Research

JAMA Pediatrics | Original Investigation

Screen Time and Developmental Performance Among Children

at 1-3 Years of Age in the Japan Environment and Children’s Study
Midori Yamamoto, PhD; Hidetoshi Mezawa, MD, PhD; Kenichi Sakurai, MD, PhD; Chisato Mori, MD, PhD; for the
Japan Environment and Children’s Study Group

Supplemental content
IMPORTANCE It is unclear whether increased television (TV) and DVD viewing in early
childhood from age 1 year decreases development or whether poor development increases
TV/DVD viewing.

OBJECTIVE To investigate the directional association between TV/DVD screen time and
performance on developmental screeners in children aged 1 to 3 years.

DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study analyzed data from
57 980 children and mothers from a national birth cohort, the Japan Environment and
Children’s Study. Data were collected in collaboration with 15 regional centers across Japan.
The mothers were recruited between January 2011 and March 2014. Analyses using random
intercept, cross-lagged panel models were performed for children aged 1, 2, and 3 years. Of
100 303 live births, children with missing developmental screening test scores and screen
time data, those with congenital diseases or cerebral palsy, and those diagnosed with an
autism spectrum disorder were excluded. Statistical analyses were conducted from October
2022 to July 2023.

EXPOSURES TV and DVD screen time.

MAIN OUTCOMES AND MEASURES Child development at ages 1, 2, and 3 years was assessed via
the mother’s or guardian’s report using the Ages and Stages Questionnaire, third edition.

RESULTS Of 57 980 included children, 29 418 (50.7%) were male, and the mean (SD)
maternal age at delivery was 31.5 (4.9) years. A negative association between screen time and
developmental scores was observed. Increased TV/DVD screen times at age 1 and 2 years
were associated with lower developmental scores at age 2 and 3 years, respectively (2 years:
β = −0.05; 95% CI, −0.06 to −0.04; 3 years: β = −0.08; 95% CI, −0.09 to −0.06). An obverse
association was observed from the Ages and Stages Questionnaires, third edition, score in the
communication domain at age 1 and 2 years to subsequent screen time (2 years: γ = −0.03;
95% CI, −0.04 to −0.02; 3 years: γ = −0.06; 95% CI, −0.07 to −0.04).

CONCLUSIONS AND RELEVANCE In this study, increased TV/DVD screen time from age 1 year
negatively affected later development. To reduce the negative consequences of excessive
media use, researchers and health care professionals should encourage family media
management and recommend social support for parents who tend to rely on the media.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Group Information: A complete list
of the members of the Japan
Environment and Children’s Study
Group appears in Supplement 2.
Corresponding Author: Midori
Yamamoto, PhD, Department of
Sustainable Health Science, Center
for Preventive Medical Sciences,
Chiba University, 1-33 Yayoi-cho,
JAMA Pediatr. doi:10.1001/jamapediatrics.2023.3643 Chiba 263-8522, Japan (midoriy@
Published online September 18, 2023. faculty.chiba-u.jp).

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 Research Original Investigation
R
esearchers have reported a significant increase
in the number of children with neurodevelopmental
and mental health problems, including language,
l e a r n i ng , b e h a v i o r a l , a n d e m o t i o n a l d i s o r d e r s . 1 , 2
This increase indicates the need to better understand the
social, medical, and environmental factors underlying
developmental problems in early childhood.
Screens, such as television (TV), are ubiquitous in
t h e h o m e s o f yo u ng c h i l d r e n . A l t h o u g h p e d i a t r i c
guidelines recommend that screen viewing be avoided for
infants younger than 2 years and limited to 1 hour per
day between the ages 2 and 5 years, 3-5 many children
fail to adhere to these recommendations.6 Excessive screen
time in children younger than 3 years is assoc iated
with adverse effects on cognitive, language, motor skills,
and soc ial-behav ioral development. 7 - 1 1 Conversely,
c h i ld re n w it h p o o r s e l f - re g u l at i o n a re m o re l i ke l y
to experience more exposure to screens.12-16 However, there
is limited evidence for a causal relationship in early
childhood regarding whether media exposure leads
to developmental delays or whether children w ith
developmental delays are more exposed to the media. After
accounting for individual traitlike differences, several stud-
ies have used the random-intercepts, cross-lagged panel
model (RI-CLPM) to clarify the bidirectional association
between screen time and development (from age 2 to 3
years).17,18
Using the RI-CLPM and Ages and Stages Questionnaires
(ASQ) as a developmental screener, Madigan et al17 showed
that increased screen time at ages 2 and 3 years led to
delayed achievement of developmental milestones at ages 3
and 5 years, respectively. The current study provides
more convincing evidence of the role of screen use on
child development and justifies the RI-CLPM used to
analyze the bidirectional association. Although brain devel-
opment during the first 3 years of life is critical, as it sets
the foundation for future cognitive and emotional
functioning,19,20 to our knowledge, no study has found a
bidirectional relationship between screen time and develop-
ment in young children, including those younger than 2
years. We replicated and extended the study of Madigan
et al17 with a larger sample size, at a slightly early age, and
with differential cultural backgrounds. Maternal prenatal or
postpartum stress and child’s sex may be associated with
c o g n it ive f u n c t i o n i ng a n d b e h av i o r a l p ro b l e m s i n
children. 21-26 Detecting interactions is crucial for public
health if maternal stress influences the fetal or children’s
environment.
We aimed to examine the bidirectional association between
TV/DVD screen time and developmental milestones during early
childhood. Additionally, we examined the association in 5 spe-
cific domains and moderation or interaction effect by child’s sex
and maternal distress. Children with psychiatric disorders, such
as autism spectrum disorder (ASD), have been reported to have
extreme screen time.27,28 Therefore, we analyzed data from the
Japanese nationwide birth cohort study on 57 980 children aged
1, 2, and 3 years with primarily typical development, excluding
those diagnosed with ASD.
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Screen Time and Developmental Performance Among Children at 1-3 Years of Age
Key Points
Question Is increased television/DVD screen time in infants
associated with poor performance on developmental screeners?
Findings In this cohort study of 57 980 children, increased
television/DVD screen time in children aged 1 and 2 years was
associated with lower developmental scores at 2 and 3 years,
respectively. Lower development scores were associated with
increased screen time in children with maternal psychological
distress.
Meaning In this study, increased screen time in early childhood
was negatively associated with poor performance on
developmental screeners, suggesting the need to support parents
in creating family media plans.
Methods
Study Design and Participants
The participants included children from the Japan Environ-
ment and Children’s Study (JECS). The study design of JECS
has been described previously.29 Briefly, 103 060 pregnan-
cies were registered between January 2011 and March 2014 in
15 regional centers across Japan. We used the dataset jecs-ta-
20190930. We included 100 303 live births, excluding 1254 mis-
carriages, 382 stillbirths, and 2123 with missing birth data. Next,
children were excluded if they met any of the following crite-
ria: missing developmental score data (n = 35 914) or missing
TV/DVD screen time data (n = 794) at age 1, 2, or 3 years; had
congenital diseases, cerebral palsy, or missing data (n = 5376);
and diagnosed with ASD (eg, autism, pervasive developmen-
tal disorder, and Asperger syndrome) at age 3 years or miss-
ing data (n = 239). A total of 57 980 children were included in
the analysis (eFigure in Supplement 1). Written informed con-
sent was obtained from all the participants. The JECS proto-
col was reviewed and approved by the Ministry of the Envi-
ronment’s Institutional Review Board on Epidemiological
Studies and the ethics committees of all participating institu-
tions. The study followed the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) reporting
guideline.30
Measures
Developmental Screener
Children’s development was assessed by the scores on the Japa-
nese version of the ASQ, third edition (ASQ-3), completed by
the parents or guardians of children aged 1, 2, and 3 years. The
ASQ-3 is widely used for assessing development in commu-
nication, gross motor, fine motor, problem solving, and per-
sonal-social domains (eTable 1 in Supplement 1).31 Each do-
main comprises 6 questions, and their total scores range from
0 to 60 points per domain, with higher scores indicating bet-
ter development. The Japanese version of ASQ-3 was vali-
dated with moderate to high sensitivity (75.3% to 100.0%) and
specificity (66.7% to 100.0%).32 The mean ASQ-3 scores of 5
domains or each domain were used as continuous variables.
jamapediatrics.com
 Screen Time and Developmental Performance Among Children at 1-3 Years of Age
Figure. Random-Intercepts Cross-Lagged Panel Model for Associations Between Television (TV)/DVD
Screen Time and Developmental Outcomes (Ages and Stages Questionnaires, Third Edition [ASQ-3], Scores)
Screen time
(stable)
1a
1a 1a
TV/DVD screen αS = 0.15; TV/DVD screen
time at age 1 y 95% CI, 0.14 to 0.16 time at age 2 y 95% CI, 0.12 to 0.15
γ = –0.01;
95% CI, –0.03 to 0.01
σSA = –0.15;
95% CI, –0.18 to –0.12
β = –0.05;
95% CI, –0.06 to –0.04
ASQ–3 score αA = 0.09; ASQ–3 score
at age 1 y at age 2 y
95% CI, 0.07 to 0.11
1a 1a
1a
ASQ–3 score
(stable)
Screen Time
At ages 1, 2, and 3 years, parents or guardians were asked to re-
port their children’s TV/DVD screen time on by asking, “How
many hours do you let your children watch TV or DVD in a typi-
cal day?” The responses were collected from among 5 catego-
ries: none, less than 1 hour, 1 hour or more but less than 2 hours,
2 hours or more but less than 4 hours, and 4 hours or more.
The categories were converted to corresponding numbers (0
hours, 0.5 hours, 1.5 hours, 3 hours, and 4.5 hours per day,
respectively).
Predictors
In the model to explore the contribution of time-invariant fac-
tors on screen time and child development, possible predic-
tors were selected a priori based on the literature,17,27 biologi-
cal plausibility, and using a directed acyclic graph. z Scores for
the following variables were included in the predictor model
using the forced entry method: sex of the child, maternal age
at delivery, maternal education, annual household income,
maternal psychological distress assessed by the Kessler
Psychological Distress Scale Japanese version33 at 1 year post
partum, the presence of an elder sibling(s), attendance at a
childcare facility, frequency of reading to the child, fre-
quency of taking the child out of the house (other than the
childcare facility), and child’s sleep time per day at age 1 year.
Categorization is illustrated in eTable 2 in Supplement 1.
Data were obtained from the questionnaire completed by the
children’s parents or guardians as well as medical record
transcripts.
Statistical Analysis
Descriptive statistics were used to summarize the distribu-
tion of participant characteristics. We examined the longitu-
dinal and directional associations between TV/DVD screen
time and ASQ-3 scores using a RI-CLPM (Figure; eAppendix
in Supplement 1). This model is a structural equation-based
approach to better approximate within-person (time-
variant) relationships by accounting for between-person
(time-invariant, traitlike) stability by including random
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Original Investigation Research
αS = 0.14; TV/DVD screen
time at age 3 y
γ = –0.02;
95% CI, –0.04 to –0.01
β = –0.08;
95% CI, –0.09 to –0.06
Standardized estimates with 95% CIs
αA = 0; ASQ–3 score
at age 3 y are presented. Solid lines in cross-lag
95% CI, –0.03 to 0.03
and autoregressive links represent
the absolute value of the
standardized estimate, which is 0.03
or more. Dashed lines represent
those less than 0.03.
a
The factor loadings constrained to 1.
intercepts to the standard cross-lagged panel model. 34
Owing to the nonnormal distribution of screen time and
ASQ-3 scores, we used an asymptotic distribution-free esti-
mation method.
Cross-lag association of the screen time with ASQ-3 scores
(β) and the association of ASQ-3 scores with screen time (γ) were
estimated in 3 types of RI-CLPM. First, to identify associa-
tions between screen time and overall or domain-specific de-
velopment, we performed estimation using the basic
RI-CLPM (Figure) using mean ASQ-3 scores or scores of each
domain, respectively. Second, to explore the interaction ef-
fects on the association between screen time and child devel-
opment, we performed a multiple-group RI-CLPM stratified by
the child’s sex and maternal psychological distress. To evalu-
ate the interaction effect, we compared a model in which the
lagged regression coefficients were constrained to be equal be-
tween the 2 groups with an unconstrained model, with dif-
ferences in the fit indices between models. We considered the
interaction effect to be insignificant when the difference in the
comparative fit index (CFI) was less than 0.010, the change in
the root mean square error of approximation (RMSEA) was less
than 0.015, and the change in the standardized root mean
square residual (SRMR) was less than 0.010.35 Third, to ex-
plore the contribution of predictors for screen time and child
development, we constructed a predictor-included RI-CLPM
by including between-level predictors affecting the random in-
tercepts simultaneously, as presented by Mulder and
Hamaker.36 In all models, benchmark values for interpreting
the size of the RI-CLPM cross-lag effect were set at 0.03 (small
effect), 0.07 (medium effect), and 0.12 (large effect).37
To assess the robustness of the findings, we performed sen-
sitivity analyses using the basic RI-CLPM for children with com-
plete data at 3 years (n = 70 226). In these analyses, we esti-
mated missing TV/DVD screen time data and ASQ-3 scores at
1 and 2 years using full information maximum likelihood es-
timation and Bayesian estimation with the Markov chain Monte
Carlo algorithm. The number of cohort participants included
and excluded from the analyses and a comparison of basic
demographic characteristics are summarized in eTable 3 in
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 Research Original Investigation Screen Time and Developmental Performance Among Children at 1-3 Years of Age

Table 1. Directional Association Between Television/DVD Screen Time and Development (Ages and Stages Questionnaires,
Third Edition [ASQ-3] Scores) in Each Domain

Standardized estimate (95% CI)a

Association Communication Gross motor Fine motor Problem-solving Personal-social
Cross-lagged effects
Screen time at age 1 y −0.06 (−0.07 to −0.01 (−0.02 to −0.01 (−0.03 to −0.01 (−0.02 to −0.01 (−0.03 to
and ASQ-3 score at age 2 y, β −0.05) 0) 0) 0) 0)
ASQ-3 score at age 1 y −0.03 (−0.04 to 0.01 (0 to 0 (−0.01 to 0) −0.01 (−0.02 to 0 (−0.01 to
and screen time at age 2 y, γ −0.02) 0.02) 0) 0.01)
Screen time at age 2 y −0.02 (−0.04 to −0.03 (−0.05 to −0.07 (−0.08 to −0.01 (−0.03 to −0.12 (−0.14 to
and ASQ-3 score at age 3 y, β −0.01) −0.01) −0.06) 0) −0.11)
ASQ-3 score at age 2 y −0.06 (−0.07 to 0.02 (0.01 to −0.02 (−0.04 to 0.02 (0 to −0.01 (−0.02 to
and screen time at age 3 y, γ −0.04) 0.03) −0.01) 0.03) 0.01)
Fit indices
CFI 1.00 1.00 1.00 1.00 1.00
RMSEA (90% CI) 0.01 (0.01 to 0.02 (0.01 to 0.03 (0.02 to 0.02 (0.01 to 0 (0 to
0.02) 0.03) 0.03) 0.02) 0.01)
SRMR 0 0.01 0.01 0 0
a
Abbreviations: CFI, comparative fit index; RI-CLPM, random-intercepts, Benchmark values for interpreting the size of the RI-CLPM cross-lag effect
cross-lagged panel model; RMSEA, root mean square error of approximation; were set at 0.03 (small effect), 0.07 (medium effect), and 0.12 (large effect).37
SRMR, standardized root mean square residual.

Supplement 1. All statistical analyses were conducted using
SPSS and SPSS Amos version 27 (IBM).
Results
Descriptive Statistics
eTable 2 in Supplement 1 summarizes the characteristics of chil-
dren and mothers. Of 57 980 included children, 29 418 (50.7%)
were male, and the mean (SD) maternal age at delivery was 31.5
(4.9) years. At ages 1, 2, and 3 years, 15 051 children (26.0%),
16 430 children (28.3%), and 17 403 children (30.0%) viewed
TV/DVD for at least 2 hours per day, respectively.
Association Between Screen Time
and ASQ-3 Scores in Each Domain
Each model demonstrated a good fit (Table 1). We observed
small to medium linking from screen time at age 1 year to ASQ-3
scores at age 2 years in the communication domain (β = −0.06;
95% CI, −0.07 to −0.05) and small to large linking from screen
time at age 2 years to ASQ-3 scores at age 3 years in gross mo-
tor, fine motor, and personal-social domains (β range, −0.03
[95% CI, −0.05 to −0.01] to −0.12 [95% CI, −0.14 to −0.11]). The
small to medium obverse linking was observed from ASQ-3
scores in the communication domain to screen time (2 years:
γ = −0.03; 95% CI, −0.04 to −0.02; 3 years: γ = −0.06; 95% CI,
−0.07 to −0.04).

Directional Association Between Screen Time
and ASQ-3 Scores
The Figure and eTable 4 in Supplement 1 summarize the es-
timates in the basic RI-CLPM. Fit indices demonstrated good
model fit. Significant variances of random intercepts were ob-
served for both TV/DVD screen time (σS2 = 0.46; 95% CI, 0.44-
0.48) and ASQ-3 scores (σA2 = 33.95; 95% CI, 32.31-35.59). This
finding indicated stable individual differences in both screen
time and developmental scores; furthermore, it was reason-
able to set a random intercept in the model. Positive autore-
gressive associations in the screen time (αS2 and αS3) implied
that children with more TV screen time were more likely to con-
tinue this behavior on subsequent occasions. We observed
negative covariances between random intercepts of TV/DVD
screen time and ASQ-3 scores (σSA = −0.15; 95% CI, −0.18 to
−0.12), suggesting that children with more screen time tended
to have lower ASQ-3 scores at ages 1 to 3 years.
Furthermore, we observed small to medium negative
cross-lags linking from screen time at age 1 year to ASQ-3 score
at age 2 years (β = −0.05; 95% CI, −0.06 to −0.04) and me-
dium linking from screen time at age 2 years to ASQ-3 score at
age 3 years (β = −0.08; 95% CI, −0.09 to −0.06).
Moderation or Interaction Effects on the Cross-Lags Link
Table 2 and Table 3 present the results of 2 multiple-group
RI-CLPMs stratified by the child’s sex and maternal psycho-
logical distress. Both models demonstrated a good fit. In the
model stratified by the child’s sex, we observed no difference
in the cross-lag effect between boys and girls (Table 2). For the
model stratified by maternal psychological distress, we ob-
served no distinct difference between the groups as assessed
by a change in fit indices (change in CFI, 0; change in RMSEA,
0; change in SRMR, 0). However, a small to medium cross-lag
association between ASQ scores at age 2 years and screen time
at age 3 years was observed only in children with maternal psy-
chological distress (γ = −0.05; 95% CI, −0.07 to −0.02) (Table 3).
Predictors of Screen Time and ASQ-3 Scores
The RI-CLPM with 10 predictors demonstrated a close model
fit, although poorer than the basic RI-CLPM (CFI, 0.94; RM-
SEA, 0.04; 90% CI, 0.04-0.04; SRMR, 0.02) (data not shown).
Increased TV/DVD screen time was associated with not attend-
ing a childcare facility, no elder sibling(s), infrequent reading
to children, lower maternal education level, psychological dis-
tress, lower income, seldom going outdoors, less sleep time,

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 Screen Time and Developmental Performance Among Children at 1-3 Years of Age Original Investigation Research

Table 2. Directional Association Between Television/DVD Screen Time Table 3. Directional Association Between Television/DVD Screen Time
and Development (Ages and Stages Questionnaires, Third Edition and Development (Ages and Stages Questionnaires, Third Edition
[ASQ-3] Scores) Stratified By Child’s Sex [ASQ-3] Scores) Stratified By Maternal Psychological Distress

Standardized estimate (95% CI)a Standardized estimate (95% CI)a

Association Boys Girls Mentally stable Mental distress
Association (<5)b (≥5)b
Cross-lagged effects
Cross-lagged effects
Screen time at age 1 y and −0.05 (−0.07 to −0.03 (−0.05 to Screen time at age 1 y and −0.04 (−0.05 to −0.06 (−0.09 to
ASQ-3 score at age 2 y, β −0.04) −0.02) ASQ-3 score at age 2 y, β −0.03) −0.04)
ASQ-3 score at age 1 y and −0.01 (−0.03 to 0 (−0.01 to ASQ-3 score at age 1 y and −0.01 (−0.03 to −0.02 (−0.04 to
screen time at age 2 y, γ 0.01) 0.01) screen time at age 2 y, γ 0.01) 0)
Screen time at age 2 y and −0.09 (−0.11 to −0.07 (−0.09 to Screen time at age 2 y and −0.08 (−0.09 to −0.09 (−0.12 to
ASQ-3 score at age 3 y, β −0.07) −0.05) ASQ-3 score at age 3 y, β −0.06) −0.06)
ASQ-3 score at age 2 y and −0.02 (−0.04 to −0.01 (−0.03 to ASQ-3 score at age 2 y and −0.02 (−0.03 to −0.05 (−0.07 to
screen time at age 3 y, γ 0.01) 0.02) screen time at age 3 y, γ −0.01) −0.02)
Fit indices Fit indices
CFI 1.00 CFI 1.00
RMSEA (90% CI) 0.01 (0.01 to RMSEA (90% CI) 0.01 (0 to
0.02) 0.01)
SRMR 0
SRMR 0
Abbreviations: CFI, comparative fit index; NA, not applicable; RI-CLPM,
Abbreviations: CFI, comparative fit index; RI-CLPM, random-intercepts,
random-intercepts, cross-lagged panel model; RMSEA, root mean square error
cross-lagged panel model; RMSEA, root mean square error of approximation;
of approximation; SRMR, standardized root mean square residual.
SRMR, standardized root mean square residual.
a
a Benchmark values for interpreting the size of the RI-CLPM cross-lag effect
Benchmark values for interpreting the size of the RI-CLPM cross-lag effect
were set at 0.03 (small effect), 0.07 (medium effect), and 0.12 (large effect).37
were set at 0.03 (small effect), 0.07 (medium effect), and 0.12 (large effect).37
b
Maternal psychological distress was assessed by the Kessler Psychological
Distress Scale Japanese version33 at 1 year post partum.
and younger maternal age (Table 4). In contrast, higher devel-
opmental performance was associated with being female, fre-
quent reading to the child, attending a childcare facility, el- Compared with another Japanese cohort that began in
der sibling(s), younger maternal age, no psychological distress, 2001,38 TV screen time for young children in the JECS cohort born
frequently going outdoors, higher income, and more sleep time. between 2011 and 2014 appeared to decline. This finding was
Even after accounting for the effects of these predictors, the consistent with the decrease in TV and DVD screen times at age
association between random intercepts of screen time and 0 to 8 years from 2011 to 2017 and is likely related to increased
ASQ-3 remained negative (σSA = −0.11; 95% CI, −0.14 to −0.08) use of mobile devices.39 For TV/DVD screen time alone, only 25%
(data not shown). to 29% of the children at ages 2 and 3 years met the guideline
limiting screen time to no more than 1 hour each day.
Sensitivity Analyses Our study results support the findings of a Canadian co-
The basic RI-CLPM was performed using full information maxi- hort study using the RI-CLPM that demonstrated a direc-
mum likelihood and Bayesian estimation for children with com- tional association of greater screen time (TVs, DVDs, comput-
plete data only at age 3 years (n = 70 226). The results were simi- ers, and game consoles) at age 24 months with a lower ASQ-3
lar to the RI-CLPM results for children with complete data at score at age 36 months.17 In addition, we found that screen time
ages 1, 2, and 3 years (n = 57 980) (eTable 5 in Supplement 1). at age 1 year affects poorer communication skills at age 2 years.
The effects on cognitive function may be partially mediated
by reduced activity in the frontal and parietal brain regions.40
Conversely, screen time at age 2 years affected subsequent mo-
Discussion tor and personal-social skills. This may be attributed to miss-
Our study demonstrated that the negative cross-lag associa- ing opportunities to learn motor and interpersonal skills by sed-
tion from screen time to developmental scores remained con- entary looking at screens.
sistent throughout toddlerhood. Notably, we found a bidirec- Our study demonstrated an obverse association from lower
tional association between TV/DVD screen time and ASQ-3 scores only in the communication domain at age 1 year
developmental scores in the communication domain from age to more screen time at age 2 years and a similar association with
1 to 2 years. Additionally, we observed negative associations a stronger effect from age 2 years to 3 years. The factors that
between TV/DVD screen time at age 2 years and the develop- may contribute to increased screen time include low devel-
mental scores in gross motor, fine motor, and personal-social opment of communication skills, an environment that does not
domains at age 3 years. A negative association between the de- promote communication development, and a child’s prefer-
velopmental score at age 2 years and screen time at age 3 years ence for the environment. The association between lower
was observed in the communication domain. No significant ASQ-3 scores and subsequent increases in screen time was par-
interaction by child’s sex or maternal psychological distress was ticularly evident among mothers experiencing mental health
observed. In addition, developmental scores at age 2 years were challenges. These findings underscore the importance of so-
negatively linked to screen time at age 3 years in children with cial support for mothers who may rely on media to manage
maternal psychological distress. their child’s behavior.

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 Research Original Investigation Screen Time and Developmental Performance Among Children at 1-3 Years of Age

environment.49 Third, promoting social networks that allow

Table 4. Predictors of Television/DVD Screen Time
and Child Development Among 53 085 Children children to have high-quality interactions with their fami-
lies is important. Active social interaction in the neighbor-
Standardized estimate (95% CI)
hood may promote healthy behaviors, such as reducing
Development
Predictor Screen time (ASQ-3 score) screen time and increasing physical activity levels.50
Maternal age −0.03 (−0.04 to −0.11 (−0.12 to
−0.02) −0.10)
Maternal education −0.11 (−0.12 to 0.02 (0.01 to Strengths and Limitations
−0.10) 0.03) The strength of this study is that it provides insights into the
Household income (≥¥4 million −0.05 (−0.06 to 0.04 (0.03 to directional association between TV/DVD screen time and de-
[≥US $27 863] vs <¥4 million −0.04) 0.05)
[<US $27 863]) velopmental milestones in typically developing young chil-
Maternal psychological distress 0.05 (0.04 to −0.09 (−0.10 to dren. It was based on a large birth cohort dataset representa-
(yes vs no)a 0.06) −0.08)
tive of the Japanese population and provides reliable results.51
Elder sibling (yes vs no) −0.19 (−0.20 to 0.14 (0.13 to
−0.18) 0.15) However, it had some limitations. First, we assessed the de-
Attending childcare facility −0.28 (−0.29 to 0.16 (0.15 to velopmental milestones and screen time based on parental re-
(yes vs no) −0.27) 0.17) ports, which is suitable for collecting data from large popula-
Reading to child −0.13 (−0.14 to 0.18 (0.17 to tions; however, it may have led to reporting bias. Second, there
−0.11) 0.19)
is a single-informant bias, ie, most of the respondents to the
Going outdoors −0.04 (−0.05 to 0.07 (0.06 to
−0.03) 0.08) questionnaire were mothers because they were the primary
Sleep time −0.03 (−0.04 to 0.05 (0.04 to caregivers of their children. These biases may weaken the gen-
−0.02) 0.05)
eralizability of the findings. Third, advances in media tech-
Child’s sex (girls vs boys) 0 (−0.01 to 0.24 (0.23 to
0.02) 0.25) nology may have changed the situation of children’s screen
2
R for the random intercept 0.14 0.15 viewing because children are increasingly exposed to por-
table media screens other than TVs and DVDs from an early
Abbreviation: ASQ-3, Ages and Stages Questionnaires, third edition.
a age. According to a 2016 Japanese survey, smartphone, tab-
Maternal psychological distress was assessed by the Kessler Psychological
Distress Scale Japanese version33 at 1 year post partum. Participants were let, and portable gaming device use among children aged 1 to
considered to be distressed if their score was 5 or greater. 3 years ranged from 2% to 32%.52 In a 2017 US survey, chil-
dren aged 2 to 4 years spent 1 hour a day on both TV and mo-
Frequent reading to the child, attending childcare, and hav- bile devices.39 Information on mobile device usage from age
ing an elder sibling(s) were particularly associated with higher 1 year was not available for this study, which may underesti-
developmental scores and lesser screen time. A similar, albeit mate total screen time. Fourth, the media content available to
weaker, association was observed for taking children out- children is becoming increasingly diverse, and they may be ex-
doors. This finding supports the existing literature41-48 by sug- posed to content intended for adults. Further research is war-
gesting that parent-child verbal interaction, communication ranted on the effects of various screens and different types of
with others, and social play are effective in promoting devel- content on children’s development.
opment for young children, besides being associated with lesser
screen time.
This study highlights several practical recommenda-
tions. First, emphasis should be placed on having opportu-
Conclusions
nities for face-to-face interaction with family members and In this study, TV/DVD screen time was associated with lower
other children rather than relying on screens from an early subsequent developmental performance in young children.
age to enhance children’s development. Second, pediatri- Screen media is prevalent in children’s environments, thus ne-
cians and health care professionals should help each family cessitating tailored media plans for each family for the better
develop a feasible media plan by making recommendations development of their child. In addition, parents experiencing
and introducing social support tools because parental atti- emotional distress require support in reducing their chil-
tudes toward media use significantly effect the home media dren’s exposure to screens from an early age.

ARTICLE INFORMATION
Accepted for Publication: July 24, 2023.
Published Online: September 18, 2023.
doi:10.1001/jamapediatrics.2023.3643
Open Access: This is an open access article
distributed under the terms of the CC-BY License.
© 2023 Yamamoto M et al. JAMA Pediatrics.
Author Affiliations: Department of Sustainable
Health Science, Center for Preventive Medical
Sciences, Chiba University, Chiba, Japan
(Yamamoto, Mori); Medical Support Center for
Japan Environment and Children’s Study, National
Center for Child Health and Development, Tokyo,
Japan (Mezawa); Department of Nutrition and
Metabolic Medicine, Center for Preventive Medical
Sciences, Chiba University, Chiba, Japan (Sakurai);
Department of Bioenvironmental Medicine,
Graduate School of Medicine, Chiba University,
Chiba, Japan (Mori).
Author Contributions: Dr Yamamoto had full
access to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Yamamoto, Mezawa.
Acquisition, analysis, or interpretation of data:
All authors.
Drafting of the manuscript: Yamamoto, Mezawa.
Critical review of the manuscript for important
intellectual content: All authors.
Statistical analysis: Yamamoto, Mezawa.
Administrative, technical, or material support:
Mezawa, Sakurai.
Study supervision: Mezawa, Mori.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by the
Japanese Ministry of the Environment.

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 Screen Time and Developmental Performance Among Children at 1-3 Years of Age
Role of the Funder/Sponsor: The funder had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Group Information: A complete list of the
members of the Japan Environment and Children’s
Study Group appears in Supplement 2.
Disclaimer: The findings and conclusions of this
article are solely the responsibility of the authors
and do not represent the official views of the
Japanese Ministry of the Environment.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We express our
gratitude to all Japan Environment and Children’s
Study participants, their families, and the
cooperating health care professionals.
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