Tablets for Tots? Maybe Not

In recent years, children under the age of two have been exposed to digital devices like tablets, smartphones, and television more than ever before. Alongside this trend, the rate of diagnoses of ADHD, autism, and ASD in kids has skyrocketed. Is there are a correlation? Some researchers have proposed that there may be a causal connection between excessive early screen exposure during critical stages of development and developmental delays. Excessive early screen exposure may lead to deficits in a child’s attention and communication skills, deficits in social behavior, and even changes in brain structure.

In 2004, Dimitri Christakis’ groundbreaking study of a thousand children found a link between toddler TV time and attention problems. For every hour of television the children watched daily, their risk of having attention problems increased by 20 percent. The American Academy of Pediatrics, cognizant of the research on screens and children’s mental health problems, recommends that parents should avoid exposing children under the age of two to digital devices. For children ages 2 to 5, the AAP recommends that screen time be limited to 1 hour per day. In the day-to-day lives of parents and children, however, that recommendation is often ignored.

In my own practice, parents have been concerned that online Kindergarten, a widespread practice during the Covid pandemic, has led to social isolation, an increase in the time their children spend in online gaming, and behavior problems. Even before the pandemic, clinicians were seeing problems resulting from excessive use of digital devices. Psychiatrist Victoria Dunckley, for example, wrote here that the use of tablets and smartphones by children “has produced more problems and setbacks in my practice than any other single factor.” She finds that children with symptoms of ASD are especially vulnerable to the effects.

Today, after almost two years of the Covid pandemic, worried parents bring up concerns about screen time in almost every session I have. I recommend that parents spend more time in enjoyable social interactions with their young children—playing board games, drawing or painting together, playing simple card games, etc. These social activities can slowly wean children from the allure of screens.

With very young children who have been exposed to excessive screen time and show early symptoms of ASD (before the age of 2), it's important to teach parents to wean their children from digital devices. The term “Digital Nanning” refers to a style of child care in which digital devices replace a child’s active relationship with parents. This term was introduced in 2000, in the first study to investigate the association between excessive screen time in tots and autism. Since then, a handful of small studies have attempted to explain the relationship between excessive screen time and children at risk for autism.

One study in particular caught my eye because it suggested that the ill effects of early screen exposure in children showing early signs of autism can be reversed by training parents to socialize with their children in healthy ways and to eliminate digital devices. The study, published in the Asian Journal of Psychiatry in 2019, is called “Behavioral and electrophysiological evidence for parent training in young children with autism symptoms and excessive screen time.” It was small and lacked a control group, but the results were statistically significant and too intriguing to ignore. The research involved 12 young children, ages 2-4, with subthreshold autism symptoms (deficits in eye contact, speech development, parent-child socialization, repetitive behaviors, etc.) who had not yet received an autism diagnosis. The children had been exposed to electronic screens for more than half their waking hours.

All parents were trained by highly experienced psychologists to decrease their child’s screen time and to have intensive interaction with their child. There were eight 90-minute training sessions over the course of two months. The protocol used for training was based on the "Focused Playtime Intervention". The principles of the intervention were:

1. Increasing the hours of parent-child interaction through enjoyable games, productive games, and caring activities like feeding, bathing and hugging.
2. The parents learned to motivate their children to communicate with people instead of objects.
3. Prevention of lonely and repetitive activities and the removal of any digital device that interfered with parent-child interaction or that encouraged the child to be alone with digital devices.
4. Application of the intervention during all of the child’s waking hours.

The intervention had three goals: developing an emotional bond between parents and child, parent-child interaction, and bilateral interactions between parents and child.

The results showed that parent training decreased by 28 percent the following behaviors in the children: stereotyped behaviors, self-injurious behaviors, compulsive behaviors, ritualistic behaviors, and restricted behaviors. The training also produced measurable changes in the activity of the children’s brains, measured by EEG recording. (The authors admit that this aspect of their research is open to interpretation and requires further future research.)

Autism Essential Reads

Autism, Adolescence, and the Creation of an Identity

Autistic Meltdowns Help Me Live a Better Life

According to the authors, their study has limitations and is only a first step in understanding how effective parent training can reduce young children’s excessive screen time and autism symptoms.

As far as the limited topic of how parent training sessions can reduce symptoms of autism in children ages 2-4, this study has some similarities to a much larger controlled study recently published in Pediatrics. Although the Pediatrics study does not involve screen time, both studies examine how training or coaching parents to communicate and socialize with young children who show early signs of autism can reduce ASD symptoms and prevent an autism diagnosis later on.