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a
Division of Community Health and Human Development, School of Public Health, University of California Berkeley, WHAT’S KNOWN ON THIS SUBJECT: Inadequate
Berkeley, California; Departments of bNutrition and cSocial and Behavioral Sciences, and ePrevention Research sleep has been identified as a risk factor for
Center, Harvard School of Public Health, Boston, Massachusetts; dTechnische Universität Berlin, Berlin, Germany;
f
National Institute for Children’s Health Quality, Boston, Massachusetts; gBureau of Community Health and obesity and other outcomes. Screen time and the
Prevention, Massachusetts Department of Public Health, Boston, Massachusetts; and hDivision of General presence of a television in the bedroom have
Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston,
Massachusetts been associated with inadequate sleep, but little
is known about small screens
Dr Falbe designed, conceptualized, and carried out the analysis, interpreted the data, and drafted
and revised the manuscript; Dr Davison, Ms Franckle, and Drs Gortmaker, Smith, and Land (eg, smartphones).
contributed to the analysis and interpretation and reviewed and revised the manuscript; Ms Gehre
WHAT THIS STUDY ADDS: Among 2048 fourth-
contributed to acquisition of data and reviewed and revised the manuscript; Dr Taveras contributed
to the design, concept, analysis, and interpretation and reviewed and revised the manuscript; and and seventh-graders, children who slept near
all authors approved the final manuscript as submitted. a small screen reported shorter sleep durations
www.pediatrics.org/cgi/doi/10.1542/peds.2014-2306 and perceived insufficient rest or sleep. Presence
DOI: 10.1542/peds.2014-2306 of a television in the bedroom and more screen
Accepted for publication Nov 10, 2014 time were also associated with poorer sleep.
2 FALBE et al
including small screens Analytic Sample beyond curtailing sleep (eg, by
(eg, smartphones) and TVs, assessed Eligible participants (2061 of 2456) interrupting sleep or shortening rapid
with the following item: “Some kids had complete data on sleep, screens eye movement sleep). Consequently,
use devices to play games or send in their environment, and covariates. to examine associations between
text messages or chats to their Of the 2061 eligible participants, 13 media and aspects of sleep beyond
friends like cell phones, were excluded because of implausible duration, model 3, a model with
smartphones, and the iPod Touch. sleep durations (ie, ,3 hours or perceived insufficient rest or sleep as
How often do you sleep with one of .16 hours).34 Therefore, our primary the outcome, additionally adjusted for
these devices near where you sleep, analytic sample consisted of 2048 sleep duration. We conducted
such as in your bed or next to your children. Our sample for examining analyses by using SAS (version 9.3;
bed?” Response options ranged from TV or DVD viewing and video or SAS Institute, Inc, Cary, NC).
0 to 7 days and were dichotomized computer game playing consisted of
as ever and never in the main 1908 youth with complete and
analysis because of the strongly RESULTS
plausible screen times (71 youth with
bimodal distribution. However, we TV or DVD or gaming time .3 SDs Mean age 6 SD of the sample
also examined exposure as from the mean were excluded). (Table 1) was 10.6 6 1.5 years.
a continuous variable. We Hispanic (40%), non-Hispanic white
determined presence of a TV in the Statistical Analyses (38%), and non-Hispanic black (10%)
sleep environment by asking, “Is were the predominant racial and
there a television in the room where Using multivariate linear regression, ethnic groups. The majority reported
you sleep?” We assessed additional we examined associations of screens sleeping near small screens (54%)
exposures (TV or DVD viewing and in children’s sleep environments and and in a room with a TV (75%).
video or computer games in the past screen time with sleep duration, A higher proportion of seventh-graders
week) by asking how much time bedtime, and waketime. Multivariate (65%) reported sleeping near a small
students spent with each on a usual log binomial regression35 was used to screen than fourth-graders (46%).
weekday and weekend in the past examine associations between Seventh-graders also reported
week. Moderate validity has been screens in children’s sleep shorter sleep durations (8.8 hours)
reported for similar surveys of child- environments and perceived than fourth-graders (9.8 hours) but
reported screen time.32,33 insufficient rest or sleep. We used were less likely to have perceived
generalized estimating equations for insufficient rest or sleep.
Covariates included self-reported estimation, specifying an
gender, grade, race or ethnicity, and exchangeable covariance structure to Associations between screens in sleep
physical activity. Students described account for clustering by school.36,37 environments and sleep duration are
their race or ethnicity by selecting presented in Table 2. Described
$1 options (white, black or African For each outcome, we ran partially here are results from fully adjusted
American, Hispanic or Latino, Asian, (model 1) and fully adjusted (model models (model 2). Children who slept
Native Hawaiian or other Pacific 2) models. Model 1 adjusted for near a small screen reported 20.6
Islander, American Indian or Alaska gender, grade, race or ethnicity, and fewer minutes of sleep per weekday in
Native, or other). Race or ethnicity city. Model 2 additionally adjusted for the past week (95% confidence
was categorized into Hispanic, non- physical activity, and when exposures interval [CI], 229.7 to 211.4) than
Hispanic white, non-Hispanic black, were screens in the sleep those who never slept near a small
non-Hispanic other (because of small environment, model 2 simultaneously screen, independent of having a TV in
numbers), and non-Hispanic examined presence of small screens the room. When modeled as
multiracial. We assessed physical and a TV in the same model; when a continuous variable, each additional
activity by asking on which days in exposures were screen time, model day of sleeping near a small screen was
the last week students took part in 2 simultaneously included hours per associated with 3.7 fewer minutes of
physical activity that made their heart day of TV or DVDs and video or sleep per weekday (95% CI, 25.4 to
beat fast or made them breathe computer games. We examined 22.0). Children who slept in a room
hard for $30 minutes. Days were heterogeneity by grade, gender, with a TV reported 18.0 fewer minutes
summed and modeled continuously. physical activity, and race or ethnicity of weekday sleep (95% CI, 227.9 to
Physical activity was included as and tested for interaction between 28.1) than those without a TV in their
a covariate to reduce confounding by presence of a small screen and a TV room, independent of small screens.
common determinants of screen time by including cross-products of these For non-Hispanic black youth, sleeping
and physical activity terms in model 2. near a small screen was associated
(eg, socioeconomic status [SES], Additionally, small screens can affect with an additional 30.8 fewer minutes
parenting). perceived insufficient rest or sleep of weekday sleep (95% CI, 252.8 to
4 FALBE et al
TABLE 2 Associations of Screens in Children’s Sleep Environment and Screen Time With Typical and between TV or DVD viewing and
Weekday Daily Sleep Duration in the Past Week perceived insufficient rest or sleep
Weekday Sleep Duration, min were stronger for seventh-graders
Model 1 (partially Model 2 (fully than fourth-graders. Lastly, physical
adjusted)a adjusted)b activity attenuated the association
between video or computer games
b (95% CI) b (95% CI)
and perceived insufficient rest or
Presence of screen in sleep environment sleep. Although most studies of
(n = 2048)
stressors related to race or ethnicity
Small screenc 222.6*** (231.3 to 213.8) 220.6*** (229.7 to 211.4)
TVd 221.3*** (230.5 to 212.1) 218.0*** (227.9 to 28.1) and sleep have been conducted among
Screen time, h/d (n = 1908) adults, it is possible that similar
TV or DVDs 24.8*** (26.4 to 23.2) 23.6*** (25.3 to 21.9) stressors increase youth’s
Video or computer games 26.0*** (28.1 to 23.9) 25.1*** (27.4 to 22.7) vulnerability to effects of screens on
a Results from multivariate linear regression models using generalized estimating equations for estimation, adjusted for sleep. Shorter sleep durations have
grade, gender, race or ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, non-Hispanic other, non-Hispanic
multiracial), and city.
been documented among racial or
b Additionally adjusted for days in past week participated in $30 min of physical activity, simultaneously included ethnic minorities,38–40 and
indicators for presence of a small screen and TV in the child’s sleep environment for models examining screens in the discrimination may partially mediate
sleep environment, and simultaneously included hours per day of TV or DVD viewing and video or computer game playing
in models examining screen time.
these differences.40 Other
c The reference group reported never sleeping near a small screen in the past week. psychosocial stressors associated with
d The reference group reported there was not a TV in the room in which they sleep.
sleep problems (eg, SES, relationship
***P , .001.
stress, neighborhood disorder, abuse,
and stressful life events)40 may have
insufficient rest or rest or sleep in the some groups. Small screens were also been more common among
past week. TV or DVD viewing and associated with shorter sleep minorities in our sample. Stronger
video or computer game playing were duration among non-Hispanic black associations observed for older youth
associated with shorter weekday may have been accounted for by
compared with non-Hispanic white
differences in content or timing. For
sleep duration and perceived children. Having a small screen or TV
example, seventh-graders may watch
insufficient rest or sleep. Children in the sleep environment was more violent or stress-inducing
with more screen time also had later associated with later bedtimes among programs and at later times than
bedtimes. non-Hispanic black and Hispanic fourth-graders, increasing impacts of
The large size of our sample enabled compared with non-Hispanic white screens on sleep. Lastly, physical
us to detect stronger associations children. Associations between activity has been associated with
between screens and sleep among presence of a TV and later bedtime better sleep quality,41,42
FIGURE 1
Differences by race or ethnicity in the associations between screens in the sleep environment and weekday sleep duration and bedtime estimated from
fully adjusted models (model 2). A, Minutes of sleep duration associated with sleeping near a small screen. B, Bedtime (minutes) associated with sleeping
near a small screen. C, Bedtime (minutes) associated with sleeping in a room with a TV. P values for differences in associations compared with non-
Hispanic white youth: aP , .05, bP , .01, cP , .001.
indicators for presence of a small screen and TV in the child’s sleep environment for models examining screens in the For all media, additional mechanisms
sleep environment, and simultaneously included hours per day of TV or DVD viewing and video or computer game playing that may underlie the screen–sleep
in models examining screen time. relationship include direct
c The reference group reported never sleeping near a small screen in the past week.
d The reference group reported there was not a TV in the room in which they sleep. displacement of sleep or of behaviors
**P , .01, ***P , .001. that may promote sleep with screen
6 FALBE et al
time; consumption of heavily potentially important confounders, a small screen and those with more
advertised beverages containing such as SES, parenting style screen time were more likely to
caffeine; evening exposure to bright, (eg, permissive parenting), or the have perceived insufficient rest or
short-wavelength light interfering with overscheduling of youth. This study sleep in the past week. Although
circadian rhythm40,41; or increased also has several strengths. It longitudinal and experimental
cognitive, physiologic, and emotional included a large, racially and studies are needed to confirm these
arousal14 after playing a video game,49 ethnically diverse sample, associations, our findings caution
watching an exciting movie or show, or investigated differences by grade, against children’s unfettered access
sending chats or texts. gender, and race or ethnicity, and to screen-based media in their
The primary limitation of this study helped to address the dearth of rooms. Future studies should
is its cross-sectional design, limiting studies assessing small screens and incorporate detailed assessments of
our ability to make causal sleep. screen content to identify the types
inferences. Although longitudinal most strongly related to poor
evidence indicates that screens CONCLUSIONS sleep. Longitudinal studies should
affect subsequent sleep, the Among a diverse sample of also continue to examine the
relationship may be bidirectional. Massachusetts fourth- and seventh- mediating contribution of sleep to
Another limitation is that measures grade public school students, the screen time’s impact on obesity and
were self-reported, introducing presence of small screens and TVs other outcomes.
random error and possible social in sleep environments and the use
desirability bias. Additionally, we of TV or DVDs and video or ACKNOWLEDGMENTS
did not measure weekend sleep computer games were associated The authors thank the thousands of
duration or media content, nor did with shorter weekday sleep students who participated in
we assess and therefore adjust for duration. Children who slept near MA-CORD.
Address correspondence to Jennifer Falbe, ScD, MPH, 50 University Hall #7360, Berkeley, CA 94720-7360. E-mail: jfalbe@berkeley.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2015 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (award
U18DP003370). Dr Falbe’s work was supported by the National Institutes of Health Training Grant in Academic Nutrition (DK007703) and the American Heart
Association Postdoctoral Fellowship (14POST20140055). The contents of this study are solely the responsibility of the authors and do not necessarily represent the
official views of the listed funding sources. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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