Trends in Screen Time Use Among Children During the COVID-19 Pandemic, July 2019 Through August 2021

Original Investigation | Pediatrics
Trends in Screen Time Use Among Children During the COVID-19 Pandemic,
July 2019 Through August 2021
Monique M. Hedderson, PhD; Traci A. Bekelman, PhD, MPH; Mingyi Li, MHS; Emily A. Knapp, PhD; Meredith Palmore, MHS; Yanan Dong, MS; Amy J. Elliott, PhD;
Chloe Friedman, MPH; Maren Galarce, MPH; Diane Gilbert-Diamond, ScD; Deborah Glueck, PhD, MS; Christine W. Hockett, PhD; Maristella Lucchini, PhD;
Julia McDonald, MPH; Katherine Sauder, PhD; Yeyi Zhu, PhD; Margaret R. Karagas, PhD; Dana Dabelea, MD, PhD; Assiamira Ferrara, MD, PhD;
for the Environmental Influences on Child Health Outcomes Program
Abstract Key Points

Question Did children’s screen time
IMPORTANCE The COVID-19 pandemic led to widespread lockdowns and school closures that may
change from before to during the
have affected screen time among children. Although restrictions were strongest early in the
COVID-19 pandemic?
pandemic, it is unclear how screen time changed as the pandemic progressed.
Findings In this cohort study of 228
OBJECTIVE To evaluate change in children’s screen time from before the pandemic to during the children aged 4 to 12 years,
pandemic, from July 2019 through August 2021. prepandemic mean total screen time
increased 1.75 hours per day in the first
DESIGN, SETTING, AND PARTICIPANTS This is a longitudinal cohort study with repeated measures pandemic period and 1.11 hours per day
of screen time collected before the pandemic and during 2 pandemic periods. Children aged 4 to 12 in the second pandemic period.
years and their parent were enrolled in 3 pediatric cohorts across 3 states in the US participating in
Meaning These findings suggest that
the Environmental Influences of Child Health Outcomes (ECHO) Program. Data analysis was
screen time among children increased
performed from November 2021 to July 2022.
during the COVID-19 pandemic and
remained elevated after many public
EXPOSURES COVID-19 pandemic period: prepandemic (July 2019 to March 2020), pandemic
health precautions were lifted.
period 1 (December 2020 to April 2021), and pandemic period 2 (May 2021 to August 2021).
MAIN OUTCOMES AND MEASURES The primary outcomes were total, educational (not including + Supplemental content
remote school), and recreational screen time assessed via the ECHO Child Media Use questionnaire. Author affiliations and article information are
Linear mixed-effects models were used for screen time adjusted for child’s age, number of siblings, listed at the end of this article.
sex, race, ethnicity, and maternal education.
RESULTS The cohort included 228 children (prepandemic mean [SD] age, 7.0 [2.7] years; 100
female [43.9%]) with screen time measured during the prepandemic period and at least once during
the pandemic period. Prepandemic mean (SD) total screen time was 4.4 (3.9) hours per day and
increased 1.75 hours per day (95% CI, 1.18-2.31 hours per day) in the first pandemic period and 1.11
hours per day (95% CI, 0.49-1.72 hours per day) in the second pandemic period, in adjusted models.
Prepandemic mean (SD) recreational screen time was 4.0 (3.5) hours per day and increased 0.89
hours per day (95% CI, 0.39-1.39 hours per day) in the first pandemic period and 0.70 hours per day
(95% CI, 0.16-1.25 hours per day) in the second pandemic period. Prepandemic mean (SD)
educational screen time was 0.5 (1.2) hours per day (median [IQR], 0.0 [0.0-0.4] hours per day) and
increased 0.93 hours per day (95% CI, 0.67-1.19 hours per day) in the first pandemic period and 0.46
hours per day (95% CI, 0.18-0.74 hours per day) in the second pandemic period.
CONCLUSIONS AND RELEVANCE These findings suggest that screen time among children
increased during the COVID-19 pandemic and remained elevated even after many public health
(continued)
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2023;6(2):e2256157. doi:10.1001/jamanetworkopen.2022.56157 (Reprinted) February 15, 2023 1/12
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JAMA Network Open | Pediatrics Trends in Screen Time Use Among Children During the COVID-19 Pandemic, July 2019 Through August 2021
Abstract (continued)
precautions were lifted. The long-term association of increased screen time during the COVID-19
pandemic with children’s health needs to be determined.
JAMA Network Open. 2023;6(2):e2256157. doi:10.1001/jamanetworkopen.2022.56157
Introduction
Excessive screen time among children is associated with obesity-promoting health behaviors (ie,
increased sedentary behavior and decreased sleep) and adverse mental health (eg, depressive
symptoms, anxiety, internalizing and externalizing behaviors, and increased craving behaviors).1 The
COVID-19 pandemic initially led to widespread school closures, shelter-in-place laws, closure of
recreational facilities and sports, increases in parents working from home, and social distancing
recommendations, all of which may have impacted screen time among children. Increases in screen
time during the early phase of the pandemic may have been inevitable as many parents transitioned
to work from home and children attended online school. Screen time during the early pandemic
period may have been beneficial by allowing children to connect with friends and learn new things
outside of school during periods of strict social distancing and remote learning.2 However, it is
possible that once these behaviors are adopted, they will be hard to reverse, and whether the
pandemic resulted in long-term changes in children’s screen time remains unclear.
Most of the existing studies on screen time were cross-sectional and examined screen time
among different cohorts of people before and during the pandemic and were conducted outside the
US.3 The few prospective studies to date4-9 were restricted to the early stage of the pandemic.
Therefore, it remains unclear what happened to children’s screen time as the pandemic persisted and
what types of screen time were most affected.
The aim of this study was to test the hypothesis that screen time increased during the COVID-19
pandemic by examining changes in screen time from the prepandemic period (July 1, 2019, to March
1, 2020) to pandemic period 1 (December 1, 2020, to April 30, 2021) and pandemic period 2 (May 1 to
August 31, 2021). We leveraged longitudinal data collected via the Environmental Influences on Child
Health Outcomes (ECHO) Program at these 3 time points and in 3 states across the US with varying
degrees of pandemic restrictions. We explored sociodemographic correlates of screen time during
the study period.
Methods
Study Design and Population
This longitudinal cohort study followed a subset of caregiver-child dyads in ECHO. The ECHO
program is a collaboration between 69 established pediatric cohort studies collecting new data
under a common protocol since 2019 to explore the association of early life environmental exposures
with children’s health outcomes.10 Single and cohort-specific institutional review boards monitored
human subject activities and the centralized ECHO Data Analysis Center. All participants in this study
provided written informed consent. This manuscript follows the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.
Of the 16 ECHO cohorts with prepandemic measures of screen time data, 3 agreed to
participate and obtained funding for supplemental data collection during the pandemic (Figure 1 and
eTable 1 in Supplement 1). Parents of children aged 4 to 12 years old who had screen time measures
during the prepandemic period were contacted. Participants were recruited by phone, email, or text,
and assessments were performed in person at a research visit or remotely by the parent or caregiver
proxy report. Participants provided written informed consent and were included in the analytic
sample if at least 1 follow-up measure during either of the 2 pandemic periods was completed.

Measures
Children’s screen time measures were collected during the 8-month period before the COVID-19
pandemic (July 1, 2019, to March 1, 2020) as part of the ECHO protocol. Repeated measures of the
same behaviors were collected during 2 pandemic periods: December 1, 2020, to April 30, 2021, and
May 1 to August 31, 2021, from the same dyads (Figure 2).
Screen time was assessed with the ECHO Child Media Use questionnaire, which was modified
from the Common Sense Census.11 Type and frequency of TV, tablet, computer, and smartphone use
was reported separately for weekdays and weekends by the parent or caregiver. We calculated a
weighted average of weekday and weekend duration for each screen time activity and created 3
categories of screen time activity: total, educational, and recreational. Total screen time comprised
time spent on 10 specific activities: watching TV shows, DVDs, or videos; playing video games;
playing games on an education game device; playing computer games; playing games or using apps
on a smartphone or tablet; video chatting; doing homework on a computer or tablet; browsing
websites; doing anything else on a computer; and doing anything else on a smartphone or tablet.
Playing games on an educational game device and doing homework on a computer or tablet were
included in educational screen time; however, because this survey was developed before the
pandemic, screen time for remote schooling was not included. All other activities were considered
Figure 1. Flowchart of Inclusion Criteria for Analytic Cohort in the Environmental Influences of Child Health
Outcomes (ECHO) Program
518 Participants in 16 ECHO cohorts that assessed

screen time among children aged 4-12 y in the
prepandemic period, July 2019 to March 2020
372 Participants in 3 cohorts that agreed to participate

and obtained funding for supplemental data
collection during the pandemic
307 Participants in 3 cohorts provided informed

consent for supplemental data collection
79 Participants excluded who did

not respond to pandemic screen
time survey
228 Participants in 3 cohorts constituted

final analytic sample
Figure 2. Date of Screen Time Outcome Assessment
50
Prepandemic Pandemic 1 Pandemic 2
40
Children, No.
30
20
10
0
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
2019 2020 2021

Date of outcome assessment
Graph shows number of children assessed for screen time each month between July 2019 and August 2021.

recreational screen time. The child’s social media access was assessed with the following question
answered by the parent or caregiver: “Does the child have one or more of his/her own social media
accounts (for example, Facebook, Twitter, Snapchat, Instagram)?” Measures of activities performed
together with a caregiver were assessed and dichotomized as some of the time or most of the time
and never or hardly ever.
We assessed sociodemographic characteristics via self-report. Categorical sociodemographic
variables include child’s sex assigned at birth (male or female), child’s age and race and ethnicity
(Hispanic all races, non-Hispanic Black, non-Hispanic other [ie, Asian, American Indian or Alaska
Native, and multiracial], and non-Hispanic White race), highest level of maternal education (high
school or general education development or less, some college, bachelor’s degree, or master’s
degree or higher), and annual household income (<$30 000, $30 000-$49 999, $50 000-$74 999,
$75 000-$99 999, or ⱖ$100 000). We also assessed whether COVID-19 affected the mother’s
employment and work modalities. Race and ethnicity were assessed in this study as imperfect
measures of other social determinants of health and should not be interpreted as biological variables.
Statistical Analysis
Data analysis was performed from November 2021 to July 2022. We summarized frequencies and
percentages of sociodemographic characteristics of participants and provided descriptive summaries
(mean and SD) of screen time measures for the 3 data collection periods. We performed linear
mixed-effects models (R package lme4) for continuous outcomes, including weighted average
screen time duration, weighted average educational screen time duration, and weighted average
recreational screen time duration.12 All models included time period of data collection as the
exposure of interest and were adjusted for child’s age, sex, race, ethnicity, number of siblings, and
maternal education. Random intercepts for cohorts and participants were specified in models to
account for within-cohort correlation and repeated outcome measures from the same child. A
secondary analysis was performed with the outcome of change in screen time between the first or
second pandemic time period and the prepandemic period, adjusting for the aforementioned
covariates and the child’s baseline (prepandemic) measure of screen time. All data analyses were
performed in R statistical software version 4.1.0 (R Project for Statistical Computing). Statistical
significance was defined as α = .05.
Results
Of 317 participants who consented to supplemental data collection, there were 228 children from 3
cohorts (Colorado, South Dakota, and California) included in the analysis (overall response rate,
71.9%). See eTable 2 in Supplement 1 for the comparison of demographic characteristics of
responders and nonresponders. Children were a mean (SD) of 7.0 (2.7) years old at the time of their
prepandemic screen time measure, and 100 (43.9%) were female. Sixty-five children (28.5%) were
Hispanic, 18 (7.9%) were non-Hispanic Black, 37 (16.2%) were non-Hispanic other, and 108 (47.4%)
were non-Hispanic White. One hundred fifty-seven (68.9%) of these children’s mothers had a
bachelor’s degree or higher (Table 1). Compared with the Colorado and South Dakota cohorts,
children from the California cohort were younger, more likely to be Hispanic, and to have lower levels
of maternal education (eTable 3 in Supplement 1).
Table 2 shows the means and SDs of the screen time measures at each of the 3 data collection
periods. Overall, the mean total screen time per day, mean recreational screen time per day, and
mean education screen time per day increased from the prepandemic period to pandemic period 1
and remained elevated at pandemic period 2 (Table 2). During the prepandemic period, 10 children
(4.4%) reported having at least 1 social media account, whereas 20 (9.5%) and 20 (11.2%) reported
having accounts at pandemic periods 1 and 2, respectively. Thirty-three children (14.5%) watched
TV with caregivers at the prepandemic period, 32 children (15.2%) did so during pandemic period 1,
and 35 children (19.6%) did at pandemic period 2. One hundred eighty-three children (80.3%) played

computer games with a caregiver at the prepandemic period and this increased to 85.3% (180
children) in pandemic period 1 and 84.4% (151 children) in pandemic period 2. One hundred seventy-
five children (76.8%) played educational games with a caregiver in the prepandemic period, and that
increased to 83.4% (176 children) in pandemic period 1 and 83.2% (149 children) in pandemic period
2. However, video games were less likely to be played with a caregiver during the pandemic (72.4%
Table 1. Characteristics of Children Aged 4-12 Years Who Participated in the Screen Time Study
Within the Environmental Influences of Child Health Outcomes Program
Characteristic Children, No. (%) (N = 228)a

Sex
Female 100 (43.9)
Male 128 (56.1)
Baseline child age, mean (SD), y 7.0 (2.7)
Baseline age group, y
4 to <5 115 (50.4)
5 to <9 50 (21.9)
≥9 63 (27.6)
Race and ethnicity
Hispanic all races 65 (28.5)
Non-Hispanic
Black 18 (7.9)
White 108 (47.4)
Otherb 37 (16.2)
State of study cohorts
California 115 (50.4)
Colorado 74 (32.5)
South Dakota 39 (17.1)
Maternal educationc
Some college, no degree or lower 71 (31.1)
Bachelor’s degree 80 (35.1)
Master’s degree or higher 77 (33.8)
Annual household income, $
<30 000 11 (4.8)
30 000-49 999 24 (10.5)
50 000-74 999 32 (14.0)
75 000-99 999 32 (14.0)
≥100 000 124 (54.4)
Missing 5 (2.2)
No. of siblings in household
a
Children were included in this sample (n = 228) if
0 15 (6.6)
they had at least one of the same screen time
1 101 (44.3) outcomes for both prepandemic (July 1, 2019, to
2 65 (28.5) March 15, 2020) and 1 pandemic period (December
3 29 (12.7) 1, 2020, to April 30, 2021, or May 1 to August 31,
≥4 13 (5.7) 2021). There were 211 children (92.5%) with a
measure during the first pandemic time point and
Missing 5 (2.2)
179 (78.5%) with a measure in the second pandemic
How COVID-19 affected maternal job (% yes) time period. A total of 162 children (71.1%) had
Moved to working remotely or from home 89 (39.0) measures at both pandemic time points.
Missing <5d b
Non-Hispanic other includes 13 Asian, 7 American
Did not have a paying job before COVID-19 23 (10.1) Indian or Alaska Native, and 17 multiple race children.
Missing <5d c
Some college, no degree, or lower includes associate
Lost the job permanently or temporarily or reduced work hours 56 (24.6) degree, trade school, high school degree, general
education development or equivalent, and less than
Missing <5d
high school diploma. Master’s degree or higher also
Got a new job or increased work hours 29 (12.7)
includes (professional) doctoral degree.
Missing <5d d
Percentages were not computed for cell sizes of <5.

Table 2. Change in Screen Time Between Prepandemic and Pandemic Periods Among Children Aged 4-12 Years in the Environmental Influences of Child Health
Outcomes Program
Prepandemic, Pandemic 1, Pandemic 2
July 1, 2019-March 15, 2020 December 1, 2020-April 30, 2021 May 1-August 31, 2021
Outcomes (n = 228) (n = 211) (n = 179)
Screen time, h/d
Total durationa
Mean (SD) 4.4 (3.9) 6.6 (4.5) 6.1 (4.5)
Median (IQR) 3.2 (1.9-5.3) 5.4 (3.5-8.7) 5.0 (3.0-7.5)
Weekday duration
Mean (SD) 4.0 (4.2) 6.5 (4.7) 6.0 (4.7)
Median (IQR) 5.0 (3.0-7.5) 5.1 (3.0-8.5) 5.0 (2.6-7.6)
Weekend duration
Mean (SD) 5.1 (3.7) 6.5 (4.3) 6.0 (4.2)
Median (IQR) 4.0 (2.8-6.5) 5.6 (3.6-8.2) 5.6 (3.6-8.2)
Educational durationb
Mean (SD) 0.5 (1.2) 1.5 (2.0) 1.0 (1.5)
Median (IQR) 0.0 (0.0-0.4) 0.9 (0.1-2.1) 0.9 (0.1-2.1)
Recreational durationc
Mean (SD) 4.0 (3.5) 5.3 (3.9) 5.2 (4.2)
Median (IQR) 2.9 (1.6-5.1) 4.1 (2.8-6.5) 4.1 (2.6-6.1)
Watching TV
Mean (SD) 2.1 (1.9) 2.4 (1.7) 2.4 (2.3)
Median (IQR) 1.6 (1.0-2.7) 2.0 (1.2-3.0) 2.0 (1.1-2.8)
Playing gamesd
Mean (SD) 1.3 (2.1) 2.0 (2.0) 2.0 (2.5)
Median (IQR) 0.6 (0.1-1.5) 1.3 (0.5-2.9) 1.3 (0.6-2.4)
Video chatting
Mean (SD) 0.1 (0.3) 0.2 (0.5) 0.2 (0.7)
Median (IQR) 0.0 (0.0-0.0) 0.0 (0.0-0.0) 0.0 (0.0-0.2)
Browsing websitee
Mean (SD) 0.1 (0.3) 0.1 (0.4) 0.2 (1.0)
Median (IQR) 0.0 (0.0-0.0) 0.0 (0.0-0.0) 0.0 (0.0-0.0)
Others
Mean (SD) 0.4 (1.1) 0.6 (1.1) 0.9 (2.4)
Median (IQR) 0.0 (0.0-0.4) 0.1 (0.0-0.7) 0.1 (0.0-0.9)
Social media account, No. (%) of children
Yes 10 (4.4) 20 (9.5) 20 (11.2)
No 214 (93.9) 188 (89.1) 157 (87.7)
Missing <5f <5f <5f
Watch TV with caregivers, No. (%) of children
Some of the time or most of the time 33 (14.5) 32 (15.2) 35 (19.6)
Never or hardly ever 195 (85.5) 177 (83.9) 143 (79.9)
Missing 0 <5f <5f
Play video game with caregivers, No. (%) of children
Missing 7 (3.1) 5 (2.4) <5f
Play computer game with caregivers, No. (%) of children
Missing 8 (3.5) 5 (2.4) 8 (4.5)
Play games on an education game device with caregivers,
No. (%) of children
Missing 11 (4.8) 8 (3.8) 9 (5.0)
(continued)

Table 2. Change in Screen Time Between Prepandemic and Pandemic Periods Among Children Aged 4-12 Years in the Environmental Influences of Child Health
Outcomes Program (continued)
Prepandemic, Pandemic 1, Pandemic 2
July 1, 2019-March 15, 2020 December 1, 2020-April 30, 2021 May 1-August 31, 2021
Outcomes (n = 228) (n = 211) (n = 179)
Play games or use apps on a smartphone or tablet with caregivers,
No. (%) of children
Missing <5f 7 (3.3) 6 (3.4)
Video-chat with caregivers, No. (%) of children
Missing 8 (3.5) 7 (3.3) 6 (3.4)
a d
Includes playing games on an education game device (eg, Leapster/LeapPad, LeapFrog Includes playing video games, playing computer games, and playing games or using
Epic, Playtime Pad, or V-Tech device, V-Smile, Mobigo, or Innotab) and doing apps on a smartphone or tablet. This is a weighted average of weekday and weekend
homework on a computer or tablet. This is a weighted average of weekday and duration.
weekend duration. e
Includes doing anything else on a computer (eg, looking at pictures, looking up things,
b
Includes watching TV shows, DVDs, or videos, playing video games, playing computer social networking, emailing, shopping, and text messaging) and doing anything else
games, playing games or using apps on a smartphone or tablet, video chatting, on a smartphone or tablet (eg, taking or looking at pictures, looking up things, social
browsing websites, doing anything else on a computer, and doing anything else on a networking, emailing, text messaging, or using other types of apps not already
smartphone or tablet. This is a weighted average of weekday and weekend duration. covered). This is a weighted average of weekday and weekend duration.
c f
Includes watching TV shows, DVDs, or videos (include time spent watching on a TV set, Percentages were not calculated for cell sizes <5.
computer, smartphone, and tablet; this includes watching shows that may have been
previously recorded). This is a weighted average of weekday and weekend duration.
[165 children] prepandemic vs 129 children [61.1%] in pandemic period 1 and 64.2% [115 children] in
pandemic period 2). In the Colorado and South Dakota cohorts, children’s reported total screen time
were the longest prepandemic durations (5.2 hours and 4.9 hours, respectively), whereas
prepandemic screen time for children in the California cohort was only 3.6 hours (eTable 4 in
Supplement 1). Adjusted analyses found increases in total screen time, educational screen time, and
recreational screen time from prepandemic to the pandemic data collection time periods (Table 3).
Total Screen Time

Prepandemic mean (SD) total screen time was 4.4 (3.9) hours per day. Children had an increase in
mean total screen time of 1.75 hours per day (95% CI, 1.18-2.31 hours per day) during the first
pandemic period and 1.11 hours per day (95% CI, 0.49-1.72 hours per day) during the second
pandemic period, compared with the prepandemic period. Throughout the study period, children
who reported being members of self-identified racial or ethnic minoritized groups had more total
screen time compared with non-Hispanic White children. Non-Hispanic Black children had 5.43 hours
per day more (95% CI, 3.87-6.98 hours per day), Hispanic children had 2.61 hours per day more (95%
CI, 1.56-3.66 hours per day), and non-Hispanic other race children had 1.83 hours per day more (95%
CI, 0.67-2.98 hours per day) (Table 3).
Educational Screen Time

Prepandemic mean (SD) educational screen time was 0.5 (1.2) hours per day (median [IQR], 0.0 [0.0-
0.4] hours per day). Educational screen time increased 0.93 hours per day (95% CI, 0.67-1.19 hours
per day) in the first pandemic period and 0.46 hours per day (95% CI, 0.18-0.74 hours per day) in the
second pandemic period. Educational screen time was also longer among all racial or ethnic
minoritized children compared with non-Hispanic White children: 0.99 hours per day (95% CI, 0.44-
1.54 hours per day) longer among Black children, 0.62 hours per day (95% CI, 0.25-0.98 hours per
day) longer among Hispanic all races children, and 0.95 hours per day (95% CI, 0.55-1.35 hours per
day) longer among other racial and ethnic groups (Table 3).

Recreational Screen Time

Prepandemic mean (SD) recreational screen time was 4.0 (3.5) hours per day. Recreational screen
time increased 0.89 hours per day (95% CI, 0.39 to 1.39 hours per day) at the first pandemic period
and 0.70 hours per day (95% CI, 0.16 to 1.25 hours per day) at the second pandemic period,
compared with the prepandemic period. Racial and ethnic minoritized children also had longer
durations of recreation screen time compared with non-Hispanic White children: 4.73 hours per day
(95% CI, 3.28 to 6.19 hours per day) longer among Black children and 2.21 hours per day (95% CI,
1.23 to 3.20 hours per day) longer among Hispanic all races children. Children of women with a
master’s degree or higher had 1.85 hours per day (95% CI, −2.88 to 0.82 hours per day) less total
screen time, 0.49 hours per day (95% CI, −0.85 to −0.14 hours per day) less educational screen time,
and 1.27 hours per day (95% CI, −2.21 to −0.33 hours per day) less recreational screen time compared
with children of women with some college, no degree, or lower (Table 3).
In analyses stratified by cohort, we found the largest increase in total screen time occurred in
the Colorado cohort and the smallest increase occurred in the California cohort (eTable 5 in
Supplement 1). Higher levels of prepandemic screen time were negatively associated with change in
total, educational, and recreational screen time between baseline and both pandemic time points
(eTables 6 and 7 in Supplement 1). For example, the change in total screen time was −0.51 hours
lower per additional hour of screen time prepandemic (95% CI, −0.65 to −0.37 hours). Older children
had larger changes in total and recreational screen time at both pandemic time points. Maternal
education was not associated with changes to screen time in the first pandemic period; however, in
the second pandemic period, children of mothers who had a bachelor’s degree had higher screen
time increases than children of mothers who did not have a college degree.
Discussion
This longitudinal cohort study among children aged 4 to 12 years across the US found increases in
total screen time, as well as in recreational and educational screen time, from before to during the
COVID-19 pandemic that persisted as the pandemic progressed. The amount of screen time that was
engaged in together with a caregiver increased during the pandemic for TV watching, educational,
and computer games but decreased for video games. There was also an increase in the percentage of
Table 3. Estimated Associations Between Total Screen Time, Educational Screen Time, and Recreational Screen
Time and Pandemic Periods
Screen time, β (95% CI), h/da

Variable Total Educational Recreational
No. of observations 618 618 618
Time pointb
Pandemic 1 1.75 (1.18 to 2.31) 0.93 (0.67 to 1.19) 0.89 (0.39 to 1.39)
Pandemic 2 1.11 (0.49 to 1.72) 0.46 (0.18 to 0.74) 0.70 (0.16 to 1.25)
Age, y 0.51 (0.36 to 0.67) 0.09 (0.04 to 0.15) 0.48 (0.33 to 0.62)
No. of siblings −0.35 (−1.16 to 0.43) −0.20 (−0.47 to 0.07) −0.25 (−0.02 to 0.47) a
Beta coefficients were calculated from linear mixed-
Male sex 0.01 (−0.36 to 0.39) 0.05 (−0.08 to 0.18) −0.01 (−0.37 to 0.34) effects models that include cohort and child as
Race and ethnicity random intercepts to adjust for the within cohort and
within child correlations. Each screen time outcome
Hispanic all races 2.61 (1.56 to 3.66) 0.62 (0.25 to 0.98) 2.21 (1.23 to 3.20)
represents the weighted average of weekday and
Non-Hispanic
weekend parent-reported screen time. Maximum
Black 5.43 (3.87 to 6.98) 0.99 (0.44 to 1.54) 4.73 (3.28 to 6.19) likelihood method was used to fit model. The analysis
White 1 [Reference] 1 [Reference] 1 [Reference] was conducted using the R package lme4.
Otherc 1.83 (0.67 to 2.98) 0.95 (0.55 to 1.35) 1.03 (−0.05 to 2.12) b
The reference group is the prepandemic period, July
Maternal education 1, 2019, to March 15, 2020. Pandemic data collection
period 1 is December 1, 2020, to April 30, 2021, and
Some college, no degree or lower 1 [Reference] 1 [Reference] 1 [Reference]
pandemic period 2 is May 1 to August 31, 2021.
Bachelor’s degree −1.48 (−2.48 to −0.48) −0.34 (−0.69 to 0.01) −1.27 (−2.21 to −0.33)
c
Other includes Asian, American Indian or Alaska
Master’s degree or higher −1.85 (−2.88 to −0.82) −0.49 (−0.85 to −0.14) −1.46 (−2.43 to −0.50)
Native, and multiple races.

children with a social media account. Older age of the child prepandemic was associated with a
greater increase in screen time during the pandemic.
Our findings of an increase in screen time among children during the COVID-19 pandemic are
consistent with prior studies largely conducted outside the US. A recent systematic review2 found
increases in screen time from before to during the initial COVID-19 lockdown among children and
adolescents; however, the studies were largely cross-sectional. Only 8 studies had prospective data
collection, studies to date lacked information on types of screen time,2 and none assessed whether
the observed increases persisted as pandemic progressed. Of the 2 studies5,13 conducted in the US,
one had only qualitative data and did not assess the size of possible increases13 and the other was
conducted among a population of children5 with autism spectrum disorder, which might not be
generalizable. We found that screen time increases persisted more than 1 year into the pandemic
when many restrictions were lifted; this suggests there may need to be more clear clinical guidelines
and policies to help parents and their children reduce screen time in the COVID-19 era. For example,
pediatricians may need to talk to parents about the importance of implementing the American
Academy of Pediatrics Family Media Plan tool,14 which helps families set media use priorities and
limits that may have been relaxed during the early stages of the COVID-19 pandemic. We found that
throughout the study period, screen time levels were higher among children of Black race or Hispanic
ethnicity, older children, and children whose mothers had less than a college education. A
prepandemic study15 of screen time usage among approximately 600 young children found that
screen time was higher among racial and ethnic minoritized populations and among children of
parents with lower socioeconomic status. It has been hypothesized that these disparities may be
associated with lack of access to structured activities for children outside of school.16-18 The early
COVID-19 pandemic led to unprecedented increases in unstructured time for all children and
exacerbated social and economic disparities,19,20 and our results suggest that children from
minoritized groups experienced larger increases in screen time. The observed racial, ethnic, and
socioeconomic disparities in screen time are likely associated with structural barriers or lack of
opportunities and poverty-related factors that may have increased reliance on screen time. The
observed disparities in screen time highlight the need for policy level interventions to improve access
to essential resources and opportunities across racial and ethnic groups.
We lacked information on the effects of screen time on health outcomes such as obesity and
mental health in this study; however, the Adolescent Brain Cognitive Development Study21 of 12 000
children found each additional hour of total screen time per day was prospectively associated with a
0.22 higher body mass index percentile (95% CI, 0.10-0.34 percentile) at 1-year follow-up, after
adjusting for covariates. In addition, a recent cross-sectional study22 found that more physical
activity and less screen time were associated with better mental health for children. This suggests a
potential strategy for mitigating the adverse effects of the increased screen time during the
pandemic. In addition, we found that 11.2% of children had a social media account in the latter
pandemic period compared with 4.4% before the pandemic. This is concerning, because all children
in our study were younger than 13 years, which is the minimum age required for social media
accounts (eg, Instagram and TikTok). Recent studies show that social media may be harmful,
especially for girls, and, in a nationally representative study,23 the use of social media was associated
with clinically significant levels of depressive symptoms and self-harm, whereas other type of media
use showed no associations. It will be important to understand the long-term health impacts of the
increased screen time and whether they vary by type of screen time.
Strengths and Limitations

This study had several strengths. The ECHO Program was uniquely able to prospectively measure
changes in screen time from the prepandemic period to during the pandemic using a common
protocol for assessing children’s media use across time and cohorts. The study included sites from 3
different US states with varying degrees of COVID-19 precautions; thus, our sample is geographically
diverse. Limitations of this study include that the survey did not assess whether children were

attending remote schooling at the time the survey was conducted and whether screen time was used
for remote schooling because that was a rare occurrence before the pandemic. This may have
impacted how parents reported educational screen time during the pandemic period. In addition,
parent-reported screen time, which correlates with objectively measured media use, often
overestimates or underestimates true usage; thus, parents may have inaccurately reported their
child’s media use.24 By including multiple cohorts across the US rather than a single cohort, we were
better able to examine screen time across diverse geographic regions, sociodemographic subgroups,
and child life stages. However, we acknowledge that this substudy nested in ECHO only included 3
of 69 ECHO cohorts. Therefore, these findings may not be representative of the entire US
population. In addition, the 3 data collection time periods occurred at different times during the year,
and changes in routines due to school calendars may have impacted screen time use. We were also
underpowered to examine specific types of screen time and how associations varied by race and
ethnicity and by geographic region of the various study sites.
Conclusions
In summary, the findings of this cohort study suggest that in the US, screen time increased 1.75 hours
per day during the early pandemic and remained 1.11 hours per day higher than the prepandemic
period as the pandemic progressed. The increased screen time was largely associated with increases
in recreational screen time, and for most types of screen time, the percentage of time that included
engagement with a caretaker increased during the pandemic. Families may need support to
re-establish healthy screen time usage and healthy behaviors as the pandemic continues.
Pediatricians may need to provide more guidance and strategies regarding healthy screen time usage
for children’s health and well-being. Future studies are needed to determine the association of
increased screen time with longer term obesity and mental health outcomes in children.
ARTICLE INFORMATION
Accepted for Publication: December 19, 2022.
Published: February 15, 2023. doi:10.1001/jamanetworkopen.2022.56157
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Hedderson
MM et al. JAMA Network Open.
Corresponding Author: Monique M. Hedderson, PhD, Kaiser Permanente Northern California Division of
Research, 2000 Broadway, Oakland, CA 94612-2304 (monique.m.hedderson@kp.org).
Author Affiliations: Kaiser Permanente Northern California Division of Research, Oakland (Hedderson, Galarce,
McDonald, Zhu, Ferrara); Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of
Colorado Anschutz Medical Campus, Aurora (Bekelman, Friedman, Sauder, Dabelea); Department of
Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Li, Knapp, Palmore, Dong);
Avera Research Institute, Sioux Falls, South Dakota (Elliott, Hockett); Department of Pediatrics, University of South
Dakota School of Medicine, Sioux Falls (Elliott, Hockett); Department of Epidemiology, Geisel School of Medicine
at Dartmouth, Hanover, New Hampshire (Gilbert-Diamond, Karagas); Department of Medicine, Geisel School of
Medicine at Dartmouth, Hanover, New Hampshire (Gilbert-Diamond); Department of Pediatrics, Geisel School of
Medicine at Dartmouth, Hanover, New Hampshire (Gilbert-Diamond); Department of Pediatrics, University of
Colorado School of Medicine, Aurora (Glueck); Department of Psychiatry, Columbia University Irving Medical
Center, New York, New York (Lucchini).
Author Contributions: Dr Knapp and Ms Palmore had full access to all of the data in the study and take
responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Hedderson, Bekelman, Knapp, Galarce, Gilbert-Diamond, Glueck, Lucchini, Sauder,
Dabelea, Ferrara.
Acquisition, analysis, or interpretation of data: Hedderson, Li, Knapp, Palmore, Dong, Elliott, Friedman, Galarce,
Gilbert-Diamond, Hockett, McDonald, Zhu, Karagas, Dabelea, Ferrara.
Drafting of the manuscript: Hedderson, Bekelman, Li, Knapp, Palmore, Dong, Galarce, McDonald.

Critical revision of the manuscript for important intellectual content: Hedderson, Knapp, Palmore, Elliott, Friedman,
Gilbert-Diamond, Glueck, Hockett, Lucchini, Sauder, Zhu, Karagas, Dabelea, Ferrara.
Statistical analysis: Li, Knapp, Palmore, Dong, Lucchini.
Obtained funding: Hedderson, Bekelman, Elliott, Karagas, Dabelea, Ferrara.
Administrative, technical, or material support: Hedderson, Bekelman, Galarce, Hockett, McDonald, Sauder.
Supervision: Hedderson, Bekelman, Knapp, Hockett, McDonald, Dabelea, Ferrara.
Conflict of Interest Disclosures: None reported.
Funding/Support: Research reported in this publication was supported by the Environmental Influences on Child
Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health, under award numbers
U2COD023375 (Coordinating Center), U24OD023382 (Data Analysis Center and support to Ms Li, Dr Knapp, and
Ms Dong), U24OD023319 (PRO Core), UH3OD023248 (to Dr Bekelman, Ms Friedman, Dr Sauder, Dr Glueck, and
Dr Dabelea), UG3/UH3 OD023279 (to Drs Elliott, Hockett, and Lucchini), UG3/UH3 OD023289 (to Drs Hedderson,
Ms Galarce, Ms McDonald, Dr Zhu, and Dr Ferrara), and UG3/UH3 OD023275 (to Drs Karagas and
Gilbert-Diamond).
Role of the Funder/Sponsor: The funders 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 collaborators for the Environmental Influences on Child Health
Outcomes Program appears in Supplement 2.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Institutes of Health.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We thank our ECHO colleagues; the medical, nursing, and program staff; and the
children and families participating in the ECHO cohorts.
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SUPPLEMENT 1.
eTable 1. Description of Cohorts Included in Analytic Sample
eTable 2. Comparison of Participants Who Completed the Survey Versus Those Consented but Who Did Not
Complete the Survey (n=317)
eTable 3. Characteristics of Study Sample, Stratified by Cohort
eTable 4. Prepandemic Screen Time by Cohort
eTable 5. Estimated Associations Between Total Screen Time and Pandemic Periods, Stratified by Cohort
eTable 6. Estimated Change in Total Screen Time, Educational Screen Time, and Recreational Screen Time
Between the First Pandemic and the Prepandemic Time Period
eTable 7. Estimated Change in Total Screen Time, Educational Screen Time, and Recreational Screen Time Between
the Second Pandemic and the Prepandemic Time Period
SUPPLEMENT 2.
Environmental Influences on Child Health Outcomes Program Group Members
SUPPLEMENT 3.
Data Sharing Statement

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Original Investigation | Pediatrics

Abstract Key Points

sex, race, ethnicity, and maternal education.

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JAMA Network Open. 2023;6(2):e2256157. doi:10.1001/jamanetworkopen.2022.56157

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518 Participants in 16 ECHO cohorts that assessed

372 Participants in 3 cohorts that agreed to participate

307 Participants in 3 cohorts provided informed

79 Participants excluded who did

228 Participants in 3 cohorts constituted

Figure 2. Date of Screen Time Outcome Assessment

Prepandemic Pandemic 1 Pandemic 2

2019 2020 2021

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Characteristic Children, No. (%) (N = 228)a

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Total Screen Time

Educational Screen Time

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Recreational Screen Time

Screen time, β (95% CI), h/da

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Strengths and Limitations

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