Media and Child Health

Abstract

After completing this article, readers should be able to: Today, American children and adolescents spend nearly half of their waking days exposed to an environmental influence that research has associated with increased risk of obesity, substance use, sexual risk behaviors, eating disorders, anxiety, sleep disturbances, and violent behaviors. Pediatricians were among the first to observe and respond to exposure to television, movies, and music, and now video games and the Internet, as risks to the physical, mental, and social health of children. The American Academy of Pediatrics (AAP) has been active in addressing the effects of media on the health and well-being of children since the late 1970s, when they resolved, in the 1977 Resolution Concerning the Effects of Television Violence on Children, to “actively oppose television programs emphasizing high degrees of violence and anti-social behavior which detrimentally affect the attitudes and social behavior of children” and made an effort to ban advertising to children. Since that time, the AAP has issued policy statements recommending that AAP members consider and respond to media exposure and its effects in their medical management. These statements have addressed exposure to and interventions on media use in general, the influence of specific media on children and adolescents, research associating specific health outcomes with media use, and strategies for intervening. The AAP also sponsored “Media Matters,” a national initiative to build awareness of media effects on child health. The result is that most pediatric residency directors now consider media education to be an essential part of training pediatricians. (1)Today, the leading causes of mortality in adolescents and of morbidity in the adults they become are the outcomes of acquired health behaviors. The top three causes of death among 15- to 24-year-olds, according to the Department of Health and Human Services, are unintended injuries (led by alcohol-related motor vehicle collisions), homicide, and suicide, all of which are outcomes of acquired health risk behaviors. When asked about their leading sources of information on issues such as health, interpersonal relationships, and social behavior, adolescents cite entertainment media as one of their top resources, (2) (3) indicating media’s function as a “superpeer” (4) to establish standards of behavior in the Information Age.A national survey conducted by the Kaiser Family Foundation in 2005 (5) found that American children between 8 and 18 years of age use media, on average, for 6 hours and 21 minutes per day (Fig. 1). Because children spend 26% of their media time “multitasking” by using several media at once, their overall exposure to media content is more than 8 hours per day (Fig. 2). This study also found that 68% of children 8 to 18 years old have televisions (TVs) in their bedrooms (Fig. 3), 49% have video game players in their bedrooms, and 63% live in homes where the TV is usually on during meals (Fig. 4). Children who had the lowest grades and lowest degree of contentedness reported higher levels of media use. (5)Even very young children spend significant amounts of time with media each day. According to another Kaiser Family Foundation study, children between 6 months and 6 years of age use media for about 2 hours a day, and 36% have a TV in their bedrooms, with 74% of infants and toddlers younger than 2 years of age having watched TV. (6) Most parents intentionally exposed their children to screen media because they believed it “mostly helps” and was “very important” to their children’s intellectual development. A follow-up survey (7) revealed that only 6% of parents of children younger than 2 years of age know the AAP recommendation that children younger than age 2 years should not watch any TV. (8) “Baby videos,” introduced for 1- to 18-month-olds in 2002, have generated hundreds of millions of dollars in sales. Despite marketing assertions, there is no evidence that “baby videos” or any screen media have any positive effects on infants and toddlers.Parents can influence their children’s TV viewing by means of household rules, coviewing, and mediation of content. Yet, numerous studies over the last 40 years have revealed that less than 50% of parents actually enforced TV viewing limits or regularly discussed TV content with their children. (9)(10)(11)Violence is not only central to the three leading causes of death in adolescents, it is the most thoroughly researched area of media effects, with hundreds of studies conducted in a wide variety of disciplines over the past 5 decades. Violent content is ubiquitous in TV shows, movies, and video games. The National Television Violence Study reviewed slightly less than 10,000 hours of television programming between 1994 and 1997 and discovered that more than 60% of programs included violence (12)(13)(14) in which 71% of the violent scenes “contain no remorse, criticism, or penalty for violence when it occurs,” and 50% of all violent incidents revealed no pain or physical harm to the victims. Less than 5% of all programs examined during the 3 years of the study incorporated antiviolence themes. Children’s programming contained some of the highest levels of violence; the average preschooler watching 2 hours of cartoons a day is estimated to see 10,000 violent incidents per year. (12)(13)(14) This is, perhaps, most disturbing because young children are especially vulnerable to television violence, in part because they are developmentally incapable of distinguishing fantasy from reality.Numerous studies have examined the effects of media violence on the development of children. To many researchers and clinicians, the evidence linking media violence exposure with increases in anxiety, desensitization, and aggressive thoughts and behaviors is compelling. In July 2000, the AAP, along with the American Medical Association, the American Academy of Child and Adolescent Psychiatry, and the American Psychological Association, released a first-ever “Joint Statement on the Impact of Entertainment Violence on Children,” concluding that “well over 1000 studies … point overwhelmingly to a causal connection between media violence and aggressive behavior in some children.” (15)Violent media exposure has been associated with increased fear and anxiety in children. Parents have reported long-lasting fears in their preschoolers after the children watched something scary on TV. Most grade school children in surveys admit having been scared by something they saw on film or TV. (16) Desensitization to real-life violence also has been associated with viewing television violence. After viewing a violent TV show, third graders were slower to ask for help when they saw two preschoolers fighting, despite instructions to seek an adult if the children were in trouble. (17) Other studies have revealed that with increased exposure to television violence (both real and fictional), children show less physiologic arousal. (18)(19) Laboratory and field studies over the past 50 years have found both short- and long-term effects of media violence on subsequent aggressive behavior in children. In the early 1960s, a number of laboratory studies by Albert Bandura demonstrated that preschool-aged children imitated specific acts of aggression they saw on film, especially when the film aggressor was rewarded. (20)(21) A double-blind prospective study of first and second graders before and after the introduction of TV to a small Canadian town in the 1970s revealed that aggressive behavior among the children increased 160% after 2 years of TV availability. Aggression among first and second graders in two matched communities (in which TV had been introduced earlier) remained constant over the same 2-year period. (22)Exposure to entertainment media is but one of many factors contributing to aggressive behavior in children. Long-term factors, such as genetic predisposition, harsh physical parental discipline, or low socioeconomic status, and short-term factors, such as drug or alcohol use, all increase the likelihood of aggressive behavior. However, in longitudinal studies, the relationship between media violence and aggression remains significant, even when these other factors are controlled for. In one of these studies, a 1960 survey of 875 8-year-olds in New York, a strikingly positive relationship was seen between children’s viewing of violence on TV and their levels of aggression. (23) Ten years later, the researchers re-interviewed more than 50% of their original subjects and found a strong relationship between the level of viewing media violence at age 8 years and a history of aggression at age 19 years, even when intelligence quotient (IQ), social status, parental aggression, social and geographic mobility, church attendance, and the child’s baseline aggression level were controlled. (24) In fact, the boys who at age 8 years were rated as “low aggressive” but watched high levels of TV were more aggressive at 19 years than those who were rated “high aggressive” but did not watch violent TV. The researchers returned to their 30-year-old subjects 12 years later and found that the greater the amount of violent TV watched by the subjects at age 8 years, the more aggressive they were while under the influence of alcohol, the more harshly they disciplined their children, and the more serious were the crimes of which they had been convicted. (25)Hundreds more studies show a striking association between media exposure and violent behavior, but how strong is the correlation? A 1994 meta-analysis of 217 studies (26) yielded a correlation between exposure to TV violence and aggressive behavior in children that is stronger than that between condom nonuse and sexually transmitted human immunodeficiency virus infection, lead exposure and lower IQ, occupational passive smoke exposure and lung cancer, and calcium intake and bone density (Fig. 5). (27)New research is revealing the biologic correlates of such media effects. A recent pilot study using functional magnetic resonance imaging to scan children’s brains while they viewed media violence revealed that areas of the brain uniquely activated by media violence included the amygdala, responsible for the “fight or flight” survival response, the premotor areas of the frontal cortex, which prepare the body for action, and the posterior cingulate, associated with encoding long-term rapid access memories, the same location in the brain that is activated when victims of posttraumatic stress disorder relive their traumas. (28) Although these findings appear to indicate a neurobiologic basis for observed behavioral changes, more comprehensive research is needed.The AAP has released no statement specifically about video or computer game violence, but research suggests that these games, especially “first-person shooter” games, may have more profound effects on children than TV. Players are immersed in the game, interacting directly with it to direct and prolong the action, performing key tasks over and over, rehearsing split-second reactions to threat, and receiving rewards when successful. Meta-analyses have found significant associations between video or computer game violence and aggressive thoughts or feelings (r=0.18 to 0.27) and aggressive behavior (r=0.15). (29)(30) One study found long-term exposure to violent video games to be associated with lower empathy in children. (31) Researchers propose that “gaming” teaches and rehearses children in behavioral scripts. Children are likely to rely on such scripts, which have been practiced repeatedly, when they find themselves in an unfamiliar situation or when they are frustrated or provoked. Additional research is necessary to understand the potential impact of interactive media, especially as games become more graphic and realistic.Recent content analyses have found that most E-rated (for Everyone, or children 6 years and older) video games contain violence and reward players for violence against others. (32) Similarly, T-rated (for Teen) games seriously underreport the amount and severity of violent content. (33) These discrepancies between media content and ratings parallel those found in television and movies (34) and call into question the usefulness of the entertainment industry’s ratings systems for protecting children.Intervention studies not only provide some of the strongest evidence for the harmful effects of media, they provide hope for effective clinical response. In one study, third- and fourth-grade children who had received 6 months of media literacy training and reduced their media use were peer-rated to be less aggressive than controls whose media use was unchanged. (35)The prevalence of childhood obesity in the United States has doubled since 1980, according to the Centers for Disease Control and Prevention (CDC); about 15% of 6- to 19-year-olds and 10% of 2- to 5-year-olds are overweight (defined as body mass index [BMI] at or higher than the 95th percentile). (36) Obesity now rivals smoking as the leading avoidable cause of morbidity and mortality, putting children at risk for a host of chronic health problems, especially type 2 diabetes and hypertension, and by adolescence, a substantially greater likelihood of becoming obese adults.Nutritional, activity level, familial, and social factors predict obesity in children, but after controlling for many of these factors, a dose-response relationship between hours of TV viewing and obesity persists. (37) Simply having a TV in a child’s bedroom is a predictor of obesity in childhood. (38)Media use(including computer use, video game play, and TV viewing) may contribute to obesity in part because it is a sedentary activity. However, what children watch and what they do while they watch also influences obesity. TV advertising encourages children to drink sugared soda and eat high-calorie snack foods. Almost all TV commercials targeted at children are for candy, sugared cereals, or fast food. Even preschoolers prefer foods advertised on television.Research has shown that children who watch more TV snack more often. They also consume more fast food and sweets and fewer vegetables. (39) In one intervention study, children encouraged to reduce their media use had significantly lower BMI ratings after 1 year than controls, even though they were not specifically encouraged to increase activity levels. (40)The number one cause of death in teenagers is alcohol-related motor vehicle crashes, and alcohol or drugs often are implicated in unintended injuries, homicides, and suicides. Yet tobacco and alcohol companies continue to market their products aggressively to children and adolescents. TV programs, movies, and advertisements glamorize and normalize the use of tobacco, alcohol, and other drugs.Cigarette and alcohol advertising is effective. Research has shown that more than 50% of 3-year-olds were able to identify Joe Camel and connect the character with Camel cigarettes. (41) Seventh graders who have more exposure to tobacco marketing are more likely to have positive attitudes about tobacco use and to initiate smoking. (42) Youth who own promotional items from cigarette companies are two to four times more likely to smoke. (43) There is now an effort to include the portrayal of smoking as a criterion for the assignment of an R rating (44) because there is ample evidence that teens who view movie stars smoking are more likely to initiate and maintain smoking habits. (45)Media use is associated with increased initiation of alcohol use in ninth graders. (46) Unlike cigarettes, alcohol is advertised directly on TV, especially during sports programs. Many distillers now advertise “alcopops” or soft drink-like, flavored malt liquor beverages intended to attract young people and establish brand loyalty to the hard liquor that shares its name and logo. This trend is of particular concern because adolescents’ exposure to alcohol advertisements is associated positively with drinking and with drinking and driving. (47)(48) Product placement in entertainment is common, with tobacco, alcohol, and other drug use portrayed as normative behavior in most prime time TV shows, top-grossing movies, and music videos. (49)According to the CDC, 46% of all high school students have had intercourse, and 14% have had four or more partners. Among sexually active teens, only 58% reported using a condom the last time they had sex. Each year, 25% of sexually active teens contract a sexually transmitted infection, and 19% of sexually active teenage girls become pregnant. (50)Much of the media popular with teens features sex. Most popular songs contain sexual references and themes, and many of the best-selling video games portray women as sex objects, awarding points for violence against them. A 2003 Kaiser Family Foundation report revealed that 64% of TV programs (excluding news, sports, and children’s shows) contained sexual material, up almost 10% since 1997 to 1998. (3) On average, there were 4.4 sexual scenes per hour. Sexual talk (61%) was about twice as common as sexual behaviors (32%). Although sexual behaviors most often were “precursory behaviors” (such as kissing or touching), one in seven programs specifically depicted sexual intercourse. Only 15% of programs that had sexual content incorporated a scene presenting sexual risks or responsibility. There was an improvement among programs that included teenagers, with 34% referencing safe sex, compared with 16% 2 years earlier. Among the 20 shows watched most by teens, 45% featured references to safe sex. (3)On the basis of a few studies, there is some evidence that teens’ sexual attitudes and behaviors are predicted by their TV viewing. Adolescents who view more programs that have sexual content start having intercourse at an earlier age and have more positive attitudes about casual sexual encounters. (51)Teens learn about sex through the media. (3) TV, in particular, is a source of behavioral scripts to guide behavior in unfamiliar sexual situations. More than 50% of teens consider television an important source of information about birth control and contraception. (52)The Internet also has become an important source of information about sexual health for youth. A 2001 survey of tenth-grade students found that 49% had used the Internet to find information about health; the most popular topics included sexually transmitted diseases and sexual behaviors, as well as diet, exercise, and fitness. (53) Children are able to gain access to mature Web sites with relative ease. They visit adult Web sites, often containing sexual topics, or see Web sites about drugs, weapons, bombs, sex, nudity, or violence. Adolescents can access pornographic Web sites and sex chat rooms on the Internet, putting them at risk for cyber-seduction and online solicitation. (54)A large and growing body of research indicates that entertainment media, including TV, movies, video games, music, and the Internet, exert a powerful influence on the health-related knowledge, attitudes, and behaviors of children and adolescents. In caring for children in the Information Age, pediatricians must remain cognizant of this potent environmental influence when they evaluate and treat their patients.Dr. Rich was supported by the National Institute of Child Health and Human Development through grant K23HD1296 during the preparation of this manuscript.