Brianah Bussey

Media & Children II

Independent Study

Professor Akerman

Negative Impacts on Increased Screen-Media Use in Preschool-aged Children

Does the amount of screen time affect the mental health of preschool-aged children? In

today’s society, electronic devices are all around us such as smartphones, tablets, computers and

many more (Stiglic & Viner, 2019). With easy access to so many devices children are being

exposed to much more screen time. In my paper, the term screen time will refer to the amount of

time a child is exposed to media. I will be studying the mental health effects of both depression

and anxiety on preschool-aged children ages 2-5. I will also discuss what anxiety and depression

are and how it is developed within young children, including how increased screen time makes

both more prevalent within them. Although electronic devices such as iPads are entertaining and

a good way to occupy time for preschool-aged children, it is not always beneficial to their mental

health. Creating programs and boundaries both on electronic devices and in physical activity can

be healthy for a preschool-aged child’s daily life. Spending more time involved in physical

activities can result in better mental health with less depression and anxiety in youth (Pizzo,

Drobinin, Sandstrom, Zwicker, Vallis, Fine,... & Pavlova, 2020). My research question is

whether the amount of screen time affects preschool-aged children’s mental health, specifically

in depression and anxiety.

Screen Media

From birth, infants and toddlers’ main source for everything are their parents/caregivers

since they are unable to make decisions for themselves. Parents/caregivers' daily actions affect

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their children as well, especially with the interaction between media exposure. This means that

before they are at the age where they can go to school, their home environment is crucial to their

lives. Emond et al., (2018) goal in this study was to quantify the relationships between household

chaos and screen use in preschool-aged children. In many homes the environment and daily

behaviors of children have an impact on their media exposure and result in negative mental and

physical effects. Household chaos in the study refers to increased levels of confusion,

disorganization and hurriedness (Emond et al., 2018). Parents were recruited for the study

through social media platforms such as Instagram, Facebook and Twitter and were conducted by

an online survey for 385 parents with children ages 2-5 years old. After being recruited, parents

then completed a series of questions in reference to their child’s typical daily screen use. Related

to household chaos, phrases such as, “We almost always seem to be rushed, You can’t hear

yourself think in our home and No matter how hard we try we always seem to be late” could be

used (Emond et al., 2018, p. 3). Of those examples parents were asked to rate on a 4-point scale

which they related, 4 being “very much” to 1 being “not at all”. The nine screen activities in the

study included watching shows/movies, playing or engaging with apps, viewing videos or clips

(other than shows or movies online, e.g, youtube), video calls, listening to streaming music,

browsing or reading electronic books/magazines, playing video games on the internet, engaging

in social media and browsing websites (Emond et al., 2018). For each screen activity selected,

parents reported the average time spent by their children engaged in that activity. The amount of

time spent using screen media before bed was also recorded. In addition to the child using the

screens individually in their bedrooms. Other factors that were significant to the study were the

parents' education level, household income, home ownership status and the amount of children

under the age of 12 and adolescents (12-17) who also live in the home. It’s important to know

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the details of parents' personal information such as education level and household income

because it has an influence on how the media plays in the child’s life. Consequently, the child's

age, race, gender, and ethnicity was also used. For example, children from the highest quartile of

household chaos were 69% more likely to use screens compared to those children in the lowest

quartile of household chaos (Emond et al., 2018).

In the final sample of the study, the average age for children was 3.3 years old, half of the

children were female and most were white and non-hispanic. Although it is advised by the AAP

that preschool-aged children engage in no more than an hour of screen time. While children in

the U.S engage in nearly 2.5 times the recommended limit (Emond et al., 2018). As a result of

the participants, children spent an average of 31 hours per week engaged with screens. That is a

very large number weekly for preschool aged children to be engaging in screen media use. The

household chaos taken place as reported by parents is well associated with children's exposure to

screen time. The accelerated amount of screen time used on children corresponds as well to other

issues concerning the child such as obesity, negative impacts on sleep, language development,

gross motor skill development and socialization (Emond et al., 2018). Parents that live in a more

chaotic household were more likely to be less strict in monitoring and managing media use for

their children (Emond et al., 2018). Furthermore, reasons as to why early exposure of screen use

for preschool-aged children are negative is because it disrupts the interaction between children

and parent engagement and interaction and play with other children. To conclude their study,

under these circumstances, household chaos is indeed associated with increased total screen use.

Having an increase of exposure to screen time as a preschool-aged child whether individually or

not can raise the risk factors of obesity, delaying and disrupting sleep which is significant during

this age, as well as more internalized behaviors such as attentional or behavioral. The decisions

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and skills of the caregivers or parents greatly affect the child. Since there are many long term

effects of screen use in preschool-aged children it is essential to intervene and change chaotic

habits in the household which then correlate to screen time.

Along with the home environment being a factor to children’s relationship with screen-

media use, television is the amongst the most used medium for young children. If a parent

decides to limit a child’s access to it they can easily replace a cell phone, gaming system or tablet

for it (Robidoux et al., 2019). According to Robidux et al., (2019) there is a relationship between

increased screen time and greater risk of physical health complications, mental health, and

negative outcomes on cognitive, language, and emotional development. They encourage having

interventions and screenings to reduce unhealthy media use in children. Parental education on

technology is recommended as well. “Providers need to be aware of media-use guidelines, screen

for at-risk media use, and provide parental education as well as recommend interventions when

indicated,” (Robidoux et al., 2019). The more knowledge a parent/guardian has on media use the

more they can guide their children on having healthy habits for it. A randomised control group

that evaluated an intervention to reduce television viewing for preschool aged children 2.6-5.5

occurred. Before being in the intervention group, children viewed 11.9 hours of television a

week (Robidux et al., 2019). In one group which was intervention children received a seven-

session program to reduce screen-media use. While children in the second group received

information pertaining to safety and injury prevention. The intervention was successful because

parents then reported a decrease in television, which went down to 8.8 hours daily. On the other

hand, the control group’s daily time spent on television increased significantly to 15.6 hours

(Robidoux et al., 2019). To successfully reduce a child’s exposure to screen time all adults such

as caregivers, parents as well as pediatricians need to be educated to both the pros and cons of it.

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They have a unique opportunity and responsibility to decrease children’s high screen time usage

for their own mental and physical well-being.

Additionally, Sharkins, Newton, Albaiz & Ernest (2015) examined the long term effects

of media, technology, and screen time (MeTS) on young children. The study they conducted uses

caregivers and guardians that young children are around daily such as parents and teachers of

preschool-aged children. Positive outcomes of MeTS on young children is that it can expand

children's knowledge (Sharkins et al., 2015). Today young children are constantly exposed to

media, technology, and screen time whether at home or not. Sharkins et al., (2015) is trying to

decide whether children should or should not be exposed to any media instead of how much

media is too much when they are exposed. “Studies reveal that children as young as two will

naturally interact with a touch screen in the same way they will use natural instincts to play with

a new toy,” (Sharkins et al., 2015). This evidence suggests that the natural interaction between

children and technology has become just as natural as playing with physical toys.

Although the introduction of technology to children can be positive with knowledge and

development skills, there are many downsides to their exposure. For example, exposure to

media, technology, and screen time have been shown to increase obesity, aggressive and violent

behaviors, bullying desentization to violence, a lack of empathy to victims, fear, depression, as

well as nightmares and sleep disturbances (Sharkins et al., 2015). The more time preschool-aged

children spend on technology and media the less time they have to engage in physical activity

which can both reduce obesity and decrease the onset of mental health issues. In the study,

caregivers and parents were surveyed 1-4 from strongly disagree to strongly agree views

concerning young children's exposure. Both parents and teachers agree that there are many issues

pertaining to young children’s exposure to media, technology, and screen time. Children’s

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interaction with METS should be interactive and have discussions with parents and peers in

order to be effective (Sharkins et al., 2015). A recommendation is that teachers should make

more efforts to make appropriate types of media, technology, and screen time that the children in

their care are exposed to.

Effects of Screen Media Use

According to McDonald, Kehler and Tough (2018) having at least one hour of screen

time of any type of media was associated with an increase of behavioral problems for children

who are two years old. In other words, the more screen time children are exposed to the more

behavior problems they will experience. This is proven by the AAP (American Association of

Pediatrics) as well as recommendations from the Canadian Pediatric Society. More screen media

time has resulted in obesity, sleep behaviors, delays in language development and many more

issues in young children (McDonald et al., 2018). The purpose of their study was to identify risk

factors for delayed social-emotional and behavioral problems for children ages two years old.

While television is the most actively used screen media technology, it is important to recognize

the growing number of tablets, smartphones and computers that preschool aged children view

daily. Issues concerning behaviors and social-emotional delays are a result of negative outcomes

at school age, poorer social functioning, academic difficulties and continued behavior problems

(McDonald et al., 2018). McDonal et al., (2018) add that when parents/caregivers are able to

identify children with delayed social emotional problems early they can have strategies to reduce

them before the child enters school. The earlier a problem is identified the quicker it is to solve it

before it worsens.

In their study, mothers were given a comprehensive questionnaire and children (two

years old) were tested on their behavior and competence outcomes from the Brief-Toddler Social

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and Emotional assessment (McDonal et al., 2018). As a result, 13% of children two years old

were identified to have delayed social-emotional development and 15% had possible behavior

problems (McDonald et al., 2018). It was found that many of the predictors of children at age

two with behavior problems were due to the mothers issues while pregnant and 2 years

postpartum. In addition, being a parent is not an easy task especially while balancing work and

other responsibilities. Mothers who reported, “it is difficult most or all of the time” to balance

everything were more likely to have a child with behavior and delayed social-emotional

developments (McDonald et al., 2018). Additionally, mothers who experience difficulties

balancing life may experience depression, stress, anxiety and lower life satisfaction. While trying

to juggle other responsibilities it becomes common for parents to use screen media as a

distraction to do other things. The environment and actions of the child’s parents at a young age

greatly affect their social-emotional development and behaviors. McDonald et al., (2018) state,

“These findings linking maternal optimism to improved coping with stress and positive parenting

practices may help to explain how maternal optimism may play a role in children's behavioral

development.” Meaning, the stress and different ways of parenting for a mother can further

explain the role they have in their children's later development. Their observation also found that

interaction factors and community engagement were specific to social-emotional competency.

Also exposure to screens and maternal coping were directed to child behavior. Based on what a

child is being exposed to on screen media in addition to observing struggles from their mother it

can likely reflect their behavior. In conclusion, McDonald et al., (2018) found that most children

with poor behavior and social-emotional problems were formed from their development at two

years old. Furthermore, recommendations they added were for mothers of young children who

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experience poor mental health should join support groups within their communities to improve

their overall mental health so that they can improve their childrens as well.

For children who have grown up surrounded by any form of digital media, screentime is

a major part of contemporary lifestyle. Although it is a part of our lives there have been many

concerns on the health as already mentioned and can impact preschool-aged children. Negative

effects of screen time are obesity, displacement of time available for physical activity, low mood

and cognitive/socioemotional development which could lead to poor educational performance

(Stiglic & Viner, 2019). Due to the concerns of screentime for children the AAP (2016)

recommended limiting screen time for children 2-5 years old to 1 hour per day. This has to do

with young children’s difficulties in differentiating between the sedentary elements of screentime

from the content watched on screens (Stiglic & Viner, 2019). Their goal was to examine the

effects screen time has on the health and the well-being of young children. In their method for

research they had 13 reviews of how screen time affects children. Their results showed us that

six reviews considered the association of screen time (obesity), three for diet and energy intake,

seven for mental health related outcomes including self-esteem and life quality, four of

cardiovascular risk, four for fitness, three for sleep and one for each pain and asthma (Stiglic &

Viner, 2019). In 3/3 studies reported there was a positive association between screen time with

depressive symptoms and found moderate evidence for a positive association between screen

time and the severity of anxiety symptoms. In addition there is still more research to be done due

to the lack of clear evidence on both anxiety and depression. For depressive symptoms it has also

been reported that higher symptoms were associated with less than or equal to two hours of

screen time daily. In conclusion, amongst the many symptoms related to higher levels of

screentime in young children depression and anxiety are included.

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 The relationships children have with their parents are crucial for this age and the rest of

their childhood development. Whether parents co-view with their children, how they talk and

play with them, and overall their formal relationship. In this next section, we learn how child-

parent interactions impact increased screen time and mental health effects on children as well.

Impact of Child and Parent Interaction

According to Lampard, Jurkowshi, and Davidson (2012) parents who restrict their

children's TV time, rules of TV viewing and overall TV time is associated with less TV use

among preschool-aged children. Children to low-income families are more at risk for increasing

TV viewing and obesity. An influence of media use for children does include the income of the

family and most children of low family income have a higher risk of being exposed to more

media, compared to a child who is from a high family income. A parent of a high income family

can afford for their children to do more activities outside of the house, thus spending less time on

screens. Lampard et al., (2012) hypothesized that the more knowledge parents/caregivers have

on the health risks of child screen time and less positive attitudes of screen time are associated

with greater restriction of child screen time.

The 147 participants of this study included parents/caregivers of children ages 2-6 years

old. Parents completed surveys about themselves which included parents age, sex, relationship to

the child, and ethnicity. On average parents were 31 years old and the majority were women.

Lastly, parents were primarily white and overweight or obese, with 25% of children also

overwieght or obese (Lampard et al., 2012). Children included in the study were an average of 3

years old. In addition to the parent restriction of the child’s screen time, parent and child screen

time, and other relevant social-cognitive factors were acknowledged. The restriction of parents

screen time of children was rated from a 4-point scale, 1 being strongly disagree and 4 being

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strongly agreeing. The three items were “I limit how long my child can watch TV or DVDs each

day”, “I limit how long my child plays video games'' and “I make sure that my child watches TV,

plays video games, or uses the computer for no more than 2 hours per day [in total]” (Lampard et

al., 2012). As stated by the AAP (American Academy of Pediatrics) children’s TV viewing

should not consist of more than 2 hours daily. TV viewing factors that are necessary to children's

development are parent-child co-viewing, discussion of program content and rules regarding the

timing and content of viewing (Lampard et al., 2012). In like manner, parents were to report the

average time that they and their preschool-aged child spend in (1) watching TV, DVDs or

videos, (2) playing video games and (3) using the computer for leisure on a typical weekday or

weekend.

As a result of this study, the average screen time for parents/caregivers was 249 minutes

per day (4 hours, 15 minutes) and for the child was 174 minutes per day (2 hours, 9 minutes).

Only 30% of parents strongly agreed to the statement regarding making sure that the child

watched TV, played video games or used the computer for no longer than 2 hours daily.

Additionally, half of the parents/caregivers agreed that children watching TV for more than 2

hours a day increased their risk of obesity. This evidence further supports the claims made by the

AAP of children being exposed to more than recommended viewing. Majority (63%) of the

parents/caregivers felt either “fairly” or “very” confident that they could limit the amount of time

their child spends on screens. For this reason, an increase in restriction of screen time for

preschool-aged children was associated with having children exposed to less screen time.

Consequently, as Lampard et al., (2012) hypothesized previously for low-income parents that the

more self-efficacy (an individual's confidence in their behavior, reflects their performance) they

had on restricting screen time for children and believed the importance of doing so was

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associated with less screen use in preschool-aged children. In spite of the health risks that screen

use has on children, low-income parents beliefs were not in correlation to restricting child screen

time. Significantly, self-efficacy was a more important target of restriction of screen time. Many

times parents will use children’s screen time to tend to other duties. Which corresponds to the

more a child is exposed to screen time, the more time parents have to do other activities. With

this in mind, parents who have a low-income may be dealing with chronic stressors of financial

hardship, poor mental health, or food insecurity (Lampard et al., 2012). To conclude, the increase

of self-efficacy of parents/caregivers to restrict screen time use in preschoolers, decreases the

time children will spend on screens which will positively affect their mental and physical health.

As demonstrated from the previous evidence, parents and home life have a big influence

on their children's time associated with media. Also to note that the mental and physical well-

being of a parent is just as important to those of the childs. When a parent is mentally stable and

physically healthy it makes a path for their children to be also, even at a young age. Now that we

have established both screen media use and the impacts it has on children, we can move forward

with how anxiety and depression are results of increased screen use as well.

Anxiety Issues from Screen Time Exposure

Anxiety disorders across the lifespan demonstrate some of the strongest stability of any

disorders, it has an early age of onset and is associated with moderate to marked life impairment

(Edwards & Rapee, 2010). Even Though anxiety symptoms are common in preschool-aged

children and can lead to greater impairments, it is still rare that they are referred for treatment

(Edwards & Rapee, 2010). It is disappointing with the lack of help and research preschool-aged

children receive for anxiety, because if it is detected early on there can be treatment done so that

it can benefit their futures.

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 By 2030, The World Health Organization predicts that internalized problems such as

depression and anxiety will be second to HIV/AIDS (Beatson et al., 2014). Internalized problems

affect 1 in 7 school aged children that impact their peer relationships, school engagement and

mental health (Beatson et al., 2014). Parental recognition of their child’s difficulties is an

important step towards seeking professional help for children. Cool Little Kids is the only

preschool-age prevention program to prevent anxiety disorders in young kids.With a name such

as Cool Little Kids, the program is meant to make those children with anxiety symptoms feel

confident and unique about themselves.

Depression Symptoms due to Screen Use

According to Ontario et al., (2019) there is a stronger association between depressive

symptoms and leisure time, such as spending time on screens. Young children are appearing to

be vulnerable to negative socio-cognitive outcomes from heavy screen use compared to teens.

To add Njoroge & Bernhardt (2011) highlight information regarding the assessment of

behavioral disorders in preschool-aged children. They state that according to the US Department

of Health and Human Services, one in five children have a diagnosable mental disorder and 10%

of preschoolers are diagnosed with mental health disorders that impair their functioning. In

addition, Njoroge & Bernhardt (2011) demonstrate that early detection and identification of

behavioral disorders is beneficial for young children. The result of taking longer to detect may

result in emotional and behavioral disturbances within the first five years of life or even worsen

during preschool years and adolescence. The measures used in this study to formulate the

pathology in preschoolers were both dimensional and categorical systems (Njoroge & Bernhardt,

2011). In addition, tests were guided by structured interviews, comprehensive assessments and

Preschool Age Psychiatric Assessments (PAPA).

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 Techniques often used include checklists and questionnaires, such as Child Behavior

Checklist (CBCL) and Preschool Feelings Checklist (Njoroge & Bernhardt, 2011). The

Preschool Feelings Checklist is significant as it is designed to identify signs of depression in

preschoolers ages 3-5 years old (Njoroge & Bernhardt, 2011). Having tools such as these are

beneficial since it is difficult to distinguish depression symptoms from a younger child rather

than an adolescent or adult. Having children assess and analyze their own feelings and emotions

are just as important as an adult doing so for them. Another consideration that can be accounted

for behavioral disorders in preschool-aged children are their relationships with family. Njoroge

& Bernhardt (2011) explain that a key factor of evaluation of a preschooler is the direct

observation of the child alone as well as interacting with parents in both structured and

unstructured settings. “And understanding the importance of observation of the child’s behaviors

and how they change in different contexts and with different relationships,” (Njoroge &

Bernhardt, 2011, p 89).The relationship and interaction between a child and parent are significant

influences to a child’s mental health, especially at a young age. Parents/caregivers are the

individuals guiding and teaching the child everything they need to know, until they can do so and

make decisions on their own. The Ages & Stages Questionnaire is a screening tool for the

parent/caregiver to identify children 6 months to 5 years old. This questionnaire is designed to

identify social, emotional or behavioral difficulties (Njoroge & Bernhardt, 2011). Diagnostic

Infant Preschool Assessment (DISPA) which is similar to PAPA, evaluates multiple symptoms

for disorders including, attention-deficit/hyperactivity disorder, oppositional defiant disorder,

conduct disorder, anxiety disorders and both major depression and sleep disorders (Njoroge &

Bernhardt, 2011).

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 Njoroge & Bernhardt’s (2011) purpose of this study was to guide parents/caregivers to

take precautionary measures for their children. The focus of the article was to inform readers on

various assessments to identify behavioral disorders in preschool-aged children. The main

principles of mental health include understanding your child’s behaviors in different settings

with different caregivers. Then, coming to the realization that your child across different settings

and interactions have many stand out factors. These may include language delays, cognitive

abilities, and social/emotional/cultural growth (Njoroge & Bernhardt, 2011).

The global pandemic of COVID-19 was a difficult time for many people of all ages who

were dealing with uncertainty as well as trying to stay healthy and safe. Especially for young

children, who were not fully aware of what was going on. To them it was an excuse to stay home

from school and interact with screen-media for longer periods of time. Although this may sound

good to some, along with the pandemic there became an increase of mental health issues in

preschool-aged children from consuming more time on screen-media.

Impact of COVID-19 on Preschool-Aged Children Mental Health

According to Werling, Walitza, & Drechsler (2021) during the devastating outbreak of

COVID-19, families around the country were forced to stay indoors and continue their daily

routines of work and school. This meant that many kids of all ages were forced to spend more

time than usual in front of a screen for educational purposes. The COVID-19 outbreak and

lockdown are connected to having many consequences on mental health (Werling et al., 2021).

Mental health in young children is not a subject that has much background information, which

should because it is very common and active in young children. Assessing behavioral disorders

in young children and how they affect their lives for parents/caregivers can be very beneficial for

them so they can identify them early on. Parents and family life play a large role as well in

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preschool aged children’s mental health. Although the amount of screen time a child is exposed

to correlates to their mental health, parents/caregivers are responsible for setting boundaries and

rules for their children. Due to preschool-aged children being so young and still developing both

mentally and physically, they can’t take much responsibility for their actions and how it will

affect them later on in life. This is why it is crucial for parents/caregivers to be knowledgeable

for their child’s sake. In addition, parents should also be cautious and aware of their own actions

and relationships with screen time because their actions affect their childrens. This includes an

“excessive and potentially harmful increase in screen media use,” (Werling et al., 2021).

Now that we are aware of how screen media use can affect preschool-aged children’s

mental health with anxiety and depression symptoms. Parents/caregivers who are still in need of

guidance for their children can look into the recommendations that are followed. At this point in

a child’s life interaction and engagement during media intake is essential for their continued

development.

Recommendations

Some ways in which children can use screen media effectively is by creating systems

with parents/caregivers. As suggested by Ontario et al., (2019) healthy digital use can be

promoted when family members remember the four M’s. The first, is managing screen use, this

can be done by being present and engaged when screens are in use, co-viewing and discussing

content with children. In addition, learn about parental controls and privacy settings and speak

proactively about what acceptable and unacceptable online behaviors are (Ontario et al.,2019).

Second is meaningful, parents can promote meaningful behaviors by prioritizing daily routines

throughout the day; interacting face-to-face, sleeping and completing some form of physical

activities over screen use. Also, being a part of your children’s media lives such as joining in

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during video game play and asking about their encounters and online experiences. Furthermore,

advocating for schools and other child-care centers to develop their own plan for media use. It is

important to promote having both screen media plans at school and at home (Ontario et al.,

2019). Modeling healthy screen use is encouraging parents to be aware of their own actions and

habits with screen media, encouraging “screen-free” times where digital devices are prohibited

such as family dinners and reminding parents to tell their children to avoid using screens 1 hour

before bedtime (Ontario et al., 2019). The last M, monitor, monitoring for signs of problematic

screen use for any age. For example, parents should look out for any screens that interfere with

sleep, school, or face-to-face interactions, also screen use that interferes with offline play,

physical activity or socializing. Be cautious of any negative emotions by your children following

online interactions or playing video games (Ontario et al., 2019). Taking these recommendations

into consideration for parents and their children can positively impact their screen time and also

prevent mental and physical issues that can occur.

Conclusion

In conclusion, the amount of screen time a preschool-aged child interacts with does

negatively affect their mental health and can result in depression and anxiety. Throughout my

research in this study I have been able to successfully answer my research question. When

preschool-aged children engage in screen-media for longer than 2 hours daily, their mental health

will be affected and can lead to anxiety and depression symptoms. As the evidence validates

preschool-aged children's relationship with screen media use has a tremendous effect on their

daily lives.While playing games and watching videos on the devices may be fun and entertaining

for children and a way to occupy time for parents, is it really worth it? For parents who do not

have the proper education and information on what screen media can do for their children, would

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they still allow them to use the devices if they were better informed? For myself and the new

material I have learned while doing this research, I can say that I will be more proactive when

the time comes of my own children’s relationship to screen-media. For preschool-aged children

and other children it is not worth the serious long-term effects. Disorders such as anxiety and

depression are very serious and must not be treated lightly. To prevent those disorders as well as

obesity, lack of sleep, language delays and more negative impacts of screen media-use sticking

to the AAP’s (2016) guidelines can be helpful. Moreso, creating family plans for limitations on

digital devices can be a good engagement and bonding experience. Children ages 2-5 years old

spend most of their time in school and participating in physical activities so their screen-media

use should not exceed the time they spend doing other necessary actions. Parental recognition

and observation of their child’s behaviors and actions are a large factor of prevention. Such as

the phrase, ‘when you know better you do better’ for all parents and caregivers who now know

better, they can do better for themselves and their children.

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