A Literature Review Ofthe Effects Ofmedia on Children's Physical And

Home , Media consumption

Childhood Development and Media Use: A Literature Review ofthe Effects ofMedia on

Children's Physical and Psychosocial Development

A Master's project submitted in partial fulfillment ofthe requirements for the degree of

MASTERS OF NURSING

Brett Douglas 0'Connor

WASHINGTON STATE UNIVERSITY-SPOKANE, WA

College ofNursing

August 2011

WaShington State University Snnl.... Rlverpoint Campus Ubra ""VRana RO. Box 1495 ry SPOkane. WA 99210-1495 To the Faculty of Washington State University:

The members ofthe Comnlittee appointed to examine the master's project of

BRETT DOUGLAS O'CONNOR find it satisfactory and recommend that it

be accepted.

Chair

ii Childhood Development and Media Use: A Literature Review of the Effects of Media

Technologies on Children's Physical and Psychosocial Development

Abstract

By Brett Douglas O'Connor, RN

Washington State University

August 2011

Chair: Dr. Mel Haberman

Television, computers, and video games are among the most widely used media activities, which engage children and adolescents for increasing amounts of time. There is a sharp increase in both the time spent and the numbers of children who use media over the past 10 years. Parents, educators, and health care providers must understand the effects that media has on childhood development and learn ways to moderate negative effects and maximize positive effects. This literature review seeks to identify the physical and psychosocial effects that media has on children and the variables of media use, which are important Variables that effect media use by children, such as age, gender, time, and content of media, are teased out ofthe literature to identify those that to lead to health consequences. The three theoretical frameworks chosen for the paper are Social Learning Theory (SLT), Message Interpretation Process Model (MIP), and

Displacement Theory (DT). The article offers recommendations to parents and health care

iii providers (HCP) for children's media use. Suggestions are based on policy statements by the

American Academy ofPediatrics (AAP) and the Kaiser Family Foundation (KFF).

Words: children and media, screen time and effects on child development, aggression and media, computers and development, physical factors, psychosocial factors, cognitive development and computers, media technologies and children.

iv TABLE OF CONTENTS

Page

ABSTRACT iii

INTRODUCTION 1

THEORETICALFRAMEWORK 3

SOCIAL LEARNING THEROY 4

MESSSAGE INTERPRETATION PROCESS MODEL 4

DISPLACEMENT THEORy 4

LITERATURE REVIEW

SEARCH METHODS 5

DETRIMENTAL PHYSICAL EFFECTS OF MEDIA ON CHILDREN 6

PSYCHOSOCIAL EFFECTS OF MEDIA USE ONCHILDREN 13

RECOMMENDATIONS 18

DISCUSSION 21

MEDIA AND PHYSICAL DEVELOPMENT OF CHILDREN 22

MEDIA AND PSYCHOSOCIAL DEVELOPMENT OF CHILDREN 22

LIMITATIONS OF EXTANT RESEARCH 23

NEED FOR FURTHER RESEARCH 24

REFERENCES 26

v Introduction

For the purposes ofthis review, media refers to both old and new media. The Collins

English Dictionary (2010) defmes media as communication, such as magazines and TV, that reaches large numbers of people. These means of communication can be thought of as old types ofmedia. New types ofmedia are defined by Flew (2007) as those forms of communication that possess the qualities of being digitalized, compressible, interactive, manipulated, networkable and dense. Some examples of new media are the Internet, computers, video games, and DVD's.

In the 1920's researchers began to ask how does media influence the behaviors of children? Children are defmed as boys and girls between the ages or 2 and 18 years old. There is continued interest in this question, especially as it influences children's development, with many ofthe questions unanswered owing to the explosion ofmedia venues. With hlUldreds ofcable and satellite TV channels, millions of DVDs, video games, cellular phones, and computers, media appears endless. It enters into most aspects of daily life with DVDs, TVs and computers central components in most family environments.

The Kaiser Family Foundation ( KFF) surveys reveal that 99% offamilies with children own televisions, 97% own video players, 80% own video game systems, 86% own a computer,

82% have cable or satellite TV, 74% have internet access, and 60% have instant messaging software (KFF, 2003, 2005). The average household has 2.9 video players, 3.5 TVs, and 1.5 computers (KFF, 2005). Not only does media engage the vast majority of families, it saturates school and public environments as well. Use of media continues to grow among children in developed cOlUltries beginning at a young age (Brandtzeag, Endestad, Heim, Kaare & Torgesen,

2004b). The KFF (2006) report that in 2005 children age eight and above spent an average of

6.43 hours with media each day. de Haan and Huysman (2004) report that sleep is the only other

1 activity that children spend nl0re time at than using media

Traditional dogma posits that media "poses a danger and a threat to children" and "induce personal isolation...where children are alone...in their own private space, thus reducing their psychosocial experiences" (Heim, Brandtzaeg, Karre, Endestad, & Torgersen, 2007. p. 426).

Media usage, such as TV viewing, often occurs alone in a sedentary manner. The media effects that correlate with negative health outcomes, such as obesity, aggression, and poor school performance, are a few ofthe health outcomes ofmost concern. However, as researchers gain greater insight into the consequences ofmedia on health, evidence suggests that there may also be beneficial health effects (de Haan & Huysman, 2004). It is reasonable to assume that there are measureable effects ofmedia usage on childhood development, though many ofthose effects are yet to be documented.

Assuming there are measurable effects, this paper seeks to delineate some ofthe variables that contribute to both the physical and psychosocial health consequences ofmedia on children.

The variables considered are the psychosocial health outcomes include time spent with media, age, gender, parental oversight, content, and context. While the variables are not exhaustive, they may provide greater understanding ofthe roles these factors play in the health effects of media usage. The psychosocial health outcomes identified in the literature are depression, isolation, aggression, scholastic performance, relationships, and delinquency. It appears that the time spent with media is the most important variable related to health consequences and media use. Reports in the literature include the metabolic abnormalities such as HTN, obesity, CAD, increased adiposity, and metabolic syndrome (MS).

The physical health consequences include a cluster ofconsequences related to metabolism and vision. These consequences include metabolic abnormalities such as

2 hypertension, obesity, coronary artery disease, increased adiposity and metabolic syndrome.

These health effects are largely due to a sedentary life and lack ofexercise.

Organizations who promote health behaviors of children, such as the American Academy ofPediatrics, conduct ongoing research into the health effects of media use on children. These organizations continue to report on their fmdings and routinely provide recommendations to parents, health care providers, and educators as to the perspicacious use ofmedia in the home and schools. Parents have the responsibility their children to impart appropriate behavior and socialization, while ensuring that their home environment provides the opportunity for their children to fully develop emotionally and academically. Parents are arguably the most important regulators ofmedia use by children.

Educators bear the responsibility to provide the best tools for education so that every child may attain their full academic potential. In the age when media is beginning to replace traditional teaching methods, educators must become well versed and proactive in efforts to support well designed, evidence driven media programming in education. The responsibility of health care providers is to promote positive health outcomes for children. It is up to the Primary

Care Providers to become versed in the health outcomes of media on children and incorporate teaching ofthese concepts to families. Primary Care Providers also bear the responsibility to affect programming, school, and community policy about media use.

Theoretical Framework

There is no one single theoretical model that can be applied to explain the current state of knowledge. Therefore, three frameworks provide the theoretical foundation for this paper.

These include Bandura's (2008) Social Learning Theory, Displacement Theory (Moses, 2008)

3 and Austin's (Arnett, 2007) Message Interpretation Process model. Each of the three theories contain separate qualities that, when used in combination, offer a better explanation ofthe phenomenon observed.

Social Learning Theory

Albert Bandura first developed the SLT in 1962. He theorizes that people learn by observing others, and thought processes are key to understanding personality (Bandura, 1986).

Knowledge is acquired through observation ofmodels. Interpersonal relations or media sources can serve as mo"dels. According to Bandura (1986), cognition, behavior, and environment influence learning and development, and are interdependent and reciprocal. For example, SLT is useful to explain and predict the media effects of TV and video games, which positively correlated with violence and aggression (Olsen et aI., 2009). The repeated imprinting of a particular behavior via observation leads to assimilation of a similar behavior in the viewer. This model assumes that constant exposure to a behavior, even ifthe result is negative, has great impact on expressed behavior.

Displacement Theory

Many researchers utilize the displacement theory (DT) to explain and guide research on the effects of media on children. DT assumes that media use is a choice and that the greater amount oftime children spend engaged with media, the less time that they have for other pursuits such as sp~rts, scho~lwork, and social interaction. The result ofthis displaced activity are increased physical and psychosocial health risks. DT is particularly useful to explain the research conclusions regarding obesity and other sedentary related disorders.

Message Interpretation Process Theory

Erica Weintraub Austin derived the Message Interpretation Process model from

4 Bandura's Social Learning Theory in order to track media effects (Arnett, 2007). Individuals apply logic-based and affect-based filters to the messages contained within media (Arnett, 2007).

Logical comparisons concern an individual's reflection ofhow a message relates to a person's life and ifit is correct or realistic. Affective comparisons involve an individual's reflection of how the message appeals to a person on an emotional level. These filters will lead to acceptance or rejection ofmedia messages. Therefore, an individual's behavior may be dominated by either logic or liking. The model postulates that media messages are subjected to both in-depth logical analysis and wishful thinking (Arnett, 2007).

Literature Review

Search Methods

The literature search included Worldcat, Griffin Libraries, and CINAHL databases.

Ebscohost and PubMed yielded the greatest numbers ofjournal articles. Titles and abstracts of

550 articles were assessed for their relevance to this review. With the exception ofa review of media and obesity by the KFF (2004), the articles were published in the past four years. All of the articles discussed are peer reviewed and published by academic institutions or in academic journals.

Nineteen articles discussed the effects of a variety ofmedia use on childhood development.

Six analyzed physical effects ofmedia on children, including obesity, metabolic syndrome, vision, and blood pressure. The research illuminated co-morbid physical effects of media usage on children and addressed the question, -Are there detrimental physical effects of media use on children?- Foreign studies were included to assess, if study findings vary across

5 geoculturallandscapes.

Thirteen articles addressed the psychosocial effects that media may have on children, such as depression, self-esteem, isolation, scholastic achievement, relationships, and aggression.

The articles are original research, meta-analysis, and reviews ofexiting literature on the psychosocial influences ofmedia on children's development. A comprehensive review ofthe research completed on the psychosocial health outcomes of media on children is beyond the scope ofthis paper. The review represents a sample ofthe research completed and assists one to answer the question -Do we understand the psychosocial implications ofmedia on children?- In addition, the literature reveals the kinds of media use that are likely to lead to risky health behaviors. The literature review examines the detrimental physical effects of media on children and psychosocial effects of media on children.

Detrimental Physical Effects of Media Use on Children

The implications of childhood obesity on mortality, morbidity, and health care costs are

enormous. The Surgeon General predicts that childhood obesity associated disease may soon exceed those associated with cigarette smoking (Ogden & Carroll, 2010) . Childhood obesity is defined as those children 2 to 18 years of age who are at or above the 95 th percentile for age and sex (Burns, 2010). Overweight is defmed as those children 2 to 18 years of age who are at or above the 85 th percentile for age and sex (Burns, 2010). The Centers for Disease Control (CDC) and Prevention (2010) estimate that 17% of children age 2-19 in the US are obese. In the last thirty years, obesity among pre-school children has doubled, tripled among 6-11 year olds, and almost quadrupled among 12-19 year olds. The AAP, CDC, and KFF agreed that approximately

80% of obese children continue to be obese in adulthood.

6 Researchers who investigate a cause for the large increase in childhood obesity discovered that there are multifactoral influences contributing to the problem. These included reduced funds for school athletic prograins, an increase in the availability of soda and snacks, an explosion offast-food availability, larger restaurant portions, and a growing number ofhigh calorie and high-fat products (Rideout, 2004). Another potential influence to childhood obesity attracting attention is that ofthe role ofmedia in obesity trends.

Rideout's (2004) testimony summarized the KFF's research in the past 20 years on media and childhood obesity. The KFF's report evaluated research in public health, marketing, media, and childhood development. As early as 1985, Rideout (2004) reported that a study of more than

13,000 children found evidence to suggest that for each additional one hour of TV viewing, there is a 2% increase in childhood obesity. This study adjusted for prior weight, socio-economic status, maternal weight, and race. The KFF (2004) reported a similar relationship in a majority of national studies, suggesting that Displacement Theory may account for the findings.

This review of the literature did not support Displacement Theory as the reason for increased rates of obesity, though logic may suggest otherwise. Rather, Rideout (2004) pointed to TV ads as the possible culprit. Children see' an estimated 40,000 ads annually, most ofwhich are for food (cereal, candy, soda, chips, fast food). With a 2004 food product budget of $10 billion, marketing increasingly focuses on children (KFF, 2004). Research demonstrated that foods ads strongly correlate to a child's choice of food, how many products they request, and which products they request. Ultimately, these requests have a high rate of success in what parents choose (Rideout, 2004). Rideout's findings supported the Social Learning Theory and the Message Interpretation Process model. Advertisers present popular children's characters, enjoyable games, exciting adventures, and promises ofpositive outcomes to the target audience

7 and thereby guide food choices..

The National Health and Nutrition Examination Survey included 2964 children ages 4 to

11 years and demonstrated a positive correlation between increased media use and increased adiposity (Anderson, Economos & Must, 2008). Others have reported similar findings

(Henderson, 2007; Anderson, Crespo, Bartlett, Cheskin, & Pratt, 1998; Mendoza, Zimmerman,

& Christakis, 2007). The research sought a correlation between weight and children engaged in low levels ofphysical activity and high levels ofsedentary behavior to understand ifage, gender, race, and weight effected results.

The Anderson, Economos and Must's (2008) analysis suggested that "a substantial proportion ofyoung children are inadequately active andhigWy sedentary" (p. 9). These two factors likely contribute to childhood obesity rates in the US. A significant higher proportion of obese girl, age 4-11 years, had low levels ofphysical activity and high sedentary behavior

(Anderson, Economos & Must, 2008). Greater media use was associated with an increased likelihood ofobesity in pre-adolescent non-Hispanic girls (Anderson, Economos & Must, 2008).

The researchers (Anderson, Economos & Must, 2008) concured with Rideout (2004) that exposure to food ads encouraged consumption ofnutrient poor, high caloric snacks while viewing TV influenced obesity rates. Displacement Theory is controversial since highly sedentary behavior alone does not predict an increase in obesity among all cohorts. The Social

Learning Theory and the Message Interpretation model provide an explanation ofthe Anderson,

Economos and Must (2008) findings. The appeal to the 4 to 11 year old TV audience includes role models, topical interest, and socially desirable outcomes, which influence the program choices of children and supports the idea that the Social Learning Theory and the Message

Interpretation Process model were at work.

8 There is compelling evidence that obesity/overweight in children is a global trend that may result from increased sedentary behavior related to increased media use. Wang and

Lobstein (2006), the World Health Organization (2000), and the International Obesity Task

Force (2004) reported that childhood obesity continues to accelerate in areas ofthe world where media access has become readily available. Health consequences of obesity in children included hypertension, metabolic syndrome, coronary artery disease, poor self-image, and reduced physical activity tolerance. International studies highlighted the morbidity of childhood obesity and its relationship to media.

A study by Lajous et aI. (2009) used a cross-sectional survey ofover 13,000 boys and girls ages 11-18 in Morales, Mexico to assess media usage and its correlation with increased fat mass and distribution. Multivariable regression analysis adjusted for potential cofounders, such as age, sex, and socioeconomic status, correlating the variables with time viewing TV, DVDs, and video games. Lajous et aI. (2009) found a positive correlation between increased adiposity and increased media use in pre-teen and teen-aged males and pre-menarche females. Increased body mass index (BMI) and fat distribution was greatest among 11-12 year old boys and lowest among sexually mature females. These results compared favorably to others, which found a correlation between obesity and increased media use (Proctor et aI., 2003; Anderson et aI., 1998;

Hernandez et al., 1999; Gortmaker et aI., 1996). Lajous et ale (2009) results may be confounded by inaccurate reporting, a lack of a reverse effect ofmedia viewing, and other unrecognized variables. The report underscored the importance ofunderstanding modifiable determinates of adolescent obesity and identifying culturally effective behavior strategies to help shape national public policy.

Kang et aI. (2010) examined the association between media use and metabolic syndrome

9 based in a cross-sectional survey ofhouseholds with children who participated in the 2005

Korean National Health arid Nutrition Examination Survey. The National C40lesterol Education

Program-Adult Treatment Panel III (NCEP-ATP III) defined metabolic syndrome. Over 10,000 households were randomly selected "through a stratified, multistage, probability sampling design that was based on geographical area, sex, and age" (Kang et aI., 2010, p. 73). A weighted probability of samples allowed for extrapolation ofresults to the entire Korean population. A group ofcardiometabolic risk factors associated with adult populations including coronary artery disease, hypertension, and metabolic syndrome were associated in children's samples as well.

The cluster of risk factors observed in children continues into adulthood (Deitz, 1998;

Katzmarzyk et aI., 2001; Srinivasan, Meyers, & Berenson, 2002).

Using quartiles of screen time, Kang et ai. (2010) data revealed that the mean BMI, waist circumference, blood pressure, total cholesterol and triglyceride levels increased positively as the quartile ofmedia time increased. A negativ~ correlation existed between income and screen time

(Kang et aI., 2010). The mean media time were higher for the subjects with metabolic syndrome.

After adjusting for age, sex, income, and geographic location, subjects who spent 2: 35 hours per week engaged in media activities had an odds ratio of 2.23 for having metabolic syndrome as compared to subjects who spent ~ 16 hours per week (Kang et aI., 2010). Media usage is independently associated with metabolic syndrome in Korea (Kang et aI., 2010). In addition, the

Kang et ai. (2010) data suggested a positive association between metabolic syndrome and increased media time. The prevalence ofmetabolic syndrome was dose dependent.

The Kang and Lajous studies appeared to lend credence to Displacement Theory. As the amount ofmedia usage increases, there are fewer hours in the day for other more physical activities. The greatest adverse health effects on children occurred when media use increased to

10 the point where there was no time left for physical activities. Reports indicated that TV viewing increased meal frequency and intake ofenergy-dense snack food (Stroebele & Castro, 2004;

Philips et aI., 2004; Lowry, Weschler, Galuska, Fulton & Kahn, 2002). As media use increased, readily available snack foods displaced more preparation-intensive healthy foods.

Children's blood pressure rates in the US have increased in recent years (Din-Dzietham,

Liu, Bielo, & Shamsa, 2007; Muntner, He, Cutler, Wildman, & Whelton, 2004). Sorof and

Daniels (2002) demonstrated an association between obesity and hypertension in children, while

Heelan and Eisennlann (2006) reported an association between adiposity and sedentary behaviors, which included media usage. A positive correlation between TV viewing and increased systolic BP was found among Belgian boys ages 6 to 12 (Guillaume, Lapidus,

Bjomtorp, & Lambert, 1997).

A novel study by Martinez-Gomez, Tucker, Heelan, Welk, and Eisenmann (2009) examined the effect of sedentary behavior on blood pressure among young children. Martinez

Gomez et al. (2009) recruited 111 participants who wore an accelerometer for seven days to obtain objective measurements of sedentary behavior in children ages 3 to 8 years old. Body composition, anthropometric measurements, and resting blood pressure were obtained. Parents reported the amount oftime subjects engaged in sedentary media activities. After controlling for age, sex, height, and adiposity, Martinez-Gomez et aI. (2009) found a positive association between increased blood pressure and increased media usage. Sedentary behavior over all did n9t correlate with blood pressure, but TV viewing has a significant association with increased blood pressure independent ofadiposity. Participants in the lowest tertile ofscreen use had the lowest blood pressure (Martinez-Gomez et al., 2009). Martinez-Gomez et aI. (2009) postulated that TV viewing and computer use may not have the same metabolic and physiological effects,

11 and they should be considered as separate variables in future research. Displacement Theory

and the Message Interpretation Process model appear to be acting upon the forgoing findings.

Negative associations between prolonged media use and detrimental outcomes among

children are numerous. Associations range from childhood violence (Centerwall, 1994) and

aggression (Robinson, Wilde, Navracruz, Haydel, & Varady, 2001) to obesity (Anderson et aI.,

1998; Gortmaker et aI., 1996; Hernandez et aI., 1999; Robinson, 1999; Crespo et ai. 2001;

Robinson, 1999) and poor school performance (Taras & Potts-Damenta, 2005). The effect of

media on children's vision is rarely studied and children often do not seek medical help for their

vision complaints. Bener, Al-Mahdi, Vachhani, AI-Nufal and Ali (2010) aimed to elucidate

whether excessive use ofmedia affected vision in school aged children in a developing country.

A cross-sectional study by Bener et ai. (2010) used random sampling to examine 2467

children ages 6 to 18 in schools in Qatar. The t-test determined significant differences between

two continuous variables. The chi-square and Fisher's exact test determined differences in

proportions of variables among groups. To determine differences between group means, the

ANOVA test was used. Bener et ai. (2010) reported significant proportion of students with low

vision spent ~ 3 hours per day on the internet. Those cohorts who reported the most time spent

. in physical activities had the largest proportion of normal vision. Low vision is "strongly

associated with unhealthy lifestyle habits, such as prolonged hours spent on the internet and

reclining and having a high BMI" (Bener et aI., 2010, p. 384). Physical activities are displaced

by media use, which may aid the development ofbetter vision by promoting different

functioning ofthe visual apparatus. It is postulated that the refractive changes that cause myopia

may be caused by extensive viewing ofnear objects during development (Straker, Pollock, &

Maslen, 2009).

12 Psychosocial Effects of Media

The current generation of children are the first to grow up in a digital world and are the

vanguards of a technological revolution. Media may have an even greater impact on children's

socialization than do parents and schools. There is a pressing need to know more about the

impact ofmedia usage in children's social and scholastic competence, relations with peers/family, self-concept, isolation, depression, delinquency, and aggression. Researchers

agreed that the foregoing are determinates of attitudes, development, beliefs, and coping skills in

children (de Haan & Huysman, 2004; Harter, 1993; Jordan, 2004). Most researchers have viewed media as a threat to children's health. However, contradictory [mdings are emerging.

Some analysts believed that media induces isolation and reduces social experiences, while others

suggested that media use represent opportunities for play, communication, social support, and knowledge.

Heim et aI. (2007) designed an exploratory study to investigate specific media use in

children to determine ifpsychosocial factors and different types ofmedia use variables were

associated. They employed a factor analysis of surveys to measure children's self-concept and media usage. Children evaluated their internal own concept of psychosocial factors and how

often they watch TV/videos, play video games, surfthe Internet, use chat, or work on their

computer. Certain activities were significantly associated with psychosocial factors (Heim et aI.,

2007). Children who spent less time on entertainment media scored higher on their perception of

scholastic competence than the children who spent more time. This suggested that mastery of

difficult technologies increased self-esteem among peers (Heim et aI., 2007). However, children

with high rates ofmedia and Gameboy use scored lower on social acceptance (Heim et aI.,

2007). Heim et aI. (2007) found an association between parental monitoring and usage of media

13 Heim et ai. (2007) suggested that "when parents are actively involved in their child's daily

activities, the child is more likely to embrace media for creative, educational purposes rather than

as a medium for games or TV" (p. 449).

In a perspective from the Department ofPediatrics, Advanced Pediatric Center in India

Ray and Jat (2010) reported that excessive TV use may be a risk factor for development of

depression and ADHD. They reported a positive correlation between frequent reading ofprint media about dieting and weight loss and girls who reported unhappiness about their body weight.

Ray and Jat (2010) suggested that TV impairs peer relationships, and increases the risk for social isolation, anxiety disorder, agoraphobia, ADHD, and antisocial behavior. There was a positive association between viewing media with violent content and increased violent behavior, ideas, and anger (Ray & Jat, 2010). The study reported a negative correlation between violent media viewing and altruistic behaviors (Ray & Jat, 2010).

Hastings et ai. (2009) conducted a study of 70 children ages 6 to 10 via parental report.

They sought information concerning the content, amount, and social context (e.g. parental monitoring, with siblings/friends etc.) ofchildren's game playing/computer use and ifthere is a relationship to child health outcomes. The results oftheir study were mixed, with the type of media and the amount oftime spent with that media largely predictive ofpositive or negative health outcomes. Educational games provided stress relief, increased attentiveness, school performance, and may increase supportive relationships (Hastings et aI., 2009). Recreational

games were associated with poor school performance and attention, increased aggressiveness,

and externalized behaviors (Hastings et aI., 2009). A strong correlation existed between violent video games and aggressive behavior. Hastings et ai. (2009) reported that both positive and negative health outcomes more strongly correlated as the time spent in media activity increases.

14 This study was limited by a homogenous, small, non-randomized cohort and biased by the use of parental report. In addition, the research represented a snapshot in time and provides no longitudinal information. Displacement Theory is not supported by the findings as increased educational media time correlated negatively to behavior problems. The Social Learning Theory and the Message Interpretation Process model may explain the results. For example, identification with violent game characters may increase propensity toward externalized behaviors.

Jackson, Brown and Pardun (2008) examined the association between risky health behaviors, media, and a TV in the bedroom. The study applied multivariable analysis to a detailed media use survey, which was completed by 1,200 participants from 14 public schools in the southeastern us. Variables included, but were not limited to having a TV in the bedroom, frequency ofTV viewing, identification with actors, parental oversight, mature content programming, ~tiation of smoking and sexual intercourse. Respondents reported the least happiness and increased loneliness when viewing TV in the bedroom. A positive correlation existed between time spent TV viewing and identification with characters (Jackson, Brown, &

Pardun, 2009). Jackson et ale (2009) reported that for white males there was a 3.5 times greater likelihood of initiation of smoking and a 2 times greater likelihood of initiation of sexual intercourse when a TV is in the bedroom. However, parental oversight appeared to moderate these negative health outcomes (Jackson et aI., 2009). The Social Learning Theory and the

Message Interpretation Process nlodel support these results. If children positively identify with

TV characters, it may have promoted risky health behaviors, especially if realistic consequences were ignored. Displacement Theory may account for feelings of unhappiness and loneliness; TV

isolated an individual and displaced social interactions.

15 Wi~son (2008) reviewed evidence ofthe link between media use and children's emotions, and explored how media affects social development. She analyzed over 110 articles published between 1963 and 2007. Her report revealed a good deal ofevidence to suggest that media contributed to children's fear and anxiety especially in younger children. Those who viewed TV

2: 6 hours per day were more likely to have anxiety, depression, and PTSD. There was strong evidence ofa positive correlation between violent TV programs and video games with aggressive behavior (Wilson, 2008). However, Wilson (2008) found that educational programs and situation comedy targeted to youth increased altruism, cooperation, and tolerance. Wilson

(2008) demonstrated that media effect "depends on the content to which the children are exposed" (p. 88), and is highly influenced by age, gender, race, home life, and temperament.

Children's choice ofmedia, identification with characters, modeling ofbehavior, and imprinting may the mechanisms by which children's behaviors were acquired. This lends support to Social

Learning Theory and the Message Interpretation Process model.

Lieberman and So (2009) selected studies on media and learning completed on children ages 3 to 6 to assess the link that different media had on children's acquisition of skills for language, thinking, reading, mathematics, creativity, and collaboration. Similarly, Hisrich and

Blanchard's (2009) literature review discussed the effects of digital media use and emergent literacy skills. Both teams reported a body ofresearch that demonstrated numerous beneficial cognitive effects of digital media when well designed computer, TV, and game programs were utilized. Digital media can increase group interaction, collaboration, and motivation (Hisrich &

Blanchard, 2009; Lieberman & So, 2009). Educational TV programs were associated with better school entry skills (Hisrich & Blanchard, 2009). Both studies reported a lasting positive effect of educational programs. Lieberman and So (2009) were unable to determine which form ofmedia

16 instruction is most effective, or isolate the reasons why one fonn is more effective than another.

Hisrich and Blanchard (2009) suggested that media exerted a.largely unknown influence on children's cognition. Most studies to date have been done with small numbers ofchildren over a short period oftime. These limitation hamper the conclusions ofLiebennan and So (2009) and

Hisrich and Blanchard (2009). Displacement Theory predicts that replacing ad hoc media use with well-designed video games, TV programs, and computer software, children's psychosocial and cognitive outcomes may improve.

Hofferth (2010), Jolin and Weller (2011), and Shen and Williams (2010) all reported at

least some detrimental psychosocial and academic effects ofincreased media use. Hofferth

(2010) and Shen and Williams (2010) found that increased loneliness was associated with increased time spent on line, though the effect may be dependent upon context and personality.

For· every one-hour increase in watching TV, there was an association with an increase in depression (Jolin & Weller, 2011). The more time spent on media activities translated to less time spent with parents, siblings, and peers (Hofferth, 2010; Jolin & Weller, 2011; Shen &

Williams, 2010), and a decreased sense ofcommunity (Shen & Williams, 2010). Poor self esteem and social incompetence are reported by subjects who spent the greatest amount oftime with media (Jolin & Weller, 2011; Shen & Williams, 2010). Hofferth (2010) found no association between increased media use and behavior problems, but Jolin and Weller (2011) reported an association with decreased attention, especially for TV viewing among 1 and 3 year olds. Jolin and Weller (2010) reported that 14 year olds who spent more than 3 hours per day with media correlated with greater academic failure and negative school attitudes. Hofferth's

(2010) study found an association between increased video game play and academic failure.

Hofferth (2010) and Shen and Williams, (2010) reported some equivocal results with

17 association. Swing et al. (2010) results concured with other studies that found an association between TV/video and attention problems/attention deficit hyperactivity disorder diagnosis, poorer executive function and proactive cognitive control (Bailey, West, & Anderson, 2010;

Bioulac, Arfi & Bouvard, 2008; Mistry, Minkovitz, Strobino & Borzekowski, 2007). The

Displacement Theory, Message Interpretation Process model, and Social Learning Theory are not useful to explain these results. A theory, which accounts for rapid changes of focus, inherent in media, and its relationship to development, would help to explain the Swing findings.

Media research studies on children and health outcomes can have different or equivocal fmdings. Olson, Kutner and Warner (2010) completed a qualitative study, which used focus groups to ascertain information regarding high school boys feelings about violent video games.

Participants made distinctions between the real world and the game world (Olson, Kutner &

Warner, 2010). A positive association between video game play and group cooperation, self esteem, creative thinking, and problem solving, and a negative correlation between game play and isolation are reported. They hypothesize that violent game play served the same function as rough and tumble play. Olson, Kutner and Warner (2010) found that boys' use ofviolent games regulates their emotions and perhaps reduced stress and real-life fighting. The Message

Interpretation Process model can be applied to the study results as the participants were more attracted to violent content due to fantasies ofpower and fame, challenge, coping with anger and stress, and sociability. In addition, the boys are aware that game actions have very different consequences in the real world. The cohorts applied both logical and emotional responses and logical comparisons in their feelings and choices about video games.

Olson et al. (2009) examined 1,254 seventh and eighth grade students to find potential links between problem behaviors and tinle spent with violent video games. Exposure to mature

19 rated games was a significant predictor ofengaging in bullying and aggression, and strongest among girls (Olson et aI. 2009). The odds ofthese behaviors increased with the dose of exposure (Olson et aI. 2009). However, there was no association with M-rated games and being the victim ofbullies or engaging in delinquent behaviors (Olson et aI. 2009). The Social

Learning Theory can be used to predict the above results via repeated imprinting and internalization of aggressive and violent behavior.

Recommendations

The Kaiser Family Foundation (2005) agreed with the AAP (2009) reconunendation that parents limit screen time to two hours per day for children and keeping children's bedroom media free. Parents can limit programs to those that are educational, informational, and non violent. The AAP (2009) further recommended that children under two years ofage be discouraged from TV viewing. Instead, parents should encourage interactive activities to enhance brain development. Violent video games should be kept out ofthe household where children are present. Most video games are content-rated allowing guidance to parents in choice ofvideo games. Mature-rated video games were to be avoided by children under 16 years of age. These rating are fairly accurate, however they do not replace parental screening.

Continued parental monitoring of children's media activities plays a vital role in moderating the potential ill effects ofmedia on children's health (Heim et aI., 2007; Jackson,

Brown, & Pardun, 2008; Wilson, 2008). Optimally, parents should participate in TV/video viewing and encourage discussion about violent, mature, or unrealistic content. Controversial programming can be used as a stepping-offpoint to initiate discussions about values, drugs, and sexuality. Parents can further support efforts to establish media education programs in schools.

20 Reading, athletics, hobbies, and creative play are alternatives parents may adopt in their toolbox ofparenting skills.

Primary Care Providers are also instrumental in supporting the wise use of media (AAP,

2009). Foremost, it is the responsibility ofproviders to educate parents on the health risks posed by media. It is essential that Primary Care Provider remain knowledgeable about the effects of media on children. The AAP Media History form assists parents to recognize the extent oftheir children's media consumption. Providers can serve as good role models by using TV appropriately in offices. For those Primary Care Providers involved in pediatric care, the AAP recommends involvement in their Media Resource Team, participating with local TV stations to ensure that they are in compliance with the Children's Television Act, and monitor TV ratings systems while advocating for substantive, content based rating. Primary Care Providers of children should lead efforts in their communities to form coalitions, not only in schools, but in churches, libraries and other community organizations as well.

Discussion

A great deal of literature addresses media effects on children, yet many questions remain.

In some cases, research on the effects of media on childhood development reveals definitive associations between media usage and a risk for childhood development and health. Other research does not support an association between media use and adverse health consequences to children. In addition, a nunlber of media studies report beneficial effects, especially as regards improved cognitive skills.

21 Media and Physical Development of Children

Studies that addressed the impact of increased media use on the physical development of children provided the best evidence for detrimental associations. Obesity among children and its relation to increased media use is arguably the most currently researched topic. Furthermore, numerous well-designed research studies reported a direct correlation between obesity and hypertension, coronary artery disease, and metabolic syndrome and media use. Both US and international studies reported that as media use increased, obesity rates increased as well. This lends credence to the idea that obesity rates are dose dependant supporting Displacement

Theory. The biological mechanism for this fmding is unclear. Some researchers believed the cause for a rise in obesity is strictly related to the amount oftinle spent with media, while others postulate that it is more related to the messages that media conveys. Rising obesity rates among children represent a major health concern owing to the co-morbidity associated with the condition. Sedentary behavior begets obesity, which begets cardiovascular and metabolic health risks.

Other physical health concerns, such as vision problems, are beginning to be addressed.

Scant research exists correlating visual deficits with media usage and requires more well designed longitudinal studies to affirm or disavow a connection. Howeve'r, at least one large retrospective study reported that visual deficits in children may result from increased media use.

Media and Psychosocial Development of Children

Studies, which analyzed the psychosocial implications of TV to the health of children, are numerous and have a long history. Media that the current generation of children routinely engage, such as video games, the Internet, and educational computer programs, are recent technological developments and only beginning to be understood. It seems clear that violent TV

22 and video games may pose a risk toward violent behaviors among certain groups (e.g. pre-teen males and teen-aged white females). Violent newscasts have been associated with fear and anxiety in very young children. Some researchers have found solid evidence that media interferes with sleep patterns, especially when there is access to media in the child's bedroom.

This phenomenon may well lead to attention problems, poor school performance, depression, and other health risks. Isolation and lowered self-esteem are consequences reported in literature that are related to solitary gaming and viewing activities. Attention deficit hyperactivity disorder has been associated with media use by some researchers as well. However, there are studies that concluded that media usage may benefit children in areas of socialization, motor skills, problem solving, and group cooperation. In conclusion, there are detrimental effects of certain media technologies, in certain groups, under certain circumstances, and some media use may affect behaviors of some children more than others.

Limitations of Extant Research

Media use is fast becoming commonplace in schools and is poised to begin replacing teachers. Therefore, it is critical that researchers investigate the best approach to design successful academic programs. Existing literature reported significant improvement in reading and math skills when well-designed programs are used to augnlent traditional teaching techniques. It is not clear which aspects ofthe teaching programs resulted in the greatest benefits to students. Questions also remain regarding which students benefit and which do not.

It would be a mistake to assume a one size fits all agenda.

Problems with the state of current media research are many. The well-designed studies have attempted to illuminate variables among different cohorts of children. As yet, not all variables can be accounted for or identified. In this review, several of the studies used standard

23 regression analysis for sex, age, race, time, and socioeconomic status to identify which variables are the most predictive of detrimental health effects. Most ofthe studies reviewed are retrospective and allow for only a single point-in time analysis. At least two ofthe studies reviewed, perform a modified longitudinal, or two-point-in time analysis. The longitudinal studies are able to assess changes over time and lasting effects ofmedia use. The sample size in current research is often limited, with the exception ofthe national Korean study (N=10,816).

Self-reported surveys impose limitations on media research as under and over reporting may occur.

Need for Further Research

Further research is required to gain a more complete picture ofmedia effects on the health ofchildren. This research should include cohorts with a control group who have similar characteristics. Cross sectional research design limit demonstrated causality. Confounding variables must be accounted for to reduce errors in drawing conclusions. Self-reporting, while important, is not as reliable as electronic tracking. Self-reporting needs to be independently verified. It may be possible to track TV, gaming, internet use purpose, and tinle with developing technologies. Scholastic program research requires studies designed to elucidate exactly why certain programs are effective and perhaps allow for greater program flexibility that accounts f

There does not appear to be any single theory that drives the findings reported in this review. Displacement Theory can be used to explain the physical effects that media has on children. It makes sense that ifchildren are spending much oftheir free time in sedentary

24 activities, such as TV viewing, they are not physically active and at a higher risk for obesity.

Psychosocial effects ofmedia are less amenable to theoretical explanation. This review demonstrated how the Social Learning Theory and the Message Interpretation Process model were useful when applied to some ofthe phenomenon observed. For example, there is a strong association between aggressive behaviors and playing video games with violent content. It is likely that a combination oftheoretical foundations will provide structure to future research, dependent upon the phenomenon ofinterest to the researcher.

Some ofthe studies reviewed supported the notion that even with questionable media content, such as violence and unrealistic consequences, the negative psychosocial health effects on children may be ameliorated by parental intervention. Supervision, limitation ofmedia use, and content discussion are strategies parents can use to reduce the negative health consequences ofmedia use. In addition, teaching, guidance, and community involvement by Primary Care

Providers and educators are strategies that can influence the health consequences ofmedia on children.

This review ofliterature revealed that the current state ofresearch on how ofmedia use influences the behavior ofchildren found a moderate amount of compelling evidence that certain fonus ofmedia do have an effect. Violence, unrealistic portrayals ofconsequences ofbehaviors, and incessant repetition ofmedia messages can provoke depression, aggression, attention problems, poor eating habits, and poor scholastic performance. Increased media usage, especially TV, to the point where it interferes with other activities, promotes sedentary behavior, increases the likelihood ofpoor food choices, and increases caloric intake leading to obesity and

subsequent metabolic problems in children.

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