprehensive information was selected. Adjusted statistics were
selected over unadjusted statistics whenever available. Global measures of internalizing or
externalizing symptoms and of screen time were selected over discrete symptoms (eg,
depression, anxiety) or screen types (eg, tablet, video games). Similar to the methods of other
meta-analyses,30,31,32 when a single study measured screen time and/or behavior problems at
multiple time points, effect sizes with the largest temporal distance between measures were
selected. When studies reported nonsignificant findings without any corresponding statistic or
P value, a P value of .50 was entered.33 Studies reporting β coefficients between –0.50 and 0.50
were imputed to correlations (r).34 Effect sizes were pooled when a single effect size among
many in a study could not be selected based on the aforementioned criteria. In addition, if a
study provided effect sizes from multiple discrete samples with different population
parameters (eg, different cohorts), these samples were entered into the meta-analysis
separately.

Statistical Analysis

Pooled effect size estimates and moderator analyses were conducted using Comprehensive
Meta-Analysis, version 3.0 (Biostat).35 Effect sizes were transformed into correlations (r) with
95% CIs using random-effects modeling.36 Correlations were interpreted as small (0.1),
moderate (0.2), or large (0.3) based on conventional standards.37

Q and I2 statistics were used to assess between-study heterogeneity. Random-effect meta-

regressions and subgroup comparisons were conducted to assess continuous and categorical
moderators, respectively. Subgroup comparisons were only conducted when there were at least
3 samples (ie, ≥3 cells) available for each categorical comparison.35 Inspection of funnel plots
and the Egger test were used to estimate publication bias.38 A 2-tailed P value of .05 was used
for the primary analyses, and owing to the number of moderator analyses conducted, a
conservative 2-sided α value of .01 was used to assess the significance of moderators.39

Results

The search strategy revealed 25 196 nonduplicate abstracts to be reviewed for determination of
meeting inclusion criteria. A total of 595 full-text articles were assessed for eligibility, and 87
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studies (with 98 unique samples) were included in the meta-analysis (Figure 1).

Figure 1. PRISMA Flow Diagram.

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aInternalizing and externalizing categories were not mutually exclusive.

Study Characteristics

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The 98 samples consisted of 159 425 participants. Sample sizes in the included studies ranged
from 15 to 15 291 participants (median, 532.5 participants). The mean (SD) age of participants
when screen time was assessed was 6.07 (2.89) years (range, 0.5-11.0 years), and the mean (SD)
age when behavior problems were assessed was 7.16 (2.70) years (range, 1.3-12.0 years). A total
of 83 246 participants (51.25%) were male (median percentage of males per study, 51.31%
[range, 36.60% to 78.70%]). Of the 98 total samples, 44 (44.9%) were in North America, 24
(24.5%) in Europe, 1 (1.0%) in Africa, 14 (14.3%) in Asia, 7 (7.1%) in Australia or New Zealand,
5 (5.1%) in the Middle East, and 2 (2.0%) in South America; 1 sample (1.0%) was multisite
(detailed study characteristics are shown in eTable 6 in the Supplement).

Screen Time and Externalizing Behavior Problems

Pooled Effect Sizes

In the 90 samples from 80 studies (124 027 children), the correlation was small but significant
(r, 0.11; 95% CI, 0.10-0.12) (Figure
2).16,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,
74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,
107,108,109,110,111,112,113,114,115,116,117,118 The Egger test result provided evidence that
studies with smaller sample sizes had more extreme effect sizes, and the funnel plot showed
asymmetry (eFigure 1 in the Supplement), indicating possible publication bias and/or small-
study effects. There was evidence of significant between-study heterogeneity (Q, 729.78; P
< .001; I2 = 87.80); therefore, moderators were explored (Table 1).

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Figure 2. Meta-analysis of the Correlation of Screen Time With Externalizing Problems.

Open in a new tab

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Markers indicate estimates, with the size of the marker indicating weight; horizontal
lines represent 95% CIs; diamonds represent pooled estimates, with the outer points
indicating 95% CIs.

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Table 1. Moderator Analyses for the Correlation Between Screen Time and Behavior
Problems.

Variable Samples, r (95% CI) Q Contrast

No. P value a

Externalizing behavior
Screen type
Video games or computer 9 0.13 (0.08 to 0.18)b 0.32 .57
Television 42 0.11 (0.09 to 0.14)b
Externalizing behavior type
Aggression 21 0.17 (0.13 to 0.20)b 11.11 .001
Attention-deficit/hyperactivity 25 0.09 (0.06 to 0.12)b
disorder symptoms
Sociodemographic risk
No 87 0.11 (0.09 to 0.12)b 0.04 .84
Yes 3 0.12 (0.03 to 0.21)c
Study design
Cross-sectional 50 0.13 (0.11 to 0.15)b 23.55 <.001
Longitudinal without control 21 0.11 (0.08 to 0.14)b
for baseline outcome
Longitudinal with control for 19 0.06 (0.04 to 0.08)b
baseline outcome
Screen time measurement
method
Activity log 9 0.12 (0.08 to 0.17)b 2.81 .25
Interview 7 0.15 (0.09 to 0.21)b
Questionnaire 74 0.10 (0.09 to 0.12)b
Screen time informant
Child 19 0.15 (0.11 to 0.18)b 5.71 .02
Parent 69 0.10 (0.08 to 0.12)b
Behavior measurement
method
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Variable Samples, r (95% CI) Q Contrast

No. P value a

Diagnosis and/or structured 8 0.12 (0.07 to 0.17)b 10.04 .007

interview
Observer report 8 0.20 (0.14 to 0.26)b
Questionnaire 74 0.10 (0.08 to 0.12)b
Behavior informant
Child 4 0.08 (0.00 to 0.15)c 15.39 .009
Clinician or coder 6 0.16 (0.08 0.23)b
Peers 8 0.20 (0.15 to 0.26)b
Teacher 7 0.07 (0.02 to 0.13)d
Parent 57 0.10 (0.08 to 0.12)b
Combination 8 0.09 (0.04 to 0.14)d
Different informants for screen
time and behavior
Yes 35 0.13 (0.09 to 0.16)b 1.56 .21
No 55 0.10 (0.08 to 0.12)b
Geographic location
Asia 13 0.12 (0.08 to 0.16)b 25.17 <.001
Australia and New Zealand 7 0.05 (−0.01 to 0.10)
Europe and UK 22 0.08 (0.06 to 0.11)b
Middle East 5 0.23 (0.17 to 0.29)b
North America 39 0.12 (0.10 to 0.15)b
Clinical sample
Yes 4 0.13 (0.03 to 0.23)c 0.16 .69
No 86 0.11 (0.09 to 0.12)b
Internalizing behavior
Screen type
Video games or computer 4 0.02 (−0.07 to 0.12) 1.58 .21
Television 8 0.09 (0.04 to 0.15)d
Study design
Cross-sectional 29 0.08 (0.05 to 0.10)b 2.76 .25
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Variable Samples, r (95% CI) Q Contrast

No. P value a

Longitudinal without control 5 0.07 (0.01 to 0.08)b

for baseline outcome
Longitudinal with control for 9 0.03 (−0.02 to 0.08)
baseline outcome
Screen time informant
Child 10 0.09 (0.04 to 0.13)b 1.43 .23
Parent 32 0.06 (0.03 to 0.08)b
Behavior measurement
method
Questionnaire 40 0.06 (0.04 to 0.08)b 0.94 .33
Diagnosis and/or structured 3 0.10 (0.03 to 0.17)d
interview
Different informants for screen
time and behavior
Yes 9 0.08 (0.05 to 0.10)b 14.86 <.001
No 34 0.01 (−0.02 to 0.03)
Geographic location
Asia 9 0.08 (0.06 to 0.10)b 1.75 .42
Europe 12 0.07 (0.03 to 0.11)d
North America 16 0.05 (0.02 to 0.09)d
Behavior informant
Child 7 0.10 (0.05 to 0.14)b 1.20 .27
Parent 33 0.07 (0.04 to 0.09)b

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a
Contrast P values represent the P values for the comparison of effect sizes between
categorical moderators.
b
P < .001 for the effect size of this categorical moderating factor alone.
c
P < .05 for the effect size of this categorical moderating factor alone.
d
P < .01 for the effect size of this categorical moderating factor alone.

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Moderator Analyses

Meta-regression analyses of the 90 samples showed that the effect size for the association
between screen time and externalizing problems increased as the percentage of males in studies
increased (b, 0.007 [SE, 0.002]; z, 3.23; P = .001). Effect sizes also decreased as the study
publication year increased (b, −0.003 [SE, 0.001]; z, –3.98; P < .001). The effect size for the
association between screen time and externalizing problems decreased as study quality
increased (b, −0.017 [SE, 0.004]; z, –4.30; P < .001) (Table 2).

Table 2. Meta-regression Analyses of the Association Between Screen Time and

Externalizing and Internalizing Problems.

Continuous moderator Samples, β (SE) z Score P value

No.
Externalizing behavior
Male 90 0.007 (0.002) 3.23 .001
Age at externalizing assessment 90 0.000 (0.000) 0.10 .92
Publication year 90 −0.003 (0.001) −3.98 <.001
Study quality 90 −0.017 (0.004) −4.30 <.001
Internalizing behavior
Male 43 0.002 (0.003) 0.52 .60
Age at internalizing assessment 43 0.000 (0.000) −0.37 .71
Publication year 43 −0.001 (0.002) −0.44 .66
Study quality 43 −0.003 (0.006) −0.49 .62

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Correlations between screen time and externalizing problems were stronger in studies
examining aggression (21 samples; r, 0.17; 95% CI, 0.13-0.20) compared with those examining
attention deficit/hyperactivity disorder symptoms (25 samples; r, 0.09; 95% CI, 0.06-0.11).
Correlations were weaker in longitudinal studies that controlled for baseline externalizing
problems (19 samples; r, 0.06; 95% CI, 0.04-0.08) compared with cross-sectional studies (50
samples; r, 0.13; 95% CI, 0.11-0.15) and longitudinal studies without baseline control (21

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samples; r, 0.11; 95% CI, 0.08-0.14). Studies conducted in the Middle East had stronger
associations between screen time and externalizing problems (5 samples; r, 0.23; 95% CI, 0.17-
0.29) compared with those conducted in all other geographic locations. Stronger correlations
were also found in studies using observer reports (8 samples; r, 0.20; 95% CI, 0.14-0.26)
compared with those using questionnaires (74 samples; r, 0.10; 95% CI, 0.08-0.12). In addition,
studies using peers to assess externalizing problems had stronger correlations (8 samples; r,
0.20; 95% CI, 0.15-0.26) compared with those that used child report (4 samples; r, 0.08; 95% CI,
0.00-0.15), parent report (57 samples; r, 0.10; 95% CI, 0.08-0.12), teacher report (7 samples; r,
0.07; 95% CI, 0.02-0.13), and a combination of informants (8 samples; r, 0.09; 95% CI, 0.04-0.14).

Screen Time and Internalizing Behavior Problems

Pooled Effect Sizes

In 43 samples from 40 studies (99 603 children), the effect size between child screen time and
internalizing problems was weak but significant (r, 0.07; 95% CI, 0.05-0.08) (Figure
3).16,42,43,45,50,51,52,56,60,66,69,73,74,76,78,81,83,84,87,88,92,94,95,98,101,105,106,107,110,113,114,115
,116,119,120,121,122,123,124,125 The funnel plot showed some asymmetry (eFigure 2 in the

Supplement), indicating possible publication bias; however, the Egger test result did not suggest
that smaller sample sizes had more extreme effect sizes. The Q statistic was significant (Q,
285.10; P < .001; I2, 85.27), and moderator analyses were conducted to explain between-study
heterogeneity (Table 1). Only 1 moderator analysis had significant results: studies that used
different informants to measure internalizing problems and screen time had a stronger
correlation (9 samples; r, 0.08; 95% CI, 0.05-0.10) compared with those with the same
informant across measures (34 samples; r, 0.01; 95% CI, –0.02 to 0.03).

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Figure 3. Meta-analysis of the Correlation of Screen Time With Internalizing Problems.

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Markers indicate estimates, with the size of the marker indicating weight; horizontal
lines represent 95% CIs; diamonds represent pooled estimates, with the outer points
indicating 95% CIs.

Discussion

The increasing rate of screen time in early childhood has engendered concern among clinicians,
policy makers, and parents regarding its possible effects on children’s mental health. This study
found small but significant correlations between screen time and children’s internalizing and
externalizing behavior problems. The magnitude of these correlations is comparable with that
found in other meta-analyses on the association between screen time and child language
skills126 and academic performance.127 Moreover, effect sizes derived in this study are similar
to those in other meta-analyses examining associations between various family and child
factors (eg, language skills128 and socioeconomic status129) and internalizing and externalizing
problems. Although the effect sizes found in this study were small, the consequences of screen
time at a population level are likely meaningful,37,130 particularly because a recent meta-
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analysis131 suggested that 75% of children younger than 2 years and 64% of children aged 2 to
5 years exceed screen time guidelines.

Effect sizes were larger for the association between screen time and externalizing problems
compared with internalizing problems given nonoverlapping 95% CIs. Future studies testing
which discrete mechanisms underlie the association between screen time and externalizing vs
internalizing problems are warranted. For example, it is possible that the content viewed (eg,
inappropriate or violent) underlies the association between screen time and externalizing
problems, whereas indirect effects such as social withdrawal or sleep disruption may underlie
the association between screen time and internalizing problems. From a methodological
perspective, externalizing problems may be easier for reporters to observe than internalizing
problems owing to their outward display, leading to poorer sensitivity for identifying
internalizing problems.132

We found stronger correlations between screen time and externalizing problems in boys
compared with girls. This finding is consistent with that of previous research in which boys had
higher screen use14,133 and more externalizing problems17 than did girls. Externalizing
behaviors, such as aggression, may be more readily modeled by boys through sex-stereotypic
socialization.134 In addition, we found that studies measuring aggression had larger effect sizes
than those measuring attention deficit/hyperactivity disorder symptoms. While viewing screen
media, children may be exposed to inappropriate content, aggression, and violence.40,135,136
Consistent with social learning theory,137 children may become desensitized after repeated
exposures and model aggressive or violent content toward others.6,40,136 Moreover, as screen
time becomes more normalized, it is possible that aggressive behavior within some screen
programming does as well. Screen use guidelines138 suggest that parents should monitor screen
time, ensure the content their children are viewing is age-appropriate, limit exposure to violent
content, communicate with their children about inappropriate on-screen content, and model
healthy device habits.139

Correlations of screen time with externalizing behavior problems were stronger in the Middle
East compared with any other geographic location; however, sample sizes in studies from the
Middle East were small, and 95% CIs were wide, limiting the conclusions that can be made. A
dose-response relationship between screen time and externalizing problems41,42,140 may
explain the stronger correlations found in countries in the Middle East because early-onset
screen use has been increasing at a faster rate in these countries compared with other
countries.141,142 More research is needed to understand how cultural differences (eg, different
guidelines and beliefs about screen time)143 contribute to associations between screen time
and behavior problems.

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The mixed findings in the literature on screen time and behavior problems may largely be the
result of methodological variability.7 Studies that used more objective methods (eg, observer
report) and reporters (eg, peers) of children’s externalizing problems had stronger correlations
than those using child, parent, or teacher reports. In addition, studies that used different
informants for screen time and internalizing problems had stronger correlations than those
using the same informant across measures. Inconsistency between informants for children’s
behavior problems is common,144 but informant discrepancies may indicate the contexts and
ways in which behavior problems are perceived by the child and others.145 For example,
aggression may be noticed more readily by peers owing to children having more opportunities
to engage with peers aggressively (eg, bullying).

Variability exists both across (ie, aggression, oppositional behavior, and hyperactivity) and
within (eg, demanding, hits others) the broad construct of externalizing behavior problems.
However, historically, externalizing problems have been examined as a composite.25,146 This
study’s finding that screen time was more strongly correlated with aggression suggests that the
use of an externalizing composite may not capture inherent nuances in the association between
screen time and behavior problems. Furthermore, as children move into adolescence, attention
problems and aggression are often measured as separate constructs.147 Future research should
consider disaggregating externalizing behaviors, presenting associations in their
subcomponents (eg, aggression, attention deficit/hyperactivity disorder symptoms), and
examining which items within the subcomponents are correlated most strongly with screen
time.

Given that methodological variability is critical for understanding patterns of associations in

this body of research, several methodological implications are suggested for future research. To
the extent possible, future research should use multi-informant (eg, peers, child), multimethod
(eg, passive sensing apps and questionnaires), and longitudinal approaches to measure the
association of screen time with child outcomes. Of importance, self-report screen time
measurement may be biased.148 None of the studies identified in our meta-analysis used
objective measures (eg, sensing apps) to evaluate screen time, presenting an opportunity for
future research to use novel screen-time measurement methods.

Two characteristics of publications were identified as significant moderators of associations

between screen time and externalizing problems: study quality and publication year.
Associations found between screen time and externalizing problems decreased as study quality
increased. Poorer quality studies often have more random error and inflated effects owing to
less methodological rigor (eg, a single informant, lack of statistical controls). Study quality is
also closely connected to study year, with larger effect sizes found in older, discovery studies
typically owing to more reliance on significance testing (P value thresholds), inadequate power,
and measurement error.149 Thus, effect sizes also decreased in newer studies, which is
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consistent with the notion of a decline effect (ie, diminishing effect sizes over time).150,151 The
accessibility and use of screens have increased over time.152 As screens become normalized in
childhood and contemporary culture, the risks associated with their use may become less
consequential for children’s behavior problems. Furthermore, parents today may be more
informed and better at monitoring screen time and content owing to awareness of screen time
guidelines.131

Limitations

This study has several limitations. First and of most importance, effect sizes are correlational,
not causal. Causal reductionism should be avoided because behavior problems are associated
with a complex combination of genetic and environmental factors. Additional research that
addresses this complexity is needed (eg, genetically informative designs).153,154,155
Directionality cannot be inferred; screens may be used as a tool to placate or negotiate with
children.156,157 Second, although there was significant heterogeneity for internalizing
problems, only 1 of the moderator analyses had significant results. Other important but
unexamined moderators, such as genetic susceptibility,155 sleep,43 or language
development,126 may have a significant role in associations. Third, with rapid shifts in
technology, generational cohorts may not use devices comparably.7 Mobile phones were
originally used almost exclusively for calling, and few children had their own; now,
smartphones are used to access web pages, play games, stream videos, and socialize, and 69% of
US children have their own smartphone by 12 years of age.22 Although we excluded studies
conducted during the COVID-19 pandemic, a cohort of children are growing up during the
pandemic. Screen time has increased significantly during the pandemic, and this increase may
affect child development.26,158,159 In addition, not all screen time is equal in terms of content,
subject, and formal features; some screen time may be more consequential than other screen
time. Our findings only apply to screen time broadly in terms of duration or quantity of use.
More nuanced aspects of screen time, such as screen content (eg, social media, violent video
games), context (eg, coviewing vs passive viewing), and quality (eg, educational vs
entertainment), should be examined. Future studies should also ensure that screen time is not
measured as a single construct across multiple devices and should instead focus on the function
of screen use (eg, entertainment, socializing, or education) to examine the way screens are
being used without being device-specific.

Conclusions

The association between screen time and children’s mental health has garnered marked
attention from academic, health, and public sectors. This systematic review and meta-analysis
found that screen time was weakly but significantly correlated with children’s internalizing and

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externalizing behaviors. Our study identified several important methodological moderators of

the association between screen time and behavior problems, such as the type of informants and
the measures of screen time used, that highlight the lack of harmony in the screen time
literature. It is essential for researchers to use more rigorous methods and approaches to
analyzing screen time data16,160 and to further explore the various facets of screen use (ie,
content and context) associated with children’s mental health in a rapidly evolving digital
world.

Supplement.

eTable 1. Search Strategy

eTable 2. Inclusion and Exclusion Criteria

eTable 3. Study Quality Evaluation Coding Criteria

eTable 4. Study Quality Scoring for Each Study Included in the Meta-analysis

eTable 5. Coding System of Study Variables

eTable 6. Study and Sample Characteristics

eFigure 1. Funnel Plot Depicting Standard Error by Fisher Z of Included Studies in Meta-
analysis of Screen Time and Externalizing Problems

eFigure 2. Funnel Plot Depicting Standard Error by Fisher Z of Included Studies in Meta-
analysis of Screen Time and Internalizing Problems

eReferences

Click here for additional data file. (681KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in
this article.

Supplementary Materials

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24/11/24, 20:13 Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systemat…

Supplement.

eTable 1. Search Strategy

eTable 2. Inclusion and Exclusion Criteria

eTable 3. Study Quality Evaluation Coding Criteria

eTable 4. Study Quality Scoring for Each Study Included in the Meta-analysis

eTable 5. Coding System of Study Variables

eTable 6. Study and Sample Characteristics

eFigure 1. Funnel Plot Depicting Standard Error by Fisher Z of Included Studies in Meta-
analysis of Screen Time and Externalizing Problems

eFigure 2. Funnel Plot Depicting Standard Error by Fisher Z of Included Studies in Meta-
analysis of Screen Time and Internalizing Problems

eReferences

Click here for additional data file. (681KB, pdf)

Articles from JAMA Psychiatry are provided here courtesy of American Medical Association

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