How Screen Time Affects Our Patients: Healthcare Practitioners Need to Know

Screen time generally includes television watching, desktop and laptop computer use, electronic tablets, smartphones, and video gaming systems. In many western and some far-east countries, there is a continuous rise in youth's digital media consumption. In 2011, 52 percent of 0 to 8-year-old children had access to a mobile device. Access increased by 2013 to 75 percent. In 1999, the average screen time of 8–18-year-olds was around 6 hours per day; this increased to approximately 7.5 hours per day by 2009 and, according to a CBS news report, remained about the same in 2018. A growing body of literature addresses excessive and addictive use of digital media, reporting adverse consequences for users physically, psychologically, socially, and neurologically. Research has increased the focus on mobile device use, including duration, content, after-dark use, media type, and the number of devices used. Findings indicate that excessive screen time is associated with poor sleep, high blood pressure, obesity, low HDL cholesterol, poor stress regulation (high sympathetic arousal and cortisol dysregulation), and Insulin Resistance. Other reported physical health effects include impaired vision and reduced bone density. Depressive symptoms and suicidal tendencies have been associated with screen time-induced poor sleep, digital device night use, and mobile phone dependency. ADHD-related behavior has been linked to sleep problems, overall screen time, and violent, fast-paced content, activating dopamine receptors. Additionally, digital media addictive behavior has been linked to structural changes in the brain affecting cognitive control and emotional regulation (Lissak, 2018).

The most significant benefit of using technology for learning appears to be motivation; when lessons and learning activities are integrated into tablets or other devices, kids become excited, active learners. Technology-based apps and programs are also reported to support individualized learning. This access is due to their ability to support multiple levels and styles of learning and allow students to work at their own pace. Personalized apps can track if a child is struggling with a certain topic and provide extra support where it is needed. Alternatively, when students excel in a specific area, they can move forward to more advanced topics. Using technology at the elementary school level helps students learn the basic skills required to operate the newest devices and latest software. It also helps them collaboratively and cooperatively with their peers with research and problem-solving. Teachers report that technology allows them to do much more when teaching their students. This technology may include interactive whiteboards or educational apps that present material in a new and more exciting way (Riskey, 2018). A large amount of research has found that educational screen media positively impacts cognitive development. Games played on computers and other devices can enhance specific cognitive skills when the game effectively teaches and exercises the skills (Anderson & Subrahmanyam, 2020). A Pew Research Center survey of U.S. teens found that many teens credit online platforms with several positive outcomes, such as strengthening friendships, exposure to different viewpoints, and helping others their age support causes they are interested in (Anderson & Jiang, 2018).

As recently as 1970, urban children spent most of their recreation time outdoors, playing anywhere they could go, on sidewalks, streets, playgrounds, parks, greenways, vacant lots, and any other available spaces. Suburban children did the same and spent time in the fields, forests, streams, and yards. Today nature-based activities have been replaced with video games, play stations, and television shows resulting in children and adults spending less time outdoors. Action figures, puzzles, and board games are not considered favorite toys of today's children; touch screens have taken over. Even though humans derive many benefits from nature, our lifestyles today are disconnected from the natural environment. Researchers estimate that today humans spend up to 90 percent of their lives indoors, missing out on the beneficial effects of nature. Because we do not spend time outdoors, we are less connected to nature and feel less responsibility to protect or preserve our environment.

Children need nature; they need to touch it, hear it, and taste it. They need sensory experiences like playing in fresh-cut grass, walking in soft mud, or experiencing a caterpillar wiggling on its finger. These are the types of sensory experiences many occupational therapists integrate into a child's treatment plan. Could the lack of time spent in nature contribute to sensory processing and modulation difficulties? Nature brings our senses alive; scientists recently discovered that humans could track by scent—some humans rival bats in echolocation or biosonar abilities. Military studies of soldiers in war zones revealed that some of them could see nuances others could not; some were even able to spot hidden bombs. The soldiers with heightened abilities grew more aware of their surroundings; they reported spending much time outdoors. Nature is reported to nurture our "nature neurons" and innate creativity. Researchers at the University of Michigan confirmed that memory performance and attention spans improved by 20 percent after just one hour in nature. When workplaces were "designed with nature in mind," employees were reported to be more productive and took less sick time. Pennsylvania researchers found that patients in rooms with tree views remained hospitalized for shorter durations, required less pain medication, and had fewer negative comments in the nurse's notes section of their chart compared to patients in rooms with views of a brick wall. Researchers in Sweden found that joggers who exercise in natural green settings reported feeling more restored and less anxious, angry, or depressed than people who burned the same amount of calories jogging in urban settings. Levels of neurochemicals and hormones associated with social bonding are elevated during animal-human interaction. Researchers at the University of Rochester reported that exposure to natural environments leads people to nurture close relationships with fellow human beings, value community, and demonstrate increased generosity with money (Sailakumar & Naachimuthu, 2017).

Research also indicates that spending time in nature provides protection against a startling range of diseases, including conditions such as depression, diabetes, obesity, ADHD, cardiovascular disease, and cancer, to name a few. Time spent in and around tree-lined streets, gardens, parks, and forest and agricultural areas has consistently been linked to long-term health outcomes. The less green in an individual's surroundings, the higher their risk of morbidity and mortality, even when controlling for socioeconomic status and other possible confounding variables (Kuo, 2015).

Participation in various outdoor activities can help strengthen children's social relationships, mental and physical health, creativity, and conservation orientations. An individual's outdoor time, particularly during childhood, can foster a connection to nature, yielding other benefits. Studies suggest that nature's "connectedness" or "relatedness" contributes to positive emotions, happiness, and subjective well-being. Screen time may be a key factor linked to declines in both outdoor time and time connecting to nature, even in rural populations, and it has been reported that as children age, the problem intensifies (Larson et al., 2018).

Natural environments are good for adults as well. They contain chemical and biological agents that have positive health implications. Many plants give off phytoncides that contain antimicrobial compounds that reduce blood pressure, alter autonomic nervous system activity, and support the immune system. The air in forest and mountain areas and areas near moving water contains high concentrations of negative air ions that reduce depression. These environments also encompass mycobacterium vaccae, a microorganism that appears to boost immune functioning. Environmental biodiversity may play a role in immune function by affecting microorganisms living on the skin and in the gut. The sights and sounds of nature have beneficial physiological effects on health. Window views and images of nature reduce sympathetic nervous activity, increase parasympathetic activity, restore attention, and promote faster healing after surgery. Blood tests before and after walks reveal that health-protective factors increased after forest but not urban walks. Dehydroepiandrosterone (DHEA) increases after walking in the forest; DHEA contains cardioprotective, anti-obesity, and anti-diabetic properties. Time in nature also increases adiponectin, which protects, among other things, against atherosclerosis. Walks in forest areas reduce inflammatory cytokines and elevated blood glucose levels. Inflammatory cytokines are released by the immune system in response to a threat and are implicated in diabetes, cardiovascular disease, and depression. Chronically elevated blood glucose carries multiple health risks, such as blindness, nerve damage, and kidney failure. The experience of nature helps shift individuals toward deep relaxation and parasympathetic activity, which improves sleep, boosts immune function, and counters the adverse effects of stress on energy metabolism, insulin secretion, and inflammatory pathways.

It appears that time spent in nature/outdoors benefits human health in various ways, and screen time appears to be limiting that time. Health care costs are rising, more and more people are presenting with chronic diseases, and with an ever-increasing population, we are infringing on natural settings, reducing this precious natural space. We as healthcare workers should take note and do what we can to educate our patients about the health benefits of being outdoors, and, at the very least, for the health of our patients, we should consider outdoor treatment sessions whenever possible (Kuo, 2015).

The prevalence of myopia has increased significantly over the past few decades; myopia is considered to be a defective distant vision. Lifestyle influences known to be risk factors for myopia include lack of outdoor exposure, duration of near work, and near working distance. Computer use has been suspected of the increasing rate of myopia but lacks firm evidence, which precipitated a study involving 5,074 children. Researchers concluded that computer use in young children was moderately associated with myopia development. Reading time had a stronger association with myopia, possibly due to the shorter near-work distance. Evidence from a meta-analysis of observational studies revealed that total near-work was a risk factor for myopia, emphasizing the consequences of near-work activities in childhood. Reading time and reading distance were both associated with myopia. However, the effect of computer use appeared somewhat less strong. The use of handheld digital devices was not part of this research which may have had a greater effect on the risk of developing myopia due to the shorter reading distance. An association between outdoor exposure in childhood and the incidence and progression of myopia has been well established by multiple randomized controlled trials. The hours of outdoor exposure needed to prevent myopia in children depend on near-work activities' intensity. Whether outdoor exposure during daylight has an extra protective effect on the eyes or whether simply not being indoors involved near work is the key was not clear in this study. In order to prevent myopia in children, studies suggest that anywhere from 7 to 12 hours per week of outdoor exposure is needed and up to 14 hours per week for protection when engaging in medium or high intensity near work (Enthovena et al., 2020).

Another study implemented a school-based program that included time spent outside and breaking up the duration of near-work tasks to control myopia. This study involved first-grade children in Taiwan. Students were encouraged to participate in 11 hours or more of outdoor time every 7 days. Before the study, teachers, children, and parents received eye health education from ophthalmologists about myopia prevention using evidence-based medicine and were informed about the possible complications of myopia. During weekends, holidays, and summer, teachers were encouraged to assign homework that included outdoor activities. Parents were invited to bring children to outdoor activities during out-of-school time. In class, after participating in near-work activities consisting of tasks such as reading, painting, writing, and screen time, for 30 minutes, children were encouraged to take 10-minute breaks outside. The study went on for one year and was effective in retarding both myopia shift in non-myopic children and myopia progression in myopic children. Researchers announced that this was the first report revealing that outdoor activities could significantly inhibit progression in myopic children, with approximately a 30 percent reduction within 1 year (Pei-Chang et al., 2018).

There is a significant association between lack of sleep and screen time. When we do not get enough sleep, there are consequences to our health. Reduced sleep has been associated with screen types in 90 percent of the studies (Hale & Guan, 2015). The amount of time spent viewing screens before bedtime has been linked with an increase in sleep problems for 2-6-year-olds. Evidence suggests that the volume of screen time rather than content is detrimental to sleep patterns. Any electronic device in a bedroom is associated with fewer minutes of sleep per night (CPS, 2017). Evening and nighttime exposure to bright light and blue light emitted from self-luminous electronics may suppress melatonin production, affect the timing of melatonin production, and, ultimately, cause circadian rhythm disruption. Furthermore, the pineal gland produces melatonin (the sleep hormone) and may sense electromagnetic radiation as light and reduce the production of melatonin (Lissak, 2018).

A report from the Division of Sleep Medicine at Harvard Medical School states that many people do not realize that a lack of sleep is associated with long-term health consequences, including chronic medical conditions like diabetes, high blood pressure, and heart disease. These health conditions can lead to a shortened life expectancy. Sleep is a potential risk factor for obesity, along with the two most commonly identified risk factors: lack of exercise and overeating. When we sleep, our bodies secrete hormones that help control our appetite, metabolize energy, and process glucose. Not getting enough sleep upsets the balance of these and other hormones. Poor sleep, for example, leads to increased production of cortisol, commonly referred to as the "stress hormone." Poor sleep is also associated with increased insulin secretion after consuming food. Insulin, a hormone that regulates glucose and promotes fat storage, is associated with weight gain when found at high levels in the body. Insufficient sleep has been associated with lower levels of leptin and higher ghrelin levels. Leptin is a hormone that lets the brain know when we are full, and ghrelin, a biochemical, stimulates appetite. Subsequently, poor sleep can result in food cravings even after eating an adequate amount of food.

Chronic insufficient sleep may lead to long-term mood disorders since chronic sleep issues have been correlated with depression, anxiety, and mental distress. When faced with an infection, people who sleep more are better able to fight the infection, suggesting that we compromise our immune system when we do not get adequate sleep. Research in animals found that those who got more deep sleep following an experimental challenge by microbial infection had a better chance of survival. Data from three large cross-sectional epidemiological studies revealed that sleeping five or fewer hours per night increased mortality risk from all causes by roughly 15 percent.

Electromagnetic field(EMF) exposure is a huge buzzword as the United States moves to 5G; this topic could easily be a separate paper. Healthcare workers should be aware of the damaging effects on their patients and themselves, and their family members, including plants and pets. A big concern with 5G is that it relies primarily on the bandwidth of the millimeter-wave (MMW); this is known to penetrate 1-2 millimeters into the human skin tissue. Evidence suggests that sweat ducts in human skin act as antennae when we encounter these waves, and many people can feel this as a burning sensation or pain. This sensation is why it is used in nonlethal crowd control weapons. MMW has also been linked to eye problems, altered heart rate variability (an indicator of stress), arrhythmias, and immune system suppression (Mercola, 2020). As early as 1979, there has been increasing evidence that some facet of electromagnetic field exposure is associated epidemiologically with an increased occurrence of leukemia and certain other cancers and non-cancers like Alzheimer's disease, Amyotrophic Lateral Sclerosis, and suicide. Children's brain tissue is more conductive than adults rendering their nervous system more vulnerable to radio-frequency electromagnetic radiation (RF-EMR) fields. The National Toxicology Program of the U.S. National Institute of Health published evidence linking radiofrequency radiation to cancer, which released partial findings from a cell phone study on rats. The study revealed tumors in the brains and hearts of male rats after exposure to RF radiation and evidence of DNA damage. RF-EMR has been found to affect various organs, including the testicles, directly or through a thermal effect, e.g., carrying a cell phone near the testes' pants pocket. Emerging data shows a decline in male semen quality; mobile phones were examined to see if they were contributing to this. Study results indicated that exposure to RF-EMR through cellular phone use or laptops or tablets is related to carcinogenic risk and reproductive damage (Lissak, 2018).

There are also non-thermal microwave/lower frequency electromagnetic fields, and this is not just your microwave oven but your portable phone, cellphone, and cellphone towers. Electromagnetic fields may affect our health, causing damage to mitochondrial function by increasing free radical damage. Low-frequency microwave radiation activates the voltage-gated calcium channels (VGCCs) in the outer membrane of human cells, causing them to open, allowing an abnormal influx of calcium ions. This influx activates nitric oxide, which is a precursor for peroxynitrite. Peroxynitrite is the most damaging type of reactive nitrogen species and triggers mitochondrial damage. According to Dr. Martin Pall, Ph.D., this drives chronic disease processes. Changes in calcium fluxes and calcium signaling following low-frequency EMF exposure can be explained due to VGCC activation. The problem with this is that where the physical locations of the VGCCs are the densest dictates where you can expect the disease to occur from chronic excessive exposure to EMFs. The highest density of VGCCs is found in your nervous system. Studies dating back to the 1950s and 60s reveal that the nervous system is the organ most sensitive to EMF exposure. Some of these studies show massive changes in the structure of neurons, including cell death and synaptic dysfunction. When the VGCCs are activated in the brain, they release neurotransmitters and neuroendocrine hormones; therefore, the consequences of chronic EMF exposure to the brain include anxiety, depression, autism, and Alzheimer's disease. It is difficult to imagine how the combinations of neuropsychiatric effects will influence human behavior and social interactions. Today the majority of the human populations on earth are exposed to increasing intensities and diversity of microwave frequency EMFs. Scientists have no idea what the consequences of these exposures will be (Pall, 2016).

According to Dr. Joseph Mercola, who recently published a book on the topic (EMF*D), the most common signs of EMF exposure are difficulty sleeping and tinnitus (ringing in the ears). Other signs include:

• Anxiety and depression
• Headaches
• Fatigue
• Vision and hearing issues
• Cognitive dysfunction, including lack of concentration and focus
• Dizziness/vertigo
• Memory changes
• Tension and restlessness
• Irritability

If you have patients complaining of these conditions, you may want to ask about their exposure to electronic devices, including wireless routers. You can also provide them with the following tips and encourage them to do some investigating on their own to find more information on what they can do to lower their exposure.

1. Find an inexpensive meter to identify significant sources of EMF in their homes.
2. Connect desktop computers to the internet via a wired connection.
3. Shut off WiFi when you are not using it, especially at night when sleeping.
4. Avoid using wireless chargers for cell phones.
5. Shut the electricity off in bedrooms at night.
6. Use a battery-powered alarm clock.
7. Consider replacing your microwave with a steam convection oven.
8. Avoid using "smart" appliances and thermostats that use wireless signaling.
9. Refuse a smart meter on your home as long as you can.
10. Do not use wireless baby monitors.
11. Remove all fluorescent lights and replace them with CFL bulbs.
12. Avoid carrying your cell phone on your body, and do not sleep with it in your bedroom unless it is in airplane mode (Mercola, 2020).

Primary language disorders in children 3.5-6.5 years of age are associated with exposure to televisions, computers, game consoles, tablets, and smartphones. Studies have demonstrated that when young children use screens, they do not engage in emotional interactions with caregivers. These interactions are important for psychomotor development, especially language development. Children exposed to screens before they start their day and rarely or never discuss the screen content with their caregivers are six times more likely to have language problems (Kuo, 2015). Screens may help with language acquisition when quality content is co-viewed and discussed with a parent or caregiver. Preschoolers learn expressive language and vocabulary best when engaged in live, direct, and dynamic interactions with caring adults. High exposure to background TV has been found to negatively affect language use and acquisition and attention, cognitive development, and executive functioning in children younger than 5 years of age. TV also reduces the amount and quality of parent-child interaction and distracts from playtime (CPS, 2017).

Sedentary behavior secondary to screen time has been linked to increased risk of obesity, HDL dysfunction, and high blood pressure, which are major risk factors for cardiovascular disease. The relationship between screen time and obesity can be explained by reduced sleep, physical inactivity, and exposure to advertising, which negatively impact the user's dietary choices (Lissak, 2018). Commercial TV exposes children to advertisements for unhealthy foods and encourages snacking, which increases overall food intake. A systematic review of TV watching and adverse dietary effects in children 2-6 years old reported that as little as one hour a day of viewing had negative effects (CPS, 2017). As little as two daily hours of internet use, TV watching, and video gaming is considered sedentary behavior and directly impacts blood pressure in all age ranges. A study involving six-year-olds reported that each hour of TV watching increased arteriolar narrowing and increased the children's systolic blood pressure by 10-mm Hg. The retinal arteriolar narrowing is a possible marker for future adverse cardiovascular events. The good news is that the children participating in "high" outdoor activity had wider retinal arterioles than children with "low" outdoor activity time (Lissak, 2018).

Screen time does not have to be passive. Digital media can be used to encourage and compliment physical activity. Children, especially those over three, respond to activity-based programming when it is fun, designed for them, and has an imitation or participation component. One study found that active video games can provide light-to-moderate or moderate-to-vigorous physical activity. Therapists might consider integrating fun, age-appropriate movement (e.g., yoga or dance), fitness apps, or console games, into a treatment session, especially in place of sedentary electronic tasks. If using mobile devices, consider using apps to explore the outdoor world by integrating them with physical activity and encourage families to do the same (CPS, 2017).

Cyberbullying is defined as: "willful and repeated harm inflicted through computers, cell phones, and other electronic devices." This bullying can happen online, through email, text messages, or by posting negative information about another person on a website. Depending on the circumstances, specific behaviors such as hurtful comments, threats, rumors, pictures, or videos posted or circulated online may constitute cyberbullying. One of the reasons bullying can be emotionally or psychologically damaging is its repetitive nature, and albeit a dysfunctional one, victims have a relationship with the bully (Hinduja et al., 2020). Understanding intent, repetition, and power in cyberbullying is much more complicated than traditional bullying. Traditional bullying is described as cruel behavior that is intentional, repetitive, and perpetrated by a more powerful individual over a less powerful target or victim. Cyberbullying is associated with traditional bullying, but the lines blur, and the questions become unclear in the digital world. When is online repetition intentional? Can a message sent to one person be forwarded to hundreds more? Who has more power online? Sometimes, digital behaviors meet the criteria for bullying, but at other times, they do not. What is clear is that cyberbullying impacts the victim in various ways and can be damaging emotionally, socially, and academically. To better understand digital interactions, we need to define better the nature of cyberbullying and other forms of digital conflict and cruelty, including online harassment and sexual harassment. We need to consider how digital communication changes interactions and how this information can be applied to develop effective and useful prevention programs for children and adolescents (Anderson & Subrahmanyam, 2020).

The following is a list of signs that an individual might be the target of cyberbullying:

• unexpectedly quitting the use of a device(s)
• appearing nervous or jumpy when using a device(s)
• appears uneasy about being at school or around peers
• appears to be angry, depressed, or frustrated after texting, chatting, using social media, or gaming
• becomes abnormally withdrawn
• avoids discussions about their online activities

The following is a list of signs that an individual may be cyberbullying:

• quickly switches screens off or hides their device when someone comes around
• uses their device(s) at all hours of the night
• gets unusually upset if they cannot use a device(s)
• avoids discussions about what they are doing online
• seems to be using multiple online accounts or an account that is not theirs

If an individual has been cyberbullied, it is important to make sure they feel (and are) safe and to convey unconditional support. Parents must show their children that they desire the same result through words and actions: cyberbullying stops, so life does not become even more difficult. It is appropriate and important to solicit a child's perspective on what might be done to improve the situation, if at all possible. It is critical to validate the individual's voice and perspective and work together to arrive at a mutually agreed-upon course of action. Targets of cyberbullying (and those who observe it) must know for sure that the adults they confide in will intervene rationally and logically, not worsen the situation.

If parents discover that their child is cyberbullying, they should first communicate how that behavior inflicts harm and causes pain in the real world and cyberspace. Adults need to remember that kids are not sociopaths; they are just kids who sometimes lack empathy and make mistakes. However, it should be clear that there are ramifications for every choice they make. Depending on the level of seriousness of the incident and whether it appears that the child understands the hurtful nature of their behavior, consequences should be firmly applied.

In general, if a child acts in inconsistent ways with their typical behavior when using devices, it is time to find out why. Therapists working with children and their families can educate parents and other caregivers about the signs and guide them, if necessary, on how they might handle the situation, and educate them on where they can get more information or assistance (Hinduja et al., 2020).

Over the past six decades or so, hundreds of research studies have been conducted on media violence. In addition to the physiological effects, which include increased activation of dopamine receptors, experimental studies have shown that exposure to violent media causes people to behave more aggressively immediately after engaging in the activity. A variety of field experiments performed in natural settings using realistic measures of aggression have produced similar results, demonstrating that effects can be long-lasting. Numerous longitudinal studies show that exposure to violent media as a child predicts aggressive and violent behavior years later as an adult. Although there is never complete consensus in any scientific field, the evidence is so convincing that dozens of major scientific and medical organizations have issued statements about the harmful effects of exposure to violent media (Anderson & Subrahmanyam, 2020).

So what is the impact of technology on the developing child? Children's developing sensory, motor, and attachment systems have biologically not evolved to accommodate today's technology's sedentary yet frenzied and chaotic nature. The impact of rapidly advancing technology on the developing child has led to an increase in physical, psychological, and behavioral disorders that the health and education systems are just beginning to detect, much less understand. Child obesity and diabetes are now national epidemics in both Canada and the U.S. and has been related to technology overuse. Diagnoses of ADHD, Autism, Developmental Coordination Disorder, developmental delays, unintelligible speech, learning difficulties, sensory processing disorder, anxiety, depression, and sleep disorders are associated with technology overuse and are increasing at an alarming rate (Rowan, 2017). Entertainment television and computer games may negatively impact when children are learning to read. This negative impact appears to be due to the displacement of time. Instead of reading, time is spent using devices (Anderson & Subrahmanyam, 2020).

Four critical factors are required for healthy child development; movement, touch, human connection, and exposure to nature. These sensory experiences ensure normal development of posture, bilateral coordination, optimal arousal states, and self-regulation. These foundation skills are necessary for eventual school success. Young children require 2-3 hours of active rough and tumble play to stimulate their vestibular, proprioceptive, and tactile systems adequately. Tactile stimulation received through touching, hugging, and play is critical for developing praxis or planned movement patterns. Touch also activates the parasympathetic system lowering cortisol, adrenalin, and anxiety. Nature and "green space" have a calming influence on children, but it also restores attention and promotes learning. When the vestibular, proprioceptive, tactile, and attachment systems are under stimulation, the visual and auditory systems are overloaded. This overload causes a sensory imbalance that alters overall neurological development, permanently impairing the brain's anatomy, chemistry, and neuro-pathways. Young children exposed to violence through TV and video games are in a high state of stress, which in turn increases stress hormones such as adrenalin. This stress happens because the body cannot differentiate between what is real and what is not and responds as if the violence is real. Children who overuse technology report persistent body sensations of overall "shaking," increased breathing and heart rate, and a general state of "unease." These sensations can be described as a persistent hyper-vigilant sensory system or a system of fight or flight in anticipation of the upcoming assault. The long-term effects of this chronic state of stress in the developing child are unknown. However, we know that chronic stress in adults results in a weakened immune system and contributes to various serious diseases and disorders (Rowan, 2017).

The upcoming DSM-5 will have a new childhood diagnosis called Disruptive Mood Dysregulation Disorder, a syndrome characterized by severe recurrent temper outbursts that are inconsistent with the individual's developmental level. According to Dr. Victoria Dunckley in Psychology Today, adverse effects related to screening time can present in various ways. However, many effects can be grouped into mood, cognition, and behavior symptoms. These symptoms appear to be linked to repeated stress on the nervous system, rendering self-regulation and stress management skills less efficient. Dysregulation can be defined as an individual's inability to modulate their mood, attention, or level of arousal appropriate to their environment. Interacting with screens shifts the nervous system into fight-or-flight, leading to dysregulation and disorganization of various biological systems. At times, this stress response happens immediately, for example, while playing an action video game, and other times, the response is more subtle and may happen only after a certain amount of repetitions. In short, interacting with screen devices causes a child to become overstimulated and "revved up." These symptoms can be markedly improved or resolved with strict removal of the electronic for three to four weeks or longer in severe cases.

Dr. Dunckley coined the term: Electronic Screen Syndrome (ESS), marked by high levels of arousal paired with an inability to regulate emotions and elevated stress levels. A classic presentation of ESS comprises irritable mood, poor focus or disorganization, low frustration tolerance, and problematic behaviors such as argumentativeness or poor eye contact. The depressed or anxious mood is also common.

Dr. Dunckley shared this quiz, which she designed to assist parents in seeing how screen time might be negatively impacting their child or teen's behavior. The parents are instructed to place a checkmark next to the questions (below) that apply to their child.

1. Does your child seem revved up much of the time?
2. Does your child have meltdowns over minor frustrations?
3. Does your child have full-blown rages?
4. Has your child become increasingly oppositional, defiant, or disorganized?
5. Does your child become irritable when told it is time to stop playing video games or get off the computer?
6. Do you ever notice your child's pupils are dilated after using electronics?
7. Does your child have a hard time making eye contact after screen time or in general?
8. Would you describe your child as being attracted to screens "like a moth to a flame"?
9. Do you ever feel your child is not as happy as he or she should be or is not enjoying activities as much as he or she used to?
10. Does your child have trouble making or keeping friends because of immature behavior?
11. Do you worry that your child's interests have narrowed recently or that interests mostly revolve around screens? Do you feel his or her thirst for knowledge and natural curiosity has been dampened?
12. Are your child's grades falling, or is he or she not performing academically up to his or her potential — and no one is certain why?
13. Have teachers, pediatricians, or therapists suggested your child might have bipolar disorder, depression, ADHD, an anxiety disorder, or even psychosis, and there is no family history of the disorder?
14. Have multiple practitioners given your child differing or conflicting diagnoses? Have you been told your child needs medication, but this does not feel right?
15. Does your child have a preexisting condition, like autism or ADHD, whose symptoms worsen after screen time?
16. Does your child seem "wired and tired," exhausted but cannot sleep, or sleeps but does not feel rested?
17. Does your child seem unmotivated and have poor attention to detail?
18. Would you describe your child as stressed, despite a few identifiable stressors?
19. Is your child receiving services in school that does not seem to be helping?
20. Do you and your child regularly argue over screens (limits, timing, content, activities, getting a new device, etc.)?
21. Does your child lie about screen use, "cheat" when on restriction, or take their device to bed?
22. Is your child a "sore loser" or hyper-competitive when playing games or sports, affecting peer relationships or enjoyment of the activity itself?
23. Does your child prefer socializing online over face-to-face interactions?
24. Do you avoid setting screen time limits because you fear your child's reaction, you are too exhausted, or because you would feel guilty doing so?
25. Do you avoid spending time with your child because you predict it will not be enjoyable or harbor negative feelings toward your child?

The parents are instructed to count the number of checked boxes to score the quiz. The more boxes checked, the higher the likelihood that screen time is affecting their child's nervous system, resulting in ESS. The higher score also reflects a higher risk for a tech addiction, even with what may be considered average or below average use of technology. If 13 or more areas are checked, Dunckley reports that it is highly likely the child has Electronic Screen Syndrome and is possibly at risk for technology addiction. Many families fall into this category. Families may feel that they are in crisis mode all the time. The positive is that being in this state can highly motivate change. When ESS is reversed, we see the most dramatic changes. If 5-12 areas are checked, the child is at moderate risk for ESS and presents with significant difficulties that likely impact more than one daily life setting (home, school, social setting). If ESS and screen time are not attended to, the child may remain "stuck" unless the issue is addressed early. If 1-5 areas are checked, the child has some risk for ESS, but the primary underlying cause may or may not be related to screen use. All mental health, learning, and behavior issues will improve when screen time is addressed properly.

In contrast to the overall score, there are some specific problematic areas. The following may assist parents in addressing and tracking these areas.

• Hyperarousal/overstimulation: Virtually all the questions relate directly or indirectly to hyperarousal, but for physiological arousal, look to items 1-7, 10, 16-18, and 22.
• Mood: Items 9, 11, 13, 17, and 22.
• Cognition/focus: Items 4, 11-15, 17 and 19.
• Behavior/social skills: Items 4, 7, 10, 20, 22, and 23.
• Attachment: Items 7, 9, 10, 20, 21, 24 and 25.
• Addiction: Items 5, 8, 9, 11, 12, 20, and 21, 23 and 24.
• Misdiagnosis: Items 12-15, and 19.

Since Electronic Screen Syndrome can mimic or exacerbate psychiatric disorders, its presence is commonly missed. The presence of ESS does not rule out other underlying conditions, but it will virtually always make other issues worse. When ESS goes untreated, the underlying disorders become more difficult (if not impossible) to address.

The quiz questions represent a wide variety of dysfunctional scenarios. These can happen when a child is operating from a more primitive part of their brain when children get more screen time than their nervous system can handle. It is not possible to just cut back on screen time because the exposure has potent biological effects, including over-activation of the brain's reward pathways, desynchronization of the body clock, sensory overload, the release of stress hormones, and electrical excitability. The systems tend to remain disorganized unless there is a complete removal of the offending cause. By removing the stimulant, the brain can get deep rest and resynchronize the clock, chemistry, and hormones while quieting the overactive neuro pathways and restoring mental energy. Recognizing and addressing overstimulation and ESS from screen time can intensely impact mood, focus, and behaviors in just weeks while simultaneously restoring peace and harmony at home (Dunckley, 2017).

Mark is a nine-year-old male with a medical diagnosis of ADHD. He was referred for assistance to initiate a behavioral intervention program. Mark lives at home with his parents, sixteen-year-old sister, and thirteen-year-old brother. Mark's parents reported that he exhibits restlessness and hyperactivity. He was also described as struggling with distractibility, listening and following directions, and playing quietly. Mark's teacher reported that he does not participate in class activities, regularly disrupts the class, and generally behaves aggressively. Mark's school previously referred him for ADHD treatment, and he was prescribed Ritalin. However, due to the side effect of weight loss, his parents were searching for an alternative treatment option.

Mark's parents were asked about his screen time use during the initial session. They reported that he had a Play Station, a computer he also used to play video games, and a TV in his bedroom. Additionally, it was reported that Mark used a multi-screen with his smartphone, occasionally using it for playing video games and virtual reality glasses. Mark's parents reported that the screens "quiet" him down.

Since Mark was not interested in participating in any after-school activities, most of his after-school time was devoted to digital media use, estimated to be seven hours on a weekday and more on weekends. Mark's weekday bedtime was typically around 11 p.m., and he was reportedly viewing screens right up until bedtime. As part of the public health treatment program, Mark was seen eleven times for counseling. In the first session, his parents were encouraged to implement a screen time reduction plan with the main focus of treatment to reduce fast-paced/violent video game time. Mark's parents were initially instructed to remove all media from his bedroom. Then steps were taken to reduce interactive video game time, encouraging him to watch slow-paced content only and ceasing screen time at least one hour before bed. Within the first two weeks of the program, Mark's parents reported improved behavior at home. His bedtime moved to 10 p.m., and Mark began initiating more non-screen activities, such as dog walking and playing table tennis. In the fourth week of the program, Marks' parents reported that there was a signal booster in his room, and they were asked to remove it. This removal was recommended to reduce radiation exposure and eliminate possible hypersensitivity; WiFi remained installed in the home. Also, in the fourth week of the program, Mark's teacher reported that she noted improved behavior in class. By the fifth week, Mark began completing his homework without help, and his father stated that he seemed more "mature." This was described as being better at delayed gratification. Mark also appeared to be less distracted at home and less hyperactive in class, but he was still aggressive at school.

Mark's parents were strongly encouraged to significantly decrease exposure to violent video game content, especially first-person games, by the tenth week. By week eleven, Mark did not demonstrate any aggressive behavior in school, and his weight returned to within a normal range. At the one-year follow-up, all improvements remained stable. The intervention plan chosen for Mark was based on the assumption that he was likely caught in a cycle consisting of attention problems that lead to rewarding craving and arousal-seeking behavior. Such behavior further exacerbates attentional and aggressive symptoms; therefore, the plan aimed to alter this cycle. There were no additional interventions implemented during the treatment period, so the changes in screen time viewing appeared to be the only factor associated with Mark's behavioral changes. It is suggested that Mark may have been over-diagnosed; and that before the treatment, he displayed a tendency for ADHD-related behavior, which was exacerbated by screen time (Lissak, 2018).

Children spend more hours engaging with screens than with any other activity. Media use can have many positive and negative effects on children's well-being depending on the time spent and consumed content. Many parents do not understand how to help children manage screen time effectively. The health professional working with a child and their family is in a good position to assist by looking at family media use patterns, parental rules regarding media, the ways parents talk about media to their children, and parental attitudes regarding media (Anderson & Subrahmanyam, 2020). The following is a list of questions a healthcare provider may use when communicating with parents or other caregivers to get a better understanding of each family's needs and how to support them.

1. Is screen time controlled in your household? Responsible adults set the screen time duration and content for infants and younger children. If limits are regularly broken and the parent reports that screen time is out of control, parenting support may be needed. For older children and adolescents, there is likely more autonomy and self-control, but this should be gradual and under the overall guidance of an adult. Adults may need to consider their use of screens, especially the unconscious use of smartphones.
2. Does screen use interfere with what your family wants to do? This interference will vary from family to family, but many families want more together time. There is good evidence that family time is beneficial for all; for example, mealtimes are an opportunity for communication (catching up). They may want to declare meals to be a 'screen-free zone.' Each family should brainstorm to find ways that work for them to maximize interaction and shared enjoyment with family members.
3. Does screen use interfere with sleep? As we already know, even modest sleep deprivation can interfere with mental and physical health, educational success, and family relationships. Emphasize the importance of establishing a good bedtime routine for young children and remember to point out the value of avoiding screens one hour before going to sleep.
4. Are you able to control snacking during screen time? Adults should monitor the food eaten during screen sessions, especially children at risk of obesity. If parents are unclear about healthy food, perhaps a referral to a registered dietitian is in order.

If a family can ask themselves (or be asked by others) these questions and feel comfortable with their answers, they can rest assured that they are likely doing what they can to address this sticky issue (Viner et al., 2019).

As evidenced by all the subcategories in this paper, many related issues come into play when looking at screen time use for children and adults. Screen exposure and many things related to it appear to lead to a major public health threat. Healthcare professionals should be aware of the current research so they know the health issues related to screen time and can inform their patients and provide information to doctors and other professionals. Health care is changing, and instead of simply assisting clients in managing their illnesses, we need to be aware of the possible root causes. Doctors cannot possibly stay abreast of all the information and are not allowed to spend time with their clients to provide education in this quickly changing world.

There is significant evidence to support the need for outdoor time, movement, exercise, limits on on-screen use for all ages, and consideration of exposure to electromagnetic fields. Children especially need sensory input for their developing nervous systems to develop their bodies, including their eyes. They cannot get that sitting in front of a screen. Children need creative play, social interaction, and conversation to develop speech, social skills, and self-confidence.

Healthcare professionals need to come together with parents, teachers, and school administrators to help society "wake up" and see the devastating effects technology has on our children. They are young; they have many years to be exposed to technology as it does not appear to be going away anytime soon. We need effective strategies to reduce technology use and promote safety when using it. It breaks my heart to see all the kindergartners wearing glasses and using tablets at school versus participating in the sensory-motor activities that, as therapists, we know are the foundation skills critical for higher-level learning and for living a healthy life well into adulthood.

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