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Improving dads antenatal knowledge and support

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Improving dads antenatal knowledge and support

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The NHS is failing Scotland's new mums & babies by sidelining dads, according to evidence from our survey of new fathers.

More than 560 of you in Scotland, and 1800 across the UK, responded to the survey of new dads' experience of antenatal, birth or health visitor services - and the results indicate that the NHS is failing to provide the 'family-centred' services required by its own rules* and desired by parents.

Although almost all of the new fathers were present in maternity services at each stage , the survey jointly undertaken by Fathers Network Scotland and the Fatherhood Institute shows that large numbers felt ignored before, during, and after delivery, even though their involvement is central to infant and maternal well-being and is desired by mothers.

Mixed policy messages

Many spoke of outdated visiting policies and inadequate or non-existent overnight facilities for dads, adding stress to an already emotionally-heightened time - even though UK NHS policy since 2004 requires maternity services to deliver 'mother-focused and family centred' care.

In Scotland, the Best Start maternity plan (2017) stipulates: "All mothers and babies are offered a truly family-centred, safe and compassionate approach to their care... Fathers, partners and other family members are actively encouraged and supported to become an integral part of all aspects of care."

Pregnant and birthing women typically want their partner with them not only because he is their closest companion but also because he provides continuity of care and support amid stretched NHS services, according to a major new report published by our colleagues at the Fatherhood Institute to coincide with the survey in the run-up to Father's Day.

Funded by the Nuffield Foundation, Who's the bloke in the room? - a review of UK evidence about new fathers and health services - details how expectant fathers in Britain are key influences on maternal and infant health and well-being , including on pregnant women's smoking, diet, physical activity and mental health, and on children's later development.

It recommends specific new measures to welcome fathers throughout pregnancy, birth and early infancy (see bottom of this article or here) reinforced by what you told us in the survey How was it for you? Read full Scottish results here or as infogram; UK results here or our Scottish/UK summary below:

Antenatal Services

65% (61% in Scotland) said antenatal healthcare professionals had rarely or never discussed fathers' roles.

Half (56% UK; 50% Scotland) had rarely or never been addressed by name.

Fewer than a quarter had been asked about their physical health (22% UK; 24.5% Scotland) or diet and exercise (18% UK; 20.9% Scotland).

48% in both UK and Scotland) had not been asked about smoking, despite the risks of passive smoking to babies, and fathers' key role in supporting pregnant mums to give up.

And even though a father's mental health is closely correlated with a mother's, only 18% (16% in Scotland) had been questioned about it.

Birth Experience

While two thirds of fathers said they felt welcome at their children's birth, the poll records high levels of disappointment in hospital policy, particularly in Scotland, where nearly half of fathers (48% in Scotland compared to 40% in UK) said that hospitals had not allowed sufficient time for the new family to spend together after the birth.

Qualitative feedback included reports of fathers missing crucial moments of bonding following their children's births, and feeling sidelined despite their partners' desire for support. Only 1 in 10 dads polled in Scotland (compared to 17% in UK) reported that their hospital had facilities for fathers to stay overnight afterwards, even though the then Prime Minister Gordon Brown called eight years ago for hospitals to provide such facilities.

In Scotland 96% of dads felt staying after the birth would be helpful to mum, and 77% believe they can be helpful to staff, who are often overstretched.

However there were also encouraging signs of change, with Dundee's Ninewells Hospital, Edinburgh Royal Infirmary, Arbroath Infirmary each singled out for praise in qualitative feedback. Crosshouse Hospital in Kilmarnock was named by one respondent as "very welcoming and inclusive" of dads.

Postnatal Care

Nearly half of the dads surveyed said that their role was rarely or never spoken about at home visits (47% in Scotland), even though dads' influence infant feeding and are key to spotting maternal depression.

Many also reported their own struggles with mental health, with no signposting for support for dads, despite evidence of paternal susceptibility to depression following birth. (continued below...)

Samantha Pringle, director of Fathers Network Scotland, said: "All the research shows that involving fathers at this crucial time of preparation, birth and post-natal care has a positive impact on the whole family. But our survey sadly shows that fathers remain an under-used resource at a time when a stretched NHS would most benefit from the support they bring to their families.
"Let's change this outdated attitude and follow the beacons of excellent practice - such as the Dads2B classes pioneered across the Lothians. They show how instilling confidence in expectant fathers can ripple through the whole community."
Adrienne Burgess, Co-Chief Executive of the Fatherhood Institute said: "Our survey shows that dads are there for mums every step of the way - at routine antenatal appointments, for the scan, labour, birth and back home. No-one can say dads are not interested or unwilling. But the survey reveals serious failings in the NHS approach at every stage.

"Too often, services are ignoring fathers, in spite of dads' importance to healthy pregnancies and babies and even though mothers want their partner to be involved and informed."

Pioneering Change

Here at Father's Network Scotland we're working with trailblazers across Scotland bringing dad-friendly best practice into health and family services with the help of our Understanding Dad programme, currently rolling out across the country.

We're also backing the recommendations of Who's the bloke in the room? which calls for a more family-centred service that enrols expectant fathers in maternity services from 'booking in', records and responds to their health needs and behaviours, and which trains maternity staff to engage with them.

The recommendations are all about making fathers welcome throughout pregnancy, birth and early infancy, and valuing the role they play not just as supportive partners but also as independent parents with a unique connection to their baby.

We want to see the NHS to include expectant and new fathers at all stages and inform them as thoroughly as it currently informs pregnant women and new mothers:

Key Recommendations from Nuffield Report
1: Change NHS terminology to refer to fathers
At the time of the birth, 95% of parents are in a couple relationship, and 95% register the birth together. For a woman to have a new partner at this stage is almost unheard-of; and only one birth in a thousand is registered to two women. Yet despite the overwhelming presence of the biological father, the term 'woman's partner' or 'mother's partner' (rather than 'father') is commonly used in maternity services. This defines the baby's father solely as a support-person and does not recognise his unique connections (both genetic and social) to his infant. The term 'woman's partner' should be widely replaced by 'father/ woman's partner'.
2: Invite, enrol and engage with expectant dads
Employed fathers in Britain have a statutory right to time off to attend two antenatal appointments. Each father (or woman's partner) should (with the pregnant woman's consent) be formally enrolled in maternity services and an oﬃcial invitation to meet the maternity team issued. This will acknowledge the father as a parent as well as a support-person, and provide a pathway to welcoming, educating and informing him, identifying strengths and challenges associated with him, and referring him to relevant services (e.g. to smoking cessation). Working groups in each of the four countries in the UK should be established to consider mechanisms for enrolling the father/ woman's partner; and to identify potential pilot sites.
3: Deliver woman-focused, family-centred services
Expectant fathers' direct impact on the mother and indirect impact on the unborn child, are significant. Maternity services should be formulated as 'woman-focused and family-centred' meaning that, while the obstetrics focus remains on the pregnant woman, the father (or, where relevant, woman's partner and other key supporters) are actively encouraged to become an integral part of all aspects of maternal and newborn care. Hospitals should collect information from both parents about their experiences of family-centred care, as part of the NHS Friends and Family Test. Working groups in each of the four countries in the UK should be established to define family-centred care during pregnancy, at the birth and in neonatal care; and to explore strategies, objectives and targets for implementation - including providing facilities for fathers to stay overnight after the birth.
4: 'Father-proof' maternity staff training
The term 'midwife' means 'with woman' and most practitioners in maternity and neonatal care services are not trained to engage effectively with men or to work in a 'partnership of care' with families. When guidelines for maternal and neonatal care are drawn up, these should include the evidence on the impacts of fathers' characteristics and behaviours on mother and infant; impacts of couple relationship functioning; and impacts of fatherhood on men.
Pre- and post- registration training curricula should be revised to include the 'whys' and 'hows' of engaging with fathers and families. When core competencies are time-tabled for revision, relevant new competencies should be drafted and included. Existing training modules (such as the NCSCT module on smoking in pregnancy) should be revised to equip healthcare practitioners to engage with both parents, rather than only with the woman.
5: 'Father-proof' information for expectant and new parents
Pre-natal health education and information should be directed at men as well as women, and maternity services should be required to provide information directly to the father/ woman's partner, rather than relying on the 'woman as educator'. To counter unconscious bias against men/ fathers as competent caregivers, the content should include the neurobiology of active fathering, co-operative caregiving (the 'parenting team') and the impacts of father involvement and couple functioning on the infant's health and development. 'Father-proofing' guidelines to equip authors of new resources (and of resources that are being revised) to address both parents effectively should be developed and made available to commissioners, authors and editors, with the requirement that these be applied and utilized as part of the Gender Equality Impact Assessment.
6: Collect better data on expectant and new dads
On the basis of our research review, and a recent independent Longitudinal Studies Strategic review, we recommend that any future 'birth' cohort study should collect data in pregnancy from both the father/ woman's partner and the mother (cohabiting or living separately), with a phase of testing for approaches to recruitment.
Where we have identified gaps in primary research and/ or in secondary analyses of data already collected, consideration should be given to commissioning primary research or secondary analysis of existing cohort data.
At birth registration, the father should be asked whether the infant being registered is his first child. Analysis of the data collected will then be able to establish fathers' age at birth of first child and men's fertility rates in Britain.

Read How was it for you? Scottish survey figures
Read How was if for you? UK survey figures
Read Who's the bloke in the room? report

*Read The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland published by the Scottish Government in 2017.

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Survey results: Maternity services sidelining dads

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The NHS is failing Scotland's new mums & babies by sidelining dads, according to alarming evidence from our survey of new fathers.

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https://www.starlight.org.uk/assets/documents/Starlight_ImpactOfPlay_Report_Oct20.pdf

Play in hospital's is vital in supporting children to navigate and understand procedures and treatment options.

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Alcohol consumption during pregnancy - Reducing FAS

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Alcohol consumption during pregnancy - Reducing FAS

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Reducing alcohol consumption during pregnancy will reduce the number of children impacted and growing up with FASD and FAS

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Factors that affect commitment to breastfeeding

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Factors that affect commitment to breastfeeding

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This research investigated experiences of mothers by considering their motivations to breastfeed, the barriers faced and effective coping strategies. The results concluded that, threats for breastfeeding was the pain and the notion of negative support. Commitment to continue breastfeeding is boosted by peer support, perceived convenience and determination.

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"If almost half of trans-spectrum youth have self-harmed (Jones and Hillier 2013) and the link between suicide and mental distress due to sexual and gender minority youth status is established (Peter et al. 2016, Wolff et al. 2014)"

https://lgbtyouth.org.uk/wp-content/uploads/2023/12/health-report-2023-digital.pdf -credit for the image

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The Promise document links to priority 3, about care experienced adolescents in education.

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Becoming a breastfeeding friendly society

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Becoming a breastfeeding friendly society

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Maintaining breastfeeding-friendly status may help change attitudes towards breastfeeding and encourage more mothers to continue breastfeeding for longer.

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Additional Support Needs (ASN) and dental health

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Additional Support Needs (ASN) and dental health

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doi: 10.1186/s12888-022-04438-5.

Affiliations

¹ Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, Scotland.

² NHS Grampian, Aberdeen, Scotland.

³ Aberdeen Centre for Health Data Science PPIE Group, Aberdeen, Scotland.

⁴ Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland.

⁵ Grampian Data Safe Haven (DaSH), University of Aberdeen, Aberdeen, Scotland.

⁶ Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, Scotland. jessicabutler@abdn.ac.uk.

doi: 10.1186/s12888-022-04438-5.

Affiliations

¹ Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, Scotland.

² NHS Grampian, Aberdeen, Scotland.

³ Aberdeen Centre for Health Data Science PPIE Group, Aberdeen, Scotland.

⁴ Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland.

⁵ Grampian Data Safe Haven (DaSH), University of Aberdeen, Aberdeen, Scotland.

⁶ Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, Scotland. jessicabutler@abdn.ac.uk.

Abstract

Background: One in eight children in the United Kingdom are estimated to have a mental health condition, and many do not receive support or treatment. The COVID-19 pandemic has negatively impacted mental health and disrupted the delivery of care. Prevalence of poor mental health is not evenly distributed across age groups, by sex or socioeconomic groups. Equity in access to mental health care is a policy priority but detailed socio-demographic trends are relatively under-researched.

Methods: We analysed records for all mental health prescriptions and referrals to specialist mental health outpatient care between the years of 2015 and 2021 for children aged 2 to 17 years in a single NHS Scotland health board region. We analysed trends in prescribing, referrals, and acceptance to out-patient treatment over time, and measured differences in treatment and service use rates by age, sex, and area deprivation.

Results: We identified 18,732 children with 178,657 mental health prescriptions and 21,874 referrals to specialist outpatient care. Prescriptions increased by 59% over the study period. Boys received double the prescriptions of girls and the rate of prescribing in the most deprived areas was double that in the least deprived. Mean age at first mental health prescription was almost 1 year younger in the most deprived areas than in the least. Referrals increased 9% overall. Initially, boys and girls both had an annual referral rate of 2.7 per 1000, but this fell 6% for boys and rose 25% for girls. Referral rate for the youngest decreased 67% but increased 21% for the oldest. The proportion of rejected referrals increased steeply since 2020 from 17 to 30%. The proportion of accepted referrals that were for girls rose to 62% and the mean age increased 1.5 years.

Conclusions: The large increase in mental health prescribing and changes in referrals to specialist outpatient care aligns with emerging evidence of increasing poor mental health, particularly since the start of the COVID-19 pandemic. The static size of the population accepted for specialist treatment amid greater demand, and the changing demographics of those accepted, indicate clinical prioritisation and unmet need. Persistent inequities in mental health prescribing and referrals require urgent action.

Keywords: CAMHS; Child & adolescent mental health; Health inequalities; Mental health prescribing.

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Conflict of interest statement

The authors declare that they have no competing interests.

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national center for biotechnology information

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Inequalities in children's mental health care: analysis of routinely collected data on prescribing and referrals to secondary care - PubMed

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The large increase in mental health prescribing and changes in referrals to specialist outpatient care aligns with emerging evidence of increasing poor mental health, particularly since the start of the COVID-19 pandemic. The static size of the population accepted for specialist treatment amid great ...

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mental health in children- mental health strategy 

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mental health in children- mental health strategy 

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The Scottish Government’s approach to mental health from 2017 to 2027 – a 10 year vision.

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Why are poorer children at higher risk of obesity and overweight?

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Why are poorer children at higher risk of obesity and overweight?

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Abstract

Background: There is limited evidence on which risk factors attenuate income inequalities in child overweight and obesity; whether and why these inequalities widen as children age. Method: Eleven thousand nine hundred and sixty five singletons had complete data at age 5 and 9384 at age 11 from the Millennium Cohort Study (UK). Overweight (age 5 : 15%; age 11 : 20%) and obesity (age 5 : 5%; age 11 : 6%) were defined using the International Obesity Taskforce body mass index cut-points. To measure socioeconomic inequalities, we used quintiles of family income and as risk factors, we considered markers of maternal health behaviours and of children's physical activity, sedentary behaviours and diet. Binary and multinomial logistic regression models were used. Results: The unadjusted analyses revealed stark income inequalities in the risk of obesity at age 5 and 11. At age 5, children in the bottom income quintile had 2.0 (95% CI: 1.4-2.8) increased relative risk of being obese whilst at age 11 they had 3.0 (95% CI: 2.0-4.5) increased risk compared to children in the top income quintile. Similar income inequalities in the risk of overweight emerged by age 11. Physical activity and diet were particularly important in explaining inequalities. Income inequalities in obesity and overweight widened significantly between age 5 and 11 and a similar set of risk factors protected against upward and promoted downward movements across weight categories. Conclusions: To reduce income inequalities in overweight and obesity and their widening across childhood the results support the need of early interventions which take account of multiple risk factors.

Introduction

In recent decades, the prevalence of obesity among children and adults has increased dramatically in the UK and elsewhere. Obesity is linked to the development of numerous chronic diseases and poses significant health and economic burdens. , In the context of lifelong health, we know that children who become overweight and obese are at higher risk of obesity throughout their lives. , There is also evidence that overweight and obese children face higher risks of negative economic and social outcomes both in childhood and adulthood. , Therefore, intervening early to reduce the prevalence of obesity and overweight could have long-term knock on effects for population health.

Numerous studies show that in many developed countries, including the UK, there are income and other socioeconomic inequalities in the risk of childhood obesity and overweight, and that these begin in the preschool years. A few studies also reveal that socioeconomic inequalities in overweight/obesity widen across childhood. , These inequalities are likely explained by differential access to resources and/or knowledge by poorer parents who may practice worse health behaviours, but until now there has been no attempt to examine and compare several potential mechanisms linking family socioeconomic position to overweight/obesity in children. Our understanding of why children from socially disadvantaged backgrounds experience higher risk of obesity and overweight-and increasingly so across childhood-is limited. ,,

Our study, which focuses on the UK context, addresses this gap in knowledge in several ways. First, we examine which markers of family health behaviours and environmental risk factors reduce income inequalities in child overweight and obesity in the UK. To investigate whether influences are similar across childhood, we considered two age points: in early childhood at 5 years and on the cusp of adolescence at 11 years. Second, we investigate whether income inequalities widen across childhood by assessing whether poorer children were more likely to experience upward movements and less likely to experience downward movements across weight categories (normal weight, overweight, obese) between age 5 and 11. Third, we investigate which risk factors protect against upward movements and which promote downward movements across weight categories. To conduct the analyses, we used data from the large population-based UK Millennium Cohort Study.

Methods

The Millennium Cohort Study

The Millennium Cohort Study (MCS) is a UK nationally representative prospective cohort study of children born into 19 244 families. The sample population was drawn from all live births in the UK from September 2000 to January 2002. The sample was selected from a random sample of electoral wards with a stratified sampling strategy to ensure adequate representation of all four UK countries, and of disadvantaged and ethnically diverse areas. The first sweep of data was collected when cohort members were around 9 months and the subsequent four sweeps of data were collected at ages 3, 5, 7 and 11 years. During home visits interviews were conducted and questions asked about socioeconomic circumstances, health-related behaviours including smoking during pregnancy, infant feeding, physical and sedentary activities and dietary markers. Interview data were available for 79 and 69% of families when cohort members were aged 5 and 11, respectively.

Child overweight and obesity

Overweight and obesity were defined using the International Obesity Taskforce (IOTF) body mass index (kg m −² ) cut-points which are age and gender specific. At ages 5 and 11, children were weighed without shoes or outdoor clothing using Tanita HD-305 scales (Tanita UK Ltd., Middlesex, UK) and weights were recorded in kilograms to one decimal place. Heights were obtained using the Leicester Height Measure Stadiometer (Seca Ltd., Birmingham, UK) and recorded to the nearest millimetre.

Family income

To measure socioeconomic inequalities, we used quintiles of family income after adjustment using the modified OECD scale, which were derived by the MCS survey team. This scale takes into account the number of people in the household by setting the family's needs relative to those of a couple with no children. , Family income was used in the analyses as a marker of access to resources (to purchase 'healthy' food, organized physical activities and to live in safer neighbourhoods etc.), and we expected children from poorer families to be at increased risk of overweight or obesity. In the analyses, the top income quintile was the reference category.

Potentially modifiable risk factors

We selected markers of health behaviours and environmental influences hypothesized to attenuate income inequalities in child overweight and obesity. To capture the mother's health-related behaviours during pregnancy and after birth, we considered whether the mother smoked during pregnancy, duration of breastfeeding (no breastfeeding, up to 2 months, 2-4 months, more than 4 months) , and whether the child was introduced to solid foods before 4 months of age. , Markers of children's physical activity and sedentary behaviours were frequency of sport/exercise (less than once, once or twice, three times or more per week), active playing with a parent (less than once, once or twice, three times or more per week), hours watching TV (less than one, between one and three, three or more per day), hours playing on a PC (less than one, between one and three, three or more per day), at least weekly use of a playground (at age 5), whether there was a playground in the area (age 11), journeys in the area by bike (measure available at age 11 only) and weekday bedtime (at age 5: before 7:30, 7:30-7:59, 8-8:59, 9 or later, no regular bedtime; at age 11: before 8, 8-8:59, 9-9:59, 10 or later, no regular bedtime). A marker of active transport-whether children actively commuted to school-was excluded as this was not significantly associated with adiposity. Markers of the dietary environment in which children were growing up were whether the child skipped breakfast, fruit consumption (none or one, two, three or more per day), sweet drinks consumption (at age 5: as main drink in between meals; at age 11: at least once a day) and maternal BMI (obtained using mothers' self-reported weight and height). Data on early life markers of maternal health behaviours were collected when cohort members were aged around 9 months (Sweep 1) and the other risk factors were, unless indicated otherwise, measured contemporaneously i.e. at ages 5 or 11 years. Children's health behaviours, at both ages, were reported by the mother at interview.

Inclusion criteria, exclusionsand losses to follow up

We dropped observations with missing values on adiposity and risk factors (at age 5 = 3104; at age 11 = 3703). From the complete case sample, we dropped children who had implausible ( z -score was ≤−5 or ≥5) BMI values (at age 5 n = 14; at age 11 n = 2). If the mother was pregnant when the cohort member was aged 5 or 11 we used mother's BMI recorded at the previous Sweep of data collection (at age 5 n = 556; at age 11 n = 121). Lastly, we also dropped twins and triplets (age 5 n = 162; age 11 n = 120) and cohort members for whom the mother was not the main interviewee at Sweep 1 (age 5 n = 1; age 11 n = 3). These exclusions reduced the analytical sample to 11 965 (78%) at 5 years, and 9384 (71%) at 11 years.

Statistical analyses

We used multinomial logistic regression to estimate income gradients in child overweight and obesity whereby non-overweight children were the reference group. Models were run jointly for boys and girls and adjusted for gender of the child. The analyses were not stratified by gender since exploratory analyses (not shown) did not reveal differences for boys and girls in the role that risk factors had in attenuating income inequalities in children's adiposity. In models estimated at age 11, we included a control variable for whether girls and boys exhibited any sign of pubertal changes (menarche, hair on body or breast growth for girls; voice change, hair on body or facial hair for boys). , The baseline model shows the unadjusted association between income and overweight/obesity. Then we revealed the role that each category of risk factors had in attenuating income gradients in child overweight and obesity by adjusting for each category of risk factors separately: model 1 adjusts for maternal health behaviours; model 2 for markers of physical activity and sedentary behaviours and model 3 for dietary markers. In order to assess to what extent income inequalities were attenuated when all the risk factors were considered, Model 4 adjusts for all categories of risk factors simultaneously.

We assessed whether income inequalities widened significantly across ages by investigating whether poorer children were more likely to experience upward movements and less likely to experience downward movements across weight categories between age 5 and 11. To do so, we created two binary variables. One variable indicating whether the child transitioned from being normal weight at age 5 to being overweight/obese at age 11 or from being overweight to obese; the other binary variable indicating whether a child transitioned from being obese at age 5 to being overweight/normal weight at age 11 or transitioned from being overweight to normal weight. Using these binary indicators as dependent variables in a logistic regression model, we estimated income gradients in/upwards/downward movements with adjustment for the gender of the child and the child's weight category at age 5 (normal weight, overweight, obese). Then, to investigate which category of risk factors measured at age 5 promoted or protected against these changes across income groups, we adjusted for each set of risk factors separately and, lastly, we estimated a model adjusting for all risk factors simultaneously. We focused on risk factors measured at age 5 in order to establish a temporal order between exposure to family health behaviours, routines and environmental risk factors, and children's experiences of (upward or downward) weight changes. Adding to the models age 11 risk factors did not change our findings (results not reported). The logistic regression models were estimated on a sub-sample given that only children who were at risk of experiencing upward (normal weight or overweight children at age 5) or downward (obese or overweight children at age 5) movements were included in these analyses.

All analyses were conducted in Stata version 13. We used weights to account for non-response and overrepresentation of disadvantaged and ethnically diverse areas and the survey command to account for the clustering of samples within strata in the MCS. The model results are reported as relative risk ratios or odds ratios with 95% confidence intervals.

Results

Table 1 shows that the prevalence of obesity was considerably higher among children in the poorest quintile compared with their peers in the top income quintile (6.6 vs. 3.5% at age 5; 7.9 vs. 2.9% at age 11). At age 5, there was no evidence of an income gradient in child overweight, but by age 11 differences between children from poorer compared with richer families had emerged (20.2 vs. 16.5%). Testing for linear trend shows that differences by income quintiles were statistically significant for obesity at age 5, and both overweight and obesity at age 11.

Table 1 also shows that there were striking income gradients in the distribution of risk factors. Children in the lower income quintiles were more likely to have mothers who smoked during pregnancy, were not breastfed or breastfed for a shorter duration, were introduced to solid food earlier; they were less likely to do sports, to engage in active playing with a parent, to be living in an area with a playground and to use a bike in the area, spent more time watching TV and using a PC, and they tended to have later or irregular bedtimes; they were also less likely to be eating fruit, to have breakfast every day and their mothers had higher average BMIs. In contrast, at age 5 children in the lower income quintiles were more likely to be taken to the playground at least weekly.

Which risk factors might explain income inequalities?

Table 2 shows selected results from the multinomial logistic regression models at age 5 ( n = 11 965): the reported risk of being overweight and obese relative to the risk of being non-overweight (results for the risk factors are available upon request). In the baseline model, poorer children experienced significantly higher relative risk of being obese than children in the top income quintile (2.0 95% CI: 1.4-2.8). Physical activity and dietary risk factors appeared most important in attenuating inequalities. After adjustment for all risk factors in the final model, income inequalities were substantially reduced. On adjustment for all risk factors in Model 4, children in the bottom income quintile had a reduction in the relative risk of obesity of around 60%. There was no evidence of an income gradient in the relative risk of being overweight at age 5.

Table 3 shows selected results of the multinomial regression models at age 11 ( n = 9384). In the unadjusted models, inequalities appeared more pronounced compared to age 5. Children in the bottom income quintile had 3.0 (95% CI: 2.0-4.5) increased relative risk of being obese at age 11. At age 11, children in the second income quintile had the highest relative risk of being obese (3.4 95% CI: 2.2-5.1), but, as revealed by the overlap in the confidence intervals, differences between the bottom and second income quintiles were not statistically significant. For children in the bottom quintile, adjusting for dietary markers did most to attenuate inequalities.

At age 11, we also observed an income gradient in the relative risk of being overweight. Children in the bottom income quintile had 1.4 (95% CI: 1.1-1.6) increased relative risk of being overweight compared to their peers in the highest income quintile. On adjustment for all risk factors in Model 4, the relative risk of overweight for children in the bottom income quintile was fully attenuated.

Upward and downward movements across weight categories and which risk factors might explain them

Table 4 shows that children, who at age 5 were either normal weight or overweight, in the bottom, second and third income quintiles were significantly more likely to experience upward movement across weight categories than children in the top quintile (results for the risk factors are available upon request). Adjustment for physical activity and dietary markers did most to attenuate inequalities. On adjustment for all risk factors, children in the lowest income quintile compared to children in the highest income quintile had a reduction in the odds of moving up a weight category of around 55%. Children in the second income quintile were less likely to experience downward movements across weight categories, but the results fail to show a clear income gradient in downward movements across weight categories for children who were either obese or overweight at age 5. Nonetheless, these results are informative because they suggest that similar risk factors were protective against upward movements and promoted downward movements (results available upon request). An earlier bedtime and fruit consumption more than 3 times a day were negatively associated with upward movements and positively associated with downward movements across weight categories. Mother's smoking during pregnancy, introduction to solid foods before 4 months and mother's BMI were positively associated with upward movements and negatively associated with downward movements across weight categories. Adjusting for risk factors measured at age 11 resulted in smoking no longer being statistically significant but the rest of the coefficients remained largely unchanged (results available upon request).

Discussion

We show, consistent with prior studies, stark income inequalities in the risk of obesity throughout childhood, the emergence of inequalities in the risk of overweight by age 11 and that inequalities became more pronounced between age 5 and 11. After adjustment for risk factors, inequalities between the bottom and top income quintiles were attenuated by at least 50% and were largely no longer statistically significant. Multiple family health behaviours and environmental risk factors were relevant when attempting to explain income inequalities in overweight and obesity amongst children. The results suggest that both markers of physical activity and diet at ages 5 and 11 were particularly relevant in attenuating inequalities throughout childhood. However, maternal health behaviours in early childhood were relevant too as on their own in the model, they attenuated inequalities in child obesity between the bottom and top income quintiles by around 20%. This perhaps indicates that pathways underpinning inequalities in child adiposity begin early in life and are cumulative over the life course. The influence of each set of risk factors was relatively similar across childhood and some markers were relevant at both ages, such as the mother's BMI, early bedtimes and watching TV less than 1 h per weekday. However, other markers were more relevant at age 5 or 11. For example, skipping breakfast was related to the risk of overweight and obesity, and fruit consumption was related to the risk of overweight at age 5, but these factors played a rather minor role at age 11. In contrast, doing sport more than three times a week played a more important and protective role at age 11 than age 5.

The magnitude of income inequalities in child obesity and overweight grew between ages 5 and 11. Poorer children were more likely to experience upward movements across weight categories than richer ones. These findings suggest that efforts to curb the increasing prevalence of obesity, particularly amongst disadvantaged children, should start early in life. Intervening in the early years when the family environment has more profound influences on children's healthy development has the potential to be particularly effective-setting children onto 'healthy', or at least healthier, adiposity trajectories. Importantly, the results reveal that similar risk factors protected against and promoted, respectively, upward and downward movements across weight categories. This might point to the importance of promoting (e.g. an earlier bedtime, fruit consumption more than 3 times a day) or discouraging (e.g. smoking during pregnancy, early introduction to solid foods and high maternal BMI) these behaviours in an effort to curb further increases in the prevalence of overweight and obesity amongst poorer children.

There are several government initiatives e.g. the Change4life programme, which aim to prevent and address body fat gain amongst children in the UK. Generally, existing policies support healthy living in the family environment by promoting-amongst adults and children-healthy eating (e.g. '5-a-day') and exercise (e.g. '10 000 steps a day'). Our findings support the development of horizontal prevention strategies aimed at tackling a wider set of risk factors from multiple domains including physical, sedentary and dietary behaviours. However, the evidence on effective policy strategies that reduce or eliminate disparities in children's adiposity is not yet conclusive. Greater efforts are needed to investigate which interventions might contribute to reduce the prevalence of child overweight and obesity. In particular, more research and evaluations are needed to understand which changes in family and children's routines might contribute to a reduction in socioeconomic inequalities in children's adiposity at different ages and their widening across childhood. Based on the findings of this study, interventions focussing on family physical activity and 'healthier diets' could be of benefit, for instance these could include family sport days, distribution of gym passes and cookery classes.

Strengths and limitations

We used data from the Millennium Cohort Study which provides a large nationally representative sample to investigate inequalities in child obesity and overweight across income quintiles. We were also able to begin exploring the mechanisms behind income disparities in child obesity and overweight but with some limitations. First, our models were unable to fully explain income inequalities in children's adiposity suggesting that other risk factors should be considered in future work. Second, the results did not allow for a conclusion regarding causality between risk factors and income inequalities in overweight and obesity. Third, maternal BMI was included in the analyses in the category 'dietary environment', but it may also reflect genetic as well as shared environment. Given that maternal BMI was the only factor consistently and significantly associated with child overweight and obesity, we ran some sensitivity tests by including the rest of the risk factors related to diet on their own (i.e. without mother's BMI). The results (not shown) reveal that maternal BMI plays a substantial role, yet modelling other dietary factors on their own partially attenuates the unadjusted differences. Fourth, BMI is an imperfect measure of adiposity as it does not distinguish between fat and lean mass. We conducted sensitivity analyses by categorizing children as overweight and obese using body fat at age 11 (not measured at age 5). The results (available on request) were largely consistent with those obtained using BMI. Fifth, health behaviours were reported by the mother. Parental reports might be more suitable for younger children, but parents are frequently unaware of the behaviours of 11-year-olds who spend considerable time beyond purview. Sixth, it could be that children who experienced upward movements across weight categories between age 5 and 11 were already on the cusp of their weight categories in the previous period and differed from children who were on the lower end of healthy weight/overweight at age 5. To assess whether this could be the case, in additional analyses (not shown), we compare average BMI at age 5 of children who experienced/did not experience upward movements across weight categories. Results reveal that although children who experienced upward movements had higher BMI levels at age 5, differences between the two groups were not large (approximately 0.2 SD of BMI) suggesting that those who moved up a weight category were not necessarily on the cusp of their weight category at age 5. Finally, as in any longitudinal study, missing data because of loss to follow-up could bias the results. In order to account for this, we used non-response weights but we may not have been able to fully adjust for sample attrition.

Future work

As the processes involved in the development of fat gain in children involve social, environmental and biological factors, future work should be directed at more closely examining different typologies of risk factors and their interaction. More work is needed to establish whether there would be a reduction in inequalities and in the widening of the inequality gap across childhood if poorer families and their children adopted healthier behaviours.

Acknowledgements

We would like to thank the Millennium Cohort Study families for their time and cooperation, as well as the Millennium Cohort Study team at the Institute of Education. The Millennium Cohort Study is funded by the ESRC.

Funding

This work has been supported by the UK Economic and Social Research Council's International Centre for Life Course Studies in Society and Health, ref: ES/J019119/1.

Conflicts of interest : None declared.

The results reveal stark income inequalities in child obesity/overweight

Income inequalities in child overweight/obesity widened across childhood

Multiple risk factors to do with physical activity and diet were particularly important in explaining income inequalities and their widening across childhood

The results support the need of early interventions which take account of multiple risk factors

References

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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Why are poorer children at higher risk of obesity and overweight? A UK cohort study

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Abstract. Background: There is limited evidence on which risk factors attenuate income inequalities in child overweight and obesity; whether and why these

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Health inequalities - socio-economic disadvantages 

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Health inequalities - socio-economic disadvantages 

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Childhood has a profound influence on subsequent health and wellbeing outcomes in the population. The early years is a crucial phase of the life course and presents key opportunities to support children and families. The second decade is also a critical period which represents the transition from childhood to adulthood.

Outcomes throughout life are strongly influenced by children's early life experiences and the social circumstances in which they live. Socio-economic disadvantage during the early years is linked to health inequalities. Children raised in are more likely to develop health problems in the future. The early experiences of ' looked after children' - those in the care of their local authority due to various circumstances - may have implications for their health. More broadly, Adverse Childhood Experiences (ACEs) can have a profound impact on health in later life. The Public Health Scotland website outlines the impacts of child poverty and on health and health inequalities.

The COVID-19 pandemic and associated restrictions has also had a huge impact on children and young people's lives. Results from the COVID-19 Early Years Resilience and Impact Survey (CEYRIS) suggest that the pandemic restricted children and young people's opportunities for play, education, and social interaction, and created other unprecedented challenges. Understanding and responding to these impacts has become a key focus.

These pages cover health issues relating to infants, children, and young people up to the age of 26. The period between conception and birth also has an important impact on future health (see our Pregnancy, births and maternity section).

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Childhood has a profound influence on subsequent health and wellbeing outcomes in the population. The early years is a crucial phase of the life course and presents key opportunities to support children and families. The second decade is also a critical period which represents the transition from childhood to adulthood.

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When looking at malnutrition in Scotland, the two common causes are not eating enough or not getting the right amount of the right food. Having a balanced diet will provide nutrients, proteins, vitamins that will add up to the right calories depending on age. The Eat well Guide that was published by The Food Standards Scotland in 2019 gives an overview of a balanced diet.

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Inequalities regarding access and use of greenspaces 

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Inequalities regarding access and use of greenspaces 

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This survey finds that the pandemic has led to greater inequalities regarding access and use of green spaces, as while there has been an increase to 77% of the population visiting greenspaces in 2021 from 60% in 2019, 73% of those visiting are classified as high socio-economic status in comparison to 59% of those classified as low socio-economic status.

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This government report that states the statistics of breastfeeding in Scotland and which factors can effects breastfeeding rates in specific areas and minorities.  It begins by introducing breastfeeding and the benefits it can have for the babies health and recommendations for infant feeding.

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Theme 1: Strengthening and coordinating breastfeeding messages across Scotland

Recommendation 1: Develop and implement a breastfeeding advocacy and promotion strategy which brings together and builds upon activity happening at local, regional and national levels, in order to build awareness of and support for breastfeeding at multiple levels from community to government.

This will include building a cohesive network of Scottish advocates and developing a coordinated events calendar building on existing activity.

Relevant BBF Scotland Gear scores: Advocacy: 2.0; Promotion: 1.7
Why is this recommendation necessary?
An international evidence review of the factors affecting breastfeeding identified a series of multiple level determinants, including socioeconomic, cultural, health system, historical and individual factors, that influence breastfeeding decisions and behaviours over time. These factors were born out in the recent Scottish Maternal and Infant Nutrition Survey (2017), which highlighted variation by maternal age and socio-economic status, and the influence of pre-birth feeding intention, previous feeding experience, feeding method on leaving hospital and feeding support to deal with feeding problems, concerns about milk supply and maternal wellbeing.

The successful protection, promotion and support of breastfeeding should therefore acknowledge this complexity and respond with measures that build on positive work to date to address these multiple layers. This should include: strengthening legislation and policy, developing service provision and promoting positive social attitudes and norms through strong advocacy that acknowledges the value of breastfeeding and the promotion of cohesive and consistent messages. Detailing their six recommendations, Rollins et al (2016) call for the robust dissemination of evidence, not just to mothers, but at all levels, from community and healthcare providers to policy and decision makers, in order to drive political will and commitment and address the negative societal attitudes and systemic barriers that prevail.

The policy context in Scotland has shown commitment to increasing breastfeeding through the Improving Maternal and infant Nutrition: A Framework for Action ( MINF, 2011) and Breastfeeding Programme for Government. Specifically, under the 'Diet and Healthy Weight Delivery plan' (2018), Scottish Government has committed to the 'stretch aim' of reducing the drop off in breastfeeding rates at six to eight weeks after birth by 10% by 2025 through collaborative work with Health Boards and the third sector to support women in ways that work best for them. There is recognition that this work must be underpinned by multiple level strategic action to strengthen commitment to breastfeeding and create an enabling environment in terms of awareness, knowledge and evidence, leadership and resourcing. Contributing towards this, Scotland has further invested in universal Unicef UK Baby Friendly Initiative ( BFI), delivering 100% coverage, and building a strong environment of knowledgeable and consistent practitioners among those most often working with mothers and babies. Infant Feeding Advisers throughout Scotland's Health Boards are connected through the Scottish Infant Feeding Adviser Network ( SIFAN) and NeoSIFAN with a focus on quality improvement. A national Maternal and Infant Nutrition Coordinator has been in post from 2008 and had breastfeeding as a large part of the remit. A new role of Scottish Government Breastfeeding Programme Lead under the Breastfeeding Programme for Government will play a more direct role in policy, coordination and the development of national campaigns.

Maintenance of this investment through an evidence-based, multiple level advocacy strategy is vital to the sustainability of the advances seen. This will drive the resources for workforce development, program delivery and promotion, with system feedback informing and strengthening the advocacy methodology and messages delivered. In their joint Advocacy Strategy report, Unicef and WHO (2015) cite successful national case studies in a diversity of countries, realised through strategic programming, strong national leadership and adequate funding. They set out a framework for breastfeeding advocacy, which also underlines how this advocacy can further reinforce outcomes in other sectors, such as early childhood development, food security and the environment, as well as children's and women's rights. The recent development in Scotland of the Breastfeeding Advocacy Lead role, funded through Scottish Government and hosted by NHS Ayrshire and Arran, will support the development and delivery of such as strategy.

Coupled and integrated with the advocacy strategy, a long term, multi-component and evidence-based promotion strategy is required to raise awareness of breastfeeding across a range of settings. This strategy should focus on 'normalising' breastfeeding, enabling it to be seen as worthwhile, normal, desirable and beneficial - but ensuring breastfeeding is described realistically and sensitively, acknowledging the difficulties and ensuring appropriate support is available.

Again, multi-component work is necessary to respond to the complexity of the breastfeeding landscape. The strong influence of the media and its shaping of breastfeeding as problematic is pervasive, but constitutes just part of the environment which affects the initiation and duration of breastfeeding. Improving Maternal and Infant Nutrition: a Framework for Action (2011) notes the importance of family and community dynamics, the healthcare system and public health policies - and that information about breastfeeding needs to compete with information on a host of other issues. This is reflected in a 2018 systematic review and meta-analysis of breastfeeding promotion interventions which found women receiving them were 2.77 times more likely to continue exclusive breastfeeding six months after birth, with implications for return on investment and cost-benefit. However, this uplift was dependent on a series of factors which determined the effectiveness of breastfeeding promotion interventions, including: multi-component nature; professional involvement; precise protocol for provider training; intervention delivery spanning pre to post-natal periods; and action across both hospital and community settings. At present in Scotland, in addition to the structural changes delivered through Unicef UK Baby Friendly and the Infant Feeding Advisor networks, there are raft promotional activities in place through statutory and third sector organisations. The BBF Scotland committee acknowledged the advances made, noting the added value of further work to evaluate the impact of existing promotional materials, learn from the evidence base on the best way to develop promotion in a way that would suit the Scottish context, and bring this evolving multi-component promotion activity together to be guided through a cohesive and coordinated strategic plan.
What do we want to happen?

The primary function of the strategy would be to deliver in positive, cohesive and coherent messages relating to breastfeeding, integrating advocacy and promotional actions across multiple related systems and improvement strategies, grounded in Scotland's context.

For example, the work should support the delivery of Action 1.2 in Scotland's Diet & Healthy Weight Delivery Plan to reduce the drop off in breastfeeding rates at 6-8 weeks by 10% by 2025 by supporting those women who want to breastfeed with any challenges and signposting them to relevant help/support. The work should acknowledge and incorporate its development, existing national marketing and advocacy campaigns.

The strategy should engage, harness and promote lay and professional voices, unifying activity taking place at a local, regional and national level; and target key decision makers in government departments and other professional bodies making policy related to or impacted by infant feeding. A key output would be a single programme of events.

The strategy should incorporate existing evidence and evidence based approaches. For example, it should align with Scottish Government's national parental audience marketing strategy; and build on existing resources, : parentclub.scot, social channels and Off to a Good Start as key delivery channels that parents to be and new parents are engaging with.

Alongside work to strengthen self-efficacy and normalise breastfeeding culturally, it should also undertake further insight research, where necessary, to inform action required, utilising behaviour change theories to drive a change in society's thinking and dismantle barriers to breastfeeding experienced by women.

The strategy would evaluate and use learning from previous breastfeeding and wider health campaigns. For example, it should adapt the messaging in Off to a Good Start to take careful note of the MIN survey results and provide key messages in a more effective way.

Led by the evidence, the strategy should undertake nationally coordinated activity which provides a unifying approach and resonates with the target audience and key stakeholders including Health Boards. This could be adaptable to local settings and populations but recognisable as a nationally promoted and endorsed campaign.

By bringing together local, regional and national advocates into a cohesive network, it will be possible to coordinate local, regional and national events into a single coherent programme of events across the year, with valued involvement of third sector organisations.

How will this be done?

Under the Breastfeeding Programme for Government, a National Advocacy Lead post has recently been appointed, based with NHS Ayrshire and Arran: this role will contribute to a change in the breastfeeding culture in Scotland, delivering effectively-framed breastfeeding advocacy stories locally and nationally and scaling up Breastfeeding Welcome schemes, including the Breastfeeding-friendly Nursery Scheme.

The National Advocacy lead will usefully work in conjunction with Scottish Government Policy leads and key stakeholders including Health Boards and Third Sector organisations, and the Scottish Government Marketing & Insight team on the process of insight gathering, development of an advocacy and promotional strategy and implementation of national promotional activity. The action plan and evaluation of the contribution of this post would feed into the overall advocacy strategy.

The work would be aligned with the national parental audience marketing strategy led by the Scottish Government Marketing and Insight team in which breastfeeding is identified as a key topic.

The strategy will be underpinned by the Improving Maternal and Infant Nutrition: a Framework for Action (2011) implementation plan which was developed under the international benchmark of the World Health Organisation's Global Strategy on Infant and Young Child Feeding, building on the Breastfeeding Etc. (Scotland) Act 2005 under which it is an offence to stop someone in a public place from feeding their child, if under two, with milk.

What is the likely impact of this recommendation?

Breastfeeding, as the biological norm, will start to become the cultural norm and be highly visible and prioritised at a systems level.

Local and regional advocacy and promotion actions will be strongly connected to national frameworks and overview.

Advocacy and media activity will be coordinated with positive impact on public perceptions of both infant feeding and its advocates.

Through careful messaging that incorporates women's voices, experience and advice and the systematic monitoring of impact, the strategy will promote a positive breastfeeding culture, reducing the amount of negative feedback and campaigning.

Strengthening and coordinating breastfeeding messages across Scotland Aim: develop & implement a breastfeeding advocacy and promotion strategy at multiple levels
Working with the Scottish Government Marketing and Insight team, Policy leads and key stakeholders including Health Boards and Third Sector organisations, this recommendation sets out to deliver the following objectives

Integrate breastfeeding advocacy and promotional actions across multiple related systems and improvement strategies

Engage, listen to and promote lay and professional voices, developing more consistent breastfeeding messages

Incorporate existing evidence and evidence based approaches for advocacy and promotion

As part of bringing together advocates into a cohesive network, coordinate local, regional and national events into a single coherent programme of events

Undertake further research and insight gathering, where necessary, to inform and deliver theory and evidence driven actions

What will success look like? Based on best evidence, this would result in an increase in breastfeeding rates, which would mean improvements in...

Coordinated advocacy and promotional activity with positive impact on public perceptions

Local and regional actions strongly connected to national frameworks and strategy

Breastfeeding highly visible at a systems level

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Becoming Breastfeeding Friendly Scotland: report

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Scotland's results and the key recommendations for the continued protection, promotion and support for breastfeeding.

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The impact of pubic health initiatives on health inequalities in childhood obesity. 

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The impact of pubic health initiatives on health inequalities in childhood obesity. 

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The study highlights the correlation between living in deprived areas and the rates of childhood obesity. This study also examines different types of initiatives to address childhood obesity and the effectiveness of these.

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oral health promotion for parents of young children aged 0-5 yrs 

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oral health promotion for parents of young children aged 0-5 yrs 

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Screen Time in low vs high socioeconomic areas

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Screen Time in low vs high socioeconomic areas

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Children from lower socioeconomic backgrounds use screens more often than children from higher socioeconomic backgrounds. Before the pandemic it was found that families from higher socioeconomic backgrounds have more spaces and resources to play therefore indicating children from lower socioeconomic backgrounds did not have these resources therefore resorted to playing games on phones and other screens.

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Effects of Excessive screen time on child development 

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Effects of Excessive screen time on child development 

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Cureus. 2023 Jun; 15(6): e40608.

Monitoring Editor: Alexander Muacevic and John R Adler

Abstract

Children's heavy reliance on screen media has raised serious public health issues since it might harm their cognitive, linguistic, and social-emotional growth. This study examines the effects of screen time on many developmental domains and covers management and limitation techniques for kids' screen usage. Screen media has a wide range of cognitive consequences, with both beneficial and detrimental effects noted. Screens can improve education and learning; however, too much time spent in front of a screen and multitasking with other media has been related to worse executive functioning and academic performance. As screen time reduces the amount and quality of interactions between children and their caregivers, it can also have an impact on language development. Contextual elements like co-viewing and topic appropriateness are key in determining how language development is impacted. Additionally, excessive screen usage has detrimental effects on social and emotional growth, including a rise in the likelihood of obesity, sleep disorders, and mental health conditions including depression and anxiety. It can obstruct the ability to interpret emotions, fuel aggressive conduct, and harm one's psychological health in general. Setting boundaries, utilizing parental controls, and demonstrating good screen behavior are all techniques that parents may use to manage children's screen usage. We can reduce the possible negative impacts of excessive screen time and promote children's healthy development and well-being by increasing knowledge and encouraging alternative activities that stimulate development.

Keywords: campaign, developmental and behavioral delay, digital learning, parenting style, screen exposure time, screen time, language development, cognitive development

Introduction and background

New technologies, such as mobile and interactive screen media, are now ingrained in a young child's daily life. Children today are "digital natives," having been born into an ever-changing digital ecosystem augmented by mobile media. The age at which kids engage with media on a regular basis has fallen from four years in 1970 to four months in the present day [ 1]. Electronic devices have revolutionized learning, communication, and information dissemination, but recent research indicates that screen media use may have serious adverse effects on children's health over the long term, making this a pressing public health concern [ 2]. It has raised the likelihood that children will become obese, experience behavioral problems, sleep irregularities, poor academic performance, etc. [ 1- 3].

This article delves into the profound effects of excessive screen time on children's cognitive, language, and social-emotional development, while also exploring the crucial strategies and responsibilities that parents and schools can undertake to effectively manage and diminish screen time in young individuals.

Review

Impact on development

Cognitive Development

Screen media use may have both beneficial and detrimental effects on a kid's cognitive results. Media devices with screens have the potential to improve education and learning [ 2]. For instance, research has suggested that electronic books and learning-to-read applications may improve young children's early reading skills and creative thinking capacities [ 2, 4, 5]. However, studies have also demonstrated the negative effects of screen media use on a number of cognitive areas such as executive functioning, sensorimotor development, and academic outcomes [ 2, 6]. Media multitasking was found to have a negative impact on executive functioning in teenagers, notably on working memory, inhibition, and the capacity to switch between tasks [ 2, 7].

The Quebec Longitudinal Study of Child Development cohort study found a long-lasting connection between early screen media exposure and cognitive abilities, with each one-hour increase in TV exposure at two years of age corresponding to a 7% unit decrease in participation in class and a 6% unit decrease in math proficiency in the fourth grade [ 8]. A Spanish research study discovered a negative correlation between the use of screen media and academic achievement, indicating that increased screen time was associated with lower academic performance. Similarly, a study conducted in the United States found a significant link between higher levels of media multitasking and lower scores on standardized tests measuring academic performance in mathematics and English [ 9].

However, adverse executive and academic outcomes may be confounded by the poorer attention and focus from multitasking behaviors rather than solely from screen media overuse, and more research is necessary to tease out this relationship. Language development has received the majority of emphasis in studies on screen usage and cognitive development in young children, whereas other cognitive development domains including executive skills have received less attention [ 10]. Thus, there are significant, albeit indirect, effects of screen media use on cognitive development in children [ 2].

Language Development​​

The early years of childhood are crucial for acquiring language skills and children develop various aspects of language, including vocabulary and phonology [ 11]. These skills are acquired through interactions with adults [ 11]. Numerous studies have highlighted the significance of human interaction, particularly the frequency and quality of exchanges between adults and children, in the development of language skills [ 12]. However, there is a growing concern that screen time diminishes the quantity and quality of interactions between children and their parents, resulting in fewer chances for the child to practice and develop their language abilities [ 11]. The relationship between screen time and speech and language development is complex, and there are multiple factors that should be taken into account [ 13]. The impact of screen viewing is predominantly influenced by contextual factors rather than the sheer amount of time spent watching [ 14]. The context encompasses several aspects, such as the behavior exhibited by adult caregivers during screen time, the appropriateness of the content for the child's age, and the level of interactivity provided by the screen [ 14]. Increasing the amount of screen time at an early age has negative effects on language development [ 13]. However, beginning screen time at a later age has some potential benefits [ 13]. The characteristics of videos, their content, and co-viewing also play a role in influencing language development [ 13]. However, other studies have reported negative effects on speech, language, motor skills, cognitive development, and social development [ 13].

Adults should be aware of the impact of background television when children are present [ 13]. Studies have shown that increased exposure to background television can have adverse effects on children's language usage, executive functioning, and cognition in children under the age of five [ 13]. Excessive television viewing can also potentially affect language development and reading abilities at a young age [ 13].

A few studies show a positive correlation between children's screen time when co-viewed with a parent and their expressive lexical, phonological, and overall language abilities [ 11]. Studies have indicated that compared to children who view screens for ≤1 hour per day, those who engage in two or more hours per day, or three or more hours per day, are more likely to experience behavioral problems and have poorer vocabulary acquisition [ 15]. These findings suggest the importance of monitoring and regulating screen time for young children to mitigate potential adverse effects on their development and behavior [ 15].

While it is true that screens have become ubiquitous in homes and are increasingly integrated into school systems, it is crucial to educate caregivers of children under the age of three years about the potential risks associated with prolonged screen exposure in inappropriate contexts [ 14]. The current findings suggest that future research should investigate the screen time patterns of the entire family and explore the cumulative impact of both children's and parents' total screen time on language skills, specifically focusing on lexical skills [ 11]. In addition to providing guidance, it is crucial to offer families alternative options to media use that promote positive development, such as parent-child play activities [ 16]. These alternatives should be made available in pediatric practices and early childhood centers to support families in creating enriching and interactive experiences with their children [ 16].

Social-Emotional Development

In recent years, the concept of screen time has become more complex, with a wide range of electronic devices available worldwide [ 17]. The advancement of technology in recent years has led to increased screen-based technology usage among young people, coinciding with a decrease in their engagement with nature and impacting their mental health and overall well-being [ 18]. Research has shown negative associations between screen time, particularly television viewing, and the development of physical and cognitive abilities. Additionally, screen time has been linked to obesity, sleep problems, depression, and anxiety [ 17]. The specific physiological mechanisms underlying the adverse health outcomes related to screen time, as well as the relative contributions of different types of screens and media content to these outcomes, are still not fully understood [ 17]. However, studies in very young children indicate that screen usage is an independent risk factor for reduced psychological well-being. One study shows that increased TV exposure between six and 18 months of age was associated with emotional reactivity, aggression, and externalizing behaviors [ 17]. Few studies indicate that higher screen time at the age of four years is associated with lower levels of emotional understanding at the age of six years. It also reveals that having a television in a child's bedroom at the age of six years predicts lower levels of emotional understanding at eight years [ 19]. Gaming was associated with lower levels of emotional understanding in boys but not in girls. This suggests that different types of screen activities may have distinct effects on the emotional development of children based on their gender [ 19].

Computer use and video gaming, but not television viewing, were shown to be connected with more severe depressive symptoms when looking at the effects of various types of screens. Video gaming, in particular, is correlated with the severity of anxiety [ 17]. These findings align with other studies showing a cumulative impact of high screen time on symptoms, with more pronounced effects emerging during early adolescence and beyond [ 17]. Screen time-induced poor sleep, nighttime use of digital devices, and dependency on mobile phones have been associated with depressive symptoms [ 20]. Sleep issues, excessive screen time, and exposure to content that is violent and fast-paced trigger dopamine and reward pathways in the brain, all of which have been associated with attention-deficit/hyperactivity disorder (ADHD)-related behavior [ 20]. Early and persistent exposure to violent content raises the chance of engaging in antisocial behavior [ 20]. Psychoneurological effects of addictive screen time use include a decrease in social coping skills and the development of craving behaviors resembling substance dependence [ 20]. Structural changes in the brain related to cognitive control and emotional regulation have been observed in individuals with addictive digital media behavior [ 20].

It is worth noting that screens can also have positive educational and informational benefits [ 17]. For example, many schools are effectively using blogs as educational tools to improve written English, and the Internet provides access to health resources, including information on sexually transmitted infections and mental health [ 17]. Starting around the age of two years, high-quality television programs that are designed for specific educational purposes can serve as an additional means for early language and literacy development in children [ 21]. Such programs can also support cognitive development, promote positive racial attitudes, and encourage imaginative play [ 21]. High-quality content can enhance social and language skills for all children aged two years and older, particularly for those who are living in poverty or facing other disadvantages [ 21]. The presence of smartphones blurs the boundaries between work and home life, making timing unpredictable, and frequently requiring emotional investment to respond to them [ 21]. These findings emphasize the potential negative consequences of excessive screen exposure during early childhood, particularly when screens are present in a child's personal space, such as their bedroom [ 19]. This study emphasizes the significance of face-to-face interaction, especially with primary caregivers, in promoting the development of social-emotional competence in young children [ 19]. Further research is needed to investigate the mechanisms underlying the connection between screen time and developmental vulnerabilities [ 22].

Strategies for managing and reducing screen time in children

Strong evidence shows that parents' awareness-raising and other straightforward actions may significantly lower children's screen time [ 23]. Early excessive screen-watching habits seem to follow throughout time and tend to cluster with other harmful lifestyle behaviors including a poor diet and lack of sleep [ 24]. The amount of time spent watching television and other forms of screen time among teens decreased only when the intervention included specific elements or activities aimed at reducing it [ 25]. Possible additions to interventions include the use of an electronic monitoring device to restrict screen time (which allows users to set time limits for TV, digital versatile disc (DVD), computer, or video game use), the TV Turn-off Challenge (a campaign to turn off the TV for a specified number of days), the conditional use of screens on physical activity, or education via mass or small media (such as newsletters, brochures, or billboards) [ 26]. Birth kits distributed to moms by maternity wards should contain information regarding newborns and toddlers seeing screens [ 23]. Health visitors should provide new parents with advice and be aware of medical evidence [ 23]. Schools should take a stand on how much time kids spend using screens both inside and outside of the classroom and let students and parents know about it [ 23].

Role of Parents in Managing Screen Time

Parents sometimes used screen time as a reward but also believed digital technology would have a negative impact on their child's behavior, social skills, sleep, and physical activity [ 27]. Parents have the chance to implement behavioral control in the home as the primary caretakers, frequently through observation and rule-setting [ 27]. In fact, treatments designed to enhance common parenting techniques at home have proved effective in raising a child's desirable behavior [ 27]. In line with this viewpoint, some research indicates that parents' usage of restrictions regarding the use of technology such as television, cellphones, tablets, and computers is linked to children spending less time on screens (such as television, video games, and computer/internet use) [ 28]. Parental controls, which are frequently present in the form of extra settings and password safeguards for different technical devices (such as televisions, laptops, cellphones, etc.), may offer a viable answer to parenting challenges around children's screen time [ 27].

The Centers for Disease Control and Prevention (CDC) and other organizations/studies have indicated that parental restrictions on screen time and the absence of screens in bedrooms both significantly lower screen time [ 29, 30]. Ideal discretionary screen time limits are 0.5-1 hour/day for three to seven-year-olds, one hour for 7-12-year-olds, 1.5 hours for 12-15-year-olds, and two hours for 16+-year-olds. Role modeling is also another crucial element. The amount of screen time parents and kids watch is closely associated; kids who live in homes where watching TV is encouraged (e.g., meals eaten in front of the TV and the TV is on when the child gets home from school) are more likely to engage in binge-watching themselves. If parents watch television for more than four hours every day, their sons and daughters will, respectively, have a 10.5-fold and a three-fold increased likelihood of doing the same [ 31].

Conclusions

Excessive screen media usage in children can have both positive and negative impacts on their development. Regarding cognitive development, screens have the potential to enhance education and learning. However, studies have shown that excessive screen time and media multitasking can negatively affect executive functioning, sensorimotor development, and academic outcomes. Early screen exposure has been associated with lower cognitive abilities and academic performance in later years. Language development is also affected by screen time, as it diminishes the quantity and quality of interactions between children and caregivers. Contextual factors such as co-viewing and appropriateness of content play a role in determining the impact on language development. Excessive screen usage can also lead to problems in social-emotional development, including obesity, sleep disturbances, depression, and anxiety. It can impair emotional comprehension, promote aggressive behavior, and hinder social and emotional competence.

Parents play a crucial role in managing and reducing screen time by raising awareness, setting boundaries, and providing behavioral controls. Parental limitations and the absence of screens in bedrooms have been found to significantly reduce screen usage. Parents should also set an example by managing their own screen time. Overall, it is important for caregivers, educators, and healthcare professionals to understand the potential risks of excessive screen usage and implement strategies to promote healthy development in children, including alternative activities that foster cognitive, linguistic, and social-emotional skills.

Notes

The authors have declared that no competing interests exist.

Articles from Cureus are provided here courtesy of Cureus Inc.

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Effects of Excessive Screen Time on Child Development: An Updated Review and Strategies for Management

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Children's heavy reliance on screen media has raised serious public health issues since it might harm their cognitive, linguistic, and social-emotional growth. This study examines the effects of screen time on many developmental domains and covers management ...