Screen-viewing among preschoolers in childcare: a systematic review

Published, peer-reviewed, English-language studies were included if there was a quantitative measurement of screen-viewing in childcare (e.g., center- and home-based childcare, family childcare homes, daycare, nursery school, preschool setting, etc.). All methods of assessing screen-time (e.g., observation, self-/proxy-report) were considered. Given that combined screen-time was of interest (i.e., across multiple screens), all literature pertaining to time preschoolers spent utilizing or engaging with various screens (i.e., television, computer, video games, smartphones, DVD/VHS) were included. Availability of screen-viewing activities was examined and included as well in order to gain a deeper understanding of the screen-viewing environment among preschoolers in childcare. Only studies focusing on children between the ages of 2.5 and 5 years were included. In cases of intervention and cohort studies, only baseline measurements were acknowledged. Given the low number of available primary research articles on the proposed review topic, all study designs and quality of evidence were considered.

Using a comprehensive search strategy^a, 12 electronic databases were searched: Embase, CINAHL, PubMed, ProQuest Allied Health and Nursing, SPORTDiscus, Medline, PyschInfo, ProQuest Dissertations and Theses, ProQuest Educational Journals, Scopus, Physical Education Index, and Sociological Abstracts. See Table 1 for one example of a search strategy used. The search frame of these electronic record searches dated from 2000 onwards; the final database search was run March 8, 2014. All retrieved articles were exported to Reference Manager software (version 12) and duplicates were removed manually from the database. Each entry in the database was assigned a unique identification number.

All titles and abstracts of potentially relevant articles were screened using a Title and Abstract Screening Form developed for this review. This screening form was reviewed by a second researcher to ensure the inclusion of appropriate eligibility standards. Articles meeting the initial screening parameters were retrieved in-full. A similar review method was used to appraise the full-text articles; a Full-Text Screening Form was created and applied. A second, independent reviewer screened the titles/abstracts as well as full-text articles to confirm the author’s extracted findings. More specifically, the reviewers compared their results to agree on a list of articles that met the inclusion criteria and would be appropriate to retrieve a full-text copy. Subsequently, each full-text document was read independently by the second reviewer to assess the appropriateness for inclusion, and again compared for consensus. Any discrepancies were discussed as a pair. Six authors were contacted for further information. Five replied, and two provided additional clarification regarding their respective studies’ findings [47, 48]. A final set of articles was agreed upon by both researchers.

The reference lists of all articles pulled for full-text screening were also reviewed. Additionally, the table of contents of five journals (which appeared to publish a number of relevant articles; i.e., the International Journal of Behavioral Nutrition and Physical Activity, the Journal of Physical Activity and Health, Preventive Medicine, Pediatrics, and Early Childhood Research Quarterly) were searched manually from 2000 to present. Lastly, in an effort to be exhaustive, the advance publication or in press sections of 13 physical activity and childcare-related periodicals were reviewed to ensure all relevant literature was retrieved (i.e., Journal of Physical Activity and Health; Pediatrics; International Journal of Behavioral Nutrition and Physical Activity; Preventive Medicine; American Journal of Preventive Medicine; Applied Physiology, Nutrition, and Metabolism; Journal of Sport Sciences; Research Quarterly for Exercise Science; Medicine & Science in Sport & Exercise; Early Childhood Research Quarterly; Pediatric Exercise Science; Journal of American Medical Association Pediatrics [formerly Archives of Pediatric and Adolescent Medicine]). All unique articles found via these search methods underwent the aforementioned screening process.

A modified version of Downs’ and Black’s checklist for quality assessment was used throughout this procedure [49]. Comparable to previous approaches, [29] only 10 of 27 items from this document were considered as they were the most relevant to this review (i.e., clear aim/hypothesis articulated?; are outcomes clearly described in the Introduction and Methods sections?; participant characteristics provided?; main findings clearly described?; are estimates of random variability supplied?; are actual probability values reported?; were invited participants representative of the population from which they were recruited?; were the participants willing to participate representative of the population from which they were recruited?; were appropriate statistical tests used to assess the main outcomes?; were valid/reliable measures used to assess the main outcomes?) [49]. Although the aforementioned factors were all considered while compiling the studies, all qualities of evidence were included in light of the limited research conducted on this particular topic.

Study characteristics were included in a standardized extraction table (see Table 2). Findings from each study relating to rates of screen-viewing and the availability of this particular activity in childcare were also extracted and collated. Influential factors (or correlates) to screen-viewing in childcare were identified and summarized where available (i.e., direction of association, percent association, strength of consistency, etc.).

Data from included studies were grouped for interpretation based on the outcome variable used to assess screen-viewing within the childcare environment. Where provided, mean rates of daily screen-viewing activities were synthesized for easy comparison across included studies; these values were grouped to create a range (i.e., the lowest and highest means were combined to highlight the extent of screen-viewing among preschoolers in this environment), and thus facilitated analyses. Data comparing screen-viewing in various childcare arrangements (i.e., center- vs. home-based) were also presented when available. Availability for screen-viewing in childcare (i.e., access and opportunities) were reported (and synthesized/integrated where possible) to provide context regarding the opportunities for this behavior to occur during childcare hours.

Using the bioecological theoretical framework, as outlined by Bronfenbrenner and Evans, [63] a number of factors and/or ‘systems’ thought to impact child development were identified (moving from most proximal to the child, to more distal). Subsequently, and in-line with previously published work, [28, 29] the correlates of screen-viewing within the childcare environment were divided into the following categories: child demographic factors, staff demographic factors, environmental factors, and social factors. A threshold of three or more studies was used to establish the presence of a potential association between screen-viewing and a particular factor. Extracted correlates were coded using a similar method outlined in other review papers [28, 64, 65]. In accordance with this model, the consistency of association, rather than the strength, was of particular focus.

The electronic database searches yielded 414 relevant articles. An additional 37 articles were retrieved via citation tracking. No new articles were identified through hand searching. After removing duplicates (n = 201), 184 articles were excluded following the title and abstract assessment, leaving 66 articles. After reviewing these articles in full for inclusion eligibility, an additional 49 papers were removed. Papers were excluded because: ineligible environment (i.e., not childcare; n = 8), absence of a quantitative screen-viewing assessment (n = 16), non-primary research (n = 12), ineligible age ranges (n = 4), failure to differentiate between screen-viewing accumulated at home versus in childcare (n = 7), and duplicated/repeated findings (n = 2). Consequently, 17 articles were included in this review (see Figure 1 for details on the identification, screening, eligibility, and inclusion process).

Of the incorporated articles, data from 22,039^bc participants, across 5,806^b childcare facilities and two countries (United States [n = 13] [11, 43, 47, 48, 50, 51, 54‐60] and Australia [n = 4] [52, 53, 61, 62]), were included. Sample sizes ranged from 6 [47] to 8,835^b[61] preschooler participants, and from 1 [47] to 2,672^b[11] childcare facilities. Twenty-nine percent of articles examined both types of childcare arrangements (i.e., center- and home-based childcare), while 47% and 24% focused solely on center-based childcare (i.e., private and public programs, preschools) or home-based childcare (i.e., family childcare homes, home daycare), respectively. Articles were published between 2004 [51] and 2014 [53]. Screen-viewing was measured primarily via proxy-report measures, [11, 48, 50, 52, 54‐62] followed by direct observation [43, 47, 51, 53]. As for types of screen mediums; one paper examined video game use, [47] nine focused on television viewing, [11, 48, 50, 53‐55, 57, 58, 60] one examined computer use, [62] and five studies explored multiple screen mediums [51, 52, 56, 60, 61]. One study refrained from specifying the screen of interest in their paper [43]. See Table 2 for additional details.

Eight studies reported the rates of daily screen-viewing among preschoolers in childcare (4 via direct observation, and 4 via surveys; Table 2) [11, 43, 47, 50, 51, 53, 55, 58]. Screen-viewing ranged from 0.1 to 1.3 hrs/day among preschoolers in center-based childcare, [11, 43, 50, 51, 53, 55, 58] and 1.8 to 2.4 hrs/day among preschoolers in home-based childcare [11, 47, 50, 58]. Three studies examined the differences in screen-viewing based on type of childcare arrangement [11, 50, 58]. In all cases, it was noted that preschoolers in home-based childcare engaged in higher amounts of screen-viewing that those attending center-based facilities. Differences in screen-viewing based on arrangement type were found to be statistically significant in Christakis and Garrison’s (p < .001) [50] and Tandon et al.’s (p < .001) [58] work, but not in Christakis et al.’s study [11]. Preschoolers in 3^d out of 8 studies were found to engage in less than 1-hour of screen-viewing per day in childcare, [43, 51, 53] 4 out of 8 engaged in 1–2 hours of screen-viewing, [11, 47, 55, 58] and 1 out of 8 engaged in more than 2 hours of screen-viewing [50]. Screen-viewing levels were reported at the center-level, rather than at the individual child-level (save Bacigalupa’s work [47]). Few studies commented on the context/purpose behind participants’ decision to engage in screen-viewing activities while in childcare [50, 54, 59, 62]. Only two papers identified which percentage of screen-viewing behavior was considered active (i.e., light physical activity or moderate-to-vigorous physical activity [MVPA]) versus sedentary[43, 51].

Two of the 17 studies specified that the majority of preschoolers’ screen-viewing behaviors in care were sedentary, [43, 51] with very little physical activity being accumulated while engaging in such activities. Approximately 27% of the studies also noted the purpose behind preschoolers’ participation in screen-viewing activities while in childcare, [50, 54, 59, 62] with the most prevalent being education- and entertainment-related.

Nine studies reported on the availability of screen-based activities (i.e., access to/opportunities for screen-viewing) within the childcare environment (Table 2) [48, 52, 54, 56, 57, 59‐62]. While many of these studies utilized a slightly different method of assessing screen availability and access (i.e., screen use policies and practices [n = 6], access to screens and/or activities while in care [n = 3]), this information provides credence to the high rates of screen-viewing in childcare facilities.

When analyzing the childcare environment as a whole, Trost and colleagues found that the participating home-based childcare facilities (n = 236) were, for the most part meeting (but not exceeding) their respective standards of rarely/never showing television or videos [60]. In contrast, Taverno Ross et al. found center-based childcare facilities were highly conducive to screen-viewing (based on high availability and frequency of screen-use) [48]. Zevenbergen and Logan also reported that preschoolers in the childcare setting had fairly regular access to computers [62].

With regard to specific policies and practices concerning screen-use in childcare, projects by Trost et al. (n = 294 facilities) [59] and Gunter et al. (n = 53 facilities) [54] reported that the majority of home-based facilities had the television turned on every day (for at least a portion of the day; 64.6% and 60.4%, respectively) and also permitted children to play video games and/or watch television at least once a day (55.1% and 58.5%, respectively); computer use was also permitted in a number of facilities across both studies. While Sisson et al. found approximately 60% of participating centers rarely/never permitted children to watch television [57], Natale and colleagues’ work indicated 474 center- and 113 home-based childcare facilities restricted television-viewing to 1-hour per day, and that 410 centre- and 186-home-based facilities limited their computer use to this same time restriction [56]. Over half the centers in Wolfenden and colleagues’ paper [61] and 45% of those in Finch et al.’s [52] paper had policies in place limiting screen-use during care hours (but did not provide specifics). While policies and practices to curtail this behavior are evident across some studies (n = 4), ease of access and opportunities to engage in screen-viewing activities in childcare are prevalent (n = 5). Consideration of both screen-viewing policies and accessibility is important to examine in order to understand the screen-time rates reported previously.

The chief finding of this review suggests preschoolers, in general, participate in somewhat high levels of daily screen-viewing while in childcare, although substantial variation exists. Of the papers that reported rates of screen-viewing, [11, 43, 47, 50, 51, 53, 55, 58] levels of screen-time ranged from 0.1 to 1.3 hrs/day and 1.8 to 2.4 hrs/day among preschoolers in center- and home-based childcare, respectively. While considerable variation across these studies is evident (with two studies reporting minimal screen-viewing levels among their center-based samples), [43, 58] the results of this review suggest participants in five studies are exceeding Canadian/Australian [26, 27] (i.e., 1 hour/day limit) guidelines, [11, 47, 50, 53, 55] and preschoolers in one study are surpassing the American [25] screen-viewing guidelines (i.e., 2 hour/day limit) [58]. These numbers are concerning, particularly due to the fact that these guidelines refer to total daily screen-viewing; because this paper focused solely on screen-viewing among preschoolers in childcare, it is possible that this population could engage in additional screen-viewing outside of care. In fact, recent work by Tandon et al. [58] which examined screen-viewing during and outside childcare hours, found that children in center- and home-based childcare accumulated an additional 3.1 and 3.8 hours of screen-viewing while at home, respectively. As per the recent finding that screen-viewing in excess of 2 hours is associated with poorer psychosocial and physical health among children, [66] action is required to decrease the amount of time this population spends engaging in this behavior. Interestingly, Brown et al. [43] and Dowda et al. [51] found a small percentage of preschoolers’ screen-viewing time was actually spent in light physical activity or MVPA (specific activities not identified in-text). Accordingly, these findings highlighted that not all screen-viewing activities require inactivity, but that perhaps the childcare environment could shift the way in which screens are used in order to include more activity.

Levels of television viewing were assessed most often (i.e., assessed in 82% of the studies and was the single screen of focus in 53% of cases). One reason explicating this finding could be that one television can entertain many children with little input from staff, rather than other types of screens (i.e., computers, tablets) which entertain only a few children at a time and require more monitoring (i.e., to ensure sharing of the devices across children) and/or assistance from staff. It is also possible that, measurement of television only is a result of the age of the studies included, as computer use, iPads, etc. might have only recently become popular and available in these facilities. However, by focusing solely on one type of screen medium (rather than all mediums accessible in childcare), researchers may be underestimating preschoolers’ total screen-time in care, and rendering it difficult to properly address this issue. While there is research to support that young children spend the majority of their screen-time watching television (and very little time engaged in other screen-based activities, like computers) within the home environment, [67] it would be interesting to explore whether similar trends exist in the childcare environment; it would also be interesting to explore whether said trends are likely to continue in light of the growing popularity of other screens and as new research on this topic emerges. Consequently, future research efforts should examine the differences in screen-viewing among preschoolers in care based on all medium types accessible by this group. This will not only capture a clearer picture of preschoolers’ screen preferences, but will also assist in determining whether environmental modifications and/or the introduction (or ratification) of policies that target specific screen types are warranted.

Building on Christakis et al.’s previous work (which administered surveys to childcare staff), [11] this review synthesized the literature regarding influential factors associated with preschoolers’ television viewing [only] in childcare. Only 2 out of 8 variables were identified as correlates to preschoolers’ screen-viewing in childcare. High staff education was found to have a negative association with participants’ screen-viewing levels; [11, 50, 58] children spent less time participating in screen-viewing activities when staff were more highly educated. Similar findings corresponding to other health behaviors have been highlighted in the literature; more favorable nutrition and physical activity outcomes have been observed among preschoolers cared for by more highly educated and trained staff [68, 69]. Due to the important role childcare staff play in promoting and modeling both negative and positive health behaviors, [33, 68] precedence should be given to providing training and education related to screen-viewing (and its associated health implications) to these key individuals.

The second potential correlate to preschoolers’ screen-viewing in childcare, the type of childcare arrangement, demonstrated a positive association to this behavior. Notably, children attending home-based childcare may be more prone to screen-viewing activities. In fact, all studies examining screen-viewing among preschoolers in home-based childcare [11, 47, 50, 58] reported their participants as surpassing Canada’s recommended 1-hour guideline [26]. While comparing levels of television viewing across both arrangements, Christakis and Garrison found that preschoolers enrolled in home-based childcare accumulated ~2 hours of screen-time over that which was accumulated by those attending centre-based programs [50]. Even more disturbing is the fact that children in home-based facilities have been found to accumulate approximately 5.6 hours of daily screen time (3.8 hours at home and 1.8. hours in childcare), in comparison to those in center-based care (3.1 hours at home and 0.1 hours in childcare) [58]. While it has been found that children who attend these settings are likely to be heavier than those in center-based childcare, [70, 71] reinforcing the need to target preschoolers in this particular care setting. There are multiple reasons that may explain this finding. Firstly, it is possible that because home-based facilities care for children of various ages (in comparison to centers that have children separated based on age/developmental stage [72]), screen-viewing may be viewed as an appropriate activity in which all children can partake. Secondly, given that these types of facilities vary considerably with regard to layout and structure, [58] it is not surprising that a lack of appropriate indoor play space may restrict active behaviors and thus support prolonged periods of sitting and screen-use [59]. Thirdly, because there is only one provider present in this particular type of childcare arrangement, it may prove more challenging to carry out certain tasks, such as meal preparation; consequently, screen-viewing may serve as an ideal ‘babysitter’ during such instances. Lastly, home-based childcare facilities tend to be less regulated than center-based programs; [73, 74] therefore, in addition to lacking policies regarding screen-time/use, the childcare providers do not require any formal education to run this business out of their private homes.

The link between access to screen sources and high screen-viewing levels has been well-established in the literature; [16, 28] subsequently, it was important to garner a deeper understanding of the opportunities for and accessibility to screen activities for preschoolers during childcare hours (as described by nine of the included studies) [48, 52, 54, 56, 57, 59‐62]. The results of this review found screens and related activities (namely television followed by computers) were accessible to preschoolers in childcare. Consequently, these participants were at-risk for accumulating higher levels of screen-viewing. Nevertheless, it is important to note that the presence of screen-use policies in childcare was highlighted in over half of the studies in this review that spoke to the availability screen-viewing in childcare; [48, 52, 54, 56, 59] therefore suggesting that, in many instances, mechanisms are in place to help minimize screen-viewing in childcare. Of particular interest, Trost’s group reported the majority of participating home facilities were meeting the Nutrition and Physical Activity Self-Assessment for Child Care’s (NAP SACC) proposed screen-viewing standards (i.e., rarely/never showing television or videos during care hours) [60]. While this discovery suggests opportunities to engage in related activities may be limited in care, it somewhat contradicts the apparent high levels of screen-viewing in home childcare observed in this review [11, 50, 58]. One possible explanation for this score could be that the NAP SACC tool is administered to staff as a self-assessment, and may in turn be subject to bias given the nature of the questions asked (e.g., amount of screen-time permitted per week; presence of written policies on screen time; discussing with children what they are viewing when screen time is offered; screen time used a reward; location of screens in childcare facilities) [75]. It is also possible that, despite the existence of screen-viewing policies and rules, there is no guarantee that these policies are being practiced nor enforced during childcare hours. Lastly, in light of the existing variation across the different screen-viewing policies presented in-text, much variability in related outcomes among young children may result; as such, further research is necessary to not only explore the emerging screen-related behaviors within these facilities, but also the implementation and enforcement of associated policies.