From the Editor

Gaming. Apps. Streaming videos.

Children today have endless options at their fingertips, allowing them to entertain themselves for hours – which means less time for reading, playing, and physical activity. What effect does this have on their mental health? That question has sparked much debate: some argue that screen time is inherently problematic while others feel that it opens doors for creativity and connection to others. But what does the literature say? 

In the first selection, Rachel Eirich (of the University of Calgary) and her co-authors consider screen time and behavioural problems in children with a new systematic review and meta-analysis, just published in JAMA Psychiatry. Pulling together 87 studies, they focus on several variables. The big finding? “This study found small but significant correlations between screen time and children’s internalizing and externalizing behavior problems.” We look at the study.

And in the second selection, continuing our consideration of the first update to the DSM series in nine years, journalist Carol Smith mulls DSM-5-TR and the new diagnosis of prolonged grief disorder. In The Washington Post, she writes about her personal experience with grief: she lost her son when he was just 7. “I never thought to ask for help. I wish I had.”


Selection 1: “Association of Screen Time With Internalizing and Externalizing Behavior Problems in Children 12 Years or Younger: A Systematic Review and Meta-analysis”

Rachel Eirich, Brae Anne McArthur, Ciana Anhorn, et al.

JAMA Psychiatry, 16 March 2022

The effects of screen time on children’s mental health have been rigorously debated. Some literature suggests that screen time may be associated with risk of poor mental health outcomes by displacing sleep and physical activities as well as social exchanges and learning opportunities known to foster well-being. Screen media may also impede self-regulation strategies and increase arousal levels owing to fast-paced and intense audiovisual effects, which may be associated with inattention and aggressive behavior. However, it has been argued that concern with regard to screen time and its effect on child mental health is not empirically justified owing to conflicting research results and methodological shortcomings.

Meta-analyses can address discrepancies in the literature by providing greater statistical precision through pooled results from multiple individual studies and can detect whether variations in study findings are explained by moderators. In the screen time literature, methodological differences have likely contributed to the conflicting findings: effect sizes may differ based on the statistical analyses conducted, how variables are measured, and whether data are cross-sectional or longitudinal. Effect sizes may also vary as a function of child sex (eg, sex differences in the associations of screen time with behavior problems), child age (eg, association of increased screen use with increasing age among children), and socioeconomic risk (eg, association of increased screen use with behavior problems in the context of low socioeconomic status). Identifying when and for whom correlations are stronger or weaker may inform the ongoing screen time debate and help develop targeted interventions for children most at risk for potential behavior problems associated with screen time. 

Owing to substantial research to date on duration of screen time and behavior problems, it appeared timely to meta-analytically summarize this body of research.

So begins a paper by et al.

Here’s what they did:

  • They drew from various databases, including PsycINFO, for articles published from January 1960 to May 2021. 
  • “Studies were included if (1) the age range of included children was 12 years or less, (2) screen time duration was measured (hours and/or minutes), (3) behavior problems (ie, internalizing, externalizing) were measured, (4) the studies were observational or experimental (with baseline data), (5) statistical data were available, and (6) the article was available in English.”
  • Studies conducted during the COVID-19 pandemic were excluded. (!)
  • The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline; data was extracted by two independent reviewers.
  • “Extracted variables were child age, sex, and socioeconomic status; informants and measurement type for screen time and behavior problems; study publication year; and study design and quality.” 
  • The primary outcome: “the association of screen time duration with externalizing (eg, aggression, attention deficit/hyperactivity disorder symptoms) and internalizing (eg, depression, anxiety) behaviors or diagnoses.”

Here’s what they found:

  • Of the 595 full-text articles assessed, 87 studies met all inclusion criteria
  • They included 98 independent samples with 159 425 participants (!).
  • Demographics. The children were in elementary school (mean age of 6.07) and the majority were male (51.30%). 
  • Externalizing problems. “In the 90 samples from 80 studies (124 027 children), the correlation was small but significant (r, 0.11…).” There was a gender difference, with males having more externalizing problems.
  • Internalizing problems. “In 43 samples from 40 studies (99 603 children), the effect size between child screen time and internalizing problems was weak but significant (r, 0.7…).” 

A few thoughts:

1. This is an impressive study.

2. A quick summary: screen time mattered.

3. There is much to like here: yes, the large number of studies and the impressive number of participants. Also, note that they only considered those 12 and under, recognizing that adolescent use of screen time is quite different (think social media).

4. How do the core findings compare to other studies? The authors write: “The magnitude of these correlations is comparable with that found in other meta-analyses on the association between screen time and child language skills and academic performance.”

5. Like all systematic reviews and meta-analyses, the authors drew from existing studies – which, not surprisingly, differed from one another. The source of the reporting was important: “Studies that used more objective methods (eg, observer report) and reporters (eg, peers) of children’s externalizing problems had stronger correlations than those using child, parent, or teacher reports.”

6. Like all papers, there are limitations. They note several, including: “although there was significant heterogeneity for internalizing problems, only 1 of the moderator analyses had significant results. Other important but unexamined moderators, such as genetic susceptibility, sleep, or language development, may have a significant role in associations.”

7. Screen time is a topic of much discussion and research. On Monday, for example, JAMA Pediatrics published a paper considering the impact of limiting recreational screen time on physical activity in an impressive cluster randomized control trail. Not surprisingly, Jesper Pedersen (of the University of Southern Denmark) and his co-authors found: “a recreational screen media reduction intervention resulted in a substantial increase in children’s engagement in physical activity.” They go on to conclude that high levels of screen time should be a public health concern. 

That paper can be found here:

8. Has the concept of screen time become too broad? The lead author suggests as much in an excellent podcast interview with Dr. John Torous (of Harvard University). She argues that the amount of screen time is important – but also how that time is used. She invites clinicians to ask clear questions of their pediatric patients. “We need to get kids thinking [about it].” How are they using these screens? How could they be more creative? How can they use devices to connect with others? (For those of us who see adults, these questions are still relevant since screen time often comes up with our patients who are parents or have a special role in the lives of children.)

The full JAMA Psychiatry paper can be found here:

Selection 2: “What I felt for years after my young son died now has a name”

Carol Smith

The Washington Post, 12 May 2022

So begins an essay by Smith. She explains the lasting impact the death had on her life. 

After I lost my only child more than 20 years ago, I told three lies over and over.

Yes, I’m fine, I said when people asked how I was doing.

I said this in the first year because I was in shock and didn’t have the words to begin to describe what I felt. My son was 7 when I got the phone call that he’d died unexpectedly while visiting his grandparents. The fact I wasn’t there to hold him in his last hours haunted me.

I said it in the second year because by then I’d instinctively absorbed the message that it’s not culturally acceptable to continue to talk about deep sadness more than a year after a loss. It makes people uncomfortable. It makes people feel they should be able to do something; it makes them feel helpless.

Three years after my son’s death, I went back to my job as a journalist for the Seattle Post-Intelligencer. I smiled, laughed even. To the outside world, it looked like I was ‘over it.’ But I was living in my own private snow globe. I avoided relationships, old and new.

Smith describes the lies she told people; for instance, that she didn’t have children – something that avoided the need to explain how her son had died. 

To her, the recent changes to DSM-5 make sense. “The organization included prolonged grief disorder in the updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5) it published in March. The diagnosis refers to intense emotional pain that persists more than a year after a loss. Criteria include numbness, withdrawal, an inability to rejoin the normal stream of life. Those who lose children are at particular risk, as are those who lose a loved one to violence, natural disasters or other tragedies. Those without support systems or who have other significant life stressors are also at risk.”

She notes the animated debate about this change; “critics argue that to suggest otherwise is to indicate that a normal process is a disease.” 

“But lost in this heated discussion is what it’s like to live with deep grief year after year. We are taught to suck it up. We are taught to power through. We get our few days of ‘bereavement leave,’ and then we’re supposed to get back to work. There’s not much of a grace period when it comes to grief. And because of that, long-term grief has been invisible to those who most need to recognize it.”

Would this diagnosis have helped her? “I believe it would have made me feel less alone – less ‘defective,’ not more so. I don’t think the new diagnosis pathologizes grief so much as makes it visible to those who suffer it and to those in their lives who might be able to help. Maybe the best thing that can come from the new diagnosis is not the view that long grief is disordered or maladaptive, but that it exists for some, is a normal response to an abnormal situation and deserves compassion.”

A few thoughts:

1. This is a moving essay.

2. As has been noted in this space before, revisions to DSM are not without controversy and criticisms, particularly new diagnoses (i.e., are we pathologizing normalcy or recognizing an underappreciated disorder?). Smith adds meaningfully to the debate by providing her perspective as a patient.

3. Prolonged grief disorder has been considered in past Readings. In one, we discussed the Prigerson et al. paper that provides an overview of the criteria and treatment.

That Reading can be found here:

The full Washington Post essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.