AMSA Singapore Policy Document - Excessive Screen Use Among Young Children in Singapore

Asian Medical Students’ Association (AMSA) Singapore Project Heads Up Policy Document Excessive Screen Use Among Young Children in Singapore Contributors • Joel Hong Jun Han (M2, LKC) • Chia Hui Yi (M3, YLL) • Chua Zheng Hong (M2, LKC) • Prabanjini Rajkumar (M2, LKC) • Ri-Ann Tan (M2, LKC) Advisor • Adjunct Assistant Professor Mae Wong, Department of Child Development, KK Women’s and Children’s Hospital Adopted on 21st December 2021 [proj.headsup@gmail.com, vp.ifmsa@amsasingapore.org]

Policy Statement Introduction According to the World Health Organisation (WHO), (sedentary) screen time is defined as “time spent passively watching screen-based entertainment (TV, computer, mobile devices)” and excludes “active screen-based games where physical activity or movement is required” [1]. Excessive screen use among young children below 5 years of age has been associated with impaired cognitive and social development [2]. Even indirect exposure to screen use such as background television has been shown to delay language acquisition among children [3].

While public health campaigns such as the National Physical Activity Guidelines for Children and Youth by the Health Promotion Board (HPB) [4] include recommendations for screen use, more emphasis could be placed on highlighting the detrimental effects of excessive screen use among young children.

Our Position In today’s technologically-dependent world, the Project recognises the prevalence and importance of technology in everyday life. The COVID-19 pandemic has accelerated the pervasiveness of technology, making excessive screen use among children a growing problem that deserves to be discussed. In summary, the Project calls upon healthcare and nonhealthcare organisations and institutions to promote the adoption of screen use guidelines in Singapore by empowering parents, caregivers and other stakeholders to effectively manage their children’s screen usage.

Call to Action Government Agencies (such as, but not limited to, HPB, MOH, ECDA, MSF and MOE) • Develop and improve guidelines regarding screen use among children (e.g. specifying recommended screen time for toddlers under the age of 2 years) • Increase emphasis on the detrimental effects of excessive screen use, including but not limited to how it causes myopia, among young children in public health campaigns • Increase public awareness of the presence of recommended screen use guidelines for young children • Promote the adoption of screen use guidelines by nurseries, preschools, parents and caregivers • Promote the public awareness and adoption of healthier screen use habits and practices for young children • Include screen use in preschools as part of the Healthy Pre-Schools (HPS) Accreditation Framework • Formulate inclusive policies that recognise the difficulties faced by parents and caregivers within certain vulnerable populations and provide the additional assistance required to reduce their children’s screen use Healthcare Professionals • Educate parents and caregivers on the detrimental effects of excessive screen use • Educate parents and caregivers on healthier screen use habits and practices for young children • Educate parents and caregivers on screen use guidelines and empower them to adopt these guidelines • Include discussions about screen use in “Well Child” check-ups

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Educate medical students and other healthcare students regarding screen use guidelines among young children as part of paediatrics modules and postings Advocate for the recognition of excessive screen use as a public health issue of concern and support relevant policies

Educational Institutions (such as preschools and schools) • Reduce sedentary screen time among children as part of the curriculum or any extracurricular activities • Encourage positive screen use habits among children • Educate parents and caregivers on the detrimental effects of excessive screen use • Educate parents and caregivers on healthier screen use habits and practices for young children • Educate parents and caregivers on screen use guidelines and empower them to adopt these guidelines • Foster close relationships with parents to help reduce screen usage among young children both inside and outside the classroom

Position Paper Background Information: Current guidelines by WHO on the recommended screen time for young children of various age groups are listed below in Table 1.

Age group

Recommended sedentary screen time per day

Less than 1 year old (infants)

0 minutes

1 year old

0 minutes

2 - 4 years old

No more than 60 minutes

Table 1: Recommended sedentary screen time for children of various age groups by WHO [1] In HPB’s “National Physical Activity Guidelines for Children and Youth”, screen use guidelines state that children under 7 years of age should not be exposed to more than 2 hours of screen use on a daily basis [4]. However, local studies have found that the prevalence of screen use among children under 2 years of age amounting to more than 2 hours a day was 16.3%, with 88.2% of children aged 18-24 months engaging in daily screen use [5]. In 2 year-old children, average daily screen use was found to be 2.4 ± 2.2 (mean ± SD) hours/day, including 1.6 ± 1.6 and 0.7 ± 1.0 hours per day for television and hand-held devices respectively [6]. Another local study in children with neurodevelopmental disorders showed that average daily screen use increased to 3.98 hours among children aged 2-5 years old [7]. As such, the Project aims to support and expand existing measures targeted towards reducing screen use among young children in Singapore, given the plethora of detrimental effects excessive screen use can cause. This position paper will also highlight social groups in which children have been found to be more prone to excessive screen use.

Discussion: Negative effects of excessive screen use The detrimental effects of excessive screen use among children have been heavily researched.

These include, but are not limited to, shorter sleep durations (with the association being stronger among children aged 6 months and below as compared to those aged 7 – 24 months) [8], increased adiposity [9], and reduced practice of healthy behaviours when these children grow older [10]. Excessive screen use has also been associated with depression and anxiety [11], and was found to be a risk factor for cardiovascular diseases, low high-density lipoproteins (HDL) cholesterol, poor stress regulation (higher sympathetic arousal and cortisol dysregulation), and increased insulin resistance [12]. Other studies have also associated earlier childhood exposure to screen use with internet addiction [13], a problem which is on the rise especially during the COVID-19 pandemic [14]. With the various negative physical, social, and neurodevelopmental effects [15] excessive screen use has on young children, it is imperative that guidelines on screen use among young children are adopted and advocated for.

Possible improvements in existing policies aimed at reducing screen time among young children Public health policies targeting young children in Singapore have historically had a focus on their physical health. This can be seen from initiatives such as the “Teeth Brushing Exercise “ in 1969 to improve the dental health of young children, as well as the “School Milk Scheme” introduced in 1974 to improve the nutritional intake of underweight children. However, health as we know it today encompasses not only one’s physical health, but includes social and mental aspects (among many others). Considering how excessive screen use among young children can affect children negatively in several ways as mentioned above, public health policies targeting young children should expand beyond promoting physical health, targeting issues such as the growing prevalence of excessive screen use among young children in Singapore.

In the Health Promotion Board’s “National Physical Activity Guidelines for Children and Youth”, screen use recommendations for children under 7 years of age do exist. However, these guidelines lack segregation of specific age groups under 7 years of age. Expanding screen use guidelines by specifying different recommendations for narrower age groups [16], instead of an overarching guideline for those under 7 years of age, will help increase awareness on screen use. Besides encouraging physical exercise, HPB’s guidelines could also include practical recommendations to reduce screen use among children (e.g. not eating meals while watching television), as well as encouraging healthy habits related to screen use (e.g. discouraging screen use 1 hour before bedtime).

In addition, seeing as how there are guidelines on suggested screen use limits for children as young as under 1 year old, the Project believes that healthy habits regarding screen use should be introduced as early as possible. Even before children start their preschool years, healthcare institutions and professionals should include parent and caregiver education on screen use for young children during antenatal and postnatal consultations. Furthermore, screen use in preschools should be made part of the Healthy Pre-Schools (HPS) Accreditation Framework, which currently focuses on provision of healthy meals and maintenance of toddlers’ weight within a healthy BMI range [17]. Given that children spend a significant portion of their day in school, ensuring that preschools are minimising exposure to screen use can help reduce excessive screen use for young children. Outside of the classroom, preprimary educational institutions can also foster close relationships with parents, educating them on screen use guidelines for young children and working together to reduce their child’s screen use.

These are only some of the many steps organisations and institutions can take towards ensuring reduced screen use among young children in Singapore, leading to positive physical, social, and mental health benefits.

Vulnerable Groups Beyond the challenge of the Internet’s pervasiveness in today’s society, which has been compounded by the COVID-19 pandemic, social factors may also predispose certain children to be more exposed to screen use. Studies have pointed to how children from Malay and Indian communities, as well as those who have younger mothers, are more likely to have longer exposure to screen use [6], [18]. Besides social factors, the intrinsic differences

between children may also predispose some to greater screen use. It was found that children with neurodevelopmental conditions face greater difficulties in disengaging from screen devices in bedrooms, and have an earlier age of screen exposure [7]. As such, targeted measures to help children found in these social groups should be introduced, along with initiatives to better aid children with neurodevelopmental disorders to disengage from screen devices.

Conclusion: In summary, there is room for expansion and improvement of existing policies and guidelines to prevent excessive screen use among young children in Singapore. Increased awareness and adoption of screen use guidelines among healthcare workers and the general public can be improved with the help of governmental institutions such as HPB and MSF. With challenges such as increasing reliance on technology in today’s society, as well as predisposing social factors that increase the likelihood of excessive screen use among children, it is only with greater discussion and collaboration that can screen use among young children in Singapore be reduced.

References: [1] World Health Organisation. Guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age. Geneva: World Health Organisation. 2019.

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2017;22(8):461-468.

[3] Madigan S, McArthur B, Anhorn C, Eirich R, Christakis D. Associations Between Screen Use and Child Language Skills. JAMA Pediatrics. 2020;174(7):665.

[4] Health Promotion Board. National Physical Activity Guidelines for Children and Youth [Internet]. Health Promotion Board; 2011 [cited 22 October 2021]. Available from: https://www.academia.edu/10443994/National_Physical_Activity_Guidelines_for_Children _and_Youth [5] Goh S, Teh L, Tay W, Anantharaman S, Dam R, Tan C et al. Sociodemographic, home environment and parental influences on total and device-specific screen viewing in children aged 2 years and below: an observational study. BMJ Open. 2016;6(1):e009113.

[6] Bernard J, Padmapriya N, Chen B, Cai S, Tan K, Yap F et al. Predictors of screen viewing time in young Singaporean children: the GUSTO cohort. International Journal of Behavioral Nutrition and Physical Activity. 2017;14(1).

[7] Lin J, Magiati I, Chiong S, Singhal S, Riard N, Ng I et al. The Relationship Among Screen Use, Sleep, and Emotional/Behavioral Difficulties in Preschool Children with Neurodevelopmental Disorders. Journal of Developmental & Behavioral Pediatrics. 2019;40(7):519-529.

[8] Chen B, van Dam R, Tan C, Chua H, Wong P, Bernard J et al. Screen viewing behavior and sleep duration among children aged 2 and below. BMC Public Health. 2019;19(1).

[9] Padmapriya N, Aris I, Tint M, Loy S, Cai S, Tan K et al. Sex-specific longitudinal associations of screen viewing time in children at 2–3 years with adiposity at 3–5 years. International Journal of Obesity. 2019;43(7):1334-1343.

[10] Chen B, Bernard J, Padmapriya N, Ning Y, Cai S, Lança C et al. Associations between earlylife screen viewing and 24 hour movement behaviours: findings from a longitudinal birth cohort study. The Lancet Child & Adolescent Health. 2020;4(3):201-209.

[11] Domingues-Montanari S. Clinical and psychological effects of excessive screen time on children. Journal of Paediatrics and Child Health. 2017;53(4):333-338.

[12] Lissak G. Adverse physiological and psychological effects of screen time on children and adolescents: Literature review and case study. Environmental Research. 2018;164:149-157.

[13] Chung S, Lee J, Lee H K. Personal Factors, Internet Characteristics, and Environmental Factors Contributing to Adolescent Internet Addiction: A Public Health Perspective.

International Journal of Environmental Research and Public Health. 2019;16(23):4635.

[14] Gupta T, Swami M K, Nebhinani N. Risk of digital addiction among children and adolescents during COVID-19 pandemic: Concerns, caution, and way out. J. Indian Assoc. Child Adolescent Mental Health. 2020;16(3):199-208.

[15] Neophytou E, Manwell L, Eikelboom R. Effects of Excessive Screen Time on Neurodevelopment, Learning, Memory, Mental Health, and Neurodegeneration: a Scoping Review. International Journal of Mental Health and Addiction. 2019;19(3):724-744.

[16] Ministry of Social and Family Development. Healthy Screen Time and Quality Media Choices: 0-2 Years [Internet]. Babybonus.msf.gov.sg. 2021 [cited 22 October 2021]. Available from: https://babybonus.msf.gov.sg/parentingresources/web/Babies/BabiesPlay_and_Learning/B abiesScreen_Time/Babies_Healthy_Screen_Time?_adf.ctrl-

state=kg7rfos0f_13&_afrLoop=75883136075562450&_afrWindowMode=0&_afrWindowId= null#%40%3F_afrWindowId%3Dnull%26_afrLoop%3D75883136075562450%26_afrWindow Mode%3D0%26_adf.ctrl-state%3Dryh85e3k6_4 [17] Health Promotion Board. Healthy Pre-School Accreditation [Internet]. Health Promotion Board.

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Available from: https://www.hpb.gov.sg/schools/school-programmes/health-promoting-programmes-forpre-schools/healthy-pre-school-accreditation [18] Duch H, Fisher E, Ensari I, Harrington A. Screen time use in children under 3 years old: a systematic review of correlates. International Journal of Behavioral Nutrition and Physical Activity. 2013;10(1):102.