(2024) 24:500
Niiranen et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-04915-8

BMC Pediatrics

RESEARCH

Open AccessChildren’s screen time and psychosocial
symptoms at 5 years of age – the roleof parental factors
Janette Niiranen1,6*, Olli Kiviruusu1, Riitta Vornanen2, Anneli Kylliäinen3, Outi Saarenpää‑Heikkilä4 and
E. Juulia Paavonen1,5

Abstract
Background and objectives Electronic media (e-media) has become a universal part of young children’s daily lives.
Previous studies have found an association between increased screen time and children’s psychosocial symptoms.
We investigated whether parents’ psychological distress and parenting style dimensions explain the association
between children’s screen time and psychosocial symptoms. Moreover, we investigated whether parents’ mental wellbeing and parenting style dimensions moderate this association.
Methods We used data from the Finnish CHILD-SLEEP birth cohort study. Parents and the child were assessed
when the child was 5 years old (N = 671). The measure of screen time included program viewing from TV and otherdevices. Child’s psychosocial problems and parents’ depression, stress and parenting style dimensions were assessedby self-reports.
Results A high level of screen time in children was associated with attention and concentration difficulties, hyperac‑
tivity and impulsivity symptoms as well as internalizing and externalizing symptoms among 5-year-olds. For the mostpart, the associations remained significant despite controlling for parents’ mental health, parenting style dimen‑
sions and multiple background factors, especially associations relating to attention and concentration difficulties
and hyperactivity symptoms were robust. Maternal stress and depression moderated the association between chil‑dren’s screen time and psychosocial symptoms, indicating a more pronounced association among stressedor depressed mothers.
Conclusion There is an independent association between children’s screen time and psychosocial symptoms whichis especially pronounced among those children whose mothers had poorer mental well-being. In clinical prac‑tice, the length of screen time should be inquired already at a young age and parents should be offered guidance
to reduce the possible ill effects of excessive screen time, as well as help with their own mental health problems.
Keywords Child, Screen time, Psychosocial symptoms, Child development, Parental mental health, Parenting styles*Correspondence:
Janette Niiranen
janette.niiranen@helsinki.fi
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom‑mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Niiranen et al. BMC Pediatrics(2024) 24:500

Introduction
Electronic media (e-media) has become a universal partof young children’s daily lives. For even younger children,
e-media use is very popular sedentary behavior [1]. The
American Academy of Pediatrics [2] (AAP) recommends
limiting the use of e-media for children aged 2–5 years
to one hour per day (see also the WHO [2]). Based ona recent study of Finnish 5-year-olds, the average daily
screen time was almost two hours [3] and among American children aged 2–4 over two–and–a–half hours [4],thus considerably larger amounts than the limits recommended by the AAP. However, there are many potential
risks associated with excessive e-media use at a young
age [3, 5], such as increased internalizing [6, 7] as well
as externalizing problems [6–10], including inattention[6–8] and impulsivity [6, 7]. In their longitudinal study,
Christakis et al. [8] reported that hours of televisionviewing per day at both ages 1 and 3 years were associated with attentional problems at age 7 (OR = 1.09; 95%
confidence interval [CI]: 1.03–1.15 and OR = 1.09; CI:
1.02–1.16]). Similarly, McNeill et al. [6] found that higher
levels of program viewing at 3–5 years of age were significantly associated with increases in externalizing behaviors (β = 0.008; CI: 0.002–0.014) and total difficulties(β = 0.013; CI: 0.005–0.022) at 12 months later. Moreover, cognitive delays at preschool age have been reported
among those children whose screen time was high during the early childhood years [11]. There seems to be a
growing body of research on the potential harmful effects
of screen time, but it is not yet clear how factors related
to family functioning contribute to the effects of screen
time in young children.
The factors related to family and it’s functioning arefor example parents’ mental well-being and the parenting styles. They are potential factors that could modify
the association between a child’s screen time and psychosocial symptoms. It has been reported that inconsistentparenting and inappropriate e-media content seems to
add to the negative effects of screen time on low-incomepreschoolers’ executive functioning, while warm parenting and educational e-media content seems to decrease
the negative effect of screen time and produce beneficial effects [12, 13]. Moreover, poor parent–child interaction seems to have an additional negative effect withincreased screen time on preschooler’s psychosocial
well-being [14]. Mistry et al. [15] noted that mothers whoreported having a child who viewed screens for two hours
or more were more likely to experience significant levelsof depression. Moreover, when controlling for maternal depression, sustained television viewing was associated with negative behavioral outcomes, such as sleep
problems, attention problems, aggressive behavior, andexternalizing problems (according to the Child Behavior

Page 2 of 15

Checklist, CBCL). A study by Ansari et al. [16] pointed
out how preschooler’s hyperactive behavior increased
their screen viewing over time, and that the association
was especially pronounced among those children whoseparents were depressed and in families with lower socioeconomic status. All in all, it seems to be that the relation of parent’s mental well-being and parents’ stress asfactors increasing screen time of young children havereceived only minimal research interest to date.
There is a long tradition of research on importanceof parenting style for child development and well-being[17]. Parenting styles refer to the ways parents consider,
respond and make demands in the interaction with theirchild; they describe patterns of behaviors and reflect attitudes and values parents have in their parenthood [18].
In contrast to the traditional parenting style paradigm
that employs a typological approach (e.g., authoritative, authoritarian, and permissive parenting [19]), in thedimensional approach, parenting style characteristics aretreated as continuous variables of a certain dimension[20]. The most studied parental style dimensions havebeen parental warmth and behavioral control [18], andthe previous findings indicate the positive role of affective warmth as a parenting style on the effects of a child’s
screen time [13]. Although there is evidence that some ofthe parenting style dimensions, such as parental warmth,
play a role in the association between children’s increased
screen time and psychosocial symptoms, the nature of
the other parenting style dimensions remain unclear.
In the present study, our first aim was to examine
whether parents’ psychological distress (parental depression and stress) or parenting style dimensions explain theassociation between children’s screen time and psychosocial symptoms, such as internalizing and externalizing
symptoms. Second, we tested whether parents’ mental
well-being and parenting style dimensions moderate thisassociation. This study is a continuum from our previous
study, where we reported associations with screentime
and children’s internalizing and externalizing symptoms
at the age of 5 years [3]. We expected that 1) screentime
is an independent risk factor that adds to the well-established risks related to parental depression and stress and2) some of the family-level risk factors moderate the risk
related to screen time, so that the effect is especially pronounced when combined with a family-level risk factor,
such as parental stress or depression.

Methods
Study design

This study is based on the five-year measurement pointof the CHILD-SLEEP birth cohort. The recruitment andbaseline measurement took place prenatally at the 32nd
week and the follow-up measurements occurred at theNiiranen et al. BMC Pediatrics(2024) 24:500

birth of the child and at 3, 8, 18, 24, and 60 months of age.
The study design, protocol, participants, and measures
have been described in more detail in Paavonen et al.
[21]. The study was approved by the by Pirkanmaa Hospital District Ethical Committee (9.3.2011, ethical researchpermission code R11032). The participants gave theirwritten informed consent. Participation in the study was
voluntary, and the families received no compensation fortaking part.
Participants

Mothers and fathers were recruited for the study fromthe Pirkanmaa Hospital District area in Southern Finland. Altogether, 2244 parents gave their approval toreceive prenatal questionnaires when they visited thematernity clinics, and 1679 (74.8%) gave their consent toparticipate in the study and returned the baseline questionnaires. The response rate when the children were at
5 years of age was 42.5% (N = 714). Children with severe
chronic illnesses or disabilities, e.g., Down’s syndrome or
Hirschsprung disease (n = 7), and all twins (n = 8) were
excluded. The final sample for the present study included
those 671 children whose parents had responded to theFive-to-Fifteen (FTF) [22] questionnaire when their children were five. Regarding these 671 children, there were
455 fathers and 643 mothers who reported their mental
well-being and parenting style dimensions when the childwas 5 years of age. Background information and sociodemographic factors of the sample are presented in Table 1.

Page 3 of 15

Table 1 Descriptive statistics of the study variables (N = 671)
Variable
Sociodemographic factors
Child’s gender, girl671

47.4 (318)Child’s age, years; mean (SD)670

5.68 (0.54)651

48.5 (316)

University-level degree (at least one
parent)More than one child in household

649

85.7 (556)Child in full-time daycare

634

67.8 (430)63480.4 (36.3)

Child’s screen time
Program viewing at 5 years, min; mean
(SD)
Over 60 min

66.8 (442)Over 120 min

16.9 (112)High dose (highest quartile; ≥ 88 min
per day)
Depressed (CES-D ≥ 10)644

21.1 (136)Stressed (PSS-5 ≥ 11)643

15.2 (98)

Parenting styles (CRPR)
Low affection (lowest quartile)644

23.3 (150)

Behavioral control (highest quartile)644

25.2 (162)

Parenting stress (highest quartile)644

23.8 (153)

Moderators, fathers
Depressed (CES-D ≥ 10)455

13.2 (60)Stressed (PSS-5 ≥ 11)455

9.9 (45)

Low affection (lowest quartile)454

27.8 (126)

Behavioral control (highest quartile)454

24.2 (110)

Parenting stress (highest quartile)454

24.0 (109)

Parenting styles (CRPR)

Child psychosocial symptoms (FTF)

In this research the e-media use measure included
screen time, i.e., program viewing on TV and otherdevices. Parents reported the time a child spent watching
screens at 5 years of age. Separate questions were asked
for weekday and weekend e-media use on how many
hours a child watches programmes (including on television or other devices). For the analyses, we first recoded
reported screen time into minutes. Second, we calculated a weighted daily average (5/7 on weekdays and 2/7
at weekends) of the measure (range 225 min). Finally, themeasure was dichotomized using a 75-percentile cut-off
to indicate those with the highest dose of e-media use:
program viewing at 5 years of age for ≥ 88 min per day(24.3%, n = 155). The mean screentime in the high dosegroup (exceeding 88 min) was 131 min (SD 28 min, range
88–240 min) while it was 64 min in the low dose group(SD 19 min, range 15–88 min).

Hyperactivity and impulsivity; mean
(SD)

Mothers’ and fathers’ depressive symptoms were asked
using the short 10-item version of the CES-D scale (The24.4 (157)Moderators, mothers

Measures
Screen time

Parental depression (CES‑D)

Valid N % (N) / Mean (SD)

Attention and concentration; mean (SD) 668

3.76 (3.41)

670

3.98 (3.63)

Internalizing; mean (SD)670

1.52 (1.78)

Externalizing; mean (SD)670

2.82 (3.25)

Center for Epidemiologic Studies Depression Scale) [23].
The scale included questions related to depressive symptoms, such as feeling lonely, feeling depressed, and restless sleep. After reversing two items, a higher sum scoreindicated more severe depressive symptoms (range 0–30
points). A cut-off score of ≥ 10 has been indicated to provide acceptable sensitivity and specificity against the criterion of caseness for clinically significant depression set
by the original 20-item CES-D [24].
Parental stressStressfulness was measured using five items on a fivepoint scale derived from the Perceived Stress Scale [25] togauge how unpredictable, uncontrollable, and overloaded

Niiranen et al. BMC Pediatrics(2024) 24:500

the respondents find their lives to be (five items: “In thelast month, have often have you felt that you were unable to control the important things in your life?” “In thelast month, how often have you felt difficulties were piling up so high that you could not overcome them?”). The
summary score (range 0–20) was dichotomized using a
cut-off score of ≥ 11 (90th percentile) points to represent
elevated levels of stress.
Parenting style dimensions

Mothers’ and fathers’ parenting style dimensions were
measured using a Finnish version of Block’s Child Rearing Practices Report (CRPR) [26], which is a modernizedversion and assesses childrearing attitudes, values, andbehaviors [18]. In the present study, we used affection,
behavioral control, and parenting stress subscales of themeasure. The affection subscale included items indicating a positive relationship with the child (10 items, e.g., “I
often tell my child that I appreciate what they try out or
achieve,” “I often show my child that I love them”). Behavioral control included items that showed how a child’s
inappropriate behavior would have clear consequences
and a parent’s willingness to confront a child who disobeys (six items; e.g., ‘‘My child needs to learn that we haverules in our family,” “When I am angry with my child, I
let them know about it,”). Parenting stress included questions related to parents’ stress and guilt about their childrearing and parenting skills (Four items; e.g., “whenI think of what kind of parent I am, I feel guilt or insufficiency,” “I have more problems with childrearing thanI expected,”). In this study, to define the risk groups thesubscales were dichotomized using the lowest quartile(to indicate low affection) or highest quartile (to indicate
higher levels of behavioral control or parenting stress).
In this study, our aim was to study both stress in general and stress related to parenting. We have previously
reported that maternal depression is related to children’s
psychiatric symptoms at 2 and 5 years of age [27]. Laterwe also reported that paternal perceived stress is related
to children’s psychosocial symptoms at 2 years of age[28]. Therefore, in this study both depression and perceived stress were considered in addition to parenting
styles. Finally, we were specifically interested in stressrelated to parenting, as this might have been related tomore screentime in children.
Outcome measures
Child’s psychosocial symptoms (FTF)

The FTF questionnaire is an extensive questionnaire forparents about children’s developmental and emotional
symptoms. It has been tested for its validity and reliability for the identification of internalizing and externalizing
symptoms in children aged five to fifteen years [22, 29].

Page 4 of 15

The questionnaire was developed to include Diagnostic Manual of Mental Disorders (DSM)-similar items of
ADHD and of its most common comorbid condition inclinical practice. Other documented associated problem
areas would also be covered in some detail, even though
not necessarily covering all the symptoms of these conditions/problems as listed in the DSM [22, 29].
In this study, we used the following four subdomains:attention and concentration difficulties, hyperactivity
and impulsivity, internalizing problems, and externalizing problems.
Background factors

Background factors that were controlled for in the analyses included the child’s gender (girl/boy), the child’s age,the parents’ education (at least one parent has a university-level degree, yes/no), whether there was more than
one child in the household (yes/no), and whether thechild participated in full-time daycare (yes/no).
Parental education was measured using an item with
six response options (1 no vocational education, 2 vocational course/courses, 3 vocational school, 4 college oruniversity of applied sciences 5 university, 6 other). Thiswas categorized into two classes due to low prevalence ofsome classes (no education, vocational courses, other).
Parental education was only used as a covariate in themodel (i.e., it was treated as a confounding factor).
Attrition analyses

Attrition (nonresponse to FTF questionnaire at five years)
was predicted by mothers’ depression (OR 1.48; 95% CI
1.06–2.05), stress (2.00; 1.30–3.10), lower than university
level education (1.26; 1.02–1.55), previous children (1.38;
1.12–1.69) and younger age (0.96; 0.94–9.98) and father’s
previous children (1.51; 1.22–1.86) in the prenatal measurement point.
Statistical methods

We first studied the distributions of the study variables
and correlations between them. The continuous variables
were reported using means and standard deviations, anddichotomous variables were reported as prevalence rates.
Pearson correlation coefficients were calculated for thecontinuous variables. In the next stage, we made a seriesof ANOVA models to evaluate the influence of background factors and parental mental well-being as wellas parenting style dimensions on children’s psychosocial
symptoms, i.e., attention and concentration difficulties,
hyperactivity and impulsivity, internalizing symptoms
and externalizing symptoms.
The modeling was performed in five stages. First, we
controlled only for the background factors: child’s gender, child’s age, parents’ education, number of children inNiiranen et al. BMC Pediatrics(2024) 24:500

the household, and child’s participation in full-time daycare. Next, separate models were analyzed for parent’s 1)
depression, 2) stress, and 3) parenting style dimensions
with all background factors in the model. In the last step,a model with background variables and all measures ofparental distress and parenting style dimensions were
simultaneously in the model. Separate models were analyzed for mothers and fathers. Before entering the variables to the multivariate models, multicollinearity wastested among the predictor variables using variance inflation factors (VIF) – all VIF values were < 1.4, thus indicating no signs of multicollinearity.
The moderating effects of parental distress and parenting style dimensions on the association between thechild’s screen time and psychosocial symptoms were analyzed by adding interaction terms (child’s screen time x
the parent-related variable in question) in the basic univariate model. In the next step we added backgroundfactors to the model. In supplementary analyses, moderation effects were analyzed using continuous measuresof screen time and parental moderator variables (seeAppendix 2; supplementary material).

Results
Descriptive statistics of the sample are shown in Table 1.
The mean age of the children in the sample was 5.7 years(standard deviation 0.5). The sample consisted of 318
girls (47.4%) and 353 boys (52.6%). The majority of thechildren (67.8%) were in full-time daycare. At least one
parent had a university-level degree in 48.5% of the families. In 85.7% of the families, the children had siblings.
Two-thirds (66.8%) of the children watched programs
for > 60 min/day. We have reported the correlations
between the main variables in the Appendix 1 (supplementary material). Mother’s mental health or parenting
styles did not correlate with child’s screen time, except
for maternal affection (r = -0.10, p < 0.05).
Among mothers, the first set of ANOVA models(Table 2, univariate models) showed that higher amountsof children’s screen time were related to their attentiondifficulties, hyperactivity, internalizing and externalizing
symptoms, despite the background factors being controlled for (all ps ≤ 0.031). Except for internalizing symptoms, these associations remained significant when we
controlled for maternal depression, stress or parenting
style dimensions suggesting that screen time is related to
psychosocial symptoms independent of parental distressand parenting style dimensions (Table 2, models 1–3).
In the full model, with all the factors jointly studied, theassociations of children’s screen time with attention difficulties, hyperactivity and impulsivity as well as externalizing symptoms remained significant (Table 2, models 4).
Practically all (with only three exceptions) associations

Page 5 of 15

between measures of maternal distress and mother’s parenting style dimensions and the four child outcomes weresignificant when studied separately (univariate models),
while mother’s parenting stress was the only factor thatremained significant predictor of all four child psychosocial symptoms in the full models.
In the responses of fathers, we found in the first set of
ANOVA models (i.e., univariate models) that higher levels of children’s screen time were associated with theirattention difficulties as well as hyperactivity and impulsivity, (both ps < 0.001) (Table 3, univariate models).
Related to child’s attention and concentration difficulties and hyperactivity and impulsivity, these associations
remained significant when we controlled for depression,stress, or parenting style dimensions (Table 3, models
1–3), and also in the full model, when all factors were
jointly studied (Table 3, models 4) (both ps ≤ 0.005), indicating that child’s screen time was associated with these
symptoms independently, i.e., despite paternal distressand parenting style dimensions being taken into account.
The associations of children’s screen time with internalizing and externalizing symptoms were not significant
in these models. Of the paternal mental well-being andparenting style dimensions, in the final models, fathers’
behavioral control remained a significant predictor ofchildren’s internalizing symptoms and parenting stress
was a significant predictor of hyperactivity and externalizing symptoms (Table 3, models 4).
In moderation analyses among mothers, interaction terms between children’s screen time and maternal
depression were significant on attention and concentration difficulties (p = 0.031) and externalizing symptoms (p = 0.038) in the unadjusted models. Similarly,
interaction terms between children’s screen time andtheir mother’s stress were significant with regard to
the children’s hyperactivity and impulsivity (p = 0.026)
and externalizing symptoms (p = 0.030) in the unadjusted models. Regarding all these significant interactions, the association between child’s screen time andpsychosocial symptoms was more pronounced whenthe mother was depressed or stressed, while in the caseof a non-depressed or non-stressed mother the association was weaker or absent (Figs. 1 and 2). The interaction
terms between child’s screen time and mother’s depression attenuated after controlling for background factors
and turned non-significant (p > 0.05), while the interaction terms regarding mother’s stress remained significant in the adjusted models. There were no significant
interaction terms regarding mother’s parenting styledimensions. Among fathers, there were no significant
interactions regarding any of the five studied moderators(parental depression, stress and the three parenting styledimensions). Supplementary moderation analyses using

3.45

3.56

Depression ≥ 10 pts

Stress ≥ 11 pts   Parenting stress ≥ 75 pct 3.32

3.72

3.85

Depression ≥ 10 pts

Stress ≥ 11 pts   Parenting stress ≥ 75 pct 3.60

1.47   Parenting stress ≥ 75 pct 1.26

3.66

2.54

2.72

Depression ≥ 10 pts< 0.001

1.54 (0.37)

0.010

1.04 (0.40)

0.031< 0.0010.010

0.63 (0.29)
0.93 (0.36)< 0.001

1.21 (0.16)

1.54 (0.31)

0.738

0.06 (1.61)

0.014

0.017

0.47 (0.20)
0.41 (0.17)

0.030< 0.001

0.36 (0.16)< 0.0011.68 (0.33)

0.76 (0.17)

0.347

0.31 (0.33)

0.003< 0.001

1.01 (0.34)< 0.001

1.33 (0.35)< 0.001

1.99 (0.31)
1.14 (0.33)

0.066

0.57 (0.31)< 0.001< 0.0011.43 (0.32)< 0.001

1.66 (0.33)

p1.10 (0.31)

B (se)

0.010

0.036

0.007

0.082

< 0.001

0.009

0.009

0.029

0.007

0.038

0.001

0.014

0.010

0.022

0.018

0.061

0.005

0.031

0.026

0.039

0.020

p

0.088

–

–

–

–

–

–

–

–

–

–

–

–

–

1.68 (0.31) 0.004–

0.59 (0.29) 0.022

–

–

–

0.56 (0.20) 0.005–

0.33 (1.68) 0.050

–

–

–

1.24 (0.40) 0.002

1.04 (0.36) < 0.001 –0.59 (0.29) 0.046

–

–
–

–
–

–
–

–

p

–

0.139

0.37 (0.30)

0.80 (0.32)

0.81 (0.40)

0.81 (0.37)

0.92 (0.30)

B (se)

Model ­4e

0.343

0.212

–

–

0.27 (0.33)

0.44 (0.36)

0.49 (0.45)

0.56 (0.41)

0.084

0.443

0.856

–

–

0.27 (0.16)

0.14 (0.16)

0.22 (0.18)

0.02 (0.22)

0.28 (0.20)

–

–

–

–

0.57 (0.28) 0.035

0.09 (0.38)

0.91 (0.35)

0.56 (0.28)

1.31 (0.17) < 0.001 1.23 (0.19)

0.12 (0.16)

0.03 (1.18)––

0.28 (0.16)

1.58 (0.36) < 0.001 1.27 (0.38)

0.31 (0.33)

0.45 (0.36)––

1.04 (0.33)

1.82 (0.32) < 0.001 1.36 (0.34)

0.44 (0.30)

0.82 (0.32) 0.011––

1.12 (0.34) < 0.001 1.06 (0.33) 0.002

–

–

–

0.76 (0.18) < 0.001 –0.29 (0.17)

–

–

–

–

–

–

–

–

B (se)

1.74 (0.37) < 0.001 –1.34 (0.36) < 0.001 –1.05 (0.34) 0.002

–

–

–

–

–

–

–

–

p

Model ­3d

1.04 (0.31) < 0.001 0.95 (0.30) 0.002

B (se)

Model ­2c

1.80 (0.32) < 0.001 –0.93 (0.31) 0.002

partial ­eta2 B (se)Model ­1b

0.207

0.013

0.043

0.028

0.002

0.812

0.011

0.049

< 0.001

0.388

0.900

0.923

0.159

0.099

< 0.001

0.413

0.225

0.273

0.169

0.002

< 0.001p(2024) 24:500

Parenting style dimension

Stress ≥ 11 pts

4.08

2.63

Screen time ≥ 75 pct

3.26

2.47

1.56

   Behavioral control ≥ 75
pct

FTF Externalizing symptoms

1.50

1.45

   Low affection ≤ 25 pct

Parenting style dimension
1.86

1.94

1.39

Depression ≥ 10 pts

Stress ≥ 11 pts

2.14

1.41

Screen time ≥ 75 pct

1.77

5.28

3.92

FTF Internalizing symptoms

4.24

3.77

   Behavioral control ≥ 75
pct

4.78

4.88

5.10

   Low affection ≤ 25 pct

Parenting style dimension

3.71

Screen time ≥ 75 pct

4.85

5.31

3.65

FTF Hyperactivity and impulsivity symptoms

4.22

3.46

   Behavioral control ≥ 75
pct

4.89

5.11

5.10

4.60

Mean

   Low affection ≤ 25 pct

Parenting style dimension

3.50

Screen time ≥ 75 pct

FTF Attention and concentration difficulties

Mean

Low risk ­groupa High risk g­ roupa Univariate

Table 2 The influence of mothers’ mental well-being and parenting style dimensions on the association between child’s screen time and psychosocial symptoms (Mother’s
N=722)

Niiranen et al. BMC Pediatrics
Page 6 of 15

4.59

0.044
< 0.001

2.25 (0.29)
0.085

0.006

0.022

–

–

–

partial ­eta2 B (se)

–

–

–

p

–

–

–

B (se)

Model ­2c

–

–

–

p

0.191

0.097

p

0.33 (0.28)

0.48 (0.31)

B (se)

Model ­4e

2.15 (0.31) < 0.001 1.87 (0.32)

0.37 (0.28)

0.60 (0.28)

B (se)

Model ­3d

Screen time + Background factors + Maternal depression. Valid N’s 609-611

Screen time + Background factors + Maternal stress. Valid N’s 609-611

Screen time + Background factors + Maternal parenting style dimensions (low affection, high behavioral control, high parental stress). Valid N’s 609-611

Screen time + Background factors + Maternal depression + Maternal stress + Maternal parenting style dimensions (low affection, high behavioral control, high parental stress). Valid N’s 609-611

b

c

d

e

Means of FTF symptoms in the low risk (below cutoff ) and high risk (above cutoff ) groups for the given dependent variable; for low affection low risk > cutoff, high risk < cutoff. Valid N’s 631-643   Parenting stress ≥ 75 pct 2.33

< 0.001

0.60 (0.30)

p1.16 (0.30)

B (se)

Model ­1b

a

3.31

2.71

3.76

2.59

Mean

   Behavioral control ≥ 75
pct

Mean

Low risk ­groupa High risk g­ roupa Univariate   Low affection ≤ 25 pct

Table 2 (continued)

0.249

0.119

< 0.001

p

Niiranen et al. BMC Pediatrics(2024) 24:500
Page 7 of 15

3.66

3.65

Depression ≥ 10 pts

Stress ≥ 11 pts   Parenting stress ≥ 75 pct 3.49

3.87

3.81

Depression ≥ 10 pts

Stress ≥ 11 pts   Parenting stress ≥ 75 pct 3.62

1.49

1.47

Depression ≥ 10 pts

Stress ≥ 11 pts   Parenting stress ≥ 75 pct 1.43

2.72

Stress ≥ 11 pts
3.56

3.82

3.43

0.004

0.032

1.10 (0.51)
1.00 (0.34)

0.125

0.092

0.081

0.70 (0.45)

0.59 (0.35)

0.33 (0.19)

0.070
0.007

0.51 (0.19)

0.166

0.403

0.33 (0.18)

0.37 (0.27)

0.20 (0.24)

0.298

0.002

1.24 (0.39)
0.20 (0.19)

0.532

0.25 (0.39)

0.004

0.042

1.14 (0.56)
1.09 (0.37)

0.418< 0.001

0.062

0.571

0.014

0.750

0.907

< 0.001p0.40 (0.50)

1.37 (0.40)

0.70 (0.37)

0.21 (0.37)

0.88 (0.36)

0.17 (0.54)

0.06 (0.47)

1.40 (0.37)

B (se)

0.019

0.010

0.005

0.006

0.007

0.016

0.007

0.004

0.002

0.002

0.022

0.001

0.018

0.009

0.001

0.027

0.008

0.001

0.013

< 0.001< 0.0010.032p

B (se)

Model ­2cp

B (se)

Model ­3dp

B (se)

Model ­4e

–
–

–

–

–

0.56 (0.44)

–

–

0.203

0.175

–

–
0.48 (0.35)

–

–

–

–

–
–

0.398

0.330

0.20 (0.24)

0.19 (0.19)

–

–

–

–

–

–

0.662

–

–

0.21 (0.49)

1.18 (0.39) 0.003

–

–

–

–
–

0.958

0.02 (0.46)

–

–

–

0.769

–

–

–

–

–

1.27 (0.50) 0.011

0.218
–

–

–

–

0.43 (0.35)

–

–

–

0.149

–
0.39 (0.27)

0.365
–

–

–

–

0.17 (0.19)

–

–

–

1.15 (0.56) 0.039–

1.13 (0.39) 0.004

–

–

–

0.15 (0.52)

–

0.310

0.155

–

0.123

–

–

0.274

0.40 (0.35)––

0.43 (0.35)

0.21 (0.20)

0.245

–

–

0.219

0.283

0.55 (0.19) 0.004

0.29 (0.19)––

0.21 (0.19)

0.94 (0.41) 0.021

0.40 (0.39)

0.55 (0.39)–

0.35 (0.35)

0.92 (0.55)

0.17 (0.48)

0.40 (0.35)

0.18 (0.20)

0.54 (0.19)

0.27 (0.19)

0.25 (0.30)

0.01 (0.26)

0.20 (0.19)

0.91 (0.42)

0.38 (0.39)

0.51 (0.39)

0.96 (0.62)

0.51 (0.54)–

1.10 (0.40)

0.42 (0.40)

0.25 (0.37)

0.57 (0.37)

0.04 (0.58)

0.19 (0.51)

–

0.325

0.514

0.128

–

–

1.13 (0.39) 0.004

0.38 (0.39)

0.24 (0.37)

0.56 (0.37)––

1.28 (0.37) < 0.001 1.27 (0.37) < 0.001 1.25 (0.37) < 0.001 1.26 (0.37)

partial ­eta2 B (se)Model ­1b

0.321

0.096

0.725

0.258

0.380

0.005

0.150

0.412

0.984

0.299

0.032

0.333

0.196

0.120

0.344

0.005

0.292

0.500

0.125

0.950

0.715

< 0.001p(2024) 24:500   Low affection ≤ 25 pct

2.56

2.74

Depression ≥ 10 pts

Parenting style dimension

2.63

Screen time ≥ 75 pct

3.22

1.76

1.39

FTF Externalizing symptoms

1.89

1.42

   Behavioral control ≥ 75
pct

1.75

1.85

1.68

   Low affection ≤ 25 pct

Parenting style dimension

1.43

Screen time ≥ 75 pct

1.62

4.86

3.86

FTF Internalizing symptoms

4.11

3.62

   Behavioral control ≥ 75
pct

4.71

4.95

4.27

   Low affection ≤ 25 pct

Parenting style dimension

3.58

Screen time ≥ 75 pct

4.95

4.20

3.62

FTF Hyperactivity and impulsivity symptoms

3.83

3.42

   Behavioral control ≥ 75
pct

4.30

3.82

3.72

4.72

Mean

   Low affection ≤ 25 pct

Parenting style dimension

3.33

Screen time ≥ 75 pct

FTF Attention and concentration difficulties

Mean

Low risk ­groupa High risk g­ roupa Univariate

Table 3 The influence of fathers’ mental well-being and parenting style dimensions on the association between child’s screen time and psychosocial symptoms (Father’s N = 531)

Niiranen et al. BMC Pediatrics
Page 8 of 15

< 0.001

1.44 (0.35)
0.036

0.003
–

–

partial ­eta2 B (se)

–

–

p

–

–

B (se)

Model ­2c

–

–

p

0.427

p

1.14 (0.36) 0.002

0.28 (0.35)

B (se)

Model ­3d

Screen time + Background factors + Paternal depression. Valid N’s 434-436

Screen time + Background factors + Paternal stress. Valid N’s 434-436

Screen time + Background factors + Paternal parenting style dimensions (low affection, high behavioral control, high parental stress). Valid N’s 434-436

Screen time + Background factors + Paternal depression + Paternal stress + Paternal parenting style dimensions (low affection, high behavioral control, high parental stress), Valid N’s 433-435

b

c

d

e

Means of FTF symptoms in the low risk (below cutoff ) and high risk (above cutoff ) groups for the given dependent variable; for low affection low risk > cutoff, high risk < cutoff. Valid N’s 437-454

3.93

0.223

p

0.44 (0.36)

B (se)

Model ­1ba   Parenting stress ≥ 75 pct 2.49

Mean
3.17

Mean

Low risk ­groupa High risk g­ roupa Univariate

2.73   Behavioral control ≥ 75
pct

Table 3 (continued)

1.05 (0.38)

0.25 (0.35)

B (se)

Model ­4e
p

0.005

0.479

Niiranen et al. BMC Pediatrics(2024) 24:500
Page 9 of 15

Niiranen et al. BMC Pediatrics(2024) 24:500

Page 10 of 15

Fig. 1 Associations of child’s screen time with attention and concentration difficulties (A) and with externalizing symptoms (B) as moderated
by mother’s depression. Estimated marginal means from ANOVA models. Error bars represent 95% confidence intervals

continuous variables are shown in the Appendix 2 (supplementary material).

Discussion
In this study, our aim was to examine whether the association between a child’s screen time and psychosocial
symptoms is in fact explained by parent-related factors,

including parental depression and stress and parenting
style dimensions. Our results indicate that for the mostpart it is not. That is, the associations between children’shigher screen time and higher attention and concentration difficulties as well as hyperactivity and impulsivity
symptoms and externalizing symptoms remained significant even after controlling for parents’ mental health,Niiranen et al. BMC Pediatrics(2024) 24:500

Page 11 of 15

Fig. 2 Associations of child’s screen time with hyperactivity and impulsivity symptoms (A) and with externalizing symptoms (B) as moderated
by mother’s stress. Estimated marginal means from ANOVA models. Error bars represent 95% confidence intervals

their parenting style dimensions as well as multiple background factors. However, the association between screen
time and internalizing symptoms did not remain significant. Thus, among mothers, family-level factors seem toattenuate the association between screentime and internalizing symptoms, while the effect was relatively weak

to begin with (p = 0.030). These findings seem to suggestthat the risks attributed to screen time do not merelyreflect parent-related distress and family adversity, butinstead the screen time is independently associated withchild’s mental health when parent-related distress andfamily adversity are statistically taken into account.

Niiranen et al. BMC Pediatrics(2024) 24:500

In addition to the independent role of screen time onchild’s psychosocial symptoms, we further analyzed
whether these associations are moderated by parentrelated factors. These analyses showed that children
are reported to have more psychosocial symptoms
when their mothers are depressed/stressed and they are
exposed to more screentime, compared to other children.
Consistently with our earlier findings [3], screen time
was associated with higher levels of children’s psychosocial symptoms. This result is in line with other studies
that have found an association between children’s screen
time and psychosocial symptoms, such as internalizing
and externalizing problems, as well as inattention andimpulsivity [6–10, 30]. As these studies have not controlled for parenting style dimensions or parental stress,
our findings add to the literature by showing that theassociations remain significant, even when these factors
are taken into account. Our results especially emphasize
how screen time is related to attention and concentrationdifficulties, hyperactivity and impulsivity symptoms, aswell as externalizing problems regardless of psychologicaldistress in the family.
There are multiple mechanisms that could explain the
results. In terms of hyperactivity and impulsivity as wellas concentration problems, previous studies suggest thatscreen time may prohibit their availability for activities
that are considered to enhance cognitive capacities andstimulate longer attention span [31–33]. Interestingly,
also in our study, associations between screen time andhyperactivity and concentration problems were the mostrobust ones, prevailing as significant in the final adjusted
models. It has also been suggested that parents in lessaffluent families would be more prone to use mobile
technology to calm their children or keep them quiet,
particularly parents who express lower perceived control over their children’s behavior and development [34].
However, in our study, most of the parents were welleducated. Furthermore, all associations between children’s screen time and psychosocial problems remained
significant when we controlled for parental education.
This again emphasizes the point that the risks related
to children’s screen time cannot solely be reduced tofamily-level factors. It is worthy of note that the sample
comprises generally typically developing children from abirth cohort, wherein children with diagnosed neurobehavioral disorders were excluded. Therefore, the findings
are limited to mainly typically developing children andsuggest that even in such a normative sample, symptomsof impulsivity and inattention can be related to screentime. For example, children with neuropsychiatric disorders (e.g., ADHD) may be predisposed to more electronic
media use. They may, for example, have more difficulties
to quit playing. We propose that children with ADHD

Page 12 of 15

should be studied in clinical samples, not in birth cohorts
like the present study to ensure adequate sample size.
Our results illustrated that risks related to screen
time and children’s psychosocial symptoms were moderated by maternal depression and stress. Althoughprevious studies have found an association between
maternal depressive symptoms and children’s increased
screen time [15], they have not reported how a mother’s stress or depression moderates the association
between screen time and their child’s symptoms. However, Huesmann & Taylor [35] found that exposure toviolent media content is associated with externalizing
symptoms such as aggressive behavior, but active discussion between parents and children when exposed
to aggressive material may buffer the effect. Moreover,Fam et al. [36] found that parents’ active mediation(i.e., communication with a child and discussion about
media-related concerns) was negatively associatedwith problematic e-media use. Moreover, studies havefound that parents’ passive co-viewing of programswith a child is detrimental to children’s psychosocial
well-being [36, 37]. It may be that when a mother isdepressed or stressed, she may not be able to actively
participate in her child’s e-media use (discussions,parental mediation) and thus not be able to buffer thenegative effects between the child’s increased screen
time and psychosocial symptoms.
Our results showed that for the most, parenting styledimensions did not significantly moderate the association
between children’s screen time and psychosocial symptoms. This differs from some previous studies reportingthat inconsistent parenting and problems in parent–childinteraction have an additional negative effect on the association between a preschooler’s screen time and psychosocial well-being [13, 14]. Also in our study, parenting
style dimensions characterized by low affection, highbehavioral control or high parenting stress were associated with higher levels of children’s psychosocial symptoms among both mothers and fathers (see also [38]),
and in fact parenting stress had the strongest effects onchild’s psychosocial symptoms, especially among mothers. However, with one exception, the effect of maternal
parenting stress on child internalizing symptoms (seeAppendix 2), the parenting style dimensions did notmoderate the association between screen time and childoutcomes. Among fathers, none of the studied moderators of parental distress and parenting styles significantly
moderated the association between children’s increased
screen time and psychosocial symptoms. This may be due
to a smaller number of fathers participating in our study
and thus a loss of power to detect interactions. Alternatively, the mechanisms relating to children’s screen timeand psychosocial problems may be different between

Niiranen et al. BMC Pediatrics(2024) 24:500

mothers and fathers. More studies are needed to further
examine these issues among fathers.
The results of the current study are not caused byparental distress being correlated with the child’s screentime because child’s screentime was not associated withparental distress (Appendix 1) except for maternal affection. Nevertheless, we point out that the associations
between the factors are complex and—as such—interpretations of the causality cannot be made. We instead
argue that the link between the factors might be bidirectional. For example, it is possible that the child’s behavioral problems could be related to higher amount ofscreen time. This is supported by a study of Ansari et al.
[16] which shows that preschooler’s hyperactive behavior increased their screen viewing over time (see also
Radesky et al. [34]). Moreover, parents’ behavior andpsychological well-being might be related to screen timewith multiple ways – for example some parents might use
e-media devices as a tool to calm their children down,
especially among children with socio-emotional difficulties. Furthermore, there is a possibility that stressed
mothers allow more screen time to cope with the child’s
problem behaviors. For example, Radesky et al. [34] argue
that when parents do not have control over the child’s
behavior it might cause both the stress and allowanceof child’s extensive media use. One example of complex
relationship between the studied factors (appearing alsoin our study) is a work by Parks et al. [42] where authors
noticed that parents who expressed not wanting theirstress to affect their child were the same parents thatallowed their child to watch television. They consideredthat this allowed them to control their emotions and notshow negative feelings towards their child.
As a limitation of our study, we mention that those withlower educational achievement are under-represented
in the sample, which seems to be common according tostudies on drop-out rates in longitudinal studies on mental health [39]. Within the participating parents, however,
we controlled the models for socio-economic status totake its effect into account. Moreover, we emphasize thatmissingness in this data was not random—it was related
to several well-known stress factors in the families, suchas depression, lower education, and to higher numberof children. As these factors are usually associated withmore psychosocial symptoms in children, drop out inthis study might lead to underestimated risk estimates
relative to the entire target population. Hence, the resultspresented here can not necessarily be generalized toentire population, but the less risky proportion of the target population. As another limitation we mention that insurvey studies, such as ours, it may be difficult for parents
to evaluate their children’s screen time precisely. Moreover, this study is a cross-sectional birth cohort study, andPage 13 of 15

as such we cannot make interpretations of the causality.
Further, we cannot rule out the possibility of reverse causality (that for example attention problems lead to more
screen time) or the influence of other variables such as
genetic dispositions. Future studies should longitudinallyevaluate the symptoms trajectories and how they relate
to screentime at different timepoints. Moreover, we did
not measure parental stress on their children’s screentime. However, we found that parental depression andstress were not correlated with the child’s screentime inthis study. Despite this, in the future, more studies areneeded to evaluate the effect of parents’ stress on theirchildren’s screen time.
It should be noted, that e-media content and parenting practices during the viewing could moderate the risks
related to screen time [37]. In the current study, we were
not able to control the age appropriateness of the screen
content nor the parenting practices or mediation thescreen time. Finally, stress factors tend to have a cumulative impact on children; the more children are exposed
to various risk factors, the higher their risk [38]. Further
studies are therefore needed to evaluate whether there isa cumulative effect of screen time and other stress factors
relative to children’s symptoms.

Conclusions
Among young children, a high amount of screen time isindependently related to multiple psychosocial symptoms even when various factors related to parents’ mental health and parenting style dimensions have been taken
into account. In addition, the risk seems to be especiallypronounced when a mother is stressed or depressed. Various psychosocial environmental risk factors in childhood(interacting with genetic dispositions) play a cumulativerole relative to children’s well-being making it important
to study multiple factors simultaneously [40, 41]. It is also
important to keep in mind that the relationship between
these factors may be bidirectional. In clinical practice,
the length of children’s screen time should be inquired
already at a young age. Furthermore, parents should beoffered guidance to reduce the possible ill effects of excessive screen time and help with their own mental healthproblems. Recognizing the risk factors related to excessive screen time and parents’ mental health is crucial
when children are young to prevent psychosocial symptoms from developing further. Moreover, monitoring theseissues when children grow older, is equally important. As
screen use is increasingly a universal part of children’s
daily lives, intervention studies are needed that aim to
reduce children’s psychosocial symptoms related to higher
levels of screen time. Enhancing parents’ active mediationand discussion of children’s e-media habits in families canpotentially prove to be promising avenues for these efforts.

Niiranen et al. BMC Pediatrics(2024) 24:500

Supplementary Information

Page 14 of 15

3.

The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s12887-​024-​04915-8.
Supplementary Material 1.
Supplementary Material 2.
Acknowledgements
The authors would like to thank all of the families that participated in the
CHILD-SLEEP birth cohort. The authors are also grateful for the nurses at thematernity clinics who introduced the study to the families.
Authors’ contributions
J.N. primarly wrote the main manuscript text. J.N, O.K. and J.P. prepared
Tables 1, 2 and 3. O.K. and J.N. prepared Figs. 1 and 2. J.P. is the leader of the
project and responsible for funding of the project. All of the authors reviewed
and commented on the manuscript.
Funding
Open Access funding provided by Finnish Institute for Health and Welfare.
This work was supported by the Academy of Finland (grant numbers 134880,
308588, 342747), the Gyllenberg Foundation, the Yrjö Jahnson Foundation, theFoundation for Pediatric Research, the Finnish Cultural Foundation.
Availability of data and materials
The data of this study is not publicly available due to legal restrictions andconfidential nature. The data is available upon request. Requests may be sent
to The Finnish Institute for Health and Welfare, who is the controller of thedata. Contact information: juulia.paavonen@helsinki.fi.

4.
5.
6.

7.

8.
9.
10.

11.

12.

Declarations
Ethics approval and consent to participate
All of the experiments were performed in accordance with relevant guidelines
and regulations. The study was approved by the by Pirkanmaa Hospital District
Ethical Committee (9.3.2011, ethical research permission code R11032). The
participants gave their written informed consent.
Consent for publication
Not applicable.

13.

14.

15.

Competing interests
The authors declare no competing interests.
Author details
1
Department of Public Health and Welfare, Finnish Institute for Healthand Welfare, Helsinki, Finland. 2 Department of Social Sciences, Universityof Eastern Finland, Kuopio, Finland. 3 Faculty of Social Sciences, Psychology,
Tampere University, Tampere, Finland. 4 Tampere Centre for Child HealthResearch, University of Tampere and, Tampere University Hospital, Tampere,
Finland. 5 Pediatric Research Center, Child Psychiatry, University of Helsinki
and Helsinki University Hospital, Helsinki, Finland. 6 Faculty of Social Sciences,
Social Psychology, University of Helsinki, Helsinki, Finland.
Received: 24 February 2023 Accepted: 27 June 2024

16.
17.

18.
19.
20.
21.

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