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Original Investigation
April 20, 2020

Association of Early-Life Social and Digital Media Experiences With Development of Autism Spectrum Disorder–Like Symptoms

Author Affiliations
  • 1Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania
  • 2Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
  • 3Value Institute, Christianacare Health System, Wilmington, Delaware
  • 4Social & Scientific Systems, Inc, Silver Spring, Maryland
  • 5Department of Psychiatry, Drexel University College of Medicine, Philadelphia, Pennsylvania
JAMA Pediatr. 2020;174(7):690-696. doi:10.1001/jamapediatrics.2020.0230
Key Points

Question  Are screen media exposure and social and demographic factors associated with the risk for autism spectrum disorder (ASD) or ASD–like symptoms on the Modified Checklist for Autism in Toddlers at 2 years of age?

Findings  This cohort study of 2152 children controlled for perinatal and demographic variables and found that television and/or video exposure and less caregiver-child interactive play at 12 months of age were each significantly associated with greater ASD-like symptoms, determined by total revised Modified Checklist for Autism in Toddlers score, but not with the risk of ASD. Additional perinatal and demographic findings are discussed.

Meaning  Less screen exposure and more parent-child play at 12 months of age were associated with fewer ASD–like symptoms at 2 years of age, and more research on early experiential factors is recommended.


Importance  Despite growing evidence that parent-child interactions and time viewing digital media affect child development, these factors have rarely been studied in association with autism spectrum disorder (ASD) symptoms.

Objective  To determine the association of experiential factors, including social activities and screen viewing in the first 18 months of life, perinatal factors, and demographic factors, with ASD-like symptoms and risk on the Modified Checklist for Autism in Toddlers (M-CHAT) at 2 years.

Design, Setting, and Participants  Data for this cohort study were derived from the National Children’s Study, a US multicenter epidemiological study of environmental influences on child health and development. A total of 2152 children were enrolled at birth from October 1, 2010, to October 31, 2012. Data were analyzed from December 1, 2017, to December 3, 2019.

Exposures  Caregivers reported whether the child viewed television and/or videos (yes or no) at 12 months of age, hours of viewing at 18 months of age, time spent by the caregiver reading to the child (number of days per week compared with daily) at 12 months of age, and frequency of playing with the child (daily or less than daily) at 12 months of age. Prematurity, maternal age at birth, child sex, household income, race/ethnicity, and caregiver English-language status were included in analysis.

Main Outcomes and Measures  Significant association of exposures with ASD risk by M-CHAT and/or ASD-like symptoms assessed by revised M-CHAT (M-CHAT-R) total score in multiple regression models.

Results  Among the 2152 children included in the analysis (1099 boys [51.1%]), television and/or video viewing (yes or no) at 12 months of age was significantly associated with greater ASD-like symptoms at 2 years of age (change, 4.2%; 95% CI, 0.1%-8.3%) but not with ASD risk (risk prevalence rates, 8.3% vs 4.4%; adjusted odds ratio [AOR], 1.40; 95% CI, 0.86-2.29). Similarly, parent-child play daily compared with less than daily was significantly associated with fewer ASD-like symptoms at 2 years of age (change, −8.9%; 95% CI, −16.5% to −0.9%) but not with ASD risk (risk prevalence rates, 6.4% vs 14.0%; AOR, 0.58; 95% CI, 0.31-1.08). However, high screen viewing at 18 months of age was not significantly associated with ASD-like symptoms (change, 10.7%; 95% CI, −2.0% to 23.0%) or ASD risk by M-CHAT (AOR, 1.18; 95% CI, 0.56-2.49) at 2 years of age.

Conclusions and Relevance  This cohort study found greater screen exposure and less caregiver-child play early in life to be associated with later ASD-like symptoms. Further research is needed to evaluate experiential factors for potential risk or protective effects in ASD.

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    1 Comment for this article
    Parental Education to Decrease Autism Spectrum Disorder-like Symptoms?
    Deborah Badawi, MD | University of Maryland School of Medicine
    This article provides information demonstrating an association between screen time and importantly less play time at 12 months of age with autism spectrum disorder-like symptoms. This is valuable information, however I find one of the conclusions may start us on a slippery slope. "These factors are potentially
    modifiable through parental education" can be construed as suggesting that more play time and less screen time can decrease the possibility of autism spectrum disorder-like symptoms, and by extension, autism. In fact the listserv on which I received this article already made that suggestion. The current study demonstrates an
    association and nothing about causality. It is quite possible that families allow their children more screen time and play with them less because their children are less interested in interacting with them, or are generally more irritable. I have seen this clinically in multiple evaluations. Pediatricians daily counsel families to avoid screen time for infants and toddlers, and that is a worthy pursuit. We need more public media campaigns to encourage parents to play with their children. However, we must be very careful to avoid sliding back to the days of "refrigerator mothers". I have sat with too many parents blaming themselves for their child's developmental disability when there is nothing they could have done to change the outcome. Unless and until a causal association is determined, we must tread very carefully when suggesting that a parent's actions have caused their child's challenges. The relationship is typically much more complex than that.