Screen-based behaviour in school-aged children with long-term illness

Electronic devices play a major role in the lives of contemporary children, but this may have negative effects on their physical or psychological health [1‐3]. Recent evidence suggests that children are involved in a wide range of online activities, such as doing school work, playing computer games, social networking and messaging [4], and many of them exceed the recommended time spent with these activities [5, 6]. Excessive spending time on the Internet or online gaming, together with other particular personal aspects [7], might precede problematic Internet use with behavioural or social problems [8]. Similarly, all these problems can be deepened by problematic Internet use. Therefore, the motivation for excessive and problematic media may be in a reciprocal relationship, as suggested by Valkenburg and Peter [9] or Slater [10].

According to the WHO [11], the prevalence of chronic conditions generally among adolescents is high. One of the most common chronic conditions with an increasing trend is e.g. asthma [12]. The presence of such a health condition requires management of the condition and patient adherence to daily treatment. This limits many areas of an adolescent’s everyday life, including his or her family, peers or school [13]. Moreover, research indicates that children with different types of chronic conditions are highly involved in a sedentary lifestyle [14] because of limitations in many other activities [15]. However, children might not perceive the impact of the chronic condition on their activities and socialization [16], which could be associated with a good health care system or with psychosocial factors of the individuals themselves [17]. Children use of electronic media, including Internet and video gaming, has increased also among children with health condition like ADHD. The Internet environment and virtual reality offers very attractive features for them. It provides very broad content for potential stimulations or various activities in simultaneously open windows, which might lead to fixation to the online world. Furthermore, video games offer immediate rewards with a strong incentive to increase the reward by trying the next level [18, 19].

Generally speaking, evidence is lacking in regard to screen-based behaviour among children with a chronic condition. In our study we focused on children with long-term illness, asthma and learning disabilities, who are at the greater risks of lower school performance and involvement in sedentary behaviour [14, 20]. Therefore, the aim of the present study was to analyse differences in the screen-based behaviour of adolescents by long-term illness, asthma and learning disabilities.

Around 20 % of adolescents had a long-term illness or medical condition that has been diagnosed by a doctor (Table 1). Moreover, more than half of adolescents exceeded the recommended time for screen-based activities, such as watching TV, playing PC games and computer work. The prevalence of screen-based activities and excessive use of the Internet was relatively similar for children with and without a chronic condition or learning disability (Table 2). Children with a long-term illness and learning disability did not differ from their peers in screen-based activities, such as watching TV, playing computer games and working with a computer. However, children with asthma had 1.59-times higher odds of excessive playing of computer games in comparison with their peers (Table 2). Children reporting learning disabilities, but not reporting long-term illness or asthma, had 1.71-times higher odd of excessive use of internet. Interactions of the effects of gender and long-term illness, asthma or learning disabilities were not statistically significant (not shown).

Our objective was to explore the association between screen-based behaviour and the occurrence of long-term illness, asthma and learning disabilities among school-aged children. We found that adolescents with asthma were more likely to play computer games than their peers without any chronic conditions. The study also showed adolescents with a learning disability were at greater risk of excessive Internet use.

Our findings corroborate prior research that children with chronic conditions incline toward sedentary behaviour [14] and expand current knowledge by identifying which screen-based activities stand for their preferred sedentary behaviours. The association between asthma and playing computer games poses a new question of whether involvement in computer games represents an alternative leisure activity that parents offer to their children in order to have them under greater surveillance. However, the explanation may also lie in the motivation of the children. Some studies suggest a relationship between asthma and increased sedentary behaviour e.g. leading to obesity [25‐27]. Due to a lack of physical activities, asthmatic children may have lower self-esteem and self-efficacy and greater mood difficulties, which has been partially shown in the literature [28, 29]. Computer gaming is often classified as a mood-management activity which increases one’s own feelings of competence [30‐32] and which may be popular among asthmatic children due to the substitution and coping strategy.

More than half of school-aged children exceed recommended time spent on screen-based activities, and adolescents with chronic conditions were rather similar to their peers. Other studies on children have also shown an increased amount of time devoted to screen-based activities [33, 34]. This pattern of spending their leisure-time thus seems to be a general trend characteristic for this young generation. It may be a result of the development of new technologies surrounding adolescents in everyday life, including school or family, which may increase the risk of sedentary behaviour.

In addition, the present study showed that adolescents with a learning disability are at higher risk of developing symptoms of excessive Internet use in comparison with their peers. There might be two alternative explanations. According to the first one, learning disability and excessive Internet use may have a common denominator that is impaired executive functions [35, 36]. It is also possible that excessive Internet use is an outcome of a maladaptive coping strategy in the sense that these children might be compensating for their shortcomings by being active online. There is a growing body of literature reporting the relationship between ADHD and excessive Internet use [19, 37]. Although learning disabilities and ADHD are not identical, they are closely related and overlapping – e.g. children of both groups have attentional difficulties and are easily bored [38]. Moreover, Cook et al. [39] indicate that multiple factors, like poor motor skills and executive function deficits in children with learning disabilities, might contribute to low levels of physical activity and to high levels of sedentary behaviour subsequently. This offers a possible explanation as to why children with learning disabilities may become fixated to the online world and why these children should be a prime target of prevention. Although further research with more sophisticated design is needed, it is worth mentioning that the present study opens a gate to this issue.

The most important strengths of the study are the representativeness of our sample of adolescents and the use of internationally recognized instruments. In addition, our study provides important information with regards to screen-based behaviour in children with long-term illness, which is lacking in the literature. Nevertheless, some limitations need to be considered. Firstly, we used only self-reported data. Measurement of long-term illness is very general and might comprise a very heterogeneous group of health problems with regard to type as well as severity, and consequently also with regard to their impact on daily activities. Secondly, our study has a cross-sectional design; therefore, we are unable to formulate conclusive statements about causality. Finally, our sample did not include children with long-term illness who are not able to attend school regularly because of their health condition.

The findings show that adolescents with long-term illness or chronic condition do not differ from their peers in screen-based behaviour, with exception of asthmatic children playing computer games more often and children with learning disabilities being more prone to excessive Internet use. However, further research focused on separate clinical groups but using a measurement used in representative samples might bring more insight and understanding regarding the lifestyle of children who are excluded from mainstream schools. Based on our results, it seems to be important to assess determinants of their social environment, which could be helpful in developing interventions to reduce involvement in excessive screen-based behaviour and the subsequent negative consequences.