Currently, individuals of all ages use media extensively to find information and connect with others all over the world (Zupanic et al., 2019). In this context, the term media refers to smartphones, videogames, tablets, game consoles, televisions, and computers. While media use can be favorable within certain limits, there is a risk of overuse. Indeed, the time spent using electronic devices continues to increase along with the growth in the range of available technologies. Media use among children has become a growing concern. The American Academy of Pediatrics (2016) recommends that children between age two and five years use media for only one hour a day, and children between six to 10 years use it for only 1.5 hours per day. Despite this recommendation, in Australian households, children’s device use and internet access have risen from 72% in 2004–2005 to 97% in 2016–2017 (Reus & Mosley, 2018). Children’s media use also has become a concern in Saudi Arabia. With the growing affordability of mobile devices, research has shown that the average time Saudi Arabian children spend using mobile devices was about two hours and 42 minutes (Statista Research Department, 2020). Furthermore, the number of internet users in Saudi Arabia is growing steadily, from 21.54 million in 2015 to 30.2 million in 2019 (Statista Research Department, 2020). This number is expected to reach 35 million in 2023 (Statista Research Department, 2020). Moreover, according to the General Authority of Statistics, 92.51% of Saudi families and 23.44% of children between five and nine use the internet (Al-Solami, 2019).
Such high media use among children can come at a cost. Studies have shown that children with more media usage have a higher body mass index (BMI), less physical activity, and diminished rest and sleep than children with lower media usage (Reus & Mosley, 2018). Media use also can influence children’s behavior. For example, children can become physically and verbally aggressive after excessive media use, sometimes imitating violent behaviors portrayed in mass media (Şengönül, 2017; Tanwar & Priyanka, 2016). The assessment of children’s behavior in this study comprises a wide range of mental and social disorders. They include depression, overanxious, separation anxiety, relational aggression, oppositional defiant, inattention, impulsivity, and social problems with peers. Unfortunately, there is a lack of evidence about the specific relationship between media use and behavioral disorders in Saudi Arabian children. Therefore, the current study focused on Saudi children aged three to 11 years.
With portable digital devices (e.g., smartphones and tablets) becoming more available and affordable, the time children spend using them is increasing rapidly (American Academy of Pediatrics, 2013). In addition, with the significantly accelerated growth of video apps, learning packages, and instructional software for young children, incentives for children to use mobile devices have expanded, resulting in longer usage periods. Furthermore, mobile device manufacturers are targeting younger children. With this widespread increase in children’s access to and usage of digital mobile devices—which has become an integral part of their lives—parents and researchers need to examine the effects of portable electronic media use (Paudel et al., 2016). Therefore, the current study aimed to determine if there is a relationship between media use and changes in children’s behavior.
Researchers have suggested that frequent mobile media usage among children can intensify social loneliness, detract from social contact with family and friends, exacerbate emotional/behavioral issues, and possibly worsen social deficits (e.g., inattention, hyperactivity, peer problems, and emotional symptoms (Hosokawa & Katsura, 2018; Poulain et al., 2018; Wu et al., 2017). Interestingly, other researchers found no correlation between device use and mental and behavioral problems in girls, while in boys, each hour spent playing video games was correlated with higher chances of exhibiting borderline/abnormal conduct problems and emotional issues (Mundy et al., 2017). Furthermore, increasing media use also has been shown to negatively affect sleep outcomes, resulting in more bedtime resistance, later bedtimes, and shorter sleep durations (Chindamo et al., 2019; Nathanson & Beyens, 2018; Wu et al., 2017). Moreover, longer TV watching periods have been linked to an increased likelihood of future self-regulation issues, while less television consumption is correlated with improved self-regulation (Cliff et al., 2018; Inoue et al., 2016). In contrast, one study showed that tablet usage contributed adversely to self-regulation only in children who slept less at night n(Nathanson & Beyens, 2018). Another study indicated that high levels of media consumption contribute to high BMIs and have a detrimental effect on athletic behaviors and motor abilities (Kaiser-Jovy et al., 2017). Finally, the aggressive behavior common in the media (especially in superhero programs) also can influence children's behaviors. A study showed that one year after pre-school children encountered superheroes via media, these children exhibited increased physical and emotional violence (Coyne et al., 2017). However, superhero engagement was not shown to be related to prosocial or defensive behaviors (Coyne et al., 2017).
Methods
Study Design
This was a descriptive cross-sectional study.
Participants
G*Power was utilized to calculate the needed sample size for this study (Faul et al., 2009). A priori analysis was employed to estimate the sample size for one sample means. The input parameters (alpha 0.05, power 0.80, and medium effect size 0.5) resulted in a recommended sample size of 67. The study’s participants were a convenience sample of Saudi Arabian parents with healthy children between the ages of three to 11 years. The participants were the parents of children; thus, the ages of children who use media under the control and supervision of their parents were determined for the purpose of this study to be between three to 11 years. The study did not include individuals who were not parents or those with children under age three, over age 11, not exposed to media, or experiencing a medical problem.
Instrument
The data were collected through an electronic survey created in Google Forms and shared through social media from January 2020 to March 2020. The authors of this study developed the first and second parts of the questionnaires. The first part of the questionnaire consisted of 10 items about sociodemographic factors: parent gender, age, marital status, employment status, number of individuals living in the household, monthly income, and education level, as well as child gender, age, and education level. The second part included multiple-choice questions about the child’s media use (the type of media used and time spent using it). The last part consisted of items adopted from the parent version of the MacArthur Health and Behavior Questionnaire (HBQ) for middle childhood (Essex et al., 2002). The HBQ includes scales that assess children’s mental health symptoms, physical health, social and school functioning. For the purpose of this study, only 44 items of HBQ addressed children's’ behaviors with regard to mental health symptoms (depression, overanxious, separation anxiety, relational aggression, oppositional defiant, conduct problems, overt hostility, inattention, and impul-sivity) and social functioning (a social with peers and prosocial behavior) were included. The HBQ requires the participant to check on the statement that applies to the behavior. The statements were assessed on a 3-point scale ranging from 0 (never or not true) to 2 (very true). The questionnaire was translated from English to Arabic using the back translation method, and the translated Arabic questionnaire was pilot-tested with five parents to ensure the clarity of items. To establish content validity, five Arabic-speaker specialists, including two doctoral-prepared and three master-prepared nurses in the field of pediatric nursing, evaluated the translated version of the HBQ and the relevance of the items to the concept of health and behavior. The HBQ (44 items) in this study demonstrated good internal consistency reliability with a Cronbach’s alpha of 0.88.
Data Analysis
Data were analyzed using SPSS software. Descriptive statistics (e.g., mean, percentages, frequencies, and standard deviation) were used to describe the study variables. One-Way Analysis of Variance (ANOVA) was employed to assess differences in children’s behavior according to type and time of media use. The level of statistical significance for statistical analysis was at 0.05.
Ethical Consideration
Ethical approval was obtained from the Nursing Research Ethical Committee (NREC Serial No: Ref No 2B. 37). The study maintained participant confidentiality, and the parents’ identities were not evident in any reports, presentations, or publications. Electronic informed consent was obtained from all participants before starting the questionnaires.
Results
In total, 234 parents participated in the study. The majority of study participants (93.2%) were mothers between 30 and 50 years (78.2%). Most of the children (60.3%) were between five and ten years of age. Details on the other demographic variables are shown in Table 1.
| Variables | N | % | |
|---|---|---|---|
| Parents | Mother | 218 | 93.2 |
| Father | 16 | 6.8 | |
| Participants’ age | Less than 30 years | 41 | 17.5 |
| From 30 to 50 years | 183 | 78.2 | |
| More than 50 years | 9 | 3.8 | |
| Child’s age | From 3 to 5 years | 85 | 36.3 |
| From 6 to 8 years | 105 | 44.9 | |
| From 9 to 11 years | 44 | 18.8 | |
| Sex of Child | Male | 107 | 45.7 |
| Female | 127 | 54.3 | |
| Marital status | Married | 226 | 96.6 |
| Divorced | 6 | 2.6 | |
| Widowed | 2 | 0.9 | |
| Employment status | Working full-time (35 hours per week) | 80 | 34.2 |
| Working part-time | 28 | 12.0 | |
| Student | 8 | 3.4 | |
| Not working | 118 | 50.4 | |
| Household | Less than five persons | 125 | 53.4 |
| From five to ten persons | 107 | 45.7 | |
| More than ten persons | 2 | 0.9 | |
| Household monthly income in Saudi Arabian Riyal (SAR) | SAR 3000 or Less | 21 | 9.0 |
| SAR 3001–SAR 8000 | 73 | 31.2 | |
| SAR 8001–SAR 13000 | 67 | 28.6 | |
| More than SAR 13000 | 54 | 23.1 | |
| Don’t know | 19 | 8.1 | |
| Educational level | Below high school | 16 | 6.8 |
| High school | 60 | 25.6 | |
| Some college | 14 | 6.0 | |
| Bachelor’s degree | 130 | 55.6 | |
| Master’s degree or higher | 14 | 6.0 | |
| Child’s educational level | Kindergarten | 59 | 25.2 |
| Grade 1 | 52 | 22.2 | |
| Grade 2 | 31 | 13.2 | |
| Grade 3 | 22 | 9.4 | |
| Grade 4 | 31 | 13.2 | |
| Not enrolled | 39 | 16.7 |
As presented in Table 2, the results of One-way analysis of variance (ANOVA) revealed that there was no significant difference in children's behavior according to the type of media [F(3, 230) = 1.673, p = 0.174]. In contrast, there was a significant difference in children's behavior according to hours per day of media use as presented in Table 3 [F(4, 229) = 2.701, p = 0.031].
| Source | Sum of Squares | df | Mean Square | F | p |
|---|---|---|---|---|---|
| Between Groups | 0.334 | 3 | 0.111 | 1.673 | 0.174 |
| Within Groups | 15.305 | 230 | 0.067 | ||
| Total | 15.639 | 233 |
| Source | Sum of Squares | df | Mean Square | F | p |
|---|---|---|---|---|---|
| Between Groups | 0.705 | 4 | 0.176 | 2.701 | 0.031* |
| Within Groups | 14.934 | 229 | 0.065 | ||
| Total | 15.639 | 233 |
The most common types of media used were smartphones (n = 87, 37.2%). The least used media device was the PlayStation (n = 19, 8.1%). Detailed information on the most common types of media used among children is presented in Table 4.
| Type of Media | f | % |
|---|---|---|
| Tablet/iPad | 68 | 29.1 |
| Smartphone | 87 | 37.2 |
| PlayStation | 19 | 8.1 |
| Television | 60 | 25.6 |
| Total | 234 | 100.0 |
The average of time spent on media use were reported, the results indicated that, of the 234 children, 20 (8.5%) spent less than 30 minutes per day, 53 spent 30 minutes to 1.5 hours (22.6%), 47 (20.1%) spent between 1.5 to 2 hours, 54 (23.1%) spent two to three hours, and 60 (25.6%) spent more than three hours (Table 5).
| Media Time | f | % |
|---|---|---|
| Less than 30 minutes | 20 | 8.5 |
| 30 minutes to 1.5 hours | 53 | 22.6 |
| 1.5 to 2 hours | 47 | 20.1 |
| 2 to 3 hours | 54 | 23.1 |
| More than 3 hours | 60 | 25.6 |
| Total | 234 | 100.0 |
Discussion
The purpose of this study was to identify relationships between media use and behavioral disorders among a sample of Saudi Arabian children between the ages of three to 11 years. The results indicated that over a quarter (25.6%) of the children in the sample spent more than three hours per day using mobile devices, which is far greater than the media limits recommended by the American Academy of Pediatrics (2016), one hour per day for two- to five-year-old and 1.5 hours per day for six- to ten-year-old. These results are concerning, as technology overuse can influence the growth of children and teenagers, as their brains are more sensitive to the effects of technology use and overuse than are adult brains (Johnson, 2020). Social media and electronic application use can also lead to psychological and physical difficulties (e.g., eyestrain, trouble concentrating on essential tasks, and poor academic achievement), which can lead to more serious health problems (Mustafaoğlu et al., 2018).
The study results also indicated that the children used various devices, ranging from stationary (television and game consoles) to portable devices (tablets and smartphones). The smartphone was the most frequently used device used, possibly due to its size and accessibility. Furthermore, because smartphones can run educational applications, parents may offer them to their children to keep them occupied and quiet in certain situations. Moreover, our findings aligned with those of other studies indicating that three-quarters of children have their own smartphones, and almost all children use them (Kabali et al., 2015; Setiadi et al., 2019). Indeed, smartphone use can be positive or negative for children, depending on the type of programs used and how long they are used.
The current study results showed no significant relationship between physical problems without a medical cause and the type of media used or the time spent using it. This finding contrasts with other study findings indicating that long periods spent viewing TV, laptops, iPads, mobile phones, and video games can contribute to fatigue (Boyd, 2020). Furthermore, the absence of body and eye movement associated with using such devices can cause headaches (Yle, 2014).
The most important finding of the current study was the significant relationship between children’s time spent in media use and behavioral disorders. This finding corroborates prior studies relating behavioral issues to time spent using media (Poulain et al., 2018; Wu et al., 2017).
Implications of the Study
The finding that the time of media uses is significantly associated with children’s behavior brings a different perspective to the media use for education, communication, and entertainment. Indeed, parents need such crucial information before deciding how much media their children should be allowed to consume. Nurses and future researchers can utilize results from this study to regulate the use of media among children. Nurses are encouraged to develop educational programs to raise awareness among parents and children regarding the consequences of excessive media use.
One obstacle to reducing children’s excessive media use is adult media overuse, which can set a bad example for children. The authors of the current study recommend that parents adhere to the media usage hours recommended by the American Academy of Pediatrics (2016). Furthermore, individuals obliged to use media for long periods should consider the American Academy of Ophthalmology’s 20-20-20 rule: for every 20 minutes of media use, shift your eyes and focus on an object at least 20 feet away, for at least 20 seconds (Boyd, 2020).
To expand upon these findings, future nursing research may replicate this study using the complete HBQ to assess children’s physical health and school functioning in relation to media use. Furthermore, qualitative research could be conducted using interviews, observations, or focus groups to explore children’s behavior secondary to media use. Moreover, larger sample sizes are needed to improve the generalization of results. Further randomized controlled trials are needed to examine the feasibility of interventions that regulate media use among children.
Limitations of the Study
This study has some limitations. While using a cross-sectional design makes it possible to identify associations between media use and behavioral disorder, causality cannot be inferred. Next, these findings may not be generalizable due to the small sample size. Moreover, using an online questionnaire made it difficult for respondents to clarify some questions they may have found difficult to answer. Constructs of the HBQ in this study have not been confirmed by exploratory and confirmatory factor analysis.
Conclusion
This study offers insights into the associations between frequent media use and children’s behavior. While the type of media used does not seem to influence children’s behavior, the time spent using media correlates with behavior problems. Therefore, it is concluded that the more time a child spends using mobile devices, the more impact such use will have on their behaviors. Future nursing research is needed to examine the feasibility of programs that regulate media use among children