TOUCH SCREEN USAGE IN RELATION TO COGNITIVE ABILITY IN PRESCHOOLERS: A CROSS SECTIONAL STUDY

CONCLUSION

Based on the results of the current study we can conclude that, touch screen usage has adverse effects on the cognitive function. Parents/caregivers should carefully allow their children to use these devices. The type and content of applications played by these devices may be beneficial if used under adult supervision.

Acknowledgments

The authors would like to show gratitude to all children and their families for participation in this work. We are also immensely grateful for the schools and nurseries for their continuous cooperation and support during the course of this research.

Disclosure statement

No potential conflict of interest was reported by the authors

TOUCH SCREEN USAGE IN RELATION TO COGNITIVE ABILITY IN PRESCHOOLERS: A CROSS SECTIONAL STUDY

Amira M. Mahmoud; Amira M. Al-Tohamy

and Amira M. Abd-Elmonem

Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy,

Cairo University, Cairo, Egypt

Key Words: Cognitive development; Digital devices; Pediatric Quality of Life Inventory cognitive functioning scale™

ABSTRACT

Background/aim: Recent literatures are associating digital technology extensive and addictive use with physical, psychosocial and cognitive inverse consequences. This research focuses more on number of touch screen devices; age started using devices and usage time in relation to cognitive function in preschoolers. Subjects and methods: Ninety-seven typically developing preschool children of both genders with age ranges from three to five years participated in this study. The Pediatric Quality of Life Inventory™ (PedsQL™) cognitive functioning scale was used to assess the cognitive function. Results: The results of the current study revealed weak positive non-significant correlation between the age started to use touch screen devices and PedsQL^TM cognition functioning scale score. There were moderate negative significant correlations between the touch screen usage time and number of used devices and PedsQL^TM cognition functioning scale score (p < 0.05). Conclusion: Based on the results of the current study we can conclude that, increase touch screen usage time and availability of several devices adversely affect the cognitive function in preschoolers. Future longitudinal studies are needed to clarify the effects and the mechanisms underlying these associations on child behavior, physical, psychosocial and school functioning.

INTRODUCTION

Today’s modern life is bounded with technology products and in the recent past there has been a huge development of digital technologies. Digital devices such as tablets and smartphones are currently the most common digital device used by younger children compared to other digital devices such as computers and laptops (Barmomanesh and Vodanovich, 2017).With augmented access to tablets in homes and pre-school settings, young children are spending a significant amount of their time using tablets for educational purposes and entertainment (Neumann and Neumann, 2015).

A recent survey conducted with 2,000 responses from parents of children before age of five, showed that 36% of children aged from three to five years own their tablet and using it for 79 minutes per day on average (Barmomanesh and Vodanovich, 2017). Touch-screen phones and tablets are increasingly available to children, but little is known about how this technology is being used by children and what effect it might have on children’s motor, social, cognitive development and behavior (Ahearne et al., 2015).

Touch-screen device with interactive applications attracts children’s attention and offers them some participation and entertainment. However, using a touch-screen tablet might positively or negatively affect children’s health (Lin et al., 2017). A previous survey based study conducted by Media and Human Development School of Communication at North- western University in the United States found that, a majority of parents believe technology have a negative impact on children’s physical activity. Their study also revealed that four in ten of parents are concerned that their child may develop addiction to new digital technologies such as smartphones or tablets. On the other hand, some parents believed that the use of these technologies could be advantageous for their children in some cases (Barmomanesh and Vodanovich, 2017).

Optimal cognitive development in early childhood involves the emergence and growth of cognitive abilities within multiple domains. For example, in the language domain, children should acquire the ability to comprehend and produce speech of increasing complexity to communicate with others. In the memory domain, children should acquire the ability to encode information in their memory and access long-term stores over increasing delays via recognition and recall mechanisms. While in the spatial domain, children should acquire the ability to encode and use information about the spatial organization of objects and layouts, and use them to guide reaching and loco-motor behavior. Regarding the executive function domain, children should acquire increased ability to regulate their attention, thoughts, actions, and emotions, sometimes suppressing a dominant response to produce a less available, but more appropriate alternative. Understanding and promoting the factors that support healthy brain and optimal cognitive development across domains in early childhood is of great important (Carson et al., 2016).

Concerns about the relation between touch screen usage and child's cognitive development worth great attention of researchers. Early ascertainment of cognitive development in preschoolers may grant convenient successful decision of using these devices either for recreation or rehabilitation purposes. Studying the effect of touch screen usage on cognitive development in typically developing children would provide the health care providers with valuable information that may be helpful to identify whether or not these devices affect the cognitive development preschoolers. Therefore, the current study was conducted to investigate the relationship between touch screen usage and cognitive development in preschoolers.

METHODS:

Study design:

This study is an observational cross-sectional design (prospective database study) carried out from January 2020 to April 2020 in accordance with the Declaration of Helsinki (Code of Ethics of the World Medical Association).

Ethical considerations:

Ethical committee approval of the Faculty of Physical Therapy, Cairo University, as well as a written consent from children‘s parents were obtained before starting the study.

Subjects:

Ninety-seven typically developing preschool children of genders with age ranges from three to five years participated in this study. They were recruited from nurseries. Children were excluded from the study if they had any of the following criteria:

1. Diagnosed with attention deficit/hyperactivity disorder.
2. Diagnosed with neuromuscular or musculoskeletal disorders.
3. Diagnosed with psychiatric conditions such as autism and depression.
4. Diagnosed with significant behavioral disorders
5.  Diagnosed with fine motor problems.
6. Significant auditory or visual deficits.

Sample size:

To avoid type II error, sample size calculation was performed prior to the study using G*POWER statistical software (version 3.1.9.2; Franz Faul, Universitat Kiel, Germany) [Correlational study, α=0.05, β=0.2, and medium effect size = 0.3] and revealed that the appropriate sample size for this study was N=84 typically developed preschool children.

Methods for assessment

General characteristics of subjects

The child’s name, age and gender were recorded. The number of touch screen devices the child uses, the touch screen usage time a day, and the age started touch screen usage. In addition, practicing sports and attending nursery were recorded.

Pediatric Quality of Life Inventory™ Cognitive Functioning Scale

 The pediatric Quality of Life Inventory™ (PedsQL™) is a modular instrument designed to measure health-related quality of life and disease-specific symptoms. The PedsQL™ Cognitive Functioning Scale was developed as a brief generic symptom-specific instrument to measure cognitive functioning. The 6-item PedsQL^TM Cognitive Functioning Scale was designed as a brief and easy-to-administer patient self-reported and parent proxy-reported generic symptom specific instrument to measure cognitive functioning across pediatric populations, originally developed in a pediatric cancer population. Subsequently, the PedsQL^TM Cognitive Functioning Scale has been demonstrated to be significantly associated with the Behavior Rating Inventory of Executive Function, a widely validated measure of executive functioning, in a pediatric head trauma sample. The PedsQL^TM Cognitive Functioning Scale includes 6 items. The format, instructions, Likert scale, and scoring method are identical to the PedsQL^TM 4.0 Generic Core Scales, with higher scores indicating better HRQOL (fewer cognitive problems). The PedsQL^TM Cognitive Functioning Scale is comprised of parallel child self-report and parent proxy-report formats. Child self-report includes ages 5–7, 8–12, and 13–18 years. Parent proxy-report includes ages 2–4 (toddler), 5–7 (young child), 8–12 (child), and 13–18 (adolescent) and assesses parent’s perceptions of their child’s cognitive functioning (Varni et al., 2002; McCarthy et al., 2005).

The PedsQL^TM Cognitive Functioning Scale parent proxy-report (Arabic version) for toddlers ages 2–4 was used in the current study. The instructions for the standard version ask how much of a problem each item has been during the past 1 month. A 5-point response scale is utilized across the parent proxy-report (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; 4 = almost always a problem). Items are reverse-scored and linearly transformed to a 0–100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, 4 = 0), so that higher scores indicate fewer cognitive problems. The Scale Score is computed as the sum of the items divided by the number of items answered (this accounts for missing data). If more than 50% of the items in the scale are missing, the Scale Score is not computed (Varni et al., 2004).

Statistical analysis

Normality of numerical data was tested using Kolmogorov Smirnov test. Correlation between various variables was estimated using Pearson moment correlation equation for linear relation of normally distributed variables and Spearman rank correlation equation for non-normal variables/non-linear monotonic relation. P values less than 0.05 was considered statistically significant. All statistical calculations were done using computer program IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 22 for Microsoft windows.

RESULTS:

General characteristics of the subjects:

Ninety- seven preschoolers participated in this study group. The mean ± SD age was 47.59 ± 8.04 months with maximum value of 59 months and minimum value of 34 months. The gender distribution revealed that there were 45 girls with reported percentage of 46.6% while the number of boys was 52 with reported percentage of 53.6%. The mean ± SD of PedsQL^TM cognitive functioning scale score was 89.42 ± 11.5 with maximum value of 100 and minimum value of 54. See table (1).

Table (1): Descriptive statistics for the age and cognition functioning of the study group:

Frequency distribution of age started to use touch screen devices, number of devices used and touch screen usage time per day :

Seventy-four (76.3%) children started to use touch screen devices at age of 24-36 months, 4 (4.1%) children started to use touch screen devices at age of 37-48 months and 19 (19.6%) children were not using touch screen. Nineteen (19.6%) children were not using touch screen devices, 60 (61.9%) children were used one touch screen device and 18 (18.6%) children were using more than one touch screen devices. See table (2).

Nineteen (19.6%) children used touch screen devices for 30-60 min/day, 35 (36.1%) children used touch screen devices for 60-120 min/day, 12 (12.4%) children used touch screen devices for 120-180 min/day and 12 (12.4%) children used touch screen devices for more than 180 min/day. See table (2).

Table (2): Frequency distribution of age started to use touch screen devices, number of devices used and touch screen usage time per day:

Cognitive function in relation to age started to use touch screen devices, touch screen usage time and number of used devices:

Regarding the relation between age started to use touch screen devices and PedsQL^TM cognition functioning scale score, there was weak positive non-significant correlation (r = 0.09, p = 0.41). In addition, the relation between touch screen usage time and PedsQL^TM cognition functioning scale score revealed moderate negative significant correlation (r = -0.32, p = 0.001). Finally, the relation between number of used devices and PedsQL^TM cognition functioning scale score showed moderate negative significant correlation (r = -0.38, p = 0.0001) as shown in table (3).

Table (3): Cognitive function in relation to age started to use touch screen devices, touch screen usage time and number of used devices:

DISCUSSION

The present study endeavored to investigate the relation between touch screen usage and cognitive development in preschoolers. Several studies have investigated the effects of modern technology on physical, social, sleep pattern and general health. Great debates have emerged amongst parents, educators, and other early childhood professionals to know what is appropriate for young children to be exposed to and the possible influences of technology on their developing bodies and minds.

The main findings of our current study were: 1) weak positive non-significant correlation between the age started to use touch screen devices and PedsQL^TM cognitive function, 2) moderate negative significant correlation between the touch screen usage time per day and cognitive function, 3) moderate negative significant correlation between the number of used devices and cognitive function.

Previous studies show both possible benefits and potential hazards related to technology use. Benefits are such as enriched creativity and participation with peers and adults, development of language and vocabulary, and opportunities for independence. However, these benefits generally occur in purposeful conditions with age appropriate educational content under adult guidance and instructions. On the other hand, hazards may be manifested as social, cognitive, sleep problems and behavioral challenges, impaired developmental skills, and fewer personal interactions. These hazards are more common when technology is used in uncontrolled manner, with violent or aggressive content, or with developmentally inappropriate requirements (Avis, 2019).

The results of the current study showed that, 78% of preschool children participated in the current study use touch screen devices and 60% have one device while 18% have two available devices to play with. These findings may be attributed to the fact that, touch screen devices are easy to use for watching videos and playing games. These devices require no higher fine motor skills as it depends on simple actions such as tapping on the screen. In addition, it is lighter in weight and easily controlled with hand compared with computers and keyboards.

Our results are supported by previous studies which reported that, the most common interactive devices for young children (age 8 and under) age group are mobile devices and those with touchscreens (Elkind, 2016). Touchscreens do not require a high level of fine motor skills or an understanding of the button symbols; therefore, these devices are the most developmentally appropriate in terms of physical use (Geist, 2014). Moreover, the mobility of the devices allow for lightweight carrying and adjusting compared to desktop computers, as well as alternative sitting or lying rather than being at a traditional upright desk (Neumann & Neumann, 2014).

Our results reported poor cognitive function with significant negative relation with the number of touch screen devices used and the time of use per day. These results may be attributed to the availability of multiple devices that in return allow the child to use touch screen devices for playing or watching media for long duration per day. Furthermore, adults around the child are usually using digital technology for several purposes such as entertainment, and documenting life. Therefore, the increase tendency to use these devices caused decline in using computers and laptops as well as watching television.

Our results are supported by the previous studies reported that, technology is ever increasing with adults, and in recent years, children alike have constant access to media, and often carry technology devices with them everywhere (Parikh, 2012). As a result, children being born into current society do not know a world without technology (Laidlaw et al., 2019; Fantozzi et al., 2018). In other words, the access to mobile devices has dramatically increased, and traditional television watching, though still prevalent, has declined (Teichert, 2017). This means young children most likely have access to several screens and devices at any time (Fantozzi et al., 2018). Parents report using technology devices for learning opportunities, entertainment, and documenting life (Teichert, 2017).

Our results come in accordance with Boddum , (2013)who reported that,             in   current  day  culture,  children  are exposed to technology at a very young age and since motor, cognitive, and social-emotional skills in children develop in early  years,  navigating  the  technological  world  and interacting with touchable devices has become easy for them.

Moreover, Plowman, (2010) stated that, a dramatic rise in the use of technology over the last decade  has  led  to   public  discussion  about  the  role  of technology   in   young   children’s   life which express the concerns parents have about the ways in which childhood is being transformed by technology, often  appealing  that  children’s  cognitive,   emotional  and social development is  at risk.

The results of the current study may be attributed to the type of games and media that the children may have access to play or watch. Usually children are attracted to applications and games with fast animation, high music and accompanied with sound as well as color effects. We believe that this type of applications might affect child’s cognitive development. This explanation is supported by previous studies which mentioned that, when devices, applications, and toys are noisy, they interfere with the kinds of interactions that are best-suited for language and cognitive development (Kerkorian et al., 2009).

Furthermore, Ellison, (2012) and Monir, (2013) concluded that, reliance on smartphones and related technologies is not aiding mental functioning, but rather, is having a negative impact on our ability to think, remember, pay attention, and regulate emotion.

The adverse effects of a early and prolonged exposure to digital technology on pre-school children has been described by several studies (Schmidt et al., 2008; Pagani et al., 2010; American Academy of Pediatrics, 2013).Among the side effects, the most reported are interferences on neurocognitive development, learning, well-being, sight and listening, metabolic and cardiological functions.  Recent studies have demonstrated that parental mobile devices usage influences child safety, emotional well-being and family interactions. In fact devices distract parents-children dyad from face-to-face interactions, having a great impact in cognitive, language, and emotional development (Glascoe and Lee, 2010).

Children’s development is also influenced by background television. It has been proven to have negative effects in young children’s brain development, reducing the amount and quality of parents-children dyad interactions (Schmidt et al., 2008). As reported by Pagani et al., (2010) and American Academy of Pediatrics, (2013), high rates of screen time are related to decrements in math and attention scores but also to peer rejection experiences. Media devices use has been associated to task inefficiency, loss of attention, and safety hazards.

Our results contradict the finding of Linebarger et al., (2014) who stated that, digital technologies are beneficial only with right contents and parents’ interaction presence.

It has been reported that, drawing applications are an activity that allows child thinking and creation of his own prospective of things (Bozzola et al., 2018). In this context, drawing apps can play a positive role in child development (Yadav and Chakraborty, 2017). Drawing apps can be used as a supplement to traditional crayons and chalk as they are safe and easily to use (Vandonick et al., 2014).

Similarly, Bozzola et al., (2018) mentioned that, mobile phones could be a tool to reinforce what children are already learning at school and improve cognitive abilities. In particular, using well-designed educational apps promote learning among preschool and early-elementary-aged children. Unfortunately, most of the downloaded apps are not designed for a dual audience (both parent and child), targets only rote academy skills and are not based on established criteria from developmental specialist or educators. Better policies for the evaluation of content in various app stores could be a means to create high quality educational apps for kids.

Limitation of the current study

The current study has certain limitations that should be considered. This study included children age 3 to 5 years therefore the results cannot be generalized on older children. Regarding the age of the children participated in the research, the duration during which children use the devices is considered a short period to assess the actual effect of the touch screen devices on the child's cognitive development. Finally, the PedsQL^TM used toassess the cognitive function is a brief generic symptom-specific instrument to measure cognitive functioning. The authors recommend investigating the long term effect of touch screen usage on cognitive function through more comprehensive assessment tools.

CONCLUSION

Based on the results of the current study we can conclude that, touch screen usage has adverse effects on the cognitive function. Parents/caregivers should carefully allow their children to use these devices. The type and content of applications played by these devices may be beneficial if used under adult supervision.

Acknowledgments

The authors would like to show gratitude to all children and their families for participation in this work. We are also immensely grateful for the schools and nurseries for their continuous cooperation and support during the course of this research.

Disclosure statement

No potential conflict of interest was reported by the authors.

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العلاقة بین إستخدام الشاشات التی تعمل باللمس والقدرة المعرفیة للاطفال سن ما قبل المدرسة: دراسة مقطعیة

أمیرة محمد محمود، أمیرة محمد التهامی ، أمیرة محمود عبدالمنعم

قسم العلاج الطبیعی للأطفال, کلیة العلاج الطبیعی, جامعة القاهرة.

الخلفیة / الهدف: تربط الأبحاث الحدیثة بین التکنولوجیا الرقمیة والإستخدام الواسع و الإدمان وبین العواقب الجسدیة ,النفسیة ,الإجتماعیة والمعرفیة. یرکز هذا البحث بشکل أکبر على دراسة عدد أجهزة شاشة اللمس, بدأ العمر باستخدام الأجهزة ووقت الاستخدام وعلاقته بالوظیفة المعرفیة فی مرحلة ما قبل المدرسة. العینة والأسالیب: شارک سبعة وتسعون من الأطفال الطبیعیون سن ما قبل المدرسة من کلا الجنسین تتراوح أعمارهم بین ثلاث إلى خمس سنوات فی هذه الدراسة. تم إستخدام مقیاس الأداء المعرفی لجودة الحیاة للأطفال (PedsQL^TM) لتقییم الوظیفة المعرفیة. النتائج: کشفت نتائج الدراسة الحالیة عن وجود إرتباط إیجابی ضعیف بین العمر الذی بدأ إستخدام أجهزة الشاشات التی تعمل باللمس ودرجة مقیاس عمل PedsQL^TM. کانت هناک إرتباطات سلبیة ذات دلالة إحصائیة بین وقت إستخدام الشاشة التی تعمل باللمس فی الیوم وعدد الأجهزة المستخدمة ودرجة مقیاس عمل الإدراک المعرفی PedsQL^TM  (P <0.05). الإستنتاج: بناءً على نتائج الدراسة الحالیة ، یمکننا أن نستنتج أن ، زیادة وقت إستخدام الشاشة التی تعمل باللمس وتوافر العدید من الأجهزة تؤثر سلبًا على الوظیفة المعرفیة فی الأطفال سن ما قبل المدرسة. هناک حاجة لدراسات مستقبلیة لتوضیح الآثار طویلة الأمد وراء للإستخدام هذه الأجهزة على سلوک الطفل ، و الحالة الجسدیة والنفسیة والاجتماعیة واللأداء المدرسی.

الکلمات الدالة: التطور المعرفی; الأجهزة الرقمیة; مقیاس الأداء المعرفی لجودة الحیاة للأطفال (PedsQL^TM).