ReviewAssociations of smartphone and tablet use in early childhood with psychosocial, cognitive and sleep factors: a systematic review and meta-analysis
Introduction
Since the debut of the iPhone in 2007, smartphones and tablets have gained immense popularity among children of increasingly younger ages (Barr, McClure, & Parlakian, 2018; Rhodes, 2017; Wartella, Rideout, Lauricella, & Connell, 2013). In 2019, at least one-third of US preschool children by the age of 3 years had access to a dedicated mobile device which they used, on average, approximately 2 hours per day (Radesky et al., 2020). The increase of smartphone and tablet use during early childhood years has raised concern about potential problematic use, yet the rapid pace of technology uptake currently outstrips research examining the potential benefits and harms associated with childhood use of screens (Radesky, Schumacher, & Zuckerman, 2015). The toddler (age 1–3 years) and preschool years (age 3–5 years) are important periods of psychosocial and cognitive development, typically characterized by large amounts of brain plasticity (Fox, Levitt, & Nelson, 2010; Jimenez, Wade, Lin, Morrow, & Reichman, 2016; Shonkoff, 2010). Early childhood years may also influence life-long screen habits, similar to other health-related behaviors such as diet and physical activity (Radesky & Christakis, 2016). To better understand the potential harms and benefits of smartphone and tablet use in young children, the present study provides a systematic review and meta-analysis of research examining the relationships of smartphone and tablet use with psychosocial, cognitive and sleep-related factors in young children.
Child development during the early years is a dynamic sequence of maturation that is influenced by family and social environments, and individual characteristics of the child. Aspects of psychosocial and cognitive development, such as maturation in thinking, regulating emotions and behavior, reasoning, problem-solving, and communication (Sigelman, Rider, & George-Walker, 2016) are key areas of early childhood development that are crucial for effective integration into the social world. For example, gaining the ability to understand and follow simple instructions by 12–18 months, having a spoken vocabulary of about 20–300 words by 18–24 months, turn taking and sharing by 3 years, and perspective taking by 4 years are examples of typical cognitive and psychosocial milestones achieved during early childhood (Petty, 2016). Milestone achievement is promoted through various stimulating behaviors such as physical activity (Hinkley et al., 2014; LeBlanc et al., 2012), active exploration of natural environments (Sigelman, Rider, & George-Walker, 2016), social interactions with caregivers (McCabe & Altamura, 2011), and child-led creative, unstructured or pretend play (Burdette & Whitaker, 2005; Ginsburg, 2007; Lillard et al., 2013).
Children who have an inadequate opportunity to interact with their environment can fail to meet developmental milestones, and this may cause further challenges in acquiring other necessary cognitive, social, and emotional skills (Sigelman, Rider, & George-Walker, 2016, Trawick-Smith, 2013). In extreme cases, children suffering severe neglect can fail to develop language, motor, and socio-emotional skills necessary for normal functioning (e.g., Carr, Duff & Craddock, 2020); however, in less extreme cases, interference to healthy development may result in adverse outcomes such as self-regulation difficulties (Phillips & Shonkoff, 2000), social withdrawal (Rubin, Coplan, & Bowker, 2009), poor literacy and communication abilities (Horwitz et al., 2003; Paul, Looney & Dahm, 1991), and physical health problems such as obesity (Suglia, Duarte, Chambers, & Boynton-Jarrett, 2012, 2013). Although some difficulties may not be severe enough to receive clinical attention, they are likely to reduce the benefit that children derive from education (Janus & Offord, 2007).
Child development research has long sought to identify factors that interfere with healthy development. Screen time has received considerable attention (Madigan, Browne, Racine, Mori, & Tough, 2019; Radesky & Christakis, 2016), with most screen time research focused on the effect of traditional screen media (e.g., television, video gaming consoles) on young children's well-being and development (e.g., Hinkley et al., 2014; Madigan et al., 2019; Madigan, McArthur, Anhorn, Eirich & Christakis, 2020; Radesky & Christakis, 2016; Thompson & Christakis, 2005; Zimmerman & Christakis, 2005; Zimmerman, Christakis, & Meltzoff, 2007). However, the potential for smartphone and tablet use to adversely affect development in early childhood has been given relatively less attention. Smartphones and tablets have become very appealing to young children (Kabali et al., 2015; Paudel, Jancey, Subedi, & Leavy, 2017), possibly due to their unique features such as portability, interactivity, internet access, and multi-functionality (Wartella et al., 2013). Their smaller size and hand-held nature also permit more solitary use, making parental supervision and monitoring more difficult (Radesky & Christakis, 2016). However, it is not clear whether the influence of smartphone and tablet use on children's well-being and development is more pronounced and persistent than that of traditional screen media (Haughton, Aiken, & Cheevers, 2015).
Several studies have found that use of interactive smartphone or tablets apps in early childhood can have developmental benefits such as improved development of fine-motor skills (Bedford, Saez de Urabain, Cheung, Karmiloff-Smith, & Smith, 2016; Vatavu, Cramariuc, & Schipor, 2015), executive functioning (Huber, Yeates, Meyer, Fleckhammer, & Kaufman, 2018), and science/mathematics learning and problem solving (see Herodotou, 2018; Xie et al., 2018 for reviews). Chiong and Shuler (2010) further suggested that when used in moderation, the benefits for young children can be optimized through well-designed, developmentally appropriate educational apps. The positive learning effects were found to be content-dependent however, and limited to mainly interactive educational apps (i.e., not passive viewing; Huber et al., 2016). However, as these studies have been predominantly conducted with smartphone or tablet use as an experimental condition (Lawrence & Choe, 2021), the extent of the positive effects and the point at which naturalistic or habitual use may become problematic (i.e., when harms outweigh the benefits), is yet to be investigated.
Domoff, Borgen, and Radesky (2020) have proposed a theoretical framework that outlines multiple levels of influence on children's problematic screen use. The model identifies proximal influences (e.g., child behavior and skills, parent beliefs and practices) and distal influences (e.g., demographics, parent use of technology, technological features) that are theorized to interactively influence early childhood screen use. The framework, adapted from Bronfenbrenner & Morris, 2006 bio-ecological model, proposes that smartphone and tablet use can be bi-directionally associated with child- and parent-related factors. For example, the child-specific skill of self-regulation (proximal factor) could be considered a predictor of screen time when considered in concert with the enticing technological features and portability of smartphones and tablets (distal factors). Together, poor self-regulation and attractive technological features may make it difficult for young children to naturally limit their own screen time, and potentially increase resistance to parental attempts to limit screen time. Conversely, screen time could, in theory, impair development of self-regulation. This could be possible if screen time displaces developmentally necessary and productive language-rich social interactions or opportunities for outdoor play (Radesky et al., 2015). Similarly, parents may in some cases rely on screens to soothe a distressed child. Effectively using a smartphone or tablet to regulate behavior could result in more frequent and prolonged episodes of childhood screen use as parental beliefs about the convenience of device use strengthen (Haughton et al., 2015; Radesky et al., 2015; Radesky, Silverstein, Zuckerman, & Christakis, 2014). Past studies have found that using smartphones or tablets as “electronic pacifiers”, “electronic babysitters” or “shut-up toys” (Radesky et al., 2015) is associated with the development of self-regulatory mechanisms. Parents may also control their child's free/outdoor play in response to their own anxiety about child safety. Studies that have examined the ideas of ‘cotton wool’ children and ‘helicopter parenting’ illustrate this pattern of hyper-cautious parental thinking (e.g., Lee, Macvarish, & Bristow, 2010), which may influence parents’ decision-making about when and how often to substitute outdoor play with digital play on smartphones and tablets.
Although there is now an emerging body of research on young children's smartphone and tablet use in early childhood, there is value in an evaluative synthesis of the current literature. For instance, the early childhood smartphone and tablet use literature concerning psychosocial or cognitive factors have reported positive associations (e.g., Huber et al., 2016; Neumann & Neumann, 2017), negative associations (e.g., Cheung, Bedford, Saez De Urabain, Karmiloff-Smith, & Smith, 2017; Lin et al., 2020), and no association (e.g., McNeill, Howard, Vella, & Cliff, 2019; Taylor, Monaghan, & Westermann, 2017). To develop clear directions for ongoing research in this area, it is important to assess the collective findings so as to draw inferences about the associations that may exist between young children's smartphone and tablet use and their psychosocial and cognitive factors. Additionally, sleep-related factors such as onset and duration should be included in any review of the literature, given the important role of sleep in childhood psychosocial (Anders, 2004, Sadeh, 2013, Zhao et al., 2018) and cognitive (Hoyniak et al., 2020; Kocevska et al., 2017) development.
Past systematic reviews of the early childhood years have not focused on relationships between smartphone or tablet use and child-specific factors in psychosocial, cognitive and sleep domains. Instead, some have focused on other aspects of screen use such as sedentary screen time (Carson et al., 2016; Hinkley et al., 2014; LeBlanc et al., 2012), television viewing (Kostyrka-Allchorne, Cooper, & Simpson, 2017; Thakkar, Garrison, & Christakis, 2006), and combined traditional and modern screen media use (Duch, Fisher, Ensari & Harrington, 2013; Kaur, Gupta, Malhi & Grover, 2019) in relation to the same domains. Despite a growing body of evidence concerning smartphone and tablet use in young children (e.g., Kabali et al., 2015; Levine, Waite, Bowman & Kachinsky, 2019; Radesky et al., 2015), to date only one review by Paudel et al. (2017) has examined correlates associated with smartphone and tablet use in early childhood. They focused on demographic and environmental correlates of smartphone and tablet use, which are considered distal factors within the Domoff et al. (2020) interactional framework.
To our knowledge, no review or meta-analysis has examined or synthesized the empirical literature on the associations of smartphone and tablet use with proximal child-specific factors in the psychosocial, cognitive, and sleep domains of early childhood development. Further, a systematic review offers both an in-depth understanding of the methodological approaches within studies, and a timely opportunity to highlight existing gaps and methodological shortcomings in this emerging area to present future research recommendations.
Therefore, we posed the following research question; what associations exist between smartphone and/or tablet use and psychosocial, cognitive and sleep-related factors, in toddlers and preschoolers? In addressing this research question, first, the systematic review sought to provide a rich overview of methodological approaches used in this literature to help generate insights into factors that might explain variations in study findings. Second, the meta-analysis sought to provide an overall synthesis of the current estimates of the strength of association between study variables.
Section snippets
Protocol
The protocol of the review was registered with PROSPERO Prospective International Register for Systematic Reviews (Registration number: CRD42020185907; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020185907). The PRISMA guidelines for reporting of systematic reviews were followed in preparation of this manuscript (see supplement S9; Moher, Altman, Liberati, & Tetzlaff, 2011).
Eligibility criteria
For a study to be included in the review, it needed to satisfy the following 5 criteria (see Table
Study selection
Fig. 1 provides the PRISMA flow diagram for study inclusion. Following removal of duplicates, 1050 unique articles were identified for title and abstract screening. An inter-rater agreement rate of 0.90 (Cohen's κ = 0.44) was established during the abstract screening process. Abstract screening identified 83 articles that potentially met the inclusion criteria and were progressed to full-text screening. An inter-rater agreement rate of 0.82 (Cohen's κ = 0.62) was maintained during the full-text
Discussion
The current study provides the first systematic review and meta-analysis of the associations of smartphone and tablet use with psychosocial, cognitive, and sleep-related factors in young children. While the meta-analysis provided an overall synthesis of the evidence of associations, the systematic review enabled an in-depth understanding of the methodology, potential covariates, and other noteworthy aspects of the included studies which helped to understand variations in study findings.
Conclusion
It is promising to see a growing number of research studies investigating intra- and inter-personal child-specific psychosocial, cognitive, and sleep factors in early childhood smartphone and tablet use. Although it is difficult to draw robust inferences about the directionality or dosage effects, there was some evidence that increased amount of smartphone and tablet use was associated with slightly poorer measures of child-specific factors, particularly in relation to sleep. Self-regulation,
Acknowledgments
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosures
Authors contribution: Sumudu R. Mallawaarachchi: Conceptualization, Methodology, Formal analysis, Investigation, Writing - original draft, Visualization. Jeromy Anglim: Conceptualization, Methodology, Writing - review & editing. Merrilyn Hooley: Conceptualization, Methodology, Writing - Review & editing. Sharon Horwood: Conceptualization, Methodology, Validation, Investigation, Writing – review & editing.
Conflict of interest: None.
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