Effect of a Family Media Use Plan on Media Rule Engagement Among Adolescents: A Randomized Clinical Trial | Adolescent Medicine | JAMA Pediatrics | JAMA Network
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Figure.  Participant Flow Diagram
Participant Flow Diagram

FMUP indicates family media use plan.

Table 1.  Demographic and Descriptive Information
Demographic and Descriptive Information
Table 2.  Participant Completion of Specific Family Media Use Plan Sections and Example Options Selected by Intervention Participants
Participant Completion of Specific Family Media Use Plan Sections and Example Options Selected by Intervention Participants
Table 3.  Evaluation of Changes in Outcome Scores From Baseline to Follow-up Assessments Within and Between Intervention and Control Groups
Evaluation of Changes in Outcome Scores From Baseline to Follow-up Assessments Within and Between Intervention and Control Groups
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    Original Investigation
    January 25, 2021

    Effect of a Family Media Use Plan on Media Rule Engagement Among Adolescents: A Randomized Clinical Trial

    Author Affiliations
    • 1Department of Pediatrics, University of Wisconsin–Madison, Madison
    • 2Associate Editor, JAMA Pediatrics
    • 3Department of Biostatistics and Informatics, University of Wisconsin–Madison, Madison
    JAMA Pediatr. 2021;175(4):351-358. doi:10.1001/jamapediatrics.2020.5629
    Key Points

    Question  Can an intervention using the American Academy of Pediatrics family media use plan lead to changes in media rule engagement reported by adolescents?

    Findings  In this randomized clinical trial involving 1520 parent-adolescent dyads, most participants in the intervention group created a family media use plan, but no statistically significant changes in media rule engagement occurred.

    Meaning  Findings of this trial suggest that, in a family that may already have various media rules in place before the intervention, some rules may become more important and others may become less important, resulting in no overall change; thus, revisions to the family media use plan may make it more effective.

    Abstract

    Importance  The American Academy of Pediatrics recommends that all families use a family media use plan to select and engage with media rules. To date, the effectiveness of this tool in promoting adolescent media rule engagement is unknown.

    Objective  To test the effect of a family media use plan on media rule engagement in adolescents.

    Design, Setting, and Participants  This randomized clinical trial with parallel design used the online Qualtrics platform for recruitment, data collection, and intervention delivery. Parents and their children (aged 12 to 17 years) who spoke and read in the English language were recruited, enrolled, and randomized to either the intervention or control group. Parent-adolescent dyads in both groups completed baseline surveys individually, and the dyads in the intervention group completed the family media use plan survey. Baseline recruitment was conducted from April 8, 2019, to May 1, 2019, and follow-up surveys were completed between June 11, 2019, and July 2, 2019.

    Interventions  The American Academy of Pediatrics family media use plan.

    Main Outcomes and Measures  The primary outcome was media rule engagement reported by adolescents. Media rules were extracted from the family media use plan, and adolescents rated each rule (using Likert scales) according to whether the rule was present or followed in their home. Secondary outcomes were adolescent-perceived technology importance and changes in sleep, physical activity, and depression.

    Results  A total of 1520 parent-adolescent dyads were enrolled in the trial and randomized to either the intervention or control group. Adolescents had a mean (SD) age of 14.5 (1.6) years, and 789 were female (51.9%) and 1027 were White (67.6%) individuals. Parents had a mean (SD) age of 44.1 (8.5) years, and 995 were women (65.5%) and 1021 were White individuals (67.2%). For media rule engagement, the between-group difference was –0.1 (95% CI, –1.1 to 0.9).

    Conclusions and Relevance  This randomized clinical trial found that completing a family media use plan did not lead to statistically significant changes in media rule engagement for adolescents in the intervention group. Future studies should consider revising the family media use plan and exploring the importance of technology as an intervention outcome.

    Trial Registration  ClinicalTrials.gov Identifier: NCT03881397

    Introduction

    In the United States, most adolescents engage with digital media, and approximately 45% of adolescents in 1 study reported that they are online “almost constantly.”1 The frequent and consistent media use among young people has both benefits and risks. Benefits include opportunities for creative expression and social support.2 Risks include several adverse health consequences. First, media use has been associated with sleep disturbance, such as delayed bedtime, and screen light exposure has been shown to disrupt melatonin levels.3-5 Second, decreased physical activity has been associated with the sedentary nature of most media use.4,6,7 Third, some studies have proposed that digital media use may be a factor in depression.8

    One approach to preventing these adverse health outcomes is to involve parents in establishing media rules. However, previous studies have found that parents struggle with setting and enforcing rules, such as removing technology from children’s bedrooms.9,10 The American Academy of Pediatrics (AAP) policy statement Media Use in School-Aged Children and Adolescents proposed that families create a family media use plan to select and engage with media use rules.11 Despite this policy recommendation, no study to date has evaluated the effectiveness of a family media use plan in promoting media rule engagement for adolescents.

    The primary purpose of this randomized clinical trial was to test the effect of a family media use plan as an intervention on media rule engagement in adolescents. We hypothesized that a parent-adolescent dyad interacting with the family media use plan would increase household media rule engagement reported by adolescents. As a secondary aim, we also tested whether the family media use plan changed the adolescent-perceived importance of technology use and the health measures associated with technology use, including sleep, physical activity, and depression.

    Methods

    This randomized clinical trial evaluated the AAP family media use plan and was conducted online. The trial protocol is available in Supplement 1. All recruitment, data collection, and intervention delivery were conducted through emails and a website. Data were collected between April 8 and July 3, 2019. This study was approved by the institutional review board at the University of Wisconsin-Madison Sociobehavioral Sciences Committee. Written informed consent was obtained from parents for their own and their children’s participation. We followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.

    The family media use plan is free, open access, and intended for parent-child dyads to use in the home setting. The plan was released concomitantly with the 2016 AAP media policy statements11,12 and was designed by AAP staff and pediatrician authors of the policies. The plan includes a list of topic areas, each of which contains suggested rules and guidelines that align with policy recommendations. Examples of these recommendations are designating screen-free zones in the home, such as the bedroom, and coviewing media with parents. The plan can be printed or a screenshot of it can be taken.

    We aimed to achieve a national sample of parent-adolescent dyads. Compared with traditional recruitment approaches, such as in-person, phone, or mail recruitment, online panels can offer broader reach and lower costs.13 We selected Qualtrics software (Qualtrics) for panel recruitment because previous studies reported that Qualtrics panels can achieve demographic attributes within a 10% range of their corresponding values in the US population.14 We established parameters for Qualtrics to recruit a sample that represented the race/ethnicity of the US census population aged 12 to 17 years.14

    Eligible participants in the Qualtrics panel were parents with children aged 12 to 17 years who were able to speak and read English language. Parents who met the eligibility criteria were provided information about the study and an opportunity to complete informed consent for their and their child’s participation. The survey manager monitored enrollment quotas to achieve demographic representation. The Figure provides the participant flow diagram. Baseline recruitment was conducted from April 8, 2019, to May 1, 2019, and follow-up surveys were completed between June 11, 2019, and July 2, 2019.

    Study Procedures

    After individuals were deemed eligible, a computer algorithm within the Qualtrics platform randomized participants to the intervention group or control group using a 1:1 ratio. Investigators were blind to the randomization process. After written informed consent was obtained, parent participants were enrolled and asked to complete the demographic questions in a baseline survey. Parents were then asked to allow their children to provide assent and complete the baseline survey independently and privately. Parents reported their own demographic information, including age, sex, race/ethnicity, educational level, and family income level. Adolescent participants also provided their own demographic information, including age, sex, and race/ethnicity.

    After the baseline survey, adolescent participants in the intervention group were asked to reengage their parent and complete the family media use plan together. All family media use plan information and prompts used in this study were identical to the AAP version but were hosted on the Qualtrics website to enable us to track participation.

    The family media use plan contains a series of topic areas with potential rules for media use at home. Parent-adolescent dyads in the intervention group were asked to select the rules or guidelines that they endorsed or wanted to implement at home. Parent-adolescent dyads could also add their ideas through a write-in option. After completing the plan, participants were instructed to either print or take a screenshot of the plan and place it in a prominent place.

    After completing the baseline survey, parent-adolescent dyads in the control group were not provided any information about the family media use plan. All control participants were contacted again 2 months later by an email from Qualtrics that invited them to complete the follow-up survey. A comparison of demographic characteristics by follow-up group is presented in eTable 1 in Supplement 2.

    Survey Measures
    Primary Outcome

    The primary outcome was adolescent-reported media rule engagement. The clinical relevance of this selected outcome was based on the AAP media policy recommendation that promotes family media use plans. To evaluate media rule engagement, we asked adolescent participants in the intervention group how strongly they agreed or disagreed with 11 rules or guideline statements that were consistent with the family media use plan suggestions. These statements were tested in a previous study.15 Example statements included “My parents and I talk about my media use,” and “I follow screen time rules before bedtime.” Participants were asked to rate each of the statements using a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree. We created a total family media use plan score by calculating the sum of the 11 items, with a higher score indicating a higher level of engagement in media rules. The score range was 11 to 55, and the scale had a Cronbach α of .93.

    To assess intervention adherence, we evaluated whether parent-adolescent dyads had completed the intervention by creating a family media use plan. Only the parent-adolescent dyads who completed all sections of the family media use plan were categorized as adherent to the intervention.

    Secondary Outcomes

    To assess the secondary outcome of adolescent-reported technology interactions and their perceived importance, we included the Adolescents’ Digital Technology Interactions and Importance (ADTI) scale (eFigure in Supplement 2). The ADTI scale asked adolescents to rate a series of technology interactions using a 5-point Likert scale, with 1 indicating not at all important to 5 indicating extremely important. Example items from the ADTI scale included “Create a piece of content … that will disappear or be impermanent” and “Video chat.” This validated 18-item scale has a total Cronbach α score of .92 and includes 3 subscales: (1) technology to bridge online and offline experiences and preferences (Cronbach α = .87), (2) technology to go outside of one’s identity or offline environment (Cronbach α = .90), and (3) technology for social connection (Cronbach α = .82).16

    Another secondary outcome was change in health measures, including sleep, physical activity, and depression. Sleep was assessed using the Pediatric Daytime Sleepiness Scale (score range: 0-32, with the highest score indicating excessive sleepiness),17 which has been validated in adolescents (Cronbach α = .82).18,19 This 8-item scale included questions such as “How often do you fall asleep or get drowsy during class periods?” and “How often do you fall back to sleep after being awakened in the morning?” Response options included never, seldom, sometimes, frequently, and always.

    Physical activity was assessed using the 3-item Physical Activity Scale (score range: 0-12, indicating lower or higher quantity and frequency of physical activity), which has been validated in adolescents (Cronbach α = .69-.74).20 Items assessed the frequency of the adolescent’s exercise or participation in sports.20 Response options ranged from never to 4 times or more a week.

    Depression was measured with the Patient Health Questionnaire (score range: 0-27, with 0-4 indicating no depression, 5-9 indicating mild depression, 10-14 indicating moderate depression, 15-19 indicating moderately severe depression, and over 20 indicating severe depression),21 which has been validated in adolescents.22 This 9-item questionnaire asked participants how often they experienced depression symptoms in the past 2 weeks. Example symptoms included “Little interest or pleasure in doing things,” and “Feeling down, depressed or hopeless.” Response options used a 4-point Likert scale ranging from not at all to nearly every day. This questionnaire demonstrates concordance with other depression measures21,23,24 and has a Cronbach α of .82.25

    No changes to trial outcomes were observed after the trial commenced.

    Statistical Analysis

    Sample size was calculated to be able to detect a 5% difference in mean changes in the primary and secondary outcome measures between the baseline and follow-up surveys. We estimated the sample size according to anticipated SDs, ranging from 20% to 50%, for the percentage changes in the primary and secondary outcome measures from the baseline to the follow-up assessment. We selected the most conservative approach. With an assumed SD of 50% for the change from the baseline to the follow-up assessment, a sample size of 1516 participants would detect a 5% difference in means with 90% power at the 2-sided P = .01 statistical significance level.

    The demographic characteristics of the parent-adolescent dyads were summarized with means (SDs) for continuous variables and frequencies (percentages) for categorical variables. Age was dichotomized as younger (12-14 years) or older (15-17 years). Educational level was dichotomized as less than a college degree or a college degree or higher. Income level was dichotomized as lower or higher than the national median income.

    The primary (media rule engagement) and secondary (changes in technology interactions, perceived technology importance, and health measures) end points were summarized with means (SDs) and stratified by study group. Absolute changes from the baseline to the follow-up assessments within each group were evaluated using a paired, 2-tailed t test. Comparisons of absolute changes from the baseline to the follow-up survey between groups were conducted using a 2-sample t test. Normal probability plots were examined to verify the distribution assumptions.

    All statistical analyses were conducted by intervention or control group. The primary analysis was conducted in the intention-to-treat population, which included all randomized participants. A secondary analysis was conducted using a modified intention-to-treat approach to assess the subgroup of participants who were adherent to the intervention. Secondary analyses were conducted for subgroups of sex, younger vs older adolescents, and lower vs higher family income level. A substantial proportion of participants had no follow-up assessment. To confirm the results of the primary complete-case analysis, we also conducted a sensitivity analysis using multiple imputation of missing data. Specifically, missing primary end point values were imputed using the Markov Chain Monte Carlo method with κ = 25 imputation replicates; proper inference adjustment methods were applied when combining the results from the imputed data sets.26

    All reported P values were 2-sided, and P < .05 was used to define statistical significance. Statistical analyses were conducted using SAS software, version 9.4 (SAS Institute Inc).

    Results

    A total of 1520 parent-adolescent dyads were enrolled at baseline and randomized to either the intervention or control group. Adolescents had a mean (SD) age of 14.5 (1.6) years, and 789 were female (51.9%) and 1027 were White (67.6%) individuals. Among parents, the mean (SD) age was 44.1 (8.5) years, 995 were women (65.5%), and 1021 were White individuals (67.2%) (Table 1). Four hundred four parents (53.9%) reported their family income as being below the national median income. Table 1 provides demographic and descriptive information.

    Among the intervention group, a total of 687 participants (90.4%) reported adherence to the family media use plan. No demographic differences were found between those who completed the intervention and those who were not adherent (eTable 1 in Supplement 2). Table 2 illustrates participant completion of specific rules in various family media use plan sections. For example, under the screen-free zones section, 546 adolescents (71.8%) endorsed any of the rules, whereas 251 adolescents (33.0%) selected specific rule options (Table 2).

    At baseline, the reported mean (SD) total score for media rule engagement was 40 (10.1) for adolescents in the intervention group (n = 760) and 39.3 (9.7) for adolescents in the control group (n = 760). eTable 2 in Supplement 2 shows engagement to individual rules in the family media use plan.

    Primary Outcomes

    Adolescent-reported media rule engagement data at follow-up included 790 participants (430 in the intervention group, and 360 in the control group). The intervention group had a mean (SD) change in summary score of –0.2 (7.9), and the control group had a mean (SD) change of –0.1 (6.5). The between-group difference was –0.1 (95% CI, –1.1 to 0.9). Table 3 illustrates these findings.

    The secondary analysis used a modified intention-to-treat approach to compare adherent participants in the intervention group with those in the control group. No statistically significant difference between groups was found. In a sensitivity analysis that included all 1520 participants after multiple imputation of missing data, the corresponding within-group changes were similar: –0.1 (95% CI, –0.8 to 0.6) for the intervention group and 0.2 (95% CI, –0.5 to 0.8) for the control group.

    Secondary Outcomes

    For the ADTI scale total score, the between-group difference was –2.2 (95% CI, –4.2 to –0.2). These differences were also seen in subscale 2 (–0.9; 95% CI, –1.9 to 0) and subscale 3 (–0.7; 95% CI, –1.4 to 0). Subgroup analysis also noted some significant findings for female adolescents with ADTI scale total score (–3.1; 95% CI, –5.7 to 0.5) and subscales 2 (–1.5; 95% CI, –2.8 to 0.2) and 3 (–0.8; 95% CI, –1.7 to 0.1) (Table 3).

    For sleep, physical activity, and depression measures, no statistically significant differences were observed between intervention and control groups for the full sample or any subgroups. No harms to participants or unintended adverse effects were detected.

    Discussion

    This randomized clinical trial tested the effect of family media use plan on a population of parent-adolescent dyads. We found that most families completed the intervention by creating a family media use plan. However, the intervention did not lead to substantial changes in media rule engagement in adolescents.

    The primary outcome of media rule engagement was adolescents’ perception, as represented by a summary score, before and after the intervention. The finding that the family media use plan did not lead to significant changes in outcomes for the intervention group compared with the control group who did not complete a family media use plan has several possible explanations. First, it is possible that the low-touch approach of the online family media use plan was not powerful enough to motivate behavior change. An in-clinic intervention may have been more effective. However, the family media use plan was designed to be an at-home activity for parent-adolescent dyads; thus, the intervention approach in this trial was consistent with the intended use of the family media use plan. Furthermore, it seems unlikely that pediatricians would have the time or willingness to complete a family media use plan during a busy clinical visit.

    Second, it is possible that some of the immediate changes after the intervention had faded by the follow-up assessment. After completing the online family media use plan, the family can access it again only by the screenshot or printout generated initially. This lack of reminders or reinforcement of the family media use plan may have decreased the ongoing engagement in media rules. Third, it is possible that providing a variety of rule options for families may have led families to believe that too many choices were available such that they could not follow all of these rules consistently. Furthermore, given that most of the studies on this topic have found that parents use a permissive media mediation style with limited regulation, it is possible that the flexible family media use plan approach did not motivate behavior change.27 The adolescent participants in this study may also have been old enough to have established their own media use behaviors and rules that were resistant to change.

    Future studies may consider testing the family media use plan in younger children. In addition, future studies may also consider seeking input from parents about their experiences with the family media use plan. The primary outcome of perceived media rule engagement may not be the most salient measure. If a family already had in place several media rules with varying importance, the importance of some rules may have increased and others may have decreased, resulting in no overall change.

    In the secondary analyses, we found that the perceived importance of technology use decreased among participants in the intervention group. In the full sample, as well as secondary group–based analyses, we found that adolescents in the intervention group reported a lower perceived importance of their technology interactions. The family media use plan likely helped adolescents reflect on the importance of their own media use as well as adjust their attitudes or perspectives on which aspects of this use were truly important. Thus, further evaluation of the family media use plan and its effects on adolescents’ experiences with technology may be warranted.

    The family media use plan has been promoted and disseminated by the AAP concomitant with the media policy statement,11 as well as through popular news media.28-30 Results of this trial may provide evidence for the revision and improvement of this popular tool. A recent study of parents found that the 3 key approaches to media rule engagement were (1) adolescent input in media rules, (2) parents building internet skills, and (3) parents as mentors and guides in their children’s media use.31 These concepts may be valuable to include in future revisions of the family media use plan. The importance of family media rules is illustrated by a previous study that found that the existence of a parent-child conflict about media rules was associated with exposure to media violence, and this combination was associated with internalizing and externalizing symptoms.32

    This study has important implications. It suggests that the current family media use plan may not have an effect on adolescents’ reported engagement in media rules. Qualitative interviews with families may illuminate ways to strengthen this tool. Revisions to the family media use plan that provide reminders or ongoing online access to the plan may also improve media rule engagement. Findings of this study also suggest that evaluating other outcomes, such as technology importance, may yield insights into the impact of media rules at home. Given that the family media use plan is currently the standard of practice recommended by pediatricians,11 further study is warranted.

    Limitations

    This study has some limitations. First, the results may not be generalizable beyond a study population of parent-adolescent dyads recruited through Qualtrics. Recruiting through an online panel meant that we could establish the size and criteria for the initial study population, but it limited our ability to assess external validity. However, the Qualtrics platform and panels have been used in similar studies,33 and the panel recruitment has closely approximated US populations.14 Second, although we could specify the baseline sample size using Qualtrics, we did not anticipate the participants lost to follow-up, which approached 50%. A possible explanation for this loss to follow-up is that the second (follow-up) survey occurred during the summer months (June and July), and summer activities or vacations may have prevented ongoing engagement with the project. This high percentage of loss to follow-up suggests that future studies using this approach should consider oversampling at baseline or working with Qualtrics to increase incentives for follow-up completion. Third, the health measures were self-assessed and self-reported, and we did not include tracking of media use, physical activity, or sleep. Responses may be subject to social desirability bias and recall bias, and we cannot ascertain whether adolescents completed their surveys privately. Fourth, although we can assess completed family media use plan in the intervention group, we cannot determine whether a plan was created by a parent-adolescent dyad as intended or whether a parent or adolescent created it separately.

    Conclusions

    This randomized clinical trial found that most parent-adolescent participants in the survey created an online family media use plan. However, this intervention did not statistically significantly change media rule engagement. One explanation for this result is that perceived media rule engagement may not be the most salient measure. In a family with established media rules with varying importance, the importance of some rules may increase and the importance of other rules may decrease, resulting in no overall change. In addition, adolescents in the intervention group reported a lower perceived importance of their technology use. Future studies should consider a revision of the family media use plan and further explore the importance of technology as an intervention outcome.

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    Article Information

    Accepted for Publication: July 7, 2020.

    Published Online: January 25, 2021. doi:10.1001/jamapediatrics.2020.5629

    Corresponding Author: Megan A. Moreno, MD, MSEd, MPH, Department of Pediatrics, University of Wisconsin–Madison, 2870 University Ave, Ste 200, Mailcode 9010, Madison, WI 53705 (mamoreno@pediatrics.wisc.edu).

    Author Contributions: Dr Moreno had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Moreno, Binger.

    Acquisition, analysis, or interpretation of data: Binger, Zhao, Eickhoff.

    Drafting of the manuscript: Binger, Zhao.

    Critical revision of the manuscript for important intellectual content: Moreno, Binger, Eickhoff.

    Statistical analysis: Zhao, Eickhoff.

    Obtained funding: Moreno.

    Administrative, technical, or material support: Binger.

    Supervision: Moreno.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by a research agreement with Facebook.

    Role of the Funder/Sponsor: The funder had a role in the design and conduct of the study. The funder had no role in the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Data Sharing Statement: See Supplement 3.

    Disclaimer: Dr Moreno is an associate editor of JAMA Pediatrics, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.

    Additional Contributions: Research staff Aubrey Gower provided valuable contributions to study conception. This individual received no additional compensation, outside of her usual salary, for her contributions.

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