Obesity Reviews - 2021 - Byrne - Measurement of Screen Time Among Young Children Aged 0 6 Years A Systematic Review

Received: 26 February 2021 Revised: 24 March 2021 Accepted: 30 March 2021
DOI: 10.1111/obr.13260
PEDIATRIC OBESITY/BEHAVIOUR
Measurement of screen time among young children aged

0–6 years: A systematic review
Rebecca Byrne | Caroline O. Terranova | Stewart G. Trost
School of Exercise and Nutrition Sciences,

Faculty of Health, Centre for Children's Health Summary
Research (CCHR), Queensland University of The impact of screen-based devices on children's health and development cannot be
Technology (QUT), South Brisbane,
Queensland, Australia properly understood without valid and reliable tools that measure screen time within
the evolving digital landscape. This review aimed to summarize characteristics of
Correspondence
Professor Stewart Trost, School of Exercise measurement tools used to assess screen time in young children; evaluate reporting
and Nutrition Sciences, Faculty of Health, of psychometric properties; and examine time trends related to measurement and
Centre for Children's Health Research (CCHR),
Queensland University of Technology (QUT), reporting of screen time. A systematic review of articles published in English across
Level 6, 62 Graham Street, South Brisbane Qld three databases from January 2009 to April 2020 was undertaken using PROSPERO
4101, Australia.
Email: [email protected] protocol (registration: CRD42019132599) and Preferred Reporting Items for System-
atic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles measured
Funding information
National Health and Medical Research Council, screen time as outcome, exposure, or confounder in children 0–6 years. The search
Grant/Award Number: APP1101675 identified 35,868 records, 1035 full-text articles were screened for eligibility, and
622 met inclusion criteria. Most measures (60%) consisted of one to three items and
assessed duration of screen time on a usual day. Few measures assessed content
(11%) or coviewing (7%). Only 40% of articles provided a citation for the measure,
and only 69 (11%) reported psychometric properties—reliability n = 58, validity
n = 19, reliability and validity n = 8. Between 2009 and 2019, the number of publi-
shed articles increased from 28 to 71. From 2015, there was a notable increase in
the proportion of articles published each year that assessed exposure to mobile
devices in addition to television. The increasing number of published articles reflects
increasing interest in screen time exposure among young children. Measures of
screen time have generally evolved to reflect children's contemporary digital
landscape; however, the psychometric properties of measurement tools are rarely
reported. There is a need for improved measures and reporting to capture the
complexity of children's screen time exposures.
KEYWORDS
mobile devices, preschoolers, psychometric properties, screen-based devices
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
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© 2021 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.
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2 of 28 BYRNE ET AL.
1 | B A CKG R O U N D users are doing and why.13–15 Time, that is, total duration, may be less
important and could mask important differences in screen use. While
Screen-based devices are now ubiquitous in the lives of children and newer measures assessing use of screens by children are being
families. Over the past 20 years, the daily duration of time that developed,14,16,17 the methods used to quantify screen time in young
children are exposed to screen-based devices is increasing, while age children in studies conducted over the last decade are rarely
at first exposure is decreasing.1 Concurrently, the range of devices scrutinized. To our knowledge, no previous review has systematically
available and their uses has rapidly expanded. While home-based documented how screen time is measured in experimental and obser-
television viewing was once the primary mode of screen viewing, con- vational studies of young children aged 0 to 6 years. A systematic
temporary screen-based devices now accessible to young children review in 2007 examined studies of children up to 18 years of age but
also include computers, game consoles, and mobile digital devices was limited to those that included a measure of the frequency and
2
such as smartphones and tablets. The advent of mobile devices has duration of television watching as the main exposure or outcome of
altered where and how children experience screen time, including interest.18 Additionally, small studies of 50–100 participants were
solitary viewing, simultaneous device use, viewing traditional excluded from that review. Furthermore, no previous review has
television content on mobile devices, viewing outside of the home, examined time trends in the assessment of screen time in young
3
and use in early childhood education and care settings. children to determine if screen time measurement tools have kept
This shift has altered the way that children interact with screen- pace with technological advancements.
based devices. Television viewing is considered largely passive, as is An equally important methodological consideration is the extent to
streaming movies or shorter video content to mobile devices.4 Yet which investigators are employing psychometrically sound measures of
smartphones and tablets also offer children opportunities for screen time with documented evidence of validity and reliability. Of
cognitive engagement, with content delivered via e-books, games, and concern, the use of items or instruments lacking appropriate evidence
bespoke applications (commonly referred to as apps). The interactive of validity and/or the prerequisite levels of reliability can severely
nature of these activities, when combined with quality educational inflate measurement error and reduce statistical power.19 This results
programming and coviewing, may offer benefits to children such as in the reporting of inconsistent results and/or potentially spurious
enhanced language skills5 and improvements in movement compe- associations (or nonassociations) with health and developmental
tence.6 Video-chat is another interactive use of screen-based devices outcomes. To date, however, the quality of reporting in relation to the
with potentially positive consequences as it supports social connec- psychometric properties of instruments to measure screen time in
7
tion in a global society. young children has not been systematically evaluated.
Although newer interactive screen-based devices may offer bene- To address these important methodological considerations, the
fits, the association between excessive use of screen-based devices objectives of this systematic review are threefold: (1) to summarize
and negative consequences in young children are well documented, characteristics of measurement tools used to assess screen time in
most notably cognitive and social/emotional delays, reduced physical children aged 0 to 6 years; (2) to evaluate reporting of psychometric
activity, higher energy intake, poor sleep, and obesity.8,9 Due to properties in research literature; and (3) to examine time trends in
potential for negative consequences, the American Academy of relation to assessment of screen time in young children and reporting
Pediatrics (AAP)7 recommends that use of screen-based devices by of psychometric properties.
children younger than 18 months be avoided, except for video-chat,
whereas for children aged 2 to 5 years, use of screen-based devices
should be limited to 1 h/day of quality programming. Similar screen 2 | METHODS
time recommendations have been issued by the World Health
Organization10 and government health agencies including Canada and 2.1 | Protocol and registration
Australia.11,12 However, it is important to note that scientific evidence
underpinning these recommendations is based primarily on television The systematic review was registered with PROSPERO International
viewing. The extent to which contemporary screen-based devices are Prospective Register of Systematic Reviews (registration number:
beneficial or harmful to child health and development continues to be CRD42019132599; http://www.crd.york.ac.uk/PROSPERO) and is
an active area of research and a topic of considerable public and reported using the Preferred Reporting Items for Systematic Reviews
scientific debate.13 and Meta-Analyses (PRISMA) guidelines for systematic reviews.20
An important methodological consideration that has received
relatively little research attention is the measurement of screen time.
If knowledge translation related to benefits and harms of screen time 2.2 | Search strategy
is to advance and be relevant to contemporary society, it is critically
important that methods used to assess screen time in young children A systematic literature search was performed across three databases:
are fit-for-purpose and reflect the current screen media landscape. PubMed, Embase, and PsycINFO. Database searches, initially con-
Some researchers have recently argued that the assessment of ducted on March 13, 2019, and updated to April 30, 2020, were
“screen time” is meaningless unless measures describe what screen restricted to articles published in the previous 10 years (i.e., from
BYRNE ET AL. 3 of 28
2009), in English language, and in young children aged 0–6 years. No 3 | RE SU LT S

study design limits were applied. Search terms were developed based
on published literature8,21–24 in conjunction with an academic The search identified 35,868 unique records. Of this, 1035 full-text
librarian, and subsequently piloted in PubMed, then tailored to each articles were screened for eligibility, and 622 met inclusion criteria
database. Search terms were organized into two constructs: (1) popu- (Figure 1).
lation of interest, for example, young child, preschool, or infant; and Descriptive characteristics of the 622 articles are summarized in
(2) exposure of interest: specific measure of screen use, for example, Table 1. Children had a mean age of 42.1 months (SD = 18.3), and
television, video gaming, or screen time—defined as composite mea- approximately half were girls (48.5%, SD = 6.0). Sample size ranged
sures of screen use, obtained via device-based or self-report methods. from nine participants29 to 77,003.30 Most studies were conducted in
An example of a full search strategy is presented in Table S1. the Americas, Europe, and Western Pacific regions. Within these
regions, the majority were conducted in high-income countries.
Articles were published in 205 different journals, and based on Scopus
2.3 | Inclusion and exclusion criteria Subject Areas, the majority were allocated to Medicine, Nursing, and
Psychology.28
25
Search results were exported into EndNote (Version X9), and dupli- The key characteristics of instruments used to measure screen
cates removed. Citations were then imported into Covidence26—a time are summarized in Table 2. Most measures were self-
web-based software platform specifically designed for systematic administered (76.3%), that is, completed by parents and were part of a
reviews—then screened using a priori defined inclusion and exclusion questionnaire (92.4%). Three quarters of articles (76%) used a tool
criteria. For inclusion, the study sample had to include young children that was exclusively designed to measure screen time. All articles col-
(i.e., 0–6 years) and measure time spent viewing any screens or evalu- lected a parent/caregiver proxy report of child screen time except one
ate measurement properties of a tool designed to measure screen article,649 which did not report on the method used. No articles used
time. Articles were also included if the sample comprised children a device-based method to measure screen time. Of the 622 articles,
older than 6 years, but the mean sample age was between 0 and 28.7% measured screen time using a single item, whereas 31.5% mea-
6 years, or they reported on a subgroup of children within this range. sured screen time using only two to three items. Most articles (80%)
Articles were excluded if it was not published in English or after 2009; measured screen time exposure at home and childcare on a daily
conducted in humans; an individual study (i.e., systematic reviews and rather than weekly basis (86.5%), with 50% measuring screen time on
commentaries); or available in full-text publication. Articles that a typical or usual day/week. Most articles (84.9%) employed measures
described or reported on the results of screen-based interventions assessing the duration of screen time rather than the frequency of
such as telehealth, internet, or m-Health platforms but did not screen viewing or the combination of viewing frequency and duration.
measure screen time were also excluded. Just under half of articles measured screen time using open-ended
items, whereas approximately one third employed measures with
fixed or multiple-choice items. Only 67 (10.8%) included items
2.4 | Selection of included articles assessing content viewed, and only 46 articles (7%) assessed parental
coviewing.
Each article was screened against the inclusion and exclusion criteria Approximately 50% of articles assessed screen time using a com-
by two independent reviewers (COT and either RB or SGT) in two posite measure that encompassed watching TV or DVD/VCR, along
stages: (1) title and abstract screening and (2) full-text screening. with use of digital technologies such as computers, game consoles,
Discrepancies were resolved by a third reviewer (RB or SGT). tablets, or smartphones (Figure 2). Approximately one quarter of arti-
Reasons for exclusion at full-text screening are shown in Figure 1. cles measured television watching only, whereas approximately one
In addition to the structured search, reference sections of relevant fifth measured screen time exposure based on the combination of
systematic reviews and articles citing relevant psychometrics studies television watching, DCD/VCR, and computer use. Only 20 articles
identified in the search were manually reviewed for potentially (3%) focused exclusively on young children's use of handheld digital
eligible articles. technologies such as smartphones and tablets.
Figure 3 summarizes the distribution of articles by publication
year and modes of screen time assessed. Over the last decade, annual
2.5 | Data extraction publication of articles measuring screen time in young children has
more than doubled from 28 articles in 2009 to 71 articles in 2019.
Data were extracted into a custom Access database by one author Since 2009, the number of articles employing composite measures of
(COT). In addition, data extraction was completed independently on screen time, that is, assessing exposure to newer digital technologies
a subsample of records (n = 49) by a second author (RB) and cross- such as tablets and smartphones, in additional to television watching,
checked for accuracy. Data were subsequently uploaded into the grew considerably, accounting for approximately 60% of articles publi-
SAS statistical package (Version 9.4)27 for calculation of sample shed between 2015 and 2019. Conversely, the number of articles
frequencies. employing “traditional” measures of screen time (television only or
FIGURE 1 PRISMA flow chart of articles through the review process
television, DVD/VCR, and computer use) diminished; but even in arti- Trends over time were evident with an increasing number of
cles published in 2019/2020, the practice remains. Prior to 2015, only articles reporting a sample item, citation, or methods article in
a small percentage of articles exclusively measured young children's 2017–2020 compared with previous 4-year intervals. There was
exposure to handheld digital technologies such as smartphones and improvement in the proportion of articles reporting tool psychometric
tablets. Of the 20 articles of this type identified in the review, properties in 2013–2016 compared with the previous 4-year interval
16 (80%) were published since 2016. (increasing from 8.5% to 13.6%) but very little change in the number
The results related to the quality of psychometrics reporting are of articles reporting both reliability and validity of the tool used to
summarized in Table 3. Of the 622 articles identified, 250 (40.2%) measure screen time.
provided a citation for the measure and 192 (30.9%) included a The articles reporting psychometric properties are summarized in
sample item in the article. For those articles providing a citation, Table S2. Of the 58 articles reporting evidence of reliability,
88 (35.2%) cited a methods paper documenting the psychometric 46 assessed test–retest reliability, 11 assessed internal consistency,
properties of the measure. Sixty-nine (11.1%) of the 622 articles and one assessed both internal consistency and test–retest reliability.
reported the psychometric properties of the measure used to assess Test–retest reliability was most frequently evaluated using intraclass
screen time. Of this, 58 (84.1%) reported evidence of reliability and correlation coefficients (ICCs) (N = 39), with the remaining articles
19 (27.9%) reported evidence of validity. Only eight of the 69 arti- using Pearson or Spearman correlation coefficients (N = 6), Kappa
cles (11.9%) reported both evidence of reliability and validity, and statistics (N = 1), or percent agreement (N = 1). ICCs ranged from
most (n = 62; 89.9%) reported psychometrics for children aged 0.44 to 0.94. Sixteen articles reported a range of ICC values for
0–6 years. test–retest reliability, and for six of these, the lower bound was well
T A B L E 1 Descriptive characteristics of articles that included a Of the 19 articles reporting evidence of validity, 18 assessed con-
measure of screen time among young children aged 0–6 years current validity with accelerometer-based measures of sedentary
Measurement N (%) behaviors, direct observation, ecological momentary assessment
Study characteristics (EMA), and television monitoring devices serving as criterion

measures. Correlations with accelerometer-based measures were
Study design
generally weak (<0.30) and of marginal statistical significance.
Case control 8 (1.3)
Stronger validity coefficients (>0.40) were reported when direct
Cross-sectional 366 (58.8)
observation, EMA, and television monitoring devices served as
Cohort 164 (26.4)
criterion measures. One article assessed convergent validity and
Quasi-experimental 18 (2.9)
reported moderate but statistically significant inverse correlations
Randomized/nonrandomized controlled trials 66 (10.6)
between screen time and measures of executive function, language
Child's age and literacy skills, and home cognitive environment.14
Infant (0 to <18 months) 71 (11.7)
Toddler (18 to 36 months) 114 (18.8)
Preschooler (>36 months) 421 (69.5) 4 | DI SCU SSION
Not reported 16 (2.6)
WHO region This systematic review reveals that over the last decade, the annual
African 4 (0.6) publication rate of articles measuring screen time in young children
has more than doubled. The year-to-year growth in publications
Americas 287 (46.1)
reflects the increasing scientific interest in delineating the health and
South-East Asia 15 (2.4)
developmental impacts of screen time in young children. The review
Europe 173 (27.8)
also provides evidence to show that measures of screen time have
Eastern Mediterranean 9 (1.4)
evolved to reflect children's contemporary digital landscape, measur-
Western Pacific 130 (20.9)
ing not only television but also exposure across the varied range of
Multiple WHO regions 4 (0.6)
screen-based devices now available to children. Between 2009 and
Subject areaa 2019, the number of articles reporting the use of composite measures
Agriculture and Biological Sciences 12 (1.3) of screen time that included television watching in combination with
Arts and Humanities 13 (1.4) digital technologies such as computers, game consoles, tablets, and
Biochemistry, Genetics and Molecular Biology 19 (2) smartphones increased nearly fivefold, accounting for 60% of articles
Computer Sciences 2 (0.2) published between 2017 and 2019. However, not all studies are keep-
Dentistry 2 (0.2) ing pace with changes in digital technology. In absolute terms, the
Environmental Science 14 (1.5) number of articles measuring only the duration of television watching
b remained relatively constant over the last decade, raising some con-
Health Professions 38 (4.1)
cerns that a nontrivial number of studies may not be capturing young
Medicine 491 (52.3)
children's exposure to newer screen-based technologies.
Multidisciplinary 23 (2.5)
Despite widespread use of measures to assess screen time, across
Neuroscience 12 (1.3)
regions and disciplines of study, only a small percentage of articles
Nursing 135 (14.4)
provide a comprehensive description of the measures used. Indeed,
Psychology 101 (10.8)
many articles reported very little about the measurement of screen
Social Sciences 58 (6.2) time beyond a sentence that it was measured. The origin of measures
Not reportedc 18 (1.9) was difficult to determine, with less than half of all articles providing a
Abbreviation: WHO, World Health Organization. citation for the tool. When authors provided a citation, they typically
a
Subject area was defined by Scimago (based on Scopus Subject Areas).28 cited other articles using the measure and not a methodological study
b
Includes allied health professions. evaluating validity and/or reliability in children aged 0 to 6 years. Few
c
No Scimago results were found for five different journals across n = 18
articles reported details of the validity and reliability of the measures
publications.
used, with only approximately 10% reporting some information
regarding psychometric properties. On the positive side, when
below acceptable benchmarks for reliability (<0.50). One article only reported, reliability and validity statistics were generally at or above
reported that ICCs were greater than 0.40. Of the 11 articles acceptable benchmarks.
assessing internal consistency, 10 reported Cronbach's alpha and one To improve the quality of psychometrics reporting and advance
reported composite reliability. Internal consistency was generally our understanding of the potential harms and benefits of screen time
acceptable. When alpha coefficients were below accepted bench- in young children, manuscripts should include adequate reporting of
marks, they were typically based on a small number of items. measures used to assess screen time. This includes details of the items
TABLE 2 Characteristics of instruments used to measure screen time in young children aged 0–6 years
Tool characteristic N (%) Citation

Mode of administration
Parent-completed 474 (76.3) 30–503
Interview-administered 147 (23.7) 14, 29, 504–648
Not reported 1 (0.2) 649
Tool type
Questionnaire 575 (92.4) 14, 29–35, 37–45, 48, 51–86, 88–95, 97–160, 162–173, 175–181, 184–206, 208–211, 214–244,
246–251, 253–271, 275, 278–293, 295–321, 323–336, 338–343, 346–360, 362, 365–414, 417–
448, 450–455, 457–494, 496–498, 500, 502–517, 519–526, 529–559, 561–580, 582–591, 593–
605, 607–621, 623–627, 629–640, 642, 644–646, 648, 649
24-h diary/log 47 (7.6) 36, 46, 47, 49, 50, 87, 96, 161, 174, 182, 183, 207, 212, 213, 245, 252, 272–274, 276, 277, 294, 322,
337, 344, 345, 361, 363, 364, 415, 416, 449, 456, 495, 499, 501, 518, 527, 528, 560, 581, 592,
606, 622, 628, 643, 647
Number of items in questionnaire tools (N = 575)
1 item 165 (28.7) 30, 33, 34, 38, 58, 62, 64, 67, 73, 74, 83–85, 90, 91, 93, 95, 97, 100, 105, 108–110, 117, 119, 121,
131, 134, 136, 139, 143, 144, 146, 148, 149, 151, 153, 156, 165, 166, 169, 181, 185, 186, 191,
195, 198, 204, 205, 208, 211, 218, 228, 230, 232, 235, 239, 241, 247, 259, 261, 266, 267, 269,
278, 283, 288, 292, 300, 301, 304, 305, 309, 310, 312, 316, 317, 323, 324, 329, 332, 333, 338–
340, 347, 351–353, 356, 362, 366, 373, 375, 379, 386, 390, 393, 396, 403, 405, 409, 419, 420,
432, 439, 441, 452, 493, 507–509, 511, 513–515, 517, 520, 521, 530, 531, 533, 534, 536, 537,
542, 543, 545, 546, 552, 557, 559, 561–563, 567, 570, 571, 573, 574, 576, 577, 579, 584–586,
588–590, 595, 597, 598, 600–602, 604, 605, 608, 609, 626, 627, 638, 640, 642, 649
2–3 items 181 (31.5) 31, 32, 35, 37, 45, 51, 53, 57, 59, 61, 70, 71, 79, 86, 88, 94, 98, 104, 107, 111, 112, 114, 115, 118,
120, 132, 135, 137, 140, 141, 145, 164, 170, 171, 178, 179, 184, 187–190, 192–194, 196, 197,
201, 202, 206, 216, 220, 224, 226, 229, 233, 236, 237, 240, 242–244, 251, 258, 262, 268, 270,
275, 284–287, 290, 291, 295, 298, 306–308, 311, 313, 315, 318, 320, 325–328, 330, 331, 334,
336, 346, 350, 354, 355, 358, 359, 365, 367, 368, 370, 377, 381–383, 385, 387–389, 392, 397,
402, 410, 417, 423, 424, 426, 431, 433, 435, 437, 440, 443, 448, 451, 453, 454, 462, 464, 466,
468, 471, 472, 474, 475, 478, 479, 483, 484, 486, 490, 496–498, 510, 516, 523, 524, 526, 529,
538–541, 544, 549, 550, 553–555, 564, 565, 568, 569, 572, 575, 578, 582, 583, 591, 593, 599,
603, 607, 614, 616, 620, 632, 634, 639, 648
3–5 items 95 (16.5) 39, 42–44, 48, 52, 60, 63, 65, 66, 68, 80–82, 89, 92, 113, 122, 123, 125–130, 133, 138, 142, 147,
150, 152, 155, 157, 162, 163, 167, 175–177, 180, 199, 203, 209, 210, 217, 219, 221, 225, 248,
263–265, 281, 293, 296, 302, 321, 335, 341, 374, 376, 378, 384, 391, 398, 400, 401, 404, 413,
414, 427, 430, 436, 444, 445, 458, 461, 467, 481, 491, 503–505, 522, 532, 547, 548, 610, 615,
617, 623, 624, 630, 637, 641
More than 5 items 92 (16.0) 14, 40, 41, 54, 56, 72, 75–78, 101–103, 106, 116, 124, 154, 158–160, 168, 172, 173, 200, 214, 215,
222, 223, 227, 231, 234, 249, 250, 253–257, 260, 279, 280, 282, 289, 299, 303, 314, 319, 343,
348, 357, 360, 369, 371, 372, 394, 399, 406–408, 411, 422, 428, 434, 442, 447, 457, 459, 460,
465, 473, 485, 489, 492, 494, 506, 512, 519, 525, 551, 556, 558, 587, 611–613, 618, 629, 633,
635, 636, 644, 645
Not reported or missing 42 (7.3) 29, 55, 69, 99, 238, 246, 271, 297, 342, 349, 380, 395, 412, 418, 421, 425, 429, 438, 446, 450, 455,
463, 469, 470, 476, 477, 480, 482, 487, 488, 500, 502, 535, 566, 580, 594, 596, 619, 621, 625,
631, 646
Screen time setting
Home only 52 (8.4) 33, 36, 42, 48–50, 77, 78, 114, 126, 134, 152, 153, 159, 195, 208, 219, 230, 237, 242, 279, 280, 294,
295, 311, 314, 360, 374, 384, 393, 396, 404, 419, 442, 451, 461, 468, 469, 472, 510, 516, 525,
538, 548, 587, 592, 597, 611–613, 619, 638
Childcare only 2 (0.3) 117, 545
Home and childcare 495 (79.6) 14, 30–32, 34, 35, 37–41, 43–47, 51–66, 68, 70–72, 74–76, 79–94, 96–98, 101–108, 111–113, 115,
116, 118–125, 127–133, 135–139, 141–143, 145, 147–151, 154–158, 160–168, 170, 172–184,
186–194, 196–207, 209, 210, 212–218, 220–229, 231–236, 238–241, 243–245, 248–265, 267,
268, 270–278, 281, 282, 284–293, 296, 298, 299, 301–303, 305–308, 310, 312, 313, 315–317,
319–331, 333–355, 357–359, 361, 363–373, 376–383, 385, 387–392, 394, 395, 397–403, 405–
411, 413–418, 420, 422–424, 426–428, 430–437, 439–441, 444, 445, 447–449, 452, 454–460,
462, 464–467, 471, 475, 478–481, 483–487, 489–492, 494, 495, 497–499, 501–506, 508, 511,
512, 514, 515, 517–524, 526–528, 530–532, 534, 536, 537, 539–543, 546, 547, 549–560, 563–
TABLE 2 (Continued)

568, 570–575, 577–579, 581, 583, 584, 586, 588–591, 593, 595, 596, 598, 599, 601–607, 609,
610, 614–618, 620–622, 624, 626–630, 632–636, 639–645, 647–649
Not specified 73 (11.7) 29, 67, 69, 73, 95, 99, 100, 109, 110, 140, 144, 146, 169, 171, 185, 211, 246, 247, 266, 269, 283,
297, 300, 304, 309, 318, 332, 356, 362, 375, 386, 412, 421, 425, 429, 438, 443, 446, 450, 453,
463, 470, 473, 474, 476, 477, 482, 488, 493, 496, 500, 507, 509, 513, 529, 533, 535, 544, 561,
562, 569, 576, 580, 582, 585, 594, 600, 608, 623, 625, 631, 637, 646
Recall interval
Day 243 (39.1) 14, 30, 33, 34, 40, 45, 49, 50, 58, 60, 63, 64, 66, 69, 71, 73, 74, 83, 85, 87, 90–93, 100, 101, 104, 105,
108, 109, 112, 114, 119, 121, 131, 132, 135–137, 140, 144, 146, 149, 151, 155, 164–166, 174,
175, 177, 184, 189, 191, 192, 194, 196, 198, 200, 202, 204, 207, 213, 218, 224, 232–235, 240–
243, 251, 252, 259–262, 266, 267, 270–274, 278–280, 283, 288, 290–292, 299–302, 304, 305,
310, 312, 316, 318, 322–325, 327, 328, 337, 339, 341, 344, 345, 348, 349, 351, 352, 356, 362,
366, 375, 376, 379–384, 387, 390, 393, 402, 403, 405, 407–410, 414–416, 420, 422, 426, 432,
434, 439, 441, 449, 451–454, 456, 460–462, 468, 469, 475, 479–481, 486, 490–492, 496, 499,
500, 508, 509, 511, 514, 515, 517, 518, 520, 523, 526–533, 536, 539, 540, 542, 543, 550, 552,
553, 557, 559–561, 563, 566–568, 571, 573, 576–578, 581, 584, 585, 589, 590, 592–594, 598,
599, 601–606, 608–610, 616–618, 621, 622, 627, 636, 639–643, 647, 648
Weekday and weekend day 268 (43.1) 31, 32, 35, 36, 39, 41–44, 46–48, 51–57, 59, 65, 70, 72, 75–82, 84, 86, 88, 89, 96, 102, 103, 106,
107, 113, 115, 116, 118, 120, 122, 123, 125–130, 133, 134, 138, 141–143, 145, 147, 152, 154,
157–163, 167, 168, 170–173, 176, 178–180, 188, 190, 193, 197, 199, 201, 203, 206, 208–210,
212, 214–217, 219–223, 225, 226, 229, 236, 239, 244, 248–250, 253–258, 263–265, 268, 275–
277, 281, 282, 284–287, 289, 293–296, 298, 303, 306, 307, 313–315, 317, 319–321, 329–331,
333–336, 340, 342, 343, 346, 350, 354, 355, 357–361, 363–365, 367–372, 374, 377, 378, 385,
388, 389, 391, 392, 394, 395, 397–401, 404, 406, 411, 413, 417, 421, 423–425, 427, 428, 430,
431, 433, 435–437, 442, 444, 445, 448, 457–459, 464–467, 470, 471, 474, 478, 483–485, 489,
494, 495, 498, 501–503, 506, 516, 519, 522, 524, 525, 541, 547–549, 551, 554–556, 558, 564,
565, 579, 583, 587, 591, 595, 607, 611–613, 615, 619, 623, 624, 629, 630, 632, 633, 635, 637,
644, 645
Weekday only 26 (4.2) 61, 62, 139, 186, 195, 230, 231, 311, 373, 418, 419, 440, 476, 477, 510, 521, 546, 570, 574, 586,
588, 596, 628, 634, 638, 649
Weekend day only 1 (0.2) 181
Week 36 (5.8) 37, 38, 68, 97, 98, 110, 117, 124, 148, 150, 156, 182, 183, 187, 205, 227, 238, 245, 308, 326, 353,
446, 447, 487, 488, 497, 504, 505, 512, 534, 537, 538, 572, 575, 614, 620
Not specified 48 (7.7) 29, 67, 94, 95, 99, 111, 153, 169, 185, 211, 228, 237, 246, 247, 269, 297, 309, 332, 338, 347, 386,
396, 412, 429, 438, 443, 450, 455, 463, 472, 473, 482, 493, 507, 513, 535, 544, 545, 562, 569,
580, 582, 597, 600, 625, 626, 631, 646
Recall period
Usual/typical duration 311 (50.0) 30, 33, 35, 37, 39, 41, 43, 44, 46, 47, 51, 57–59, 62, 65, 70, 72, 75, 76, 80–82, 84–86, 88–90, 92, 97,
98, 102–104, 106, 113, 117–124, 126–136, 141, 147, 149, 152, 154, 158–160, 162–167, 170,
172, 173, 175–177, 180, 181, 184, 186, 187, 190, 192–194, 197, 198, 200–203, 206, 209, 210,
214, 215, 217, 219, 221–224, 226, 227, 229, 230, 236, 238, 243, 244, 248–250, 253–258, 260,
261, 263–265, 268, 281, 282, 285–287, 289, 291, 293, 295, 296, 298, 301–303, 306–308, 311,
313–315, 321, 324–331, 334–336, 340, 341, 349, 350, 355, 357, 358, 360, 365–369, 371, 374,
377, 378, 381–384, 388, 389, 391–394, 398, 399, 404–409, 411, 413, 414, 417–419, 424, 427,
428, 431, 433–437, 440–442, 444–448, 451, 452, 454, 457, 459–461, 464–467, 469, 471, 479,
481, 483–486, 488–494, 496–498, 502, 503, 506, 510, 511, 515, 517, 519, 521–523, 526, 527,
530, 532, 539, 540, 543, 548, 549, 555, 556, 558, 565, 566, 568, 570, 572, 575, 578, 581, 583,
586–592, 594–596, 599, 602–605, 614–617, 621, 628–630, 633–635, 637, 640–643, 645, 647,
649
Specific time period 79 (12.7) 36, 38, 49, 50, 54–56, 68, 77, 78, 87, 93, 96, 115, 156, 161, 168, 174, 178, 182, 183, 207, 212, 213,
231–234, 240, 245, 252, 271–274, 276, 277, 279, 280, 294, 310, 322, 337, 342, 344, 345, 353,
361, 363, 364, 376, 380, 397, 415, 416, 422, 439, 449, 456, 462, 475, 480, 495, 499, 501, 504,
505, 512, 518, 560, 567, 593, 606, 610, 618, 620, 622, 639, 644
Not specified 232 (37.3) 14, 29, 31, 32, 34, 40, 42, 45, 48, 52, 53, 60, 61, 63, 64, 66, 67, 69, 71, 73, 74, 79, 83, 91, 94, 95, 99–
101, 105, 107–112, 114, 116, 125, 137–140, 142–146, 148, 150, 151, 153, 155, 157, 169, 171,
179, 185, 188, 189, 191, 195, 196, 199, 204, 205, 208, 211, 216, 218, 220, 225, 228, 235, 237,
239, 241, 242, 246, 247, 251, 259, 262, 266, 267, 269, 270, 275, 278, 283, 284, 288, 290, 292,
297, 299, 300, 304, 305, 309, 312, 316–320, 323, 332, 333, 338, 339, 343, 346–348, 351, 352,
(Continues)
TABLE 2 (Continued)

354, 356, 359, 362, 370, 372, 373, 375, 379, 385–387, 390, 395, 396, 400–403, 410, 412, 420,
421, 423, 425, 426, 429, 430, 432, 438, 443, 450, 453, 455, 458, 463, 468, 470, 472–474, 476–
478, 482, 487, 500, 507–509, 513, 514, 516, 520, 524, 525, 528, 529, 531, 533–538, 541, 542,
544–547, 550–554, 557, 559, 561–564, 569, 571, 573, 574, 576, 577, 579, 580, 582, 584, 585,
597, 598, 600, 601, 607–609, 611–613, 619, 623–627, 631, 632, 636, 638, 646, 648
Dimensions recalled
Duration only 528 (84.9) 30–63, 65, 66, 69–71, 73–91, 93, 95–98, 100–110, 112, 114–145, 147–152, 154–163, 165–170,
172–174, 176, 178–181, 183, 184, 186–195, 197–199, 201–206, 208–220, 222–226, 228–236,
238, 239, 241–245, 249–251, 253–255, 258–261, 263–268, 270, 272–278, 281–296, 298–318,
320–340, 342, 344–347, 349–374, 377–380, 384–393, 395–398, 400–403, 405, 407, 409–412,
415–421, 423–428, 430–437, 439–449, 451–454, 457, 460–462, 464–469, 471, 472, 474–479,
482–487, 489, 490, 492, 494–503, 506, 508–512, 514–533, 536, 538–543, 545–568, 570–574,
576–579, 581–586, 588–614, 619, 621–625, 627–630, 632–634, 637–640, 643, 645–649
Frequency only 13 (2.1) 94, 111, 182, 246, 271, 450, 455, 488, 493, 534, 537, 569, 626
Frequency and duration 59 (9.5) 14, 68, 72, 92, 113, 164, 175, 177, 196, 200, 207, 221, 227, 237, 240, 248, 252, 256, 257, 262, 279,
280, 319, 341, 343, 348, 376, 381–383, 394, 399, 404, 406, 408, 413, 414, 422, 456, 458, 459,
473, 480, 481, 491, 504, 505, 575, 587, 615–618, 620, 635, 636, 641, 642, 644
Not specified 22 (3.5) 29, 64, 67, 99, 146, 153, 171, 185, 247, 269, 297, 375, 429, 438, 463, 470, 507, 513, 535, 544, 580, 631
Response format
Fixed choice 201 (32.3) 14, 30, 31, 33, 37, 41–44, 46–48, 52, 57, 63, 64, 69, 71, 80–82, 84, 86, 87, 92, 94, 101, 110–116,
120, 122, 125, 129, 132, 133, 138, 142, 149, 154, 155, 157, 162, 167, 172–176, 180, 184, 187,
189, 197, 198, 200, 201, 208, 216, 217, 219, 227, 229, 240, 243, 244, 246, 248, 251, 252, 255,
256, 258, 260, 263–265, 267, 272–274, 276, 277, 291, 293, 294, 296, 302, 305, 311, 313, 320,
325, 327, 328, 337, 338, 340, 341, 343, 346, 348, 350–353, 359, 361, 363, 366, 368, 370, 372,
375, 379, 381–385, 387, 390–392, 395, 397, 398, 400, 401, 403–405, 407, 410, 413, 414, 416,
436, 437, 442, 444, 445, 449, 450, 455, 457, 459–461, 465, 466, 481, 483–485, 488–490, 492,
493, 495, 501, 502, 511, 515, 517, 523, 524, 526, 531, 534, 547, 550, 552, 555, 561, 563–565,
568, 569, 573, 574, 586, 602–606, 614, 618, 626, 630, 632, 636, 639, 642
Open-ended 286 (46.0) 32, 34–36, 38, 40, 45, 49–51, 53–56, 58–62, 65, 66, 68, 70, 72, 73, 75–79, 83, 88, 93, 96–98, 102,
103, 106, 107, 117, 119, 121, 123, 124, 126–128, 130, 131, 134–136, 147, 150, 152, 156, 158–
161, 164–166, 168, 170, 177, 178, 181, 183, 190–194, 196, 199, 202–204, 206, 207, 209, 210,
212–215, 218, 220–226, 230, 232–234, 236, 238, 241, 242, 245, 249, 250, 253, 254, 257, 259,
262, 268, 271, 275, 279–282, 284–290, 292, 298, 301, 303, 304, 307, 308, 310, 312, 314–317,
319, 321, 322, 324, 326, 329–331, 334, 335, 339, 344, 345, 355–358, 360, 364, 365, 367, 369,
371, 373, 374, 376–378, 380, 388, 389, 393, 394, 396, 399, 406, 408, 409, 411, 415, 417–420,
422, 424, 426–428, 430, 431, 433, 435, 439, 440, 447, 448, 452, 456, 458, 462, 469, 475, 479,
480, 486, 491, 497, 503–506, 508–510, 512, 514, 516, 518–522, 525, 527–530, 532, 533, 536–
538, 540, 543, 546, 548, 551, 554, 556, 557, 567, 570–572, 575–578, 581, 583, 584, 587, 589–
593, 595, 596, 599, 601, 607, 609–613, 615–617, 620–622, 627–629, 633, 634, 637, 638, 640,
643–645, 647, 649
Not specified 135 (21.7) 29, 39, 67, 74, 85, 89–91, 95, 99, 100, 104, 105, 108, 109, 118, 137, 139–141, 143–146, 148, 151,
153, 163, 169, 171, 179, 182, 185, 186, 188, 195, 205, 211, 228, 231, 235, 237, 239, 247, 261,
266, 269, 270, 278, 283, 295, 297, 299, 300, 306, 309, 318, 323, 332, 333, 336, 342, 347, 349,
354, 362, 386, 402, 412, 421, 423, 425, 429, 432, 434, 438, 441, 443, 446, 451, 453, 454, 463,
464, 467, 468, 470–474, 476–478, 482, 487, 494, 496, 498–500, 507, 513, 535, 539, 541, 542,
544, 545, 549, 553, 558–560, 562, 566, 579, 580, 582, 585, 588, 594, 597, 598, 600, 608, 619,
623–625, 631, 635, 641, 646, 648
Content assessed
Yes 67 (10.8) 14, 40, 49, 50, 92, 94, 96, 98, 150, 172, 182, 183, 196, 227, 240, 244–246, 248, 249, 252, 257, 260,
271, 299, 319, 327, 348, 363, 364, 369, 387, 390, 407, 408, 450, 454, 455, 460, 467, 473, 480,
482, 483, 492, 502, 507, 512, 518, 524, 527–529, 539, 540, 556, 560, 580, 581, 592, 618, 621,
622, 628, 636, 643, 647
No 555 (89.2) 29–39, 41–48, 51–91, 93, 95, 97, 99–149, 151–171, 173–181, 184–195, 197–226, 228–239, 241–
243, 247, 250, 251, 253–256, 258, 259, 261–270, 272–298, 300–318, 320–326, 328–347, 349–
362, 365–368, 370–386, 388, 389, 391–406, 409–449, 451–453, 456–459, 461–466, 468–472,
474–479, 481, 484–491, 493–501, 503–506, 508–511, 513–517, 519–523, 525, 526, 530–538,
541–555, 557–559, 561–579, 582–591, 593–617, 619, 620, 623–627, 629–635, 637–642,
644–646, 648, 649
TABLE 2 (Continued)

Coviewing assessed
Yes 46 (7) 14, 50, 54, 80–82, 99, 106, 133, 180, 182, 183, 212, 217, 232, 233, 246, 248, 263–265, 319, 348,
408, 421, 442, 444, 445, 450, 455, 462, 467, 473, 480, 490, 501, 512, 518, 529, 580, 610, 621,
622, 628, 629, 636
No 576 (93) 29–49, 51–53, 55–79, 83–98, 100–105, 107–132, 134–179, 181, 184–211, 213–216, 218–231,
234–245, 247, 249–262, 266–318, 320–347, 349–407, 409–420, 422–441, 443, 446–449, 451–
454, 456–461, 463–466, 468–472, 474–479, 481–489, 491–500, 502–511, 513–517, 519–528,
530–579, 581–609, 611–620, 623–627, 630–635, 637–649
F I G U R E 2 Distribution of articles included in

the review by modes of screen time assessed
used and a citation for the methodological paper in which the mea- screen use. Only approximately 10% of articles identified assess con-
sure was developed and tested. Supporting evidence of validity and tent viewed, whereas 7% of the articles identified assessed coviewing.
reliability in the population under study should be provided. Journal Of note, measures with greater than three items did not necessarily
editors and reviewers should monitor the reporting of screen time provide a more comprehensive assessment of screen time. Rather,
measures during peer review and advocate for greater transparency in these tools tended to include separate items to assess duration across
reporting so that screen time assessment methods can be replicated segments of the day, for example, morning versus afternoon, and
in other studies. hence, the number of items increased. Development of measures that
Just as the range of devices assessed has expanded, there are can accurately estimate duration that a child spends engaging in differ-
appeals to move beyond measurement of duration of screen time to ent screen time activities15 (e.g., passive television watching, coviewing
15
include measures of quality of screen use, namely, the content age-appropriate content, and social interaction using video-chat) will
viewed and the context in which screens are being used.650 The AAP greatly enhance the evidence base regarding the impact of screen time
emphasizes the importance of adult interaction during media use, on health and developmental outcomes.
particularly for children under the age of 2 years, that is, the parent One aspect that was consistently reported across articles was the
7
watching with the child and reteaching the content. However, apart use of self-report measures by proxy. A systematic review published
from some notable exceptions,14 comprehensive screen time measures in 200718 examining television viewing in children and adolescents
are absent from the research literature. The results of this systematic argued that self-report methods for assessing television exposure
review confirm that studies conducted over the last decade have have not kept pace with research interest, calling for an increase in
primarily employed brief assessment tools consisting of between one the use of objective measures. Despite that call, no articles that used
and three items designed to measure the total duration of screen time a device-based method of assessing screen time were identified in the
on a usual day, with fewer than 10% of articles assessing frequency of present systematic review. Radesky et al. describe the use of “mobile
FIGURE 3 Distribution of articles included in the review by publication year and modes of screen time assessed
TABLE 3 Summary of the analyses evaluating the quality of psychometrics reporting in articles measuring screen time in young children aged
0–6 years
Methods Sample Reliability Psychometrics

Citation for article item Psychometrics Reliability Validity and validity were for the same
N measurea citedb reporteda reporteda reportedc reportedc reportedc study populationc
All 622 250 (40.2) 88 (35.2) 192 (30.9) 69 (11.1) 58 (84.1) 19 (27.9) 8 (11.9) 62 (89.9)
By publication period
2009–2012 142 37 (26.1) 9 (24.3) 37 (26.1) 12 (8.5) 7 (58.3) 7 (58.3) 2 (16.7) 11 (91.7)
2013–2016 235 106 (45.1) 36 (34.0) 74 (31.5) 33 (14.0) 30 (90.9) 6 (18.2) 3 (9.1) 27 (81.2)
d
2017–2020 245 107 (43.7) 43 (40.2) 81 (33.1) 24 (9.8) 21 (87.5) 6 (26.1) 3 (13.6) 24 (100)
a
Percentage is based on the total number of included papers and the number of papers for each publication period.
b
Percentage is based on the number of papers providing a citation for the measure used.
c
Percentage is based on the number of papers reporting the psychometric properties of the measure within the publication.
d
Data include papers published to April 2020; 2017–2020 represents duration of 40 months compared with previous increments of 48 months.
device sampling,”17 using application usage data collected by mobile exposure since 2009 was conducted, resulting in nearly 36,000 titles
devices to assess daily duration of device use among children aged and abstracts to review and over 1000 full-text articles examined for
3 to 5 years. Data were compared with a single item assessing parent inclusion. To supplement this search, an extensive manual search of
report of duration of child's device use on a typical day, resulting in relevant systematic reviews and individual studies identified in the
only 30% of parents being considered accurate reporters. This structured search was conducted. The review and extraction pro-
approach is promising, but challenges remain regarding how to assess cesses were rigorous, whereby titles and abstracts and full-text
usage across multiple devices and distinguish between individual users records were reviewed by two independent authors, and a subsample
when young children tend to share devices with other family of records independently checked for accuracy after data extraction.
651
members. The Access database used for data extraction was custom designed to
reduce possibility of data entry errors. However, there are some limi-
tations. There is a possibility that not all relevant publications were
5 | STRENGTHS AND LIMITATIONS found through the systematic search or cross-reference searches.
Locating studies that measured screen time is a challenge as informa-
The current review has several strengths. An extensive search for all tion on measurement of screen time is often lacking in the titles and
articles that measured screen time in young children as outcome or abstracts, particularly if screen time was not a primary outcome
measure. Measures published in languages other than English, or in 5. Madigan S, McArthur BA, Anhorn C, Eirich R, Christakis DA.
the gray literature, were not included in this review. There are addi- Associations between screen use and child language skills: a
systematic review and meta-analysis. JAMA Pediatr. 2020;174(7):
tional tools that have been used to assess screen time among children
665-675.
under 6 years of age but were excluded, because the relatively large 6. Trost SG, Brookes DSK. Effectiveness of a novel digital application
age range of participants resulted in a mean age in the sample of to promote fundamental movement skills in 3- to 6-year-old chil-
greater than 6 years. There may also be a larger number of measures dren: a randomized controlled trial. J Sports Sci. 2021;39(4):453-459.
7. Council on Communications and Media. Media and young minds.
that assess content and coviewing, but due to the lack of detail in
Pediatrics. 2016;138(5):e20162591.
reporting of items, these were not able to be identified and included 8. Poitras VJ, Gray CE, Janssen X, et al. Systematic review of the
in frequencies. Given the wide range of measures used and inconsis- relationships between sedentary behaviour and health indicators in
tency of reporting, we did not attempt to estimate average screen the early years (0–4 years). BMC Public Health. 2017;17(Suppl
5):868.
time duration across publications.
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Behaviour and Sleep for Children Under 5 Years of Age. Geneva: World
Health Organization; 2019.
This systematic review identified a more than doubling in the number
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of publications in the decade 2009–2019, which have used predomi- adopting/adapting guidelines—the Australian 24-Hour Movement
nantly brief tools to measure screen time duration among young Guidelines for the early years (birth to 5 years): an integration of
children. There is a notable shift from measuring exposure to televi- physical activity, sedentary behavior, and sleep. BMC Public Health.
2017;17(5):869.
sion, DVDs, and computers to measures that also encompass contem-
12. Tremblay MS, Chaput J-P, Adamo KB, et al. Canadian 24-hour
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The assistance of Queensland University of Technology librarian,
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Funding from the National Health and Medical Research Council, 2020;20(1):664.
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Received: 26 February 2021 Revised: 24 March 2021 Accepted: 30 March 2021

Measurement of screen time among young children aged

Rebecca Byrne | Caroline O. Terranova | Stewart G. Trost

School of Exercise and Nutrition Sciences,

Obesity Reviews. 2021;22:e13260. wileyonlinelibrary.com/journal/obr 1 of 28

2009), in English language, and in young children aged 0–6 years. No 3 | RE SU LT S

FIGURE 1 PRISMA flow chart of articles through the review process

Study characteristics (EMA), and television monitoring devices serving as criterion

Tool characteristic N (%) Citation

Tool characteristic N (%) Citation

Tool characteristic N (%) Citation

Tool characteristic N (%) Citation

F I G U R E 2 Distribution of articles included in

Methods Sample Reliability Psychometrics

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