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April 20, 2020

Early Media Exposure and Autism Spectrum Disorder: Heat and Light

Author Affiliations
  • 1Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
JAMA Pediatr. 2020;174(7):640-641. doi:10.1001/jamapediatrics.2020.0659

The rising prevalence of autism spectrum disorder (ASD) has given pause to many epidemiologists and spawned aggressive attempts to search for an explanation. Whatever the underlying genomics of autism are, they cannot explain the increase because they have remained largely unchanged while the incidence has steadily risen. Hence it seems logical to think of environmental perturbations that have occurred concomitant with this rise that might plausibly be linked to it and would lend themselves to modification or remediation. Notably, the rise in ASD incidence began in earnest in 1996.1 What else began in the early 1990s? Infant television viewing. In 1970, the mean age at which children began to watch television was 4 years; by 2006 it was 4 months.2 Ecological associations are always fraught and problematic, but there are compelling theoretical reasons to believe that a potential causal linkage may exist between excessive early exposure to media and developmental outcomes in children, many of which are enumerated by Heffler et al3 in this issue of JAMA Pediatrics as motivating their study.

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3 Comments for this article
Additional Difficulty in Drawing Causal Inferences
Lori Mills, MLIS | McLaren Macomb
It is quite possible that if children at one-year of age who do not reciprocate caregiver engagement--that is. who do not laugh, make eye contact, etc.-- may be more likely to be placed in front of the television.
Wouldn't It Be Wonderful?
Leonard Oestreicher, MD | Society for Study of Autism and Social Communication
This study raises an interesting question.

What if there was something that parents could do during the first year of life to lower the risk of their children developing the traits of ASD? What if that something was as simple and rewarding as spending more social time with their infants while exposing them to less screen time?

There can be no serious argument anymore that the prevalence of ASD, no matter how it is defined, is dramatically increasing each year here in the United States and around the world. I would think that you would be
hard pressed to find one practicing primary pediatrician in the country (the world?) who has not noticed this difference in their patient populations over the past twenty years. Likewise there can be no serious argument that screen time during the first year of life has not dramatically increased during this same period.

A correlation proves nothing is true. And if we are looking for proof of a casual relationship between these factors, we will not find them in this study. However the correlation ultimately is true or false whether we can scientifically demonstrate it or not. The authors have done their best but the data was never intended to answer this pressing question. It is important that we do much more research to find out where the actual truth lies. Meanwhile the correlation they found is tantalizing. The real question is if it is actionable. China has made their decision and clearly taken the lead in this matter, prohibiting any child under five years of age from watching screens for more than an hour a day.

Suppose we, who take care of families with infants, were to make a blanket recommendation that all such children avoid screen time and all caretakers use that time as much as possible to be face to face with their infants. If the correlation is really false, can we all agree that there is nothing lost.

If it is really true then wouldn't it be wonderful to discover that caretakers and the choices they make during the first year of life, during the time of peak brain plasticity, could actually make a positive difference to their infants and the social skills they ultimately develop? Would that be so surprising?
The ELEPHANT in the room
Richard Schmidt, BPharm PhD | [Retired pharmacist]
In 2009, Good [1] published an article in which a compelling case is made for acetaminophen / paracetamol being the underlying "environmental perturbation". He pointed out the synchronicity of the switch in the 1980s to using acetaminophen rather than aspirin in infancy and childhood with the beginning of an an exponential rise in the incidence of autism. And in 2016, JAMA Pediatrics published an article by Stergiakouli et al. [2] in which the conclusion was reached that "Children exposed to acetaminophen prenatally are at increased risk of multiple behavioral difficulties ...". And then in 2017, Pediatrics published an article by Ystrom et al.[3] in which the conclusion was reached that "Short-term maternal use of acetaminophen during pregnancy was negatively associated with ADHD in offspring. Long-term maternal use of acetaminophen during pregnancy was substantially associated with ADHD even after adjusting for indications of use, familial risk of ADHD, and other potential confounders." Other such articles may be found on PubMed yet the medical and regulatory authorities appear to want to take no notice of these findings. Olsen & Liew [4] concluded, in my view quite reasonably, that "The harm of doing nothing may well exceed the harm for taking precautionary actions considering the consequences at stake." In other words, the precautionary principle needs to be invoked.

I have corresponded with the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK on this matter, only to informed that it was being considered at higher level in the EU. This has been followed by a deafening silence.

[1] http://www.altmedrev.com/archive/publications/14/4/364.pdf
[2] https://doi.org/10.1001/jamapediatrics.2016.1775
[3] https://doi.org/10.1542/peds.2016-3840
[4] https://doi.org/10.1080/14740338.2017.1384812