LITERATURE REVIEW

Impact of Digital Technologies on Health and Wellbeing of

Children and Adolescents: A Narrative Review
Julie Cullen BHSc (Physiotherapy), PGDip HSc
Paediatric Physiotherapist, Auckland University of Technology, Auckland, New Zealand

Alex Muntz MSc, PhD

Research Fellow, Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand;
Professor, Head of Institute of Optometry, University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland

Samantha Marsh MPH, PhD

Senior Research Fellow, School of Population Health, University of Auckland, Auckland, New Zealand

Lorna Simmonds BSR, DipEd

Massey University, Auckland, New Zealand

Jan Mayes MSc (Audiology)

Independent Author, Vancouver, British Columbia, Canada

Keryn O’Neill BA, MA (Psychology), PGCert (Ed Psych)

Senior Researcher, Brainwave Trust Aotearoa, Auckland, New Zealand

Scott Duncan MSc, PhD

Professor, Behavioural Nutrition and Physical Activity Department, School of Sport and Recreation, Auckland University of
Technology, Auckland, New Zealand

ABSTRACT
As the world digitises, children and adolescents are increasingly using digital technologies. These devices offer benefits such as
exposure to social contacts and support, potential learning opportunities, and access to health promotion material. However, along
with these benefits, emerging evidence is indicating that frequent, extended use of digital technologies is associated with negative
impacts on the health and wellbeing of children and adolescents. There are many ways to use digital technologies both for learning
and recreation, so understanding the context of use is important when considering these impacts. As the pace of change unfolds,
this narrative review provides an overview of the impacts of using digital technologies on the health and wellbeing of children
and adolescents across eight areas: vision, hearing, obesity, pain, sleep, cognition, mental health, and social impacts. Key points
summarise the current state of evidence with relating expert opinion on reducing the risk of harm (where indicated), with the aim
to aid decision-making and risk intervention. Sources include global large-scale studies, systematic reviews, and meta-analyses.
Physiotherapists, with a professional scope focusing on physical health, quality of life, health promotion, and advocacy, are well
positioned to support children and families, and to contribute to interventions aimed at reducing risk.
Cullen, J., Muntz, A., Marsh, S., Simmonds, L., Mayes, J., O’Neill, K., & Duncan, S. (2024). Impact of digital technologies
on health and wellbeing of children and adolescents: A narrative review. New Zealand Journal of Physiotherapy, 52(1),
62–77. https://doi.org/10.15619/nzjp.v52i1.364
Key Words: Adolescent, Child, Digital Technologies, Health, Screen Use, Wellbeing

INTRODUCTION Screen time further increased with the Covid-19 pandemic

response for children and young people (Madigan et al.,
The use of digital technologies (defined in this review as screen-
2022), and recent research suggests that rates of use have not
based digital tools including hand held digital devices and
returned to pre-pandemic levels (Hedderson et al., 2023). Online
computers) is increasing for children and adolescents worldwide.
schooling was rapidly adopted, and a future direction for hybrid
From 2012 to 2018, the global rate of adolescent digital device
schooling has emerged (Raad & Odhabi, 2021). These rapid
use increased from 21 to 35 hours per week (OECD, 2021). In
changes have occurred in a timeframe not matched by policy or
Aotearoa New Zealand, it increased from 22 to 42 hours per
guidance in many countries.
week in the same period (OECD, 2021). In the school setting,
New Zealand students have among the world’s highest use of Digital technologies present both benefits, such as potential for
digital devices and the highest use of internet in class in the educational gain, exposure to social connections and support,
world (IEA, 2019; Medina & McGregor, 2019; OECD, 2015, and access to health promotion information (AAP Council on
2021). Communications and Media, 2016), and risks to young people.

62 | New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1

Risks can include compromise of privacy and confidentiality, adolescents, with the aim to provide a holistic overview
exposure to harmful and inaccurate content, and reduced to aid risk intervention (implementing interventions to
educational outcomes (AAP Council on Communications and reduce associated risks) and decision-making. Pragmatic
Media, 2016; OECD, 2015; Sutcliffe & Webber, 2021). Screen- recommendations developed by subject experts are provided for
based digital tools can be used in many ways, and content and clinicians, educators, and parents, to assist with mitigating risk
context of use can influence potential impacts. This can include and encouraging safer screen use behaviour in education and
(among other factors) different screen media activities, different home settings. These are set broadly due to a wide relevance,
devices, the user’s age and developmental stage, independent or including to physiotherapists. Further to communicating advice
collaborative use, gender, and pre-existing health. While these or delivery of interventions, developing awareness about what
factors are highly relevant, an increasing body of evidence also other professional roles entail can aid referral processes and
shows potential harm to the health and wellbeing of children encourage interdisciplinary and patient-centred approaches.
and youth associated with frequent and extended use of digital Recommendations appear prudent in the context of a growing
technologies (AAP Council on Communications and Media, 2016; body of evidence in this space, the rise in digital screen time
Stewart et al., 2019; Stiglic & Viner, 2019; Wong et al., 2021), compounded by the Covid-19 pandemic (Madigan et al., 2022;
across a wide range of health domains, as summarised in Table 1. Wang et al., 2021), an overall earlier age onset of frequent and
extended screen use (Kabali et al., 2015), and the development
An exact figure after which total screen use (including school
of best-practice guidelines or recommendations for the safer use
and home use over a 24-hour day) can be described as excessive
of digital technologies globally (Appendix B).
remains elusive and difficult to establish. Additionally, both no
or low usage and heavy internet use have been associated with METHODS
adolescent mental and physical health problems (McNaughton,
This narrative review preferentially focused on systematic
2021). Furthermore, screen use duration, content, and quality
reviews, meta-analyses, and large-scale studies with sample
can have an unequal impact on different health and wellbeing
sizes of thousands of participants. Given the large heterogeneity
domains. Figures associated with harm within this review
across disciplines, smaller studies were considered in areas
commonly range from two to six hours of screen use per day for
where a high level of evidence was not available, as highlighted
children over 5 years old, between various studies and reports.
in the results and discussion sections. Areas of child and
While there is considerable variation between these figures, they
adolescent health and wellbeing investigated were those
nonetheless highlight the need for interventions to encourage
associated with using digital technologies in the peer-reviewed
healthier screen behaviours, when considering current rates of
literature to date (Table 1). Databases searched included
total screen use for young New Zealanders.
PubMed, MEDLINE, EBSCO, CINAHL, Cochrane, and Google
Concerns about impacts of excessive screen use have been Scholar. In addition, references were gained from reference
raised by not only parents, health professionals, and educators, lists of sourced articles. The inclusion criteria required studies
but by young people themselves (Jiang, 2018; Sahlburg & to be published between January 2010 to September 2023, in
Graham, 2020). Parents look to schools and health providers for the English language, be peer-reviewed, include participants
information. For physiotherapists and other professionals within aged 0 to 19 years old, and report potential effects of screen
health and education sectors, understanding the evidence use in school and/or the home environment. Publications
base along with available guidance, strategies, and resources were excluded if participants were over 19 years old, or if they
is key to supporting young people to gain benefits from digital focused only on television (TV) use.
technologies, while minimising harms. Physiotherapists, whose
One author (JC) screened the title and/or abstract of the results
professional scope focuses on physical health, quality of life,
and, if meeting criteria, full text articles were acquired. Key
health promotion, and advocacy (using knowledge to promote
words, multiple terms, and Boolean operators are included in
health and wellbeing), are well positioned to support children
Table 2.
and families, and to contribute to interventions aimed at
reducing risk (Appendix A). For mental health and social impacts, a more systematic search
strategy was beyond the scope of this review, and brief narrative
This review sets out to examine the impacts of digital
reviews were included to provide a comprehensive overview.
technologies on the health and wellbeing of children and
Case-reports and conference proceedings were excluded from

Table 1
Areas of Children’s Health and Wellbeing Impacted by Digital Technology Use Reported To Date

Physical Neurological/cognitive Psychosocial

Vision Attention Mental health

Hearing Language Cyberbullying
Obesity Cognition Problematic internet use
Pain syndromes Behaviour Family conflict
Sleep Structural changes Self-harm/sexual harm

New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1 | 63

Table 2
Search Equations Used for This Review

Category Search terms

Vision (child* OR adolescen* OR teen* OR pre-schooler* OR paediatric OR pediatric OR young OR youth)

AND (computer OR digital device OR “screen media” OR “screen use” OR “screen time” OR (electronic OR
digital) AND media)
AND (dry eye* OR computer vision* OR “occular surface disease” OR “ocular dryness” OR keratoconjunctivitis
sicca)
AND (myopi* OR refractive error)
Hearing (child* OR adolescen* OR teen* OR pre-schooler* OR paediatric OR pediatric OR young OR youth)
AND (personal music player OR personal listening device OR headphones OR earbuds)
AND (“hearing loss” OR ‘’hearing risk” OR “noise induced hearing loss” OR “noise-induced hearing loss” OR
NIHL OR hearing threshold* OR hearing problem*)
Obesity (child* OR adolescen* OR teen* OR pre-schooler* OR paediatric OR pediatric OR young OR youth)
AND (computer OR “digital device” OR “screen media” OR “screen use” OR “screen time” OR (electronic OR
digital) AND media)
AND (obesi* OR adipos* OR “weight gain” OR “body mass index”)
Pain (child* OR adolescen* OR teen* OR pre-schooler* OR paediatric OR pediatric OR young OR youth)
AND (computer OR “digital device” OR “screen media” OR “screen use” OR “screen time” OR (electronic OR
digital) AND media))
AND (back pain OR neck pain OR posture OR spinal OR cervical) OR (headache* OR repetitive strain OR
musculoskeletal pain)
Sleep (child* OR adolescen* OR teen* OR pre-schooler* OR paediatric OR pediatric OR young OR youth)
AND (computer OR “digital device” OR “screen media” OR “screen use” OR “screen time” OR (electronic OR
digital) AND media)
AND (sleep OR bedtime routine)
Cognition (child* OR adolescen* OR teen* OR pre-schooler* OR paediatric OR pediatric OR young OR youth)
AND (computer OR “digital device” OR “screen media” OR “screen use” OR “screen time” OR (electronic OR
digital) AND media)
AND (cogniti* OR *attention OR hyperactivity OR ADHD OR behaviour* OR memory)

the review but were utilised for discussion purposes along with Historically, dry eye disease has been seen to predominantly
peer-reviewed New Zealand reports, where appropriate. affect aging populations, with a global prevalence of up to 50%
(Stapleton et al., 2017). Lately, however, dry eye is increasingly
FINDINGS: IMPACTS OF DIGITAL DEVICE USE ON HEALTH
reported among youth as well, primarily in association with
AND WELLBEING
extended screen use, irrespective of content (Muntz et al.,
Dry eye disease and screen use 2021). Several recent studies in children reveal that hours of
Up to 90% of adult computer users report eye discomfort with daily screen use can predict symptoms of discomfort (Akib et al.,
extended screen use (Coles-brennan et al., 2019). The visual, 2021; Alnahdi et al., 2022; Elhusseiny et al., 2021; Moon et al.,
cognitive, and ergonomic demands of screen use interfere with 2014; Moon et al., 2016; Wu et al., 2020). Emerging evidence
the physiological blinking mechanism that drives the production suggests a link between the early age onset of extended
and distribution of tears, to ensure clear, comfortable vision screen use and structural changes in ocular surface health,
(Talens-Estarelles et al., 2021). This protective tear film some irreversible (Cremers et al., 2021; Kawashima & Tsubota,
destabilises and evaporates more quickly as a result of reduced 2013). As such, a purported earlier onset of dry eye disease may
blinking during digital screen use, causing discomfort (Stapleton predispose children and youth to a steeper progression of the
et al., 2017). Over time, these symptoms can aggravate and condition and more severe impacts on quality of life.
contribute to dry eye disease. Digital screen use, given its
Interventions shown to be beneficial in alleviating signs and
pervasiveness, has thus been recognised as a consistent risk
symptoms of dry eye related to screen use include reducing
factor for dry eye disease. This progressive, multifactorial,
time of use, the use of breaks, and re-training habitual blinking
chronic condition involves inflammation, damage of the eye
patterns (Kim et al., 2021; Moon et al., 2014).
surface, discomfort, and visual disturbance (Craig et al., 2017).
Dry eye has been shown to impact patients’ quality of life, Key recommendations:
mental health, work productivity, learning, and the economy
• Limit daily screen time.
(Stapleton et al., 2017).
• Regular breaks (“20 min, take a break”).

64 | New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1

• Education to develop awareness of the relationship between useful, long-term adoption of increased device use could raise
dry eye, screen use, and blinking (“think and blink”). risks to children’s vision (Wong et al., 2021).
• Implement routine clinical screening and intervention Spending time outdoors has been found to have a protective
programmes. role in the development of myopia, although not in its
progression once diagnosed, and encouraging two hours a
Myopia: Risks and protective interventions
day outdoors has been described as a practical public health
Myopia, or “short-sightedness” is a common vision problem that
intervention to lower risk (Wong et al., 2021; Xiong et al.,
causes blurring of distance vision (Martínez-Albert et al., 2023).
2017). In China, government policies restricting screen use
However, myopia has emerged recently as a serious public health
and promoting outdoor time have been implemented to try to
concern; there has been a rise in the prevalence of myopia, as
combat the development of the myopia epidemic (Wong et al.,
well as a progressively younger age of onset and accelerated
2021).
myopic progression (Chua et al., 2016; Foreman, Salim, Koca et
al., 2021; Morgan et al., 2018). Myopia is a significant cause of Key recommendations:
visual impairment and, when diagnosed, steps are taken to slow
• Educate to develop awareness of the relationship between
the progression and risk of developing high levels of myopia (high
myopia, near work, and reduced outdoor time.
myopia), which is associated with blinding pathologies, including
myopic maculopathy, cataracts, and glaucoma. Children with high • Aim for a minimum of two hours per day outdoors.
myopia are at a significantly increased risk of developing these
• Encourage frequent breaks from near work (“20 min, take a
potentially blinding conditions in later life and these risks cannot
break”) and limiting recreational screen use.
be prevented with optical correction (Foster & Jiang, 2014).
Paediatric myopia has reportedly doubled over the last decade, • Encourage outdoor activities at school, and a balance of
with the global prevalence predicted to rise to 50% by 2050. screen-based learning with screen breaks and non-digital
Of note, an estimated 10% will qualify as high myopia, which activities.
exponentially increases the risk of blinding ocular pathology
• Regular vision testing and education on prevention of
(French et al., 2013; Holden et al., 2016).
myopia and interventions.
Factors contributing to the onset and progression of myopia
Noise-induced hearing loss and headphone/earbud use
include genetic risk, reduced exposure to natural sunlight, and
Portable digital devices are now frequently used as personal
near work (including screen time) (Martínez-Albert et al., 2023;
listening devices (PLD) for sounds, speech, and music from
Wong et al., 2021). The link between screen use and myopia
audio-visual and audio sources, including smartphones, tablets,
in children is considered to relate to increased time spent on
laptops, and portable music players (Alcântara et al., 2017;
visual near work, which usually occurs indoors (Watts, 2020).
Gilliver et al., 2017). The popularisation and access to such
When compared to books, children use screens for longer
devices have increased the exposure of young people to higher
periods of time, at younger ages, and may have a closer viewing
levels of noise (Alcântara et al., 2017). Headphone and earbud
distance with small screen size and font (Foreman, Salim, Koca
use with portable digital devices are considered in this section
et al., 2021; Foreman, Salim, Praveen et al., 2021). Screen
as they channel audio directly into the ear when compared to
time is recognised as a modifiable risk in myopia management,
speaker use, creating a greater noise level risk to hearing (World
and advising reduced screen time is common practise among
Health Organization, 2021). Headphones/earbuds are commonly
paediatric ophthalmologists (Zloto et al., 2018).
used by children and teenagers for recreational purposes and
Previous studies on the association between screen time and while studying or doing schoolwork (Gilliver et al., 2017; Le
myopia report mixed results (Lanca et al., 2021). A lack of Clercq et al., 2018). Use can also be required by schools and
association in some of these studies has been ascribed to the along with learning apps, audio books, and video content,
inclusion of television viewing, due to the greater viewing just under half of teenagers report listening to music through
distance compared to a tablet, computer, or phone (Lanca et headphones during school time (Le Clercq et al., 2018; Widen
al., 2021), and the relatively recent emergence of extended et al., 2017).
digital device use in young populations (Foreman, Salim, Koca et
Exposure to loud noise over a brief period, or high levels of
al., 2021). The majority of recent studies (from 2014 onwards)
noise over extended periods, can damage the structure of
showed an association between screen use and myopia
the inner ear, resulting in noise-induced hearing loss (NIHL)
(Alvarez-Peregrina et al., 2020; Enthoven et al., 2019; Enthoven
(Levey et al., 2012). Children have a unique level of risk, as
et al., 2020; Foreman, Salim, Praveen et al., 2021; Harrington
patterns of hearing at the cochleas can have an important role
& O’Dwyer, 2023; Masihuzzaman et al., 2023; Mccrann et al.,
in central auditory development; therefore, loss of peripheral
2021; Mineshita et al., 2021; Saxena et al., 2017; Wang et al.,
hearing could affect central mechanisms of hearing (Harrison,
2021). A review of studies exploring the impact of increased
2008; Levey et al., 2012). In addition, children and adolescents
digital device usage due to lockdown measures on myopia
are considered a noise-sensitive population, more likely at
found that increased screen use, near work, and reduced time
higher risk from harmful noise impacts than exposed adults
outdoors were significantly associated with a progression in
(Fink & Mayes, 2021). Noise-sensitive factors include risk of
myopia (Kaya & Uzel, 2023; Kurupp et al., 2022; Wang et
permanent damage during development of the peripheral and
al., 2021; Wong et al., 2021). This raised concerns that while
central auditory systems, which continues into at least late
temporary online learning from home due to lockdowns was
adolescence. Further, hearing loss has greater consequences for

New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1 | 65

children and adolescents, because early onset can negatively Strength of evidence has been described as weak (Biddle et
impact cognition, speech communication, mental health, al., 2017), to moderate for a dose-dependent relationship with
socialisation, education, and future vocational success (Fink & television and total screen time (Li et al., 2020; Stiglic & Viner,
Mayes, 2021; World Health Organization, 2021). 2019). Duration of screen use associated with obesity ranged
between studies from greater than one hour for children under
The association between headphone/earbud use and NIHL are
24 months, to greater than two to four hours in children older
well accepted by international health bodies and institutes, and
than 24 months.
the World Health Organization (WHO) estimates that 50% of
(or 1.1 billion) young people aged 12 to 35 years are at risk of A number of experimental studies have examined reducing
hearing loss due to prolonged or excessive sound, including screen use to test the relationship between screen use and
through the use of PLD (Mayes & Fink, 2021; Wang et al., 2019; weight, showing a reduction in obesity when screen use is
World Health Organization, 2021). Headphone/earbud users lowered (Biddle et al., 2017; Buchanan et al., 2016; Leung et
have up to a 4-fold risk of developing NIHL than non-users, and al., 2012). However, some interventions addressed diet and
hearing loss has been reported in users as young as 9 years old physical activity in addition to reducing screen time, limiting
(Fink & Mayes, 2021; Le Clercq et al., 2018). Repeated use of interpretation of results (Biddle et al., 2017). Current evidence
headphones/earbuds for more than five years has been found to indicates the importance of consideration of the entire 24-hour
cause high frequency hearing loss (World Health Organization, day (both home and school) when considering the impacts
2019c). of screen time on the activities of children and youth (World
Health Organization, 2019b). Physical activity guidelines in New
The WHO and International Telecommunication Union
Zealand recommend recreational screen time limits for 5 to
recommend volumes for using headphones/earbuds should
17 year olds (see Appendix B) and advise at least one hour of
be set at less than 60% for the general population (which
moderate to vigorous activity per day, along with participating in
equates to approximately 80 dB mean SPL) (Fink & Mayes, 2021;
light physical activities and breaking up sitting time (Ministry of
World Health Organization, 2019c). Safer daily average sound
Health, 2017b).
exposures for the public have been described as 70 dB LAEQ24h or
less (Neitzel & Fligor, 2019; World Health Organization, 2019a), Key recommendations:
with 8-hour equivalent daily average workplace exposures
• Educate that high sedentary screen use can displace health-
at or over 80 dB posing a risk of hearing loss in adults (Fink,
promoting behaviours.
2017). Because young people are considered noise-sensitive
populations, a threshold for children and adolescents to use the • Recommend moderation of screen time along with
lowest functional personal listening volume below 50% (to limit encouraging active behaviours in the paediatric population.
exposure to less than 70 dB LAEQ24h) has been recommended
Back/neck/repetitive strain injury pain syndromes
for a better margin of safety, with health advice that the less
Physical complaints including back and neck pain, recurrent
time on headphones, the lower the risk of hearing loss (Fink &
headaches, and repetitive strain injury (RSI) of the upper limb
Mayes, 2021). Current evidence suggests young headphone/
have been described in relation to high screen use in children
earbud users are at risk of hearing loss, and safe practice at
and youth (Lui et al., 2011; Torsheim et al., 2010; Yue et
home and in schools could reduce harms.
al., 2023), with posture thought to play an aetiological role
Key recommendations: (Straker et al., 2007). While different screen-based activities can
contribute to different ergonomic pressures, using computers
• Educate that the less time on headphones, the lower the risk
and touch screen devices usually involves sitting work in static
of hearing loss.
postures with repetitive upper extremity movements, and can
• Use headphones/earbuds for children at the lowest increase flexion of the cervical spine (Joergensen et al., 2021).
functional personal listening setting (that is, the lowest
Emerging evidence suggests that duration of screen time is
volume they can hear clearly with), generally as low as
associated with back pain in children and adolescents, with
possible below 50% volume (50% volume equates to
evidence of a dose-dependent relationship; however, the level
around 70 dB).
of evidence is weak (Joergensen et al., 2021; Torsheim et
• Regular hearing testing and education on prevention and al., 2010; Yue et al., 2023). Light and visual stimulation has
interventions. been linked to headache and migraine onset, with screen use
identified as a potential trigger (Montagni et al., 2016). Several
Obesity/reduced physical activity
large-scale studies have examined the association between
Insufficient physical activity in children and adolescents has
headache and screen use in young people. Total screen media
been highlighted as a health concern by the WHO, noting
use and time spent using computers was significantly associated
that high screen use displaces more active health-promoting
with headaches (Brindova et al., 2015; Taehtinen et al., 2014;
behaviours (World Health Organization, 2019b). Screen time has
Torsheim et al., 2010), with a dose-dependent relationship
been linked to a risk of obesity in preschoolers, children, and
found in a study investigating 10 to 12 year olds (Taehtinen et
adolescents (Buchanan et al., 2016; Chang et al., 2023; Engberg
al., 2014), providing a weak level of evidence.
et al., 2019, 2020; Fang et al., 2019; Li et al., 2020; Mineshita
et al., 2021; Robinson et al., 2017; Stiglic & Viner, 2019; Tripathi Further research is needed to investigate the association
& Mishra, 2020), although a recent review and meta-analysis between headache and computer/device use, along with RSI
suggests not in central obesity (Ghasemirad et al., 2023). of the upper limb, where only small-scale studies and a weak

66 | New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1

level of evidence currently exists in children. Studies examining as well as “sensitive” periods for some functions, where
headache and musculoskeletal pain have also noted that young experiences may have a greater impact on brain development
people reported rarely receiving information on workstation (Fandakova & Hartley, 2020; Kolb et al., 2017). While measures
layout and ergonomic advice for device use, and education of digital screen time on cognition have been a common focus
alongside appropriate furniture in schools may reduce risks in research, different screen media activities may have different
(Palm et al., 2007; Straker et al., 2007). impacts (Kirlic et al., 2021).
Key recommendations: Large-scale studies and reviews of screen use in excess of
guidelines and cognitive outcomes in children under 6 years
• Ergonomic guidance for the safer use of digital devices
old (including executive control, emotional maturity, inhibitory
should be given to youth, schools, and caregivers, alongside
control, and attention) have shown a trend of negative
appropriate furniture.
association (Corkin et al., 2021; Jourdren et al., 2023; Kerai et
• Encourage a balance of screen and non-screen activities. al., 2022; Reus & Mosley, 2018; Tamana et al., 2019; Wu et
al., 2022). To explore cause and effect, a longitudinal cohort
Sleep disturbance and associated impacts
study explored the directional association of screen time and
Inadequate sleep is associated with numerous poor health
developmental delay in participants at 24, 36, and 60 months,
outcomes (Janssen et al., 2020). Excessive screen use has been
measures of which included communication and socioemotional
linked to sleep disturbance in young people, from infancy to
health. Results supported a directional association between
adolescence (Hale & Guan, 2015; Janssen et al., 2020; Magee
screen time predicting developmental delays, not that children
et al., 2014; Sahlburg & Graham, 2020). Sleep-onset, quality,
who have developmental delays are given more screen time
and duration are noted impacts of screen use, and several
(Madigan et al., 2019).
mechanisms are thought to contribute (Hale & Guan, 2015).
These include through displacement of physical activity and Numerous studies and reviews have indicated language delays
sunlight that may help to regulate sleep, screen-light exposure associated with hours of screen use in infants and toddlers
delaying the release of melatonin leading to disruption of the (Karani et al., 2022; Kerai et al., 2022; Raheem et al., 2023;
circadian rhythm, increased arousal following interactive media Takahashi et al., 2023). A recent meta-analysis, however, found
content before bedtime, and delayed bedtime due to screen use no significant associations between screen time and vocabulary
and nightly alerts. Sleep is particularly important during periods with non-experimental or “natural” media exposure, and
of heightened brain development, such as early childhood and small positive associations with experimental content (content
adolescence. A U-shaped relationship has also been described researchers had created) or educational media exposure (Jing
whereby sedentary screen use leads to delayed sleep, which et al., 2023). Two systematic reviews investigating the impact
increases fatigue resulting in further sedentary activities the of screen use on language skills in children found that greater
following day (Magee et al., 2014). quantity of screen use was associated with lower language skills
(Alamri et al., 2023; Madigan et al., 2020). Educational viewing
While small-scale studies exploring the link between screen use
was positively associated, along with co-viewing and the age of
and sleep at various stages of children’s development show mixed
onset of screen use, suggesting that any language benefits from
results, very few studies showed favourable screen-sleep trends
educational content were likely to occur later in childhood than
(Belmon et al., 2019; Carter et al., 2016; da Silva et al., 2022;
earlier. Authors noted that the quality of educational viewing
Hale & Guan, 2015; Hysing et al., 2015; Janssen et al., 2020;
varied between studies; therefore, caution needed to be taken
Li et al., 2020; Lund et al., 2021; Mei et al., 2018; Mortazavi
in interpreting results to mean that all educational viewing is
et al., 2019). A recent Organization for Economic Cooperation
beneficial. Madigan et al (2020) concluded that “too soon, too
and Development (OECD) report noted that the negative impact
much” screen use negatively impacts language skills for young
of screen time on adolescent sleep duration when objectively
children, along with wider negative impacts of excessive screen
measured was small; however, objective measures from a
use on developmental, behavioural, physical, and learning
large-scale Spanish birth cohort study were contrary to those
outcomes; therefore, high quality viewing should only occur in
referenced (Cabré-Riera et al., 2019; OECD, 2020; Orben &
moderation, with co-viewing advised.
Przybylski, 2020). Further research using objective measures is
needed to explore the impact of screen use on sleep. ADHD symptoms have been found to have a statistically
significant association with screen use in children and
Key recommendations:
adolescents, from meta-analyses and longitudinal studies (Liu
• Promote physical activity and time outdoors. et al., 2023; Nikkelen et al., 2014; Ra et al., 2018; Yifei et al.,
2023). Limitations exist in these studies, however, including
• Advise removing screens from bedrooms and limit bedtime
symptoms measured through self-report and in the absence of
screen use.
a formal diagnosis of ADHD. Further, causality is not inferred,
Cognition: Inattention, language, cognitive function, and and a bidirectional effect has been found between ADHD
behaviour symptoms and screen time, whereby children with symptoms of
The impact of digital technologies on the developing brain is ADHD seek higher screen exposure, which goes on to heighten
an emerging area of research. The brain changes in response symptoms (Yang et al., 2022).
to experiences, undergoing potentially lasting structural and
Conversely, a Dutch longitudinal study found no association
functional change. Young people have a high level of brain
between screen time in the early years and a diagnosis of ADHD
plasticity, particularly in infancy, and again in adolescence,

New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1 | 67

at 8 and 10 years (Levelink et al., 2021). Notably, children in this • Promote a balance of screen and non-screen activities for
study had lower screen time than the previous studies, with an older children and adolescents.
average of 30 minutes per day compared to 1.5 to 3.6 hours at
• Teach healthy screen behaviours to children and adolescents.
age two in similar studies.
Mental health and digital technologies: Moral panic or
The use of TV, social media, and total screen use have been
tangible risk?
negatively associated with cognitive performance, including
Mental health problems in adolescents have increased in recent
fluid and crystalised intelligence, although educational viewing
years, and a connection between the timing of this increase
has been associated with some benefits (Paulus et al., 2019;
coinciding with increased technology use has been drawn
Walsh et al., 2020). Videogaming has mixed reports, including
(Tang et al., 2021; Twenge & Campbell, 2018). A number of
both enhanced and reduced cognitive performance in specific
systematic reviews and meta-analyses have examined this link
areas, both increased and decreased grey matter on magnetic
recently, although from predominantly cross-sectional studies
resonance imaging (MRI) studies of 14 year olds depending
that make causation very difficult to assess. These reviews
on the strategies used for game playing, and increased reward
themselves produce mixed results, from significant associations
centres and neural activity in the reward centres. These latter
to significant but small associations, and several have described
changes have incited concern due to similarities with gambling
the strength of evidence as weak (Santos et al., 2023; Stiglic &
and addictive behaviours (Kühn et al., 2011). Overall, while the
Viner, 2019; Tang et al., 2021; Zou et al., 2021).
majority of participants studied were adults, video games are
thought to have both positive and negative impacts, although A dose-dependent relationship is demonstrated in numerous
gains may depend on age and developmental stage (Gottschalk, studies between excessive screen use and mental health
2019; Kühn et al., 2011; Walsh et al., 2020). problems. While moderate use was not associated with poorer
outcomes, more frequent daily screen use has been found to
The relationship between screen use and brain structure is
be associated with lower reported mental wellbeing. However,
complex (Paulus et al., 2019). MRI studies show neural changes
the amount varies between studies, from more than one or two
associated with total screen media use in children. General screen
hours per day of screen use (Twenge & Campbell, 2018; Khan et
media use over and above the time recommended in guidelines
al., 2021; Kidokoro et al., 2022; Zhang et al., 2020), more than
for pre-schoolers has been associated with lower integrity of
three or four hours of daily screen use (Leung & Torres, 2021;
white matter on MRI studies in areas involved with language
Mougharbel et al., 2023; Yang et al., 2013), and more than six
and emergent literacy skills, as well as poorer performance on
hours per day of screen use (OECD, 2015).
behavioural tests (Hutton et al., 2020). In 9 and 10 year olds,
over seven hours a day of screen use was associated with a Gender impact, with females showing a greater risk factor for
thinner cortex, reduced volume, and difference in sulci depth on screen use and mental health problems, is a trend that has been
MRI, along with reduced fluid and crystalised intelligence and reported in numerous studies (Barthorpe et al., 2020; Leung
mixed changes in cognitive performance, although cause and & Torres, 2021; Nigg et al., 2021; Twenge & Farley, 2021). A
effect cannot be determined (Paulus et al., 2019). positive association between high screen use and emotional
symptoms and reduced emotional understanding in younger
The impacts of screen use on cognition are not well understood
children has also been found in longitudinal studies (Allen
and appear to differ according to screen media activity and
& Vella, 2015; Skalická et al., 2019). Whether screen time is
developmental stage. While some content (such as educational
directly or indirectly (via an impact on sleep) associated with
content) can have benefits in children over 2 years old, studies
depression and anxiety in adolescents has also been explored.
have found that greater time spent on screens is associated with
Leung and Torres (2021) found that more than four hours of
negative impacts on cognition and development. Duration of
screen time was associated with depression and anxiety in
screen use may interfere with experiences needed for healthy
adolescents, and that this was not mediated by sleep.
development such as social contact, physical activity, and sleep,
while displacing non-screen free play and leisure activities that While the use of digital technologies can support wellbeing
enhance cognitive, social, and emotional skills (Kerai et al., (Berger et al., 2022), excessive screen use does appear to have
2022). Guidelines advising no screen use in children under 2 a negative association with mental health outcomes in young
years old, and no more than one hour of high-quality content people, but the strength of evidence is weak. Along with
with co-viewing recommended in children aged 2 to 5 years time spent on screens, gender, pre-existing mental health and
therefore are positioned to minimise harm in these age groups. the type of media matters, and may be more relevant than
Future studies may shed light on this recently explored topic. exposure, with different devices or content impacting results in
several studies.
Key recommendations:
Key recommendations:
• Continue current advice for screen time limits for children
under 5 years old. • Promote a balance of screen and non-screen activities for
older children and adolescents.
• Educate on the importance of high-quality viewing and
recommend co-viewing with children under 5 years old. • Advise removing screens from bedrooms and limit bedtime
screen use.
• Monitor digital screen content for children.
• Educate older children and adolescents about healthy social
media and internet use.

68 | New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1

Social impacts: Cyberbullying, self-harm, sexual harm, (Kay et al., 2017; Sahlburg & Graham, 2020), it is useful to
problematic internet use, and family conflict factor both cumulative home- and school-based screen use
Internet use can have positive social impacts for young people, into a child’s overall screen use when considering balance and
enabling them to connect with like-minded communities, and to holistic wellbeing. While recreational guidelines for screen use
seek support and information (among other benefits). Harmful exist in New Zealand with a focus on time limits (Appendix B)
impacts can also occur, and internet use can negatively impact (Ministry of Health, 2017a, 2017b), current initiatives to address
the health and wellbeing of children and adolescents through screen use in education focus largely on cyber security, reducing
exposure to inappropriate content and pornography, solicitation harmful online content exposure, and cyberbullying (Lee et
and child abuse, cyberbullying, and obsessive or addictive al., 2023; Ministry of Education, 2024). The United Nations
behaviour (see Appendix C) (Sasaki & Hobbs, 2012; Slavtcheva- Educational Scientific and Cultural Organization (UNESCO) has
Petkova et al., 2015). While the severity of harms caused by recently noted the risk that excessive screen exposure through
such online risks can vary from mild to severe, these issues school use can also contribute to exacerbation of overall risk,
impact on the health and wellbeing of high numbers of children and has called for discussion and decision-making to support
and youth, and therefore are important to target. children’s access to safer, fairer, and effective use of technology
(UNESCO, 2023; United Nations General Assembly, 2022).
Key recommendations:
The challenge, however, is that frequent, extended use of
• Utilise netsafety resources within homes and schools, family
digital technologies has become commonplace as screens are
media plans, and supervision of screen use for younger
used for recreation, school, and work. A return to balance may
children to reduce risks of online harm.
benefit the long-term health of children and adolescents. Wise
• Continue existing education programmes to reinforce digital solutions are needed to minimise health risks posed by digital
citizenship and cyber security within schools. technologies, including information about how to engage
with screens positively, and a multi-pronged approach will be
• Legislative change may be required to reduce harms, such as
needed to achieve this (Sahlburg & Graham, 2021; Wilkinson
improving safeguards and enforcing age limits on restricted
et al., 2021). Some health risks may relate more to content
sites.
and context of screen use, while others are associated with
DISCUSSION total screen use (or the displacement of non-screen activities
that may be protective or enhance development). Therefore,
Digital technologies are here to stay and will be an integral part
recommending time limits or a balance of screen and non-
of the future for children and adolescents, as they already are
screen activities may be a component of such advice, dependent
a part of their lives. Digital technologies can offer benefits and
on age and developmental stage of the young person. Further
in themselves are not universally harmful. Exploring the impacts
research is needed to better understand and define what
and examining the ways in which we use technologies may
qualifies as “excessive” screen use and to guide setting “safer”
allow us to maximise their potential and allow young people to
limits for use duration.
gain essential skills.
Limitations
The impact of quantity versus quality of screen media use on
This review is not without limitations. Key data may have been
health is not equivocally accepted, nor fully understood. While
missed through the exclusion of non-English publications.
some suggest that quality is more relevant than quantity, this
The narrow, field-specific focus of many reports hampers the
review found more nuanced relationships. Time spent using
development of a holistic perspective needed for decision-
digital technologies appears to affect some areas of health
making in a timely manner, especially in the absence of
(including dry eye disease, myopia, NIHL, and pain syndromes),
consensus on definitions or methodology (Haby et al., 2016). A
through mechanisms of use and/or displacement of health-
broader search strategy and full systematic approach was limited
promoting behaviours, more than quality of screen media
by the breadth and scope of this analysis. This review therefore
content. Conversely, quality, and type of screen media may
lacks formal assessment of the quality of evidence of included
affect mental health, wellbeing, and cognition, with age
studies, introducing risk of bias. Further research is needed to
and developmental stage as further potential confounding
explore the impacts of digital technologies on the health of
factors (Madigan & Reich, 2023). While content and context
children and adolescents, including longitudinal studies on the
are fundamental, as many excessive activities can be harmful,
impact of recent technologies, and solutions to circumvent the
emerging research indicates that high use of digital screens comes
effects of recall-bias with self-reported values. As the majority
with numerous risks to health. More studies are needed; however,
of studies within this review are international in origin, more
a broad and growing body of literature outlines a range of harms
research is required within New Zealand to ensure transferability
associated with frequent, extended use of digital technologies.
of results, and a cultural understanding of health in the
The impact of educational technology on health specifically context of this population. Research shaped with Indigenous
has not been explored in depth, partly due to its complexity. perspectives of health would not only be more informative with
The use of digital technologies can certainly support learning; balanced and holistic understandings, but would help improve
however, devices can be used diversely, and tasks can be high health access and equity in Indigenous communities in New
value or low value. As educational and recreational use become Zealand and elsewhere.
more intertwined, with homework tasks completed at home
Digital screen use is not a single construct; different screen
online and recreational screen use taking place during class
media activities can have different influences and future research

New Zealand Journal of Physiotherapy | 2024 | Volume 52 | Issue 1 | 69

needs to take this into consideration to more clearly understand ACKNOWLEDGEMENTS
impacts (Kirlic et al., 2021). A reliance on observational research
Dr Yvonne Anderson (Paediatrician, Associate Professor, Faculty
has been noted to limit strength of evidence and proof of
of Medical and Health Science, Paediatrics, University of
causation (Wilkinson et al., 2021). Substantiated evidence
Auckland, New Zealand) for early support, conceptualisation,
through longitudinal, controlled trials is key, if difficult to attain,
and feedback of early drafts of the manuscript.
given the pervasiveness of screens, absence of controls, and
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Appendix A
RELEVANCE OF DIGITAL TECHNOLOGIES TO PAEDIATRIC PHYSIOTHERAPISTS
Understanding the effects of screen use on child/adolescent Beyond these roles, physiotherapy as a profession involves
health is important for physiotherapists. Digital technologies are wider integration of digitalisation in delivery of care. While not
progressing more rapidly than any other innovation in history. the focus of this review, physiotherapists can also utilise digital
Balancing the opportunities they present to young people technologies during sessions for motivation, distraction, physical
against the risk of harms (including harms of excessive use) is a activity, and planning (including use of exercise-based gaming
global priority (United Nations General Assembly, 2022). While software), and for remote delivery of services. Understanding
a broad range of health risks have been found, physiotherapists a child’s daily screen use could therefore influence choice of
also operate across a wide field of practice. Not only is the intervention, and to help shape advice on balance and active
influence of digital technologies on children’s musculoskeletal play. As an example, physical conditions relating to excessive
health relevant, but physiotherapists also work in a varied scope screen use might indicate interventions including patient and
with roles that are less prominent, such as eye health, mental caregiver advice (with reference to recreational screen guidelines
health, obesity, and general population health. Alongside other and/or family media plans), and non-screen based treatments
medical disciplines, physiotherapists are positioned to lead in (Ministry of Health, 2017a, 2017b). Further, treatment ideas
designing health interventions, and their unique skillset brings could be adapted for co-existing conditions, for example,
a valuable perspective to this field. Indeed, guidelines for screen interventions for patients with high screen use and myopia
use for children have often focused strongly on the mind, to could include suggestions for outdoor play. Conversely, digital
the exclusion of the body (Straker et al., 2016). Physiotherapists interventions can allow access or engagement with treatment
currently have active roles not only in providing treatment for that would otherwise be challenging.
health issues directly associated with excessive screen use, but
also in research, health promotion, and guideline development.

Appendix B
BEST PRACTICE GUIDELINES
Best practice guidelines or recommendations for recreational Best-practice guidelines, recommendations, or legislation for
screen use have been developed in numerous countries the safer use of digital technologies in education have been
worldwide, including New Zealand (Ministry of Health, 2017a, developed in numerous countries or states, including among
2017b). Guidelines for recreational screen use in New Zealand others the United States (Department of Legislative Services,
focus on time limits, including advice to discourage screen time 2018; Maryland State Department of Health and Maryland State
for under 2 year olds and to limit screen time for children aged Department of Education, 2019; Virginia General Assembly,
2 to 5 years old to less than one hour per day, noting that “less 2020), China (Cyberspace Administration of China, 2023; The
is best” (Ministry of Health, 2017a). For 5 to 17 year olds, no State Council, The People’s Republic of China, 2018), India
more than 2 hours per day of recreational screen time is advised (Nishank, 2020), and Australia (NSW Government, 2020).
(Ministry of Health, 2017b).
Alongside recent commentary from the United Nations
The American Academy of Pediatrics has moved away from and UNESCO on the impacts of digitisation of education,
advising specific time restrictions for children over 5 years old, Sweden and Denmark, with comparatively high use of digital
instead (1) encouraging families to set and enforce their own technologies in education compared to other wealthy countries,
time limits, (2) providing education on harms of excessive screen are developing guidelines with a view to encourage a balance
use and poor quality screen media content, and (3) providing of learning on and off screens, and to limit screen use in the
advice to support higher-quality screen use (American Academy classroom for younger school-aged students (UNESCO, 2023;
of Pediatrics, 2023). United Nations General Assembly, 2022).

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Appendix C
SOCIAL IMPACTS OF DIGITAL TECHNOLOGIES: RELATIONSHIP OF HARMS TO CONTENT AND DESIGN
Sex-related harm due to online experiences for children and Much has been made of the addictive nature of technology in
adolescents can result from abusive sexting, sexual solicitation, media, coined persuasive design. Fifty percent of adolescents
child pornographic exploitation, child abuse, and viewing of have described themselves as feeling “addicted” to their
pornographic material (whether intentional or unintentional) phones, with 90% agreeing that too much time spent online is
(Slavtcheva-Petkova et al., 2015). Impacts can include the a problem facing their age group, and 60% saying it’s a major
development of problem sexualised behaviours (PSB), early problem (Common Sense Media, 2016; Jiang, 2018). The term
initiation of sexual behaviours, normalisation and desensitisation addiction in relation to technology has been challenged, and
of sexual violence, sexual aggression, and the psychological and the WHO’s addition of Gaming Disorder to the International
physical impacts of abuse (Sasaki & Hobbs, 2012). Compendium of Diseases has been criticised.
Websites promoting dietary restrictions, anorexia, self-harm, and While also controversial, problematic internet use (PIU), defined
suicide can be considered harmful through the normalisation as excessive internet use ultimately leading to distress or
of injurious behaviour and by inciting self-harm (Slavtcheva- impairment, has a reported incidence of 1% to 25% (Restrepo
Petkova et al., 2015). Nearly 50% of children and adolescents et al., 2020). PIU in turn can reduce emotional wellbeing and
aged 8 to 17 years old have reported seeing inappropriate quality of life. Indeed, while mental health diagnosis can be
content online that made them feel worried or upset (Children’s a precursor to PIU, PIU also has been found to predict poor
Commissioner, 2022). mental health (Anderson et al., 2017). Certain populations may
have a greater risk of PIU, including those with a diagnosis of
Cyberbullying is a well-recognised significant public health
Autistic Spectrum Disorder, ADHD, and psychiatric disorders. It
issue for children and adolescents. New Zealand students have
is also suggested that adolescents are at higher risk due to their
the third highest incidence of cyberbullying globally, with a
developing cognitive control mechanisms (Restrepo et al., 2020).
prevalence of 27% compared to an international range reported
Two thirds of parents report struggling to support children
at 14 to 21% (Ipsos, 2018). Cyberbullying increases the risk
to keep balanced screen habits, and 65% of parents report
of suicidal thoughts and attempts in young people, and is
that negotiating screen use causes conflict with their children
associated with declining academic results and post-traumatic
(Sahlburg & Graham, 2021; Sasaki & Hobbs, 2012; Slavtcheva-
stress disorder (PTSD). Students who experienced cyberbullying
Petkova et al., 2015).
were found to be twice as likely to commit suicide as those who
had not (Hinduja & Patchin, 2019).

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