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Clinical Context

The Omicron variant has once again pushed rates of COVID-19 to new heights, and children are bearing more of a burden of COVID-19 in the current surge. This has, in turn, led to many absences from school and thousands of school closures across the United States, but are schools a primary site for transmission of COVID-19? This question has been asked repeatedly since the beginning of the pandemic, and a meta-analysis of 37 population-based or contact-tracing studies confirms previous research that the answer appears to be "no." This study by Viner and colleagues was published in the December 22, 2021 issue of Vaccine.^[1]

Transmissibility of COVID-19 among children was similar to that found among adults; however, the secondary attack rate (SAR) of COVID-19 in schools was 0.7%, compared with an SAR of 7.6% in household studies. Still, there was evidence of clustering of cases within classes at schools. At the same time, the incidence of COVID-19 cases in schools correlated well with the incidence of cases in the broader community.

One of the consequences of school closures has been more screen time for children and adolescents. Previous research has found that screen time among young people can increase depression, anxiety, and hyperactivity. The current study by Li and colleagues evaluates the effects of screen time during the COVID-19 pandemic on the mental health of children.

Study Synopsis and Perspective

Older Canadian schoolchildren who spent the most time looking at screens during the COVID-19 pandemic experienced higher levels of anxiety and depression whereas their younger counterparts had more conduct problems, researchers have found; however, the study does not definitively prove that screen time is harmful, and an expert challenged the conclusions.

Still, a study co-author said the findings highlight the potential harms of excessive screen time, especially in the context of pandemic-era virtual learning.

Clinicians "really need to advocate for policies that would be protective for children to reduce their screen time and social isolation and increase their involvement with school, sports, and academic activities," Catherine S. Birken, MD, a pediatrician at the University of Toronto, said in an interview.

The study was published December 14 in the journal JAMA Network Open.^[2]

Birken and her colleagues launched the study to examine whether heightened levels of screen time during the pandemic disrupted mental health in children. In particular, they wanted to break down different types of screen time, such as virtual learning, watching television, and playing video games.

"The bulk of the literature is supportive of a strong relationship between screen time and mental health symptoms like anxiety," Birken said.

For the study, the researchers surveyed parents to track the screen time of 2026 children between May 2020 and April 2021.

In a cohort of 532 younger children (mean age, 5.9 ± 2.5 years; 52% male; 69% of European ancestry), the researchers linked each extra daily hour of TV or use of digital media to worse behavior, as measured by the Strengths and Difficulties Questionnaire: 0.22 (95% CI: 0.1, 0.35); P < .001 in an adjusted model for children aged 2 to 4 years; and 0.07 (95% CI: 0.02, 0.11); P = .007 in an adjusted model in children aged 4 years and older.

Nonetheless, the researchers observed no statistically significant links to more anxiety/depression or hyperactivity/inattention in this group of children.

Among 1494 older kids (mean age, 11.3 years; 57% male; 58% of European ancestry), researchers linked greater daily use of TV or digital media to higher levels of depression symptoms in a dose-dependent relationship, Birken said (1 hour: β = 0.21 [95% CI: −1.28, 0.78]; 2-3 hours: β = 1.81 [95% CI: 0.29, 3.33]; 4-5 hours: β = 2.8 [95% CI: 1.15, 4.44]; 6-8 hours: β = 5.16 [95% CI: 3.32, 7.01]; 9 hours: β = 5.42 [95% CI: 3.3, 7.54]; overall P < .001).

"Similarly, higher TV or digital media time per day was associated with higher levels of anxiety symptoms," the researchers reported. "TV or digital media time per day was also significantly associated with differences in symptoms of irritability, inattention, and hyperactivity/inattention."

More time spent learning virtually was associated with higher levels of depression and anxiety in both groups of children, according to the researchers. Whether this finding reflects an effect of screens themselves or because the children most exposed to virtual learning may also have been the most exposed to the stressful disruptiveness of the pandemic is unclear.

The researchers also found "insufficient evidence" to link more virtual learning to irritability, inattention and hyperactivity, inattention, and hyperactivity/impulsivity in adjusted models.

Video chatting did not appear to have a protective effect, Birken said. The researchers also specifically analyzed children with autism and found no link between more screen time and various mental health/conduct problems.

Is it possible that kids with more anxiety, depression, and isolation simply turn to screens because they are anxious, depressed, and isolated? Birken said researchers adjusted the findings to account for previous mental health problems, and she noted that the study linked more pandemic-era virtual learning to more depression/anxiety. It is "hard to imagine" how more mental health problems would cause more virtual learning, she said.

Chris Ferguson, PhD, a professor of psychology at Stetson University in DeLand, Florida, who studies screen time, criticized the study in an interview.

"The observed effects are so tiny, it's impossible to know if they are real or a false-positive artifact common to social science research," he said. "Ultimately, this study is better evidence about how many scholars are bad at statistics than anything having to do with kids and screens."

Ferguson said that the results may be confounded because kids turn to screens to reduce their anxiety.

"For the most part, screens were a godsend during COVID-19," he said. "They helped kids stay inside and gave them something to do while social distancing and allowed them to keep in touch with friends and families. Honestly, what else were we expecting kids to do, stare at the wallpaper?"

Children with depression and anxiety often retreat into screens or books to escape the unpleasantries of real life.

"That doesn't mean the screens or books are the culprits," he said.

Instead of focusing on screen time, Ferguson suggested parents consider these factors: "Keeping in mind not every kid is a genius, is your kid doing about as well in school as you'd expect, given their natural ability? Are they getting at least some exercise every day? Are they getting adequate sleep? Are they able to socialize with friends in some context, either in real life or online? Are they happy?"

The study was funded by the Canadian Institutes of Health Research, the Center for Brain & Mental Health at The Hospital for Sick Children, the Ontario Ministry of Health, and the Miner's Lamp Innovation Fund in Prevention and Early Detection of Severe Mental Illness at the University of Toronto, Toronto, Alberta, Canada.

Clinical Implications

• A previous meta-analysis by Viner and colleagues found that the transmissibility of COVID-19 among children was similar to that found among adults; however, the SAR of COVID-19 in schools was 0.7%, compared with an SAR of 7.6% in household studies. Still, there was evidence of clustering of cases within classes at schools. At the same time, the incidence of COVID-19 cases in schools correlated well with the incidence of cases in the broader community.
• In the current study by Li and colleagues, increasing time watching television or digital media during the COVID-19 pandemic were associated with higher conduct problems as well as hyperactivity/inattention among younger children and increased depression and anxiety among older children. Video game time was positively associated with depressive symptoms, irritability, inattention, hyperactivity, and impulsivity among older children, but video chatting did not improve mental health symptoms.
• Implications for the healthcare team: The healthcare team should provide evidence based guidance when discussing the potential impact of increased screen time among children and adolescents, especially during the COVID-19 pandemic.

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