Smartphone use and addiction during the coronavirus disease 2019 (COVID-19) pandemic: cohort study on 184 Italian children and adolescents

The lives of many children and adolescents are today increasingly influenced by new technological devices and means of communication (smartphones, tablets, social network) [1]. Specifically, in recent years, smartphone use has rapidly increased worldwide. In Italy, the number of users is constantly growing, and it is estimated to reach in 2025 around 42 million subjects [2]. Its overuse may lead to clinical, psychological and social adverse outcomes [3‐5]. Although smartphone addiction is not included in the latest version of the Diagnostic and Statistical Manual for Mental Disorders, research studies and social interventions were conducted to address its related unfavorable effects [6]. The coronavirus disease 2019 (COVID-19) pandemic occurred at a time of global digitalization, characterized by quick connection of people and information anywhere in the world. Children and adolescents had lower incidence and mortality rates of COVID-19 than adults [7, 8]. However, they had relevant adverse psychological and behavioral effects, especially among school-age ones, due to home confinement and other infection control measures, such as social distancing, and closure of schools and shared public spaces [9]. This led them, as well as adults, to spend more time at home and with major use of technological devices [10]. The goal this study proposes is to evaluate health outcomes and social implications of smartphone overuse among Italian children and adolescents during the COVID-19 pandemic, analyzing patterns and aims of utilization, as well as the eventual presence and degree of addiction, and comparing them with those of the pre-epidemic period.

Although the present survey was equally proposed to subjects of both genders, a significantly greater adhesion by females was however observed. This may reflect a higher degree of attention and interest of girls, than boys, to initiatives (including those realized at school) relating to health education. Furthermore, although distributed to subjects belonging to different Italian regions, a wider participation of Sicilian subjects occurred for reasons likely related to direct knowledge of the pediatricians promoting the study. Despite the limitations of an inhomogeneous representation of the population analyzed (either in gender or age or geographic origin), however, the validity of the results obtained may not be affected, also in light of the overlapping conditions of the different Italian regions, in terms of mortality/morbidity rates due to the COVID-19 pandemic, as well as of economic, social and school settings, during the period under investigation. Our study, indeed, showed that, during the pandemic, children and adolescents significantly increased their average daily smartphone use. This may be explained by the wide and multiple role played by smartphones during the epidemic. This is unsurprising, also considering the potential tasks of smartphones as source of communication, information and entertainment [16]. They, indeed, combine the services provided by the web and those of the mobile phone, allowing distance communication and information. At a time of social separation, as that observed in present study, people relied on such useful aspects more than in normal circumstances. Actually, during the COVID-19 pandemic people’s behaviors (and also those of children and adolescents) changed, and partially limited the effects of the crisis [17]. Indeed, smartphones may be used for many purposes, like human connection, learning, and entertainment, and they thus provided psychological and social support. Our study documented an increase, during the pandemic, of smartphone functions like telephone calls, videos, online chats, and social network. This may reflect the lack of physical relationships and contacts with relatives (especially grandparents) and/or friends experienced in this period by children and adolescents, due to the strict social distancing measures adopted [18]. Then, our findings highlighted how during the pandemic communication devices ceased to be only a support for human relationships, and almost entirely replaced face-to-face interactions, becoming the main channel for social connections, especially among young people. Moreover, smartphones provided to children and adolescents the opportunity to continue schooling. Indeed, the partial closure of schools imposed during the pandemic forced teachers to create and use online learning systems [19]. This had pedagogical/psychological consequences in students’ life and families’ organization, due to the need of adequate technological skills, new learning strategies, as well as availability of digital devices and fast connectivity [20, 21]. Online learning led to an increase of the screen time, resulting in turn to a greater possibility of students’ distraction by social media or games [22]. Furthermore, increased digitalization widened the “educational gap” among families. Specifically, poorest children were the most penalized, as they do not likely have a quiet place in their home for their studies, or their own digital devices to access online education [23]. The majority of children and adolescents of present survey, indeed, reported that COVID-19 pandemic affected their learning: online education quality was perceived as lower than in presence one, and pandemic-related anxiety had a negative impact on students’ academic performances [17, 24]. Owing to the temporary and partial closure of educational institutions and suspension of related activities, as well as to the prohibition of shared public spaces, school-age children and adolescents used smartphones more frequently also for entertainment. Indeed, our survey confirmed that their use for recreational purpose became more frequent during the pandemic. The occurrence of infections and/or diseases due to SARS-CoV-2 among family members and/or friends contributed to increase the anxiety levels in children and adolescents, which were related to their variable degree of awareness on risks and consequences of the pandemic [25]. Then, they reported that smartphones allowed to contain negative emotions, stress, sense of isolation and boredom, enabling to avoid, even temporarily, the difficult reality lived during the COVID-19 pandemic and to provide psychological support through different modalities. Specifically, games helped to feel them better and enhance self control, and likewise listening music gave relief from the epidemic-related stressful events [26, 27]. However, by converse, smartphone addiction became more frequent in comparison with the pre-epidemic period. Smartphone overuse may have many negative effects [28, 29]. It may cause cyberbullying, hikikomori, and different neuropsychological and social problems, such as depression, eating and anxiety disorders, low self-confidence, stress, insecurity and solitude, which adversely affect children’s and adolescents’ development and construction of identity [30‐34]. School performances may also be negatively influenced by inappropriate use of smartphones, which may lead young people to spend their time unproductively, to be less concentrated and to have a more superficial approach to learning [33, 35]. Smartphone overuse may also lead to adverse clinical outcomes, as observed in our study [36]. Indeed, during the COVID-19 pandemic our children and adolescents had sleep disturbances, ocular alterations and musculoskeletal disorders more frequently than before. Pain on neck, shoulders, wrists and fingers are the musculoskeletal disorders associated to smartphone overuse more frequently reported [37]. They may be influenced by many factors, including smartphone display size, number of messages sent, daily hours spent in front of the screen, and not physiological posture during smartphone use [38]. Their inadequate utilization may also result in ocular problems, such as dry eye disease, irritation and fatigue, burning sensation, conjunctival injection, decreased visual acuity, strain, macular degeneration and acute acquired comitant esotropia [39, 40]. These clinical symptoms may improve limiting smartphone use. This latter is frequent during bed-time among children and adolescents. This is in agreement with our study, in which a major use after midnight at least 3 times per week was observed during the pandemic. The pre-sleep smartphone use may interfere with both sleep duration and quality, and this was reported also in our study [41, 42]. However, sleep disturbances may also be associated with changed sleep-wake habits, which may have independently occurred during the COVID-19 pandemic among children and adolescents.

Finally, parents faced challenging difficulties during the pandemic in the control of their children’s screen time. This was partly likely due to their attempts in finding a complex balance between personal and working life, and family responsibilities [43]. Indeed, in regard to this, a greater parental permissive attitude towards smartphone use was observed, which may have contributed to its major frequency of use during the period under investigation. Parents should set up rules to limit and appropriately use screen time, and oriented to increasingly find moments for effective interactions with their children [44, 45]. This may be crucial for the creation of their emotional and psychological bases, necessary to ensure adequate growth and development.

Our study showed more frequent smartphone use among Italian children and adolescents during the COVID-19 pandemic, compared to the pre-epidemic period. This may be likely related to the social distancing measures adopted during the months under investigation. The present survey interestingly revealed the changing patterns and aims in the use of smartphones among young people, which allowed to limit some effects of the crisis. Indeed, they were exploited for many purposes such as human connection, learning and entertainment, providing psychological and social support. In the meantime, it was observed a significant increase of overuse and addiction. This led to many unfavorable clinical (sleep, ocular and musculoskeletal disorders), psychological (distraction, mood modification, loss of interest) and social (superficial approach to learning, isolation) outcomes. Pediatricians and health care professionals should be aware of such potential risks related to inappropriate use of smartphones. They should monitor, in cooperation with parents, possible associated adverse effects, in order to early recognize signs and symptoms suggestive, or at high risk, for addiction [46‐48]. They must realize, as well, the necessary interventions to prevent and/or lower the detrimental impact of smartphone overuse on children and adolescents’ health, oriented to sustain adequate physical and psychological development as well as social relationships.