Benoit Bediou
Faculty of Psychology and Education Science, Department of Psychology, University of Geneva, Switzerland
Michael Rich
Boston Children's Hospital/Harvard Medical School, United States
Daphne Bavelier
Faculty of Psychology and Education Science, Department of Psychology, and Campus Biotech University of Geneva, Switzerland
Contradictory statements are often heard about the effects of digital technology use on health or cognition, posing practical dilemmas to parents, educators, health professionals and policy makers. We argue that one source of inconsistencies lies in an oversimplistic concept of "screen time", which fails to capture the complexity of digital media practices. For example, research shows that action video game play and media “multitasking,” two activities that count as screen time, have opposite effects on attention. We urge adoption of standardised definitions and propose guiding principles to achieve greater granularity, accuracy and consistency in conceptualising and addressing media effects.
The continuous rise in digital technology consumption has raised issues in multiple domains, including health (physical inactivity, problematic use), development (isolation, anxiety) and education (21st century skills), but also ethics (data access, privacy, cybersecurity, artificial intelligence), equity (inclusion, digital divide) and law (individual rights). Parents, educators and health professionals, as well as governments, organisations and authorities are constantly confronted with contradictory messages and in need of evidence-based recommendations.
Two views are frequently opposed. One side, mostly represented by health organisations, warns against the negative consequences of excessive digital media use, underscoring, for example, that the physical inactivity associated with screens is known to increase numerous health risks (Stiglic and Viner, 2019[1]). The other side emphasises the importance of information technology (IT) skills for successful personal, social and professional development in a digital world. Innovation industries advocate for digital media proficiency, not without potential conflict of interest (Selwyn, 2010[2]). Overall, concerns have been raised regarding sleep (LeBourgeois et al., 2017[3]), obesity (Robinson et al., 2017[4]), anxiety/depression (Hoge, Bickham and Cantor, 2017[5]) and cognitive development (Anderson, Subrahmanyam and Workgroup, 2017[6]), while at the same time the potential benefits for learning and social communication have been recognised (Council on Communications and Media, 2016[7]).
Conflicting views about the effects of technology use have important implications for policy making and economics. Where should we invest? Should governments and authorities develop guidelines and regulations to restrict screen use for public health reasons? Or should we instead provide paediatricians, parents and educators the training and resources to better support individuals and families in developing digital practices that are in their best interest?
Studies investigating the effects of digital technology tend to focus either on harmful effects of using digital media or on strategies for leveraging digital technologies to empower users, with little discourse or consensus-building between these lines of research. Strongly polarised positions hinder reaching agreement on questions as important as the nature of and criteria defining media-related disorders, such as dysfunctional, uncontrolled use of interactive digital media.
Findings from the line of research investigating harmful effects often motivate a call for restrictions, such as limiting access to and time using screen media. When high durations of television viewing were found to be associated with increased risk for obesity, the American Academy of Pediatrics recommended limiting television watching among children and adolescents (American Academy of Pediatrics, 2001[8]). However, it has often proven difficult to translate such advice into practical action (Houghton et al., 2015[9]) due to the proliferation of screens in nearly every environment and their integration in every activity from learning to communication to social life. Conversely, results from research exploring digital potential often call for new technological development and adaptation. Therapeutic applications of video games to slow memory loss in the elderly or to improve focus in children with attention-deficit hyperactivity disorder (ADHD) encourage innovation of digital technologies for health care (Bavelier and Davidson, 2013[10]; Mishra, Anguera and Gazzaley, 2016[11]; Primack et al., 2012[12]). While each of these lines of research is valid and useful, they can give rise to apparently contradictory recommendations being published by the same entity. The Australian government’s 24-hour Movement Guidelines for the Early Years recommends limitations in screen use (Okely et al., 2017[13]), while their Early Years Learning Framework promotes digital technology uses in early childhood education (Fox and Diezmann, 2017[14]; Sumsion, 2019[15]; White and Fleer, 2019[16]).
The situation is similarly complex when it comes to the effects of digital technology consumption on health. Scientific studies have provided inconsistent evidence leading to divergent conclusions, sometimes despite analysing the same datasets (Przybylski and Weinstein, 2017[17]; Twenge et al., 2018[18]; Twenge and Campbell, 2019[19]). Using data from 120 115 15-year-olds in the United Kingdom, Przybylski and Weinstein (2017[17]) found that screen time over two hours per week explained 1.0% or less of the observed variability in the mental well-being of the young people in the sample. The authors highlighted that such an effect is three times smaller than the positive associations between well-being and eating breakfast regularly or getting regular sleep, and concluded that "the possible deleterious relation between media use and well-being may not be as practically significant as some researchers have argued". Twenge and Campbell (2019[19]) in contrast argued that the "percent variance is not a good measure of practical impact". These authors emphasised that "those who spent seven or more hours a day on computers (vs. a half‑hour) were also twice as likely to be low in well-being" and that "the percentage of adolescents low in well-being increased by 14% with each additional hour of smartphone use". These authors underline that the effect size of excess media use is comparable to other psychological phenomena such as gender differences, and that even smaller effects have led to practical action, as in the case of smoking tobacco.
Such conflicting evidence-based recommendations pose dilemmas for practice and policy making (Straker et al., 2018[20]). Messages can shift from restriction to promotion of the same activity, as was seen with some governments and health agencies recently promoting video gaming and the use of social media to maintain communication and social contact during the COVID-19 confinement (Przybylski and Etchells, 2020[21]). We argue here that scientific research has remained poorly informative concerning best use of digital media, in great part because it has relied on the simplistic construct of "screen time". Although apparently contradictory, these views can be reconciled by deconstructing monolithic “screen time” and recognising the heterogeneity of how screens are used.
The notion of "screen time" encompasses an increasingly diverse set of activities in terms of the cognitive, emotional or social experiences screens can provide. Historically, the concept of screen time tracked technological development, starting with the first electronic screens, cathode ray tubes or CRTs, back in the 1920s. With the introduction of liquid crystal displays (LCDs) in the early 2000s, screens were no longer bulky televisions and desktop computer monitors, becoming an essential part of entertainment, advertising, and information technologies. With LCD miniaturisation, screens could be pocketed, even worn, making screens accessible 24/7 and expanding their functions to communication and human connection. As technology has evolved, the duration of screen use has exploded and the variety of experiences that screen time can afford has become more heterogeneous in content, in contexts of use, and in interactivity and immersion.
Asking about the effect of hours of screen time consumption on health or behaviour is akin to asking about the effect of kilograms of food consumption on health or behaviour. Can valid conclusions be drawn when asking about quantity in such an undifferentiated way? Some studies indicate that small amounts of screen use may be beneficial, whereas larger amounts may have negative effects (Twenge et al., 2018[18]; Kushlev and Leitao, 2020[22]; Orben and Przybylski, 2019[23]; Przybylski and Weinstein, 2017[17]; Radesky, Schumacher and Zuckerman, 2015[24]). A similar contrast between positive and negative impact as function of dose was recently documented when considering only video game play (Pujol et al., 2016[25]). Meta‑analytic work examining the relationship between screen time and depression also indicates effects dependent on dose in a non-linear way, with a greater risk for depression for no screen time as compared to one hour per day of screen time and a continuously increasing risk for depression beyond one hour per day (Liu, Wu and Yao, 2015[26]). Twenge reported a similar J-shaped correlation curve between social media use and depression in adolescents (ages 13 to 18); one to two hours per day of use was associated with lower levels of anxiety/depression than either longer durations of use or no use (Twenge et al., 2018[18]).
The best-powered (N = 355 358) study addressing the impact of screen time on adolescent well-being documents an effect of less than 0.5% of the variance in well-being (between 0.1% and 0.4% depending on the dataset and analysis), similar in size to regular consumption of potatoes in one’s diet (Orben and Przybylski, 2019[23]). Are we to conclude that screen use has little impact on behaviour? Of course not. We argue here that using screen time as the independent variable in media effects research is vague and misdirected, as would be asking about kilograms of food consumed on health – without asking what types of food were consumed.
It is crucial to recognise that screen time is now anything but a unitary experience. As illustrated by neuroscience research on experience-dependent brain plasticity (Holtmaat and Svoboda, 2009[27]), different effects are to be expected from different types of screen uses. Passively viewing a cooking show on YouTube should not be expected to have the same impact on brain and behaviour as playing a video game, even though both qualify as screen time. The type of screen content and the social context of consumption (at home vs. in school, alone vs. with friends) have been reported to influence behavioural outcomes (Orben and Przybylski, 2020[28]; Twenge et al., 2020[29]).
To complicate the situation, individual personality, motivation, preferences and vulnerabilities have also been documented to matter, both at the level of media consumption pattern (e.g. gender differences in social media vs. gaming) and of its impact (Piotrowski and Valkenburg, 2015[30]; Nesi and Prinstein, 2015[31]). The media that are used and how they are used, rather than total screen time, are crucial determinants of the effects. Accordingly, they should be taken into account when providing guidelines (Ashton and Beattie, 2019[32]; Canadian Paediatric Society, Digital Health Task Force, Ottawa, Ontario, 2019[33]). Two recent lines of research provide useful insight into why investigating the duration of screen time affects cognitive development can lead to confusion.
Research on the relationships between video game play and cognitive abilities shed light on a more nuanced understanding of media effects. Recent meta-analyses of these studies could be perceived as reaching conflicting conclusions (Bediou et al., 2018[34]; Sala, Tatlidil and Gobet, 2018[35]). A closer look, however, suggests that the source of these divergent findings lies in the level of granularity with which video game play was examined. When all video games are considered together, the cognitive impact of gaming appears mixed (Sala, Tatlidil and Gobet, 2018[35]). Yet, when only action (first- and third-person shooter) video games are considered, better cognitive abilities have been reported, both in regular players and in interventions with naïve players (Bediou et al., 2018[34]; Wang et al., 2017[36]). In particular, action video game play enhances attentional abilities. Thus, not all video games affect cognition equally or similarly. The effects are specific enough to call for careful consideration of game genre when studying the impact of video game play on cognition and beyond (Dale et al., 2020[37]).
To add to the complexity of capturing screen use, recent studies indicate that approximately one third of the time youth use two or more screen media concurrently, such as texting while watching television (Common Sense Media, 2016[38]). This practice, termed media multitasking (MMT), refers to the simultaneous consumption of multiple media at the same time. MMT has increased with the development of touch screens and smartphones providing flexible, nearly constant access to digital media. This practice is starting to raise concerns as studies suggest it may be associated with lower attentional and executive functions, such as difficulty suppressing irrelevant information (Ophir, Nass and Wagner, 2009[39]). Real‑world MMT has been linked with robust effects on subjective or self-reported measures of attentional performance, findings corroborated by some, albeit not all, laboratory-based measures (Uncapher, Thieu and Wagner, 2015[40]; van der Schuur et al., 2015[41]; Wiradhany and Koerts, 2019[42]; Wiradhany and Nieuwenstein, 2017[43]).
From Multiplayer Online Battle Arena games to social-simulation games, video games present a very diverse array of experiences. In our research, action video games have been mostly studied in the context of first- or third-person shooter video games, and are defined according to particular game mechanics. These games combine pacing, or the demand to answer under time pressure, with the need for distributed attention, and at the same time the capacity to swiftly shift from distributed to focused attention, as well as between different goals and sub-goals (Cardoso-Leite, Joessel and Bavelier, 2020[44]).
The positive impact of action video games on attentional control has been established first by comparing players of action video games with non-video game players on objective, laboratory-based attentional tasks. Critically, intervention studies whereby naïve participants were asked to play action video games provided evidence that action video game play also causally enhances attentional skills.
Interestingly, participants asked to play action video games showed greater attentional benefit than those asked to play other genres of commercially available video games, establishing that action video game play enhances attentional control and other aspects of cognition to a greater extent than other video games (Bavelier and Green, 2016[45]). This finding also holds for popular “brain-training games”, which, while similar, do not appear to deliver the same attentional benefits.
Here are two media uses, action video game play and MMT, that affect attention in opposite directions, yet, if quantified as screen time, these two media uses would be grouped together. As it becomes recognised that different uses of screens can have different, even opposite effects, research needs to study more granular variables than screen time, quantifying different types of screen use separately, as well as their interaction. This calls for a number of advances in the field of media effects research, from standardising accurate classification of media types, a complex challenge given the fast-evolving nature of the digital media ecosystem, to better measures of consumption that document not only how long media are consumed, but what media are used, when, where and with whom they are used.
Another limitation of studies investigating the effects of screen time is that most evidence is correlational, with researchers documenting how durations of everyday screen usage are correlated with cognitive or health outcomes. Correlations are notoriously difficult to interpret. The fact that individuals who go to the hospital more often are more frequently sick than those who do not go to the hospital does not mean that it is the hospital that causes diseases. Similarly, when finding a correlation between social media use and depression, should we conclude that social media use increases risk for depression or that adolescents at risk for depression consume more social media, possibly as a source of distraction or coping?
Although intervention studies are essential to establishing causality, they raise ethical issues when negative cognitive or health effects are hypothesised. To date, the few interventions designed to reduce screen time have yielded encouraging results on screen time (Maniccia et al., 2011[46]) and increasing sleep (Martin, Bednarz and Aromataris, 2020[47]), but their impact on health-related outcomes or cognition remains unknown (Guinness, Beaulieu and MacDonald, 2018[48]; Parry and le Roux, 2019[49]; Tassone et al., 2020[50]). One exception is the systematic randomised control trials comparing the cognitive effects of playing commercially available action video games vs. control games from different genres that uniquely demonstrated that not all video games have the same cognitive impact (Bavelier and Green, 2016[45]). Similar rigorous studies are essential to advancing our understanding of the relative risks and benefits of any media-related activity.
Another challenge to rigorous study of the effects of media use and to effectively responding to the findings has been the “balkanization” of the media effects field. Researchers from diverse disciplines from communication to paediatrics, psychology to education have pursued independent inquiries of often narrow questions about how screen media use affects us. Insufficient, frequently indirect, research funding has led to many “one-off” projects without follow-through, continuity of inquiry, or translation of findings into interventions and strategies for prevention of harm. Findings have remained largely within their discipline‑specific academic literature, with few cross-disciplinary reviews or interdisciplinary studies, so useful evidence has remained sequestered in academic silos. Thus far, we have largely failed to reach across disciplines to compare, contrast, challenge and synergise findings into a “big picture” understanding of how the media we use and how we use them influence the well-being of individuals and society at large.
Media innovators have extended the capabilities of digital technology with the goal of increasing user engagement, but with little or no consideration of the short- and long-term effects on users and society. From the earliest days of television, concerns about the impact of screen media have been framed as values-based, “good vs. bad”, “right vs. wrong”. As a result, effects on human behaviour and development have been set in opposition to freedom of expression as if the concepts of well-being and free speech were mutually exclusive. The technology and entertainment industries, to avoid restrictions, have traditionally ignored or argued against media effects concerns as “moral panic”. Instead of moving forward on a comprehensive, balanced evidence base showing how we are changed, in positive and negative ways, by our use of screen media, we have remained in a values-based stalemate.
Dysfunctional use of interactive screen media illustrates how the fragmentation of research and the values‑based polarisation around media use has slowed or stalled solutions. The term “Internet addiction” was originally coined by a psychiatrist in a parody of the language used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. The response he received to his satirical description was, to his surprise, recognised by clinicians as behaviour exhibited by their patients and, in some cases, themselves. Led by Kimberly Young, PhD, research and clinical care for this growing phenomenon began in the mid-1990s. In 2008, China recognised “Internet Addiction Disorder (IAD)” as a diagnosis (Huang, Li and Tao, 2010[51]) and developed “boot camps”, clinics and inpatient hospitals dedicated to treating it. Korea treated 140 000 young people for IAD in 2018 (BBC, 2019[52]) and estimated that 20% of the population was at risk for it (Sullivan, 2019[53]). The fifth edition of the once‑parodied Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists Internet Gaming Disorder not as a diagnosis, but as a Condition for Further Study (American Psychiatric Association, 2013[54]) and, while the World Health Organization also does not designate it as a diagnosis, they have included “Gaming Disorder” in their International Classification of Diseases (ICD-11) (WHO, 2018[55]). In the research literature, diagnostic criteria, characterisation and even nomenclature for uncontrolled interactive media use varies widely. Including the aforementioned three names, there are more than 70 descriptions of this problem, ranging from Binge Watching Behaviours to Compulsive Use of Sexually Explicit Internet Material to Smartphone Overuse to Social Media Dependence to Problematic Internet Use. Although each of these names describes the behaviours studied, they contribute to fragmentation, rather than furtherance of knowledge, by focusing narrowly on the device, platform or application involved instead of investigating the behaviour in context. More than two decades have passed and we are still debating what is occurring and how to describe it.
Meanwhile, with the proliferation of interactive screen media and increasingly sophisticated algorithms of variable reward designed into games, social media and streaming services, a subset of users, predominantly young users, have developed uncontrolled interactive media use behaviours that impair their physical, mental and social health. Evidence-informed therapeutic intervention was needed. Clinical experience has revealed that, despite the plethora of conditions researched, there is more commonality than differences among these dysfunctional behaviours. The problem is not caused by specific technological devices, platforms or applications – it occurs with gaming, but also with social media, pornography and video/information bingeing. It is not a true addiction, with measurable physiologic changes when using or withdrawing as is seen with addiction to substances. It is the interactivity, with its designed-in variable rewards, that children and adolescents, with their still-maturing executive functions, are unable to self-regulate. To be accurate, comprehensive, and to prevent the care-avoiding stigma of “addiction”, the consensus nomenclature of Problematic Interactive Media Use (PIMU) (Rich, Tsappis and Kavanaugh, 2017[56]) was developed. PIMU is defined as a syndrome of behaviours characterised by compulsive use of, increasing tolerance to, and negative reactions to being removed from interactive screen media use (gaming, social media, pornography, information- or video-bingeing) which impair the individual’s physical, psychological, cognitive and/or social function.
In addition, efforts to determine and describe PIMU as a diagnosis may be misguided. Medical evaluations of patients presenting with PIMU have revealed underlying conditions such as ADHD, learning disabilities, anxiety or mood disorders, either known or subclinical, that manifest themselves in the interactive media environment. For example, a young person with ADHD, who is distracted and out of touch in the classroom, thrives in a first-person shooter video game that does not punish distractibility; rather, gaming is a self‑soothing behaviour because it provides an environment in which this young person can perform as well or better than neurotypical peers. What had been narrowly investigated as a potential diagnosis caused by technology appears, on deeper, more comprehensive study, to be a syndrome, a group of symptoms that manifests itself in the interactive media environment. When the underlying diagnosis is determined and treated, PIMU becomes controllable (Pluhar et al., 2019[57]).
Over the past few decades, studies examining the impact of digital technology on various aspects of human cognition and health have accumulated, bringing some consensus and some disagreement regarding how beneficial or harmful digital technology could be. Recent work suggests that an important source of inconsistencies lies in the failure to take into account the heterogeneous nature of digital media practices. This has led to mixed messages which pose a practical dilemma at many levels, whether parents, educators, health professionals or policy makers.
Using research on the cognitive effects of action video game play and media multitasking and clinical experience with PIMU, we argue that part of the inconsistencies and conflict arise from a lack of granularity in conceptualising both media use (e.g. screen time) and their effects (diversity of outcomes and measures). A few important principles are emerging that will require significant research effort as we move forward:
1. The type of media matters: Using social media will not produce the same effects as playing video games.
2. Content matters: An educational video game focused on reading will not have the same impact as a social simulation video game.
3. Context matters: Using screen media for shared activities promoting collaboration and co-operation does not have the same impact as watching videos alone (Mayer and Mayer, 2005[58]).
4. Delivery interface matters: Although virtual reality-based devices may promote engagement over screen-based devices for teaching, the device can distract from or contribute to achieving learning objectives (Makransky et al., 2020[59]; Parong and Mayer, 2018[60]).
5. Interactivity matters: The cognitive effects of action video games have been largely attributed to game play mechanics. The interactivity of action video game play loads attentional processes in a very different manner than puzzle or social simulation games (Cardoso-Leite, Joessel and Bavelier, 2020[44]).
6. Last but not least, users matter: Users with different characteristics and at different stages of neurodevelopment have differential susceptibilities to positive and negative effects from using media (Piotrowski and Valkenburg, 2015[30]).
To advance further our understanding of how screen use impacts human development and behaviour, it is crucial to recognise the heterogeneity of screen time, and properly qualify the multiple dimensions of media usage. We thus need to study each and every media use in earnest according to these six principles.
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