DR.

JIN-HWA MOON (Orcid ID : 0000-0003-0235-5318)

Accepted Article
Article type : Regular Article

Title: Smart device usage in early childhood is differentially associated with

fine motor and language development

Authors:

Jin-Hwa Moon1,2*, Sang Yeon Cho1, Sung Min Lim1, Joo Hyung Roh1, Min Sook Koh2,

Yong Joo Kim1, Eunwoo Nam3

1
Department of Pediatrics, Hanyang University College of Medicine, Seoul, Republic of

Korea

2
Child Neurodevelopmental Lab, Department of Pediatric Neurology, Hanyang University

Guri Hospital, Guri, Republic of Korea

3
Biostatistical Consulting and Research Lab, Hanyang University College of Medicine,

Seoul, Republic of Korea

Running head: Smart devices usage and childhood development

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/apa.14623

This article is protected by copyright. All rights reserved.

 *
Corresponding author: Jin-Hwa Moon, M.D., PhD.

Address: Department of Pediatrics, Pediatric Neurology, Hanyang University Guri Hospital,

Accepted Article
Gyeongchun-ro 153, Guri-si, Gyeonggi-do, 11923, Republic of Korea.

Tel: +82-31-560-2258, Fax: +82-31-552-9493, E-mail: jinhwamoon@hanyang.ac.kr

ABSTRACT

Aim: We evaluated the relationships between the use of smart devices, such as

smartphones and tablet computers, and the development levels and language scores in

young children.

Methods: A cross-sectional analysis with 117 children aged three to five years was

conducted. The participants were recruited from kindergartens in South Korea between

November 2015 and April 2016. Parental questionnaires to assess smart device usage

status by children, developmental screening test and receptive-expressive language scale

were administered; metrics included smart device usage frequency and usage time,

appropriate smart device usage level, developmental levels and language scores.

Results: Smart device usage frequency was significantly positively correlated with fine

motor skill development (Spearman’s correlation coefficient (rs)=0.426) in three-year-old

children. Appropriate smart device usage level was also positively correlated with social

development (rs=0.466). However, smart device usage time was significantly negatively

correlated with expressive language months (rs= -0.481). There were no such correlations in

children aged four to five years. For the subcategories of appropriate usage level, the

suitability of social relationship was significantly positively correlated with social development

in three-year-old children (rs=0.474).

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 Conclusion: In three-year-old children, smart device usage was positively correlated with

fine motor development and negatively correlated with language development.

Accepted Article
Keywords: smartphone, child development, motor skills, language, preschool

Key Notes

 We investigated the correlation between smart device usage-related factors and early

child development and language.

 Smart-device usage related factors were differentially correlated with early child

development and language skills.

 In three-year-old children, those who spent more time using smart devices exhibited less

developed language skills, while those who used smart devices more frequently had

more developed fine motor skills.

INTRODUCTION

Smart devices are small, wireless electronic instruments that connect to other devices or

networks. Currently, the most popular smart devices are smartphones, tablet computers and

touch screens. As they are interactive and easily held, smart devices are becoming

increasingly used by children. In Korea, the use rate of smart devices in early childhood has

been reported to be 84.5-95.0% (1-3). According to a nationwide survey in the USA, almost

all children (96.6%) aged from six months to four years used mobile devices. At the age of

two, most children spent comparable amounts of time watching television and using mobile

devices (4). The National Information Society Agency in Korea has reported that 2.5% of

children aged three to five years were at high risk for smart device dependence and 11.4%

were potential risk (3).

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 From before the era of smart device, the relation between the use of conventional screen

media such as television and computer games and chid development has been extensively
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studied (5-12). Such studies reported that excessive or inappropriate media exposure

increased the health and developmental risks including sleep, obesity, child development,

executive function and infant self-regulation (9,13). In both cross sectional and longitudinal

analyses, children watching television over two hours per day had increased risk of low

communication scores (14). Television viewing had mostly negative association for language

and executive function in children younger than two years old (12). In a study for media

exposure in six-month-old infants, media exposure duration at age six months was

associated with low cognitive ability at age 14 months (11). Although impacts of media on

cognitive development depend on the child’s age, the type of content and the viewing

context, current consensus is that watching television has a significant negative effect on

cognitive development in children less than two years of age. Even real-word usage of

educational media did not promote cognitive stimulation activities or reading and teaching

(5).

Because of the relatively recent increase of smart device use among children, studies on

smart devices and mobile screen media use are still on-going and fewer than conventional

media. Currently, most investigations on smart device use among children and adolescents

have focused on usage status, parental factors, mother’s perception, overuse and health

problems such as esotropia and exposure to radiofrequencies (4,15-19). According to a

systemic review by Paudel et al, children younger than eight years of age were more likely to

consume mobile screen media if they were older, were more skilled at using smart devices,

or had a parent who used screen media extensively at home (15). There were no

associations between children’s use of mobile screen media and parent’s age, sex or

educational status (15). Another study by Sigmund et al reported that any kind of media

consumption was higher on weekends than on weekdays (20).

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 Currently, mother’s perception on smart device usage by children seems various. Bently et

al reported varying attitudes of mothers of preschool children towards the use of smart
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devices. In their report, while mothers often used them as a distraction tool, some valued

their educational potential and some were concerned about their children’s use of mobile

devices (21). However, most mothers believed that the consumption of smart devices would

become unavoidable and felt the need to set rules curbing their use (21). Another study by

Kostyrka-Allchorne reported that parents of children aged three to six years believed that the

overall effects of smartphones and tablets on developmental outcomes were positive (22).

Their research found that children mostly used smart devices for educational games and

applications (22). In contrast, Kabali et al found that children between six months and four

years of age preferred content delivery and entertainment applications, such as YouTube or

Netflix; lesser children used educational applications (4). In our previous Korean report with

same participants group in the present study, the most common content accessed was video

clips (73.9%) (3). Most parents considered smart devices to have negative (53.0%) or

unknown (28.5%) effects on children. Thus, parents in this group generally considered smart

device use to be negative (3).

Despite the uncertain concerns or expectations on smart device usage by children, studies

on the relationship between smart device usage and early development are scarce (23). As

an example, a study of Bhatt et al for the association between the use of mobile and

cordless phone and cognitive function had been performed with Australian children. They

concluded that only limited evidence for changes in cognitive function was found (24). Since

there are not enough evidences, it can be assumed that the impact of smart devices on

development of children will be similar to that of other screen-based media. However, the

evolving technologies of smart devices such as interactive function needing user’s response

and customisable application may affect differently on the children from conventional media.

Therefore whether the smart device usage is more harmful or beneficial than conventional

media usage has yet to be elucidated. Further, as the different developmental domains such

as motor, cognitive, language and social area may be differently engaged during using smart

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 device, they can be differentially affected by the use of smart devices. This is also why it is

difficult to make uniform assumption for the effect of smart device on child developments. In
Accepted Article
spite of such challenges, clinicians and parents may benefit from knowing the objective

results concerning the use of smart devices and child development.

From these backgrounds, we aimed to evaluate the relationships between the smart

device usage-related factors such as usage frequency, usage time and appropriate usage

level and developmental level and language scores in young children. Since the brain

development of young children is rapidly changed by age, we hypothesised that smart

device usage in children might be differentially associated by age and also by developmental

domains.

MATERIALS AND METHODS

Participants

The present study was conducted between November 2015 and April 2016. The

announcements of the study were sent to the four kindergartens located in Seoul, and Guri

city, a metropolitan area adjacent to Seoul, and volunteers to participate were recruited. We

included the children aged three to five years and their parents. To avoid possible

confounding factors, children who had been diagnosed with a developmental disability and

those who were receiving treatment for developmental problems were excluded from the

study. At the end of the study, parents were given the results of their children and

educational advices.

Questionnaires and developmental tests

The types of smart devices considered by this study were limited to smartphones and tablet

computers. The present study included the following analyses: a parental questionnaire to

assess smart device usage status (1), a parental scale for appropriate smart device usage

level (25), the Korean-developmental screening test and the Preschool receptive-expressive

language scale to evaluate language ability. Parents completed all examinations except for

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 the language scale, which was conducted during individual interviews with children at their

kindergartens. The procedures were supervised by a child neurologist (JHM) and a

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developmental psychologist (MSK). All research protocols were approved by the institutional

review board at Hanyang University Guri Hospital. Written informed consent was obtained

from parents on behalf of both themselves and their children.

Parental questionnaire for smart device usage status

We employed two items of modified version from the original 22-question parental survey

used by Lee et al. Smart device usage frequency (the number of times smart devices were

used per week) and usage time (the number of hours smart devices were used per day) (1).

For statistical analysis, usage frequency and usage time were rated as numeric scores. For

usage frequency, responses were categorised into does not use, uses between one and two

times per week, between three and four times per week and more than five times per week.

These responses were assigned a score from one to four, respectively. For usage time,

responses were categorised into less than one hour per day, between one and two hours

per day, between two and three hours per day and more than three hours per day. Each

response was assigned a score from one to four, respectively. Then we combined the usage

time scores for weekdays and weekend into a single number by calculating their weighted

mean.

Parental scale for appropriate smart device usage level

To assess the degree of appropriate usage of smart devices, we used the scale for parents

to verify the extent of early childhood's use of smart devices, which was developed and

validated by Kwak and Lim for Korean children (25). It comprises 43 statements, each

accompanied by a five point Likert scale, which corresponded to one (never) to five (always).

The total score ranges from 43 to 215, while the mean score ranges from one to five. This

scale represents the level of suitability or recommendable use of smart device by children in

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 terms of motivation, methods, social relationship, value, spent time and communication. The

higher the total or mean score, the more appropriate the level of smart device use. The
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statements belonged to one of the six following subcategories: 15 items regarding the

suitability of motivation of use, five items assessing suitability of usage method, seven items

evaluating the suitability of social relationships, five items measuring the extent of value

perception towards the smartphone, five items pertaining to the suitability of spent time and

six items assessing the suitability of communication.

The Korean-developmental screening test

The Korean-developmental screening test was completed by parents of children. It was

developed by the Korean Ministry of Health and Welfare and the Korean Centers for Disease

Control and Prevention. It evaluates the six developmental domains in children aged less

than 72 months as follows: gross motor, fine motor, cognitive, language, social and self-help

skills. Each domain has eight items by a zero (never) to three (always) point Likert scale.

The summed points are classified at four levels as follows: recommendation to professional

evaluation (< -2 standard deviation (SD)), recommendation of follow-up (-2 SD to < -1 SD),

average development (-1 SD to < +1 SD), and advanced development (≥ +1 SD). The four

levels of the Korean-developmental screening test were also converted into scores of one to

four, respectively.

The preschool receptive-expressive language scale

The preschool receptive-expressive language scale is a standardised diagnostic tool that

measures language development of children in Korea. It is implemented using face-to-face

interview in which both receptive and expressive language levels are scored as language

months and percentiles.

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 Statistical analysis

Demographic information of the study population is presented as the mean ± SD for

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continuous variables and as frequency (percentage) for categorical variables. Correlation

analysis among the scores of usage frequency, weighted mean usage time, appropriate

usage level and developmental level and language test were performed. Since most

variables considered by this study were recorded as ordinal data, we performed non-

parametric analyses and report Spearman’s correlation coefficients (rs). As the growth and

developmental status are very different in young ages, we performed correlation analyses on

each age category. A p value under 0.05 was considered to indicate statistical significance,

and the Bonferroni-corrected threshold for statistical significance was computed and applied

in each age category. Statistical analyses were performed using IBM SPSS statistics version

24.0 (IBM Corp, Armonk, North Castle, NY, USA).

RESULTS

The present study had initially enrolled 130 participants. A detailed analysis including the

parental questionnaire for smart device usage status and the parental scale for appropriate

smart device usage level concerning these children has been reported in a previous study

(3). After reviewing the completeness of the other questionnaires and individual tests, the

data of 117 participants (mean age: 4.5 ± 0.9 years old, 53.8% male) were deemed eligible

for further analysis. Demographic data of the study population and the results of smart

device usage-related factors (usage frequency, usage time and appropriate usage level),

developmental test and language scale are described in Table 1 and Table S1.

Most children used smart devices between one to four times per week (67.5%), followed

by those who used them more than five times per week (23.9%) and the children who did not

use smart devices (8.6%). Approximately 60.7 - 70.1% of the children in this study used

smart devices less than one hour per day, while 86.3 - 95.7% of the children used them less

than two hours per day on weekdays or the weekend. Less than 1 - 2% of the children used

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 smart devices for more than three hours per day on weekdays or the weekend. The mean of

total appropriate usage level score was 148.9 ± 20.3 (range 64.0 - 196.0), and the mean of
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mean appropriate usage level score was 3.5 ± 0.4 (range 2.4 - 4.6).

Correlations between the results of smart device usage-related factors and developmental

test and language scale are as follows. Correlations among the scores of smart device

usage frequency, usage time and mean appropriate usage level by age group are described

in Table S2. In three-year-old children, smart device usage time was significantly negatively

correlated with mean appropriate usage level (rs = -0.663) (Figure 1A). In five-year-old

children, significant positive correlation between usage time and usage frequency (rs =

0.431) and significant negative correlations between appropriate usage level and usage

frequency (rs = -0.652) and usage time (rs = -0.483) were found (Figure 1B-D).

Correlations among the scores of smart device usage-related factors and developmental

levels by age group are described in Table S3. In three-year-old children, we found a

significant positive correlation between smart device usage frequency and fine motor skills

(rs = 0.426) (Figure 2A). In addition, mean appropriate usage level was significantly

positively correlated with social domain (rs = 0.466) (Figure 2B). There was no significant

relation among usage-related factors and developmental levels in children aged four to five

years.

Correlations among the scores of smart device usage-related factors and language scale

by age group are described in Table S4. In three-year-old children, there was a significant

negative correlation between smart device usage time and expressive language months (rs =

-0.481) (Figure 3). Although total language months was also negatively correlated with

usage time in three-year-old children (rs = -0.333), it was not significantly lower than

Bonferroni corrected threshold. There was no significant relation among smart device usage-

related factors and language ages in children aged four to five years.

Further analysis of the relationships among the six subcategories of appropriate usage

level and developmental test and language scale are described in Table S5 and S6. Overall,

several subcategories of appropriate smart device usage level scale were correlated with the

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 some domains of developmental test and language scales. However, only the suitability of

usage subcategory in three-year-old children was significantly positively correlated with

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social domain of developmental test (rs = 0.474) when applied by corrected threshold. The

suitability of usage subcategory was positively correlated with receptive (rs = 0.380) and total

language months (rs = 0.379) near significantly in three-year-old-children.

DISCUSSION

Smart devices are attractive to young children and are becoming increasingly more popular.

In this study, we investigated the relationship between smart device usage and

developmental issues in children aged three to five years. As expected, we found that the

usage time and the usage frequency in children were positively correlated with each other

and negatively correlated with appropriate smart device usage level. The association

between usage time and appropriate usage level was the strongest in three-year-old

children, while the association between usage frequency and appropriate usage level was

the strongest in five-year-old children. This suggests that associations between time spent

consuming screen media and frequency of use with appropriate usage differ according to

age.

This study showed that smart device usage time was significantly negatively correlated

with expressive language in three-year-old children. Although such evidences were not

found in children aged four to five years, negative association between smart device usage

time and language was in line with the results from the previous studies for other screen

media such as television (5,11-14). The mean appropriate usage level score was not

significantly correlated with language scores. However, suitability of usage subcategory in

three-years-old children was positively correlated with receptive and total language ages

with marginal level of significance (Table S6). These results suggest that smart device usage

may not be entirely detrimental to language development but rather augment development if

concurrent with good usage attitude.

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 The benefit of appropriate smart device usage was also reflexed in the positive correlation

between appropriate usage level and social development of developmental test in three-
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year-old children (Table S3, Figure 2B). In the parental scale for appropriate usage level,

appropriateness was measured by motivation, usage, social relationship, value perception,

spent time and communication when using smart device (25).

Interestingly, three-year-olds who used smart devices frequently exhibited more advanced

fine motor development, which was not the case for usage time. However, this association

was not found in children between four and five years of age. Bedford et al similarly reported

that fine motor milestone achievements of toddlers at 19-36 months of age were associated

with early touchscreen scrolling (23). They suggested that frequent use of the index finger

could facilitate fine motor development in young children. However, regardless of the

potential benefits of smart device use on early fine motor development, children seem to

develop fine motor skills in various ways and the correlation became almost disappeared

until four to five years of age.

The results of cognitive development assessed via the developmental screening test were

not significantly correlated with smart device usage status. Similarly, a study in Australian

primary school children reported limited evidence of the effect of using mobile and cordless

phones on cognitive functioning (24). However, such findings on the effect of smart devices

on cognitive development in children are not conclusive. For example, interactive contents

may facilitate visual tracking or deteriorate visual refraction in young children. Also the

development of executive functions may be facilitated when guided by parents with suitable

programs or impaired with unmonitored use. Further studies should therefore investigate

different smart device usage practices in more depth.

In our previous report on detailed smart device usage status of 130 participants of this

study, 40.0% of children used the smart device unassisted by family members, most

commonly at home (59.2%). The most frequent causes of use were according to the child’s

want (37.7%) and when the mother needed to do other work (36.6%) (3). Another survey

also showed that most parents gave children mobile devices when they were doing house

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 chores or to keep them calm, and most three- and four-year-old children used the device

independently (4).
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Although most of the children use smart device for entertainment applications (3,4),

carefully designed smart device technologies can be used as the adjunctive treatment to

improve communication skills in children with autistic spectrum disorder, promote meaningful

mother-child interaction, and reduce sedentary behaviour among young children (26-28).

Therefore parental interaction or engagement during smart device use may be paramount to

whether the effects of smart device usage are positive or negative.

The American Academy of Pediatrics has thus recommended against the use of digital

media for children younger than two years of age. For children that are between two and five

years old, limiting screen use to one hour per day was recommended (29). In the present

study, about 90% of children used the smart devices for less than two hours per day and one

third of the children used them less than one hour per day (Table 1). However, as we did not

include other screen times, such as the duration spent watching television or videos, the

total time spent consuming media could have been longer than two hours. The correlation

between smart device usage and language development may thus be caused by increased

total media time or by a specific effect of smart devices.

The negative effects of smart device use on social and language functioning and the

positive effects on fine motor skills were most evident in three-year-old children. Younger

children may be more sensitive to overuse or inadequate smart device usage and as such

practices may reduce the mother-child interaction time and interfere with both verbal and

nonverbal communication.

Maternal mobile-device use can also affect parent-child engagement. Radesky et al

reported that maternal mobile-device use was associated with fewer interactions with

children, particularly nonverbal interactions, and during the introduction of unfamiliar food

(16,17). Previous findings have suggested that a mother’s verbal interaction during

electronic media exposure, such as television, videos, DVDs, movies and games mitigated

the adverse impacts on toddlers’ language development. A paediatric primary care-based

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 program designed to enhance parent-child interactions resulted in a reduction in the total

duration of media exposure in infants (30). Similarly, parental intervention regarding smart
Accepted Article
device usage may be beneficial by reducing the potential adverse effects of smart device

overuse.

The limitations of this cross-sectional study included a relatively small sample size and

not identifying the causal relationships. Considering that smart devices are also used by

children younger than those included in the present study, such as one-year-old or even

younger infants, future studies should investigate the effects of smart devices in children

younger than three years of age.

CONCLUSION

Smart device usage-related factors were correlated with early child development and

language development. They were differentially associated with age and developmental

domains, such as fine motor skills, language and social domains. Among three-year-old

children, those who spent more time using smart devices exhibited less developed language

skills, while those who used smart devices more frequently had more developed fine motor

skills. Advanced social skill was also related with appropriate smart device usage. This study

recommends implementing parent-child education for appropriate smart device usage as

early as possible and reducing the absolute usage time to improve language development in

three-year-old children.

FUNDING

This work was supported by the National research foundation of Korea (NRF-

2017R1D1A1B03034869) and research fund of Hanyang University (HY-2016).

CONFLICTS OF INTERESTS

The authors have no conflict of interest to declare.

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 Table 1 Analysis of demographic data, smart device usage frequency and time

Demographic characteristics
Accepted Article
Age group 3 years old 4 years old 5 years old Total

Subject number n = 40 n = 36 n = 41 n = 117

Mean age ± SD 3.5 ± 0.3 4.4 ± 0.3 5.4 ± 0.3 4.5 ± 0.9

Male : Female 22 : 18 19 : 17 22 : 19 63 : 54

Smart device usage frequency and time

Usage frequency
(number of used times per No use 1 or 2 times 3 or 4 times ≥ 5 times
(score 1) (score 2) (score 3) (score 4)
week)
n (%) 10 (8.6) 45 (38.5) 34 (29.1) 28 (23.9)
1- < 2 2- < 3
Usage time < 1 hour ≥ 3 hours
(number of used hours per day) (score 1)
hours (score hours (score (score 4)
2) 3)

Weekdays, n (%) 82 (70.1) 30 (25.6) 4 (3.4) 1 (0.9)

Weekend, n (%) 71 (60.7) 37 (31.6) 7 (6.0) 2 (1.7)

Weighted mean score of usage
1.4 ± 0.6
time

SD = standard deviation; n = number.

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 Figure legends
Accepted Article
Figure 1 Relationship among scores of smart device usage-related factors in three

and five-year-old children.

Scatter plot of scores of usage time (uTime, as weighted mean of weekdays and weekend)

vs scores of appropriate usage level (uLevel) in three-year-old (A). Scatter plots of scores of

uTime vs scores of usage frequency (uFreq) (B), scores of uLevel vs uFreq (C) and scores

of uLevel vs uTime (D) in five-year-old children. The solid line and shaded area stand for the

Loess trend curve with 95% confidence interval, and the size of circle increases in proportion

to the number of observations in each point. rs: Spearman’s correlation coefficient.

*Significant correlation at p < 0.017 (by Bonferroni correction applied in the age category).

Figure 2 Relationship between scores of smart device usage-related factors and

developmental test in three-year-old children.

Scatter plots of scores of fine motor skill development level (FM) vs scores of usage

frequency (uFreq) (A) and scores of social development level (Social) vs scores of

appropriate usage level (uLevel) (B). The solid line and shaded area stand for the Loess

trend curve with 95% confidence interval, and the size of circle increases in proportion to the

number of observations in each point. rs: Spearman’s correlation coefficient. *Significant

correlation at p < 0.01 (by Bonferroni correction applied in the age category).

Figure 3 Relationship between scores of smart device usage time and expressive

language months in three-year-old children.

Scatter plot of scores of usage time (uTime, as weighted mean of weekdays and weekend)

vs expressive language months (ELM) by language scale. The solid line and shaded area
stand for the Loess trend curve with 95% confidence interval, and the size of circle increases
in proportion to the number of observations in each point. rs: Spearman’s correlation
coefficient. *Significant correlation at p < 0.01 (by Bonferroni correction applied in the age
category).

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.