An appropriate mechanism for measuring children’s digital engagement needs to be developed
Today’s children have screens integrated into daily life from an early age. There are advantages of having this online world at their fingertips, but the potential threat to their health and development has become of increasing concern. This has led to the United Kingdom Chief Medical Officers (UK CMOs) commissioning an independent map of published evidence, and publishing a commentary on this with advice for parents and carers with recommended next steps for other stakeholders.
The UK CMOs delineate three distinct component areas for discussion.
The first is “screen time,” used to refer to the amount of time children spend in front of electronic screens, for activities such as education, television, gaming and social media use. There is currently inadequate evidence to determine an optimal amount of screen time for children and young people. An association between prolonged screen time and symptoms of depression and anxiety in young people continues to be found, but no direct causation has yet been established. [1,2] Importantly, the most influential factors on child development, such as sleep, social interaction, and physical activity, are at risk of displacement by screen time.
The second component is the content children are exposed to online, which may be harmful or inappropriate for their age, or illegal. Where technology companies do not create content they may be the gatekeepers to it. A quarter of children have reported experiencing something upsetting while using social media, including being victims of “cyberbullying” and both viewing and receiving explicit content. Despite a minimum age limit of 13 years for joining, research has concerningly found that as many as three quarters of 10-12 year olds have a social media account. [3,4]
The third component is that of “persuasive design”; the techniques employed by companies to keep users continually engaged. Persuasive design works to increase time spent online, thereby increasing children’s exposure to advertisements and perpetuating engagement with possible harmful content. It can also result in displacement of other activities, as children themselves report compulsivity in their use and feeling pressured to be constantly connected. 
Published research is insufficient to support evidence-based guidelines on screen time, but there is enough basis to warrant precautionary action by schools, government, and technology companies to protect children and young people.
Technology companies, encompassing those that create hardware, software, and online platforms for use by the public, must now accept they have a duty of care to keep our children and young people safe. Some technology companies have already taken steps to protect users, promoting access to health and support services and providing tools for monitoring their screen time. They can all however do more to tackle the elements of their service which have been identified as contributing to harm, and work with the government to develop and utilise rigorous age verification tools. A White Paper on internet harms is due to be released this year and will likely lead to action being mandated through legislation. Technology companies should act sooner to meet their responsibility to keep children and young people safe.
Children have been shown to internalise messages about online safety from a young age, highlighting the potential for parents and schools to be influential on their behaviour.  Children and young people have said they want schools to take a lead in providing education for social media use, so the UK CMOs encourage the Departments of Education in all four nations to continue their work on including internet safety in the health and relationships curricula.  Parents can be great influencers on children’s screen time habits, and it is imperative that they set an example of healthy online behaviours. The UK CMOs commend the work of the Royal College of Paediatrics and Child Health in developing questions and practical tips to support families’ discussion of their screen use.  The UK CMOs have also produced advice for parents on how to incorporate screen use into health development. 
To better understand the intersection of screen time and health more comprehensive research should be supported by health bodies and research institutions. An appropriate mechanism for measuring children’s digital engagement needs to be developed, as well as longitudinal studies to assess the temporal relationship between screen time and health and development. Performing meaningful research will rely on provision of anonymised data from technology companies themselves.
Time spent online can be of great benefit to children and young people, providing opportunities for learning and skills development, as well as allowing young people to find support and information. As health professionals we should engage with families and collaborate with industry to ensure our children and young people continue to reap these benefits and do not come to harm.
Lisa Murphy, clinical fellow, Public Health England.
Marc Masey, head of office and senior private secretary to the CMO, Department of Health and Social Care England.
Orla Murphy, CMO independent annual reports manager, Department of Health and Social Care England.
Frank Atherton, CMO, Department of Health and Social Care England, Welsh Government.
Catherine Calderwood, CMO, Department of Health and Social Care England, Scottish Government.
Michael McBride, CMO, Department of Health and Social Care Northern Ireland.
Sally C Davies, CMO, Department of Health and Social Care England.
Competing interests: None declared
- Dickson K1, Richardson M1,, Kwan I1 , MacDowall W2, Burchett H2 , Stansfield C1, Brunton G1, Sutcliffe K1, Thomas J1 (2018) Screen-based activities and children and young people’s mental health: A Systematic Map of Reviews, London: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London.
- Kelly Y., Zilanawala A., Booker C et al. (2018) Social media use and adolescent mental health: findings from the UK Millennium Cohort Study.
- Lilley, C., Ball, R. and Vernon, H. (2014) The experiences of 11-16 year olds on social networking sites.
- Children’s Commissioner for England (2018) Life in ‘Likes’: Children’s Commissioner Report into Social Media use among 8-12 year olds.
- Royal Society for Public Health (2018) Status Of Mind: Social media and young people’s mental health and wellbeing.
- Goodyear V., Armour K. Wood H. (2018) Young people and their engagement with health related social media: new perspectives.
- Royal College of Paediatrics and Child Health (2019) The health impacts of screen time: a guide for clinicians and parents.
- Davies S.C., Atherton F., Calderwood C., McBride M. (2019) ‘United Kingdom Chief Medical Officers’ commentary on ‘Screen-based activities and children and young people’s mental health and psychosocial wellbeing: a systematic map of reviews’: Department of Health and Social Care