Children and Adolescents and Digital Media PDF

TECHNICAL REPORT
Children and Adolescents

and Digital Media
Yolanda (Linda) Reid Chassiakos, MD, FAAP, Jenny Radesky, MD, FAAP, Dimitri Christakis, MD, FAAP, Megan A.
Moreno, MD, MSEd, MPH, FAAP, Corinn Cross, MD, FAAP, COUNCIL ON COMMUNICATIONS AND MEDIA
Today’s children and adolescents are immersed in both traditional and new abstract
forms of digital media. Research on traditional media, such as television,
has identified health concerns and negative outcomes that correlate with
the duration and content of viewing. Over the past decade, the use of digital
media, including interactive and social media, has grown, and research
evidence suggests that these newer media offer both benefits and risks This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have
to the health of children and teenagers. Evidence-based benefits identified filed conflict of interest statements with the American Academy
from the use of digital and social media include early learning, exposure of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
to new ideas and knowledge, increased opportunities for social contact Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
and support, and new opportunities to access health promotion messages
and information. Risks of such media include negative health effects on Technical reports from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
sleep, attention, and learning; a higher incidence of obesity and depression; external reviewers. However, technical reports from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
exposure to inaccurate, inappropriate, or unsafe content and contacts; and organizations or government agencies that they represent.
compromised privacy and confidentiality. This technical report reviews the
The guidance in this report does not indicate an exclusive course of
literature regarding these opportunities and risks, framed around clinical treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
questions, for children from birth to adulthood. To promote health and
wellness in children and adolescents, it is important to maintain adequate All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
physical activity, healthy nutrition, good sleep hygiene, and a nurturing revised, or retired at or before that time.
social environment. A healthy Family Media Use Plan (www.healthychildren. DOI: 10.1542/peds.2016-2593
org/MediaUsePlan) that is individualized for a specific child, teenager, or PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
family can identify an appropriate balance between screen time/online time
Copyright © 2016 by the American Academy of Pediatrics
and other activities, set boundaries for accessing content, guide displays
of personal information, encourage age-appropriate critical thinking and FINANCIAL DISCLOSURE: The authors have indicated they do
not have a financial relationship relevant to this article to
digital literacy, and support open family communication and implementation disclose.
of consistent rules about media use.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have

INTRODUCTION indicated they have no potential conflicts of interest to
disclose.
What Are the Differences Between Traditional Media and New Digital or
Social Media? To cite: Reid Chassiakos Y, Radesky J, Christakis D, et al.,
AAP COUNCIL ON COMMUNICATIONS AND MEDIA. Children
and Adolescents and Digital Media. Pediatrics. 2016;138(5):
Today’s generation of children and adolescents are surrounded by and
e20162593
immersed in a digital environment. Traditional media, such as television
Downloaded from www.aappublications.org/news by guest on June 14, 2020

PEDIATRICS Volume 138, number 5, November 2016:e20162593 FROM THE AMERICAN ACADEMY OF PEDIATRICS
(TV), radio, and periodicals, have in changes in the patterns of media access to mobile technology and the
been supplemented by new digital use. For example, in 1970, children Internet in lower-income families,
technologies that promote interactive began to regularly watch TV at 4 a smaller study in 2015 called this
and social engagement and allow years of age, whereas today, children disparity into question by showing
children and teenagers instant access begin interacting with digital media that almost all (96.6%) 0- to 4-year-
to entertainment, information, and at 4 months of age. olds recruited from a low-income
knowledge; social contact; and pediatric clinic had used mobile
As new media platforms and social
marketing. Traditional media, also devices, and 75% owned their own
media have been incorporated into
referred to as broadcast media, device.5 This study also showed
children’s media diets, hours spent
typically were created externally by an that most 2-year-olds used mobile
in TV viewing have slowly decreased
established production source, such as devices on a daily basis and that most
over the past 2 decades. Loprinzi
a film studio, TV network, or editorial of the 1-year-olds assessed (92.2%)
and Davis1 examined trends in
staff and were provided either to had already used a mobile device.
parent-reported TV viewing among
individuals or to a broader audience Although a digital divide likely still
preschoolers 2 to 5 years of age
for passive viewing or reading. In exists in terms of access to quality
(n = 5724) and children 6 to 11 years
contrast, newer digital media, which content and reliable Wi-Fi, it is now
of age (n = 7104) between 2001 and
include social and interactive media, clear that most young children seen
2012 using data from the National
are a form of media in which users by a pediatric health care provider
Health and Nutrition Examination
can both consume and actively will have used or have been exposed
Survey (NHANES), showing
create content. Examples include to mobile technology.
significant decreases in mean TV
applications (apps), multiplayer video
viewing over time, primarily for
games, YouTube videos, or video
preschoolers and, to a lesser extent, Exactly what young children are
blogs (vlogs). For children and young
for school-aged children. Non- doing on mobile technology has not
adults today, this evolving integration
Hispanic white boys demonstrated been studied in great detail, because
of passively viewed and interactive
the largest decrease in mean viewing mobile device usage is relatively
media is seamless and natural; the
of 29%, from 2.24 hours of TV per recent and methodologically
distinctions and boundaries between
day down to 1.59 hours of TV per difficult to assess. By parent report,
traditional/broadcast and interactive/
day. Despite these decreases, the most children in the Kabali et al
social media have become blurred or
majority of parents still reported that study5 watched YouTube or Netflix
imperceptible.
their children watched TV for 2 or primarily, and smaller proportions
Digital media allow information more hours per day. watched educational programs
sharing across a variety of media and played early-learning apps
It is unclear whether these decreases
formats, including text, photographs, (eg, alphabet and counting apps).
are in part the result of parents
video, and audio. Today’s video A large minority also played games
heeding expert recommendations
games, for example, often represent a or watched cartoons. Common
to limit screen time (evidence
merging of both traditional and social
would suggest not)2 or whether Sense Media’s Zero to Eight survey
media, as users can virtually “inhabit”
they represent a displacement of has found disparities in the use of
impressively produced worlds and
TV viewing by the use of novel educational media on mobile devices,
interact with other users in remote
platforms. In young children, with 54% of children from higher-
locations. Video game participants
use of mobile devices, such as income families often or sometimes
can even work collaboratively to
smartphones and tablet computers, using educational content on mobile
cocreate virtual worlds. Thus, digital
has risen dramatically since the devices but only 28% of children
media can provide an engaging
Kaiser Family Foundation first from lower-income families doing
experience in which the media
began surveying parents of 0- to so.4 Thus, younger children and
experiences of children and teenagers
8-year-olds about their technology those from lower-income families are
become highly personalized.
use.3 For example, in 2011, 52% more likely to use mobile devices for
of children 0 to 8 years of age had entertainment purposes.
MEDIA USE ESTIMATES access to a mobile device (although
only 38% had ever used one). By How Are Media Being Used in Older
How Are Media Usage Patterns 2013, this access had increased to Children and Teens Today? Which
Changing in Young Children? 75% of 0- to 8-year-olds.4 Although Modes of Use Are Most Popular?
The evolution of media from these national surveys continued to
traditional to newer forms of digital demonstrate a digital divide on the Studies show that social media use
media in the past decade has resulted basis of economic status, with less patterns and rates among older

e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
children and adolescents have to message your opponent while GAMIFICATION AND ADVERTISING
continued to grow over the past engaging in a remote video game
decade, aided in part by the recent or tweet while watching a TV What Is Gamification? What Is the
rise in mobile phone use among show, viewers and gamers often Impact of Gamification on Media Use
children and teenagers. At present, link their entertainment to social by Children?
approximately three-quarters of media. Modes of communication Gamification applies gaming
teenagers own a smartphone, 24% have become more fluid, with elements to a real-world activity
of adolescents describe themselves conversations jumping back and in a seamless, user-friendly, and
as “constantly connected” to the forth between text messages to attractive way. Commercial video
Internet6 and 50% report feeling social media sites. Text messages games have incorporated cutting-
“addicted” to their phones.7 Mobile also may include links to media, such edge graphics, behavioral reinforcers
apps provide a breadth of specific as personal videos, YouTube videos, (ie, for reaching certain levels of
functions, such as gaming, photo and links to Web sites and social play), and exciting stories, which
and video sharing, and global networking sites. have been delivered through
positioning system monitoring. Pew data from 2012 suggest that stationary personal computers,
Social media sites and their teenagers between 14 and 17 dedicated gaming consoles, or
associated mobile apps provide years of age sent a median of 100 multiplayer networks. One key
a platform for users to create an texts a day. With all likelihood, this difference today is the portability
online identity, communicate with number will continue to increase achieved via smartphones, mobile
others, and build a social network. as new data become available. Wi-Fi, and broad social networks,
Among the myriad accessible social Texting no longer is limited to which has changed how and
networking sites, Facebook remains cellular phone systems but can be where games can be played and
the most popular, with 71% of 13- facilitated by messaging apps, such how gaming functions can be
to 17-year-olds surveyed by the as Kik or WhatsApp. Pew data from applied. These portable “games”
Pew Research Center in 2014 and 2015 show that these apps are most can now be integrated into daily
2015 reporting using this site/app.6 popular with Latino (46%) and life by functioning as sources for
However, adolescents today do not African-American (47%) teenagers, information and guidance and by
typically dedicate themselves to compared with white teenagers providing motivation to achieve
just 1 site; most teenagers maintain (24%).6 academic and wellness goals. For
a “social media portfolio” of example, the Nike+ app tracks
several selected sites including, as Video games also remain very
exercisers’ routes, pace, steps,
indicated by rates of use in the Pew popular among families; it is
distance, and time and challenges
survey, Instagram (52%), Snapchat estimated that 4 out of 5 households
runners to compete with friends
(41%), Twitter (33%), Google+ own a device used to play video
and improve their performance.
(33%), Vine (24%), Tumblr (14%), games, and approximately half
Such design also serves to reinforce
and other social media (11%).6 of US homes own a dedicated
behavior (both health behaviors and
game console.8 Video games also
for using the app), resulting in more
are available via apps on mobile
As communication moves from engagement with both.11
devices. Additionally, apps that
face-to-face and voice-only phone
have a practical function are also
conversations to more screen-
being marketed with a gaming How Have Mobile and Social Media
to-screen interactions via apps,
such as FaceTime or Skype, daily
perspective; this approach is known Changed the Ability of Advertisers to
as “gamification.” Reach Children and Teenagers?
communication is becoming
intertwined with screen time. It is common for adolescents today Newer media have provided
Texting, using a smartphone to engage in more than 1 form of expanding opportunities for
keyboard to send a written message media at the same time, a practice marketers and advertisers to adapt
or a visual symbol (emoji) to another referred to as media multitasking. their messages to reach millions
smartphone, also has become a This multitasking may include of children and teenagers.12 These
prominent means of communication watching TV and using a computer9 newer forms of media may broaden
for teenagers. or being online and engaging in more the types of products and behaviors
than 1 activity. In one study of older to which children and adolescents
Lines are also becoming adolescents, approximately 50% are exposed. For example, although
blurred between media use of the time students were online, restrictions may exist to limit
for communication versus for they were engaged in more than 1 exposure to advertisements for
entertainment. With the ability activity.10 alcohol in traditional media, research

PEDIATRICS Volume 138, number 5, November 2016 e3
suggests that the major alcohol Pediatrics (AAP) recommendations toddlers lose the knowledge learned
brands maintain a strong presence on to discourage media exposure over time without repetition.23
Facebook, Twitter, and YouTube.13,14 for children younger than 2 years
From a marketing perspective, were based on research on TV and More recent research has shown that,
social media are consumer focused, videos, which showed that in-person under particular conditions, children
allowing interaction and input interactions with parents are much between 15 and 24 months of age
that can build relationships.15 more effective than video for learning can learn from repeated viewing
Social media also allow targeted of new verbal or nonverbal problem- of video demonstrations without
ads that reflect content that users solving skills.17 This research showed adult help. Dayanim and Namy
have posted on their own pages. In that infants and toddlers experience showed that 15-month-olds could
one study, researchers found that what was referred to as the “video learn the meaning of sign language
placing content related to exercise deficit:” difficulty learning from symbols after 3 weeks of watching
or nutrition as a status update on 2-dimensional video representations a commercially available video 4
Facebook led to advertisements at younger than 30 months of age. times per week.24 However, children
for sports gear and diets as well as The video deficit is thought to be in a comparison study group whose
junk food.15 Thus, social media ads attributable to infants’ and young parents used a book of sign language
can directly address individuals or toddlers’ lack of symbolic thinking, symbols to teach the content retained
groups who would be interested and immature attentional controls, and more knowledge about the symbols’
responsive. Social media ads may the memory flexibility required meanings for a longer period of time.
also be interactive and are more to effectively transfer knowledge
affordable to create and disseminate. from a 2-dimensional platform to a Building parasocial relationships
However, this ability for marketers to 3-dimensional world.18 Before 2 years with TV or video characters (ie, the
reach children through social media of age, children are still developing perceived relationship that audience
is understudied. cognitive, language, sensorimotor, and members develop with characters
Marketing to parents of young social-emotional skills, which require who speak to them, such as Elmo or
children also is common, because hands-on exploration and social Dora) also has been shown to improve
advertisers know that many interaction with trusted caregivers for toddlers’ learning. Calvert et al25
parents fear that their children successful maturation. showed that, after 3 months of playing
may fall behind in the skilled use of with a personalized interactive toy,
technology without early exposure Therefore, adult interaction 21-month-olds could learn how to
to it.16 In reality, parents can be remains crucial for toddlers to learn stack cups from a video demonstration
reassured that their children will effectively from digital media. For by the same character, suggesting
learn to use digital media quickly example, from 12 to 24 months of that building an emotional bond with
when they are introduced at home or age, toddlers can begin to learn novel an on-screen character improves
in school. words from commercially available learning potential. However, a primary
“word learning” videos, but only if limitation of such experimental studies
their parents watch with them and is that they do not examine how
BENEFITS AND OPPORTUNITIES OF reteach the words, essentially using repeated media use displaces other
MEDIA USE the videos as a learning scaffold to activities, and they do not examine
build the language skills.19,20 In one longer-term outcomes. For example, in
Fortunately, new media use is longitudinal study of low-income the study by Calvert and colleagues,25
not without its benefits, but these families, 14-month-olds whose children randomly assigned to
benefits largely depend on a child’s mothers had talked with them during the group that did not receive the
age and developmental stage, a child’s educational TV programming since interactive toy for 3 months actually
characteristics, how the media are infancy showed more advanced scored better in terms of language
used (eg, with a parent or without), language development than infants development at 21 months of age.
and the media content and design. whose mothers did not talk with
Early Childhood them during media use (although Are Touchscreens More Educational?
this finding also may have reflected
At What Age Can Infants and Toddlers how much mothers spoke to children Pedagogic theory has long
Learn From Screens? in general).21 The few experimental emphasized that interaction improves
Evidence continues to show limited studies showing independent learning. This understanding
educational benefits of media for learning of words from videos at this has been the motivation for
children younger than 2 years. age have been limited by their low recommending coviewing of
Earlier American Academy of ecologic validity22 or have shown that media, along with evidence that

parent interaction increases young programs, such as Sesame Street and in the educational section of app
children’s engagement with media Mister Rogers’ Neighborhood) can stores have evidence-based design
and understanding of content.26 demonstrably improve cognitive, input with demonstrated learning
The interactivity of new media via linguistic, and social outcomes effectiveness. In fact, recent reviews
touchscreens allows apps to “know” for children 3 to 5 years of age. of hundreds of toddler/preschooler
whether a child is responding Although there have been few large apps labeled as educational have
accurately and tailor responses, community-based, randomized demonstrated that most apps show
reinforcement, and next steps to the trials, many observational studies low educational potential, target
child’s input. Theoretically, this may and some small experimental ones only rote academic skills (eg, ABCs,
increase educational potential by have demonstrated that preschoolers colors), are not based on established
providing scaffolding to build skills at can learn literacy, numeracy, and curricula, and include almost no
the child’s edge of competence. prosocial skills from high-quality TV input from developmental specialists
programs.31,32 In addition, Sesame or educators.35,36 An additional
Empirical evidence regarding Workshop and other child content concern is that the formal features
interactive media use in infants and creators have been responding (ie, bells and whistles) that are
toddlers is sparse. At 24 months of to current child health and designed to engage the child in an
age, a child can learn words from developmental needs (eg, obesity, interactive experience may actually
live video-chatting with a responsive resilience) by crafting programming decrease the child’s comprehension
adult27 or from carefully designed, aimed at teaching parents and or distract from social interaction
interactive screen interfaces that children relevant knowledge and between caregivers and children
prompt the child to tap on relevant skills. during use, as has been shown
learning items.28 Starting at 15 for e-books,37 which is important,
months of age, toddlers can learn Choosing PBS content has been found because active parent involvement
novel words from touchscreens to be protective of poor executive in both digital play and book reading
in laboratory-based studies (with function outcomes observed in improves children’s learning from
specially designed, not commercial, children who start consuming media the experience.38,39
apps) but have trouble transferring in early infancy.33 Preschoolers
this knowledge to the 3-dimensional randomly assigned to change from One reason that children may be
world,29 particularly if they regularly inappropriate or violent content to less socially engaged during digital
use touchscreen platforms to view high-quality prosocial programming play is that gaming design involves
entertainment media. were found to have significant behavioral reinforcement meant
improvements in their externalizing to achieve a maximum duration of
and internalizing behavior,32 which engagement, which may explain
Is Skyping Appropriate for Infants and
also speaks to the importance of why interrupting children’s digital
Toddlers?
content. For families who find it play leads to tantrums, particularly
Many parents now use video-chat (eg, difficult to modify the overall amount when games or videos are set on
Skype, Facetime) as an interactive of media use in their homes, changing autoadvance.40 To address these
media form that facilitates social to high-quality content may be a concerns, academic and industry
connection with distant relatives. more actionable alternative; to make leaders have recently recommended
New evidence shows that infants and these changes, pediatric providers creating digital products for children
toddlers regularly engage in video- can direct them toward curation that are appropriately engaging, but
chatting,30 but the same principles services, such as Common Sense not distracting; that are designed
regarding need for parental support Media, for reviews of videos, apps, TV to be used by a dual audience (ie,
would apply in order for infants and shows, and movies. both parent and child) to facilitate
toddlers to understand what they are family participation in media use and
seeing. Because video-chat episodes Are “Educational” Apps and e-Books modeling of more effective social and
usually are brief,30 promote social Really Educational? learning interactions35,41; and that
connection, and involve support from have automatic “stops” as the default
As content from PBS high-quality
adults, this practice should not be design to encourage children and
programs is translated into apps and
discouraged in infants and toddlers. caregivers to pause the game use and
game formats (eg, Martha Speaks, Big
turn to the 3-dimensional world.40
Bird’s Words, and Cookie Monster’s
What Is the Best Approach to Selecting Challenge apps), educational benefits One recent app, for example,
Quality Content for Young Children? have been shown in preschoolers.34 demonstrates such an adult–child
High-quality TV programs (eg, Unfortunately, very few of the dyad-centered design. Bedtime Math
Public Broadcasting Service [PBS] commercially available apps found creates a platform and a structure for

parents and children to read stories How Can Social Media Be Used To Social media may be used to enhance
and answer math problems together Promote Improved Health? health and wellness and promote
on a nightly basis. It is one of the healthier behaviors, such as smoking
few apps that has been tested in a Health benefits of social media may cessation and balanced nutrition.44
randomized controlled community- include enhanced access to valuable However, there are a myriad of
based trial and shown benefits.42 support networks. These networks easily accessible Web sites and
Embedding, indeed requiring, social may be particularly helpful for social networks that facilitate and
interactivity for functionality may patients with ongoing illnesses, even promote unhealthy behaviors,
hold great promise for even younger conditions, or disabilities46 as well as such as disordered eating. “Pro-ana”
children as well. However, recent for those identifying as lesbian, gay, (anorexia nervosa) and “pro-mia
population-based surveys suggest bisexual, transgender, questioning, (bulimia)” sites, for example, are
that joint media engagement43 (and or intersex (LGBTQI) seeking forums in which peers actively
designs to facilitate it)35 is not as helpful information or a welcoming support restricted eating or purging
common as individual use. community. Recent literature and frequently offer life-threatening
indicates that transgender teenagers suggestions and advice.49
School-Aged Children and Teenagers who feel supported by their families
Do Screen Time Limits Apply for
How Can Media Use in Older Children have lower rates of depression Children With Disabilities Who Use
and Teenagers Increase Collaboration and anxiety.47 Connections with a Mobile Devices To Communicate?
and Tolerance? supportive online community (eg,
An important benefit from new
the “It Gets Better” project) may be
Research studies as well as anecdotal media has been the development and
beneficial to teenagers who identify
reports have suggested benefits of use of technology-aided interventions
as LGBTQI, but most such programs
media use for today’s children and in children and adolescents with
have not been studied to determine
adolescents, such as communication disabilities, particularly through
effects and outcomes.
and engagement.44 Additional benefits the expanding use of assistive and
include exposure to new ideas and Research also supports the use of interactive digital media to learn and
immersive learning experiences. social media to foster social inclusion to communicate in youth with autism
Many social media platforms provide or peer-to-peer connection among spectrum disorder (ASD),50 physical
tools that students can use to touch patients who might otherwise feel disabilities, speech impairment, and
base with and collaborate with excluded, for example, patients intellectual disability to learn and
others on projects. Communicating with obesity48 or mental illness.13 communicate.51 However, because
across distance is made easier by Individuals with mental illness report teenagers with ASD have higher
social media; these communications greater social connectedness and rates of problematic media use,52,53
may include connecting via video- feelings of group belonging when limits still should be placed on
chatting with family or friends using social media in this manner, entertainment media use, such
who are separated geographically. because they foster the ability to as watching videos or playing
Traditional and social media can also share personal stories and strategies gaming apps, which can represent a
raise awareness of current events for coping with challenges.14 The restricted interest in children with
and issues, and social media can advantages of these connections ASD.
provide tools to promote community include avoiding feared stigma,
participation and civic engagement. enhancing social networks, learning
A study by Kidd and Castano45 about resources from peers online, HEALTH AND DEVELOPMENTAL RISKS
indicated that reading literary fiction and gaining information and OF MEDIA USE
improves empathy in children. insight. However, risks of such
interactions can include exposure What Are the Developmental and
Although books are a traditional
to misinformation, negativity or Behavioral Risks in Early Childhood?
form of media, the study indicates
that exposure to character-focused hostility in communications, delays in Population-based studies continue
media can break stereotypes and seeking out traditional resources, and to show associations between
help children understand people unhealthy influences. excessive TV viewing in early
from whom they differ. Internet Young adults describe the benefits childhood and cognitive,54–56
usage/digital media consumption of seeking health information language,57,58 and social/emotional
is positioned to have a similar online and through social media delays.59–62 Possible mechanisms
impact, which is important to help and recognize these channels as for these outcomes include the
children learn about, understand, and useful supplementary sources of effects of viewing inappropriate,
empathize with marginalized groups. information to health care visits.15 adult-oriented content54 (as well as

some inappropriate child-directed temperament69,70 or self-regulation Studies of older children and
content),58 a decrease in parent–child problems.71 Toddlers with social- teenagers show clear correlations
interaction when the TV is on,63 emotional delays are more likely between increases in hours of TV
and poorer family functioning in to be given a mobile device to calm viewing and higher risk of obesity.80
households with high media use.60 them down,72 especially if their In a 1996 study of 5- to 10-year-olds,
parents are facing parenting control the odds of being overweight were
An earlier age of media use onset,
challenges. However, it is not clear 4.6 times greater for youth watching
greater cumulative hours of media
whether more “difficult” infants more than 5 hours of TV per day
use, and content that is not of
and toddlers have more positive compared with those watching 0 to 2
high quality all are significant
or negative outcomes over time hours.81 This study greatly influenced
independent predictors of poor
when exposed to longer media the AAP recommendations for 2
executive functioning (impulse
duration, which likely depends hours or less of sedentary screen
control, self-regulation, mental
on content quality and other time daily for children 2 through
flexibility)33 as well as “theory of
contextual factors. For example, 18 years of age. However, a more
mind” deficits (ie, the ability to
Linebarger et al73 found that the recent study in the Netherlands of
understand others’ thoughts and
quality of parenting can modify children 4 through 13 years of age
feelings) in preschoolers.64 Media
associations between media use and found that watching TV over 1.5
multitasking, once thought to be a
child development: inappropriate hours per day was a significant
pastime only of only adolescents,
content and inconsistent parenting risk factor for obesity. In this study,
now is observed even in children
had cumulative negative effects on however, an association between
younger than 4 years.13 The orienting
low-income preschoolers’ executive TV and obesity was only found for
response to novel stimuli is very
function, and warm parenting and children 4 through 9 years of age.82
strong in young children, so their
educational content interacted to A large international study with almost
attention is drawn to the engaging
produce additive benefits. 300 000 children and adolescents
and quickly changing features of
found that watching between 1 and
digital media, such as animation,
3 hours of TV a day led to a 10%
sounds, and highlighted features Is Media Use Linked to Obesity? to 27% increase in risk of obesity.83
they can tap and swipe.65 These
High levels of media use are linked These more recent studies suggest
features, however, may decrease
to obesity and cardiovascular risk74 that setting limits of TV viewing to
young children’s comprehension.66
throughout the life course, but these between 1 and 1.5 hours a day
It is unknown whether rapid shifts
associations are observed starting may be more effective to prevent
in attention to and from digital
in early childhood. For example, obesity than the 2 hours per day
stimuli may have long-term effects
heavy media use during preschool standard presented in earlier AAP
on children’s attention span or
years is associated with small but recommendations.
information processing.
significant increases in BMI,75 which
Because strong associations between sets the stage for greater weight gain Additional studies have identified
violent media content and child later in childhood. The association relevant factors around TV viewing
aggressive behavior have been between using ≥2 hours of media per beyond solely the number of hours
clearly documented,67 parents should day and obesity persists even after for families to use in developing
continue to monitor the content of adjusting for children’s psychosocial household rules. Another recent
their children’s media. Today, more risk factors or behavioral problems.76 study found that the association
children own and use mobile devices Research in preschoolers often uses between TV viewing and obesity risk
independently,13 making monitoring a 2-hour cutoff to define excessive was only significant for children who
and regulation much more difficult.16,68 media use, but a recent study of were already at the higher end of
More research is needed on how 2-year-olds found that BMI increased the BMI distribution.84 A large study
parents can best supervise and guide for every hour per week of media using a national dataset of children
their children’s media use. consumed.77 Moreover, media use reported that it was not just the
behaviors may explain some of the hours of TV viewing that predicted
Are Certain Children or Families obesity risk disparities among young obesity, but the combination of
More Susceptible to These Risks? black and Hispanic children.78 None low physical activity and high
TV has been used as an “electronic of these studies examined mobile sedentary TV viewing that was most
babysitter” for decades, but recent media specifically, which may be contributory to obesity risk.85 A
evidence suggests that excessive more easily used during meals and, 2008 study directly examined the
media use is more likely in infants therefore, distract children from AAP recommendations for 2 hours
and toddlers with a “difficult” satiety cues.79 a day or less of sedentary media

consumption and found that boys mobile device in the bedroom in associations between electronic
who exceeded 2 hours a day of early childhood have been associated media use in bed before sleep,
sedentary media use were 1.7 with fewer minutes of sleep per sleep difficulties, and symptoms of
times more likely to be overweight night, especially among children depression in teenagers.
compared with those who had 2 of racial/ethnic minority groups.91
hours a day or less of sedentary Later bedtimes after evening media Daytime screen use may also affect
media use. The results for girls were use and violent content in the media sleep. According to a Norwegian
much less impressive, in that girls also may be contributing factors,92 study, daytime and bedtime use
with over 2 hours a day of sedentary and suppression of endogenous of electronic devices both affected
media use were only 1.2 times more melatonin by blue light emitted from sleep measures, with an increased
likely to be overweight compared screens is another possible cause.93 risk of short sleep duration, long
with girls who had 2 hours or less of Associations between media and sleep onset latency, and increased
media use time.86 sleep are seen in infants as well; 6- to sleep deficiency. A dose–response
12-month-olds who were exposed to relationship emerged between
The association between TV viewing sleep duration and use of electronic
and obesity previously attributed screen media in the evening hours
showed significantly shorter night- devices.100 Ensuring that children
to food advertising87 may now be and teenagers obtain the necessary
decreased, because children watch time sleep duration than those who
had no evening screen exposure.94 hours of healthy sleep is an
more videos from streaming services important goal of a Family Media
(eg, Netflix, Hulu), which do not Studies of older children and Use Plan (www.healthychildren.org/
contain advertisements, but this has teenagers have found that MediaUsePlan).
yet to be studied. participants with higher social media
Another area of obesity risk is the use95 or who sleep with mobile What Are the Risks of Social Media
presence of a TV in the bedroom. A devices in their room96,97 were at Use In School-Aged Children and
2007 study found that having a TV greater risk for sleep disturbances. Teenagers?
in the bedroom was an independent One study of adults found that taking
a phone into the bedroom led to The links between media and health
risk factor for obesity. A more recent behaviors among adolescents
study found that the combination longer sleep latency, worse sleep
quality, more sleep disturbance, have been backed by decades of
of a TV in the bedroom and greater evidence in traditional media.101–104
use of screen time had the strongest and more daytime dysfunction.98
This study illustrates the multiple Studies have shown that exposure
association with obesity.88 to alcohol or tobacco use or risky
mechanisms by which media use
Fortunately, studies also suggest around bedtime, or during bedtime, sexual behaviors in TV or movies is
that making efforts to reduce can disrupt sleep and affect daytime associated with initiation of these
children’s sedentary media use function. behaviors,101,102,105,106 leading some
can have positive health effects. An to describe TV as a “superpeer.”107
intervention study focused on third Bruni et al90 studied the use of A growing body of evidence suggests
and fourth graders worked with the technology on sleep quality in that these influences also are
participants to reduce time spent adolescents and preadolescents. strong in digital and social media.
watching TV and playing video Adolescents’ bad sleep quality was Several studies have illustrated
games. The study demonstrated associated consistently with greater that adolescents’ displays on social
that children in the intervention mobile phone use and the number media frequently include portrayal
group reported reduced TV viewing of devices in the bedroom, and in of risky health behaviors, such as
and meals in front of the TV and preadolescents, bad sleep quality illegal alcohol use or overuse, illicit
had reduced BMIs, illustrating that was associated with greater Internet substance use, high-risk sexual
interventions to reduce sedentary use and later media turn-off time. behaviors, and harmful behaviors,
media use can positively impact The authors concluded that evening such as self-injury and disordered
health behaviors as well as BMI.89 circadian preference, mobile phone eating.108–112 A growing body of
and Internet use, the number of other evidence suggests that peer viewers
activities engaged in after 9:00 PM, of this content are influenced to
How Does Media Use Affect Sleep?
later media turning-off time, and the see these behaviors as normative
There is a growing body of evidence number of devices in the bedroom and desirable.113–115 Social media
that suggests that media use have different, but significant, combine the power of interpersonal
negatively affects sleep.90 Increased negative influences on sleep quality persuasion with the reach of
duration of media exposure and in preadolescents and adolescents.90 mass media. Fogg described this
the presence of a TV, computer, or Similarly, Lemola et al99 reported mass interpersonal persuasion as

“the most significant advance in when more TV viewing displaces Despite efforts by some social media
persuasion since radio was invented real-life experiences that might build sites to protect privacy or even to
in the 1890s.”116 self-esteem. delete content after it is viewed,
The interactive and selective privacy violations and content
Although restrictions exist to protect sharing are always possible.126,127
youth and children from exposure components of social media may
offset some of these traditional media This risk illustrates the need for
to alcohol, tobacco, and marijuana continued discussion about media
advertisements on traditional media drawbacks, because social media
use in moderation can enhance and privacy with children and
platforms, such as TV, there is teenagers with parents, caregivers,
concern about the extent to which social support and connection.
However, use in moderation and the teachers, and other responsible
youth are exposed to promotion of adults. These discussions should be
these substances on social media specific way in which social media
are used may be the key. Previous included in schools through their
Web sites from marketers or peers. digital citizenship programs and in
For example, research from both research has suggested a U-shaped
relationship between Internet use pediatric well-child examinations
the United States and the United with parents and teenagers.
Kingdom indicate that the major and depression, with increased
risks for depression at both the high Pediatricians can introduce and
alcohol brands maintain a strong work with families to develop a
advertising presence on Facebook, and low ends of Internet use.118,119
A recent study examined social Family Media Use Plan (see the AAP
Twitter, and YouTube.13,14 Targeted guide to making a plan at www.
advertising via social media may media use and depression and found
a positive association.120 Older healthychildren.org/MediaUsePlan)
have a significant effect on adolescent that can mitigate or avoid such risks.
behavior. adolescents who used social media
passively by solely viewing content
reported declines in well-being Is Cyberbullying Different From
How Does Media Use in School-Aged Traditional Bullying?
Children and Teenagers Relate to and life satisfaction, whereas those
Mental Health? who used social media actively by Cyberbullying is commonly defined
interacting with others and posting as “an aggressive, intentional
Research studies have identified content did not experience these act or behavior that is carried
both benefits and concerns regarding declines.121 Another study found that out by a group or an individual,
mental health and media use. In one teenagers who used Instagram to using electronic forms of contact,
longitudinal panel survey, 396 white follow strangers and engage in social repeatedly and over time against a
and black preadolescent boys and comparisons had higher depression victim who cannot easily defend him
girls were assessed to determine the symptoms, but others who followed or herself.”128 Unfortunately, there
long-term effects of TV consumption friends and engaged in less social are many online platforms in which
on global self-esteem. TV exposure comparison had fewer depression bullying may take place, including
was found to be significantly related symptoms.122 These studies illustrate E-mail, blogs, social networking
to self-esteem, but whether it that, beyond the number of hours Web sites/apps, online games,
increased or decreased self-esteem spent on social media, a key factor is and text messaging. There is clear
was influenced by demographic how an individual uses social media. overlap between cyberbullying and
factors. Greater exposure resulted in a
traditional bullying,129 but several
decrease in self-esteem for both white
Do Children and Adolescents features of online bullying present
and black girls and for black boys but
Understand the Privacy Risks new challenges. These challenges
resulted in an increase in self-esteem Associated With Social Media Use? include that perpetrators can
for white boys.117 Analyzing these
bully at any time of day and can be
results, the authors postulate that An important issue across all social
anonymous, the rapidity with which
the majority of the TV content served media and interactive apps is privacy,
information can spread online,130
to reinforce both gender-role and because content that a child or
and the fluidity with which bully and
racial stereotypes, which tended to adolescent chooses to post on any
target roles can switch in the online
be positive for white boys but not the site or app becomes public in some
world. Estimates of the number of
other groups. The authors suggested way. Removal of such content may
youth who experience cyberbullying
that the black children and white be difficult or impossible. Previous
vary, ranging from 10% to 40%,
girls could be internalizing the “social work suggests that adolescents vary
depending on the age group and how
norms” portrayed and using these in their understanding of privacy
cyberbullying is defined.
messages as a basis for self-evaluation, practices, and even among those who
negatively affecting their self-esteem. do know how to set privacy settings, Cyberbullying shares many
There is also an opportunity cost many choose not to do so.123–125 similarities and a few key differences

with traditional bullying. For levels of depression and lower self- surveyed, 48.5% of girls and 63.6%
example, victims of cyberbullying esteem. Victims were at higher risk of boys had sent a sext, and 70% of
often do not know who the bully is of both suicidal ideation and suicide girls and 82% of boys had received
or why they are being targeted, the attempts. a sext. The authors report that girls
hurtful actions of a cyberbully can expressed significantly more concern
Fortunately, newer studies suggest
reach a child or teenager anytime than boys about how sexting could
that interventions targeting bullying
he or she uses a smartphone or affect their reputation, including
also may reduce cyberbullying.138
computer (so there is no safe haven getting caught by an adult with a sext
Moreno states: “Parents can play
of home), and the bullying messages and how others would think of them.
a role in preventing cyberbullying
can also spread virally through the Fortunately, 52% of respondents said
by educating their children about
Internet to many other people at they would be comfortable talking
appropriate online behaviors. Parents
school or in the community, making with their doctor about sexting.
should have discussions early and
this type of bullying potentially very Pediatricians may, therefore, find
often about their child’s friendships
embarrassing and lasting. their teen patients receptive to a
and relationships to develop and
conversation about sexting and its
Descriptive research has shown maintain open communication
implications and risks.
that vulnerable populations exist about these topics.”139 The Centers
and are more likely to be targeted for Disease Control and Prevention Ybarra and Mitchell, in their article,
for bullying. Youths identifying panel reviewing effective prevention “‘Sexting’ and its relation to sexual
as LGBTQI are more likely to be strategies recommends media activity and sexual risk behavior in a
victimized in bullying dynamics literacy education as a “promising national survey of adolescents,”142
and are at risk online as well.131 approach,” along with collaborative suggest that sexting is related to
Children and adolescents with strategies among teenagers, parents, behaviors indicative of psychosocial
ASD are a population particularly and schools that encourage victims to challenge and risky sexual behavior
vulnerable to bullying (https://www. report cyberbullying and seek adult for some youth. Significant findings
autismspeaks.org/family-services/ support.140 include a higher frequency of sexting
bullying) and could easily be a target among females and lesbian, gay,
for cyberbullying. The 2016 National What Is Sexting and How Can the and bisexual youth. Additionally,
Academies of Sciences, Engineering, Risks of Sexting Be Avoided or a greater number of past-year sex
and Medicine report, “Preventing Addressed? partners and a greater odds of
Bullying Through Science, Policy, Sexting is a serious issue in depression and substance abuse
and Practice,”132 addressed the adolescence. Sexting is commonly were found among teenagers who
concept of populations vulnerable defined as the electronic sext.
to bullying to propose that there is a transmission of nude or seminude Findings related to lesbian, gay, and
need for research that moves beyond images as well as sexually explicit bisexual populations are consistent
descriptive studies and labeling of text messages.111 It is estimated that with previous studies on sexting;
youth as vulnerable and considers approximately 12% of youth 10 to 19 of note, transgender youth were
processes that can explain why years of age have ever sent a sexual not included. Earlier research
individuals may have differences photo to someone else112; sadly, had demonstrated a significant
in their bullying experiences and many youth who have participated in association between sexting and
consequences depending on their sexting report having felt pressured risky sexual behaviors in lesbian, gay,
context. into sending a sext. When dealing bisexual, and transgender youth.142
Previous studies have examined the with youth and sexting, adults,
negative effects that cyberbullying authorities, and schools need to be Ybarra and Mitchell’s study142 found
can have on both bullies and aware that the situation may be more that sexting was indicative of sexual
victims. Victims are more likely complicated. activity and risky sexual behaviors,
to report lower grades and other Spencer et al141 examined sexting and further research may identify
academic problems as a result of the and youth in an urban population; predictive outcomes of sexting.
experience. Similar to traditional 55 youth presenting for care at the One study suggests that sexting
bullying, cyberbullying can lead to Teen Health Center at Children’s may precede sexual intercourse.142
short- and long-term133,134 negative Hospital Los Angeles were surveyed The predictive value of a sexting
social, academic, and health134–137 to evaluate prevalence and sexting history may inform sex education
consequences for both the behaviors, such as forwarding sexts, and HEEADSSS (home, education
perpetrator and target. Both bullies reasons for sending sexts, and youths’ & employment, eating, activities,
and victims often report higher concerns regarding sexting. Of those drugs, sexuality, suicide/depression,

and safety) assessments. Moreover, and providing safer and less risky Online child sexual exploitation
discussions between pediatricians alternatives for social connections. also may involve recruitment and
and teenagers about sexting may advertisement of children for
indicate risky sexual behaviors and prostitution and other forms of
a number of psychosocial issues, CHILD PORNOGRAPHY AND CHILD exploitation.147 The Internet may
such as depression, anxiety, and ABUSE be used by human traffickers to
low self-esteem, that may be further facilitate movement of victims and to
addressed. How Has Social Media Changed the manage a criminal network.148
Landscape of Child Pornography and
Temple et al143 examined whether Child Abuse? Internet-initiated sex crimes
adolescents who report sexting involving offenders who meet and
Unfortunately, the Internet has groom children online tend to involve
exhibited more psychosocial health also created opportunities for
problems than their nonsexting adolescents rather than very young
the exploitation of children by children: 99% of victims in one
counterparts. The authors reported sex offenders. Online predators
that teen sexting was significantly study were 13 to 17 years old, and
can gain access to children and 48% were 13 to 14 years old. Many
associated with symptoms of teenagers through social networking,
depression, impulsivity, and of these crimes involve face-to-face
chat rooms, E-mail, and online sexual contact, which the victim
substance use. When adjusted for games. Cases of child trafficking,
previous sexual behavior, age, perceives as “consensual.” Sexual
cybergrooming, and sexual abuse relationships in early adolescence
gender, race/ethnicity, and parent for private and commercial
education, however, sexting was only are associated with an increased risk
purposes have increased with the of social, academic, and behavioral
related to impulsivity and substance help of the anonymous cyberspace
use. The authors concluded that adverse outcomes.149,150
environment. For example, online
“while teen sexting appears to grooming leads to establishment of Research has shown that parents
correlate with impulsive and high- a trusting relationship, often with underestimate the likelihood that
risk behaviors (substance use), we the perpetrator misrepresenting their child might engage in online
did not find sexting to be a marker of himself as another child or teenager. conversation with people they do
mental health.”143 This developing online relationship not know. Therefore, it is critical
may lead to sexting or to convincing that parents promote online safety
Sexting is a behavior that will with their children from an early age,
likely continue and expand with the child to meet the perpetrator in
person. Children may be deceived, monitor children’s Internet use, and
technologic advances that make use tools, such as parental control
photography and communication tricked, or coerced into engaging
in sexual acts for the production software, to maintain awareness
more accessible. Active debate of their child’s online activities.151
continues regarding the ethical of child sexual abuse materials
(child pornography), which then Pediatricians should consider
and legal components of sexting, asking appropriate questions to
especially among underage youth. can circulate online for years to
come. Child sexual abuse images explore this possibility and to
Concerns include the identification educate youth about protecting
of sexts as pornography or sexual often involve young and very young
children. Of 43 597 children assessed themselves from exploitation. All
misconduct. Even consensual, health care professionals should
noncoercive sexting may result in in sexual abuse images and videos,
49.6% appeared to have a sexual report any suspicions of sexual
criminal prosecution that may lead to abuse/exploitation as per child abuse
long-term legal consequences. maturity rating of 1, and 28.7%
appeared to have a sexual maturity reporting laws.
Addressing risky sexual behaviors rating of 2.144 Besides the adverse
and psychological symptoms effects associated with child sexual
associated with sexting through abuse,145,146 victims who have had USE OF MEDIA BY PARENTS AND
education and guidance should online sexual images (pornography CAREGIVERS
help to promote wellness and and sexting) posted may experience
responsibility within adolescent significant anxiety and stress related What Effect Does Parent Media Use
populations. Further research to knowledge that the abuse images Have on Young and School-Aged
evaluating sexting among may be downloaded and viewed by Children and Teenagers?
gender minority populations (eg, millions of people for an indefinite Parents and caregivers play an
transgender adolescents) also period of time. Thus, the exploitation important role in modeling optimal
will be valuable in understanding continues for months and years after behaviors for their children in
and discouraging the behavior the images were obtained.144 general, including when it comes to

the consumption and use of media. technology and childrearing, so and understand each family’s values
The growth of digital and social pediatric providers can support and health goals—for example, how
media, particularly in the last 5 their efforts to create boundaries good nutrition, an active lifestyle,
years, has seen dramatic increases in and “unplugged” zones in their good sleep hygiene, parent–child
adults’ use of social media as well as households. emotional connection, and creative
use by children and teenagers; more play fit into the family’s typical day—
than 70% of adults now use social and identify areas in which good
media152 and 27% report feeling THE FAMILY MEDIA USE PLAN health and wellness can be enhanced.
“addicted” to their mobile devices.7 Pediatricians can suggest ways in
Social media can provide positive • How can pediatric health care which media can be used to connect,
social experiences for adults, such as providers help families use media learn, and create instead of simply
opportunities for parents to connect in healthy ways? consume.
with their child in a college dorm • What is the AAP Family Media Use
via video-chatting services. Such These discussions can also allow
Plan? pediatric health care providers to
services also can promote social and
emotional connection among distant Pediatricians and other pediatric consider screening for problematic
relatives or deployed parents and health care professionals can be Internet use and Internet gaming
children. However, some parents can, helpful resources for families seeking disorder using validated tools, such
themselves, overuse digital media. specific advice about how to develop as the Internet Gaming Disorder
For example, research has shown that and individualize family rules and scale (https://www.researchgate.
parents’ own TV viewing distracts guidelines to meet their distinct net/publication/270652917_The_
from parent–child interactions153 and needs. Unfortunately, only 16% of Internet_Gaming_Disorder_Scale) and
children’s play.154 Children younger pediatricians ask families about the Problematic and Risky Internet
than 2 years are more likely to be their media use. In addition, only Use Screening Scale (http://mediad.
exposed to and watch inappropriate 29% of parents report relying on publicbroadcasting.net/p/kplu/
“background” media (eg, TV) than their pediatrician for advice about files/201502/PRIUSS_scale_and_
older children.155 Heavy parent broadcast and social media, although guidelines.pdf).
use of mobile devices is associated those who do tend to follow AAP
If challenges in implementing a
with fewer verbal and nonverbal recommendations.161
media use plan are anticipated,
interactions between parents and When discussing media use with pediatric health care providers can
children156 and may be associated families, pediatric health care consider introducing motivational
with more parent–child conflict.157 providers can print out and help interviewing or engaging in problem
families begin completing the AAP solving with parents and children
Because parent media use is a strong Family Media Use Plan (www. about possible solutions. The
predictor of child media habits,158 healthychildren.org/MediaUsePlan). pediatrician has an opportunity to
reducing parental TV viewing, Providers can discuss with parents discuss specific tools to address
including “background” TV, and and developmentally ready children identified family needs and concerns,
enhancing parent–child interactions how each of the media-specific including social services and
may be an important area of behavior behaviors and health concerns can be community resources, if needed.
change that pediatricians can help addressed through practical, family- Finally, the pediatrician may be able
to facilitate. Because parent–child centered approaches. The Family to provide families with referrals
interactions during family routines Media Use Plan can act as a teaching to educational and informational
are an important opportunity for tool through which pediatricians resources, such as vetted Web sites
emotional connection, have been can provide information about the (eg, www.HealthyChildren.org).
shown to be protective of child benefits and health risks of both
health outcomes, such as asthma and traditional and new media. The
high-risk behavior,159 and are the potential risks of interactive media,
primary driver of early childhood CONCLUSIONS
such as reduced physical activity,
development of language, cognition, inadequate sleep, and unhealthy New digital and social media
social skills, and emotion regulation, influences like cyberbullying and facilitate and promote social
it is important to preserve them. weight bias, are important to discuss interactions as well as participation
Parents often report feeling that with families as well. and engagement that involve both
technology speeds up their lives viewing and creating content. The
and work demands160 and that it The plan also can be a tool through effects of media use, however, are
is difficult to multitask between which the pediatrician can explore multifactorial and depend on the

type of media, the type of use, the LIAISONS Balance. San Francisco, CA: Common
amount and extent of use, and the Kris Kaliebe, MD – American Academy of Child
Sense Media; 2016, Available at
characteristics of the individual and Adolescent Psychiatry https://www.commonsensemedia.
child or adolescent using the media. Jennifer Pomeranz, JD, MPH – American Public org/research/technology-addiction-
Health Association concern-controversy-and-finding-
Children today are growing up
Brian Wilcox, PhD – American Psychological balance. Accessed May 16, 2016
in an era of highly personalized
Association 8. Entertainment Software Association.
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parents should be encouraged to 2015 Sales, Demographic, and Usage
STAFF Data. Essential Facts About the
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Thomas McPheron Computer and Video Game Industry.
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Washington, DC: Entertainment
attend to each child’s age, health, Software Association; 2015
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AAP: American Academy of behavior: concurrent television and
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ASD: autism spectrum disorder 10. Moreno MA, Jelenchick L, Koff R,
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LGBTQI: lesbian, gay, bisexual, Eickhoff JE, Diermyer C, Christakis DA.
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Children and Adolescents and Digital Media
Yolanda (Linda) Reid Chassiakos, Jenny Radesky, Dimitri Christakis, Megan A.
Moreno, Corinn Cross and COUNCIL ON COMMUNICATIONS AND MEDIA
Pediatrics 2016;138;
DOI: 10.1542/peds.2016-2593 originally published online October 21, 2016;
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Children and Adolescents and Digital Media
Yolanda (Linda) Reid Chassiakos, Jenny Radesky, Dimitri Christakis, Megan A.
Moreno, Corinn Cross and COUNCIL ON COMMUNICATIONS AND MEDIA
Pediatrics 2016;138;
DOI: 10.1542/peds.2016-2593 originally published online October 21, 2016;
The online version of this article, along with updated information and services, is
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TECHNICAL REPORT

Children and Adolescents

POTENTIAL CONFLICT OF INTEREST: The authors have

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