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 University of Southampton

Faculty of Environmental and Life Sciences

School of Psychology

Examining the Relationship Between Children’s Screen Use and Externalising

Behaviours

by

Chloe Dickel BSc (Hons) MSc

Thesis for the degree of Doctorate in Clinical Psychology

June 2021

Word Count: 8035

 Abstract

Children’s screen use and its relationship with young people’s mental health has
received significant attention in recent years. The research conducted in this area is often
cross-sectional in design and therefore unable to explore the bi-directional relationship
between these two constructs.

The first chapter is a meta-analysis of existing screen time literature and its
relationship with externalising behaviours in children aged 4 – 18 years. Child age, screen
type, type of measure and reporter of measure were included as moderators. The meta-
analysis included 17 studies including a total of 15,448 young people. The overall
association between children’s screen use and externalising behaviours was significant but
small, Z = 0.117 (95% Confidence Interval [CI] = 0.061 – 0.173, p < .001). Screen type,
type of measure were significant moderators of this relationship. The current meta-analysis
suggests that there is a relationship between children’s screen use and externalising
behaviours which is moderated by screen type, reporter of externalising measure and type
of externalising measure. The review highlights a number of methodological limitations of
the studies included and suggests further research is conducted before screen use
guidelines for children over five are implemented.

The second chapter is an empirical study on pre-schoolers’ screen use and

externalising behaviours during the Covid-19 pandemic in England. The study aimed to
overcome some of the methodological limitations of previous studies by employing a
longitudinal design and using cross-lagged analysis to explore the bi-directional
association between pre-schoolers screen use and externalising behaviours. Types of
screen use, active and passive, were also explored separately. The study was conducted
using data from the Co-Spyce dataset. The results showed one cross-lagged effect;
increases in active screen use at baseline significantly predicted externalising behaviours at
one month follow-up (β = 0.25, p = .013). This relationship was not bi-directional. There
was no over-time relationship between passive screen use and externalising behaviours but
there was a within-time relationship. Active screen use significantly predicts externalising
behaviour overtime whilst passive screen use does not. The strength of this relationship is
weak but suggests that the mechanisms underlying the relationship between active and
passive screen use and externalising behaviour differs.

Keywords: pre-schoolers, children, screen use, externalising behaviours

 Table of Contents

Table of Contents

Table of Contents ..................................................................................................................i

Table of Tables ................................................................................................................... iii
Table of Figures .................................................................................................................... v
Research Thesis: Declaration of Authorship ...................................................................vii
Acknowledgements ..............................................................................................................ix
Definitions and Abbreviations ...........................................................................................xi
Chapter 1 Screen Time and Externalising Problems in Primary Aged Children: A
Meta-Analysis ................................................................................................... 1

Abstract ................................................................................................................................ 2
Introduction.......................................................................................................................... 3
Method ................................................................................................................................. 6
Results.................................................................................................................................. 9
Discussion .......................................................................................................................... 14
References.......................................................................................................................... 21

Chapter 2 Examining the Relationship between Preschoolers’ Screen Use and

Externalising Behaviours during the Covid-19 Pandemic; A Co-Spyce
Study ................................................................................................................ 29

Abstract .............................................................................................................................. 30
Introduction........................................................................................................................ 32
Method ............................................................................................................................... 35
Results................................................................................................................................ 40
Discussion .......................................................................................................................... 43
References.......................................................................................................................... 49

Appendix A – Search Syntax ............................................................................................. 57

Appendix B - Quality Assessment Criteria Scores .......................................................... 59
Appendix C – Summary of Data Extracted from Studies included in Analysis........... 63
Appendix D – Ethics Approval Confirmation ................................................................. 67

i
 Table of Tables

Table of Tables

Table Title Page No.

No.

1 Demographics 30

2 Data on Easing of Social Restrictions for each of 32

the Devolved Nations

iii
 Table of Figures

Table of Figures

Figure Title Page No.

No.

1 PRISMA Flowchart 8

2 Forest Plot 11-12

3 General Cross-lagged Panel Model for Screen Use 35

and Externalising Behaviour

4 Post-analysis Cross-lagged Model Depiction 36

v
 Research Thesis: Declaration of Authorship

Research Thesis: Declaration of Authorship

Print name: Chloe Dickel

Title of thesis: Examining The Relationship Between Children’s Screen Use and
Externalising Behaviours

I declare that this thesis and the work presented in it are my own and has been generated by
me as the result of my own original research.

I confirm that:

1. This work was done wholly or mainly while in candidature for a research degree at this
University;
2. Where any part of this thesis has previously been submitted for a degree or any other
qualification at this University or any other institution, this has been clearly stated;
3. Where I have consulted the published work of others, this is always clearly attributed;
4. Where I have quoted from the work of others, the source is always given. With the
exception of such quotations, this thesis is entirely my own work;
5. I have acknowledged all main sources of help;
6. Where the thesis is based on work done by myself jointly with others, I have made
clear exactly what was done by others and what I have contributed myself;
7. None of this work has been published before submission.

Signature: Date: 5th June 2021

vii
 Acknowledgements

Acknowledgements

Firstly, I’d like to say thank you to my thesis supervisors; Dr Pete Lawrence and Dr Jana
Kreppner. Pete, your knowledge and passion for research has been inspiring and I’m very
grateful for the hours of supervision you dedicated to this project. Jana, thank you for
anchoring me when things got tricky and for always being such a smiley supportive
presence.

Thank you to all the families that have taken part in the Co-Spyce study. This wouldn’t
have been possible without you.

Thank you to Michael Miles for his support with the meta-analysis. For sticking with me
through what was a steep learning curve and for persevering through the screening and
extraction. Wishing you the best of luck with the next stage of your journey, Michael.

To Dr Simona Skripkauskaite – without whom I’d have been tearing my hair out over the
statistics – thank you. You’ve consistently been so patient and kind and I’m so grateful for
your help.

Thank you to Dr Amy Orben. Your passion for research on screen use shines through and
your knowledge of the literature has been invaluable.

To my cohort of clinical psychology trainees… This journey has been such a rollercoaster
and I’m very lucky to have enjoyed the ride with you all. You started off as colleagues but
have become firm friends. Thanks for the memories!

Finally, a huge thank you to Colin, my parents and friends. Qualifying as a Clinical
Psychologist wouldn’t have been possible without you. Mum and Dad – I got there in the
end! Thanks for supporting me throughout this journey. Charlotte, thank you for always
reminding me to practice what I preach and looking after myself when I’ve been bogged
down in work. And to Colin, thank you for ensuring that I’m always fed and watered,
helping me to put things into perspective, always making me laugh and for being my
biggest cheer leader.

ix
 Definitions and Abbreviations

Definitions and Abbreviations

CBCL ............................... Child Behaviour Checklist

CI ...................................... Confidence Interval

Co-Spyce .......................... Covid-19: Supporting Parents and Young Children during

Epidemics

M ...................................... Mean

NHS .................................. National Health Service

R ....................................... Statistical Software

SD ..................................... Standard Deviation

SDQ .................................. Strengths and Difficulties Questionnaire

WHO ................................ World Health Organisation

Z ....................................... Fisher’s Z Transformation

xi
 Chapter 1

Chapter 1 Screen Time and Externalising Problems in

Primary Aged Children: A Meta-Analysis

The following paper has been prepared in line with author guidelines for the Journal of

Child Psychiatry and Psychology.

1
Chapter 1

Abstract

Background;

Young people’s screen use and its link with their mental health is a topical subject

and cause of concern amongst parents and politicians. Screen use guidelines recommend

restricting the use of screens in children under five, however, there are not any suggestions

for older children.

Methods;

We conducted a meta-analysis of studies exploring the relationship between screen

use and externalising behaviours as measured by the Strengths and Difficulties

Questionnaire or the Child Behaviour Checklist in children between 4 and 18 years. Child

age, screen type, type of measure and reporter of measure were included as moderators.

Results;

We included 17 studies with a total of 15,448 young people. The overall association

between children’s screen use and externalising behaviours was significant but small, Z =

0.117 (95% Confidence Interval [CI] = 0.061 – 0.173, p < .001). Screen type and type of

measure were significant moderators of this relationship.

Conclusions;

The current meta-analysis suggests that there is a relationship between children’s

screen use and externalising behaviours which is moderated by screen type, reporter of

externalising measure and type of externalising measure. The review highlights a number

of methodological limitations of the studies included and suggests further research is

conducted before screen use guidelines for children over five are implemented.

Keywords; screen use, children, young people, externalising behaviour

2
 Chapter 1

Introduction

Children and young people’s screen use is a topical subject and a cause of concern

particularly in relation to their mental health (Davies, Atherton, Calderwood & McBride,

2019). In a recent survey, over two thirds of parents of children aged 11 years and younger

expressed concern that their child may spend too much time in front of screens (Auxier,

Anderson, Perrin & Turner, 2020). Leisure time use of screens, thus not accounting for

school or homework, amongst 8 – 12 year olds has been reported to exceed 4.5 hours each

day whilst for 13-18 year it is almost 7.5 hours (Rideout & Robb, 2019). It is not only the

amount of time young people are exposed to screens that is causing concern. As children

grow, so too does the diversity of screens and content they witness. Three decades ago, it

would have been common place to have one television in the familial home which was

shared in a communal area. Now, by the time a child reaches the age of 6 years they are

likely to have access to a TV, tablet and computer within the family home and own their

own smart phone by the age of 12 (Ibbetson, 2020).

Inflammatory media headlines appear to contribute to the commonly held belief

that screen use can have a negative impact on children and young people causing concern

amongst parents, educators and politicians (Ofcom, 2019). Consequently, the ostensible

risk of excessive screen time has been researched considerably. Whilst the theoretical

underpinnings of the link between childhood screen time and psychopathology remain

ambiguous, there is evidence emerging which implicates brain structure. Paulus and

colleagues (2019) tested the maturational coupling hypothesis (i.e. the concept that

synchronised patterns of structural changes to the brain correspond with certain

behaviours) and its association with psychopathology in 4277 adolescents. They found that

some regions of the brain are associated with screen media activity and that some of these

are linked to increased externalising difficulties amongst youth. This finding is novel and

promising in developing our understanding of the link between screen time and

psychopathology.

3
Chapter 1

In an attempt to protect children’s health, including mental health and wellbeing,

guidelines recommending restrictions on the use of screens have been developed. The

World Health Organisation (WHO; 2019) state that screen time is not recommended for

children under two years whilst those between two and four years should not be exposed to

more than an hour each day. In the UK, the Royal College of Paediatrics and Child Health

(RCPCH, 2019) guidelines for screen time do not stipulate specific screen time cut-offs,

due to the limited robustness of the evidence. Instead, they advocate for screen time being

controlled within the household and ensuring that screen time does not interfere with other

family activities or sleep. Consequently, current guidelines are limited by their

predominant focus on those under the age of 5 years. Furthermore, research by Martin-

Biggers et al. (2015) prior to the publication of the WHO and RCPCH guidelines, found

that despite parental worries around screen time previous guidelines had largely been

ignored. In their study, 133 parents of pre-school children cited the following reasons for

non-adherence to screen time guidelines: few affordable alternative entertainment options,

parental fatigue, the need to prioritise house-hold chores and adverse weather.

Polanczyk, Salum, Sugaya, Caye, & Rohde (2015) conducted a meta-analysis of

prevalence estimates of mental health disorders amongst children and young people, which

included 41 studies from 27 countries of origin. They established that the worldwide

prevalence of mental health disorders in children and young people was 13.4%, anxiety

disorders being most prevalent (6.5%). Research in the UK highlights that prevalence

estimates appear to be increasing over time. In 1999, the number of 5-15 year olds with a

mental health disorder was reported at 9.7% and this figured increased to 10.1% in 2004,

11.2% in 2017 and 16% in 2020 (NHS Digital, 2017; NHS Digital, 2020). These reports

also suggest that emotional disorders are more common in girls whilst behavioural and

hyperactivity disorders are more common in boys. The research exploring the link between

children’s screen use and mental health outcomes has predominantly been cross-sectional

4
 Chapter 1

and those which have used a longitudinal design have only focussed on a uni-directional

relationship (Dickson et al., 2018) and shown inconclusive findings.

Research examining the role of screen time in children’s externalising behaviours is

often of limited quality. Media portrayal of young people’s screen time is frequently

misconstrued as it implies causation which cannot be inferred from the correlational

research that informs the reports. Small effect sizes tend to be misinterpreted and

statistically significant results rather than meaningful effects are focussed upon (Kardefelt-

Winther, 2019). Screen time literature is also impacted by the reliance on self-reported

measures which are prone to social desirability effects and the reliability of participant

memory (Abeele, Beullens & Roe, 2013; Grondin, 2010). Finally, studies typically fail to

distinguish between types (e.g. active vs passive) and content (e.g. violent, prosocial,

educational) of screen use (Kaye, Orben, Ellis, Hunter, & Houghton, 2020). As a result,

conclusions are drawn and generalised to all types of screen use. However, evidence

suggests, for example, that educational TV content has a positive impact on children’s

behaviour, literacy and cognition (Anderson, Huston, Schmitt, Linebarger, & Wright,

2001) and socially interactive content can ameliorate a child’s ability to acquire new words

compared to passively watching the word on a screen (Roseberry, Hirsh-Pasek &

Golinkoff, 2013). It is important, therefore, to distinguish between the type and content of

screen use as generalisation of findings universally is not warranted. Ultimately, current

scientific research is too inconclusive to underpin evidence-based guidelines on children’s

screen use (Gottschalk, 2019).

A review of the literature on the relationship between children’s screen use and

externalising behaviours is necessary to establish whether existing literature demonstrates a

strong and significant relationship between these two constructs. A review will also aid our

understanding around the types and content of screen use that are related to externalising

behaviours and how consistently these are being assessed. The current review aims to

5
Chapter 1

synthesise the literature on the relationship between children’s screen time and

externalising behaviours. It is intended to add to existing literature by including the type of

screen (e.g. TV, computer, mobile device) and type of media as moderators where the

studies under review have included this information. The review includes other moderators

of interest including child age, reporter of screen use, reporter of externalising measure and

scale of externalising behaviour.

Method

Protocol

This review was pre-registered with the International Prospective Register of

Systematic Reviews (PROSPERO; Registration ID. CRD42020193674) and was guided

and reported by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA, n.d.). We modified the original protocol to account for the narrower scope of

this review. The focus of the current review is on the relationship between screen time and

externalising behaviour. Those studies which met the criteria in our registered protocol but

focussed on behaviour more broadly and/or cognition, but not externalising behaviour, will

be reported independently.

Eligibility Criteria

Eligible studies included children between the ages of four and 11 years, published

in peer reviewed journals and written in English. Studies were required to include either a

retrospective or tracking measure of screen use (i.e. television, computer, video games,

smart phones) reported by the child, parent/guardian or teacher as well as a validated

measure of externalising behaviour (i.e. Strengths and Difficulties Questionnaire [SDQ;

Goodman, 1997] or Child Behaviour Checklist [CBCL; Achenbach & Edelbrock, 1983]).

Other measures of externalising behaviour were included in the screening phase, however,

we excluded them due to concerns over validity and their relatively infrequent use. Studies

6
 Chapter 1

which reported solely qualitative data, review papers and studies in which screen use was

an intervention were excluded from analysis.

Information Sources and Search Terms

After conducting scoping searches, the following four databases were searched for

relevant literature published between 1980 and November 2020; PsycINFO and Medline

(EBSCO platform), Embase (Ovid platform) and Web of Science. Search terms were

adapted from those used by Poitras et al. (2017) and were checked by a research librarian

specialising in systematic reviews. Appendix A contains the search syntax used for each

database.

Outcome Measures

The primary outcome of the current review was externalising behaviour measured

by one of two validated questionnaires; SDQ or CBCL. Externalising behaviour,

operationalised by these measures, includes; conduct, delinquency, aggression and

hyperactivity/inattention.

Study Selection

Two reviewers (the candidate and an undergraduate Psychology student)

independently conducted title and abstract screening. Full text papers considered eligible

by either reviewer at title and abstract screening were obtained where possible.

Disagreements regarding eligibility at full text screen were discussed with a third reviewer

(one of the candidate’s supervisors). There was 81% agreement between raters.

Disagreements predominantly centred on the age group included in the studies and

agreements were reached following discussion between the three reviewers.

Study Quality Assessment

7
Chapter 1

We used the Standard Quality Assessment Criteria for Evaluating Primary

Research Papers from a Variety of Fields (Kmet, Lee & Cook, 2004) as it is appropriate for

assessing research quality across an array of study designs. This tool includes 14 criteria by

which to rate each study. Three criteria were not applicable to the studies used in our

analysis because they focus on experimental designs and were excluded. Each criterion is

rated on a three-point Likert scale; 0 (not met), 1 (partially met) and 2 (met). A total

summary score, between 0 and 1, for each study was derived from the sum of scores for

each item and divided by the total achievable score. The quality ratings for included

studies are presented in Appendix B. Quality ratings for all 17 studies was high ranging

from 0.73 to 1.00.

Data Extraction and Statistical Analysis

Appendix C details the extracted data including outcomes and relevant participant

and study characteristics. The primary researcher wrote to 49 authors of 49 studies to

request additional information and received three responses. Given our aim to understand

the relationship between screen use and externalising behaviours, we opted to use zero-

order Pearson’s correlation co-efficient (r) as our effect size. Borenstein, Hedges, Higgins

& Rothstein (2009) recommend standardising the correlation coefficient r to generate

summary effects, confidence intervals and variance. Thus, for papers which reported either

odds ratios or d as their effect size, we converted these to r using equations recommended

by Borenstein et al. (2009) and inputted these values into the ‘Practical Meta-Analysis

Effect Size Calculator’ (Wilson, n.d.) to obtain confidence intervals and variance.

RStudio (RStudio Team, 2021) was used to conduct statistical analysis. The

following packages were employed; ‘metafor’ for meta-analysis and ‘robumeta’ for meta-

analyses of dependent effect sizes (Fisher & Tipton, 2015). The t2 and I2 statistics were

used as an estimate of between-study heterogeneity. More than one effect size (e.g.

hyperactivity/inattention and conduct) was reported in 14 studies, which were therefore a

8
 Chapter 1

violation of the independence assumption in meta-analysis. Robust variance estimation

was used to address dependency by modifying standard errors to account for associations

between effects within studies (Hedges, Tipton, & Johnson, 2010).

Publication Bias

We used Egger’s test (Egger, Smith, Schneider, & Minder, 1997) and a funnel plot
(Viechtbauer, 2010) to measure publication bias.

Results

Included Studies

A total of 54 studies met our inclusion criteria (Figure 1 illustrates the PRISMA

flowchart of included studies). We obtained data from five studies and e-mailed 49 authors

to request additional data. Three authors responded to our request, all of whom gave the

9
Chapter 1

Figure 1. PRISMA Flowchart.

data we requested. We were able to transform data from an additional nine papers using an

effect size calculator. Consequently, we had data for 17 studies including 45 effect sizes

with a total of 15,448 participants available for meta-analysis.

Sensitivity Analysis

Sensitivity analyses were executed and indicated that the effect sizes and Tau2 did

not differ according to the size of rho.

10
 Chapter 1

Main Analysis

Initially, the robust variance meta-analysis examined the overall association

between children’s screen use and externalising problems and gave a small significant

association. The overall intercept model showed a point estimate of Z = 0.117 (95%

Confidence Interval [CI] = 0.061 – 0.173, p < .001). Heterogeneity was high: I2= 89.12%.

A visual representation of the analysis is available by means of forest plot (Figure 2).

Moderation Analyses

Further analysis was undertaken to establish whether the relationship between child screen
use and externalising behaviours was moderated by other variables.

Child Age

Due to the limited number of studies available reporting solely on primary aged

children (4-11 year olds), we extended our criteria to include studies which reported on

those up to the age of 18 years. Overall effects did not significantly differ by child age t (6,

5) = -0.223, p = .831.

Screen Type

Next, we explored whether screen type moderated the relationship between child

screen use and externalising behaviours. Six different screen types were reported which

meant that moderation analyses were unreliable as degrees of freedom were below 4. To

address this problem, we developed theoretically coherent categories which pooled

together the data to compare ‘videogame based’ screen use and ‘non-videogame based’

screen use. The association between screen use and externalising behaviours was higher

when children use ‘non-video-game based screens’ (Z = 0.180, CI = 0.118 – 0.242) than

when they used ‘videogame based’ screens (Z = -0.133, CI = -0.219 – -0.046) and this

difference in screen type was significant (t(14, 7) = 6.78, p = <.001).

11
Chapter 1

12
 Chapter 1

Figure 2. Forest Plot illustrating the effect size (Z) between screen use and externalising

behaviour from 45 effect sizes from 17 studies.

Note. The position of the black square indicates the effect size, with horizontal lines

marking the 95% confidence interval. The size of the black square indicates its weight in

the meta-analysis. The name in bold is the first author of the published study along with

the publication year. The type of externalising outcome is listed under each study. The

upper and lower 95% confidence intervals are shown in the two columns on the right-hand

side. The white diamond with black outline represents the point estimate and 95%

confidence interval.

Reporter of Screen Use

Overall effects did not significantly differ according to the reporter of screen use

(i.e. child or parent), t (9, 5) = 1.14, p = .283.

Reporter of Externalising Measure

13
Chapter 1

The association between child screen use and externalising behaviour was higher

when externalising behaviour was reported by parents (Z = 0.123, 95% CI = 0.065 – 0.181)

than by teachers (Z = -0.083, 95% CI = -0.545 – 0.379), however, this difference was not

statistically significant.

Scale of Externalising Measure

Finally, we examined whether the measure of externalising behaviours moderated

the relationship between child screen use and externalising behaviours. Initially, we ran the

analysis using the scales of the SDQ and CBCL. There were seven different scales used

which again resulted in unreliable results as degrees of freedom were below 4 so we

grouped together the relevant SDQ sub-scales (hyperactivity/inattention, conduct and SDQ

externalising full scale) and the relevant CBCL sub-scales (attention, conduct, delinquency

and CBCL externalising full scale) to form two categories. The association between child

screen use and externalising behaviour was greater when measured using the SDQ (Z =

0.140, 95% CI = 0.065 – 0.216) than when it was measured by the CBCL (Z = -0.053, 95%

CI = -0.172 – 0.066), although again, this difference was not statistically significant.

Discussion

Summary of Findings

The aim of the current review was to establish whether there was a link between

children’s screen use and externalising behaviour. In addition, we planned to inspect the

effect of other factors on the strength of the association between children’s screen use and

externalising behaviour including; child age, reporters of screen use and externalising

behaviour measure, scale of externalising behaviour and screen type. Finally, we

anticipated using screen content as a covariate, however, due to the limited number of

studies reporting content it was not possible to conduct this analysis.

14
 Chapter 1

The primary analysis demonstrated a significant relationship between children’s

screen use and externalising behaviour. This finding is consistent with previous literature

examining the relationship between screen use and mental health outcomes. Wang, Li and

Fan (2019), for example, conducted a meta-analysis and found that adults reporting higher

screen use were significantly more likely to experience depression. In their systematic

review Keikha et al (2020) found that children who spent more time watching television

were at greater risk of displaying violent behaviours. It is important to note, however, that

heterogeneity was high which reduces confidence in the findings (Imrey, 2020).

Child age did not moderate the strength of the association between screen use and

externalizing behaviour. This is an interesting finding given that we were originally

interested in primary aged children as opposed to adolescents, however, given the limited

number of studies focussing specifically on this age group we included studies which

reported on children aged 4-18 years. This result suggests that we’d have had similar

results if we had focussed only on the primary aged children.

Screen type was examined as a moderator. We found that screen type significantly

moderated the relationship between screen use and externalising behaviour and that this

was significantly higher for ‘non-video-game base screens’ than ‘video game based’

screens. We had hoped to include screen content (e.g. educational, social media, cartoons

etc) as a moderator in addition to screen type, however, unfortunately, this data was not

available in the studies included in the analysis.

Reporter of screen use was also accounted for and found not to effect the primary

outcome. In addition, there was no significant difference in the screen time report of

children and parents. Teacher reports of screen use had been included in the analysis but

data was unavailable for this sub-group. This finding supports previous literature which

has demonstrated high concordance between parent and child reports of child screen use

(Wood et al., 2019; Levine & Waite, 2000). The consistency in screen use reports across

15
Chapter 1

children and parents is interesting. Children, for example, may wish to under-report their

screen use for fear that they will be encouraged to reduce it. Parents on the other hand

might over-inflate their children’s screen use as they want it to decrease or perhaps they’re

motivated to under-report out of concern for being judged negatively.

Reporter of externalising measure was found to affect the relationship between

children’s screen use and externalising behaviour. This was slightly higher when reported

by parents than by teachers but not significantly so. This is consistent with previous

findings which demonstrated high rater agreement between parents and teachers on the

SDQ (Stone, Otten, Engels, Vermulst, & Janssens, 2010).

Finally, externalising behaviour scale was also examined as a moderator. Due to the

relatively small number of studies reporting on scales of the CBCL, we decided to merge

the SDQ outcome scales and compare these with the CBCL outcome scales. The

relationship between screen use and externalising behaviour was significantly moderated

by the scale used and found to be higher, though not significantly so, when measured by

the SDQ as opposed to the CBCL.

It’s possible that there were a number of other important mechanisms to consider

which may explain the relationship between screen use and externalising behaviours

amongst young people. Sleep has frequently been associated with psychological wellbeing

(Cheng et al., 2020) and it’s been suggested that excessive screen time may be displacing

sleep (Carson et al., 2016). Alternatively, screen use may be displacing social interactions

amongst children and their families which promote social-emotional development

(Madigan, Browne, Racine, Mori, & Tough, 2019). Furthermore, family composition may

be an important factor. Larger families in which children may need to compete more for

resources may use screens more as a tool to reduce parental demand. Radesky, Peacock-

Chambers, Zuckerman, & Silverstein (2016) argue that family dysfunction, associated with

limited reinforcement strategies to tackle challenging behaviours and navigate media

16
 Chapter 1

usage, could be another alternative explanation for the link between screen use and

externalising behaviours.

Strengths

There are a number of important strengths of the current meta-analysis. The review

was pre-registered with PROSPERO and a broad systematic literature search was

conducted informed by several databases with the support of a research librarian. This

ensured that the review process was transparent and enhanced the validity of the findings.

Additionally, abstract and full-text screening was completed blinded by two reviewers

using pre-defined inclusion and exclusion criteria which increased the reliability of the

review. Furthermore, two well-validated measures of externalising difficulties, the SDQ

and the CBCL, were used as the outcome measures. Regarding analysis, meta-analysis was

used to calculate effect size and robust variance estimation was used which allowed us to

incorporate multiple effect sizes from an individual study whilst controlling for data

dependencies.

Limitations

First, despite contacting authors of 49 included studies, there was a lack of data

available limited to the age group, four to eleven year olds, with whom we were originally

interested. Consequently, we extended our maximum age to 18 years. This has therefore

limited our ability to draw conclusions solely relevant to primary aged children. Child age

did not significantly moderate the association between screen use and externalising

behaviours. The issue regarding the limited number of studies focussing on 4-11 year olds

was in part due to the manner in which some studies reported their results. Whilst we

identified 54 studies for inclusion in the meta-analysis, we were only able to use a total of

17 for various reasons (e.g. age group, reporting of total SDQ/CBCL only, no direct

analysis between the variables of interest).

17
Chapter 1

There were a small number of papers reporting on certain facets of screen type and

externalising scales which resulted in unreliable degrees of freedom (i.e. <4). To improve

the reliability of the findings we amalgamated the data when conducting the moderation

analyses on each of these variables. This mean, however, that we were unable to draw

conclusions about more specific screen types and scales of externalising difficulties.

Studies relied on self-reported data which is prone to social desirability effects

(Althubaiti, 2016) which impacts the validity of the findings. In a bid to improve this, we

included data from a variety of reporters (i.e. child, parent and teacher). The majority of

studies also used retrospective reports of screen use rather than time use diaries. Evidence

suggests that there is a weak correlation between retrospective and time use diaries (Orben

& Przybylski, 2019) which disputes the reliability of the screen use data.

The review is further limited by the over-reliance on cross-sectional studies.

Although our inclusion criteria allowed for longitudinal studies, only one study used a

longitudinal design. As such, the relationship between child screen use and externalising

behaviours over time is still not well understood. Another methodological issue centres on

the use of correlational rather than experimental approaches. Whilst there are valid ethical

concerns around experimental manipulation of screen use in children, the nature of

correlational designs means that causation cannot be inferred. Thus, the study designs

predominantly used in the existing literature not only limit our knowledge about the causal

relationship between these variables but also the direction of the relationship (Ophir,

Lipshits-Braziler & Rosenberg, 2020).

Finally, the age of the papers used in the analysis may pose a threat to the validity

of the findings. Whilst the majority of the studies included were conducted during the last

three years, papers ranged from as early as 2002 to 2020. The rapid development of

technology and specifically screen types, as well as evidence suggesting that children’s

18
 Chapter 1

screen time grows year on year (Mediacom, 2019), some of the older papers incorporated

in the analysis may not reflect current screen use.

Implications and Future Research

Our review suggests that there is a relationship between children’s screen use and

externalising behaviour although this relationship is moderated by a number of factors

(screen type, reporter of externalising measure and type of externalising measure). Policy

makers may wish to use it to help inform guidelines on screen use for children and young

people, however, it will be important to use this review in conjunction with future research

in the area. Clinically, health professionals may wish to include questions about the type of

screen time a young person is usually engaging in within their assessments as well as

consideration of the impact of screen use on the individual (e.g. regarding sleep and social-

emotional development). An aim of our research had been to establish whether content of

screens moderated the relationship between children’s screen use and externalising

behaviours. Unfortunately, due to a lack of data on screen content, we were unable to

examine this. Previous studies have highlighted this as an issue (Dickson et al., 2018) and

we would echo their recommendations for future research to specify the content of screen

use. Furthermore, there were a number of studies that were eligible for the meta-analysis

but were not used. This problem relates more widely to the need for an open science

framework providing access to study data; we could have then analysed the data we

required.

Conclusion

In summary, the current meta-analysis suggests that there is a relationship between

children’s screen use and externalising behaviours which is moderated by screen type,

reporter of externalising measure and type of externalising measure. Whilst this review is

limited by the age of the children included in the analysis, availability of study data,

reliance on retrospective self-report measures and cross-sectional designs it does provide

19
Chapter 1

some helpful findings and guidance for future research with a specific suggestion around

the content of children’s screen use.

20
 Chapter 1

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Chapter 2 Examining the Relationship between Pre-

schoolers’ Screen Use and Externalising
Behaviours during the Covid-19 Pandemic;
A Co-Spyce Study

The following paper has been prepared in line with author guidelines for the Journal of
Child Psychiatry and Psychology.

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Chapter 2

Abstract

Background;

Pre-schoolers mental health is important and previous research has examined the

relationship between screen use and mental health in this population. Concerns have been

raised about children’s screen use during the Covid-19 pandemic. The current study aims

to explore the relationship between pre-schoolers mental health and screen use in the

context of a global pandemic and to overcome some of the methodical limitations of

existing research.

Methods;

Data was drawn from the Co-Spyce dataset. Six hundred and two caregivers of pre-

schoolers provided information on their 2-4 year old pre-schoolers’ screen use and

externalising behaviours between April and June 2020 via monthly online surveys.

Separate data was obtained for active and passive screen use. Cross-lagged analysis was

used to analyse the two screen use models.

Results;

One cross-lagged effect was found; increases in active screen use at baseline

significantly predicted externalising behaviours at one month follow-up (β = 0.25, p

= .013). This relationship was not bi-directional. There was no over-time relationship

between passive screen use and externalising behaviours but there was a within-time

relationship.

Conclusions;

Active screen use significantly predicts externalising behaviour overtime whilst

passive screen use does not. The strength of this relationship is weak but suggests that the

30
 Chapter 2

mechanisms underlying the relationship between active and passive screen use and

externalising behaviour differs.

Keywords; screen use, pre-schoolers, externalising behaviour, mental health

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Chapter 2

Introduction

Pre-schoolers’ mental health is important. The prevalence of emotional and

behavioural difficulties in this age group is estimated to be 7 – 21% (Gothelf et al., 2006).

It may be argued that these difficulties are transient, however, research suggests that such

problems are more chronic (Hughes & Ensor, 2007). Mental health difficulties at this life

stage can negatively impact children’s development (Caspi et al., 1997; Shaw, Gilliom,

Ingoldsby & Nagin, 2003). This is a key period for the emergence of social relationships

outside the family and preparation for formal education settings (American Academy of

Pediatrics, 2021; Ladd, 2009). Longitudinal research also indicates that poor mental health

during the early years tends to predict poorer mental health outcomes throughout an

individual’s life (Lavigne et al., 1998). Therapeutic input prior to school commencement

has shown efficacy over later intervention (Dawson & Osterling, 1997) and appears to

offer lasting treatment effects (Webster-Stratton & Hammond, 1997).

Pre-schoolers mental health during the Covid-19 pandemic has received relatively

little attention compared to the research emerging about school-aged children. According

to the Mental Health of Children and Young People Survey (MHCYP; Vizard et al., 2020)

there has been a rise in the number of mental health conditions affecting this age group

from 10.8% in 2017 to 16% in July 2020. This is likely to have affected the number of

referrals to children’s mental health services; there was a 35% increase between 2019/2020

compared to the previous year (Children’s Commissioner, 2021). Ford, John & Gunnell

(2021) argue that factors influencing mental health amongst children, such as isolation,

familial disputes, separation from peers and financial strain, are perpetuated by pandemic

restrictions. Parents of UK children aged 4 – 11 years have reported worsening mental

health difficulties and augmented behavioural problems between the start of lockdown

restrictions and May 2020 (Waite et al., 2020). The MHCYP (Vizard et al., 2020) found

32
 Chapter 2

that around 5% of 5 to 16 year olds experienced loneliness during the pandemic whilst

over a quarter had difficulties sleeping. The aforementioned research indicates that the

pandemic has had an impact on young people’s mental health and provides support for the

importance exploring pre-schoolers mental health at this time.

Parents have been particularly concerned about their children’s screen use during

the pandemic (Marsh, 2021). According to a report by Ofcom (2021), three in ten parents

of pre-schoolers found it difficult to control their child’s screen time during the pandemic

whilst 90% of parents implemented rules around their pre-schoolers gaming. Poitras et al

(2017) examined the relationship between screen based sedentary behaviour and

psychosocial outcomes in under five year olds. They found mixed results across 17 studies.

Externalising behaviours were most consistently negatively associated with screen use

whilst null effects were reported for internalising difficulties. Despite this research, the

theoretical link between childhood screen time and psychological difficulties is unclear.

There is some budding neurobiological evidence concerning the maturational coupling

hypothesis (i.e. the idea that changes in brain structure are associated with specific

behaviours). Research has shown that certain regions of the brain are associated with

screen media activity and some of these have been related to elevated externalising

problems in young people (Paulus et al., 2019).

There are, however, a number of limitations of existing screen use literature. There

is an over-reliance on cross-sectional correlational research which limits our ability to draw

conclusions about the direction(s) of the relationship between screen use and children’s

mental health outcomes (Dickson et al., 2018). Type of screen use is also considered to be

important. Sweetser, Johnson, Ozdowska and Wyeth (2012) provide definitions which

distinguish passive (“sedentary screen-based activities and/or passively receiving screen-

based information, such as watching TV or a DVD”) from active screen use (“cognitively

or physically engaging in screen-based activities, such as playing video games or

completing homework on a computer”). Type of screen use has been found to moderate the

33
Chapter 2

relationship between screen use and mental health outcomes (Sanders, Parker, Pozo-Cruz,

Noetel & Lonsdale, 2019). Despite this finding, the differentiation between active and

passive screen use has rarely been included in previous studies (Dickson et al., 2018).

Given that the sample used by Sanders et al (2019) comprised of 10 and 11 year olds, it

would be interesting to establish whether the same findings apply to a population of pre-

schoolers who may spend more time passively, rather than actively, watching screens. To

overcome the methodological limitations of previous research, longitudinal studies are

required to examine the direction of associations between screen use and externalising

behaviour problems and distinguish different types of screen use.

When considering pre-schoolers’ mental health it is essential to consider family

context. Family mental health has been put under strain during the Covid-19 pandemic

(Prime, Wade & Browne, 2020). Prime and colleagues identified a variety of different

stressors facing caregivers including financial worries, health concerns, reduced social

support associated with social restrictions and extended isolation, changes to work roles

and routines, meeting the social and educational needs of children with the closure of

schools and childcare settings. Consequently, caregivers are pressured with increased

demand and reduced resources which can lead to maladaptive ways of coping. Research

has suggested that such a combination leads to poorer relationship quality between parents

and their children as well as poor psychosocial adjustment in children (Patterson, 2016). It

is therefore important to consider systemic factors, such as parents’ mental health and

stress, in research on pre-schoolers’ mental health in the context of the Covid-19

pandemic.

Existing literature regarding the importance of pre-schooler’s mental health, their

screen use and limitations of cross-sectional research warrants examination of the

longitudinal associations between pre-schoolers’ screen use and mental health in the

context of the Covid-19 pandemic. We hypothesise that:

34
 Chapter 2

1. There will be a positive prospective relationship between pre-schoolers’ active

screen use and externalising behaviour problems over the course of the Covid-

19 pandemic.

2. There will also be a positive prospective relationship between pre-schoolers’

passive screen use and externalising behaviour during the Covid-19 pandemic.

3. These relationships will be bi-directional.

We also included a number of control variables. Gender differences in externalising

behaviour have previously been reported (Bulotsky-Shearer, Fantuzzo, & McDermott,

2008); thus we controlled for child gender. Findings by Prime et al. (2020) highlight the

impact of the pandemic on family mental health and therefore the study controls for

caregiver mental health. Caregiver educational achievement has also been controlled for

given that the impact of Covid-19 disproportionately affects those from low socio-

economic backgrounds (Whitehead & Duncan, 2021). Finally, we included reporter age

given evidence that the severity of Covid-19 increases with age (Centre for Disease

Control and Prevention, 2021).

Method

Participants

Opportunity sampling was used to recruit parents and carers of pre-school aged

children between the ages of 2 and 4 years old living in the UK. The current study focusses

on a subsample of 602 participants who completed a survey at T1 – during the month prior

to the easing of social restrictions and a second survey at T2 - in the month following this.

Demographic information is displayed in Table 1.

Table 1

Demographics

35
Chapter 2

Variable N (%) M (SD)

Country of Origin

England 530 (88.04)

Northern Ireland 4 (0.66)

Scotland 59 (9.80)

Wales 8 (1.33)

Child Gender

Female 311 (51.66)

Male 290 (48.17)

Not reported 1 (0.17)

Reporter Age 36.63 (4.86)

Reporter Type

Parent 598 (99.34)

Grandparent 3 (0.50)

Not available 1 (0.17)

Reporter Educational Attainment

No qualification 5 (0.83)

Post 16 vocational course 6 (1)

GCSEs or equivalent 23 (3.82)

A Levels or equivalent 36 (5.98)

Undergraduate degree 254 (42.19)

36
 Chapter 2

Variable N (%) M (SD)

Postgraduate degree 275 (45.68)

Not available 3 (0.50)

Reporter DASS score 25.75 (19.59)

Procedure

The study received ethical approval from The University of Southampton Research

Ethics Committee (Ergo No: 56217; Appendix D). As part of the Co-SPYCE project, a

baseline survey was disseminated between April and May 2020 through which

parents/carers provided informed consent and subsequent surveys were e-mailed to

participants on a monthly basis. Participants were asked to choose an ‘index’ child upon

which to base their responses if they had more than one child within the specified age

range. Specific cut-off dates were identified for T1 and T2 for each of the devolved nations

according to when social restrictions began easing and are outlined in Table 2. Full

procedural information can be found in the protocol (https://osf.io/rukpt/?view_only=).

Table 2

Data on easing of social restrictions for each of the devolved nations.

Country Date Social Restrictions Easeda Time 1 Data Time 2 Data

England 1st June 2020 30th April 2020 – 28th May 2020 –

31st May 2020 28th June 2020

Northern Ireland 19th May 2020 18th April 2020 – 19th May 2020 –

18th May 2020 19th June 2020

Scotland 28th May 2020 27th April 2020 – 28th May 2020 –

27th May 2020 28th June 2020

37
Chapter 2

Wales 1st June 2020 30th April 2020 – 1st June 2020 –

31st May 2020 1st July 2020

a
Social restrictions easing varied across the devolved nations. The ‘rule of six

outdoors’ was implemented in England (Stewart, 2020) and Northern Ireland

(McCormack, 2020). The ‘rule of two households outdoors’ was used in Scotland (Brooks,

2020) and in Wales (Evans, 2020).

Measures

Demographics

Participants provided data on their age and highest educational qualification as well as

their child’s gender. Educational attainment was used an indicator of socio-economic status

rather than income (“No qualifications”, “completed GCSE/CSE/O-levels or equivalent (at

school till aged 16”, “completed post-16 vocational course”, “A levels or equivalent (at

school till aged 18)”, “undergraduate degree or professional qualification” and

“postgraduate degree”).

Parental Mental Health

Participants completed the Depression Anxiety and Stress Scale (DASS-21;

Lovibond & Lovibond, 1995) as a measure of their own mental health. The DASS includes

21 items rated on a four point Likert scale reflecting severity from 0 (“Did not apply to me

at all”) to 3 (“Applied to me very much or most of the time”). The total score is obtained

by multiplying each of the three sub-scale scores by two and summing together. DASS

scores were included as a continuous variable.

Screen Use

Participants were asked to report how much time per day their child had spent on

screens over the previous week. Separate answers were provided for active screen use

38
 Chapter 2

(“Playing a screen-based game e.g., on phone, tablet, computer) and passive screen use

(“Watching a screen, but not interacting with it e.g. watching a programme on CBeebies on

BBC i-player, or videos on youtube, whether on a television, tablet, phone, computer etc.)

Participants responded using a five point Likert scale ranging from 1 (“Did not do”) to 5

(6+ hours).

Child Externalising Difficulties

The externalising scale of the parent/carer report version of the Strengths and

Difficulties Questionnaire (SDQ; Goodman, 1997) was used to assess child externalising

difficulties. Participants were asked to answer the questions in relation to their child’s

behaviour over the last month. The SDQ comprises 25 items which are rated on a three

point Likert scale from 0 (“not at all”) to 2 (“certainly true”). The externalising scale of the

SDQ comprises of two subscales; conduct problems and hyperactivity/inattention. An

externalising score is generated by summing the responses for the two sub-scales.

Data Analysis

All analyses were conducted using R Studio (RStudio Team, 2021). To test our

hypotheses, two cross lagged panel models were performed using structural equation

modelling in the Lavaan package (Rosseel, 2012). A number of pre-analysis checks were

undertaken. Little’s Missing Completely at Random test was used from the Baylor Ed Psych

package (Beaujean, 2015) to assess for patterns of missing data. This showed that there were

not any significant issues with missing data. Chronbach alphas were generated to assess

reliability of measures over time. Correlations were conducted to test for linearity.

Histograms and qqplots were used to inspect the distribution of residuals amongst the

outcome variables.

The first model explored whether active screen use and externalising problems at T1

predicted each other at T2, whilst the second model investigated whether passive screen use

39
Chapter 2

and externalising problems at T1 predicted each other at T2. The following were explored

as potential control variables; child gender, reporter age, educational attainment and DASS

score. For each model, we built an initial model which involved regressing each of the

outcome variables onto one another to produce auto-regressive, co-variant and cross-lagged

relationships (Figure 3). We then used a bottom up approach to remove constraints on the

control variables using the top five recommendations from the model indices. This was

repeated either until removing constraints did not improve the model or there were not any

additional relevant (i.e. did not explore the relationships with which we were interested)

recommendations. The final step involved constraining the co-variances of the outcome

variables. If they did not significantly worsen the model then they were included in the final

model.

Model fit was evaluated using the following fit indices; X2, comparative fit index

(CFI), root mean square error of approximation (RMSEA) and standardized root mean

squared residual (SRMR). We adopted cut-offs from Kline (2005), who suggests that

model fit is good when X2 is >.05, CFI ≥ .90, RMSEA <.08 and SRMR <.08.

Figure 3. The general cross-lagged panel model for screen use and externalising behaviour.

Results

Descriptive Statistics

40
 Chapter 2

The most common response for passive screen use at each time point was ’30

minutes to 2 hours’ whilst the most common response for active screen at each time point

was ‘did not do’ although the spread was more evenly distributed amongst the first three

categories (‘did not do’, ‘less than. 30 minutes’ and ’30 minutes to 2 hours’) than it was for

passive screen use. Externalising behaviour was similar at T1 (M = 8.36, SD = 3.78) and

T2 (M = 7.99, SD = 3.80). Reliability of measures over time was good for active screen use

(α = .80) and externalising problems (α = .86) and acceptable for passive screen use (α

= .68).

Main Results

The results are displayed for each model in Figure 4.

Model 1 – Active Screen Use

The final active screen model included regressions amongst each of the outcome

variables (active screen use at each time point and externalising behaviours at each time

point), externalising behaviour at T1 was regressed on to child gender and DASS score,

active screen use at T1 was regressed on to education and reporter age and the co-variances

were constrained to be equal. The overall model exhibited good fit based on fit indices. X2

was 0.142, CFI was 0.994, RMSEA was 0.026 and SRMR was 0.039.

41
Chapter 2

Figure 4. (A) The cross-lagged panel model including standardised structural regression

co-efficients for active screen use and externalising behaviour. (B) The cross-lagged panel

model including standardised structural regression co-efficients for passive screen use and

externalising behaviour. * p < .05, ** p < .01, *** p < .001.

In terms of the auto-regressive effects, active screen use at T1 significantly predicted

active screen use at T2 (β = 0.66, p < .001) whilst externalising behaviour at T1

significantly predicted externalising behaviour at T2 (β = 0.76, p < .001).

Within time co-variances between active screen use and externalising behaviours

demonstrated that these variables were not significantly correlated (β = 0.09, p = .200).

The cross-lagged effects revealed that active screen use at T1 significantly

predicted externalising behaviour at T2 (β = 0.25, p = .013). However, this relationship

42
 Chapter 2

was not reciprocal as externalising behaviour at T1 did not significantly predict active

screen use at T2 (β = 0.01, p = .537).

Model 2 – Passive Screen Use

The final passive screen model included regressions amongst each of the outcome

variables, externalising behaviour at T1 was regressed on to DASS score, passive screen

use at T1 was regressed on to DASS score and reporter age and the co-variances were

constrained to be equal. Child gender and parental educational achievement were excluded

from this model as releasing them did not significantly improve the model fit. The overall

model exhibited good fit based on fit indices. X2 was 0.335, CFI was 0.999, RMSEA was

0.016 and SRMR was 0.022.

In terms of the auto-regressive effects, passive screen use at T1 significantly

predicted passive screen use at T2 (β = 0.47, p < .001) whilst externalising behaviour at T1

significantly predicted externalising behaviour at T2 (β = 0.76, p < .001).

Within time co-variances between passive screen use and externalising behaviours

demonstrated that there was a significant positive correlation between these variables (β =

0.16, p = .002).

The cross-lagged effects revealed that passive screen use at T1 did not significantly

predict externalising behaviour at T2 (β = 0.16, p = .255) and that externalising behaviour

at T1 did not significantly predict passive screen use at T2 (β = 0.01, p = .537).

Discussion

Finding 1 – Cross Lagged Effects

The primary findings relates to the cross-lagged effects. A cross-lagged effect is

demonstrated for active screen use suggesting that active screen use at baseline

significantly predicts externalising behaviour at follow-up, however, this relationship is not

43
Chapter 2

bi-directional which supports hypothesis 1 but is inconsistent with hypothesis 3. Passive

screen use and externalising behaviours were not significantly related over time in either

direction which disproves hypothesis 2. Research has previously shown that mental health

difficulties are associated with higher screen use (Zink, Belcher, Kechter & Stone, 2019)

but our results do not support this assertion. It is possible that children who dealt with

pandemic related stress by playing on screens more frequently displayed more

externalising difficulties as restrictions were eased but we did not have pre-pandemic data

available so could not explore this idea. An alternative explanation for the differences

between each model over time could be accounted for by passive screen use being a

quieter activity compared to active screen use. Caregivers may be more inclined to report

externalising difficulties when active screen use is high if the child becomes distressed

about losing a game for example. It’s important to note that externalising behaviour is a

very poor predictor of screen use in both models and although passive screen use at

baseline does not significantly predict later externalising behaviour the β value isn’t much

smaller than that in the active model. The findings do, however, suggest that the

mechanisms underlying the effects of active and passive screen use on externalising

behaviour are slightly different.

Finding 2 – Auto-regressive Effects

Observing the auto-regressive effects also provides us with some important findings.

Each of active and passive screen use at baseline significantly predicted screen use one

month later although the association was stronger for active use of screens. Furthermore,

externalising behaviours at baseline significantly predicted externalising behaviours at

follow-up. These findings illustrate that each of the three main constructs remain stable

over time and suggest that the easing of social restrictions did not have a short-term impact

on either active screen use, passive screen use or externalising behaviour. We would not

necessarily expect a dramatic reduction in externalising behaviours so quickly after the

easing of social restrictions although we may have expected a decrease in screen use if

44
 Chapter 2

parental concerns about increased screen time during lockdown are to be taken into

account. We did not assess adherence to guidelines on social restrictions and this may have

impacted our findings.

Finding 3 – Co-variance Effects

The third finding relates to the within time co-variances. There was not a

significant relationship between active screen use and externalising behaviours when

measured at the same time point. On the other hand, passive screen use and externalising

behaviours were significantly related when measured at the same time point. It’s likely,

however, that there is a third variable which better predicts each construct and therefore

explains why the relationship between these variables over time is not significant.

Interestingly, caregiver DASS score predicted both passive screen use and externalising

behaviour. Therefore, it may be that caregivers who are struggling with their own mental

health difficulties, due in part to perhaps balancing the demands of working from home

and caregiving, are more likely to allow their children to watch more screens.

Alternative Explanations

There are other important factors to incorporate when thinking about the function

of the relationship between pre-schoolers screen use and externalising difficulties. Firstly,

sleep, which is particularly important during the early years (Jiang, 2019) may be replaced

by screen time which subsequently leads to elevated externalising problems (Carson et al.,

2016). Secondly, social interaction, which promotes social-emotional growth, may also be

replaced by screen time again resulting in increased externalising difficulties. It’s

important to note, however, in the context of the pandemic that screen time may have

enhanced social interaction at a time when this was otherwise limited. Finally, family

dysfunction might underlie the relationship between screen use and externalising problems.

Families with few or poor reinforcement strategies may use screens as a way of managing

difficult behaviours (Radesky, Peacock-Chambers, Zuckerman, & Silverstein, 2016).

45
Chapter 2

Strengths

There were a number of strengths of the current study. First, we included a large

sample reporting on an approximately even number of boys and girls. This will have

enhanced statistical power (Suresh & Chandrashekara, 2012) and generalisability of the

findings across genders. The longitudinal design was also a strength as it allowed us to

assess relationships amongst the variables over time whilst employing cross lagged

analysis enabled us to look at multiple relationships simultaneously as well as bi-

directionality (Selig & Little, 2012). Whilst our time points were theoretically informed, as

we predicted that the changing of social restrictions would influence screen time and

externalising behaviours, it would have been interesting to include further time points to

explore these variables as the pandemic progressed. Previous screen time literature has

been criticised for ignoring the type of children’s screen use (Dickson et al., 2018). In an

attempt to overcome this limitation, we explored the relationships between externalising

behaviour and active/passive screen use separately and found that these relationships did

differ based on type of screen time. Finally, we focussed on a topical area of research with

important clinical implications and areas for further research that will be of interest to the

general public, politicians and health care professionals.

Limitations

The current study was limited in a number of ways. Its sample predominantly

consisted of higher educated individuals residing in England. The sampling method was

also flawed in that participants were self-selecting. This may explain the disproportionate

number of well-educated people completing the study, consistent with previous findings

(Brall et al., 2021), as they may have been more likely to hear about the study or value the

contribution of research. Research has also shown that screen use tends to be higher

amongst families of a lower socio-economic background (Cameron et al., 2015), as are

mental health difficulties (Gutman, Joshi, Parsonage, & Schoon, 2015), which would likely

46
 Chapter 2

have had an impact on our results. Furthermore, although electronic questionnaires were an

effective method for collecting large volumes of data, they are limited by the potential for

socially desirable responses and reliance on participant memory (Abeele, Beullens & Roe,

2013; Grondin, 2010) as well as the potential for exclusion of hard to reach populations

who do not have easy access to the internet. Furthermore, we did not explore the impact of

co-viewing screen content with pre-schoolers. Spending time with a parent watching

screens may be beneficial for pre-schoolers, however, the benefits would likely be

associated with proximity to the caregiver or opportunities for displays of affection at these

times as opposed to being directly linked to the screen content itself. Finally, whilst we did

explore active and passive screen use separately, these variables could have been better

defined. The findings for passive screen use, for example, could differ depending on

whether the child was watching a violent cartoon or educational content (Prescott, Sargent

and Hull, 2018; Baydar, Kağitçibaşi, Küntay, & Gökşen, 2008). We also did not account

for whether the child was actively engaged in discussion about the content which therefore

could be classified as active rather than passive screen use as defined by Sweetser et al

(2012).

Implications and Future Research

The current study offers some interesting findings but emphasises the need for

further high quality research. The study highlights the differences between active and

passive screen use and as such has clinical implications for the assessment of externalising

difficulties in pre-schoolers (i.e. incorporating questions about screen use) and advice

clinicians offer which should focus on the type and quality of screen use rather than time

spent engaging in screens. This advice may only be relevant to those of a higher socio-

economic background, however, given that the population in the current study was heavily

skewed in terms of SES. This raises implications regarding the recruitment of under-

represented backgrounds in research. Creativity should be employed in recruitment e.g.

approaching those who have direct involvement with these populations such as religious

47
Chapter 2

leaders, teachers and social services. In terms of future search, we focussed on

externalising behaviours which have been reported more predominantly in boys (Bulotsky-

Shearer et al., 2008) and so exploration of internalising difficulties, which tend to be more

frequently reported in girls, is warranted. Further differentiation between types of passive

and active screen use is also recommended in future research to establish whether

relationship differ between screen content which promotes learning vs competitive gaming

for example. We would also suggest using more than two time points for data analysis to

explore how these relationships differ over a more significant period of time.

Conclusions

To conclude, the current study suggests that the underlying processes of how active

and passive screen use predict externalising behaviours in pre-schoolers are slightly

different but ultimately there is not strong compelling evidence that increased screen use,

active or passive, predicts behaviour problems later on.

48
 Chapter 2

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55
 Appendix A – Search Syntax

“television watch*” or “tv watch*” or “cartoon watch*” or “television viewing” or

Screentime or (screen or computer or television) N3 time or (watch* or view*) N2 (dvd*

or video*) or “social media” or “screen media” or (SUBJECT HEADING) “social media”

or “video gam* or videogam* or “computer gam*” or “electronic gam*” or gaming or

“screen based entertainment” or Smartphone* or “smart phone*” or “cell phone*” or

“mobile phone*” or “small screen*” or (SUBJECT HEADING) “mobile devices” or

Texting or “text messag*” or app or apps or “mobile applications” or Iphone* or ipad* or

ipod* or tablet* or laptop*

AND

“aggressive behavio?r” or “anger control” or “emotion* control” or “emotion* regulation”

or “impulse control disorder” or SUBJECT HEADING) “aggressive behavio?r” or

“behavio?r disorder” or “anti-social behavio?r” or “behavio?r problem*” or “interpersonal

relationships” or “interpersonal interaction” or “prosocial behavio?r” or “social behavio?r”

or “cognitive ability” or “cognitive development” or “cognitive ability” or attention or

“attention deficit disorder” or concentrat* or distract* or (SUBJECT HEADING) attention

or (SUBJECT HEADING) memory or (SUBJECT HEADING) “executive function”

AND

Child* or “pre-teen” or (primary or elementary N1 (school or age*)

57
 59
0.95

0.86

0.86

0.86
Summary
Score

21

19

19

19
Score
Total

14. Conclusion supported by results?

2

13. Results reported in sufficient detail?

2

12. Controlled for confounding?

2

11. Some estimate of variance is reported

Appendix B - Quality Assessment Criteria Scores

for the main results?

2

10. Analytic methods described/justified and

appropriate?
2

2
9. Sample size appropriate.
2

2
8. Outcome well defined and robust to
measurement/misclassification bias?
2

2
4. Subject characteristics sufficiently
described.

2
3. Method of subject/comparison group
selection OR source of info/input variable
described and appropriate.

1
2. Study design evident and appropriate.

2
1. Question/objective sufficiently described.

Hosokawa (2018)
Guxens (2019)
Basay (2020)
Ahn (2017)
Paper
 1.00

0.86

0.77

0.95

0.91
Summary
Score

22

19

17

21

20
Score
Total

14. Conclusion supported by results?

2

13. Results reported in sufficient detail?

2

12. Controlled for confounding?

2

11. Some estimate of variance is reported

for the main results?
2

2
10. Analytic methods described/justified and
appropriate?
2

2
9. Sample size appropriate.
2

2
8. Outcome well defined and robust to
measurement/misclassification bias?
2

1
4. Subject characteristics sufficiently
described.
2

2
3. Method of subject/comparison group
selection OR source of info/input variable
described and appropriate.

2
2. Study design evident and appropriate.

1
1. Question/objective sufficiently described.

Kostyrka-Allchorne

Kovess-Masfety

Lobel (2017)
Kahn (2020)

Pujol (2016)
(2020)

(2016)
Paper

60
0
 61
0.73

0.73

0.86

0.86

0.82

0.68
Summary
Score

16

16

19

19

18

15
Score
Total

14. Conclusion supported by results?

2

13. Results reported in sufficient detail?

0

12. Controlled for confounding?

0

11. Some estimate of variance is reported

for the main results?
2

10. Analytic methods described/justified and

appropriate?
1

2
9. Sample size appropriate.
2

2
8. Outcome well defined and robust to
measurement/misclassification bias?
2

1
4. Subject characteristics sufficiently
described.
2

2
3. Method of subject/comparison group
selection OR source of info/input variable
described and appropriate.

1
2. Study design evident and appropriate.

1
1. Question/objective sufficiently described.

Hastings (2009)

Ozmert (2002)
Jamnik (2018)
Alonso (2017)

Milani (2015)
Leiner (2014)
Paper
 1.00

0.86
Summary
Score

22

19
Score
Total

14. Conclusion supported by results?

2

13. Results reported in sufficient detail?

2

12. Controlled for confounding?

2

11. Some estimate of variance is reported

for the main results?
2

10. Analytic methods described/justified and

appropriate?
2

9. Sample size appropriate.

2

8. Outcome well defined and robust to

measurement/misclassification bias?
2

4. Subject characteristics sufficiently 2

described.
2

2
3. Method of subject/comparison group
selection OR source of info/input variable
described and appropriate.

2
2. Study design evident and appropriate.

1
1. Question/objective sufficiently described.

Yousef (2014)
Xie (2020)
Paper

62
0
 Appendix C – Summary of Data Extracted from Studies included in Analysis

Author Year Number of Mean Age Design Type of Screen Reporter of Measure Scale Reporter of
Participants (Years) Screen Measure

Ahn 2017 327 11.9 Cross- Screen Time Parent SDQ Hyperactivity- Parent
sectional Inattention

Alonso 2017 88 - Cross- Computer/Videogames Child CBCL Attention Parent

sectional Internet Parent Aggression

Basay 2020 277 11.98 Cross- Screen Time Parent SDQ Hyperactivity- Parent
sectional Inattention
Conduct

Guxens 2019 3102 5.15 Cross- TV Parent SDQ Hyperactivity- Parent

sectional Computer/Videogames Inattention Teacher
Conduct

Hastings 2009 70 7.8 Cross- Videogames Parent CBCL Attention Parent

sectional Aggression
Delinquency

63
0

Hosokawa 2018 1642 - Cross- Mobile Devices Parent SDQ Hyperactivity- Parent
sectional Inattention
Conduct

Jamnik 2018 184 5 Cross- TV/Videogames Parent CBCL Aggression Parent

sectional

Kahn 2020 145 4.9 Cross- Screen Time Parent SDQ Externalising Parent
sectional

Kostyrka- 2020 520 6.7 Cross- Screen Time Parent SDQ Hyperactivity- Parent
Allchorne sectional Inattention
Conduct

Kovess- 2016 3195 8.7 Cross- Videogames Parent SDQ Hyperactivity- Parent
Masfety sectional Inattention Teacher
Conduct

Leiner 2014 579 11.1 Cross- Videogames Child CBCL Attention Parent
sectional Aggression

Lobel 2017 194 9.22 Longitudinal Videogames Child SDQ Hyperactivity- Parent
Inattention
Conduct

64
Milani 2015 346 11.64 Cross- Videogames Child CBCL Externalising Parent
sectional

Ozmert 2002 689 7.95 Cross- TV Parent CBCL Attention Parent

sectional Aggression
Delinquency

Pujol 2016 2014 8.6 Cross- Videogames Parent SDQ Hyperactivity- Parent
sectional Inattention
Conduct

Xie 2020 1897 - Cross- Screen Time Parent CBCL Attention Parent
sectional Aggression

Yousef 2014 179 8.7 Cross- TV/Videogames Child CBCL Attention Parent
sectional Externalising

65
Appendix D – Ethics Approval Confirmation

67