Original Investigation | Pediatrics

Screen Media Use and Mental Health of Children and Adolescents

A Secondary Analysis of a Randomized Clinical Trial
Jesper Schmidt-Persson, PhD; Martin Gillies Banke Rasmussen, PhD; Sarah Overgaard Sørensen, MSc; Sofie Rath Mortensen, MSc; Line Grønholt Olesen, PhD;
Søren Brage, PhD; Peter Lund Kristensen, PhD; Niels Bilenberg, PhD; Anders Grøntved, PhD

Abstract Key Points

Question Does reducing leisure-time
IMPORTANCE Excessive screen media use has been associated with poorer mental health among
screen media use improve mental health
children and adolescents in several observational studies. However, experimental evidence
among children and adolescents?
supporting this hypothesis is lacking.
Findings In this prespecified secondary
OBJECTIVE To investigate the effects of a 2-week screen media reduction intervention on children’s analysis of a randomized clinical trial
and adolescents’ mental health. including 89 families (181 children and
adolescents), reducing screen media use
DESIGN, SETTING, AND PARTICIPANTS This prespecified secondary analysis of a cluster had an overall positive effect on
randomized clinical trial with a 2-week follow-up included 89 families (with 181 children and children’s and adolescents’ behavioral
adolescents) from 10 Danish municipalities in the region of Southern Denmark. All study procedures difficulties. The most noticeable
were carried out in the home of the participants. Enrollment began on June 6, 2019, and ended on benefits associated with reduced screen
March 30, 2021. This analysis was conducted between January 1 and November 30, 2023. media use was a decrease in
internalizing behavioral issues and
INTERVENTION Families were randomly allocated to a screen media reduction group or a control enhanced positive social interactions.
group. The 2-week screen media reduction intervention was designed to ensure a high level of
Meaning The findings provide evidence
compliance to the reduction in leisure-time screen media use. Participants allocated to the
for a causal link between a short-term
intervention group had to reduce their leisure-time screen media use to 3 hours per week or less per
reduction in screen media use during
person and hand over smartphones and tablets.
leisure and improvements in children’s
and adolescents’ psychological
MAIN OUTCOMES AND MEASURES The main outcome was the between-group mean difference
symptoms.
in change in total behavioral difficulties, measured by the Strengths and Difficulties Questionnaire at
2-week follow-up. Results were estimated using mixed-effects tobit regression models. Analyses
were carried out as both intention to treat and complete case. + Visual Abstract
RESULTS In the sample of 89 families including 181 children and adolescents (intervention group [45
+ Invited Commentary
families]: 86 children; mean [SD] age, 8.6 [2.7] years; 42 girls [49%]; control group [44 families]: 95 + Supplemental content
children; mean [SD] age, 9.5 [2.5] years; 57 girls [60%]), there was a statistically significant between- Author affiliations and article information are
group mean difference in the total difficulties score, favoring the screen media reduction listed at the end of this article.

intervention (−1.67; 95% CI, −2.68 to −0.67; Cohen d, 0.53). The greatest improvements were
observed for internalizing symptoms (emotional symptoms and peer problems; between-group
mean difference, −1.03; 95% CI, −1.76 to −0.29) and prosocial behavior (between-group mean
difference, 0.84; 95% CI, 0.39-1.30).

CONCLUSIONS AND RELEVANCE This secondary analysis of a randomized clinical trial found that a
short-term reduction in leisure-time screen media use within families positively affected
psychological symptoms of children and adolescents, particularly by mitigating internalizing
behavioral issues and enhancing prosocial behavior. More research is needed to confirm whether
these effects are sustainable in the long term.

(continued)

Open Access. This is an open access article distributed under the terms of the CC-BY License.

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Abstract (continued)

TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04098913

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Introduction
The proportion of children and adolescents with poor mental health has increased over the past
years in many countries.1-4 In the US, the number of adolescents reporting poor mental health during
the past month was 29% in the 2021 Youth Risk Behavior Survey.5 Based on data from 45 European
countries, 25% of 11- to 15-year-old adolescents reported symptoms related to psychological health
(such as nervousness, irritability, and difficulties falling asleep).6 Individuals are particularly
vulnerable to negative or stressful environmental experiences during adolescence.7 Furthermore,
research shows that self-reported life satisfaction has the steepest decrease during adolescence
compared with other stages of the lifespan.8
The past decades have brought substantial advancements in digital technology, and more
children and adolescents have their own personal screen media devices.9-11 Use of screen media
devices has become a central aspect in children’s and adolescents’ daily lives, offering endless
options for entertainment including watching videos, gaming, social media interaction, and
communicating with family and friends.9-11 Screen media use is a complex and broad construct that
includes active and passive engagement with different types of devices and content.12 Although the
use of screen media devices, particularly smartphones, can facilitate many daily activities and some
social interactions, concerns have been raised over the past years about the potential negative effect
of digital screen media use on children’s and adolescents’ mental health,13 yet the research is still
sparse and remains inconclusive.14-20 Some observational studies find moderate-sized associations
between high levels of screen media use and poor mental health,15,21 while some researchers claim
that observed associations are too weak to have any societal relevance.17 A recent systematic review
and meta-analysis of 87 studies on the association between children’s screen media use and
internalizing and externalizing symptoms found small but significant positive associations,
suggesting that higher levels of screen media use might be associated with more behavioral
problems.22 However, all the included studies were observational and based mainly on self-reported
measures of screen media use. Thus, carefully designed randomized clinical trials are warranted to
investigate the potential short-term and long-term effects of reducing screen media use on children’s
and adolescents’ mental health. The present study focuses on the short term and investigates the
effect of a family-based, 2-week break from leisure-time screen media use on children’s and
adolescents’ mental health.

Methods
Study Design
This study is a prespecified secondary analysis of the SCREENS (Short-term Efficacy of Reducing
Screen-Based Media Use) trial, which is a parallel cluster randomized clinical trial (study protocol
available in Supplement 1).23 Results for the primary outcome of the SCREENS trial and a secondary
analysis have previously been reported.24,25 The primary outcome analysis revealed that children
and adolescents allocated to the screen media reduction group increased their nonsedentary leisure
time by 45 minutes per day compared with children and adolescents in the control group.24 In the
present study, we report the results for children’s and adolescents’ behavioral strengths and
difficulties based on data from the Strengths and Difficulties Questionnaire (SDQ).26,27 The SDQ has
been found to be a useful measure of young people’s mental health.27 The trial design was developed
on the basis of the results and experiences from the pilot trial.28 Family enrollment started on

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June 6, 2019, and the final follow-up assessments were completed on March 30, 2021. Ethical
approval for the SCREENS trial was granted by the Ethical Committee of Southern Denmark. All
families provided written informed consent before undergoing any assessments; parents provided
consent verbally and in writing on behalf of their children, but children were present and could ask
questions to their parents and the research staff. Signs of child dissent were considered
contraindicatory to participation. This study is reported in compliance with the Consolidated
Standards of Reporting Trials (CONSORT) reporting guideline and statement for cluster
randomized trials.

Participants
We recruited families from a population-based survey concerning family screen media habits.11,29 A
survey invitation was sent to parents with at least 1 child aged 6 to 10 years in 10 municipalities in the
region of Southern Denmark.11 Recipients of the survey were randomly selected by the Danish Health
Data Authority using data from the Danish Civil Registration system. At the end of the survey,
responders were asked to answer (yes or no) whether they were interested in receiving more
information about another study: a family-based screen media reduction trial. We assessed families’
eligibility among respondents who answered yes. Initial eligibility criteria were that the respondent
parent had to have leisure-time screen media use above the 40th percentile (based on the first 1000
responses) and have a full-time job or study full time. We excluded families with children younger
than 4 years of age living in the household. A research team member telephoned the family if these
criteria were fulfilled, to confirm that at least 1 child and 1 adult in the household wanted to
participate and were able to hand over smartphones and tablets to the researchers. The study also
included a measurement of physical activity using accelerometers. Therefore, participants were not
eligible if they could not engage in regular physical activities of daily life, had a sleep disorder, or had
any neuropsychiatric or developmental disorders.

Randomization Procedure
The randomization was performed on day 8 of the trial after completion of baseline assessments in
the families’ homes. A web-based randomization platform operated by a third party (Odense Patient
Data Explorative Network) was used to perform the randomization. The Odense Patient Data
Explorative Network generated the random sequence in blocks of 2 to 4 families and ensured
allocation concealment until a family was assigned to a group. We chose to randomize and intervene
on a family level rather than based on individuals to increase compliance with the intervention and
decrease potential contamination between experimental conditions.

Intervention
The aim of the trial was to compare a reduction in leisure-time screen media use (intervention) with
usual leisure-time screen media use (control) in families with children. The intervention lasted for 2
weeks and consisted of the following elements. All children and at least 1 adult (preferably all adults in
the household) had to hand over smartphones or tablets during the 2 weeks of the intervention.
They were also asked to reduce their leisure-time screen media use (all use of screen media devices
outside self-reported work and school hours) on other devices, such as televisions and computers, to
3 hours per week or less. Participants who handed over their smartphone received a
non-smartphone in return that could call and send text messages. Participants were asked to register
all leisure-time screen media use during the intervention. Small intervention reminder posters were
put up in the household, and each family received a small financial reimbursement of approximately
€70 (US $76). Participants were allowed 30 minutes per day of necessary screen media use to enable
coordination of appointments, completion of school assignments, and other necessary tasks.
Necessary screen media use was not considered a part of their leisure-time screen media use. A more
detailed description of the intervention and the theoretical framework underpinning the
intervention is described in the study protocol.23 Families allocated to the control group were asked

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to carry on with their usual screen media habits until they completed the follow-up measurements,
at which time they would be offered to try the intervention condition.

Intervention Compliance
As outlined in the previous study,24 we evaluated adherence to the screen media reduction
intervention using objective measures, including research-based smartphone and tablet tracker
applications,30 PC software, and television monitors. In the screen media use reduction group, 97%
of the children and adolescents (83 of 86) were sufficiently compliant to the intervention, defined
a priori as having less than or equal to 7 hours per week of leisure-time screen media use to ensure a
distinct contrast with the control group, while allowing for a marginal deviation from the target.24

Outcomes
We administrated the SDQ as part of a larger questionnaire at both baseline and follow-up to assess
changes in children’s and adolescents’ behavioral strengths and difficulties. The SDQ has been found
to be valid and suitable for use in randomized clinical trials.31,32 Parents answered the questionnaire
on behalf of their children at the start of the baseline protocol before randomization and at follow-up
(at the end of the intervention), with 21 days between assessments. At baseline, parents were asked
to report based on the previous 6 months, and at follow-up, they were asked to report based on the
past 2 weeks. A digital link to an age-appropriate Danish version of the SDQ (versions: 2-4 years, 5-6
years [not in school], 4-10 years [in school], and 11-17 years) was sent to the parents via email. The
SDQ consists of 25 items (eg, “Considerate of other people’s feelings”) for which parents have to
answer 1 of the following 3 categories: not true (scored as 0), somewhat true (scored as 1), and
certainly true (scored as 2). Five items were scored in the reverse order (ie, not true [scored as 2],
somewhat true [scored as 1], and certainly true [scored as 0]). Items were then summarized into 5
different subscales (ie, emotional symptoms, conduct problems, hyperactivity or inattention, peer
problems, and prosocial behavior). A higher score denotes more behavioral difficulties, except in the
case of the prosocial behavior score, in which a higher score indicates favorable behavior.
Externalizing symptoms (score range, 0-20 points) were calculated as the sum of the conduct
problems and the hyperactivity or inattention scales. Internalizing symptoms (score range, 0-20
points) were calculated as the sum of the emotional symptoms and peer problems scales. Total
difficulties (score range, 0-40 points) were generated by summing all subscales except for the
prosocial behavior scale.

Statistical Analysis
Statistical analysis was conducted between January 1 and November 30, 2023. We constructed violin
plots to depict the distribution for the SDQ scores for total difficulties, internalizing symptoms, and
externalizing symptoms among both groups at baseline. Mixed-effects tobit regression models were
used to estimate the between-group mean differences in the total difficulties score, externalizing
score, internalizing score, emotional symptoms, conduct problems, hyperactivity or inattention, peer
problems, and prosocial behavior, with family ID as a random effect to account for the clustered
design of the study. Tobit regression was used to account for potential floor effects,33 with values
censored at 0 (lower limit) because scores were low at baseline among many participants. All models
were adjusted for age because there was a slight imbalance between groups at baseline. Analyses
were carried out as intention to treat, and 95% CIs were estimated. We report complete-case
analyses for all outcomes, and for the primary analysis (change in total difficulties score), we also
report a sensitivity analysis in which missing change scores were imputed for 20 of 181 participants
(11%) with missing SDQ data at baseline and/or follow-up using multiple imputation by chained
equations with 20 imputed datasets.34 The imputation model included biological sex, age, total
leisure-time screen media use at baseline, parental educational level, and child’s body mass index z
score. We also conducted post hoc subgroup analyses for the total difficulties score, examining
statistical interactions based on biological sex, age groups, and baseline amount of leisure-time

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screen media use. We examined assumptions of mixed-effects tobit regression models and found no
violations. Statistical analyses were carried out using Stata, version 18 (StataCorp LLC). All P values
were from 2-sided tests, and results were deemed statistically significant at P < .05. A per-protocol
analysis was not carried out due to near perfect compliance.

Results
The flow of study participants has been described in detail elsewhere24 and is presented in the
eFigure in Supplement 2. In summary, we found 408 eligible families among 1420 interested families
identified from a population-based survey concerning screen media behaviors in families with
children.11 A total of 92 families agreed to participate in the trial and completed baseline assessments.
Three families dropped out after baseline assessments, and 89 families (including a total of 181
children) were randomized to either the screen media reduction group (45 families [86 children]:
mean [SD] age, 8.6 [2.7] years; 42 girls [49%] and 44 boys [51%]) or the control group (44 families
[95 children]: mean [SD] age, 9.5 [2.5] years; 57 girls [60%] and 38 boys [40%]) (Table). Baseline
characteristics were generally similar across the 2 groups.
The violin plots (Figure 1) illustrate that the distributions of the total difficulties scores,
internalizing symptoms scores, and externalizing symptoms scores were similar between groups at
baseline. A substantial number of participants registered a baseline value of zero for each of these
outcomes. Moreover, most children’s scores fell within the normal range for Danish children aged 5 to
17 years.35,36
A total of 8 participants (4%) had missing SDQ data at baseline, and 19 participants (11%) had
missing SDQ data at follow-up. Of those who had missing SDQ data at follow-up, 9 participants were
from the screen media reduction group, and 10 participants were from the control group.
Participants with missing SDQ data at follow-up had a mean (SD) age of 9.3 (3.0) years, and 67% (8
of 12) were girls (eTable 1 in Supplement 2). Total difficulties scores were similar for participants with
missing data at follow-up compared with those with complete data at baseline and follow-up.

Table. Baseline Characteristicsa

Control Intervention
Characteristic (n = 44 families) (n = 45 families)
Children, No. 95 86
Age, mean (SD) [range], y 9.5 (2.5) [4-15] 8.6 (2.7) [4-17]
Sex, No./total No. (%)
Female 57/95 (60) 42/86 (49)
Male 38/95 (40) 44/86 (51)
BMI z score, mean (SD) 0.1 (1.2) 0.2 (1.0)
Leisure-time smartphone or tablet use, median (IQR), h/wk 9.6 (3.1-15.9) 10.4 (3.6-19.7)
Leisure-time computer use, median (IQR), h/wk 10.1 (6.0-19.7) 9.4 (2.1-27.0)
Leisure-time television use, median (IQR), h/wk 4.7 (1.5-10.2) 6.2 (2.4-9.6) Abbreviations: BMI, body mass index (calculated as
weight in kilograms divided by height in meters
Adults, No. 82 82
squared); ISCED, International Standard Classification
Educational attainment, No./total No. (%)b
of Education.
ISCED 0-3 16/82 (20) 14/82 (17) a
Baseline characteristics of included children, their
ISCED 4-6 40/82 (49) 48/82 (59) parents’ educational attainment according to the
ISCED 7-8 26/82 (32) 20/82 (24) ISCED, and the household environment.
Household environment b
ISCED scores: 0 to 3, early childhood education to
No. of children, median (range) 2 (1-4) 2 (1-4) upper secondary education or equivalent; 4 to 6,
No. of adults, median (range) 2.0 (1-3) 2.0 (1-3) postsecondary nontertiary education to bachelor’s
degree or equivalent; and 7 to 8, master’s degree to
No. of devices, median (IQR) 11.0 (8.0-12.0) 9.0 (7.0-11.0)
doctorate or equivalent.

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Effects of the Screen Media Reduction Intervention on Mental Health

The effects of the screen media reduction intervention on children’s behavioral strengths and
difficulties are presented in Figure 2 and eTable 2 in Supplement 2. There was a statistically
significant between-group mean difference in change on the total difficulties score from baseline to
follow-up of −1.67 (95% CI, −2.68 to −0.67) in favor of the screen media reduction intervention,
which corresponds to a Cohen d effect size of 0.53. The sensitivity analysis for the total difficulties
score with missing data imputed using chained equations yielded similar results, with a between-
group mean difference of −1.71 (95% CI, −3.10 to −0.33). Analyses of the SDQ subscales (internalizing
and externalizing symptoms) showed that the effect was most pronounced on children’s
internalizing symptoms (ie, emotional problems and peer problems; −1.03; 95% CI, −1.76 to −0.29).
The analysis of the score for the prosocial subscale showed a significant intervention effect in favor of
the screen media reduction group (0.84; 95% CI, 0.39-1.30; Figure 2). Removing the adjustment for
age did not alter the results in any of the analyses.

Figure 1. Violin Plots of Total Difficulties, Internalizing Symptoms, and Externalizing Symptoms Scores

Total difficulties
Control
Total difficulties score
Median, 7 (IQR, 4-10)
Intervention
Median, 7 (IQR, 4-10)

Internalizing symptoms
Internalizing symptoms score Control
Median, 2 (IQR, 1-5)
Intervention
Median, 3 (IQR, 1-5)

Externalizing symptoms
Control Control
Externalizing symptoms score Median, 3 (IQR, 2-5)
Screen use restriction
Intervention
Median, 4 (IQR, 2-5)

0 5 10 15 20 25
Strengths and difficulties at baseline, points

Violin plots display the estimated density of the scores derived from the Strengths and Difficulties Questionnaire data by group at baseline. The median and IQRs are shown within
the plots for each group (vertical lines).

Figure 2. Between-Group Mean Difference in Change in Behavioral Strengths and Difficulties From Baseline
to Follow-Up

Between-group
mean difference Favors Favors
Study (95% CI) interventiona controla
Behavioral strengths and difficulties
Total difficulties –1.67 (–2.68 to –0.67)
Internalizing symptoms –1.03 (–1.76 to –0.29) Estimates are from mixed-effects tobit regression
Externalizing symptoms –0.54 (–1.15 to 0.08) models adjusted for age (n = 174). Internalizing
Conduct problems –0.15 (–0.48 to 0.17) symptoms, emotional and peer problems;
Hyperactivity or inattention –0.37 (–0.84 to 0.10) externalizing symptoms, conduct and hyperactivity
Emotional symptoms –0.46 (–1.08 to 0.15) problems.
Peer relationship problems –0.54 (–0.85 to –0.24) a
Negative values favor the intervention and positive
Prosocial behavior 0.84 (0.39 to 1.30)
values favor the control, with the exception of
–3.0 –2.5 –2.0 –1.5 –1.0 –0.5 0 0.5 1.0 1.5 prosocial behavior, for which this relationship is
Between-group mean difference (95% CI) reversed.

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Subgroup Analyses for the Total Difficulties Score

The results of the post hoc subgroup analyses are presented in Figure 3. We found no statistically
significant interactions in the subgroup analyses performed. However, the point estimates were
higher for boys, children with higher screen media use at baseline, and children with higher total
difficulties at baseline.

Discussion
Results from this cluster randomized clinical trial showed that reducing leisure-time screen media use
in families for a period of 2 weeks had a significant positive effect on children’s and adolescents’
mental health. Considering the different mental subdomains, a reduction in screen media use
resulted in improvements in internalizing symptoms (emotional symptoms and peer problems) and
prosocial behavior. This finding suggests that while limiting screen media use had a broad positive
effect on behavioral difficulties, the most pronounced benefits associated with limiting screen media
use may be in mitigating internalizing behavioral issues and enhancing positive social interactions
among children and adolescents.
To our knowledge, this is the first family-based randomized clinical trial examining the effect of
reducing leisure-time screen media use on children’s and adolescents’ mental health. Our study
confirms that reducing leisure-time screen media use improves several aspects of mental health
among children and adolescents in the short term, which is in line with results of several
observational studies showing that higher levels of screen media use are associated with poorer
mental health among children and adolescents.22,37 In contrast to previous studies reporting that
effect sizes on the association between screen media use and mental health were negligible,17 the
results of our trial suggest that the effect size is moderate (Cohen d = 0.53). The observed mean
difference of 1.67 points in the SDQ total difficulties score mirrors effects seen in multifocus
treatments for mental health conditions among youths.38,39 When extrapolated to the Danish
population of children, a downward shift in total difficulties score corresponding to the effect sizes
seen among boys and girls would notably alter the distribution within the SDQ’s diagnostic
categories, particularly decreasing the proportion classified as abnormal for both boys and girls
(eAppendix and eTable 3 in Supplement 2). However, the intervention is not designed to be
implemented among families in the long term, which, in combination with the short-term follow-up
of 2 weeks, limits the generalizability of the results to families’ everyday lives. However, the results

Figure 3. Subgroup Analyses From Baseline to Follow-Up

Between-group
mean difference Favors Favors
Subgroup (95% CI) intervention control
Biological sex
Female (n = 94) –0.92 (–2.29 to 0.45)
Male (n = 80) –2.52 (–4.00 to –1.05)
Age group, y
4–7 (n = 76) –1.29 (–2.83 to 0.25)
8–10 (n = 50) –2.66 (–4.10 to –1.22)
11–17 (n = 48) –1.27 (–3.53 to 0.97)
Baseline screen media use, h/d
<1 (n = 71) –1.03 (–2.78 to 0.72)
1–3 (n = 58) –1.31 (–3.08 to 0.47)
>3 (n = 45) –2.43 (–4.06 to –0.81)
The subgroup analyses show subgroup-level estimates
Baseline total difficulties score
from mixed-effects tobit regression models. The
Below median (n = 81) –0.55 (–1.64 to 0.55)
median score for baseline total difficulties was 7
Above median (n = 92) –2.36 (–3.76 to –0.96)
(below median: <7, median or above: ⱖ7). Analyses
–4.5 –4.0 –3.5 –3.0 –2.5 –2.0 –1.5 –1.0 –0.5 0 0.5 1.0 1.5 were adjusted for age, except for the age group
Between-group mean difference (95% CI) analysis.

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highlight that positive mental health effects can be achieved by taking a short break from screen
media use as a family.
There were some indications that boys, compared with girls, and that children aged 8 to 10
years, compared with those aged 4 to 7 years and 11 to 17 years might respond better to the screen
reduction intervention. This difference in response might be caused by different types of
engagement with screen media devices and use of different screen media content across sex and age
groups,9-11 which could affect mental health differently. Also, the results suggest that the
intervention may have a greater effect among children and adolescents with higher levels of screen
media use and higher total difficulties scores at baseline. However, these subgroup differences were
not statistically significant. Given that our study sample was drawn from a general population of
children and adolescents, rather than from a high-risk group, a large portion of the participants
reported minimal behavioral difficulties. This left limited room for improvement but stresses the
need for further trials in high-risk groups. In the analysis stratified by baseline level of the total
difficulties score, a more pronounced favorable effect of the intervention was observed among
individuals scoring above the median for total difficulties. In contrast, we observed no significant
intervention effect among those scoring below the median for total difficulties score at baseline.
However, future studies are needed to investigate whether reducing screen media use has a greater
effect among groups with higher total difficulties scores.
We can only speculate about the mechanisms underlying the positive effects of limiting screen
media use on children’s and adolescents’ mental health. When children and adolescents spend much
of their leisure time using screen media devices, a putative effect may be diminishing face-to-face
social engagement with friends, peers, and family members.40,41 A possible explanation of the
positive effects found among both children and adolescents could be that parents participating in the
SCREENS trial also reported improved mental well-being (WHO-5 Well-being Index score), as
reported previously.25 The positive effects may also be explained by increases in shared leisure time
among family members without use of screen media devices during the intervention, potentially
making room for more social interactions. Reduced interpersonal engagement could heighten
emotional symptoms, manifesting as amplified feelings of isolation, loneliness, and social
anxiety.42,43 Beyond the sheer volume of screen time and the potential displacement of face-to-face
interactions, the specific type and content of digital engagements, especially on platforms such as
social media, might play a critical role in influencing mental well-being. Randomized experiments
with young or middle-aged adults indicate that limiting social media use yields positive psychological
outcomes across various age groups. For instance, among college-aged individuals, short daily limits
or brief breaks from social media have been associated with decreased feelings of loneliness and
depression symptoms.44 Similarly, among adults, either taking a short break from social media or
setting strict daily limits has been associated with improved well-being and reduced symptoms of
depression and anxiety.45,46 Also, prospective observational studies suggest that reduced and
intentional social media use is associated with better mood and mental well-being among young
individuals.47 Results from a recent observational study indicate that children and adolescents may
be more sensitive to negative effects of social media during specific periods (ie, males aged 14-15
years and 19 years and females aged 11-13 years and 19 years).48 We did not observe any consistent
age-dependent effects of reducing general leisure screen media use; however, further studies are
needed to investigate this.

Strengths and Limitations

This study has some strengths. A key strength is its design as an efficacy study with high ecological
validity. Our cluster randomized clinical trial, conducted in young people’s natural environments,
allows for a more rigorous examination of causality compared with investigations in observational
studies. In addition, objective assessment of compliance to the screen media reduction intervention
further enhances the internal validity of our findings, ensuring that participants genuinely reduced

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 JAMA Network Open | Pediatrics Screen Media Use and Mental Health of Children and Adolescents

their screen media use. Another strength is the low dropout and missing data rate, which minimizes
the potential for attrition bias.
Nevertheless, the findings must be interpreted with some limitations in mind. First, the open-
label nature of the study might have introduced bias in the assessment of behavioral strengths and
difficulties, as the parents’ responses could have been influenced by their knowledge of group
allocation. Second, some families in the control group also decreased their leisure-time screen media
use to a moderate extent and thus reduced the contrast in screen media use between the 2
conditions, which may have resulted in an underestimation of the intervention effect. Third, while
parental involvement was crucial for achieving a high level of compliance with the intervention,
parents, children, and adolescents in this study may represent a subgroup with a particularly high
motivation to reduce screen media use, as families volunteered for participation, which could
influence the generalizability of the results. Fourth, the use of the parented-reported version of the
SDQ reflects the parent’s perception of the child’s behavioral strengths and difficulties to a larger
degree, rather than the child’s own perception.

Conclusions
Taken together, the results of this secondary analysis of a randomized clinical trial show that when
entire families—both parents, children, and adolescents—reduce their leisure-time screen media use
for 2 weeks, it can positively affect children’s and adolescents’ behavioral strengths and difficulties.
The intervention targeted an overall reduction in screen media use during leisure time, without
pinpointing specific types of screen media activities. Future research should explore the potential
differential effects of various types of screen media use and look deeper into whether collective
family participation in such interventions is a pivotal component for observed benefits. Moreover,
more research is needed to confirm whether these effects are sustainable in the long term.

ARTICLE INFORMATION
Accepted for Publication: April 26, 2024.
Published: July 12, 2024. doi:10.1001/jamanetworkopen.2024.19881
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024
Schmidt-Persson J et al. JAMA Network Open.
Corresponding Author: Jesper Schmidt-Persson, PhD, Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark ([email protected]).
Author Affiliations: Department of Sports Science and Clinical Biomechanics, Research Unit for Exercise
Epidemiology, Centre of Research in Childhood Health, University of Southern Denmark, Odense, Denmark
(Schmidt-Persson, Rasmussen, Sørensen, Mortensen, Kristensen, Grøntved); Applied Research in Child and Adult
Health, Department of Midwifery, Physiotherapy, Occupational Therapy, and Psychomotor Therapy, University
College Copenhagen, Copenhagen, Denmark (Schmidt-Persson); Steno Diabetes Center Odense, Odense
University Hospital, Odense, Denmark (Rasmussen); Research and Implementation Unit PROgrez, Department of
Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
(Mortensen); Steno Diabetes Center Aarhus, Aarhus University Hospital, Skejby, Aarhus, Denmark (Olesen); MRC
Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom (Brage); Child and Adolescent
Psychiatric Department, Mental Health Hospital and University Clinic, Region of Southern Denmark, Odense,
Denmark (Bilenberg).
Author Contributions: Dr Schmidt-Persson had full access to all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the data analysis.
Concept and design: Schmidt-Persson, Olesen, Kristensen, Bilenberg, Grøntved.
Acquisition, analysis, or interpretation of data: Schmidt-Persson, Rasmussen, Sørensen, Mortensen, Brage,
Grøntved.
Drafting of the manuscript: Schmidt-Persson, Kristensen, Grøntved.
Critical review of the manuscript for important intellectual content: All authors.

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 JAMA Network Open | Pediatrics Screen Media Use and Mental Health of Children and Adolescents

Statistical analysis: Schmidt-Persson, Rasmussen, Kristensen.

Obtained funding: Grøntved.
Administrative, technical, or material support: Schmidt-Persson, Rasmussen, Olesen.
Supervision: Schmidt-Persson, Bilenberg, Grøntved.
Conflict of Interest Disclosures: Dr Bilenberg reported receiving grants from the Novo Nordisk Foundation, the
Lundbeck Foundation, and the Tryg Foundation outside the submitted work. No other disclosures were reported.
Funding/Support: The SCREENS study was founded by the European Research Council (grant 716657). Dr Brage
was supported by the UK Medical Research Council (grants MC_UU_12015/3 and MC_UU_00006/4) and the
National Institute for Health and Care Research Biomedical Research Centre in Cambridge (grant
IS-BRC-1215-20014).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 3.
Additional Contributions: We thank all the participating families. We also thank the researcher service
organization Open Patient Data Explorative Network for assisting with trial management.

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SUPPLEMENT 1.
Trial Protocol

SUPPLEMENT 2.
eFigure. Flow Chart
eTable 1. Comparison of Total Difficulties Scores at Baseline
eTable 2. Analyses for Behavioral Strengths and Difficulties
eTable 3. Comparison of Norm Data Proportions to Simulated Proportions
eAppendix.

SUPPLEMENT 3.
Data Sharing Statement

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