Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006
Studies indicate that children use media (television, video, and computer) more than the recommended limit of 2 h/d, but little is known about parents' role in mediating their children's media use.
Office-based survey. Data were collected on demographics, reported media behaviors, parental awareness about media effects, television in the bedroom, and parental concern. We developed logistic regression models to examine factors associated with the following 3 mediation approaches: restrictive, instructive, and unlimited.
Pediatric Research in Office Settings practices.
Parents with children aged 2 to 11 years (n = 1831) presenting for a well-child visit.
Almost half of parents reported a single mediation approach, including restrictive for 23%, instructive for 11%, and unlimited for 7%, with 59% reporting the use of multiple strategies. Restrictive (odds ratio [OR], 1.16; P<.001) and instructive (OR, 1.06; P = .02) approaches were associated with increased awareness about negative media effects, whereas a decreased awareness existed for those who used an unlimited approach (OR, 0.87; P<.001). A restrictive strategy also occurred with increased parental concern (OR, 1.77; P<.001) and 2 adults in the home (OR, 1.64; P<.01). The only strategy associated with the child's age was instructive mediation, noted more often with younger children (OR, 1.41; P<.001). Allowing unlimited media use occurred when parents permitted a television in the child's bedroom (OR, 2.13; P<.001) and were Latino (OR, 2.03; P<.01) or African American (OR, 2.20; P<.001). Mother as primary decision maker and maternal education were not statistically significant.
Pediatric health care providers should identify parental practices and reinforce active media mediation strategies.
According to the American Academy of Pediatrics (AAP), American children and adolescents aged 2 to 18 years spend an average of more than 4 hours using electronic media daily, more than they spend on any other single activity except sleep.1 Media exposure has been associated with aggressive behavior,2- 5 poor moral reasoning,6 desensitization,7 the conception of the world as a mean and scary place,8 obesity,9,10 and decreased attention span.11 Conversely, it has also been associated with positive social interactions,12 improved intelligence scores,13 improved problem-solving skills,14 accelerated language acquisition,15,16 and enhanced school performance.17 The difference exists in the content of the programming and the time spent engaged in media use.9,11- 15,18
Owing to these facts, the AAP recommends limiting media exposure to no more than 1 to 2 hours per day of educational, quality programs for children older than 2 years. In addition, the AAP recommends that parents use the media's influence in a positive manner by helping their children to be intelligent media viewers, restricting their media exposure, watching with their children, explaining what the child sees, and creating an electronic media–free environment in children's rooms.19,20 To have this effect, however, it is necessary that parents engage in some form of mediation, by setting limits on media exposure and discussing content with children. These behaviors have been found to mitigate some of the negative effects of media exposure on children.21,22
Research on mediation suggests that various types exist,23 including (1) restrictive mediation, in which parents set rules or prohibit exposure to certain content, (2) instructive mediation, in which parents discuss certain portions of the programming they view together, and (3) social coviewing, in which the programming is watched together. Social coviewing is associated with overall heavier viewing patterns for parents and their children.1 It is unlimited viewing that is perhaps most problematic and may require the greatest intervention.
Active mediation, such as restrictive and instructive approaches, has positive associations with younger children,15,18- 22 mothers as media decision makers,21 increased parental education,24 and increased socioeconomic levels.23,25 Several family variables still remain largely unexplored. For example, positive parent-child relationships have an association with increased effective rule setting in contexts such as eating and sleeping26; therefore the quality of the parent-child relationship might also have a potential association with increased media mediation. The influence of ethnicity or family structure on media mediation is not known. It is possible that in homes where 2 parents reside, mediation is more likely simply because 2 parents are available to provide mediation. It is clear that in parenting areas such as discipline, one's own experiences as a child influence current strategies.26 Likewise, past media experience as a child could influence tendencies to provide mediation as a parent. It is important, therefore, to discern the effects of all these potential contributors on parental mediation strategies.
In a world where media burgeons and children's exposure is likely to grow, understanding how parents mediate their children's media use and the attendant associations becomes necessary. Information is needed to shape interventions suitable for the pediatric provider's office, a venue that children and their families routinely use.
Most surveys that purport to estimate the percentage of parents who use mediation21- 24 are limited by small sample sizes. In 1 of the larger samples, Cheng et al27 reported a convenience sample of almost 700 parents. That study was limited in its assessment of various mediation styles. These authors found that female parents and younger children were more likely to be associated with limits on violent television viewing.21- 24,27
Conducting a study with a national scope allows an assessment of an expanded model of potential influences on media mediation. The purpose of the present analysis was to explore how often parents mediate media, what strategies they use, and what variables predict active media mediation to inform the development of potential interventions based in the pediatric provider's office.
This study was conducted by Pediatric Research in Office Settings, the practice-based research network of the AAP. Institutional review board approval was obtained from the Wake Forest University School of Medicine, Winston-Salem, NC, and the AAP. Parents participated in an office-based survey before the visit for the well-child examination of children aged 2 to 11 years. We limited enrollment to 1 child per family with English- or Spanish-speaking parents. A list of participating practices is given in the box at the end of the article.
Parents/legal guardians answered questions regarding demographics (age of child, number of children in the home, self-identified race/ethnicity of the child, parental home structure, maternal education), reported media behaviors, television in the bedroom, parental awareness about negative violent media effects, parental media concern, primary decision maker about media use, parent-child relationship, and parental history of television use as a child.
Media-related behavior questions included “When this child is at home, how many hours per day does he or she watch television/videos? play computer games/Gameboy?” This was broken down by hours on an average weekday and average weekend day. For the purposes of our analysis, we collapsed these data to reflect hours of average media use (inclusive of television, video, computer games, and electronic handheld devices) per day. Our survey presented 3 survey items assessing parental strategies for their child's media use. These questions asked, in the past month, how often the parent restricted use, explained content, or allowed unlimited media use. The response scale for each question ranged from “never” to “always” on a 4-point scale. Three media-related questions assessed parental awareness about the potential negative outcomes of watching violent media, including “Watching violent television programs makes children more afraid,” “Children's behavior is not influenced by what they see on television,” and “Children who watch violent television think real-life violence is normal behavior.” These responses were rated on a 5-point scale from “strongly disagree” to “strongly agree.” We developed an awareness scale (range, 3-15; Cronbach α = 0.6) from these 3 questions. A higher value on the awareness scale indicated better understanding of the effects of exposure to violent media.
To gauge parental concern about media use, parents responded yes or no to the question, “I’m concerned about what this child sees in the media.” Also, we assessed parents' perception of their relationship with their child with the statement, “My relationship with this child is poor, fair, good, very good, or excellent.” Respondents chose 1 response.
Questions were also asked about the primary caregiver's own childhood experience with media. The following 3 statements make up the Family History Scale: “My family watched a lot of television,” “My family allowed children to watch as much television as they wanted,” and “My family monitored the programs that children watched on television.” Each question was answered on a 3-point scale; the range of the Family History Scale was 3 to 9 points, with a mean of 5.1 (SD, 2.1) and Cronbach α of 0.60. Higher numbers indicated more exposure to television.
We examined descriptive statistics and bivariate associations with the outcomes of interest including use of restrictive, instructive, or unlimited media mediation. Each outcome was dichotomized as never/sometimes vs often/always. We chose this cut point owing to response variation and the underlying concept that parents are more likely to be similar in these identified categories. We assessed bivariate associations with those variables determined from our literature search or clinical judgment to have a potential contribution to parental media behaviors. These included age of the child, awareness that violent media exposure can influence children's behavior, parental concern about media exposure, maternal education level, ethnicity, relationship between parent and child, mother as primary decision maker, number of children in the home, family history, and a 1- vs 2-parent home structure. To create a parsimonious model, we included those variables that had a statistically significant bivariate association (odds ratio or χ2 for categorical variables; correlation for continuous variables) with the outcomes of interest at the .05 level in logistic regression models to examine factors associated with the 3 mediation styles.
Participants included 1831 families with children aged 2 to 11 years attending their well-child visit. They represented families from 64 community-based pediatric practices in 27 states, Canada, and Puerto Rico. Table 1 includes the sample description. Most caregivers completing the survey were mothers (89.6%), with 24.3% of the respondents indicating that they run a single-parent home. About half of the patients were aged 2 to 5 years. Most (70.0%) of the patients were white, 11.4% were Latino, and 11.7% were African American. Most of the caregivers reported that the mother's education was less than a college degree, with more than one third of respondents indicating that the mothers were college graduates or beyond. Almost half of the sample reported that the mother was the primary decision maker for their child's media use. Close to three fourths of respondents indicated that they were concerned about their child's media use. Almost three fourths of caregivers reported that when they were children, their family allowed unlimited television use or watched a lot of television. Of the respondents, 74.9% indicated that children who watch violent media (1) are more afraid, (2) are influenced by what they see, and (3) think real-life violence is normal. For the 1775 parents who completed the questions on awareness of violent media effects, the mean (SD) score was 12.0 (2.4); for the 1782 who completed the Family History Scale, the mean (SD) score was 5.2 (2.1).
Parents reported mutiple mediation styles, including restrictive (restricting content or time of viewing), instructive (parent/guardian explaining media to the child as they watch together), and/or unlimited viewing (allowing the child to decide the period of time to engage in media activities). Respondents reported mean (SD) media exposure in general as 2.7(1.5) h/d. The amount of media exposure time varied depending on reported media mediation style, with means of 2.4 (1.3) hours for restrictive, 2.9 (1.5) hours for instructive, and 4.1 (1.6) hours for unlimited mediation styles. In our sample, 36% of children had televisions in their bedrooms. The likelihood of having a television in a child's bedroom was twice as high if the child was aged 6 to 11 vs 2 to 5 years (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.86-2.71). Moreover, parents who reported a television in their child's bedroom indicated increased exposure to media (mean [SD] of 3.6  hours vs 2.5 [1.7] hours; P<.001).
A little more than half of respondents (59%) indicated that they used multiple media mediation strategies. The remaining 41% of respondents indicated that they used a single approach, including restrictive for 23.4%, instructive for 11.2%, and unlimited for 6.9%.
Media mediation strategies did not differ in a statistically significant way for younger children (aged 2-5 years) compared with older children (6-11 years) (Figure 1). Once we examined the logistic regression models controlling for other variables, however, an instructive mediation strategy was positively associated with younger children (Table 2).
Parental media mediation approaches for children aged 2 to 5 vs 6 to 11 years. Mediation approaches are described in the “Reported Media Use and Parental Media Mediation Styles” subsection of the “Results” section.
Logistic regression models (Table 2) indicated that restrictive and instructive approaches had positive associations with increased awareness about negative media effects, whereas a decreased awareness existed for those who used an unlimited approach. Those respondents who indicated parental concern about their child's media exposure and who had 2 adults in the home were more likely to use a restrictive media strategy (Figure 2). Allowing unlimited media use occurred more often when parents permitted a television in the child's bedroom. Conversely, the absence of a television in the child's bedroom was associated with a restrictive strategy. Latino and African American ethnicities were associated with allowing unlimited media use more than was white ethnicity in our sample (Figure 3). The number of children in the home (1 vs >1) and mother as the primary decision maker for media use did not have statistically significant bivariate relationships and, therefore, were not included in the logistic regression models.
Number of parents in the home and use of mediation approaches. Mediation approaches are described in the “Reported Media Use and Parental Media Mediation Styles” subsection of the “Results” section.
Mediation approaches across different ethnicities. Mediation approaches are described in the “Reported Media Use and Parental Media Mediation Styles” subsection of the “Results” section.
Parents play a key role in shaping how their children use the media.23,27,28 In the present large-scale national sample, a majority (59%) of parents reported using a variety of mediation strategies. It is reassuring that only 7% allowed unlimited media use and engaged in no mediation. A third of the sample reported using a single active media strategy, including 11% who used instructive mediation and 23% who used restrictive mediation. In this sample with a national scope, unlike other studies, we did not see that mother as a primary decision maker or younger children were associated with a restrictive media mediation strategy.21 However, we noted that parents reported using an instructive strategy more often with younger children. Each media strategy demonstrated varying degrees of reported media exposure, with a restrictive approach associated with the least amount of exposure (mean [SD], 2.4 [1.3] hours) and an unlimited approach associated with the greatest amount of exposure (4.1 [1.6] hours). If we take the average, our findings are consistent with previous studies.29,30 Our data emphasize that exposure to media has an important influential factor, ie, parents.
Our research identified some other factors associated with increased active parental mediation. Our data identified demographic factors, such as single-parent homes and children of African American and Latino ethnicites, associated with less active mediation. This fact may be further compounded because African American and Latino families watch more television on average.1 Therefore, more overall viewing combined with less active mediation may put African American and Latino children at greater risk for the problematic effects of media content. These populations may benefit most from promotion of active media mediation strategies by practitioners.
Moreover, our data suggest that parents who understand that media can have harmful effects and who express concern about those effects are more likely to mediate actively. Therefore, 1 strategy to increase mediation is to provide information to parents about the negative effects of media. Given that a higher level of parental concern increases restrictive mediation, encouraging a healthy level of concern about media exposure among parents may influence their willingness to try active mediation strategies. Conversely, we could provide information about positive educational programming available to children.14,31 The data are limited, however, in that they focus primarily on young children's programming (≤5 years of age). Research is needed to assess what programs exist with strong educational, positive effects for children older than 5 years.
The negative effects of exposure to media,3 especially when parents do not play an active role in mediating that exposure,32 make it critical to minimize the barriers to parental mediation. In this sample we found that 36% of parents allowed children to have a television set in their bedroom. Many of the parents of childen with a television in their bedroom allowed unlimited viewing, regardless of the child's age. A growing body of evidence links excessive media exposure (>2 h/d) to poorer cognitive outcomes.33,34 In a recent study, third graders found to have a television in their bedroom had a significant negative association with their cognitive test scores.33 Televisions in the bedroom not only might be detrimental to an elementary school-aged child's health, it also might create an opportunity for unsupervised media exposure. It is not clear what drives parents' decisions to allow children to have a television in their bedroom. Entering into a dialogue with families about this topic could provide an important starting point for making active parental mediation possible.
During the course of the study, the concept of media has continued to expand. We asked families to report on use of television, videos, computer games, and electronic handheld devices. We cannot make an association between this use and the now even fuller gamut of media use in our society, such as instant messaging, or multiple uses of the computer simultaneously, such as doing one's homework while watching a movie in the corner of the screen. Although self-reported information on media exposure is commonly presented in studies, evidence suggests that this method can lead to over estimation.35 Conversely, it could lead to underestimation, because parents could be unaware of their child's exposure if a television is in the bedroom. In this study, we focused on parental perceptions of their child's media use and did not gather data on parental use. In future work, gathering these data would be useful because it is family behaviors that often guide children's exposure to media.36
We asked 1 yes/no question to gauge parental media concern. This does not allow us to investigate the complexity of parental concern but mirrors how clinicians usually ask the question during a routine office visit. From this question, we cannot infer whether families are unconcerned because they control the media use to their satisfaction or because they are unconcerned about the problem regardless of their family behaviors. However, nearly 75% of parents indicated concern, regardless of their reported media mediation strategies.
Although proportions of African American and Latino children in our sample were substantial and approach the national population percentages, it is possible that our findings do not accurately represent these populations. In addition, all data were derived from a self-administered survey of parents' reports that can be associated with socially desirable reporting. Nevertheless, we identified statistically significant and clinically meaningful information to help direct our next steps as pediatric health care providers working with families. Finally, we asked families to report behaviors that occurred in their home; therefore, we cannot make statements or implications related to other environments such as schools and the homes of friends or other family members. It will be important for future researchers to describe mediation strategies that occur in these environments as well.
Children use television and computers at younger and younger ages,24 making mediation increasingly important. The pediatric health care provider interacts with families of young children, educating them on healthy behaviors routinely. Our study indicates that when providers discuss media use, they need to identify parental media concerns, share information about potential negative media effects, and encourage active media mediation approaches, such as restriction and instruction, with parents of children aged 2 to 11 years. For many families, this discussion could begin with ascertaining the presence of a television in the child's bedroom.
Correspondence: Shari Barkin, MD, Department of Pediatrics, Wake Forest University Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (email@example.com).
Accepted for Publication: July 12, 2005.
Financial Disclosure: None.
Funding/Support: This study was supported by grant HD 42260 from the National Institute of Child Health and Human Development, Rockville, Md; the Agency for Healthcare Research and Quality, Rockville; the Robert Wood Johnson Generalist Faculty Scholars Program, San Antonio, Tex; and the Friends of Children Fund, American Academy of Pediatrics, Elk Grove Village, Ill.
Acknowledgment: We especially appreciate the efforts of the Pediatric Research in Office Settings practices and practitioners.
Participating Pediatric Practices or Individual Practitioners by American Academy of Pediatrics Chapter
Alabama: Pediatric Care Group (Montgomery); Alaska: Anchorage Pediatric Group, LLC (Anchorage), Joy Neyhart, MD (Juneau); Arizona: Orange Grove Pediatrics (Tucson); California 1: Palo Alto Medical Foundation (Palo Alto), Pediatric and Adolescent Medical Associates of the Pacific Coast, Inc (Salinas); California 3: East County Community Clinic–Lakeside (Lakeside), La Jolla Pediatrics (La Jolla); Colorado: Rocky Mountain Health Center (Denver); Connecticut: Pediatric Associates of Connecticut, PC (Waterbury), Jeff Cersonsky, MD (Southbury); Florida: Atlantic Coast Pediatrics (Merritt Island); Georgia: Victor Lui, MD (Chamblee), Snapfinger Woods Pediatric Associates, PC (Decatur); Indiana: Georgetown Pediatrics (Indianapolis), Jeffersonville Pediatrics (Jeffersonville); Kansas: Ashley Clinic (Chanute); Louisiana: Carousel Pediatrics (Metairie), Shalom Clinic for Children (Natchitoches); Maryland: Steven E. Caplan, MD (Baltimore); Maine: Maine Coast Pediatrics (Ellsworth); Massachusetts: Holyoke Pediatric Associates (Holyoke), Mary Lane Pediatric Associates (Ware); Michigan: Pediatric Health Care (Sterling Heights); Minnesota: Brainerd Medical Center, PA (Brainerd), Lakeview Clinic–Watertown Pediatrics (Watertown); Missouri: Children's Mercy Hospital Pediatric Care Center (Kansas City); New Hampshire: Foundation Pediatrics (Nashna); New York 1: Elmwood Pediatric Group (Rochester), Lewis Pediatrics (Rochester); New York 3: Pediatric Primary Care at Montefiore Medical Center (Bronx); North Carolina: Aegis Family Health Center–Winston East Pediatrics (Winston-Salem), Guilford Child Health, Inc–High Point (High Point); Ohio: Oxford Pediatrics & Adolescents (Oxford); Oklahoma: Pediatric & Adolescent Care, LLP (Tulsa); Ontario: Richard J. MacDonald, MD (Oakville, Ontario); Pennsylvania: Buckingham Pediatrics (Buckingham), Laurel Health Center–Blossburg (Blossburg), Pediatric Practices of Northeastern Pennsylvania (Honesdale), Pennridge Pediatric Associates (Sellersville); Puerto Rico: Ethel Lamela, MD (Isabela); Quebec: Clinique Enfant-Medic (Dollard des Ormeaux); South Carolina: Palmetto Pediatrics & Adolescent Clinic, PA (Columbia); Tennessee: East Tennessee State University Physicians & Associates (Johnson City); Texas: The Pediatric Clinic (Greenville), Su Clinica Familiar (Harlingen), Winnsboro Pediatrics (Winnsboro); Utah: Utah Valley Pediatrics, LC (American Fork), Willow Creek Pediatrics–Draper (Draper); Vermont: Brattleboro Pediatrics (Brattleboro), Rebecca Collman, MD (Colchester), Springfield Pediatric Network (Springfield), University Pediatrics, UHC Campus (Burlington), University Pediatrics (Williston); Washington: Central Washington Family Medicine (Yakima); West Virginia: Grant Memorial Pediatrics (Petersburg); Wisconsin: Gundersen Clinic–Whitehall (Whitehall); Wyoming: Jackson Pediatrics (Jackson).
Barkin S, Ip E, Richardson I, Klinepeter S, Finch S, Krcmar M. Parental Media Mediation Styles for Children Aged 2 to 11 Years. Arch Pediatr Adolesc Med. 2006;160(4):395-401. doi:10.1001/archpedi.160.4.395