TECHNICAL REPORTChildren and Adolescentsand Digital Media
Yolanda (Linda) Reid Chassiakos, MD, FAAP, Jenny Radesky, MD, FAAP, Dimitri Christakis, MD, FAAP, Megan A.
Moreno, MD, MSEd, MPH, FAAP, Corinn Cross, MD, FAAP, COUNCIL ON COMMUNICATIONS AND MEDIA

Today’s children and adolescents are immersed in both traditional and newforms of digital media. Research on traditional media, such as television,
has identiﬁed health concerns and negative outcomes that correlate withthe duration and content of viewing. Over the past decade, the use of digital
media, including interactive and social media, has grown, and research
evidence suggests that these newer media offer both beneﬁts and risks
to the health of children and teenagers. Evidence-based beneﬁts identiﬁed
from the use of digital and social media include early learning, exposure
to new ideas and knowledge, increased opportunities for social contact
and support, and new opportunities to access health promotion messages
and information. Risks of such media include negative health effects on
sleep, attention, and learning; a higher incidence of obesity and depression;
exposure to inaccurate, inappropriate, or unsafe content and contacts; andcompromised privacy and conﬁdentiality. This technical report reviews theliterature regarding these opportunities and risks, framed around clinicalquestions, for children from birth to adulthood. To promote health andwellness in children and adolescents, it is important to maintain adequate
physical activity, healthy nutrition, good sleep hygiene, and a nurturingsocial environment. A healthy Family Media Use Plan (www.healthychildren.
org/MediaUsePlan) that is individualized for a speciﬁc child, teenager, orfamily can identify an appropriate balance between screen time/online timeand other activities, set boundaries for accessing content, guide displaysof personal information, encourage age-appropriate critical thinking anddigital literacy, and support open family communication and implementationof consistent rules about media use.

abstract

This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors haveﬁled conﬂict of interest statements with the American Academyof Pediatrics. Any conﬂicts have been resolved through a process
approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
Technical reports from the American Academy of Pediatrics beneﬁt
from expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, technical reports from the American
Academy of Pediatrics may not reﬂect the views of the liaisons or theorganizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reafﬁrmed,
revised, or retired at or before that time.
DOI: 10.1542/peds.2016-2593
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they do
not have a ﬁnancial relationship relevant to this article todisclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors haveindicated they have no potential conﬂicts of interest to
disclose.

INTRODUCTION
What Are the Differences Between Traditional Media and New Digital orSocial Media?
Today’s generation of children and adolescents are surrounded by andimmersed in a digital environment. Traditional media, such as television

To cite: Reid Chassiakos Y, Radesky J, Christakis D, et al.,AAP COUNCIL ON COMMUNICATIONS AND MEDIA. Children
and Adolescents and Digital Media. Pediatrics. 2016;138(5):e20162593

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PEDIATRICS Volume 138, number 5, November 2016:e20162593

FROM THE AMERICAN ACADEMY OF PEDIATRICS

(TV), radio, and periodicals, havebeen supplemented by new digitaltechnologies that promote interactive
and social engagement and allow
children and teenagers instant accessto entertainment, information, andknowledge; social contact; andmarketing. Traditional media, also
referred to as broadcast media,
typically were created externally by anestablished production source, such asa film studio, TV network, or editorial
staff and were provided either toindividuals or to a broader audiencefor passive viewing or reading. In
contrast, newer digital media, which
include social and interactive media,
are a form of media in which users
can both consume and actively
create content. Examples include
applications (apps), multiplayer video
games, YouTube videos, or video
blogs (vlogs). For children and young
adults today, this evolving integrationof passively viewed and interactive
media is seamless and natural; thedistinctions and boundaries between
traditional/broadcast and interactive/social media have become blurred orimperceptible.
Digital media allow information
sharing across a variety of media
formats, including text, photographs,
video, and audio. Today’s video
games, for example, often represent a
merging of both traditional and social
media, as users can virtually “inhabit”
impressively produced worlds andinteract with other users in remotelocations. Video game participants
can even work collaboratively tococreate virtual worlds. Thus, digital
media can provide an engaging
experience in which the media
experiences of children and teenagers
become highly personalized.

MEDIA USE ESTIMATES
How Are Media Usage Patterns
Changing in Young Children?
The evolution of media fromtraditional to newer forms of digital
media in the past decade has resulted

e2

in changes in the patterns of media
use. For example, in 1970, children
began to regularly watch TV at 4
years of age, whereas today, children
begin interacting with digital media
at 4 months of age.
As new media platforms and social
media have been incorporated into
children’s media diets, hours spentin TV viewing have slowly decreased
over the past 2 decades. Loprinzi
and Davis1 examined trends inparent-reported TV viewing amongpreschoolers 2 to 5 years of age(n = 5724) and children 6 to 11 yearsof age (n = 7104) between 2001 and2012 using data from the National
Health and Nutrition Examination
Survey (NHANES), showing
significant decreases in mean TV
viewing over time, primarily forpreschoolers and, to a lesser extent,
for school-aged children. NonHispanic white boys demonstrated
the largest decrease in mean viewingof 29%, from 2.24 hours of TV per
day down to 1.59 hours of TV perday. Despite these decreases, themajority of parents still reported that
their children watched TV for 2 ormore hours per day.
It is unclear whether these decreases
are in part the result of parents
heeding expert recommendations
to limit screen time (evidence
would suggest not)2 or whether
they represent a displacement of
TV viewing by the use of novel
platforms. In young children,use of mobile devices, such as
smartphones and tablet computers,
has risen dramatically since theKaiser Family Foundation firstbegan surveying parents of 0- to
8-year-olds about their technology
use.3 For example, in 2011, 52%of children 0 to 8 years of age hadaccess to a mobile device (although
only 38% had ever used one). By
2013, this access had increased to
75% of 0- to 8-year-olds.4 Althoughthese national surveys continued todemonstrate a digital divide on thebasis of economic status, with less
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access to mobile technology and theInternet in lower-income families,a smaller study in 2015 called thisdisparity into question by showingthat almost all (96.6%) 0- to 4-yearolds recruited from a low-income
pediatric clinic had used mobile
devices, and 75% owned their own
device.5 This study also showedthat most 2-year-olds used mobile
devices on a daily basis and that mostof the 1-year-olds assessed (92.2%)
had already used a mobile device.
Although a digital divide likely still
exists in terms of access to quality
content and reliable Wi-Fi, it is now
clear that most young children seen
by a pediatric health care provider
will have used or have been exposed
to mobile technology.
Exactly what young children are
doing on mobile technology has notbeen studied in great detail, because
mobile device usage is relatively
recent and methodologicallydifficult to assess. By parent report,
most children in the Kabali et al
study5 watched YouTube or Netflix
primarily, and smaller proportions
watched educational programs
and played early-learning apps
(eg, alphabet and counting apps).
A large minority also played games
or watched cartoons. Common
Sense Media’s Zero to Eight survey
has found disparities in the use of
educational media on mobile devices,with 54% of children from higherincome families often or sometimes
using educational content on mobile
devices but only 28% of children
from lower-income families doingso.4 Thus, younger children andthose from lower-income families are
more likely to use mobile devices forentertainment purposes.

How Are Media Being Used in Older
Children and Teens Today? Which
Modes of Use Are Most Popular?
Studies show that social media use
patterns and rates among older

FROM THE AMERICAN ACADEMY OF PEDIATRICS

children and adolescents havecontinued to grow over the past
decade, aided in part by the recent
rise in mobile phone use amongchildren and teenagers. At present,
approximately three-quarters ofteenagers own a smartphone, 24%of adolescents describe themselves
as “constantly connected” to theInternet6 and 50% report feeling“addicted” to their phones.7 Mobile
apps provide a breadth of specificfunctions, such as gaming, photoand video sharing, and global
positioning system monitoring.
Social media sites and theirassociated mobile apps provide
a platform for users to create an
online identity, communicate withothers, and build a social network.
Among the myriad accessible social
networking sites, Facebook remains
the most popular, with 71% of 13to 17-year-olds surveyed by the
Pew Research Center in 2014 and2015 reporting using this site/app.6
However, adolescents today do not
typically dedicate themselves tojust 1 site; most teenagers maintaina “social media portfolio” ofseveral selected sites including, as
indicated by rates of use in the Pew
survey, Instagram (52%), Snapchat(41%), Twitter (33%), Google+(33%), Vine (24%), Tumblr (14%),and other social media (11%).6
As communication moves fromface-to-face and voice-only phone
conversations to more screento-screen interactions via apps,
such as FaceTime or Skype, daily
communication is becomingintertwined with screen time.
Texting, using a smartphonekeyboard to send a written message
or a visual symbol (emoji) to anothersmartphone, also has become aprominent means of communication
for teenagers.
Lines are also becoming
blurred between media use
for communication versus forentertainment. With the ability

PEDIATRICS Volume 138, number 5, November 2016

to message your opponent while
engaging in a remote video gameor tweet while watching a TV
show, viewers and gamers often
link their entertainment to social
media. Modes of communication
have become more fluid, withconversations jumping back andforth between text messages tosocial media sites. Text messages
also may include links to media, suchas personal videos, YouTube videos,and links to Web sites and social
networking sites.
Pew data from 2012 suggest thatteenagers between 14 and 17
years of age sent a median of 100
texts a day. With all likelihood, thisnumber will continue to increaseas new data become available.
Texting no longer is limited tocellular phone systems but can befacilitated by messaging apps, suchas Kik or WhatsApp. Pew data from2015 show that these apps are mostpopular with Latino (46%) and
African-American (47%) teenagers,
compared with white teenagers(24%).6
Video games also remain very
popular among families; it isestimated that 4 out of 5 households
own a device used to play video
games, and approximately halfof US homes own a dedicatedgame console.8 Video games also
are available via apps on mobile
devices. Additionally, apps thathave a practical function are also
being marketed with a gaming
perspective; this approach is known
as “gamification.”
It is common for adolescents today
to engage in more than 1 form of
media at the same time, a practicereferred to as media multitasking.
This multitasking may include
watching TV and using a computer9
or being online and engaging in morethan 1 activity. In one study of older
adolescents, approximately 50%of the time students were online,
they were engaged in more than 1
activity.10
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GAMIFICATION AND ADVERTISING
What Is Gamiﬁcation? What Is the
Impact of Gamiﬁcation on Media Use
by Children?
Gamification applies gaming
elements to a real-world activity
in a seamless, user-friendly, andattractive way. Commercial video
games have incorporated cuttingedge graphics, behavioral reinforcers(ie, for reaching certain levels ofplay), and exciting stories, whichhave been delivered throughstationary personal computers,
dedicated gaming consoles, or
multiplayer networks. One key
difference today is the portability
achieved via smartphones, mobile
Wi-Fi, and broad social networks,
which has changed how andwhere games can be played andhow gaming functions can beapplied. These portable “games”
can now be integrated into daily
life by functioning as sources for
information and guidance and byproviding motivation to achieve
academic and wellness goals. For
example, the Nike+ app tracks
exercisers’ routes, pace, steps,
distance, and time and challenges
runners to compete with friends
and improve their performance.
Such design also serves to reinforce
behavior (both health behaviors andfor using the app), resulting in moreengagement with both.11

How Have Mobile and Social Media
Changed the Ability of Advertisers toReach Children and Teenagers?
Newer media have provided
expanding opportunities formarketers and advertisers to adapt
their messages to reach millionsof children and teenagers.12 These
newer forms of media may broaden
the types of products and behaviors
to which children and adolescentsare exposed. For example, although
restrictions may exist to limit
exposure to advertisements foralcohol in traditional media, researche3suggests that the major alcoholbrands maintain a strong presence on
Facebook, Twitter, and YouTube.13,14
From a marketing perspective,social media are consumer focused,allowing interaction and inputthat can build relationships.15
Social media also allow targeted
ads that reflect content that users
have posted on their own pages. In
one study, researchers found that
placing content related to exercise
or nutrition as a status update on
Facebook led to advertisements
for sports gear and diets as well as
junk food.15 Thus, social media ads
can directly address individuals orgroups who would be interested andresponsive. Social media ads may
also be interactive and are more
affordable to create and disseminate.
However, this ability for marketers toreach children through social media
is understudied.
Marketing to parents of young
children also is common, because
advertisers know that many
parents fear that their children
may fall behind in the skilled use oftechnology without early exposure
to it.16 In reality, parents can bereassured that their children willlearn to use digital media quickly
when they are introduced at home orin school.

BENEFITS AND OPPORTUNITIES OF
MEDIA USE
Fortunately, new media use is
not without its benefits, but thesebenefits largely depend on a child’s
age and developmental stage, a child’scharacteristics, how the media areused (eg, with a parent or without),
and the media content and design.

Early Childhood
At What Age Can Infants and Toddlers
Learn From Screens?
Evidence continues to show limited
educational benefits of media forchildren younger than 2 years.
Earlier American Academy ofe4

Pediatrics (AAP) recommendations
to discourage media exposurefor children younger than 2 years
were based on research on TV andvideos, which showed that in-person
interactions with parents are much
more effective than video for learningof new verbal or nonverbal problemsolving skills.17 This research showedthat infants and toddlers experience
what was referred to as the “video
deficit:” difficulty learning from
2-dimensional video representations
at younger than 30 months of age.
The video deficit is thought to be
attributable to infants’ and young
toddlers’ lack of symbolic thinking,immature attentional controls, andthe memory flexibility required
to effectively transfer knowledge
from a 2-dimensional platform to a
3-dimensional world.18 Before 2 yearsof age, children are still developing
cognitive, language, sensorimotor, andsocial-emotional skills, which require
hands-on exploration and social
interaction with trusted caregivers for
successful maturation.
Therefore, adult interaction
remains crucial for toddlers to learn
effectively from digital media. For
example, from 12 to 24 months ofage, toddlers can begin to learn novel
words from commercially available“word learning” videos, but only iftheir parents watch with them andreteach the words, essentially using
the videos as a learning scaffold tobuild the language skills.19,20 In one
longitudinal study of low-income
families, 14-month-olds whose
mothers had talked with them during
educational TV programming since
infancy showed more advanced
language development than infants
whose mothers did not talk withthem during media use (although
this finding also may have reflected
how much mothers spoke to children
in general).21 The few experimental
studies showing independent
learning of words from videos at thisage have been limited by their low
ecologic validity22 or have shown that
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toddlers lose the knowledge learned
over time without repetition.23
More recent research has shown that,
under particular conditions, children
between 15 and 24 months of age
can learn from repeated viewingof video demonstrations without
adult help. Dayanim and Namy
showed that 15-month-olds could
learn the meaning of sign language
symbols after 3 weeks of watchinga commercially available video 4
times per week.24 However, children
in a comparison study group whoseparents used a book of sign language
symbols to teach the content retained
more knowledge about the symbols’
meanings for a longer period of time.
Building parasocial relationships
with TV or video characters (ie, theperceived relationship that audience
members develop with characters
who speak to them, such as Elmo or
Dora) also has been shown to improve
toddlers’ learning. Calvert et al25
showed that, after 3 months of playing
with a personalized interactive toy,
21-month-olds could learn how tostack cups from a video demonstrationby the same character, suggestingthat building an emotional bond withan on-screen character improves
learning potential. However, a primary
limitation of such experimental studies
is that they do not examine how
repeated media use displaces otheractivities, and they do not examine
longer-term outcomes. For example, inthe study by Calvert and colleagues,25
children randomly assigned to
the group that did not receive theinteractive toy for 3 months actually
scored better in terms of language
development at 21 months of age.

Are Touchscreens More Educational?
Pedagogic theory has longemphasized that interaction improves
learning. This understanding
has been the motivation forrecommending coviewing of
media, along with evidence that

FROM THE AMERICAN ACADEMY OF PEDIATRICS

parent interaction increases young
children’s engagement with media
and understanding of content.26
The interactivity of new media via
touchscreens allows apps to “know”
whether a child is responding
accurately and tailor responses,
reinforcement, and next steps to thechild’s input. Theoretically, this may
increase educational potential byproviding scaffolding to build skills at
the child’s edge of competence.
Empirical evidence regarding
interactive media use in infants andtoddlers is sparse. At 24 months ofage, a child can learn words fromlive video-chatting with a responsive
adult27 or from carefully designed,interactive screen interfaces that
prompt the child to tap on relevant
learning items.28 Starting at 15
months of age, toddlers can learn
novel words from touchscreensin laboratory-based studies (withspecially designed, not commercial,apps) but have trouble transferring
this knowledge to the 3-dimensional
world,29 particularly if they regularly
use touchscreen platforms to viewentertainment media.

Is Skyping Appropriate for Infants andToddlers?
Many parents now use video-chat (eg,Skype, Facetime) as an interactive
media form that facilitates social
connection with distant relatives.
New evidence shows that infants andtoddlers regularly engage in videochatting,30 but the same principles
regarding need for parental support
would apply in order for infants andtoddlers to understand what they areseeing. Because video-chat episodes
usually are brief,30 promote social
connection, and involve support fromadults, this practice should not be
discouraged in infants and toddlers.

What Is the Best Approach to Selecting
Quality Content for Young Children?
High-quality TV programs (eg,Public Broadcasting Service [PBS]

PEDIATRICS Volume 138, number 5, November 2016

programs, such as Sesame Street and
Mister Rogers’ Neighborhood) can
demonstrably improve cognitive,
linguistic, and social outcomesfor children 3 to 5 years of age.
Although there have been few large
community-based, randomized
trials, many observational studies
and some small experimental ones
have demonstrated that preschoolers
can learn literacy, numeracy, andprosocial skills from high-quality TV
programs.31,32 In addition, Sesame
Workshop and other child content
creators have been responding
to current child health anddevelopmental needs (eg, obesity,
resilience) by crafting programming
aimed at teaching parents andchildren relevant knowledge andskills.
Choosing PBS content has been foundto be protective of poor executivefunction outcomes observed inchildren who start consuming media
in early infancy.33 Preschoolers
randomly assigned to change frominappropriate or violent content tohigh-quality prosocial programmingwere found to have significant
improvements in their externalizing
and internalizing behavior,32 which
also speaks to the importance ofcontent. For families who find it
difficult to modify the overall amountof media use in their homes, changing
to high-quality content may be amore actionable alternative; to makethese changes, pediatric providers
can direct them toward curation
services, such as Common Sense
Media, for reviews of videos, apps, TVshows, and movies.

Are “Educational” Apps and e-Books
Really Educational?
As content from PBS high-quality
programs is translated into apps andgame formats (eg, Martha Speaks, Big
Bird’s Words, and Cookie Monster’s
Challenge apps), educational benefits
have been shown in preschoolers.34
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in the educational section of appstores have evidence-based design
input with demonstrated learning
effectiveness. In fact, recent reviewsof hundreds of toddler/preschooler
apps labeled as educational havedemonstrated that most apps show
low educational potential, target
only rote academic skills (eg, ABCs,
colors), are not based on establishedcurricula, and include almost no
input from developmental specialists
or educators.35,36 An additional
concern is that the formal features(ie, bells and whistles) that aredesigned to engage the child in aninteractive experience may actually
decrease the child’s comprehension
or distract from social interaction
between caregivers and children
during use, as has been shownfor e-books,37 which is important,because active parent involvement
in both digital play and book reading
improves children’s learning fromthe experience.38,39
One reason that children may beless socially engaged during digitalplay is that gaming design involves
behavioral reinforcement meant
to achieve a maximum duration ofengagement, which may explain
why interrupting children’s digitalplay leads to tantrums, particularly
when games or videos are set on
autoadvance.40 To address theseconcerns, academic and industry
leaders have recently recommended
creating digital products for childrenthat are appropriately engaging, but
not distracting; that are designed
to be used by a dual audience (ie,both parent and child) to facilitatefamily participation in media use andmodeling of more effective social andlearning interactions35,41; and thathave automatic “stops” as the default
design to encourage children andcaregivers to pause the game use andturn to the 3-dimensional world.40
One recent app, for example,
demonstrates such an adult–childdyad-centered design. Bedtime Mathcreates a platform and a structure fore5parents and children to read stories
and answer math problems together
on a nightly basis. It is one of the
few apps that has been tested in arandomized controlled communitybased trial and shown benefits.42
Embedding, indeed requiring, social
interactivity for functionality may
hold great promise for even younger
children as well. However, recent
population-based surveys suggestthat joint media engagement43 (anddesigns to facilitate it)35 is not as
common as individual use.

School-Aged Children and Teenagers
How Can Media Use in Older Children
and Teenagers Increase Collaboration
and Tolerance?
Research studies as well as anecdotalreports have suggested benefits ofmedia use for today’s children andadolescents, such as communicationand engagement.44 Additional benefits
include exposure to new ideas andimmersive learning experiences.
Many social media platforms provide
tools that students can use to touchbase with and collaborate withothers on projects. Communicating
across distance is made easier bysocial media; these communications
may include connecting via videochatting with family or friends
who are separated geographically.
Traditional and social media can also
raise awareness of current eventsand issues, and social media canprovide tools to promote community
participation and civic engagement.
A study by Kidd and Castano45
indicated that reading literary fiction
improves empathy in children.
Although books are a traditional
form of media, the study indicatesthat exposure to character-focused
media can break stereotypes andhelp children understand people
from whom they differ. Internet
usage/digital media consumption
is positioned to have a similar
impact, which is important to help
children learn about, understand, andempathize with marginalized groups.

e6

How Can Social Media Be Used To
Promote Improved Health?
Health benefits of social media may
include enhanced access to valuable
support networks. These networks
may be particularly helpful forpatients with ongoing illnesses,
conditions, or disabilities46 as well as
for those identifying as lesbian, gay,bisexual, transgender, questioning,or intersex (LGBTQI) seeking
helpful information or a welcoming
community. Recent literature
indicates that transgender teenagers
who feel supported by their families
have lower rates of depression
and anxiety.47 Connections with asupportive online community (eg,the “It Gets Better” project) may bebeneficial to teenagers who identify
as LGBTQI, but most such programs
have not been studied to determine
effects and outcomes.
Research also supports the use ofsocial media to foster social inclusionor peer-to-peer connection among
patients who might otherwise feel
excluded, for example, patientswith obesity48 or mental illness.13
Individuals with mental illness report
greater social connectedness andfeelings of group belonging whenusing social media in this manner,because they foster the ability toshare personal stories and strategies
for coping with challenges.14 The
advantages of these connections
include avoiding feared stigma,
enhancing social networks, learning
about resources from peers online,
and gaining information andinsight. However, risks of suchinteractions can include exposure
to misinformation, negativity or
hostility in communications, delays inseeking out traditional resources, andunhealthy influences.
Young adults describe the benefitsof seeking health information
online and through social media
and recognize these channels as
useful supplementary sources of
information to health care visits.15
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Social media may be used to enhance
health and wellness and promotehealthier behaviors, such as smoking
cessation and balanced nutrition.44
However, there are a myriad ofeasily accessible Web sites andsocial networks that facilitate andeven promote unhealthy behaviors,such as disordered eating. “Pro-ana”(anorexia nervosa) and “pro-mia(bulimia)” sites, for example, areforums in which peers actively
support restricted eating or purging
and frequently offer life-threatening
suggestions and advice.49

Do Screen Time Limits Apply forChildren With Disabilities Who Use
Mobile Devices To Communicate?
An important benefit from new
media has been the development anduse of technology-aided interventions
in children and adolescents withdisabilities, particularly throughthe expanding use of assistive andinteractive digital media to learn andto communicate in youth with autism
spectrum disorder (ASD),50 physicaldisabilities, speech impairment, andintellectual disability to learn andcommunicate.51 However, because
teenagers with ASD have higher
rates of problematic media use,52,53
limits still should be placed onentertainment media use, suchas watching videos or playing
gaming apps, which can represent a
restricted interest in children withASD.

HEALTH AND DEVELOPMENTAL RISKSOF MEDIA USE
What Are the Developmental and
Behavioral Risks in Early Childhood?
Population-based studies continue
to show associations between
excessive TV viewing in earlychildhood and cognitive,54–56
language,57,58 and social/emotional
delays.59–62 Possible mechanisms
for these outcomes include theeffects of viewing inappropriate,
adult-oriented content54 (as well as

FROM THE AMERICAN ACADEMY OF PEDIATRICS

some inappropriate child-directed
content),58 a decrease in parent–childinteraction when the TV is on,63
and poorer family functioning inhouseholds with high media use.60
An earlier age of media use onset,
greater cumulative hours of media
use, and content that is not ofhigh quality all are significant
independent predictors of poor
executive functioning (impulse
control, self-regulation, mental
flexibility)33 as well as “theory ofmind” deficits (ie, the ability tounderstand others’ thoughts andfeelings) in preschoolers.64 Media
multitasking, once thought to be apastime only of only adolescents,
now is observed even in children
younger than 4 years.13 The orienting
response to novel stimuli is verystrong in young children, so theirattention is drawn to the engaging
and quickly changing features ofdigital media, such as animation,
sounds, and highlighted features
they can tap and swipe.65 Thesefeatures, however, may decrease
young children’s comprehension.66
It is unknown whether rapid shifts
in attention to and from digital
stimuli may have long-term effects
on children’s attention span orinformation processing.
Because strong associations between
violent media content and childaggressive behavior have beenclearly documented,67 parents should
continue to monitor the content of
their children’s media. Today, morechildren own and use mobile devices
independently,13 making monitoring
and regulation much more difficult.16,68
More research is needed on how
parents can best supervise and guidetheir children’s media use.

Are Certain Children or Families
More Susceptible to These Risks?
TV has been used as an “electronicbabysitter” for decades, but recent
evidence suggests that excessive
media use is more likely in infants
and toddlers with a “difficult”

PEDIATRICS Volume 138, number 5, November 2016

temperament69,70 or self-regulation
problems.71 Toddlers with socialemotional delays are more likely
to be given a mobile device to calm
them down,72 especially if theirparents are facing parenting control
challenges. However, it is not clear
whether more “difficult” infants
and toddlers have more positiveor negative outcomes over time
when exposed to longer media
duration, which likely depends
on content quality and othercontextual factors. For example,
Linebarger et al73 found that thequality of parenting can modify
associations between media use andchild development: inappropriate
content and inconsistent parenting
had cumulative negative effects on
low-income preschoolers’ executivefunction, and warm parenting andeducational content interacted to
produce additive benefits.

Is Media Use Linked to Obesity?
High levels of media use are linked
to obesity and cardiovascular risk74
throughout the life course, but theseassociations are observed startingin early childhood. For example,
heavy media use during preschool
years is associated with small but
significant increases in BMI,75 whichsets the stage for greater weight gain
later in childhood. The association
between using ≥2 hours of media per
day and obesity persists even after
adjusting for children’s psychosocial
risk factors or behavioral problems.76
Research in preschoolers often uses
a 2-hour cutoff to define excessive
media use, but a recent study of
2-year-olds found that BMI increased
for every hour per week of media
consumed.77 Moreover, media use
behaviors may explain some of theobesity risk disparities among young
black and Hispanic children.78 Noneof these studies examined mobile
media specifically, which may be
more easily used during meals and,
therefore, distract children fromsatiety cues.79
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Studies of older children andteenagers show clear correlations
between increases in hours of TV
viewing and higher risk of obesity.80
In a 1996 study of 5- to 10-year-olds,
the odds of being overweight were
4.6 times greater for youth watching
more than 5 hours of TV per daycompared with those watching 0 to 2
hours.81 This study greatly influenced
the AAP recommendations for 2
hours or less of sedentary screen
time daily for children 2 through18 years of age. However, a more
recent study in the Netherlands ofchildren 4 through 13 years of age
found that watching TV over 1.5
hours per day was a significant
risk factor for obesity. In this study,
however, an association between
TV and obesity was only found forchildren 4 through 9 years of age.82
A large international study with almost
300 000 children and adolescents
found that watching between 1 and3 hours of TV a day led to a 10%
to 27% increase in risk of obesity.83
These more recent studies suggestthat setting limits of TV viewing to
between 1 and 1.5 hours a day
may be more effective to prevent
obesity than the 2 hours per day
standard presented in earlier AAP
recommendations.
Additional studies have identified
relevant factors around TV viewing
beyond solely the number of hours
for families to use in developing
household rules. Another recent
study found that the association
between TV viewing and obesity risk
was only significant for children who
were already at the higher end of
the BMI distribution.84 A large study
using a national dataset of children
reported that it was not just thehours of TV viewing that predictedobesity, but the combination of
low physical activity and highsedentary TV viewing that was mostcontributory to obesity risk.85 A
2008 study directly examined the
AAP recommendations for 2 hours
a day or less of sedentary media

e7consumption and found that boys
who exceeded 2 hours a day ofsedentary media use were 1.7
times more likely to be overweightcompared with those who had 2
hours a day or less of sedentary
media use. The results for girls weremuch less impressive, in that girls
with over 2 hours a day of sedentary
media use were only 1.2 times more
likely to be overweight comparedwith girls who had 2 hours or less of
media use time.86
The association between TV viewing
and obesity previously attributed
to food advertising87 may now be
decreased, because children watch
more videos from streaming services(eg, Netflix, Hulu), which do notcontain advertisements, but this has
yet to be studied.
Another area of obesity risk is thepresence of a TV in the bedroom. A
2007 study found that having a TV
in the bedroom was an independentrisk factor for obesity. A more recent
study found that the combinationof a TV in the bedroom and greateruse of screen time had the strongest
association with obesity.88
Fortunately, studies also suggestthat making efforts to reducechildren’s sedentary media use
can have positive health effects. Anintervention study focused on thirdand fourth graders worked with theparticipants to reduce time spent
watching TV and playing video
games. The study demonstrated
that children in the intervention
group reported reduced TV viewing
and meals in front of the TV andhad reduced BMIs, illustrating thatinterventions to reduce sedentary
media use can positively impact
health behaviors as well as BMI.89

How Does Media Use Affect Sleep?
There is a growing body of evidence
that suggests that media use
negatively affects sleep.90 Increased
duration of media exposure andthe presence of a TV, computer, ore8

mobile device in the bedroom inearly childhood have been associatedwith fewer minutes of sleep pernight, especially among childrenof racial/ethnic minority groups.91
Later bedtimes after evening media
use and violent content in the media
also may be contributing factors,92
and suppression of endogenous
melatonin by blue light emitted fromscreens is another possible cause.93
Associations between media andsleep are seen in infants as well; 6- to
12-month-olds who were exposed toscreen media in the evening hours
showed significantly shorter nighttime sleep duration than those who
had no evening screen exposure.94
Studies of older children andteenagers have found thatparticipants with higher social media
use95 or who sleep with mobile
devices in their room96,97 were at
greater risk for sleep disturbances.
One study of adults found that taking
a phone into the bedroom led tolonger sleep latency, worse sleep
quality, more sleep disturbance,and more daytime dysfunction.98
This study illustrates the multiple
mechanisms by which media use
around bedtime, or during bedtime,
can disrupt sleep and affect daytime
function.
Bruni et al90 studied the use oftechnology on sleep quality inadolescents and preadolescents.
Adolescents’ bad sleep quality was
associated consistently with greater
mobile phone use and the numberof devices in the bedroom, and inpreadolescents, bad sleep quality
was associated with greater Internet
use and later media turn-off time.
The authors concluded that evening
circadian preference, mobile phone
and Internet use, the number of otheractivities engaged in after 9:00 PM,
later media turning-off time, and thenumber of devices in the bedroom
have different, but significant,negative influences on sleep quality
in preadolescents and adolescents.90
Similarly, Lemola et al99 reported
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associations between electronic
media use in bed before sleep,
sleep difficulties, and symptoms ofdepression in teenagers.
Daytime screen use may also affectsleep. According to a Norwegianstudy, daytime and bedtime useof electronic devices both affected
sleep measures, with an increased
risk of short sleep duration, long
sleep onset latency, and increased
sleep deficiency. A dose–response
relationship emerged between
sleep duration and use of electronic
devices.100 Ensuring that children
and teenagers obtain the necessary
hours of healthy sleep is an
important goal of a Family MediaUse Plan (www.healthychildren.org/
MediaUsePlan).

What Are the Risks of Social MediaUse In School-Aged Children and
Teenagers?
The links between media and healthbehaviors among adolescents
have been backed by decades ofevidence in traditional media.101–104
Studies have shown that exposure
to alcohol or tobacco use or risky
sexual behaviors in TV or movies is
associated with initiation of thesebehaviors,101,102,105,106 leading someto describe TV as a “superpeer.”107
A growing body of evidence suggeststhat these influences also arestrong in digital and social media.
Several studies have illustrated
that adolescents’ displays on social
media frequently include portrayalof risky health behaviors, such as
illegal alcohol use or overuse, illicit
substance use, high-risk sexual
behaviors, and harmful behaviors,such as self-injury and disorderedeating.108–112 A growing body ofevidence suggests that peer viewersof this content are influenced tosee these behaviors as normativeand desirable.113–115 Social media
combine the power of interpersonal
persuasion with the reach ofmass media. Fogg described thismass interpersonal persuasion as

FROM THE AMERICAN ACADEMY OF PEDIATRICS

“the most significant advance inpersuasion since radio was invented
in the 1890s.”116

when more TV viewing displaces
real-life experiences that might build
self-esteem.

Although restrictions exist to protect
youth and children from exposure
to alcohol, tobacco, and marijuana
advertisements on traditional media
platforms, such as TV, there isconcern about the extent to whichyouth are exposed to promotion ofthese substances on social media
Web sites from marketers or peers.
For example, research from boththe United States and the United
Kingdom indicate that the major
alcohol brands maintain a strong
advertising presence on Facebook,
Twitter, and YouTube.13,14 Targeted
advertising via social media may
have a significant effect on adolescentbehavior.

The interactive and selective
components of social media may
offset some of these traditional media
drawbacks, because social media
use in moderation can enhancesocial support and connection.
However, use in moderation and thespecific way in which social media
are used may be the key. Previous
research has suggested a U-shaped
relationship between Internet use
and depression, with increased
risks for depression at both the highand low ends of Internet use.118,119
A recent study examined social
media use and depression and founda positive association.120 Olderadolescents who used social media
passively by solely viewing content
reported declines in well-being
and life satisfaction, whereas those
who used social media actively byinteracting with others and posting
content did not experience thesedeclines.121 Another study found thatteenagers who used Instagram tofollow strangers and engage in social
comparisons had higher depression
symptoms, but others who followed
friends and engaged in less social
comparison had fewer depression
symptoms.122 These studies illustrate
that, beyond the number of hours
spent on social media, a key factor is
how an individual uses social media.

How Does Media Use in School-Aged
Children and Teenagers Relate to
Mental Health?
Research studies have identified
both benefits and concerns regarding
mental health and media use. In one
longitudinal panel survey, 396 whiteand black preadolescent boys andgirls were assessed to determine thelong-term effects of TV consumption
on global self-esteem. TV exposure
was found to be significantly related
to self-esteem, but whether it
increased or decreased self-esteem
was influenced by demographic
factors. Greater exposure resulted in adecrease in self-esteem for both whiteand black girls and for black boys but
resulted in an increase in self-esteem
for white boys.117 Analyzing theseresults, the authors postulate thatthe majority of the TV content served
to reinforce both gender-role andracial stereotypes, which tended to
be positive for white boys but not theother groups. The authors suggested
that the black children and whitegirls could be internalizing the “social
norms” portrayed and using thesemessages as a basis for self-evaluation,negatively affecting their self-esteem.
There is also an opportunity cost

PEDIATRICS Volume 138, number 5, November 2016

Do Children and Adolescents
Understand the Privacy Risks
Associated With Social Media Use?
An important issue across all social
media and interactive apps is privacy,
because content that a child or
adolescent chooses to post on any
site or app becomes public in someway. Removal of such content may
be difficult or impossible. Previous
work suggests that adolescents varyin their understanding of privacy
practices, and even among those who
do know how to set privacy settings,
many choose not to do so.123–125
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Despite efforts by some social media
sites to protect privacy or even todelete content after it is viewed,
privacy violations and content
sharing are always possible.126,127
This risk illustrates the need forcontinued discussion about media
and privacy with children andteenagers with parents, caregivers,
teachers, and other responsible
adults. These discussions should be
included in schools through theirdigital citizenship programs and inpediatric well-child examinations
with parents and teenagers.
Pediatricians can introduce andwork with families to develop a
Family Media Use Plan (see the AAP
guide to making a plan at www.
healthychildren.org/MediaUsePlan)
that can mitigate or avoid such risks.

Is Cyberbullying Different From
Traditional Bullying?
Cyberbullying is commonly defined
as “an aggressive, intentional
act or behavior that is carriedout by a group or an individual,using electronic forms of contact,repeatedly and over time against avictim who cannot easily defend him
or herself.”128 Unfortunately, there
are many online platforms in whichbullying may take place, including
E-mail, blogs, social networking
Web sites/apps, online games,
and text messaging. There is clear
overlap between cyberbullying andtraditional bullying,129 but several
features of online bullying present
new challenges. These challenges
include that perpetrators canbully at any time of day and can beanonymous, the rapidity with which
information can spread online,130
and the fluidity with which bully andtarget roles can switch in the online
world. Estimates of the number ofyouth who experience cyberbullying
vary, ranging from 10% to 40%,
depending on the age group and how
cyberbullying is defined.
Cyberbullying shares many
similarities and a few key differencese9with traditional bullying. For
example, victims of cyberbullying
often do not know who the bully isor why they are being targeted, thehurtful actions of a cyberbully canreach a child or teenager anytime
he or she uses a smartphone orcomputer (so there is no safe havenof home), and the bullying messages
can also spread virally through theInternet to many other people atschool or in the community, making
this type of bullying potentially very
embarrassing and lasting.
Descriptive research has shownthat vulnerable populations exist
and are more likely to be targeted
for bullying. Youths identifying
as LGBTQI are more likely to be
victimized in bullying dynamics
and are at risk online as well.131
Children and adolescents with
ASD are a population particularly
vulnerable to bullying (https://www.
autismspeaks.org/family-services/bullying) and could easily be a target
for cyberbullying. The 2016 National
Academies of Sciences, Engineering,and Medicine report, “Preventing
Bullying Through Science, Policy,
and Practice,”132 addressed theconcept of populations vulnerable
to bullying to propose that there is aneed for research that moves beyond
descriptive studies and labeling ofyouth as vulnerable and considers
processes that can explain why
individuals may have differencesin their bullying experiences andconsequences depending on theircontext.
Previous studies have examined thenegative effects that cyberbullying
can have on both bullies andvictims. Victims are more likely
to report lower grades and otheracademic problems as a result of theexperience. Similar to traditional
bullying, cyberbullying can lead toshort- and long-term133,134 negativesocial, academic, and health134–137
consequences for both theperpetrator and target. Both bullies
and victims often report higher

e10levels of depression and lower selfesteem. Victims were at higher riskof both suicidal ideation and suicide
attempts.
Fortunately, newer studies suggestthat interventions targeting bullying
also may reduce cyberbullying.138
Moreno states: “Parents can playa role in preventing cyberbullying
by educating their children about
appropriate online behaviors. Parents
should have discussions early andoften about their child’s friendships
and relationships to develop andmaintain open communication
about these topics.”139 The Centers
for Disease Control and Prevention
panel reviewing effective prevention
strategies recommends media
literacy education as a “promising
approach,” along with collaborative
strategies among teenagers, parents,and schools that encourage victims toreport cyberbullying and seek adultsupport.140

What Is Sexting and How Can the
Risks of Sexting Be Avoided or
Addressed?
Sexting is a serious issue inadolescence. Sexting is commonly
defined as the electronictransmission of nude or seminude
images as well as sexually explicit
text messages.111 It is estimated thatapproximately 12% of youth 10 to 19
years of age have ever sent a sexualphoto to someone else112; sadly,
many youth who have participated in
sexting report having felt pressured
into sending a sext. When dealing
with youth and sexting, adults,
authorities, and schools need to beaware that the situation may be more
complicated.
Spencer et al141 examined sexting
and youth in an urban population;
55 youth presenting for care at the
Teen Health Center at Children’s
Hospital Los Angeles were surveyed
to evaluate prevalence and sexting
behaviors, such as forwarding sexts,
reasons for sending sexts, and youths’
concerns regarding sexting. Of those
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surveyed, 48.5% of girls and 63.6%
of boys had sent a sext, and 70% ofgirls and 82% of boys had received
a sext. The authors report that girls
expressed significantly more concern
than boys about how sexting could
affect their reputation, including
getting caught by an adult with a sext
and how others would think of them.
Fortunately, 52% of respondents said
they would be comfortable talking
with their doctor about sexting.
Pediatricians may, therefore, findtheir teen patients receptive to aconversation about sexting and its
implications and risks.
Ybarra and Mitchell, in their article,“‘Sexting’ and its relation to sexual
activity and sexual risk behavior in anational survey of adolescents,”142
suggest that sexting is related tobehaviors indicative of psychosocial
challenge and risky sexual behavior
for some youth. Significant findings
include a higher frequency of sexting
among females and lesbian, gay,and bisexual youth. Additionally,a greater number of past-year sex
partners and a greater odds ofdepression and substance abuse
were found among teenagers who
sext.
Findings related to lesbian, gay, andbisexual populations are consistent
with previous studies on sexting;of note, transgender youth were
not included. Earlier research
had demonstrated a significant
association between sexting andrisky sexual behaviors in lesbian, gay,bisexual, and transgender youth.142
Ybarra and Mitchell’s study142 foundthat sexting was indicative of sexual
activity and risky sexual behaviors,and further research may identify
predictive outcomes of sexting.
One study suggests that sexting
may precede sexual intercourse.142
The predictive value of a sexting
history may inform sex educationand HEEADSSS (home, education& employment, eating, activities,
drugs, sexuality, suicide/depression,

FROM THE AMERICAN ACADEMY OF PEDIATRICS

and safety) assessments. Moreover,discussions between pediatricians
and teenagers about sexting may
indicate risky sexual behaviors anda number of psychosocial issues,
such as depression, anxiety, andlow self-esteem, that may be further
addressed.
Temple et al143 examined whether
adolescents who report sexting
exhibited more psychosocial healthproblems than their nonsexting
counterparts. The authors reported
that teen sexting was significantly
associated with symptoms ofdepression, impulsivity, andsubstance use. When adjusted forprevious sexual behavior, age,gender, race/ethnicity, and parent
education, however, sexting was only
related to impulsivity and substanceuse. The authors concluded that“while teen sexting appears tocorrelate with impulsive and highrisk behaviors (substance use), we
did not find sexting to be a marker ofmental health.”143
Sexting is a behavior that will
likely continue and expand withtechnologic advances that makephotography and communication
more accessible. Active debate
continues regarding the ethicaland legal components of sexting,especially among underage youth.
Concerns include the identificationof sexts as pornography or sexual
misconduct. Even consensual,noncoercive sexting may result incriminal prosecution that may lead to
long-term legal consequences.
Addressing risky sexual behaviors
and psychological symptoms
associated with sexting througheducation and guidance should
help to promote wellness andresponsibility within adolescentpopulations. Further researchevaluating sexting among
gender minority populations (eg,transgender adolescents) also
will be valuable in understanding
and discouraging the behavior

PEDIATRICS Volume 138, number 5, November 2016

and providing safer and less risky
alternatives for social connections.

CHILD PORNOGRAPHY AND CHILD
ABUSEHow Has Social Media Changed theLandscape of Child Pornography andChild Abuse?
Unfortunately, the Internet has
also created opportunities forthe exploitation of children bysex offenders. Online predators
can gain access to children andteenagers through social networking,chat rooms, E-mail, and online
games. Cases of child trafficking,cybergrooming, and sexual abusefor private and commercial
purposes have increased with thehelp of the anonymous cyberspaceenvironment. For example, online
grooming leads to establishment ofa trusting relationship, often withthe perpetrator misrepresenting
himself as another child or teenager.
This developing online relationshipmay lead to sexting or to convincing
the child to meet the perpetrator inperson. Children may be deceived,
tricked, or coerced into engaging
in sexual acts for the productionof child sexual abuse materials(child pornography), which thencan circulate online for years tocome. Child sexual abuse images
often involve young and very young
children. Of 43 597 children assessedin sexual abuse images and videos,
49.6% appeared to have a sexual
maturity rating of 1, and 28.7%
appeared to have a sexual maturity
rating of 2.144 Besides the adverse
effects associated with child sexual
abuse,145,146 victims who have had
online sexual images (pornography
and sexting) posted may experiencesignificant anxiety and stress related
to knowledge that the abuse images
may be downloaded and viewed bymillions of people for an indefinite
period of time. Thus, the exploitation
continues for months and years after
the images were obtained.144
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Online child sexual exploitation
also may involve recruitment andadvertisement of children for
prostitution and other forms of
exploitation.147 The Internet may
be used by human traffickers tofacilitate movement of victims and to
manage a criminal network.148
Internet-initiated sex crimes
involving offenders who meet andgroom children online tend to involve
adolescents rather than very young
children: 99% of victims in one
study were 13 to 17 years old, and
48% were 13 to 14 years old. Manyof these crimes involve face-to-facesexual contact, which the victim
perceives as “consensual.” Sexual
relationships in early adolescenceare associated with an increased riskof social, academic, and behavioral
adverse outcomes.149,150
Research has shown that parents
underestimate the likelihood that
their child might engage in online
conversation with people they do
not know. Therefore, it is criticalthat parents promote online safetywith their children from an early age,monitor children’s Internet use, anduse tools, such as parental control
software, to maintain awarenessof their child’s online activities.151
Pediatricians should consider
asking appropriate questions to
explore this possibility and toeducate youth about protecting
themselves from exploitation. All
health care professionals shouldreport any suspicions of sexual
abuse/exploitation as per child abuse
reporting laws.

USE OF MEDIA BY PARENTS AND
CAREGIVERS
What Effect Does Parent Media Use
Have on Young and School-Aged
Children and Teenagers?
Parents and caregivers play animportant role in modeling optimal
behaviors for their children ingeneral, including when it comes toe11

the consumption and use of media.
The growth of digital and social
media, particularly in the last 5
years, has seen dramatic increases inadults’ use of social media as well as
use by children and teenagers; morethan 70% of adults now use social
media152 and 27% report feeling“addicted” to their mobile devices.7
Social media can provide positivesocial experiences for adults, such asopportunities for parents to connect
with their child in a college dorm
via video-chatting services. Suchservices also can promote social andemotional connection among distantrelatives or deployed parents andchildren. However, some parents can,themselves, overuse digital media.
For example, research has shown thatparents’ own TV viewing distracts
from parent–child interactions153 andchildren’s play.154 Children younger
than 2 years are more likely to be
exposed to and watch inappropriate“background” media (eg, TV) thanolder children.155 Heavy parent
use of mobile devices is associatedwith fewer verbal and nonverbal
interactions between parents andchildren156 and may be associatedwith more parent–child conflict.157
Because parent media use is a strong
predictor of child media habits,158
reducing parental TV viewing,
including “background” TV, andenhancing parent–child interactions
may be an important area of behavior
change that pediatricians can help
to facilitate. Because parent–childinteractions during family routines
are an important opportunity foremotional connection, have beenshown to be protective of childhealth outcomes, such as asthma andhigh-risk behavior,159 and are theprimary driver of early childhood
development of language, cognition,social skills, and emotion regulation,
it is important to preserve them.
Parents often report feeling thattechnology speeds up their lives
and work demands160 and that itis difficult to multitask between

e12

technology and childrearing, so
pediatric providers can support
their efforts to create boundaries
and “unplugged” zones in theirhouseholds.

THE FAMILY MEDIA USE PLAN
• How can pediatric health careproviders help families use media
in healthy ways?

• What is the AAP Family Media Use
Plan?
Pediatricians and other pediatrichealth care professionals can be
helpful resources for families seeking
specific advice about how to develop
and individualize family rules andguidelines to meet their distinct
needs. Unfortunately, only 16% of
pediatricians ask families about
their media use. In addition, only
29% of parents report relying on
their pediatrician for advice aboutbroadcast and social media, althoughthose who do tend to follow AAP
recommendations.161
When discussing media use withfamilies, pediatric health careproviders can print out and help
families begin completing the AAP
Family Media Use Plan (www.
healthychildren.org/MediaUsePlan).
Providers can discuss with parents
and developmentally ready children
how each of the media-specificbehaviors and health concerns can beaddressed through practical, familycentered approaches. The Family
Media Use Plan can act as a teachingtool through which pediatricians
can provide information about thebenefits and health risks of bothtraditional and new media. The
potential risks of interactive media,
such as reduced physical activity,
inadequate sleep, and unhealthy
influences like cyberbullying andweight bias, are important to discusswith families as well.
The plan also can be a tool throughwhich the pediatrician can explore
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and understand each family’s values
and health goals—for example, howgood nutrition, an active lifestyle,good sleep hygiene, parent–childemotional connection, and creative
play fit into the family’s typical day—and identify areas in which good
health and wellness can be enhanced.
Pediatricians can suggest ways inwhich media can be used to connect,learn, and create instead of simply
consume.
These discussions can also allow
pediatric health care providers toconsider screening for problematicInternet use and Internet gaming
disorder using validated tools, suchas the Internet Gaming Disorderscale (https://www.researchgate.
net/publication/270652917_The_
Internet_Gaming_Disorder_Scale) and
the Problematic and Risky Internet
Use Screening Scale (http://mediad.
publicbroadcasting.net/p/kplu/
files/201502/PRIUSS_scale_and_guidelines.pdf).
If challenges in implementing a
media use plan are anticipated,
pediatric health care providers canconsider introducing motivational
interviewing or engaging in problem
solving with parents and children
about possible solutions. The
pediatrician has an opportunity to
discuss specific tools to address
identified family needs and concerns,
including social services andcommunity resources, if needed.
Finally, the pediatrician may be able
to provide families with referrals
to educational and informational
resources, such as vetted Web sites(eg, www.HealthyChildren.org).

CONCLUSIONS
New digital and social media
facilitate and promote social
interactions as well as participationand engagement that involve bothviewing and creating content. The
effects of media use, however, aremultifactorial and depend on the

FROM THE AMERICAN ACADEMY OF PEDIATRICS

type of media, the type of use, theamount and extent of use, and thecharacteristics of the individual
child or adolescent using the media.
Children today are growing up
in an era of highly personalized
media use experiences; therefore,
parents should be encouraged todevelop personalized Family MediaUse Plans for their families that
attend to each child’s age, health,temperament, and developmental
stage and ensure that each childcan practice and benefit from theessentials for healthy growth anddevelopment, such as a healthy
diet, good sleep hygiene, adequate
physical activity, and positive social
interactions.
Parents should recognize andunderstand their own roles inmodeling appropriate media use
and balance between media timeand other activities. Pediatricians
can help families identify andadopt a healthy Family Media Use
Plan, minimize unhealthy habits
and behaviors, and recognize andaddress issues that occur related
to the use of traditional and new
media that can negatively affecthealth, wellness, social and personal
development, and academic
performance and success.
LEAD AUTHORS
Yolanda (Linda) Reid Chassiakos, MD, FAAP
Jenny Radesky, MD, FAAP
Dimitri Christakis, MD, FAAP
Megan A. Moreno, MD, MSEd, MPH, FAAP
Corinn Cross, MD, FAAP

COUNCIL ON COMMUNICATIONS AND MEDIAEXECUTIVE COMMITTEE, 2016–2017
David Hill, MD, FAAP, Chairperson
Nusheen Ameenuddin, MD, MPH, FAAP
Yolanda (Linda) Reid Chassiakos, MD, FAAP
Corinn Cross, MD, FAAP
Jenny Radesky, MD, FAAP
Jeffrey Hutchinson, MD, FAAP
Rhea Boyd, MD, FAAP
Robert Mendelson, MD, FAAP
Megan A. Moreno, MD, MSEd, MPH, FAAP
Justin Smith, MD, FAAP
Wendy Sue Swanson, MD, MBE, FAAPPEDIATRICS Volume 138, number 5, November 2016

LIAISONS
Kris Kaliebe, MD – American Academy of Childand Adolescent Psychiatry
Jennifer Pomeranz, JD, MPH – American Public
Health Association
Brian Wilcox, PhD – American Psychological
Association

STAFF
Thomas McPheron

ABBREVIATIONSAAP: American Academy of
Pediatrics
app: application
ASD: autism spectrum disorder
LGBTQI: lesbian, gay, bisexual,
transgender,
questioning, or intersex
PBS: Public Broadcasting Service
TV: television

Balance. San Francisco, CA: Common
Sense Media; 2016, Available athttps://www.commonsensemedia.
org/research/technology-addictionconcern-controversy-and-ﬁndingbalance. Accessed May 16, 2016
8. Entertainment Software Association.
2015 Sales, Demographic, and Usage
Data. Essential Facts About theComputer and Video Game Industry.
Washington, DC: Entertainment
Software Association; 2015
9. Brasel SA, Gips J. Media multitasking
behavior: concurrent television andcomputer usage. Cyberpsychol Behav
Soc Netw. 2011;14(9):527–534
10. Moreno MA, Jelenchick L, Koff R,
Eickhoff JE, Diermyer C, Christakis DA.
Internet use and multitasking amongolder adolescents: an experiencesampling approach. Comput Human
Behav. 2012;28(4):1097–1102
11. Kim B. The popularity of gamiﬁcation in
the mobile and social era. Libr Technol
Rep. 2015;51(2):5–9

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

Children and Adolescents and Digital Media
Yolanda (Linda) Reid Chassiakos, Jenny Radesky, Dimitri Christakis, Megan A.
Moreno, Corinn Cross and COUNCIL ON COMMUNICATIONS AND MEDIA
Pediatrics; originally published online October 21, 2016;
DOI: 10.1542/peds.2016-2593
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2016 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Children and Adolescents and Digital Media
Yolanda (Linda) Reid Chassiakos, Jenny Radesky, Dimitri Christakis, Megan A.
Moreno, Corinn Cross and COUNCIL ON COMMUNICATIONS AND MEDIA
Pediatrics; originally published online October 21, 2016;
DOI: 10.1542/peds.2016-2593

The online version of this article, along with updated information and services, islocated on the World Wide Web at:/content/early/2016/10/19/peds.2016-2593.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2016 by the American Academyof Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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