THE EFFECTS OF ON DEVELOPING YOUTH WITH ASD

A THESIS

Presented to the University Honors Program

California State University, Long Beach

In Partial Fulfillment

of the Requirements for the

University Honors Program Certificate

Robert Shin

Fall 2017

I, THE UNDERSIGNED MEMBER OF THE COMMITTEE,

HAVE APPROVED THIS THESIS

THE EFFECTS OF SCREEN TIME ON DEVELOPING YOUTH WITH ASD

BY

Robert Shin

______Lindsey Sterling, Ph.D. (Thesis Advisor) Clinical

California State University, Long Beach

ABSTRACT

THE EFFECTS OF SCREEN TIME ON DEVELOPING YOUTH WITH ASD

By

Robert S. Shin

December 2017

The purpose of this literature review is to compile the findings of studies concerning the effect of screen time on youth with autism spectrum disorder (ASD).

There already exists a sizable body of research on the detrimental effects that excessive screen time had on typically developing youth but research on youth with ASD is significantly lacking. Through this literature review, it was found that youth with ASD are affected by screen time in many of the same ways as typically developing children but often to a greater degree. Common symptoms of ASD include social difficulties and sensitivity to visual stimulus. These symptoms are reflected in their screen time preferences. Continued research is necessary to combat against these detrimental effects and find possibilities to use screen time in beneficial ways.

ii

ACKNOWLEDGEMENTS

I would like to thank all of my friends and family that supported me through this academic process. It was a long, grueling process and I would not have been able to be here and even have this opportunity to write this thesis without all of their support, love, and encouragement.

Thank you to Dr. Sterling for inspiring me to write on this topic. Without her help, I would have never been aware of the many intricacies and misunderstanding of those suffering from ASD. I would not have been able to focus my thesis on this important topic without her guidance.

Lastly, thank you to the University Honors Program for guiding me and supporting me through this entire process. I never would have thought that I would be completing a thesis in my time as an undergraduate student but here I am. Thank you for pushing me and showing really what I am academically capable of.

iii TABLE OF CONTENTS

Page

ABSTRACT ...... ii

ACKNOWLEDGEMENTS ...... iii

CHAPTER

1. INTRODUCTION ...... 1

What is Screen Time? ...... 1 Effects of Screen Time...... 2 Autism Spectrum Disorder ...... 6

2. METHODS ...... 8

3. RESULTS ...... 9

General Screen Time Usage...... 9 Physical Activity Levels and Obesity ...... 10 Disruption...... 11 Social Screen Time ...... 12 Education ...... 13

4. DISCUSSION ...... 14

Visual Perceptual Skills ...... 14 Social Interaction ...... 16

5. CONCLUSION ...... 18

REFERENCES ...... 19

iv

Chapter 1

INTRODUCTION

What is Screen Time?

Screen time refers to the consumption of any form of electronic media. Electronic media today comes in many different forms: television, Internet, tablets, , video games, computers, and laptops (Di Bartolo & Braun, 2017). In the world today,

51.7% of the world’s population have access to the internet and uses it on a regular basis.

Since the year 2000, there has been a 976% growth in the amount of people that have access to the internet (Internet usage statistics, 2017). This new generation of children and adolescents will be the most technologically immersed generation ever because of this rapid growth, expansion of internet use, and the wide availability of the internet.

With the revolutionary invention of the , individuals can now stay connected to their social networks, entertainment media, and the internet practically every moment of their lives. Recent studies have already shown that children in this generation are consuming electronic multimedia upwards of 8 hours a day; sleep is the only other activity that more time is spent on per day (Turner, 2015). Similar hours of screen time usage by adolescents have been shown throughout the world and it continues to show an increasing trend (Bucksch et al., 2015).

Within the past 10 years, electronic devices have quickly become integrated with the child-rearing process. Surveys show that 78% of parents approve of their children’s

1 use of electronic devices and even more report that they do not feel that it has created any problems. 41% of parents give their children a tablet or smartphone while at restaurants in order to keep them occupied and as a distraction to keep them entertained (Sharkins et al, 2016). Parents who were more educated allowed more time for their children to view electronic devices such as television as they often believed that these devices can be used to help regulate their behavior and provide educational material that will have a positive effect on their academic and neural development: these devices are being used as electronic “babysitters” (Beyens & Eggermont, 2014). But this seems to be far from the case as much of these claims and thoughts have little to no evidence supporting them (Di

Bartolo & Braun, 2017).

Effects of Screen Time

With so many adolescents and children being exposed to such a significant amount of screen time on a daily basis, it is impossible to deny or ignore its influence on them. But because this technology sprang forth so rapidly within the past decade, research of screen time effects is still in its infancy; much of the research that has taken place beyond 10 years ago is quickly becoming outdated due to the innovation of screen time devices. Despite the infancy of these studies, there have already been some clear trends seen. The overall conclusion found was that screen time is linked to several detrimental effects on an individual’s overall health.

One of the largest findings in the research thus far is the connection of screen time and sleep. A study conducted by Twenge, Krizan, & Hisler (2015) found that adolescents in 2015 were 17% more likely to get less than 7 hours of sleep on a regular basis. Not only is sleep shorter overall, it is also interrupted more frequently throughout the night 2 resulting in a lowering of the overall quality of sleep (Parent, Sanders, & Forehand,

2016). Delay of sleep has been suspected to be caused by the exposure to the bright lights emanating from electronic screens before going to bed which causes a disruption in the circadian rhythm by suppressing the production of melatonin (Higuchi et al, 2005). Along with this disruption, there is also the likelihood of physiological arousal caused by screen usage such as the stress response being activated during emotionally stimulating videos or video games. There has even been evidence shown that electromagnetic radiation from smartphones changes the structure of sleep and suppress the production of melatonin as well (Cain & Gradisar, 2010).

Another prominent negative effect of screen time is an increased risk of obesity.

The amount of time spent watching television was a predictor for a change in body mass index for adolescent boys while time spent using a computer was a significant predictor for body fatness in both boys and girls (Altenburg et al, 2012). Further studies have also shown that more screen time is positively correlated with a higher risk of cardiovascular disease and premature death. These risks were found to be present regardless of an individual’s amount of physical activity (Stamatakis, Hamer, & Dunstan, 2011). Screen time usage in adolescence is also a strong predictor of adulthood obesity. Especially in females, screen time is strongly correlated with the incidence of obesity in adulthood, to the point that reducing screen time could prove to be an effective strategy to prevent adulthood obesity (Boone et al, 2007). Logically, the more screen time an individual consumes, the less time they have for physical activity thus the amount of physical activity an individual partakes in lowers dramatically.

3 Recent findings have also found a strong link between screen time usage and behavioral problems. Increased average screen time has been shown to be connected with behavioral health problems which include internalizing behaviors as well as externalizing behaviors. These behaviors can manifest as bullying, vandalism, fearfulness, and social withdrawal (Parent, Sanders, & Forehand, 2016). High video game use in particular was found to be a significant predictor of violent behaviors in adolescents; these behaviors include bullying and engagement in physical fights (Janssen, Boyce, & Pickett, 2012).

With children, we see a similar trend of aggression when exposed to violent media; they show higher aggressive behavior, verbally, relationally and physically, as well as showing less prosocial behaviors later in their school years. Not only are these children more likely to show aggressive behaviors, but they also are more likely to form cliques with other aggressive children, thus reinforcing their aggressive behaviors and attitudes.

Because of this, the overall risk factors for long-term negative effects on their behavior increases significantly (Gentile, Coyne, & Walsh, 2011). However, it seems that risks of obesity and physical activity decrease can be combated against depending on the lifestyle of the parent. Parents have an incredible strong influence on the lifestyle of their children as the children often mirror the lifestyle of their parents. As a result, if a child’s parents live a life with a healthy diet and a healthy amount of physical activity, much of the risk due to screen time usage is offset (Dong et al, 2016).

Internet screen time activities such as browsing internet websites have also been linked to cognitive impairments that possibly could cause disruptions in childhood and adolescent brain development. These disruptions are thought to be caused by an overstimulation of the brain due to the bombardment of information received while

4 browsing the internet (Small et al, 2009). With the abundance of information that an individual receives while browsing the internet, users often rely on multitasking to sort all of this information. But this overreliance on multitasking becomes a detriment to an individual’s task-switching abilities as they are less efficiently able to filter out irrelevant information and focus on a single task (Ophir, Nass, & Wagner, 2009). Due to the malleability of the adolescent brain, there is a large possibility that exposure to screen time has lasting biological effects on the brain. The overstimulation of the brain could lead to an underdeveloped brain and increased distractibility as well as lead to an attention-deficit disorder (ADD) or attention-deficit hyperactivity disorder (ADHD) diagnosis (Williams, 2012).

But with all of these negative effects and dangers of screen time usage, there also seems to be a buffer that controls most of these detrimental effects on childhood and adolescent development: moderation. A groundbreaking study by Ferguson (2017) found that youth with screen time usage slightly higher than the American Academy of

Pediatrics’s recommended two hours of screen time a day were not more likely to engage in risky or delinquent behaviors. And with excessive screen time, there was only a weak relation to lower academic achievement and depression (Ferguson, 2017). So, with all of these possibly risks and negative effects caused by screen time usage, it seems that most of these issues only arise when they are used excessively and without any restrictions set.

It is clear that there is quite an extensive body of research that exists today on the effects of screen time on children and adolescents, and the body of research only continues to expand and mature to keep up with the constant advancements in technology and new forms of media that people are being exposed to. But with a clear majority of

5 these studies, the focus is on typically developing individuals and fails to consider those who do not fall into that category. A sizable and significant population that is heavily understudied are individuals with autism spectrum disorder.

Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a complex developmental disorder that impacts the social and behavioral functioning of an individual with varying levels of impairment ("What Is Autism?", 2017). Socially, ASD causes deficits in both verbal and nonverbal communication with difficulties in managing relationships. Behaviorally, ASD can cause repetitive and restrictive behaviors with intense, fixated interests ("What Is

Autism?", 2017). These impairments can also be accompanied by various medical and mental-health issues such as depression, , sleep disturbances, and obsessive- compulsive disorder ("Autism's associated medical and mental-health conditions", 2017).

Along with these issues, another prominent struggle of individuals with ASD is with their social skills; they often face various social difficulties such as trouble communicating with others and maintaining relationships with others (White, Keonig, & Scahill, 2007).

But the severity at which individuals experience any of these symptoms varies from person-to-person, henceforth the disorder is referred to as a spectrum with some of those affected by this disorder being high functioning while others are low functioning (“What

Is Autism?”. 2017).

Today, autism’s prevalence is at 1 in 68 children with 1 in 42 boys being affected and 1 in 162 girls being affected ("What Is Autism?", 2017). But this high prevalence has only been discovered in recent studies and surveys. Within the past decade, there has been almost a 100% increase in the prevalence of ASD among children aged 4 or older in 6 the United States (Schieve et al, 2012). But this trend of high ASD prevalence is not just isolated to the United States. The worldwide prevalence of ASD within children has been shown to be comparable to the rates in America (Hewitt et al, 2016). Many studies in the past taken from foreign countries have reported very low ASD prevalence in their youth but a revisiting of these studies often show that autism prevalence is typically much higher than previously estimated due to past studies mostly being based on assumptions.

A revisiting of a study of South Korean children has actually found that ASD prevalence is likely double than what was initially concluded, with about 6% of South Korean children being affected by ASD (Pantelis, & Kennedy, 2016).

With such a high prevalence of ASD amongst children around the entire world, research on the impact of screen time is heavily lacking. While the study of screen time effects on typically developing youth is constantly being reassessed and expanded upon, these studies cannot simply be expanded to apply to individuals with ASD; there must be a push for studies that explicitly focus their research on individuals with ASD. This study attempts to compile what little research has already been done in order to look for trends and more effectively guide future research in this subject matter.

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Chapter 2

METHODS

A systematic literature search was performed in PsycINFO for original scientific research article publications concerning ASD and screen time. The following keywords were used to search for the articles used: “screen time AND ASD,” “ASD AND media,”

“screen time AND autism,” “autism AND media.” The search results were further filtered by year to only contain articles from between 2007 to 2017. Articles were excluded that did not pertain to the focus of this literature review such as articles pertaining to parents or caregivers of individuals with ASD. Additional searches were conducted on Google

Scholar to consider articles that were not in the original search. Based on the results of the search, a total of 8 studies were analyzed for their findings and the specific focus of the studies.

8

Chapter 3

RESULTS

General Screen Time Usage

While all eight studies studied the screen time usage of youth with ASD to some degree, only two of the studies focused primarily on how much screen time youth with

ASD uses compared to the screen time usage of a typically developing youth as well as studying which types of screen time both group tend to use most (Mazurek & Wenstrup.

2013; Shane & Albert, 2008). Both studies concluded that youth with ASD spend more time engaged in screen time than typically developing youth. So much time that youth with ASD spend more time engaged in screen time than any other leisure activity such as reading or playing sports (Shane & Albert, 2008). Youth with ASD were found to spend upwards of 62% more time just watching television and video games than any other nonelectronic-based activity (Mazurek & Wenstrup. 2013).

The form of screen time that was most frequently used among youth with ASD was watching television with playing video games at a close second. Television shows viewed mostly consisted of children’s cartoons which made up 66% of all television viewing. This preference is also reflected in their preference for movies as 89% of the respondent reported that they preferred a cartoon-type movie over all other movies.

Overall, there was consistently a strong preference for cartoon-style media in all forms of screen time. (Shane & Albert, 2008).

9 While only being the second most common form of screen time consumption, playing video games has been shown to have rather problematic effects on youth with

ASD. Youth with ASD become addicted to video games far more frequently than typically developing youth. This addiction can manifest itself through several ways such as becoming upset when having to disengage from playing, constantly think about the game, and spending more time playing video games than with friends or family. Another striking finding was that, while both groups spend a large portion of their screen time activities playing video games, youth with ASD differ greatly from typically developing youth in what types of video games that they play and how they engage in their time spent playing. Typically developing youth often played video games with other people, whether this be through online multiplayer or face-to-face interactions. On the other hand, a majority of youth with ASD had never played a video game with another person in their entire lives (Mazurek & Wenstrup. 2013). Youth with ASD seem to view the video game experience as a solitary one while typically developing youth often use it as a form of a social activity done with friends or even strangers.

Physical Activity Levels and Obesity

Of the eight studies analyzed, two of them focused primarily on the relationship between screen time and physical activity (Must et al, 2016; Healy et al, 2017). Both of these studies also specifically focused on the difference of screen time effects between adolescents with ASD and typically developing adolescents. From the findings of these studies, it seems to be clear that adolescents with ASD partake in significantly less physical activity than typically developing adolescents. This remains true even when both groups are using similar amounts of screen time per day. Most teenagers with ASD

10 reported that they only engage in vigorous exercise about once or twice in a two-week timespan, compared to typically developing teenagers that spend upwards of 9 to 10 days of vigorous exercise in the same timespan (Healy et al, 2017).

This lack of physical activity in individuals with ASD was shown to be linked with increased feelings of being barred off from physical activity. These barriers were shown to primarily come in the form of social barriers such as teenagers with ASD being excluded from sports or not having any friends to participate in group physical activities with (Must et al, 2016). These barriers result in teenagers with ASD to use more screen time in order to fill this time that is not spent with physical activity. Teenagers with ASD reported that they choose not to participate in vigorous physical activity because they would “prefer to play computer games” (Healy et al, 2017). This preference to screen time over physical activity is leading to teenagers with ASD replacing their physical activity time with screen time, potentially leading to significant health risks. Along with the increased average screen time and lowered average physical activity, teenagers with

ASD also have a significantly higher risk of obesity just like many typically developing teens that use excessive amounts of screen time. The study from Healy et al (2017) revealed that the overweight/obese status according to the Body Mass Index (BMI) was the most common body status of teenagers with ASD.

Sleep Disruption

A total of two of the eight studies analyzed dealt with studying sleep and screen time (Mazurek et al 2016; Wu et al, 2016). Just as with typically developing youth, screen time usage was found to be correlated with sleep disruptions and overall poorer quality of sleep. It seems that time between screen time usage and bedtime plays a large 11 role in the magnitude of the effect it has on an individual. When screen time is part of the bedtime routine, there is a significant delay in the onset of sleep. In addition to this, delay of sleep is prolonged even further with the exposure to violent media prior to going to bed (Mazurek et al 2016). Associations between increased screen time and problem behaviors were also found, similar to associations between low sleep durations and problem behaviors. These behaviors include peer problems, conduct problems. and hyperactivity (Wu et al, 2016). Drawing from these two studies, it likely that high screen time results in lower sleep duration, thus causing these behavior problems due to increased tiredness and unhealthy sleep cycles. All other findings from these studies coincided with previous research that had been done on typically developing youth.

Social Screen Time

Social media has quickly become an increasingly important type of screen time, especially during adolescence. They use these sites, applications, and services to stay connected with various social circles through means such as email, text messaging, and social networking websites such as Facebook. Of the eight studies, two of them focused their research on how adolescents with ASD use and navigate through social media (van

Schalkwyk et al, 2017; Mazurek & Wenstrup. 2013). The studies found that adolescents with ASD typically only use social media for less than 15 minutes per day. This is significantly less than typically developing adolescents who use it for at least an hour a day (Mazurek & Wenstrup. 2013).

Although adolescents with ASD seem to have little interest in using social media compared to typically developing adolescents, adolescents with ASD seems to have the most to benefit from through the use of social media. The results of one study indicate 12 that adolescents with ASD report better friendship quality when they are connected with their friends through social media and these results are not seen in typically developing adolescents. It is only when an individual experiences high levels of anxiety that this benefit is not seen. This result possibly indicates that adolescents with ASD are able to use social media to compensate for their weaknesses in face-to-face social encounters by using social media (Schalkwyk et al, 2017).

Education

Only one, small study was conducted to study the possible effects that screen time could have on education for youth with ASD. This study found that using screen time, in the form of an iPad to assist in teaching a lesson, helped improve the performance of children with ASD in retaining the lesson material and improvement in their ability to recall the information on tests. They were also much more cooperative and willing to learn during the lesson. (El Zein et al, 2016). But the introduction of the iPad in itself was unable to do this, it only was able to reap these benefits when it was used in conjunction with more interaction-focused teaching from the teacher. While this study does have striking results and findings, they cannot be completely trusted as of yet as the study is very limited: only three children were used in this study and the children were all from the same school. Although it is too early to draw any large conclusions from this study, a direction for future research is being paved.

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Chapter 4

DISCUSSION

The results of this literature review suggest that youth with ASD tend to engage in more screen time than typically developing youth because it appeals to their specific strengths and weaknesses as an individual with ASD. Two of the most prominent results that were found across all the studies were a preference towards television and video game screen time and a lack of social use of screen time. These two preferences point to a possible explanation as to why youth with ASD are more drawn to screen time than typically developing youth. These findings also pave the way for future research in ways that screen time can be used to enhance and benefit the lives of youth with ASD by specifically catering it their needs and wants.

Visual Perceptual Skills

Studies have shown in the past that individuals with ASD show greater strengths in visual perceptual skills compared to typically developing individuals (Mottron et al,

2006; Jolliffe and Baron-Cohen 1997;). Because of their strength in this area, cartoon- style television shows and movies provide a much more rewarding viewing experience because of their visual vibrancy and creative characters. Video games become more rewarding experiences as well due their clear visual cue and the ability to interact with a game world in which there are clear rules and space in which to interact with this space.

This could lead to youth with ASD to feel that these activities are the most rewarding for

14 them and neglect other activities such as sports, reading, and other leisure activities as these do not give them as much internal rewards as watching television and playing video games do.

It seems that even in the classroom setting, youth with ASD are more willing to learn and pay attention in class when there is an element of visual perceptual interaction within the curriculum. This could lead to possible implications that youth with ASD have difficulty in school not always because they are not capable of learning the material, but instead that they do not find the material rewarding to learn. This leads to possible implications that video games and television programs could be designed to specifically help youth with ASD learn but further research in this area would need to be done in order to make a stronger case for it.

But as previously stated, this overreliance on screen time can become problematic and detrimental to their health. To compensate for this, there needs to be future research on how to replicate a similar sense of internal rewarding from more healthy activity such as sports and exercise to avoid issues such as obesity that are becoming more prominent with youth with ASD. As more research is conducted, it could potentially lead to the creation of specialized programs that are designed to help this population of individuals become more engaged in healthy lifestyles choices and not solely rely on screen time as a means to feel fulfilled. This same principle of playing to specific strengths in order to create more rewarding experiences can also be applied to education and the classroom setting. By introducing more visually-stimulating aspects to their education curriculum, youth with ASD can be more engaged in their learning experiences and find school to be more rewarding overall. Further research would need to be conducted to find effective

15 ways that these could be implemented into curriculum but the study from El Zein et al

(2016) already points to the effectiveness of playing games to reinforce concepts taught in class.

Social Interactions

Children with ASD often have fewer friends and difficulty navigating through social interactions. This often leads to them being more socially isolated and having anxiety towards social interactions and forming relationships with others (Rowley et al,

2012). Similar finding of social anxiety and isolation are seen consistently throughout the studies that were analyzed for this literature review. Higher screen time seemed to be associated with less social interaction with others in youth with ASD. These findings seem to indicate that youth with ASD use screen time as an escape from having to deal with the anxiety-inducing ordeal of interacting with other people. This group of children gravitates toward more solitary forms of screen time such as television and single-player video games while shying away from social media and playing games with others as it overcomplicates the activity for them and gives them anxiety. Because of their difficulty understanding and interacting with other people, youth with ASD find comfort and safety in being able to enjoy screen time. While it is healthy for them to enjoy screen time activities, this could later create a dependency on screen time. These youth will grow into adulthood and still be unable to socially engage with other people.

These findings illuminate a grim direction that youth with ASD might be facing if screen time continues to dominate their life and shy away from social interactions. But this research also points to ways in which screen time can be used to develop their social skills and improve the relationships that they already have. From the study by van 16 Schalkwyk et al (2017), it seems that one of the largest barriers to engaging in social media and other social activity was anxiety. This means that it is not that youth with ASD do not desire social relationships with others, but instead that their anxiety stops them from trying. Possible treatments for improving the social skills of youth with ASD could be teaching and practicing social skills through screen time. By using social media, they can become more comfortable socializing with others in a more nonthreatening, digital environment. It is only when they begin to feel more confident and comfortable they can be exposed to face-to-face interactions with others. Through this process, not only will they feel less anxious in social environments, but they will also feel more satisfaction with their friendship as they learn to better socialize with their friends through social media as well (Schalkwyk et al, 2017).

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Chapter 5

CONCLUSION

The usage of screen time has become an integral part of our society and almost unavoidable with the abundance electronic devices that have integrated their way in to almost every single aspect of our lives. While these screens can be a great benefit to our lives, excessive screen time has been shown to have several different detrimental affects on both typically developing youth and youth with ASD. Youth with ASD are particularly vulnerable as well because their screen usage is more likely to become problematic and detrimental to their development. Their use of screen time seems to be connected with and almost amplified as a result of their ASD. While this does prove to be dangerous as it can further impede their development, the development of screen time programs tailored to youth with ASD can be used to promote social and cognitive development. But further research and awareness is necessary to further shed light on this issue.

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