Objective To determine whether the amount, type, and patterns of television viewing predict the onset or the persistence of externalizing problems in preschool children.
Design Longitudinal study of a prospective population-based cohort in the Netherlands.
Setting Parents reported time of television exposure and type of programs watched by children. Externalizing problems were assessed using the Child Behavior Checklist at 18 and 36 months.
Participants A population-based sample of 3913 children.
Main Exposure Television viewing time, content, and patterns of exposure (at 24 and 36 months) in children with and without preexisting problems to assess the incidence and persistence of externalizing problems.
Main Outcome Measures Externalizing problems at 36 months.
Results Program content and time of television exposure assessed at 24 months did not predict the incidence of externalizing problems at 36 months (odds ratio, 2.24; 95% CI, 0.97-5.18). However, the patterns of exposure over time reflecting high levels of television viewing were associated with the incidence of externalizing problems (odds ratio, 2.00; 95% CI, 1.07-3.75) and the persistence of the preexisting externalizing problems (2.59; 1.03-6.55).
Conclusions Our study showed that high television exposure increases the risk of the incidence and the persistence of externalizing problems in preschool children.
According to the recently updated guidelines of the American Academy of Pediatrics,1 media exposure at a young age should be discouraged because it may have negative consequences for the health and development of children. It has been reported that 17% to 48% of children aged 3 years or younger do not comply with these recommendations.2 A study of media consumption in the United States has demonstrated that 73% of preschool children watch television (TV) on a daily basis, spending approximately 2 hours a day in front of TV.3 Increased media exposure time among young children,4,5 a shift toward younger age,2,3,6 and exposure to adult content6 reflect the importance of this public health problem.
Exposure to media encompasses both viewing time and the content of the media.7-10 Several studies showed positive effects of educational content on a number of developmental outcomes.7,11,12 However, there is also evidence suggesting an association between exposure time and behavioral outcomes regardless of the content.13,14 Negative effects of excessive TV viewing and its content were reported in particular for aggressive behavior13,15-20 and attention problems.5,15-17 However, these studies were conducted mostly in school-aged children and adolescents, whereas aggressive behavior and attention problems, which are well-known risk factors for a number of disorders, are already prevalent in early childhood.18 Poor attention ability and aggression in children are referred to as externalizingproblems. The term also refers to such behaviors as noncompliance, hyperactivity, and concentration difficulties.18-20
Currently, despite the high prevalence of TV viewing among preschool children, little is known about the effects of TV exposure on subsequent externalizing problems. Several high-quality studies examined the prevalence of media exposure21 and its associations with cognitive development,22 hyperactivity-inattention, and prosocial behavior.23,24 Most studies13,25,26 of externalizing problems in preschool children, however, have limitations, such as relatively small and high-risk samples25 and cross-sectional data,13,26 which cannot establish the temporality of the observed association. Furthermore, earlier studies did not address content of TV programs watched by young children23 and did not adjust for parental psychosocial risk factors.13,23
Using prospective data from a large population-based cohort in the Netherlands, we addressed the following questions: (1) Is the duration and content of TV exposure at 24 months associated with externalizing problems at 36 months? (2) What is the effect of the patterns of TV exposure between 24 and 36 months on incident and persistent externalizing problems at 36 months?
Compared with earlier similar research,27 we examined behavioral outcomes among children at a younger age and accounted for the preexisting problems to examine the persistence of problem behavior. Whereas most of the previous studies were conducted in the United States with high levels of TV viewing, we examined the effects of TV viewing on externalizing problems among children in Europe.
Design and study participants
This study was performed within the Generation R Study, a large population-based cohort in Rotterdam, the Netherlands. The cohort has been described in detail elsewhere.28 The Generation R Study was approved by the Medical Ethics Committee of the Erasmus University Medical Center.
Pregnant women living in Rotterdam (delivery date of April 1, 2002, through January 31, 2006) were invited to participate. Full consent for study participation was obtained from 7295 mothers. All participants provided written informed consent. Data on children's TV exposure at 24 and 36 months were available for 4368 children. For 3913 of these children, information on externalizing problems at 18 and 36 months was available. Analyses of these 3913 children were performed in 2 strata: children without preexisting externalizing problems (n = 3437) and children with externalizing problems present at 18 months (n = 476). However, analyses of repeated measure of TV exposure patterns were performed in 3761 children (ie, in 2 strata of 3309 and 452 children from this group of 3761).
Parental questionnaires at 24 and 36 months contained questions on TV exposure of children. In a similar study using a continuous measure to assess TV viewing at 2.5 and 5.5 years, exposure was categorized as more than 2 hours of daily TV viewing.27 We used a similar categorization but the maximum duration of TV viewing at 24 months was adapted to “more than 1 hour” accounting for the younger age. Therefore, duration of daily TV viewing was assessed using the following answer categories: “never,” “less than 0.5 hour,” “0.5 to 1 hour,” and “more than 1 hour” a day. Categories at 36 months were adapted (categories “1 to 2 hours” and “more than 2 hours” were added) to differentiate at the high ranges in older children.
At 24 months, parents also reported whether their child watched TV programs suitable or unsuitable for children. In the Netherlands, TV is state regulated and is organized by channels, which have content appropriate for children (eg, cartoons and educational programs). Parents reported channels and programs their children watched, and whether their children watched programs for adults or age-inappropriate programs (the category “unsuitable-for-children TV programs”). Programs shown on the channels for children were categorized as “suitable-for-children TV programs.”
On the basis of TV exposure at 24 and 36 months, we created a variable reflecting the patterns of daily exposure over time: “never or less than 0.5 hour” (<0.5 h/d at 24 and 36 months) (n = 789), “continued low TV exposure” (0.5-1 h/d at both ages) (n = 974), “continued moderate TV exposure” (1 h/d at both ages) (n = 681), and “high exposure” (reflecting an increase in exposure and continued high exposure) (n = 1317). The size of the latter group allowed more specific exposure definitions: “increased TV exposure time” (increased from <0.5 h/d at 24 months to ≥1 h/d at 36 months) (n = 276); and “continued high TV exposure” (≥0.5 h/d at 24 months and ≥1 h/d at 36 months) (n = 1041). The 2 categories reflecting decreasing exposure were too infrequent for meaningful analyses (total n = 152 for 2 exposure categories over 2 strata); therefore, these categories were not used in further analyses. Consequently, the analyses of the patterns of TV exposure were performed in 3761 of 3913 children (ie, in 2 strata of 3309 and 452 children from this group of 3913).
The Dutch version of the Child Behavior Checklist (for children aged 1½-5 years)19,29 was used to obtain parent reports on children's behavioral problems in the preceding 2 months at 18 and 36 months on a 3-point Likert scale. The externalizing scale consists of 2 subscales: attention problems (5 items) and aggressive problems (19 items). Examples of items assessing attention and aggression problems are “Can't sit still, restless, or hyperactive” and “Hits others,” respectively. Because the distribution of the continuous variable was skewed and could not be transformed to satisfy the assumption of normality, a dichotomous variable was used. We applied a cut-off point based on Dutch norms.29 The subscale score equivalent to the Dutch norm (83rd percentile) for externalizing problems was a score of 18, which in our sample corresponded to the 88th percentile. The Child Behavior Checklist (for children aged 1½-5 years) has good reliability and validity.19,29
Confounders were considered on the basis of previous studies of TV exposure.2,5,8,17,21,27,30 Child sex, age, national origin, day care attendance, maternal and paternal age, educational level, marital status, monthly income, maternal symptoms of psychiatric disorders, parenting stress, and parity were assessed by questionnaires. National origin of a child was defined by country of birth of the parent(s) and categorized as Dutch, other Western, or non-Western.31 The highest attained educational level of the parents (4 categories) ranged from “low” (<3 years of general secondary education) to “high” (higher academic education or PhD).32 The net monthly household income comprised the categories: “less than [euro]1200” (approximately US $1500), “[euro]1200 to [euro]2000” (approximately US $1500-$2500), and “more than [euro]2000” (approximately US $2500).
The Brief Symptom Inventory, a validated instrument containing 53 self-appraisal statements,33 was used to assess general symptoms of maternal psychiatric disorders when children were 2 months old. Parenting stress was assessed by the Nijmeegse Ouderlijke Stress Index–Kort,34 a questionnaire consisting of 25 items on parenting stress related to parent and child factors. Weighted sum scores were used in the analyses. Day care attendance was categorized as “less than 16 hours per week” and “16 hours or more per week” (modal value).
Analyses were performed in 2 different strata of children. A stratum without behavioral problems at 18 months was analyzed (n = 3309), allowing us to identify incident behavioral problems at 36 months. The second stratum (n = 452) consisted of children who had developed externalizing problems by 18 months (ie, some months before TV viewing was assessed). This enabled us to determine the influence of TV exposure on persistence of behavioral problems.
First, we examined whether TV exposure time at the age of 24 months and exposure to specific content predicted behavioral problems at the age of 36 months, using logistic regression analyses. Three models were examined: (1) univariate, (2) adjusted for externalizing symptoms score at the age of 18 months using the continuous measure, and (3) additionally controlled for socioeconomic and psychosocial covariates. Next, we examined whether patterns of TV exposure from 24 to 36 months were associated with incident or persistent externalizing problems at 36 months using the same set of models.
The externalizing problems score at 36 months had a skewed distribution; it was dichotomized and analyzed with logistic regression. To control for the degree of externalizing problems at baseline, a continuous measure of externalizing problems at 18 months was used because logistic regression does not require the assumption of normality. The dichotomous measure of externalizing problems at 18 months was used to define the preexisting externalizing problems for the stratified analyses.
Missing data on covariates were estimated using multiple imputation techniques (SPSS, version 17 [SPSS, Inc]). All covariates were used to estimate missing values. The reported effect estimates are the pooled results of 30 imputed data sets.
Children with missing data on behavioral problems at 18 months and TV exposure time at 24 months were compared with those without missing information on these variables. Data were missing more often in children of non-Dutch national origin (45.8% vs 12.4%; P < .001). Mothers of children with missing data also were less educated (47.6% vs 23.8%), younger (mean difference, 1.4 years), and more often single (26.4% vs 15.6%) and had a lower income level (33.4% vs 32.1%) than mothers without missing data (P < .001 for all).
There were more boys (56.3% vs 48.4%) and more children of non-Dutch national origin (38.5% vs 28.1%) among children who had externalizing problems at 18 months (P < .001 for both) (Table 1). Mothers of children who had externalizing problems were slightly younger (30.9 vs 31.9 years), had lower educational levels (47.5% vs 37.3%) and lower household income (29.5% vs 21.7%), were more often single (13.7% vs 6.0%), and had higher scores for symptoms of psychiatric disorders (0.36 vs 0.19).
Table 1. Child and Parental Characteristics and Externalizing Behavioral Problems at 18 Months
Incidence of externalizing problems
We examined the effects of TV exposure time and content at 24 months on the incidence of externalizing problems. Exposure time of more than 1 h/d did not predict the incidence of externalizing problems at 36 months (odds ratio [OR], 2.24; 95% CI, 0.97-5.18). The association was weaker once adjusted for socioeconomic and psychosocial covariates (OR, 1.53; 95% CI, 0.62-3.81). Also, watching unsuitable TV programs at 24 months was not related to the incidence of externalizing problems at 36 months (OR, 2.56; 95% CI, 0.95-6.88).
Next, we examined the association of children's patterns of TV exposure over time with the incidence of externalizing problems (Table 2). The overall high TV exposure was associated with incident externalizing problems (OR, 2.62; 95% CI, 1.48-4.66) and remained statistically significant after controlling for any preexisting externalizing symptoms and socioeconomic and psychosocial covariates (2.00; 1.07-3.75). Continued high exposure, a subgroup of children with high TV exposure, predicted incidence of externalizing problems also after full adjustment of the association (OR, 2.09; 95% CI, 1.08-4.01). The effect of the increased exposure time over time on the incidence (OR, 2.50; 95% CI, 1.15-5.41) attenuated once adjusted for externalizing symptoms at 18 months (1.90; 0.86-4.21).
Table 2. Incident Externalizing Problems by TV Watching Patterns
Persistence of externalizing problems
We examined the effect of the patterns of TV exposure on the persistence of externalizing problems at 36 months in children who already had behavioral problems at the age of 18 months (Table 3). The variable reflecting overall high TV exposure predicted the likelihood of the persistent externalizing problems (OR, 3.24; 95% CI, 1.39-7.54) also after full adjustment for the confounders (2.59; 1.03-6.55). Again, we performed additional analyses in the subgroups. Adjusting the association between continued high exposure and persistent externalizing problems for preexisting externalizing symptoms and psychosocial covariates rendered it nonsignificant (OR, 2.13; CI, 0.82-5.51). Although few children had an increase in exposure between 24 and 36 months, the effect of increased TV viewing on the persistence of externalizing problems was strong in children with preexisting problems (OR, 5.99; 95% CI, 1.86-19.30).
Table 3. Persistent Externalizing Problems by Television Exposure Over Time
Post hoc analyses of TV exposure patterns were performed for Aggression and Attention subscales. The obtained point estimates were in line with those for externalizing problems, although only the results for persistent attention problems reached statistical significance (see eTables 1-3).
Children develop their TV viewing patterns early in childhood and these patterns are likely to be sustained.2,35 We found that young children's continued exposure to TV increases their risk for incident externalizing problems, and children with preexisting externalizing problems are more likely to have persistent problems due to high (increasing) TV exposure early in childhood.
Several theories offer an explanation for the influence of media on child development. Content-based theories emphasize the importance of the quality of programs. According to these theories, children learn from the content by using cognitive and social learning mechanisms.9 However, studies regarding the learning effects of TV viewing are inconclusive and there is little evidence for beneficial outcomes in young children.1 In our study, the effect of content on development of externalizing problems was not statistically significant. However, the prevalence of exposure to an inappropriate content was low (8.4% in children with externalizing problems and 5.6% in those without); our sample may have been too small to detect an effect. Also, the measure of content may not have been sensitive enough, or mothers may have been disinclined to report their children's exposure to inappropriate content.
According to the displacement theory,9 time spent viewing TV replaces other intellectually and physically stimulating activities. Also, the rapid pace and various visual and audio effects may be too difficult for a young child to process.9 Having to process images in rapid sequence with little time to reflect on the content may have negative effects on attention abilities. In our study, a high level of exposure time was a risk factor for the onset and persistence of externalizing behaviors.
Our longitudinal study demonstrated the importance of repeated assessments of TV exposure and behavior. Sustained and excessive exposure posed a risk for development of behavioral problems in young children, and this conclusion is in line with earlier research on the topic.27 Collecting data longitudinally already at such a young age and differentiating between incident and persistent cases helps to address the issue of reverse causality. It is, however, more difficult to infer causality in the relation with persistent externalizing problems. Children may watch TV as a result of their preexisting problems.36,37 Parents could be more inclined to allow TV viewing.38 If children have behavioral problems, parents may be tempted to use TV as a babysitter to keep their child occupied.21 Nevertheless, the effects of high levels of exposure found in our study were consistent across incident and persistent externalizing problems.
Television exposure in this population was relatively low compared with the prevalence reported for children in the United States.3,5,21 Only 34% of children exceeded 1 h/d of TV viewing at 36 months, and only 7% exceeded 2 h/d at 36 months. This difference in exposure could be related to the high number of working hours of the parents or the societal attitudes about TV viewing.
Large population-based cohort studies provide an opportunity to prospectively investigate the association between TV viewing in early childhood and behavioral problems. Differentiating the effect of such exposure on the incidence and the persistence of behavioral problems helped in establishing the temporality of the association. Furthermore, all studied associations were adjusted for a large number of covariates.
The nonresponse analyses indicated possible selective nonresponse, which could have biased our results. Another limitation of our study is the use of parent-reported media exposure. Mothers could have underreported the TV exposure giving socially desired answers. Using objective and specific measures could have provided more extensive and more precise information on TV viewing behaviors among children. Several other studies have used diary methods that appear to be more accurate in measuring the exposure and its content.7,25,35,39 However, the mother's report is well correlated with the diary method.39 Another limitation of our study is the use of a categorical rather than a continuous measure of the TV time exposure. Nevertheless, previous epidemiologic studies23,40,41 of population-based samples have used similar categorical measures. Furthermore, other factors that may affect both TV viewing and externalizing problems, such as exposure to aggression or abuse in real life42,43 or temperament of a child,44,45 were not addressed. Finally, distinguishing between foreground and background exposures can advance the understanding of the mechanisms through which TV viewing affects child development.
In conclusion, preschool children are a major target audience of the TV market in Western societies.13,46 Extensive exposure to media influences development, behavior, and day-to-day activities of young children. We have demonstrated that high levels of TV exposure increase the likelihood of externalizing problems in preschool children, even in those who did not have preexisting externalizing problems. Having considered the findings of this and previous studies,2,13,16,17,26,27,47-52 the most useful advice for parents of preschool children would be to follow the American Academy of Pediatrics guidelines1,53 and discourage young children's exposure to TV either as the main activity or as a background exposure. Perhaps in doing so not only will externalizing problems be reduced but also associated problems such as obesity54-57 and other negative outcomes30,58-60 may be prevented.
Correspondence: Henning Tiemeier, MD, PhD, Department of Child and Adolescent Psychiatry, Erasmus University Medical Center, PO Box 2060, 3000 CB Rotterdam, the Netherlands (h.tiemeier@erasmusmc.nl).
Accepted for Publication: March 7, 2012.
Published Online: August 6, 2012. doi:10.1001 /archpediatrics.2012.653.
Author Contributions:Study concept and design: Verlinden, Tiemeier, Hofman, Verhulst, and Jansen. Acquisition of data: Tiemeier, Jaddoe, Raat, Hofman, and Verhulst. Analysis and interpretation of data: Verlinden, Tiemeier, Hudziak, Jaddoe, Raat, Guxens, and Verhulst. Drafting of the manuscript: Verlinden, Tiemeier, and Hudziak. Critical revision of the manuscript for important intellectual content: Verlinden, Hudziak, Jaddoe, Raat, Guxens, Hofman, Verhulst, and Jansen. Statistical analysis: Verlinden, Jaddoe, Raat, Guxens, and Jansen. Obtained funding: Tiemeier, Jaddoe, and Hofman. Study supervision: Tiemeier, Hudziak, Hofman, Verhulst, and Jansen.
Financial Disclosure: Dr Hudziak reports that he has received funding from the National Institute of Mental Health and the National Institute of Diabetes and Digestive and Kidney Disease. His primary appointment is with the University of Vermont. He has additional appointments with Erasmus University in Rotterdam; Vrije University in Amsterdam; Dartmouth Medical School in Hanover, New Hampshire; and Avera Institute of Human Behavioural Genetics in Sioux Falls, South Dakota. Dr Verhulst reports that he is a contributing editor for the Achenbach System of Empirically Based Assessment, from which he receives remuneration.
Funding/Support: The Generation R Study is made possible by financial support from the Erasmus University Medical Center Rotterdam and the Netherlands Organization for Health Research and Development (grant ZonMW “Geestkracht” program 100001003). The present study was supported by grant 017.106.370 (NWO ZonMW VIDI) from the Netherlands Organization for Scientific Research (Dr Tiemeier) and grant 602 from the Sophia Foundation for Medical Research SSWO (Dr Jansen). The work of Ms Verlinden was supported by the grant from the Netherlands Organization for Health Research and Development (ZonMW “Geestkracht” program 100001003).
1.Brown A.Council on Communications and Media. Media use by children younger than 2 years.
Pediatrics. 2011;128(5):1040-104522007002
PubMedGoogle ScholarCrossref 2.Certain LK, Kahn RS. Prevalence, correlates, and trajectory of television viewing among infants and toddlers.
Pediatrics. 2002;109(4):634-64211927708
PubMedGoogle ScholarCrossref 3.Rideout V, Vandewater EA, Wartella EA. Zero to Six: Electronic Media in the Lives of Infants, Toddlers, and Preschoolers. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2003
5.Christakis DA, Ebel BE, Rivara FP, Zimmerman FJ. Television, video, and computer game usage in children under 11 years of age.
J Pediatr. 2004;145(5):652-65615520768
PubMedGoogle ScholarCrossref 6.Kennedy CM. Television and young Hispanic children's health behaviors.
Pediatr Nurs. 2000;26(3):283-288, 292-29412026392
PubMedGoogle Scholar 7.Wright JC, Huston AC, Murphy KC,
et al. The relations of early television viewing to school readiness and vocabulary of children from low-income families: the early window project.
Child Dev. 2001;72(5):1347-136611700636
PubMedGoogle ScholarCrossref 8.Zimmerman FJ, Christakis DA. Associations between content types of early media exposure and subsequent attentional problems.
Pediatrics. 2007;120(5):986-99217974735
PubMedGoogle ScholarCrossref 9.Anderson DR, Huston AC, Schmitt KL, Linebarger DL, Wright JC. Early childhood television viewing and adolescent behavior: the recontact study.
Monogr Soc Res Child Dev. 2001;66(1):i-viii, 1-14711326591
PubMedGoogle Scholar 12.Thakkar RR, Garrison MM, Christakis DA. A systematic review for the effects of television viewing by infants and preschoolers.
Pediatrics. 2006;118(5):2025-203117079575
PubMedGoogle ScholarCrossref 13.Ozmert E, Toyran M, Yurdakök K. Behavioral correlates of television viewing in primary school children evaluated by the Child Behavior Checklist.
Arch Pediatr Adolesc Med. 2002;156(9):910-91412197799
PubMedGoogle Scholar 14.Pagani LS, Fitzpatrick C, Barnett TA, Dubow E. Prospective associations between early childhood television exposure and academic, psychosocial, and physical well-being by middle childhood.
Arch Pediatr Adolesc Med. 2010;164(5):425-43120439793
PubMedGoogle ScholarCrossref 16.Swing EL, Gentile DA, Anderson CA, Walsh DA. Television and video game exposure and the development of attention problems.
Pediatrics. 2010;126(2):214-22120603258
PubMedGoogle ScholarCrossref 17.Landhuis CE, Poulton R, Welch D, Hancox RJ. Does childhood television viewing lead to attention problems in adolescence? results from a prospective longitudinal study.
Pediatrics. 2007;120(3):532-53717766526
PubMedGoogle ScholarCrossref 18.Campbell SB. Behavior problems in preschool children: a review of recent research.
J Child Psychol Psychiatry. 1995;36(1):113-1497714027
PubMedGoogle ScholarCrossref 19.Achenbach TM, ed, Rescorla LA, ed. Manual for ASEBA Preschool Forms and Profiles. Burlington: University of Vermont Research Center for Children, Youth, and Families; 2000
21.Zimmerman FJ, Christakis DA, Meltzoff AN. Television and DVD/video viewing in children younger than 2 years.
Arch Pediatr Adolesc Med. 2007;161(5):473-47917485624
PubMedGoogle ScholarCrossref 22.Zimmerman FJ, Christakis DA. Children's television viewing and cognitive outcomes: a longitudinal analysis of national data.
Arch Pediatr Adolesc Med. 2005;159(7):619-62515996993
PubMedGoogle ScholarCrossref 23.Cheng S, Maeda T, Yoichi S, Yamagata Z, Tomiwa K.Japan Children's Study Group. Early television exposure and children's behavioral and social outcomes at age 30 months.
J Epidemiol. 2010;20:(suppl 2)
S482-S48920179364
PubMedGoogle ScholarCrossref 24.Ostrov JM, Gentile DA, Crick NR. Media exposure, aggression and prosocial behavior during early childhood: a longitudinal study.
Soc Dev. 2006;15(4):612-627
Google ScholarCrossref 25.Tomopoulos S, Dreyer BP, Valdez P,
et al. Media content and externalizing behaviors in Latino toddlers.
Ambul Pediatr. 2007;7(3):232-23817512884
PubMedGoogle ScholarCrossref 26.Manganello JA, Taylor CA. Television exposure as a risk factor for aggressive behavior among 3-year-old children.
Arch Pediatr Adolesc Med. 2009;163(11):1037-104519884595
PubMedGoogle ScholarCrossref 27.Mistry KB, Minkovitz CS, Strobino DM, Borzekowski DLG. Children's television exposure and behavioral and social outcomes at 5.5 years: does timing of exposure matter?
Pediatrics. 2007;120(4):762-76917908763
PubMedGoogle ScholarCrossref 28.Jaddoe VW, van Duijn CM, van der Heijden AJ,
et al. The Generation R Study: design and cohort update 2010.
Eur J Epidemiol. 2010;25(11):823-84120967563
PubMedGoogle ScholarCrossref 29.Tick NT, van der Ende J, Koot HM, Verhulst FC. 14-year changes in emotional and behavioral problems of very young Dutch children.
J Am Acad Child Adolesc Psychiatry. 2007;46(10):1333-134017885575
PubMedGoogle ScholarCrossref 30.Hancox RJ, Milne BJ, Poulton R. Association of television viewing during childhood with poor educational achievement.
Arch Pediatr Adolesc Med. 2005;159(7):614-61815996992
PubMedGoogle ScholarCrossref 31. Allochtonen in Nederland 2004 [in Dutch]. Voorburg/Heerlen: Statistics Netherlands; 2004
32. Standaard Onderwijsindeling 2003 [in Dutch]. Voorburg/Heerlen: Statistics Netherlands; 2004
33.Derogatis L. Brief Symptom Inventory (BSI): Administration, Scoring and Procedures. 3rd ed. Minneapolis, MN: National Computer Systems; 1993
34.De Brock AJLL, Vermulst AA, Gerris JRM, Abidin RR. Nijmeegse Ouderlijke Stress Index (NOSI): Manual. Lissie, the Netherlands: Swets en Zeitlinger; 1992
35.Huston AC, Wright JC, Rice ML, Kerkman D, St. Peters M. Development of television viewing patterns in early childhood: a longitudinal investigation.
Dev Psychol. 1990;26(3):409-420
Google ScholarCrossref 36.Acevedo-Polakovich ID, Lorch EP, Milich R. Comparing television use and reading in children with ADHD and nonreferred children across two age groups.
Media Psychol. 2007;9(2):447-472
Google ScholarCrossref 37.Ebenegger V, Marques-Vidal P-M, Munsch S,
et al. Relationship of hyperactivity/inattention with adiposity and lifestyle characteristics in preschool children [published online December 29, 2011].
J Child Neurol. 2011;22209757
PubMedGoogle Scholar 38.Jordan AB, Hersey JC, McDivitt JA, Heitzler CD. Reducing children's television-viewing time: a qualitative study of parents and their children.
Pediatrics. 2006;118(5):e1303-e131017079531
PubMedGoogle ScholarCrossref 39.Anderson DR, Field DE, Collins PA, Lorch EP, Nathan JG. Estimates of young children's time with television: a methodological comparison of parent reports with time-lapse video home observation.
Child Dev. 1985;56(5):1345-13574053746
PubMedGoogle ScholarCrossref 40.Jago R, Page A, Froberg K, Sardinha LB, Klasson-Heggebø L, Andersen LB. Screen-viewing and the home TV environment: the European Youth Heart Study.
Prev Med. 2008;47(5):525-52918722400
PubMedGoogle ScholarCrossref 41.Johnson JG, Cohen P, Kasen S, Brook JS. Extensive television viewing and the development of attention and learning difficulties during adolescence.
Arch Pediatr Adolesc Med. 2007;161(5):480-48617485625
PubMedGoogle ScholarCrossref 42.Litrownik AJ, Newton R, Hunter WM, English D, Everson MD. Exposure to family violence in young at-risk children: a longitudinal look at the effects of victimization and witnessed physical and psychological aggression.
J Fam Violence. 2003;18(1):59-73
Google ScholarCrossref 43.Shahinfar A, Fox NA, Leavitt LA. Preschool children's exposure to violence: relation of behavior problems to parent and child reports.
Am J Orthopsychiatry. 2000;70(1):115-12510702856
PubMedGoogle ScholarCrossref 44.Anderson SE, Bandini LG, Dietz WH, Must A. Relationship between temperament, nonresting energy expenditure, body composition, and physical activity in girls.
Int J Obes Relat Metab Disord. 2004;28(2):300-30614647179
PubMedGoogle Scholar 45.Copeland W, Landry K, Stanger C, Hudziak JJ. Multi-informant assessment of temperament in children with externalizing behavior problems.
J Clin Child Adolesc Psychol. 2004;33(3):547-55615271612
PubMedGoogle ScholarCrossref 46.Garrison M, Christakis D. A Teacher in the Living Room? Educational Media for Babies, Toddlers, and Preschoolers. Menlo Park, CA: Kaiser Family Foundation; 2005
47.Cunningham C. Reducing television, videotape, and video game use in children decreased peer rated aggressive behaviour.
Evid Based Ment Health. 2001;4(3):87
Google ScholarCrossref 48.Bushman BJ, Huesmann LR. Short-term and long-term effects of violent media on aggression in children and adults.
Arch Pediatr Adolesc Med. 2006;160(4):348-35216585478
PubMedGoogle ScholarCrossref 50.Christakis DA, Zimmerman FJ. Violent television viewing during preschool is associated with antisocial behavior during school age.
Pediatrics. 2007;120(5):993-99917974736
PubMedGoogle ScholarCrossref 51.Christakis DA, Zimmerman FJ, DiGiuseppe DL, McCarty CA. Early television exposure and subsequent attentional problems in children.
Pediatrics. 2004;113(4):708-71315060216
PubMedGoogle ScholarCrossref 52.Robinson TN, Wilde ML, Navracruz LC, Haydel KF, Varady A. Effects of reducing children's television and video game use on aggressive behavior: a randomized controlled trial.
Arch Pediatr Adolesc Med. 2001;155(1):17-2311177057
PubMedGoogle Scholar 53.American Academy of Pediatrics, Committee on Public Education. American Academy of Pediatrics: children, adolescents, and television.
Pediatrics. 2001;107(2):423-42611158483
PubMedGoogle ScholarCrossref 54.Dennison BA, Erb TA, Jenkins PL. Television viewing and television in bedroom associated with overweight risk among low-income preschool children.
Pediatrics. 2002;109(6):1028-103512042539
PubMedGoogle ScholarCrossref 55.Jackson DM, Djafarian K, Stewart J, Speakman JR. Increased television viewing is associated with elevated body fatness but not with lower total energy expenditure in children.
Am J Clin Nutr. 2009;89(4):1031-103619244374
PubMedGoogle ScholarCrossref 56.Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial.
JAMA. 1999;282(16):1561-156710546696
PubMedGoogle ScholarCrossref 57.Hancox RJ, Poulton R. Watching television is associated with childhood obesity, but is it clinically important?
Int J Obes (Lond). 2006;30(1):171-17516158085
PubMedGoogle ScholarCrossref 58.Dworak M, Schierl T, Bruns T, Strüder HK. Impact of singular excessive computer game and television exposure on sleep patterns and memory performance of school-aged children.
Pediatrics. 2007;120(5):978-98517974734
PubMedGoogle ScholarCrossref 59.Steuer FB, Applefield JM, Smith R. Televised aggression and the interpersonal aggression of preschool children.
J Exp Child Psychol. 1971;11(3):442-4475570452
PubMedGoogle ScholarCrossref 60.Zimmerman FJ, Glew GM, Christakis DA, Katon W. Early cognitive stimulation, emotional support, and television watching as predictors of subsequent bullying among grade-school children.
Arch Pediatr Adolesc Med. 2005;159(4):384-38815809395
PubMedGoogle ScholarCrossref