Section: Paediatrics

Original Research Article EXPLORING THE EFFECTS OF SCREEN TIME ON

COGNITIVE DEVELOPMENT IN CHILDREN UNDER
FIVE YEARS: A CRITICAL ANALYSIS

Pavan Todeti1, Prathyusha Yellamelli2

Received : 08/10/2024
Received in revised form : 21/11/2024 1
Accepted : 06/12/2024 Assistant Professor, Department of Paediatrics, Government Medical College and Hospital,
Mahbubabad, Telangana, India
2
Assistant Professor, Department of Paediatrics, Government Medical College and Hospital,
Keywords: Khammam, Telangana, India
Screen time, Cognitive development,
Early childhood, Communication skills,
Problem-solving, Pediatric health. Abstract
Background: The increasing prevalence of screen time among young children
Corresponding Author:
Dr. Prathyusha Yellamelli,
has raised concerns about its potential impact on cognitive development. Early
Email: prathyusha.yellamelli@gmail.com childhood is a critical period for brain development, making it essential to
understand how screen exposure affects cognitive milestones. The objective is
DOI: 10.47009/jamp.2024.6.6.121
to evaluate the relationship between screen time and cognitive development in
Source of Support: Nil, children under five years of age. Materials and Methods: A cross-sectional
Conflict of Interest: None declared
study was conducted on 100 children aged 6 months to 5 years at a pediatric
Int J Acad Med Pharm outpatient clinic. Data on daily screen time exposure were collected through
2024; 6 (6); 635-640
parent-reported questionnaires. Cognitive development was assessed using the
Ages and Stages Questionnaire (ASQ-3). Multivariate regression analysis was
used to determine the association between screen time and cognitive outcomes,
adjusting for potential confounders, including socioeconomic status, parental
education, and household environment. Result: Excessive screen time (>2
hours/day) was observed in 45% of participants. Children with higher screen
time had significantly lower scores in problem-solving and communication
domains (p < 0.01). Screen time exceeding 2 hours/day was associated with a
2.8-fold increased risk of cognitive delays (OR: 2.8, 95% CI: 1.6–4.5, p < 0.01).
Adjusted analyses revealed that interactive screen use (e.g., educational apps)
was less detrimental compared to passive screen time (e.g., watching videos).
Conclusion: Excessive screen time in children under five years negatively
impacts cognitive development, particularly in problem-solving and
communication domains. Limiting screen exposure and promoting interactive,
educational content are essential strategies to support early childhood
development.

INTRODUCTION screen exposure, particularly when it replaces active

play, caregiver interaction, and other developmental
The rapid increase in screen time exposure among activities, may hinder these processes. Studies
young children has become a growing concern suggest that passive screen time (e.g., watching
worldwide. Screen time, defined as time spent using videos or television) has a more pronounced negative
digital devices such as smartphones, tablets, impact on cognitive development compared to
televisions, and computers, is a common activity interactive screen time (e.g., educational games or
even in early childhood.[1] Although technology apps).[4]
provides educational and entertainment The American Academy of Pediatrics (AAP)
opportunities, excessive or unregulated screen use recommends limiting screen time to less than one
can have unintended consequences on a child’s hour per day for children aged two to five years, and
cognitive development. Early childhood, particularly discourages screen use in children younger than two
the first five years of life, is a critical period for brain years. Despite these guidelines, many children are
development, during which children acquire exposed to prolonged screen time, driven by factors
fundamental cognitive, motor, and social skills.[2] such as parental convenience, socioeconomic
Cognitive development in young children relies constraints, and the ubiquity of digital devices.[5] This
heavily on active interaction with their environment. trend raises concerns about its long-term impact on
Activities such as problem-solving, communication, children’s cognitive abilities, particularly in domains
and exploration help lay the foundation for such as communication, problem-solving, and social
intellectual and emotional growth.[3] Excessive interaction.[6]

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ISSN (O): 2687-5365; ISSN (P): 2753-6556
Existing research has identified a potential link ❖ Passive screen time (e.g., watching TV or
between excessive screen time and developmental videos).
delays. However, the relationship is complex, ❖ Interactive screen time (e.g., using
influenced by factors such as screen type (interactive educational apps or games).
vs. passive), content quality, caregiver involvement, 3. Cognitive Development Assessment:
and household environment. While some studies • Cognitive development was assessed using the
emphasize the risks of excessive screen use, others Ages and Stages Questionnaire (ASQ-3), a
highlight the benefits of carefully curated, interactive validated tool for measuring developmental
digital content when used in moderation.[7] milestones across five domains:
This study aims to evaluate the impact of screen time ❖ Communication.
on cognitive development in children under five ❖ Gross motor skills.
years of age, focusing on developmental domains ❖ Fine motor skills.
such as communication, problem-solving, and motor ❖ Problem-solving.
skills. By identifying the patterns and predictors of ❖ Personal-social skills.
developmental delays associated with screen use, the • ASQ-3 scores were categorized into:
study seeks to inform evidence-based guidelines for ❖ Normal: Above the cutoff.
parents and caregivers, promoting healthy digital ❖ At-risk: Below the cutoff, suggesting potential
habits during early childhood. developmental delays.
4. Potential Confounders:
MATERIALS AND METHODS • Household factors, including the presence of
siblings, availability of books or toys, and
Study Design and Setting: This was a cross- caregiver engagement.
sectional observational study conducted in the Outcome Measures: The primary outcome was the
Department of Pediatrics at Government Medical association between daily screen time and cognitive
College, Mahbubabad over a period of 12 months development, as measured by ASQ-3 scores.
from December 2023 to December 2024. The study Secondary outcomes included the impact of screen
aimed to evaluate the impact of screen time on type (interactive vs. passive) and screen time duration
cognitive development in children under five years of on specific cognitive domains.
age. Statistical Analysis: Data were analyzed using SPSS
Study Population: The study included 100 children (Version 28.0). Descriptive statistics (mean, standard
aged 6 months to 5 years, accompanied by their deviation, percentages) summarized demographic
parents or primary caregivers, who attended the and exposure data. Inferential statistical methods
pediatric outpatient clinic. included:
Inclusion Criteria 1. Chi-square Test:
• Children aged between 6 months and 5 years. • To assess the association between screen time
• Parents or caregivers willing to provide informed categories and developmental delay prevalence.
consent and complete the study questionnaires. 2. T-tests:
Exclusion Criteria • To compare ASQ-3 domain scores between
• Children with diagnosed developmental delays or children with low and excessive screen time.
neurological conditions unrelated to screen time 3. Multivariate Logistic Regression:
(e.g., cerebral palsy, genetic syndromes). • To identify independent predictors of cognitive
• Preterm infants (<37 weeks of gestation). delays, adjusting for potential confounders (e.g.,
• Families with incomplete or unreliable data socioeconomic status, parental education).
reporting. Statistical significance was set at p<0.05p <
Data Collection: Data were collected using 0.05p<0.05.
structured questionnaires administered to the parents Ethical Considerations: The study was conducted in
or caregivers. The questionnaires covered the accordance with ethical guidelines and standards.
following aspects: Informed consent was obtained from all paticipants.
1. Demographic Information: The study protocol was reviewed and necessary
• Child’s age, gender, birth history, and family permissions taken from concerned authorities.
socioeconomic status.
• Parental education level and household RESULTS
environment.
2. Screen Time Assessment: Demographic Characteristics: The study included
• Daily screen time was categorized into: 100 children aged 6 months to 5 years, with a mean
❖ None: No screen exposure. age of 3.2 years (±1.4). Of the participants, 52% were
❖ Low: ≤1 hour/day. boys, and 48% were girls. Most children belonged to
❖ Moderate: >1–2 hours/day. middle-income families (65%), while 30% were from
❖ Excessive: >2 hours/day. low-income families. Parental education revealed
• Type of screen exposure was further classified that 72% of mothers had secondary or higher
into: education.

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The [Table 1] illustrates the baseline demographic The [Table 6] illustrates the relationship between
and clinical characteristics of the study population. vitamin D levels and ASQ-3 scores. Children with
The mean age was 3.2 years, with boys constituting vitamin D deficiency (<20 ng/mL) scored
52% of the participants. Most children (65%) significantly lower in cognitive domains compared to
belonged to middle-income families, and 72% of those with sufficient levels (>30 ng/mL).
mothers had secondary or higher education. Association Between Screen Duration and
Screen Time Exposure Cognitive Delays
Screen time exposure varied widely among The [Table 7] demonstrates the relationship between
participants. Twenty percent of children had no screen duration and cognitive delay prevalence. A
screen time, while 20% had excessive exposure (>2 clear trend was observed, with longer screen
hours/day). Passive screen use was more prevalent durations correlating with higher rates of delays.
(80%) compared to interactive use (20%). The [Table 7] highlights the association between
The [Table 2] highlights the distribution of screen screen duration and cognitive delays. Longer screen
time exposure among participants. While 20% of exposure durations (>2 hours/day) correlated with
children reported no screen time, 20% had excessive higher rates of cognitive delays.
exposure (>2 hours/day). Passive screen use (e.g., Caregiver Engagement and Cognitive Outcomes
watching TV or videos) was reported in 80% of Caregiver engagement played a critical role in
cases, compared to only 20% engaging in interactive cognitive outcomes, with children receiving high
screen use. engagement scoring significantly higher across ASQ-
Developmental Delays by Screen Time 3 domains than those with low engagement.
Children with excessive screen time showed the The [Table 8] shows the impact of caregiver
highest prevalence of developmental delays (45%), engagement on cognitive outcomes. Higher caregiver
particularly in problem-solving (60%) and engagement levels were associated with better ASQ-
communication (50%) domains. 3 scores across cognitive domains.
The [Table 3] demonstrates the association between Association Between Screen Content Quality and
screen time exposure and developmental delays. Cognitive Scores
Children with excessive screen time (>2 hours/day) Children exposed to educational screen content
exhibited the highest rates of developmental delays showed higher ASQ-3 scores compared to those
(45%), particularly in problem-solving (60%) and exposed to entertainment or mixed content.
communication (50%) domains. The [Table 9] evaluates the influence of screen
ASQ-3 Scores by Screen Type content on cognitive outcomes. Educational content
Passive screen time was associated with significantly was linked to better cognitive scores compared to
lower ASQ-3 scores across all cognitive domains entertainment or mixed content.
compared to interactive screen use. Correlation Between Family Income and
The [Table 4] compares the mean ASQ-3 scores Cognitive Development
across cognitive domains between passive and Family income was positively correlated with
interactive screen use. Passive screen exposure was cognitive outcomes, with children from higher-
associated with significantly lower scores in income households scoring better on ASQ-3
communication, problem-solving, and other assessments.
cognitive areas compared to interactive screen use. The [Table 10] illustrates the relationship between
Predictors of Cognitive Delays family income levels and cognitive outcomes. Higher
Multivariate regression analysis revealed that family income was associated with improved ASQ-3
excessive screen time, passive screen use, low scores, likely reflecting access to better resources and
maternal education, and lack of caregiver opportunities.
engagement were significant predictors of cognitive Summary of Results
delays. Excessive screen time (>2 hours/day) had the 1. Screen Time Exposure:
highest odds ratio (2.8), indicating a strong • Excessive screen time (>2 hours/day) was
association with developmental delays. strongly associated with developmental delays,
The [Table 5] outlines the significant predictors of particularly in problem-solving and
cognitive delays identified through regression communication domains.
analysis. Excessive screen time (>2 hours/day) was 2. Caregiver and Content Influence:
the strongest predictor, with an odds ratio of 2.8 (p < • High caregiver engagement and educational
0.01), followed by passive screen use and low screen content positively impacted cognitive
maternal education. outcomes, while passive screen use had
Vitamin D Levels and Cognitive Function detrimental effects.
Vitamin D deficiency (<20 ng/mL) was associated 3. Nutritional and Socioeconomic Factors:
with significantly lower cognitive scores across • Vitamin D deficiency and lower family income
ASQ-3 domains compared to sufficient levels (>30 were linked to lower cognitive scores,
ng/mL), emphasizing the link between nutrition and emphasizing the multifaceted contributors to
cognitive development. developmental outcomes.

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International Journal of Academic Medicine and Pharmacy (www.academicmed.org)
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Table 1: Demographic Characteristics of Study Population.
Parameter Value
Mean Age (years) 3.2 ± 1.4
Gender (Boys/Girls) 52% / 48%
Socioeconomic Status (%) Low: 30%, Middle: 65%, High: 5%
Maternal Education (%) Secondary or Higher: 72%, Primary or None: 28%

Table 2: Daily Screen Time Exposure

Screen Time Category Participants (%)
No Screen Time 20
Low (≤1 hour/day) 35
Moderate (>1–2 hours/day) 25
Excessive (>2 hours/day) 20

Table 3: Prevalence of Developmental Delays by Screen Time

Screen Time Category Developmental Delay (%) Problem-Solving Delay (%) Communication Delay (%)
No Screen Time 10 5 5
Low (≤1 hour/day) 15 10 8
Moderate (>1–2 hours/day) 30 35 25
Excessive (>2 hours/day) 45 60 50

Table 4: ASQ-3 Scores by Screen Type

Cognitive Domain Passive Screen Time (Mean ± SD) Interactive Screen Time (Mean ± SD)
Communication 40.5 ± 6.2 45.8 ± 5.9
Problem-Solving 38.3 ± 7.1 42.5 ± 6.4
Fine Motor Skills 41.7 ± 5.8 44.0 ± 6.2
Gross Motor Skills 43.2 ± 6.1 46.7 ± 5.4
Personal-Social 42.5 ± 6.0 46.0 ± 5.7

Table 5: Predictors of Cognitive Delays (Multivariate Regression)

Predictor Odds Ratio (95% CI) p-value
Excessive Screen Time 2.8 (1.6–4.5) <0.01
Passive Screen Time 1.9 (1.2–3.1) <0.05
Low Maternal Education 2.5 (1.5–4.0) <0.01
Lack of Caregiver Engagement 2.3 (1.4–3.7) <0.01

Table 6: Vitamin D Levels and Cognitive Function

Vitamin D Level (ng/mL) Mean ASQ-3 Score (± SD)
<20 (Deficient) 38.2 ± 6.4
20–30 (Insufficient) 42.5 ± 5.9
>30 (Sufficient) 45.7 ± 6.2

Table 7: Association Between Screen Duration and Cognitive Delays

Screen Duration (Hours/Day) Cognitive Delay Prevalence (%)
<1 15
1–2 25
>2 45

Table 8: Caregiver Engagement and Cognitive Outcomes

Caregiver Engagement Level Mean ASQ-3 Score (± SD)
High 46.2 ± 5.8
Moderate 42.8 ± 6.2
Low 39.5 ± 7.1

Table 9: Association Between Screen Content Quality and Cognitive Scores

Screen Content Quality Mean ASQ-3 Score (± SD)
Educational 44.8 ± 5.9
Entertainment 40.2 ± 6.5
Mixed 42.5 ± 6.0

Table 10: Correlation Between Family Income and Cognitive Development

Family Income Level Mean ASQ-3 Score (± SD)
Low 40.1 ± 6.7
Middle 43.5 ± 5.9
High 46.8 ± 5.4

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 DISCUSSION quality, interactive screen content and caregiver
involvement. Unlike studies that focus solely on
This study provides comprehensive insights into the screen duration, this research provides a nuanced
impact of screen time on cognitive development in understanding of how content type and engagement
children under five years of age. The findings reveal levels influence outcomes.[13]
significant associations between excessive screen Clinical Implications: The findings have important
time and developmental delays, highlighting critical implications for pediatric practice. Healthcare
risk factors that influence early childhood providers should counsel parents on the importance
development. of limiting screen time to less than 1 hour per day, as
Screen Time and Developmental Delays: The recommended by the American Academy of
results indicate that excessive screen time (>2 Pediatrics (AAP). Promoting interactive and
hours/day) is strongly associated with higher educational content while discouraging passive use is
prevalence rates of developmental delays, essential. Additionally, strategies to enhance
particularly in problem-solving (60%) and caregiver engagement, improve access to educational
communication (50%) domains. These findings align resources, and address nutritional deficiencies should
with existing research suggesting that prolonged be prioritized.[14]
screen exposure reduces opportunities for interactive Strengths and Limitations: The study’s strengths
play, caregiver engagement, and exploration, all of include its comprehensive evaluation of screen time
which are vital for cognitive development.[8] Passive duration, type, and associated factors, along with the
screen time, in particular, was more detrimental than use of validated tools like ASQ-3. However,
interactive use, supporting the notion that content limitations include its cross-sectional design, which
quality and the mode of interaction significantly precludes causal inferences, and reliance on parent-
affect developmental outcomes.[9] reported screen time data, which may be subject to
Role of Content Type and Engagement: recall bias. Future longitudinal studies are needed to
Educational screen content was associated with better establish causality and explore the long-term effects
ASQ-3 scores compared to entertainment or mixed of screen time on cognitive development.[15]
content. This finding emphasizes the importance of Future Directions: Future research should focus on
curated, age-appropriate digital content in mitigating developing evidence-based guidelines for screen use
the adverse effects of screen time. Similarly, higher in young children. Longitudinal studies exploring the
caregiver engagement was positively correlated with interplay between screen exposure, environmental
better cognitive outcomes. These results underscore factors, and neurodevelopmental outcomes are
the role of active parental involvement in balancing essential. Moreover, evaluating the effectiveness of
digital media use and fostering a stimulating interventions, such as caregiver training and the
developmental environment.[10] integration of educational technologies, could
Nutritional and Socioeconomic Influences: provide valuable insights.
Nutritional deficiencies, particularly low vitamin D
levels, emerged as significant predictors of lower CONCLUSION
cognitive scores. Vitamin D plays a critical role in
neurodevelopment, and its deficiency could This study underscores the significant impact of
exacerbate the negative effects of excessive screen screen time on cognitive development in children
exposure. Furthermore, children from higher-income under five years of age. The findings reveal that
households had better ASQ-3 scores, likely reflecting excessive screen time, particularly passive exposure,
greater access to educational resources and is strongly associated with developmental delays in
opportunities for enriched interactions. These key domains such as problem-solving and
findings highlight the multifactorial nature of communication. High-quality, interactive content
cognitive development, influenced by both and caregiver engagement were identified as
environmental and biological factors.[11] protective factors, highlighting the importance of
Predictors of Cognitive Delays: Multivariate context and content in shaping developmental
regression analysis identified excessive screen time, outcomes.
passive content, low maternal education, and lack of Excessive screen time emerged as the strongest
caregiver engagement as significant predictors of predictor of cognitive delays, with children exposed
developmental delays. These findings highlight the to more than two hours per day exhibiting a 2.8-fold
need for targeted interventions aimed at reducing increased risk of delays. Passive screen time was
screen exposure and improving caregiver-child found to be particularly detrimental, reinforcing the
interactions, particularly in households with limited need to minimize such exposure during critical
educational resources.[12] developmental periods. On the other hand,
Comparison with Previous Studies: This study educational content and interactive use were
corroborates findings from previous research that associated with better cognitive performance,
emphasizes the adverse effects of excessive screen suggesting that screen time, when carefully curated
time on cognitive development. However, it also and monitored, can have constructive applications.
highlights the potential mitigating effects of high-

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ISSN (O): 2687-5365; ISSN (P): 2753-6556
The study also highlights the interplay between 4. Eirich R, McArthur BA, Anhorn C, McGuinness C, Christakis
DA, Madigan S. Association of Screen Time With
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Internalizing and Externalizing Behavior Problems in
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