Children's Screen Viewing is Related to Psychological Difficulties Irrespective of Physical Activity Angie S. Page, Ashley R.

Cooper, Pippa Griew and Russell Jago Pediatrics 2010;126;e1011; originally published online October 11, 2010; DOI: 10.1542/peds.2010-1154

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/126/5/e1011.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Childrens Screen Viewing is Related to Psychological Difculties Irrespective of Physical Activity

AUTHORS: Angie S. Page, PhD, Ashley R. Cooper, PhD, Pippa Griew, MSc, and Russell Jago, PhD
Centre for Exercise, Nutrition, and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom KEY WORDS television, computer, physical activity, sedentary time, children, psychological well-being ABBREVIATIONS CIcondence interval IMDIndex of Multiple Deprivation MVPAmoderate/vigorous physical activity ORodds ratio SDQStrengths and Difculties Questionnaire The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health. The funding agencies were not involved in the design, analysis, or writing of the study. www.pediatrics.org/cgi/doi/10.1542/peds.2010-1154 doi:10.1542/peds.2010-1154 Accepted for publication Aug 2, 2010 Address correspondence to Angie S. Page, PhD, Centre for Exercise, Nutrition, and Health Sciences, School for Policy Studies, University of Bristol, Tyndall Avenue, Bristol BS8 1TH, United Kingdom. E-mail: a.s.page@bris.ac.uk PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.

WHATS KNOWN ON THIS SUBJECT: It is not known whether use of specic electronic media (computer use or television viewing) or total sedentary time is most strongly related to psychological difculties and the extent to which objectively measured physical activity moderates this relationship. WHAT THIS STUDY ADDS: Greater television or computer use was related to greater psychological distress for 10- to 11-yearold children, irrespective of objectively measured physical activity or sedentary time. Limiting computer use and television viewing may be important for optimal well-being for young people.

abstract
OBJECTIVE: We hypothesized that greater screen use would be associated with greater psychological difculties and that children with high levels of screen entertainment use and low levels of physical activity would have the most-negative psychological proles. METHODS: Participants were 1013 children (age, mean SD: 10.95 0.41 years), who self-reported average daily television hours and computer use and completed the Strengths and Difculties Questionnaire. Sedentary time (minutes per day with 100 cpm) and moderate/vigorous physical activity (MVPA) (minutes with 2000 cpm) were measured by using accelerometers. Multivariate regression models examined the association between television viewing, computer use, sedentary time, and Strengths and Difculties Questionnaire scores, with adjustment for MVPA, age, gender, level of deprivation, and pubertal status. RESULTS: Greater television and computer use were related to higher psychological difculty scores after adjustment for MVPA, sedentary time, and confounders. However, sedentary time was inversely related to psychological difculties after adjustment. Children who spent 2 hours per day watching television or using a computer were at increased risk of high levels of psychological difculties (television, odds ratio [OR]: 1.61 [95% condence interval [CI]: 1.20 2.15]; computer, OR: 1.59 [95% CI: 1.321.91]), and this risk increased if the children also failed to meet physical activity guidelines (television, OR: 1.70 [95% CI: 1.09 2.61]; computer, OR: 1.81 [95% CI: 1.023.20]). CONCLUSION: Both television viewing and computer use are important independent targets for intervention for optimal well-being for children, irrespective of levels of MVPA or overall sedentary time. Pediatrics 2010;126:e1011e1017

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The availability of electronic media has increased markedly in recent years.1 Television viewing has been positively associated with childhood obesity,2 and combined use of television and computers (screen entertainment) was reported to be positively related to psychological difculties (emotional, peer, concentration, and conduct problems) among young people.35 Use of electronic media by young people may vary according to both medium (computer use versus television viewing) and purpose (computer use for gaming versus homework), and it is unclear the extent to which these activities contribute to overall sedentary time. Objectively measured sedentary time has been positively related to insulin resistance in young people,6 but its relationship with psychological well-being is not well documented. Traditionally, sedentary time has been assessed through either childrens selfreports or parents proxy reports, but the validity of both of these approaches is limited by recall accuracy. Accelerometers provide an objective method of quantifying sedentary time7,8 but cannot provide information about the activities being conducted while the individual is sedentary. Therefore, it is unclear whether time spent static and/or the amount of time spent using screen entertainment is most closely related to well-being.3,5,9 Although screen viewing has been reported to be inversely related to wellbeing,3 physical activity has been shown to be positively related to wellbeing among children and adolescents.10,11 Therefore, any potential negative psychological consequences of sedentary behaviors and/or time may be ameliorated by higher levels of physical activity. A recent study with 4to 12-year-old Scottish children found that children with the highest scores for screen entertainment and the lowest levels of physical activity had the
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highest levels of psychological difculties.5 However, that study and other studies in this area relied on selfreported physical activity. It is important to account for confounders such as socioeconomic position in this area, because adolescents from a lower socioeconomic position report less participation in sports/exercise and greater screen viewing behavior, compared with those from a higher socioeconomic position.12,13 Because boys report a higher volume of use of electronic media, especially computers,13 and girls report lower levels of activity routinely, it also is important to account for gender when assessing associations between sedentary indicators and well-being.14 Overweight also is a potential confounder, because lower levels of physical activity have been associated with higher levels of overweight15 and overweight has been positively associated with psychological difculties.16 This study addressed weaknesses in the literature by assessing associations between objectively measured physical activity levels, sedentary time, television/computer use, and psychological difculties in a large sample of 10- to 11-year-old UK children. We hypothesized that frequency of use of screen entertainment and sedentary time would be positively associated with psychological difculties and that moderate/vigorous physical activity (MVPA) would be inversely associated, after adjustment for confounders. We also hypothesized that participants with high screen entertainment use combined with low levels of MVPA would have the most negative psychological proles.

gland) as part of the Personal and Environmental Associations with Childrens Health project between September 2006 and July 2008. Ethical approval for the study was provided by a University of Bristol ethics committee, and informed parental consent was obtained for all children. Complete information on recruitment and data collection procedures was reported elsewhere.17 Measures Sedentary Time Sedentary time was measured with accelerometers (ActiGraph GT1M [ActiGraph, Pensacola, FL]).18 Children were instructed to wear the accelerometer on a belt around their waist during waking hours for 7 consecutive days, and the instruments were programmed to record data every 10 seconds. Data were collapsed into 1-minute epochs, and sedentary time was dened as any minute in which 100 counts were recorded.8,19 Sedentary Behaviors Children were asked to report, through single items on a computerized questionnaire, How many hours a day do you usually spend watching TV? and How many hours a day do you usually spend playing on a computer (not for homework)? Responses ranged from 0 to 5 hours per day. Physical Activity MVPA was used in analyses because it has been related consistently to psychological well-being.20 For consistency with other related studies, MVPA was dened as any minute in which 2000 accelerometer counts were recorded.8,21 Psychological Difculties Psychological difculties were assessed by using the self-report Strengths and Difculties Question-

METHODS
Sample Participants were year 6 children (10 11 years of age) recruited from 23 primary schools within Bristol (En-

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naire (SDQ),22 one of the most widely used inventories of young peoples psychological well-being.23 Participants responded to 25 items on a 3-point scale (scored from 0 to 2), from which 20 items were summed to create a total difculty score (range: 0 40). On the basis of this score, categories were created to represent low (scores of 0 14), borderline (scores of 1519), and high (scores of 20 40) levels of psychological difculties. Potential Confounders Level of Deprivation The UK Index of Multiple Deprivation (IMD) 2007 score was obtained for each participants full postal code. The IMD score is based on 6 categories of deprivation (income, employment, health and disability, educational skills and training, housing, and geographical access to services),24 and a higher score indicates a higher level of deprivation. Pubertal Status Pubertal status was measured by using the scale developed by Petersen et al,25 and 5 derived stages (equivalent to Tanner stages) were used in analyses. BMI Height (in meters) was measured by using a stadiometer, and weight (in kilograms) was measured by using digital scales (Seca, Hamburg, Germany), with children wearing indoor clothing and no shoes. BMI SD scores were derived from standard tables.26 Data Reduction and Analyses Means, SDs, and checks for normality were calculated for all variables. Participants were included in analyses only if they provided 3 days of accelerometer data, with 600 minutes of registered time per day. Periods of 60 epochs of 0 counts were interpreted as time when the monitor was
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not worn and were discarded, as were data from midnight to 7 AM, to minimize the inuence of sleep on sedentary time. Minutes with 100 cpm and 2000 cpm were used to represent sedentary time and MVPA, respectively.8 We acknowledge the debate concerning the appropriate thresholds of accelerometer counts to dene sedentary time and MVPA in children; therefore, analyses also were conducted for alternative thresholds for sedentary time (800 cpm) and moderate physical activity (3200 cpm).27 Results are reported in the tables for 100 cpm and 2000 cpm, but any differences in associations with alternative cutoff points are reported in the text. Differences in television viewing, computer use, and pubertal status between boys and girls were assessed by using Pearson 2 tests, with independent t tests being used for all continuous variables. Spearman correlations between sedentary behaviors, sedentary time, and MVPA were determined. Multivariate linear regression models were used to assess the associations between television viewing, computer use, sedentary time, MVPA, and SDQ total scores. Baseline models were unadjusted (model 1). Models then were adjusted for confounders (age, gender, deprivation, and pubertal status [model 2]) and then MVPA (model 3). Screen viewing and sedentary time also were adjusted for each other (model 4). When confounders were signicantly related to psychological difculties, terms for interactions with other signicant exposures were entered into the model and F tests were used to test the signicance of the interactions. Robust SEs were used to take into account clustering of participants in schools (ie, nonindependence of pupils from the same school). To interpret data in the context of current public health guidelines, participants were grouped according to

whether they met or exceeded screen entertainment guidelines of 2 hours per day28,29 and/or physical activity guidelines of 60 minutes of MVPA per day.30 Data for these groups were entered into multivariate logistic regression analyses (with adjustment for confounders) to determine whether meeting screen entertainment and/or physical guidelines was related to risk of belonging to the group with borderline/high SDQ scores, which have been related to clinically diagnosed disorders.31 All analyses were conducted by using Stata 10 (Stata Corp, College Station, TX), and signicance was set at P .05.

RESULTS
Of the 1899 year 6 children from the 23 schools who were invited to take part in the study, 1340 (70.5%) provided parental consent. Of these, 33 were absent on the days of measurement. Seven participants did not complete the computerized questionnaire, 34 accelerometers were not returned or failed to download data, 24 accelerometers had timing errors, and 229 children did not meet the inclusion criteria for valid accelerometer data, which left data for 1013 children for analyses. There were no differences in age, gender, BMI SD scores, or pubertal status for the children included in analyses, but those who were included had lower IMD scores and spent signicantly less time watching television or using a computer, compared with those who were excluded. Girls had signicantly less MVPA time and more sedentary time, compared with boys (Table 1). There were no gender differences in total SDQ scores or time spent watching television, but boys spent signicantly more time using computers, compared with girls. Girls were signicantly more advanced in pubertal status and were heavier than boys. Sixty-nine percent of chile1013

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TABLE 1 Participant Characteristics According to Gender

Male (N 467) Sedentary time (100 cpm), mean SD, min MVPA (2000 cpm), mean SD, min SDQ total score, mean SD Age, mean SD, y Weight, mean SD, kg Height, mean SD, m BMI SD score, mean SD Daylight time (after 3 PM), mean SD, min IMD score, mean SD Television use, n (%) None 1 h/d 2 h/d 3 h/d 4 h/d 5 h/d 5 h/d Computer use, n (%) None 1 h/d 2 h/d 3 h/d 4 h/d 5 h/d 5 h/d Pubertal status, n (%) 1 2 3 4 5 465.9 57.3 83.3 25.9 12.9 5.7 10.9 0.41 38.5 8.3 1.4 0.07 0.37 1.1 194.9 86.4 26.1 18.1 9 (1.9) 144 (30.8) 173 (37.0) 77 (16.5) 30 (6.4) 12 (2.6) 22 (4.7) 64 (13.7) 185 (39.6) 147 (31.5) 40 (8.6) 10 (2.1) 8 (1.7) 13 (2.8) 98 (20.8) 190 (40.7) 160 (34.3) 18 (3.9) 1 (0.2) Female (N 540) 494.8 58.0 62.6 19.8 12.4 5.7 10.9 0.40 10.3 9.7 1.4 0.07 0.30 1.2 196.1 86.2 25.5 16.9 13 (2.4) 176 (32.6) 204 (37.8) 87 (16.1) 37 (6.9) 10 (1.9) 13 (2.4) 82 (15.2) 259 (48.0) 129 (23.9) 45 (8.3) 12 (2.2) 5 (0.9) 8 (1.5) 88 (16.3) 125 (23.1) 284 (52.6) 42 (7.8) 1 (0.2) P .01 .01 .19 .25 .01 .08 .31 .76 .59 .22

TABLE 2 Multivariate Linear Regression

Models for Screen Entertainment, Sedentary Time, Physical Activity, and SDQ Total Scores
(95% CI)
Television viewing Model 1 Model 2b Model 3c Model 4d Computer use Model 1 Model 2b Model 3c Model 4d Sedentary time Model 1 Model 2b Model 3d Model 4e Physical activity Model 1 Model 2b Model 3c Model 4e 1.02 (0.74 to 1.30)a 0.93 (0.65 to 1.20)a 0.96 (0.68 to 1.24)a 0.93 (0.65 to 1.21)a 0.84 (0.54 to 1.13)a 0.79 (0.51 to 1.08)a 0.81 (0.52 to 1.10)a 0.79 (0.50 to 1.08)a 7.58 (13.13 to 2.03)a 6.64 (12.40 to 0.87)a 13.46 (21.83 to 5.01)a 8.03 (13.61 to 2.45)a 3.00 (8.02 to 14.03) 0.89 (11.07 to 12.85) 19.27 (36.55 to 1.97)a 4.24 (7.45 to 15.96)

.01

.01

Model 1 is the unadjusted baseline model. a Signicant association. b Adjusted for age, gender, IMD score, and pubertal status. c Adjusted for sedentary time. d Adjusted for MVPA (2000 cpm). e Adjusted for television viewing and computer use.

dren (n 899) were in the low category, 17.2% (n 221) were in the borderline category, and 13.8% (n 180) were in the high category for psychological difculties, on the basis of SDQ scores. Hours of computer and television use were weakly but signicantly positively related to sedentary time (computer, 0.065; P .023; television, 0.076; P .04) but not to MVPA (computer, 0.025; P .383; television, 0.006; P .827). The correlation between television viewing and computer use was weak to moderate ( 0.275; P .01), whereas the association between sedentary time and MVPA was strong ( 0.726; P .01). For potential confounders, higher SDQ scores were signicantly associated with more-advanced maturational status ( 0.82 [95% condence interval [CI]: 0.40 1.22])
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and greater deprivation ( 0.04 [95% CI: 0.01 0.07]). Younger children also had higher SDQ scores ( 1.41 [95% CI: 2.17 to 0.11]), but there was no signicant association between gender ( 0.40 [95% CI: 1.11 to 0.29]) or BMI SD scores ( 0.07 [95% CI: 0.23 to 0.37]) and SDQ scores. Table 2 shows that greater television viewing and computer use were associated with higher SDQ scores in all models. Conversely, greater sedentary time (minutes with 100 cpm) was associated with lower (more-positive) SDQ scores in all models. Greater MVPA was signicantly related to lower SDQ total scores only when sedentary minutes were taken into account (model 3). Further investigation indicated that this might be attribut-

able to the association in different directions between MVPA and the 4 subscales that constitute the SDQ total score. MVPA was signicantly inversely correlated with internalizing difculties (emotional, 0.99; P .001) and peer problems ( 0.059; P .039) but was positively correlated with externalizing difculties (hyperactivity, 0.090; P .002) and conduct problems ( 0.127; P .001), which potentially neutralized any association with total SDQ scores. Associations were similar in direction, magnitude, and signicance for sedentary time assessed as minutes with 800 cpm, MVPA assessed as minutes with 3200 cpm, and mean cpm values (data not shown), which suggests that the ndings were not a function of the cutoff points selected. The only signicant (P .05) interactions between confounders and sedentary indicators were between gender and computer use ( 0.59 [95% CI:

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1.16 to 0.02]) and between pubertal status and television use ( 0.30 [95% CI: 0.19 0.41]), but entering these into the models did not alter any associations. In logistic regression analyses with borderline to high SDQ scores as the dependent variable, children who exceeded guidelines for television viewing (n 288 [28.6%]) or computer use (n 141 [14.0%]) had higher SDQ scores (television, odds ratio [OR]: 1.61 [95% CI: 1.20 2.15]; computer, OR: 1.59 [95% CI: 1.321.91]). Risk of high SDQ scores was greatest for the small proportion of children (n 69 [6.8%]) who spent 2 hours watching television and 2 hours per day playing on a computer (OR: 2.27 [95% CI: 1.56 3.13]). Children who met physical activity guidelines (n 352 [34.7%]) were not at signicantly increased risk of psychological difculties (OR: 1.03 [95% CI: 0.08 to 1.19]) unless they also failed to meet screen guidelines for either television viewing (OR: 1.69 [95% CI: 1.09 2.61]) or computer use (OR: 1.81 [95% CI: 1.023.20]). However, those who met activity guidelines but exceeded screen entertainment guidelines for either television viewing (OR: 1.54 [95% CI: 1.072.31]) or computer use (OR: 1.48 [95% CI: 1.08 2.04]) were at increased risk of psychological distress.

hanced negative effect for children with both high screen-viewing levels and low physical activity levels.3,5 Contrary to our original hypothesis, MVPA was not signicantly related to SDQ scores except when sedentary time was taken into account. This lack of association may be attributable in part to the fact that SDQ subscales were related in different directions to physical activity, a nding supported by 2 other longitudinal studies in which higher levels of self-reported physical activity were associated with lesser emotional and peer problems32,33 and greater hyperactivity problems.32 One study with 1397 US adolescents 12 years of age also investigated the association between objectively measured physical activity and depression and, similar to this study, found no signicant association between MVPA and psychological outcomes.19 However, other studies showed an independent relationship between higher levels of self-reported physical activity and higher total SDQ scores, even when sedentary behaviors were included in the analysis.3,5 Taken together, these studies suggest that the relationship between physical activity and well-being may depend on both the measures of exposure and the outcomes used. Additional studies are required to determine whether conicting ndings are a function of different measures of physical activity (objective versus self-reported) and/or whether physical activity is related differently to different psychological outcomes in young people. The nding that less-objectively measured sedentary time was related to increased psychological difculties was contrary to the hypothesized result. It may be that the threshold used here to dene sedentary time (100 cpm) was inappropriate, but analyses using an alternative recommended

threshold (800 cpm)27 yielded the same results (data not shown). One other study did report a very weak but signicant inverse relationship between sedentary time (minutes with 100 cpm) and depression scores.19 The weak association between sedentary time and screen entertainment found here and in other studies8,34 supports the view that sedentary time and sedentary behaviors are different constructs.35 Additional studies are necessary to conrm the relationship between sedentary time and psychological difculties and should include sedentary activities that may have a benecial impact on psychological well-being (for example, socializing and reading), as well as those that have a negative impact. The main limitation of this study is its cross-sectional design, because we could not determine whether higher levels of screen entertainment were associated with the development of negative well-being or negative wellbeing preceded higher levels of screen entertainment. Other limitations include the sample, which, although relatively large, was limited to 1 predominantly urban area. However, levels of screen entertainment and average sedentary time reported here were similar to those reported for other UK samples.3,5,8 The mean SDQ scores in this study were similar to those reported for 2 UK studies with older adolescents (1114 years32 and 1316 years3 of age), but mean SDQ scores and the proportions of children with borderline/high SDQ scores were signicantly greater in this study, compared with a younger sample of Scottish 4- to 12-year-old children.5 Other limitations of this study include the use of single self-report items to measure screen entertainment, which is inuenced by childrens recall ability. However, single-item measures
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DISCUSSION
This study found that greater television and computer use was related to greater psychological difculties, independent of gender, age, level of deprivation, pubertal status, and objectively measured physical activity and sedentary time. In addition, children who reported 2 hours of daily computer or television use but engaged in 60 minutes MVPA per day were at increased risk for psychological difculties. This is consistent with other studies that demonstrated an enPEDIATRICS Volume 126, Number 5, November 2010

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have been shown to have high validity, compared with other methods used currently.36 Accelerometers may not capture sedentary time when the child is not moving sufciently to register a count, although it is unlikely that children of this age remain that static for long periods. To maintain a sufcient number of children with borderline/ high SDQ scores in the analyses, a 3-day inclusion criterion for accelerometer data was selected, which is consistent with some childhood studies, although others recommended a 4- to 5-day minimal inclusion criterion at this age.37 However, use of a 5-day inclusion criterion did not yield different ndings for any of the analyses (data not shown) and would have meant excluding 163 of the children (34.1%) with borderline/high levels of psychological difculties. Finally, although this study adjusted for important confounders, other factors that may inuence childrens psychological difculties, such as parental psychological well-being and screen viewing REFERENCES
1. Ofce for National Statistics. Internet access. Available at: www.statistics.gov.uk/ cci/nugget.asp?id8. Accessed September 15, 2010 2. Eisenmann JC, Bartee RT, Smith DT, Welk GJ, Fu Q. Combined inuence of physical activity and television viewing on the risk of overweight in US youth. Int J Obes (Lond). 2008; 32(42):613 618 3. Ussher MH, Owen CG, Cook DG, Whincup PW. The relationship between physical activity, sedentary behaviour and psychological wellbeing among adolescents. Soc Psychiatry Psychiatr Epidemiol . 2007;42(10): 851 856 4. Tripodaki E, Kormas G, Konstantoulaki E, et al. Internet use and abuse in an adolescent population in Athens: associations with psychological prole and lifestyle of users. Pediatrics. 2008;121(suppl):S89 S90 5. Hamer M, Stamatakis E, Mishra G. Psychological distress, television viewing, and physical activity in children aged 4 to 12 years. Pediatrics. 2009;123(5):12631268

content, were not included in these data. The strengths of this study include the separate investigation of television and computer use, objective measurement of sedentary time and physical activity, and the use of a multidimensional, widely used index of well-being that has shown good validity and reliability for children. Important confounders (age, pubertal status, level of deprivation, weight status, and gender) were accounted for in analyses. Associations for screen entertainment media and sedentary and physical activity were presented independently and in combination. This investigation of combined physical activity and sedentary behaviors is important to consider for intervention, because it has been reported that both parents and children perceive that 2 hours of use of electronic media is acceptable as part of a balanced lifestyle and that excessive use of electronic media is not a concern if children are physically active.38 40 These data support some restriction of screen entertainment

use irrespective of levels of physical activity and indicate that guidelines for both sedentary and physical activity behavior are warranted.41 The current guidelines from the United States28 and Australia29 for screen entertainment of no 2 hours per day were able to differentiate between children with normal versus borderline/high levels of psychological difculties.

ACKNOWLEDGMENTS This work was supported by the National Prevention Research Initiative (grant G0501311) and the World Cancer Research Fund. This report involves research arising from a Career Development Fellowship (to Dr Jago), supported by the National Institute for Health Research. We are very grateful to the participants and their families who gave their time to the study. We also acknowledge all members of the Personal and Environmental Associations with Childrens Health Project team not listed as coauthors of this article.

6. Sardinha LB, Andersen LB, Anderssen SA, et al. Objectively measured time spent sedentary is associated with insulin resistance independent of overall and central body fat in 9- to 10-year-old Portuguese children. Diabetes Care. 2008;31(3):569 575 7. Ekelund U, Brage S, Besson H, Sharp S, Wareham NJ. Time spent being sedentary and weight gain in adults: reverse or bidirectional causality? Am J Clin Nutr. 2008; 88(3):612 617 8. Steele RM, van Sluijs EM, Cassidy A, Grifn SJ, Ekelund U. Targeting sedentary time or moderate- and vigorous-intensity activity: independent relations with adiposity in a population-based sample of 10-y-old British children. Am J Clin Nutr . 2009;90(5): 11851192 9. Sanchez-Villegas A, Ara I, Guilln-Grima F, Bes-Rastrollo M, Varo-Cenarruzabeitia JJ, Martnez-Gonzlez MA. Physical activity, sedentary index, and mental disorders in the SUN Cohort Study. Med Sci Sports Exerc. 2008;40(5):827 834

10. Fox KR. The inuence of physical activity on mental well being. Public Health Nutr. 1999; 2(3A):411 418 11. US Department of Health and Human Services. Physical Activity Guidelines Advisory Committee Report. Washington, DC: US Department of Health and Human Services; 2008 12. Gorely T, Atkin AJ, Biddle SJH, Marshall SJ. Family circumstance, sedentary behaviour and physical activity in adolescents living in England: Project STIL. Int J Behav Nutr Phys Act. 2009;6:33 13. Fairclough SJ, Boddy LM, Hackett AF, Stratton G. Associations between childrens socioeconomic status, weight status, and sex, with screen-based sedentary behaviours and sport participation. Int J Pediatr Obes. 2009;4(4):299 305 14. Nader PR, Bradley RH, Houts RM, McRitchie SL, OBrien M. Moderate-to-vigorous physical activity from ages 9 to 15 years. JAMA. 2008;300(3):295305 15. Page A, Cooper AR, Stamatakis E, et al. Phys-

e1016

PAGE et al

Downloaded from pediatrics.aappublications.org by guest on May 14, 2012

ARTICLES

16.

17.

18.

19.

20.

21.

22.

23.

ical activity patterns in nonobese and obese children assessed using minute-by-minute accelerometry. Int J Obes (Lond). 2005; 29(9):1070 1076 Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):18131819 Page AS, Cooper AR, Griew P, Davis L, Hillsdon M. Independent mobility in relation to weekday and weekend physical activity in children aged 10 11 years: the PEACH Project. Int J Behav Nutr Phys Act. 2009;6:2 Corder K, Brage S, Ekelund U. Accelerometers and pedometers: methodology and clinical application. Curr Opin Clin Nutr Metab Care. 2007;10(5):597 603 Johnson CC, Murrray DM, Elder JP, et al. Depressive symptoms and physical activity in adolescent girls. Med Sci Sports Exerc. 2008;40(5):818 826 Chief Medical Ofcer. At Least Five a Week: Evidence on the Impact of Physical Activity and Its Relationship to Health. London, England: Department of Health; 2004 Ekelund U, Sardinha LB, Anderssen SA, et al. Associations between objectively assessed physical activity and indicators of body fatness in 9- to 10-y-old European children: a population-based study from 4 distinct regions in Europe (the European Youth Heart Study). Am J Clin Nutr. 2004;80(3):584 590 Goodman R, Meltzer H, Bailey V. The Strengths and Difculties Questionnaire: a pilot study on the validity of the self-report version. Eur Child Adolesc Psychiatry. 1998; 7(3):125130 Vostanis P. Strengths and Difculties Questionnaire: research and clinical applications. Curr Opin Psychiatry. 2006;19(4):367 372

24. Niggebruge A, Haynes R, Jones A, Lovett A, Harvey I. The Index of Multiple Deprivation 2000 access domain: a useful indicator for public health. Soc Sci Med. 2005;60(12): 27432753 25. Petersen AC, Crockett L, Richards M, Boxer A. A self-report measure of pubertal status: reliability, validity, and initial norms. J Youth Adolesc. 1988;17(2):117133 26. Cole TJ, Freeman JV, Preece MA. Body mass index reference curves for the UK, 1990. Arch Dis Child. 1995;73(1):2529 27. Puyau MR, Adolph AL, Vohra FA, Butte NF. Validation and calibration of physical activity monitors in children. Obes Res. 2002; 10(3):150 157 28. American Academy of Pediatrics, Committee on Public Education. Children, adolescents, and television. Pediatrics. 2001; 107(2):423 426 29. Department of Health and Ageing. Active Kids Are Healthy Kids: Australias Physical Activity Recommendations for 512 Year Olds. Canberra, Australia: Department of Health and Ageing; 2004 30. US Department of Health and Human Services. Physical Activity Guidelines for Americans. Washington, DC: US Department of Health and Human Services; 2008 31. Goodman A, Goodman R. Strengths and Difculties Questionnaire as a dimensional measure of child mental health. J Am Acad Child Adolesc Psychiatry . 2009;48(4): 400 403 32. Wiles NJ, Jones GT, Haase AM, Lawlor DA, Macfarlane GJ, Lewis G. Physical activity and emotional problems amongst adolescents. Soc Psychiatry Psychiatr Epidemiol. 2008;43(10):765772 33. Sagatun A, Sgaard AJ, Bjertness E, Selmer R, Heyerdahl S. The association between

34.

35.

36.

37.

38.

39.

40.

41.

weekly hours of physical activity and mental health: a three-year follow-up study of 1516-year-old students in the city of Oslo, Norway. BMC Public Health. 2007;7:155 van Sluijs EM, Page A, Ommundsen Y, Grifn SJ. Behavioural and social correlates of sedentary time in young people. Br J Sports Med. 2010;44(10):747755 Biddle SJH, Gorely T, Marshall SJ. Is television viewing a suitable marker of sedentary behavior in young people? Ann Behav Med. 2009;38(2):147153 Bryant MJ, Lucove JC, Evenson KR, Marshall S. Measurement of television viewing in children and adolescents: a systematic review. Obes Rev. 2007;8(3):197209 Trost SG, Pate RR, Freedson PS, Sallis JF, Taylor WC. Using objective physical activity measures with youth: how many days of monitoring are needed? Med Sci Sports Exerc. 2000;32(2):426 431 Granich J, Rosenberg M, Knuiman M, Timperio A. Understanding childrens sedentary behaviour: a qualitative study of the family home environment. Health Educ Res. 2010; 25(2):199 210 Gordon-Larsen P, Grifths P, Bentley ME, et al. Barriers to physical activity: qualitative data on caregiver-daughter perceptions and practices. Am J Prev Med. 2004;27(3): 218 223 Crawford D, Timperio A, Telford A, Salmon J. Parental concerns about childhood obesity and the strategies employed to prevent unhealthy weight gain in children. Public Health Nutr. 2006;9(7):889 895 Healy GN, Dunstan DW, Salmon J, Shaw JE, Zimmet PZ, Owen N. Television time and continuous metabolic risk in physically active adults. Med Sci Sports Exerc. 2008;40(4): 639 645

PEDIATRICS Volume 126, Number 5, November 2010

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Children's Screen Viewing is Related to Psychological Difficulties Irrespective of Physical Activity Angie S. Page, Ashley R. Cooper, Pippa Griew and Russell Jago Pediatrics 2010;126;e1011; originally published online October 11, 2010; DOI: 10.1542/peds.2010-1154
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/126/5/e1011.full. html This article cites 36 articles, 12 of which can be accessed free at: http://pediatrics.aappublications.org/content/126/5/e1011.full. html#ref-list-1 This article, along with others on similar topics, appears in the following collection(s): Office Practice http://pediatrics.aappublications.org/cgi/collection/office_pra ctice Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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