Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Television viewing associates with delayed language development

Weerasak Chonchaiya, Chandhita Pruksananonda (pchandhi@hotmail.com)
Division of Growth and Development, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University,
Bangkok, Thailand

Keywords
Language development, Television viewing
Correspondence
Chandhita Pruksananonda, Associate Professor, MD,
Division of Growth and Development, Department
of Pediatrics, Sor Kor Building 11th floor, King
Chulalongkorn Memorial Hospital, Faculty of
Medicine, Chulalongkorn University,
Bangkok 10330, Thailand.
Tel: 662-256-4943 |
Fax: 662-256-4911 |
Email: pchandhi@hotmail.com
Received
27 January 2008; revised 31 March 2008;
accepted 3 April 2008.
DOI:10.1111/j.1651-2227.2008.00831.x
Abstract
Aim: To identify impact of television viewing on language development.
Methods: The case-control study included 56 new patients with language delay and 110 normal
children, aged 15–48 months. Language delay was diagnosed by reviewing language milestones and
Denver-II. Television viewing variables and child/parental characteristics between both groups were
interviewed. The data were analyzed by ANOVA and chi-square test. Adjusted odds ratios and 95%
confidence intervals were calculated from multivariate logistic regression model.
Results: Forty-six boys and 10 girls; mean [±SD] age, 2.11 ± 0.47 years of the case group and
59 boys and 51 girls; mean [±SD] age, 2.23 ± 0.80 years of the control group were enrolled.
Children who had language delay usually started watching television earlier at age 7.22 ±
5.52 months vs. 11.92 ± 5.86 months, p-value < 0.001 and also spent more time watching
television than normal children (3.05 ± 1.90 h/day vs. 1.85 ± 1.18 h/day; p-value < 0.001).
Children who started watching television at <12 months of age and watched television >2 h/day
were approximately six times more likely to have language delays.

Conclusion: There is a relationship between early onset and high frequency of TV viewing and language delay.

METHODS
INTRODUCTION
Participants
The causes of delayed language development are complex,
A pilot study was done to find odds ratios of the correla-
representing a close interaction between the biological de-
tion between television viewing and delayed language devel-
velopment of the child and environment. Multiple factors
opment. The pilot study showed that children who started
such as hearing, cognitive abilities, speech organs and envi-
watching television at <12 months of age and watched >2 h
ronmental factors can contribute to delayed development of
each day, tended to have language delay sixfold greater when
language. Although some of these conditions can occur in
compared to children who started watching television after
isolation, there is usually a combination of interrelated areas
that and/or watched television <2 h in a typical day. The
of dysfunction (1).
final number of participants after calculation was 30 in each
Young children, not only in the United States but also
group.
in Thailand, watch an astonishing amount of television,
From September 2005 to August 2006, 110 new patients
spending more time in front of a screen than any other
with language delay who came to developmental clinics
single activity except sleep (2,3). The American Academy
and 110 normal children, aged between 15 and 48 months
of Pediatrics recommends that children ≥2 years of age
old, at King Chulalongkorn Memorial Hospital, Bangkok,
should have <2 h of screen time per day and that children
Thailand were evaluated. Fifty-four of 110 new patients were
<2 years of age be discouraged from television watching.
diagnosed with autistic spectrum disorder (ASD) by DSM
These recommendations are often ignored by caregivers (4).
IV criteria, they were excluded from this study. Therefore,
Anderson reported that background TV disrupts play and
56 new patients with language delay were included in the
interactions with parents (5), but organizing the speech and
study. We excluded participants who had language delay due
language systems needs early exposure to a rich and varied
to ASD, known genetics causes, hearing problems, cerebral
verbal environment (6). From our observations, we usually
palsy, neurological disorder and global developmental delay.
found that children who have had language delay in our de-
The normal children were selected by a simple random-
velopmental clinics seem to watch television during early
ized sampling from all children who came to the well child
infancy.
care clinic weekly. Caregivers from each group were inter-
Correlations between onset and frequency of televi- viewed by a developmental paediatrician during the visit
sion viewing and language milestones have been studied and/or by telephone survey in order to complete the data.
rarely (7,8). Linebarger and Walker found that content Parental consent was obtained from all participants.
and program type of television viewing has a variable effect
on language development in young children (7). We, there- Diagnosis of delayed language development
fore, need to identify television viewing and other risk factors Children were diagnosed with language delay based on early
that may have an impact on language development. signs of disorders in language and speech (9,10). A delay of


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Television viewing risk to language delay
25% or greater by 16–24 months of age is considered signif-
icant (9). For example, a 24-month-old child who functions
as a typical 18-month-old can be considered to have a clini-
cally significant language delay (9).
Clinical history taking, performing physical examination,
head circumference measurement, observation of child’s
play, language, cognitive ability, sociability, repetitive, hy-
peractive behaviour, joint attention and hearing screening
were performed by developmental paediatricians. In addi-
tion, developmental assessment was done using Denver-II
by developmental paediatricians who had received special
training followed by demonstration of competence in the
use of the study instruments. Suspected language delay was
measured by at least two cautions or at least one delay of
language items following the Denver-II manual. All of the
diagnostic methods were used to fulfil the diagnosis of de-
layed language development (case group) and normal lan-
guage milestone (control group).
The interview protocol consisted of questions about
the child, parental/family/home environment and TV/time
characteristics.
Language developmental level (years) was determined by
the age at 75th percentile of language developmental mile-
stones, which the child could attain in Denver-II. The mean-
ing of neologism was the child has persistent idiosyncratic
speech or immature jargoning.
Child rearing pattern (11) was determined by parental sen-
sitivity to the child’s needs, expectations for self-control, and
type of discipline. In addition, the child rearing pattern pro-
tocol that was collected via interview has been shown in
Appendix. We thoroughly understand that this subject mat-
ter is subjective and may be categorized judgmentally;
however, careful consideration was given to the particular
parenting styles that would most likely match each case.
All of the interview protocol was reviewed and com-
pleted by the same researcher to facilitate consistency across
participants.
Ethical approval
The ethical approval was obtained by the Research Ethics
Committee of King Chulalongkorn Memorial Hospital
(No.432/2005).
Data analysis
Data were analyzed using SPSS 11.5. All values for quan-
titative variables in each group were expressed as means
and SD. Comparison of means tests were used: one-way
ANOVA, Mann–Whitney U-test, Robust tests of equality of
means and Kruskal–Wallis H-test depending on distribution
of the data, difference of SD in each comparative groups and
the number of comparative groups. Odds ratio analyses were
conducted to compare the probability that children with and
without language delay had been exposed to the risk factors
as defined earlier.
For all binary risk variables, odds ratios were estimated us-
ing unconditional logistic regression. Each run of this statis-
tical analysis provided a chi-square test result. To determine
the relationship between all significant risk variables and
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Chonchaiya and Pruksananonda
language development, multivariate logistic regression mod-
elling was performed. Given the large number of variables,
the analyses were adjusted for multiple comparisons by mul-
tivariate logistic regression modelling. Adjusted odds ratios
and their corresponding 95% confidence intervals were cal-
culated from logistic regression model. Significant differ-
ences existed between the two language groups when the
confidence intervals for the odds ratios did not include an
odds ratio = 1.0.
RESULTS
Our sample included 56 children who had language delay
and 110 controls that had normal language development.
The male-to-female ratio of patients with language delay was
4.6:1, but in the control group it was 1.16:1. The mean age
of 2.11 ± 0.47 years in the case group and 2.23 ± 0.80 years
in the control group was not significantly different (p-value
0.747). Mean language developmental level of the case group
was 1.39 ± 0.47 years. The mean language developmental
level of the control group was 2.56 ± 0.99 years. Children
who had language delay usually started watching television
at the mean age of 7.22 ± 5.52 months and spent 3.05 ±
1.90 h/day watching television. In comparison, children who
had normal language development started watching televi-
sion at the mean age of 11.92 ± 5.86 months, which was sig-
nificantly later, (p-value <0.001), spending 1.85 ± 1.18 h/day
watching television that was significantly less than the case
group, (p-value < 0.001). Caregivers in the case group spent
7.03 ± 3.01 h/day and had conversations about 3.62 ±
2.19 h/day with their children. This was significantly less
than the control group (p-value < 0.001). Children in the
control group usually spent 9.26 ± 2.26 h/day and had con-
versations 5.80 ± 2.23 h/day with their caregivers. Charac-
teristics of cases and controls are shown in Table 1.
Individual risks for language delay
Table 2 shows the number and percentage of children with
and without language delay who had each binary risk vari-
able, the corresponding unadjusted odds ratios (OR), and
their 95% CI. All of the following factors were strongly
correlated to predict language delay in children. Male sex
(OR = 3.98), delivered by caesarean section (OR 2.26),
noneasy temperament (OR = 2.08), children who had ne-
ologism (OR = 3.29), family history of developmental delay
(OR = 7.79), neglectful parenting style (OR = 7.56), care-
givers other than mother (OR = 2.91), father’s education ≤
primary school level (OR = 4.91), spending time <6 h/day
with children (OR = 6.73) and having <2 h/day conversation
between caregiver and child (OR = 7.68) had statistically sig-
nificant odds ratios.
We found that there were interesting variables includ-
ing not doing interactive activity during television viewing
(OR = 6.74), onset of television viewing <12 months of
age (OR = 3.14), and spending >2 h/day watching televi-
sion (OR = 3.94), which also had a correlation to language
delay.
Almost all TV programs, which the participants watched
were live TV. Although most of the nonadult TV programs
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Chonchaiya and Pruksananonda Television viewing risk to language delay

Table 1 Characteristics of cases and controls (mean ± SD)

Groups Case Control

Variables (Mean ± SD) (Mean ± SD)
N = 56 N = 110 P-value

Child characteristics
Age (years) 2.11 ± 0.47 2.23 ± 0.80 0.747
Birth weight (grams) 3115.36 ± 505.51 2994.00 ± 548.06 0.085
Breast feeding duration (months) 5.50 ± 7.61 5.68 ± 7.93 0.803
First word (months) 17.38 ± 4.37 11.91 ± 2.01 <0.001∗
Language developmental level (years) 1.39 ± 0.47 2.56 ± 0.99 <0.001∗
Difference between language developmental level and CA (years) −0.72 ± 0.37 0.33 ± 0.33 <0.001∗

Parental characteristics
Father’s age (years) 36.57 ± 5.76 35.24 ± 6.76 0.112
Father’s income (Baht) 24 874.55 ± 30 908.10 21 614.35 ± 18 181.18 0.785
Mother’s age (years) 32.66 ± 4.43 31.73 ± 5.90 0.238
Mother’s income (Baht) 15 052.73 ± 16 802.89 12 000.46 ± 13 050.35 0.159

Time characteristics
Onset of TV viewing (months) 7.22 ± 5.52 11.92 ± 5.86 <0.001∗
TV viewing/day (h) 3.05 ± 1.90 1.85 ± 1.18 <0.001∗
Spending time with children/day (h) 7.03 ± 3.01 9.26 ± 2.26 <0.001∗
Talking time/day (h) 3.62 ± 2.19 5.80 ± 2.23 <0.001∗

CA: chronological age.

TV viewing/day (h): Total amount of time that the child actually watched television each day.
Spending time with children/day (h): Total amount of time that caregivers spent doing interactive activity with their children each day such as helping them to
brush their teeth, taking a bath, dressing themselves, telling stories, reading to them, talking with and listening to them about daily activities, eating with them,
teaching and encouraging them to talk, etc.

Table 2 Risk variables of the case and the control group, Odds Ratios (OR) and 95%CI

Groups Case Control

Variables N = 56 N = 110 P-value Odds ratios 95% CI

Child characteristics
Male sex 46 (82.1%) 59 (53.6%) <0.001∗ 3.98∗ 1.82–8.67
Prenatal risk factors 10 (17.9%) 19 (17.3%) 0.925 0.96 0.41–2.23
First birth order 33 (58.9%) 59 (53.6%) 0.517 1.24 0.65–2.38
Preterm labour 4 (7.1%) 9 (8.2%) 0.814 0.86 0.25–2.94
Type of delivery (C/S) 31 (55.4%) 39 (35.5%) 0.014∗ 2.26∗ 1.17–4.35
Positive past medical illness 23 (41.1%) 47 (42.7%) 0.838 1.07 0.56–2.06
Temperament (Non easy child) 36 (64.3%) 51 (46.4%) 0.029∗ 2.08∗ 1.07–4.04
Neologism 45 (80.4%) 61 (55.5%) <0.002∗ 3.29∗ 1.54–7.02

Parental and family characteristics

No family support 15 (26.8%) 42 (38.2%) 0.144 0.59 0.29–1.20
Number of family members (>3) 45 (80.4%) 78 (70.9%) 0.189 0.60 0.27–1.30
Positive Family history of developmental delay/delayed language development 37 (66.1%) 22 (20.0%) <0.001∗ 7.79∗ 3.78–16.07
Neglectful child rearing pattern 17 (30.4%) 6 (5.5%) <0.001∗ 7.56∗ 2.78–20.56
Caregiver (Non mother) 36 (64.3%) 42 (38.2%) 0.001∗ 2.91∗ 1.49–5.69
Number of communicative languages in family (>1) 27 (48.2%) 57 (51.8%) 0.661 1.16 0.61–2.20
Father’s education (≤Primary school) 14 (25.0%) 7 (6.4%) 0.001∗ 4.91∗ 1.85–13.01
Mother’s education (≤Primary school) 10 (17.9%) 11 (10.0%) 0.150 1.96 0.78–4.93

Television and time characteristics

No interactive activity during TV viewing 32 (57.1%) 18 (16.5%) <0.001∗ 6.74∗ 3.24–14.02
Watching adult TV program 34 (60.7%) 49 (44.5%) 0.049∗ 1.92∗ 1.00–3.70
Onset of viewing TV <12 months of age 39 (69.6%) 46 (42.2%) 0.001∗ 3.14∗ 1.58–6.23
TV viewing/day (>2 h/day) 34 (60.7%) 31 (28.2%) <0.001∗ 3.94∗ 2.00–7.76
Spending time with children/day (<6 h/day) 21 (37.5%) 9 (8.2%) <0.001∗ 6.73∗ 2.82–16.08
Talking time/day (<2h/day) 15 (26.8%) 5 (4.5%) <0.001∗ 7.68∗ 2.62–22.50


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Television viewing risk to language delay Chonchaiya and Pruksananonda

Table 3 Variables in logistic regression model predicting speech and language developmental delay
95.0% C.I. for EXP(B)
Adjusted odds
Variables Sig. ratios EXP(B) Lower Upper

Onset of TV viewing < 12 months of age and TV viewing > 2 h/day 0.002∗ 5.70 1.85 17.61
Watching adult TV program 0.037∗ 3.23 1.07 9.72
No interactive activity during TV viewing <0.001∗ 8.47 2.63 27.29
Male 0.042∗ 3.45 1.05 11.42
Family history of developmental delay/delayed language development <0.001∗ 9.22 2.97 28.57
Type of delivery: caesarean section <0.001∗ 10.03 2.78 36.25
Neglectful parenting style <0.001∗ 35.06 5.51 222.95
Father’s education: ≤ Primary school 0.007∗ 8.10 1.76 37.17
Neologism 0.007∗ 5.86 1.63 21.16

that children watched in both groups were cartoons, but
most of these cartoon-programs in Thailand were created
for older children. Furthermore, most parents, 90.9% in the
control group and 94.6% in the case group did not choose
educational media for their children.
Adjusted odds ratios
To examine the impact of each putative individual risk factor
while controlling for the others, we developed a multivariate
logistic regression model. Table 3 represents adjusted odds
ratios, and their 95% CI of all variables in the logistic regres-
sion model, which could predict language delay.
From our study, we concluded that the most significant
risk factors that could strongly predict language delay were
neglectful parenting (OR = 35.06), children who were de-
livered by caesarean section (OR = 10.03), family history of
developmental delay/delayed language development (OR =
9.22), no interactive activity during television viewing (OR =
8.47), father’s education ≤ primary school level (OR = 8.10),
children who had neologism persistently (OR = 5.86), the
onset of television viewing <12 months of age and television
viewing >2 h each day (OR = 5.70), male sex (OR = 3.45)
and watching adult programs (OR = 3.23), respectively.
DISCUSSION
More very young children are currently watching television
than in the past. We found that children who had language
delay tended to start watching television about 10 months
earlier than they could speak their first meaningful word.
This result is contrast to children who had normal language
development. The control group had usually started watch-
ing television after they could speak their first single word.
Children who started watching television at <12 months
of age and watched television >2 h each day were approx-
imately six times more likely to develop language delays.
There seems to be a negative association of language devel-
opment and television viewing, especially when <2 years
of age. This confirms studies by Linebarger and Walker,
Nelson, Zimmerman Christakis and Meltzoff (5,12).
Surprisingly, only one girl (0.6% of all children) in our
study had not yet watched television during the first visit at
her age of 18 months old. This result is a much smaller num-
ber than in the study by Rideout, Vandewater, and Wartella
(2), which reported percentages of children <3 years of age
who did not watch television on a typical day ranging from
21% to 48%.
Normal children in our study watched more television
than the AAP recommendations; as high as 95.5–100% in
children who had language delay when compared to 36.18%
of general children in the study of Certain (13). Therefore,
these findings seem to imply that most Thai children in our
study tended to watch television at younger age and longer
duration than the AAP recommendations. Our children may
lack opportunity to do more beneficial activities such as play
skills and social interaction. Caregivers probably did not
recognize or were not concerned about adverse effects of
television viewing on their children. These disadvantages of
television viewing were similar to the study by DeLoache
(National Research Council and Institute of Medicine)
(14).
Nearly 60% of children who had language delay in our
study were left watching television on their own. We also
found that if children watched television alone, they were
8.47 times more likely to have language delay when com-
pared to children who interacted with their caregivers during
television viewing. This outcome was similar to the study by
Tanimura et al., which found that the quality and quantity of
parental utterances to their children declined while the TV
was on (8). This increased risk of language delay would be
from very young children learning less from television than
from equivalent real-life experiences (5).
Background television can be distracting and interfering
as the child tries to engage in other activities such as toy
play or interacting with family members (5,15). This result
seems to have a negative impact on the dynamics and inter-
active process of developing language milestones in children.
Caregiver–child interaction in the normal children group
was significantly more than in the control group. It could
be implied that development of language is built on early
interactions with caregivers and is augmented later by the
presence of a rich, conversational environment (16).
There were more male participants in the case group. This
result would be from language delay is more common in boys
than girls (9). Furthermore, Certain found that male and fe-
male children watched more TV than the AAP guidelines
(13). This was the reason why we did not match the gender

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Chonchaiya and Pruksananonda
difference between both groups. Therefore, participants in
our study had similar important background variables in-
cluding children’s age, parental age, income and maternal
education, which may limit possible confounds in interpret-
ing the results of this study.
Besides television viewing, neglectful parenting style was
the strongest risk factor in our study to be associated with
language delay due to lack of child–caregiver interaction.
This was like the study by Carol Scheffner Hammer et al.
(17). Other important factors such as birth order, multilin-
gual family environment, low-birth weight, noninvolvement
of domestic help in child care, maternal education, socioe-
conomic status and behavioural problems in the child were
not significantly associated with language delay in our study.
This result may or may not be significantly similar to reported
risk factors in other studies (18–28). Most risk factors of
language delay, which were present before the diagnosis of
language delay, were less likely to be prevented. However,
environmental influence and nurturing factors such as au-
thoritative parenting style, appropriateness of parent–child
interaction and following the AAP recommendation about
television viewing should be promoted.
There was a limitation of the Denver-II in screening for
language delay due to its relatively low–to-moderate sensi-
tivity (0.56–0.83) and specificity (0.43–0.80) (29). It may fail
to identify some children with expressive language problems.
We also lacked of standardized measures to determine
other important variables, for example, temperament, be-
havioural problems, interactive activity and parenting style
because these variables were collected only through parent
interview only.
There was also a limitation in the case-control study due
to the retrospective nature of the design, which may have
interviewer bias and limitations in human recall. However,
the interviewer followed a standard protocol and asked all
of the questions with clarified definitions of terms that were
contained in each question. Furthermore, television view-
ing patterns should be researched in more in-depth inter-
views in order to better understand the individual, familial,
and sociocultural forces that affect children’s television
viewing. A longitudinal, prospective study is needed to
examine the impact of television viewing on language
development.
There seems to be an association among early onset and
high frequency of TV viewing and language delay. This re-
sult might not be a direct cause and effect one. However,
television is a complex medium and requires brain matura-
tion and cognitive skills to decipher, typically develop after
2 or 3 years of age (14,30). Furthermore, TV viewing may
be one of the important environmental triggers that has a
negative impact on language development in young chil-
dren. In other perspectives, if children have language de-
lay they will tend to watch more television, which could
be an additional detrimental effect on their language ac-
quisition. Physicians and other professionals may need to
include the amount and onset of TV viewing ‘on their radar’
when interacting with parents and children around language
development.

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Television viewing risk to language delay
ACKNOWLEDGEMENTS
We especially thank the following for their assistance: the
cooperative participants in this study, fellows and staff of
the growth and developmental division, medical personnel
who helped to arrange for the participants at the outpatient
clinic of King Chulalongkorn Memorial Hospital, Profes-
sor Vorasuk Shotelersuk, Division of Medical Genetics and
Metabolism, Department of Pediatrics, Chulalongkorn Uni-
versity for his helpful suggestions and Publications and Edi-
torial Working Group, Division of Research Affairs, Faculty
of Medicine, Chulalongkorn University.
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APPENDIX: THE CHILD REARING PATTERN PROTOCOL
We conducted an in-depth interview in Thai. According to
the child rearing pattern, we have re-arranged in English
to clarify this question. We followed Baumrind’s concept of
parenting style. The construct of parenting style is used to
capture normal variations in parents’ attempts to control and
socialize their children (Baumrind). Categorizing parents ac-
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C 2008 The Author(s)/Journal Compilation 
Chonchaiya and Pruksananonda
cording to whether they are high or low on parental de-
mandingness and responsiveness creates a typology of four
parenting styles: authoritarian, authoritative, indulgent, and
uninvolved (neglectful). We asked the primary caregivers
about this description from item 1 to 4 by masking them the
real typology of parenting style. Finally, we let them choosing
the particular parenting styles that would most likely match
each case.
1. Authoritarian parents are highly demanding and di-
rective, but not responsive. ‘They are obedience-
and status-oriented, and expect their orders to be
obeyed without explanation’. These parents provide
well-ordered and structured environments with clearly
stated rules.
2. Authoritative parents are both demanding and re-
sponsive. ‘They monitor and impart clear standards for
their children’s conduct. They are assertive, but not in-
trusive and restrictive. Their disciplinary methods are
supportive, rather than punitive. They want their chil-
dren to be assertive as well as socially responsible, and
self-regulated as well as cooperative’.
3. Indulgent parents (‘permissive’ or ‘nondirective’) are
more responsive than they are demanding. They are
nontraditional and lenient, do not require mature be-
haviour, allow considerable self-regulation, and avoid
confrontation.
4. Neglectful (uninvolved parents) are low in both re-
sponsiveness and demandingness. In extreme cases,
this parenting style might encompass both rejecting–
neglecting and neglectful parents, although most par-
ents of this type fall within the normal range.
In addition, parents were interviewed about their disci-
plinary practices. Specifically, they were asked about how
frequently they used the following: used time out, scolded
or yelled at their children, took away privileges, spanked
their children with a hand, spanked them with an object,
and talked about the problem. Furthermore, we observed
parental sensitivity to child’s needs and their interaction dur-
ing the session to gauge their specific child rearing pattern.
Parenting style Authoritarian Authoritative Indulgent Neglectful
characteristics parenting parenting parents parenting
Limits/control firm, highly firm on their few uninvolved
demanding, actions
directive
Punishment frequent rational few uninvolved
Verbal exchange limit extensive highly involved uninvolved
Nurture limit warm highly involved uninvolved
C 2008 Foundation Acta Pædiatrica/Acta Pædiatrica 2008 97, pp. 977–982