Parent-Toddler Social Reciprocity During Reading From Electronic Tablets vs Print Books | Pediatrics | JAMA Pediatrics | JAMA Network
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Figure 1.  Results of Child Solitary Space
Results of Child Solitary Space

Book conditions include enhanced tablet-based, basic tablet-based, and print. Data are expressed as mean (SD, denoted with error bars).

aP < .05 compared with print book condition.

bP < .01 compared with print book condition.

Figure 2.  Results of Child and Parent Discrete Behaviors
Results of Child and Parent Discrete Behaviors

Book conditions include enhanced tablet-based, basic tablet-based, and print. Data are expressed as mean (SD, denoted with error bars).

aP < .01 compared with print book condition.

bP < .001 compared with print book condition.

cP < .05 compared with enhanced tablet-based book condition.

Table 1.  Coding Scheme
Coding Scheme
Table 2.  Participant Characteristics
Participant Characteristics
1.
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Psouni  E, Falck  A, Boström  L, Persson  M, Sidén  L, Wallin  M.  Together I can! joint attention boosts 3- to 4-year-olds’ performance in a verbal false-belief test.  Child Dev. 2018;90(4):35-50. doi:10.1111/cdev.13075Google Scholar
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Radesky  JS, Eisenberg  S, Kistin  CJ,  et al.  Overstimulated consumers or next-generation learners? parent tensions about child mobile technology use.  Ann Fam Med. 2016;14(6):503-508. doi:10.1370/afm.1976PubMedGoogle ScholarCrossref
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Radesky  JS, Schumacher  J, Zuckerman  B.  Mobile and interactive media use by young children: the good, the bad, and the unknown.  Pediatrics. 2015;135(1):1-3. doi:10.1542/peds.2014-2251PubMedGoogle ScholarCrossref
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Rocissano  L, Slade  A, Lynch  V.  Dyadic synchrony and toddler compliance.  Dev Psychol. 1987;23(5):698-704. doi:10.1037/0012-1649.23.5.698Google ScholarCrossref
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Sameroff  A.  Transactional models in early social relations.  Hum Development. 1975;18(1-2):65-79. doi:10.1159/000271476Google ScholarCrossref
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Yogman  M, Garner  A, Hutchinson  J, Hirsh-Pasek  K, Golinkoff  RM; Committee on Psychosocial Aspects of Child and Family Health; Council on Communications and Media.  The power of play: a pediatric role in enhancing development in young children.  Pediatrics. 2018;142(3):e20182058. doi:10.1542/peds.2018-2058PubMedGoogle ScholarCrossref
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Sosa  AV.  Association of the type of toy used during play with the quantity and quality of parent-infant communication.  JAMA Pediatr. 2016;170(2):132-137. doi:10.1001/jamapediatrics.2015.3753PubMedGoogle ScholarCrossref
22.
Radesky  J, Miller  AL, Rosenblum  KL, Appugliese  D, Kaciroti  N, Lumeng  JC.  Maternal mobile device use during a structured parent-child interaction task.  Acad Pediatr. 2015;15(2):238-244. doi:10.1016/j.acap.2014.10.001PubMedGoogle ScholarCrossref
23.
Radesky  JS, Kistin  CJ, Zuckerman  B,  et al.  Patterns of mobile device use by caregivers and children during meals in fast food restaurants.  Pediatrics. 2014;133(4):e843-e849. doi:10.1542/peds.2013-3703PubMedGoogle ScholarCrossref
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Fogg  BJ. A behavior model for persuasive design. Paper presented at: Proceedings of the 4th International Conference on Persuasive Technology; April 26-29, 2009; Claremont, CA.
25.
Munzer  TG, Miller  AL, Weeks  HM, Kaciroti  N, Radesky  J.  Differences in parent-toddler interactions with electronic versus print books.  Pediatrics. 2019;143(4):e20182012. doi:10.1542/peds.2018-2012PubMedGoogle ScholarCrossref
26.
Feldman  R.  The relational basis of adolescent adjustment: trajectories of mother-child interactive behaviors from infancy to adolescence shape adolescents’ adaptation.  Attach Hum Dev. 2010;12(1-2):173-192. doi:10.1080/14616730903282472PubMedGoogle ScholarCrossref
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Ingersoll  B.  Teaching imitation to children with autism: a focus on social reciprocity.  J Speech Lang Pathol Appl Behav Anal. 2007;2(3):269-277. doi:10.1037/h0100224Google ScholarCrossref
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Yuill  N, Martin  AF.  Curling up with a good e-book: mother-child shared story reading on screen or paper affects embodied interaction and warmth.  Front Psychol. 2016;7:1951. doi:10.3389/fpsyg.2016.01951PubMedGoogle ScholarCrossref
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Pavlov  PI.  Conditioned reflexes: an investigation of the physiological activity of the cerebral cortex.  Ann Neurosci. 2010;17(3):136-141. doi:10.5214/ans.0972-7531.1017309PubMedGoogle ScholarCrossref
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Meyer  M, Adkins  V, Yuan  N, Weeks  HM, Chang  Y-J, Radesky  J.  Advertising in young children’s apps: a content analysis.  J Dev Behav Pediatr. 2019;40(1):32-39. doi:10.1097/DBP.0000000000000622PubMedGoogle ScholarCrossref
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Dale  PS.  The validity of a parent report measure of vocabulary and syntax at 24 months.  J Speech Hear Res. 1991;34(3):565-571. doi:10.1044/jshr.3403.565PubMedGoogle ScholarCrossref
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Nordahl-Hansen  A, Kaale  A, Ulvund  S.  Inter-rater reliability for the MacArthur-Bates Communicative Development Inventory: parent and preschool teacher ratings of children with childhood autism.  Res Autism Spectrum Disord. 2013;7(11):1391-1396. doi:10.1016/j.rasd.2013.08.006Google ScholarCrossref
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Strouse  GA, Ganea  PA.  Toddlers’ word learning and transfer from electronic and print books.  J Exp Child Psychol. 2017;156:129-142. doi:10.1016/j.jecp.2016.12.001PubMedGoogle ScholarCrossref
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Strouse  GA, Ganea  PA.  Parent-toddler behavior and language differ when reading electronic and print picture books.  Front Psychol. 2017;8:677. doi:10.3389/fpsyg.2017.00677PubMedGoogle ScholarCrossref
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    Original Investigation
    September 30, 2019

    Parent-Toddler Social Reciprocity During Reading From Electronic Tablets vs Print Books

    Author Affiliations
    • 1Department of Pediatrics, University of Michigan Medical School, Ann Arbor
    • 2Center for Human Growth and Development, University of Michigan, Ann Arbor
    • 3Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
    • 4Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor
    • 5Department of Biostatistics, University of Michigan, Ann Arbor
    JAMA Pediatr. 2019;173(11):1076-1083. doi:10.1001/jamapediatrics.2019.3480
    Key Points

    Question  How does parent-toddler social reciprocity differ when engaging in tablet-based reading compared with print book reading?

    Findings  In this counterbalanced, laboratory-based, within-participants study of 37 parent-toddler dyads, parents and toddlers showed lower social reciprocity with tablet-based books compared with print books as evidenced by greater frequency of solitary body posture, social control, and intrusive behaviors occurring during the reading of tablet-based books.

    Meaning  These findings suggest that parents and toddlers may find engaging in shared tablet-based experiences to be challenging.

    Abstract

    Importance  Although the American Academy of Pediatrics recommends parent-child joint engagement with digital media, recent evidence suggests this may be challenging when tablets contain interactive enhancements.

    Objective  To examine parent-toddler social reciprocity while reading enhanced (eg, with sound effects, animation) and basic tablet-based books compared with print books.

    Design, Setting, and Participants  This within-participants comparison included 37 parent-toddler dyads in a counterbalanced crossover, video-recorded laboratory design at the University of Michigan from May 31 to November 7, 2017. The volunteer sample was recruited from an online research registry and community sites. Dyads included children aged 24 to 36 months with no developmental delay or serious medical condition, parents who were the legal guardians and read English sufficiently for consent, and parents and children without uncorrected hearing or vision impairments. Data were analyzed from October 18, 2017, through April 30, 2018.

    Exposures  Reading an enhanced tablet-based book, a basic tablet-based book, and a print book in counterbalanced order for 5 minutes each.

    Main Outcomes and Measures  Video recordings were coded continuously for nonverbal aspects of parent-toddler social reciprocity, including body position (child body posture limiting parental book access coded in 10-second intervals), control behaviors (child closing the book, child grabbing the book or tablet, parent or child pivoting their body away from the other), and intrusive behaviors (parent or child pushing the other’s hand away). Coding intracorrelation coefficients were greater than 0.75. Poisson regression was used to compare each outcome by book format.

    Results  Among the 37 parent-child dyads, mean (SD) parent age was 33.5 (4.0) years; 30 (81%) were mothers, and 28 (76%) had a 4-year college degree or greater educational attainment. Mean (SD) age of children was 29.2 (4.2) months, 20 (54%) were boys, 21 (57%) were white non-Hispanic, and 6 (16%) were black non-Hispanic. Compared with print books, greater frequency of child body posture limiting parental book access (mean [SD], 7.9 [1.9; P = .01] for enhanced; 8.4 [1.8; P = .006] for basic), child closing the book (mean [SD], 1.2 [0.4; P = .007] for enhanced; 1.2 [0.5; P < .001] for basic), parent pivoting (mean [SD], 0.4 [0.2; P = .05] for enhanced; 0.9 [0.4; P = .004] for basic), child pushing parent’s hand (mean [SD], 0.6 [0.2; P < .001] for enhanced; 0.4 [0.2; P = .002] for basic), and parent pushing child’s hand (mean [SD], 1.7 [0.3; P < .001] for enhanced; 2.4 [0.5; P < .001] for basic) occurred while reading enhanced and basic tablet-based books. Child pivots occurred more frequently while reading basic tablet-based books than print (mean [SD], 1.0 [0.3] vs 0.3 [0.1]; P = .005).

    Conclusions and Relevance  In this study, toddlers and parents engaged in more frequent social control behaviors and less social reciprocity when reading tablet-based vs print books. These findings suggest that toddlers may have difficulty engaging in shared tablet experiences with their parents.

    Introduction

    Mobile technology ownership and use have grown exponentially in recent years, with an almost ubiquitous presence in the daily lives of families.1-3 Among children 8 years and younger, 42% have their own tablet devices and 78% have a tablet device in the home.2 This shift in children’s digital media habits is illustrated by the displacement of the shared experience of television viewing2 by more individual and parallel use of mobile devices.4 The effects of mobile device use on children’s development are not completely understood, although excessive use of digital media has been associated with externalizing behaviors,5 greater risk for developmental delays,6 and poor sleep.7,8 Parents play an important role in moderating these outcomes,9 and prior evidence suggests that young children learn better from screen media (television and interactive apps) when parents view media with their children and help children meaningfully apply new knowledge to their lives.10-14 Therefore, the American Academy of Pediatrics recommends time limitations on screen media in addition to parent and child joint media engagement in early childhood to support children’s learning and facilitate parent awareness of the content being viewed.7

    However, a growing body of evidence suggests that parent-child social interactions occurring over digital media may not be as robust as interactions in other settings because audiovisual stimuli from digital media may distract from reciprocal dyadic interactions.15-17 These “serve-and-return” interactions are characterized by positive contingent engagement and respect for children’s autonomy compared with controlling or intrusive behaviors, which disrupt dyadic engagement.11,18,19 Such interactions can be conceptualized as social reciprocity and provide context for parent-child coregulation, forming the basis for children’s social-emotional and cognitive development.20 Previous studies have shown less parent-infant social reciprocity when dyads play with digital toys, such as a baby laptop, compared with traditional toys and books.21 Observational and laboratory-based studies occurring during mealtime have found that when parents’ attention is engaged with their mobile device, they initiate fewer verbal and nonverbal social bids toward their children,22,23 possibly owing to the visually salient design features that may capture the parent’s attention and reduce their responsiveness toward children.24

    In recently published work,25 we found that parent-toddler verbal interactions and collaborative reading behaviors were less frequent when engaging in tablet-based books with and without interactive enhancements (eg, hot spots, sound effects) compared with print books. We surmised that audiovisual distractors and children’s conceptualization of tablets as individually used4 may have led to decreased reading quality, verbal exchanges, and responsiveness, resulting in less social reciprocity.25

    Although prior work has characterized parent-child reciprocity during free play,26,27 only 2 studies have considered this construct with a focus on nonverbal behaviors during tablet-based play.15,28 Hiniker and colleagues15 examined differences in play interactions around traditional toys and tablets among 15 preschool-aged children and their parents. Through qualitative analysis, they observed that children often created a solitary space around the tablet that limited parents’ access to it.15 Particularly when playing fast-paced apps, children were less responsive to parent bids, and some parents exhibited intrusive or controlling behaviors (eg, increasing directives and questions, touching the tablet while child was playing). Another study describing parent-child body posture while reading print and tablet-based books28 found that children frequently took a head-down solitary position during tablet-based reading compared with print reading, which limited parents’ ability to view the screen and led to parent “shoulder surfing” to engage in the activity. These studies suggest that design affordances of the tablet (ie, handheld, individually used) or interactive media (ie, high visual salience, positively reinforcing)24,29-31 may limit parent-child joint media engagement and that reclusive body posture may be an important indicator of social reciprocity in this context; however, these findings were qualitative and used small samples.15,28

    Therefore, this study aimed to examine differences in parent-toddler social reciprocity—defined as nonverbal behaviors such as body position, control, and intrusive behaviors that are parent-child regulatory mismatches that impede reciprocity—during reading of enhanced and basic tablet-based books compared with print books. We chose a book-reading paradigm for examining these aspects of joint media engagement around tablets because social interactions during book reading have been well characterized, and controlling or intrusive behaviors during print book reading have been associated with lower child engagement and more insecure or disorganized attachment relationships.32,33 Manipulating book format (ie, tablet vs print) and interactivity (ie, enhanced vs basic tablet book) allowed tight experimental control to test our hypotheses. We examined toddlers because they may be particularly susceptible to visually salient and behaviorally reinforcing interactive design due to their immature executive functioning.34 This developmental period is also characterized by emerging autonomy and self-direction, which may make shared tablet use more challenging. We hypothesized that parents and children would show lower social reciprocity while reading basic and enhanced tablet-based books compared with print books, characterized by (1) more child solitary body posture, (2) higher frequency of child and parent control behaviors (closing the book, grabbing the book, moving the body with the book), and (3) higher frequency of child and parent intrusive behaviors (hand pushing).

    Methods
    Study Design

    We conducted an experimental laboratory study consisting of video-recorded free play, a reading paradigm that involved a counterbalanced book protocol (each dyad reading 1 enhanced tablet-based, 1 basic tablet-based, and 1 print book), and surveys, with a duration of 75 minutes. This paradigm was chosen because of the well-studied effects of promoting parent-child joint engagement and positive body language behaviors in reading interactions32,35,36 and for tight control over the design affordances of these objects (different levels of enhancements in tablet-based books in addition to comparison with print). After participation, parents were compensated $50. The institutional review board of the University of Michigan, Ann Arbor, approved this study. Parents provided written informed consent.

    Participants

    Data were collected from May 31 through November 7, 2017. As previously described,25 we recruited 37 parent-toddler dyads from the University of Michigan online research registry (UMhealthresearch.org) and community-based settings, including pediatrician offices and child-care and community centers. Inclusion criteria consisted of (1) child age of 24 to 36 months, (2) no child developmental delay or serious medical condition, (3) parent ability to read English sufficiently to provide consent, (4) parent as legal or physical custodial guardian, and (5) no uncorrected hearing or vision impairments in the parent or the child.

    Procedure

    The laboratory approximated a living room, with couches, 3 books in boxes (2 tablet books and 1 print book) placed out of children’s reach, a 1-way mirror, and video cameras. Participants first completed a 5-minute video-recorded free play with nondigital toys, followed by a random counterbalanced, preassigned reading activity of the enhanced tablet-based book, basic tablet-based book, and print book. The reading protocol consisted of a preassigned, random sequential reading activity of an enhanced tablet-based book, basic tablet-based book, and print book occurring in a counterbalanced fashion in 1 of 6 total book format permutations. A total of 6 different book format permutations included (1) enhanced-basic-print, (2) enhanced-print-basic, (3) basic-enhanced-print, (4) basic-print-enhanced, (5) print-basic-enhanced, and (6) print-enhanced-basic. Within each book format permutation, the order of 3 different book titles was counterbalanced, achieving a total of 36 unique permutations. All participants read the same 3 books, but not all books were read in the same format or order across participants. Parents received instructions to complete each book sequentially as prompted for 5 minutes each.

    Book Formats

    Three Mercer Mayer Little Critter books (Just Grandma and Me, All By Myself, and Just a Mess) were chosen owing to similar length, reading difficulty, and availability in 3 formats. Print books were 8 × 8-inch softcover. Basic and enhanced tablet-based books were preloaded on a 10-inch Samsung Galaxy tablet computer (Galaxy; Samsung). Basic tablet-based book capabilities allowed for swiping to turn pages and tapping illustrations to produce visual appearance of words, without autonarration or sound effects. Enhanced tablet-based books contained audiovisual hot spots with interactive animation and sound effects. Tapping most pictures resulted in appearance and narration of the word (eg, tapping a baseball picture resulted in the appearance and narration of the word baseball). Tapping other pictures or turning a page produced a sound effect (eg, tapping a dog would produce the sound of a dog panting; turning the page to a beach produced sounds of ocean waves). Parents received instruction to select “read it myself” such that the tablet-based book was not narrating the book text; tapping and holding down an individual sentence in the enhanced tablet-based book would narrate that text, but this feature was only briefly used by 2 dyads.

    Survey Measures

    Parents completed surveys regarding covariates for potential inclusion in statistical models, including demographic information (parent’s age, sex, educational attainment, household income, race/ethnicity, relationship to child, and marital status; child’s age, sex, race/ethnicity, and prematurity) and standardized measures of child language, social-emotional development, and digital media use practices. The MacArthur-Bates Communicative Development Inventory–Short Form assessed toddler language development using a 100-word validated,37 reliable38 vocabulary checklist generating an age-dependent percentile score for expressive vocabulary (range, 1-99, with higher scores indicating more expressive vocabulary).24

    The Brief Infant-Toddler Social and Emotional Assessment is a validated,39 reliable25 42-item questionnaire screening for child social-emotional problems, with parent-rated items on a 3-point Likert scale generating Problem (range, 0-14, with higher scores indicating more social-emotional problems [Cronbach α = .68]) and Competence (range, 14-22, with higher scores indicating more competence [Cronbach α = .58]) subscales. Standardized questions assessed frequency of digital media use by the child at home (including tablet, smartphone, and electronic book) and parental mediation strategies (instructive, restrictive, and coviewing).40

    Coding Parent-Toddler Nonverbal Interactions

    Social reciprocity indicators were coded from the videos (Table 1); all intercorrelation coefficients were greater than 0.75. We considered solitary space as an indicator of lower social reciprocity based on previous observations that children adopted solitary postures that excluded parents in tablet-based contexts, reducing the ease of reciprocal serve-and-return interactions.15,28 We coded for the presence of solitary space in 10-second intervals, defined as child body posture limiting ease of parental book access. We coded frequency of child and parent control and intrusive behaviors (counts) across a 5-minute interval based on prior work on dyad nonverbal behaviors (eg, pulling the book away,33 pushing the other’s hand away32) during shared book reading.32,33 Control behaviors included the child closing the book, the child grabbing the book or tablet, and the child or the parent pivoting their body away from the other while holding the book or tablet. Intrusive behaviors included the child or the parent pushing the other’s hand away. The parent closing and grabbing the book or tablet occurred too infrequently to code reliably. The 5-minute free-play session was coded for shared positive affect, which we examined as a potential covariate but was not found to improve model fit. Two undergraduate students blinded to the hypothesis coded the videos for reliability with a Cohen κ of at least 0.70 (20% of videos were double-coded to ensure no coder drift).

    Statistical Analysis

    Data were analyzed from October 18, 2017, through April 30, 2018. We conducted Poisson regression using the Proc Genmod comparing each behavioral outcome by book format. Given occasional variation in reading duration, total elapsed time was adjusted. All models included a repeated-measures statement to allow within-participants comparison of behavioral outcomes by book format. Covariates in final models with 2-sided P < .05 were included to improve model fit (eg, order of book presentation, parent income, race/ethnicity, child sex, and MacArthur-Bates Communicative Development Inventory–Short Form or Brief Infant-Toddler Social and Emotional Assessment score). Analyses were completed in SAS, version 9.4 (SAS Institute Inc).

    Results

    As shown in Table 2, the mean (SD) age of children was 29.2 (4.2) months; of parents, 33.5 (4.0) years. Among the parents, 30 (81%) were mothers and 7 (19%) were fathers, 28 (76%) had a 4-year college degree or greater educational attainment, and 33 (89%) were married. Of the children, 20 (54%) were boys and 17 (46%) were girls, 21 (57%) were white non-Hispanic, 6 (16%) were black non-Hispanic, and 10 (27%) were other race/ethnicity.

    Compared with print books (mean [SD] frequency, 3.3 [1.1]), children demonstrated more solitary space during enhanced (mean [SD] frequency, 7.9 [1.9]; P = .01) and basic (mean [SD] frequency, 8.4 [1.8]; P = .006) tablet-based book conditions (Figure 1). As shown in Figure 2, children generally exhibited more control behaviors over enhanced or basic tablet-based books compared with print books. Compared with when reading print books (mean [SD] 0.4 [0.1]), children exhibited higher frequency of closing the book when reading enhanced (1.2 [0.4]; P = .007) and basic (1.2 [0.5]; P < .001) tablet-based books. There were no differences in book or tablet grabs by book format type. Compared with the basic tablet-based book (mean [SD] frequency, 1.0 [0.3]), children exhibited fewer pivot behaviors with the enhanced tablet-based and print books (mean [SD] frequency for both, 0.3 [0.1]; P = .03 for basic vs enhanced; P =.005 for basic vs print).

    Parents likewise exhibited more control behaviors over tablet-based books compared with print books (see Figure 2). Parents exhibited more pivot behaviors during the enhanced tablet-based book condition (mean [SD] frequency, 0.4 [0.2]; P = .05) or the basic tablet-based book condition (mean [SD] frequency, 0.9 [0.4]; P = .004) compared with print books (mean [SD] frequency, 0.2 [0.1]).

    Similarly, intrusive behaviors were greater for children and parents during either tablet-based book condition compared with print. Children exhibited a higher frequency of pushing the parent’s hand away during the enhanced (mean [SD] frequency, 0.6 [0.2]; P < .001) and the basic (mean [SD] frequency, 0.4 [0.2]; P = .002) tablet-based book conditions compared with the print book (mean [SD] frequency, 0.1 [0.04]). Compared with the print book (mean [SD] frequency, 0.06 [0.1]), the parent pushed the child’s hand away more frequently during enhanced (mean [SD] frequency, 1.7 [0.3]; P < .001) and basic (mean [SD] frequency, 2.4 [0.5]; P < .001) tablet-based book conditions.

    Discussion

    Although the American Academy of Pediatrics recommends coviewing when engaging in mobile devices—including tablets—by parents and young children, little research has examined how interpersonal dynamics might change when interacting over tablets. To address this gap, we used a book-reading paradigm to examine differences in nonverbal social reciprocity while reading tablet-based vs print books. The high frequency of child solitary body posture, parent-child control behaviors, and intrusiveness during tablet-based book reading compared with print suggests that it may be challenging for dyads to engage in shared experiences over tablets because it may interfere with parent-child social reciprocity, particularly during book reading.

    One way that tablet design may affect parent-child social reciprocity is by promoting more solitary body orientation in children.15,41 This orientation may reflect the ways in which parents and children use tablets and other mobile devices at home, in a solitary fashion. Domoff and colleagues4 analyzed home audio recordings from 75 families with young children and found that mobile media is often used in parallel rather than shared. Parents have described relishing the independence that children have when using tablets and mobile devices, pride that children are self-sufficient, and the peace afforded by children’s independent tablet use, each of which may be viewed as a benefit.42 Nonetheless, creation of solitary space may inhibit children’s social responsiveness, joint attention, and parental ability to scaffold, which are all important in children’s learning.11,18,32,33,43-45

    Social reciprocity during parent-child activities lays the groundwork for social competence in future relationships; greater parent-child social reciprocity is associated with greater reciprocity with peers,46 whereas negative reciprocity with parents is associated with greater expressed negative affect with peers.46,47 Importantly, social reciprocity is influenced not just by the qualities of the parent-child dyad but also by affordances of play materials. Previous studies have found that digital toys, such as an infant toy cell phone or infant laptop, may yield lower parent verbalizations and conversational turns than traditional toys or books.21 We found that nonverbal control and intrusive behaviors aimed at managing possession of the tablet were more frequent around tablets than print books. Children closed the book application frequently, possibly to escape the electronic book, to look for other apps, or by accident. This situation interfered with the book reading experience, and parents frequently redirected their children to reopen the book. During tablet-based book conditions, children did not appear to want their parents to touch the tablet and engaged in pivoting and intrusive hand-pushing behaviors to control the tablet. Children may have viewed the tablet as a highly desirable object that may be limited at home and therefore exhibited controlling and intrusive behavior. Another explanation is that children may be accustomed to engaging with tablets independently or may not previously have experience using an electronic book, so it may not feel natural to share it with an adult4; however, adjusting for parent-reported mediation (ie, restricting and coviewing) practices and children’s previous electronic book use did not alter our results. Finally, the child’s attention may be drawn to audiovisual stimuli, making it more challenging to respond to parent bids. The tablet-based books chosen for this study had a relatively low number of enhancements and may not reflect how children would interact with highly gamified apps that are prevalent.31 Nonetheless, our findings are similar to previous results showing that children may have difficulty transitioning away from highly engaging devices.48

    We observed a higher frequency of parental control and intrusive behaviors during tablet book conditions, likely in response to child behaviors. Parents were more likely to pivot their body to move the tablet away and gain control of the experience, similar to previous work in toddlers and older children showing that parental mediation strategies tended to be restrictive and reactive.4 Such restriction and behavioral control interactions appeared to detract from rich language exchange around the reading activity, as we found in a prior analysis.25 Parents may have been trying to engage in the reading experience as they would with a traditional book by preventing their child’s tapping and swiping behaviors. Prior work has shown that parental intrusiveness has been associated with negativity and reduced dyadic mutuality among toddlers49 and lower verbal and perceptual cognition among preschoolers.50

    Strengths and Limitations

    This study is the first, to our knowledge, to examine the social reciprocity and nonverbal indicators toddlers and parents exhibit when interacting around tablets. Strengths include a counterbalanced design that inherently controlled for family characteristics that might influence interactional style. We chose a commercially based book app, so our results are more ecologically valid than previous laboratory-based experiments that created their own electronic books.51,52 Another contribution of this study is objective examination of novel aspects of parent mediation, such as conflicts over device possession and solitary space, that are not reflected in self-reported parent mediation measures.40

    Several limitations are worthy of mention. Our sample was small, highly educated, and predominantly married; laboratory-based observation may limit generalizability to the home; and choice of a low-enhancement app may underestimate the influence of interactive enhancements on parent-child behavior. Social reciprocity is just 1 facet of the interaction occurring over tablets. We acknowledge other potential benefits to tablet-based play for older children depending on the educational content of apps used.53,54 Future work should include understanding whether parents exhibit less autonomy support and more control around media use compared with other play and what influence this has on children’s play skills, media use, and social-emotional development over time.

    Conclusions

    Although the American Academy of Pediatrics recommends coviewing when using mobile devices, doing so may be challenging for parents and toddlers to accomplish owing to tablet design affordances. Tablets increased solitary space, control behaviors, and intrusiveness in toddlers and parents in this study, which may interfere with the types of parent-child play interactions shown to improve executive functioning and self-regulation, such as autonomy support and social reciprocity. Technology designers may wish to consider a design that promotes positive shared experiences (eg, apps facilitating taking turns and collaboration). Pediatric health care professionals may wish to counsel parents that, if it is difficult to engage with children around tablets, they consider making times for shared viewing of other media platforms (eg, movie nights), using apps designed for shared use, and making time for play with traditional toys that encourage social reciprocity.

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    Article Information

    Accepted for Publication: May 25, 2019.

    Corresponding Author: Tiffany G. Munzer, MD, Department of Pediatrics, University of Michigan Medical School, 300 N Ingalls St, 1024 NW, Ann Arbor, MI 48109 (chungti@med.umich.edu).

    Published Online: September 30, 2019. doi:10.1001/jamapediatrics.2019.3480

    Author Contributions: Drs Munzer and Radesky had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Munzer, Miller, Radesky.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Munzer.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Weeks, Kaciroti.

    Obtained funding: Munzer, Radesky.

    Administrative, technical, or material support: Miller, Radesky.

    Supervision: Miller, Radesky.

    Conflict of Interest Disclosures: Dr Munzer reported receiving grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) through a T32 training and grants from the Academic Pediatric Association and Reach Out and Read during the conduct of the study. Dr Miller reported receiving grants from the National Institutes of Health outside the submitted work. Dr Weeks reported receiving grants from the Academic Pediatric Association during the conduct of the study. Dr Radesky reported receiving personal fees from the Public Broadcasting Service Parents website and serving on the board of directors and consulting for Melissa & Doug, LLC, outside the submitted work. No other disclosures were reported.

    Funding/Support: This study was supported by the Reach Out and Read Young Investigator Award 2017 from the Academic Pediatric Association (principal investigator, Dr Radesky) and by grant T32HD079350 from the NICHD (principal investigator, Julie C. Lumeng, MD).

    Role of the Funder/Sponsor: The sponsors 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.

    Additional Contributions: Rosa Ball, BA, University of Michigan, managed the study laboratory. Ranya Alkhayyat, University of Michigan, assisted with behavioral coding. Joy Boakye, BA, assisted with participant recruitment, protocol administration, and behavioral coding, and Anastasia Pacifico, BS, University of Michigan, assisted with behavioral coding. They were all compensated for this work.

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