Journal Reading

Divisi Pediatrik Sosial

Exposure To Screens And

Children’s Language Development
In The EDEN Mother–child Cohort
Pauline Martinot, Jonathan Y. Bernard, Hugo Peyre, Maria De Agostini, Anne
Forhan, Marie‑Aline Charles , Sabine Plancoulaine & Barbara Heude

Oleh
Annisa trie anna
(C1105191005)

Pembimbing :
Dr. dr. Martira Maddepungeng, SpA (K)

DEPARTEMEN ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN UNHAS
 Abstract
Studies in children have reported associations of screen time and background TV on
language skills as measured by their parents. However, few large, longitudinal studies have
examined language skills assessed by trained psychologists, which is less prone to social
desirability. We assessed screen time and exposure to TV during family meals at ages 2, 3
and 5–6 years in 1562 children from the French EDEN cohort. Language skills were
evaluated by parents at 2 years (Communicative Development Inventory, CDI) and by
trained psychologists at 3 (NEPSY and ELOLA batteries) and 5–6 years (verbal IQ).
Cross‑sectional and longitudinal associations were assessed by linear regression adjusted
for important confounders. Overall, daily screen time was not associated with language
scores, except in cross‑sectional at age 2 years, where higher CDI scores were observed for
intermediate screen time. Exposure to TV during family meals was consistently associated
with lower language scores: TV always on (vs never) at age 2 years was associated with
lower verbal IQ (− 3.2 [95% IC: − 6.0, − 0.3] points), independent of daily screen time and
baseline language score.
In conclusion, public health policies should better account for the context of screen
watching, not only its amount.

Children’s language
development is greatly
inluenced by their immediate
environment (i.e., parents,
siblings, and peers)
The observed efects largely
depend on the age, the media
content and the social and
family context of viewing
Introduction
Over the last decades, screens
have become an additional part Research has provided
of the children’s environ- ment, convincing evidence that it may
and preschool-aged children lead to poorer cognitive and
spend considerable time behavioral outcomes
watching screens, especially TV
There is limited evidence from
Daily screen time has been
large epidemiological studies on
frequently, although not
the role of the context of TV
consistently, associated with
exposure on language
language delays in infants and
development of pre-school
toddlers
children.
 Disparate indings in Lastly, few
Most of these there is compelling
the literature may be longitudinal studies
studies were cross- evidence that screen
attributed to have used speciic
sectional and time increases
sampling diferences psychological tests to
focused on children during early
due to small sample assess language
younger than age childhood and this
sizes, type of screen development and
3 years, which limits change needs to be
time measurement, most studies rely on
drawing conclusions accounted for when
and use of diferent parental evaluation
on potential reverse analyzing
language of the child’s
causation. longitudinal data.
assessments. language skills.

Analyzing data from the French mother–child EDEN cohort, we

used both cross-sectional and longitudinal analyses to explore
associations of daily screen time and exposure to TV during
family meals with children’s language development at ages 2, 3
and 5–6 years while accounting for a wide range of established
confounders and covariates.
 Methods
Study design and population.

Briely, 2002
pregnant women
study design were enrolled A total of 1907
Children born at < 33 weeks’
gestation (n = 23) and children
and protocol between 2003 and children were without any language assessment
have been 2006 in public included and or assessed out of the assessment
age window (n = 322) were
maternity units of followed up.
published Poitiers and Nancy, excluded from the present work
France.

Exclusions Criteria

• history of diabetes,
• Twin pregnancies
• Intention to deliver outside the maternity unit or to
move out of the study Region within the next 3 years,
• an inability to speak French.
Exposure to screens
Parents reported the time
spent daily by their child
Exposure to screens.
watching TV or playing
Questionnaires were
video or computer games
completed at ages 2, 3 and
on typical weekdays,
5–6 years.
Wednes days (day of from
school), and weekend days.
we categorized it as 0, 1– the categories 0 and 1–
30, 31–60, 61–120, 30 min were grouped
and>120 min at age because of insufcient
2 years. At ages 3 and 5– number of children not
6 years, watching screens at all.
As the frequency
Daily screen time was
distribution of daily screen
calculated as
time was multimodal
(4×weekday+Wednesday+2
(greater number of round
×weekend day)/7.
values)
“How ofen is the television
Exposure to TV during
on in the dining room
family meals was
while the child is eating at
repeatedly assessed at the
home?” with four response
three ages with the
items: never, sometimes,
following question:
ofen, or always.
Languange Assesment
Language assessment. When
children were 2 years old,
parents completed the French
version of the MacArthur-
Bates Communicative
Development Inventory (CDI)
At age 3 years, two trained
psychologists (one per study
center) assessed language
development by using five
neuropsychological subtests
At age 5–6 years (mean [±SD]:
67.9 [±1.8] months), trained
psychologists administered the
French version of the Wechsler
Preschool and Primary Scale of
Intelligence-Tird Edition25.
an assessment of expressive
vocabulary with high test–retest
reliability and strong validity
against the full version21.
Assessment 23 batteries:
semantic fuency, word and
nonword repetition, sentence
comprehension task, sentence
repetition, and picture naming.
Te core subtests were assessed
(information, vocabulary, word
reasoning) to derive an age-
adjusted verbal IQ.
From a list of 100 words, parents
indicated those their child could
say spontaneously; and the sum
was used as a score.
In the present work, we re-
From these five subtest scores, a
scaled this variable (mean=100,
standardized composite
standard deviation=15) so that
language score was derived by
principal component analysis
subsequent efect sizes were
more comparable with the
with oblique rotation, as
verbal intelligence quotient (IQ)
previously published24.
scale described below.
 Covariates

Mothers completed questionnaires on

Child sex, gestational age at birth,
their pre-pregnancy weight and Data on partial and exclusive
study center and birthweight were
tobacco and alcohol consumption breastfeeding duration were collected.
collected from obstetric records.
during pregnancy.

At age 5–6 years, the quality of

Mothers and fathers completed
children’s cognitive stimulation and
questionnaires on their speech and
emotional support in their home
Symptoms of postpartum depression language delay histories during
environment was assessed by the
were assessed. childhood and on the frequency of
parents with items from Observation
shared cognitive activities with their
for the Measurement of the
child
Environment (HOME) scale

Additional information on potential

confounders collected included
maternal age, household income, Parents reported children’s night sleep
Parents reported the date when their
bilingual household, both parents’ duration per 24 h, nap durations at
child entered preschool.
education level, main caretaker, and ages 2 and 3 years, and sleep quality
number of older siblings aged<14 years
who were living at home.
Statistical analyses

Analyzes were conducted both cross-

We describe the characteristics of We analyzed the associations of
We assessed the diferences between sectionally (i.e., models with exposure
participants with means (±SDs) and exposure to screens with language
excluded and included samples with to screens and outcome measured at
numbers (percentages) for continuous scores by multivariable linear
Student t and chi-square tests. concurrent time points) and
and categorical variables, respectively. regression.
longitudinally

Longitudinal models were adjusted for We adjusted for schooling duration

To gain precision in the prediction of
language score at age 2 years only in models at age 3 years,
We adjusted regression models for the outcomes, we adjusted for the
(baseline) to estimate the efect of the because, in our sample, almost no
the above-described confounders child’s exact age at language
exposure to screens at age 2 years on children had entered school at age
(except for sleep variables, see below). assessment (except for verbal IQ,
language at age 5–6 years while 2 years, and almost all were in school
which is already age-adjusted).
keeping baseline language constant. at age 5–6 years.

We also examined the correlation

We evaluated the presence of
between the two screen variables
multicollinearity between predictors
(Daily screen time and TV during We tested the interactions between We imputed 10 datasets by using the
of the models by calculating their
family meals) and ran covariate- daily screen time and TV during family fully conditional specifcation method
variance infation factor; as all were
adjusted regression models with and meals but found none (data not and combined the estimates following
below 3, we considered
without mutual adjustment for the shown). Rubin’s rules.
multicollinearity not to be an issue in
two exposure variables to evaluate
our models.
confounding by each other.
Figure 1. Flowchart of the EDEN participants analyzed in the present study. CDI
communicative development inventory, IQ intelligence quotient.
 Results
Table 1. Maternal, child and household characteristics of the
participants from the EDEN cohort.

a
Unless otherwise indicated, data are number (percentage) of
participants. bData were missing for 31 participants (2%) for
pre-pregnancy body mass index, 5 (0.3%) for tobacco
consumption during pregnancy, 6 (0.4%) for alcohol
consumption during pregnancy, 16 (1.0%) for symptoms of
postpartum depression, 1 (0.1%) for birthweight, 1 (0.1%) for
duration of breastfeeding, 3 (%) for older siblings, 22 (1.4%) for
mother’s language difculties, 131 (8.4%) for father’s language
difculties, 9 (0.6%) for household income.
Table 2. Children’s characteristics at ages 2, 3 and 5–6 years
in the EDEN cohort a

CDI Communicative Development Inventory, HOME Home

Observation Measurement of the Environment, IQ
intelligence quotient. a Unless otherwise indicated, data are
expressed number (percentage) of participants. bSample
sizes indicated in column headers refect largest sample size
(i.e., the number of children with data for language
development); data for exposure to TV and covariates were
calculated without imputation for missing data and may be
based on smaller sample sizes.
 Table 3. Unadjusted and adjusted cross-sectional associations between exposure to screens and child
language development at each time point in the EDEN cohort (N=1,562).

a
CDI Communicative Development Inventory, IQ intelligence quotient, HOME Home Observation Measurement of the Environment. a Values are adjusted mean diferences
(vs the reference group) from linear regression models conducted on multiply imputed datasets (n=1,562). Models are of cross-sectional design, i.e., outcomes are being
predicted by exposure to screens as measured at concomitant age. Exposure to screens variables (Daily screen time and TV on during family meals) were mutually adjusted
for each other. Adjusted models were further adjusted for the following covariates: study center, maternal age at delivery, pre-pregnancy body mass index, tobacco and
alcohol consumption during pregnancy, symptoms of postpartum depression, child sex, gestational age at birth, birthweight, breastfeeding duration, number of older
siblings, parental education level, bilingual household, maternal and paternal language difculties during childhood, household income, main caretaker, cognitive stimulating
activities, HOME score. Models at ages 2 and 3 years were further adjusted for the child’s exact age at language assessment (verbal IQ scoring accounts for age). Models at
age 3 years were further adjusted for schooling duration.
Figure 2. Mean diference in verbal IQ at age 5–6 years according to daily screen time (panel A) and exposure to TV
during family meals (panel B) at age 2 years in the EDEN cohort. Error bars represent 95% confidence intervals
around the mean diference estimates. P values for trend across categories are 0.60 and 0.002 for Panel A and Panel
B, respectively. IQ intelligence quotient.
 Discussions

a cross-sectional inverted U-shaped

association between children’s daily
screen time at age 2 years and
language development (with
increased language scores for
children watching screens for
intermediate durations), but no
associations at 3 or 5–6 years of age.
In contrast, exposure to TV during
family meals was negatively
associated with language scores at
every age,including when analyzing
data longitudinally with adjustment
for language skills at baseline.

Another study found that infants

Overall, we found no linear
exposed to no media actually had
associations between daily screen
lower levels of language development
time and language development,
than infants with some exposure
 Several studies have identiied that
we explored the association between In several studies, less verbal
human interaction, especially the
exposure to TV during family meals interaction with children when the TV
frequency and quality of adults’
and language development was on were noted, as was less verbal
exchanges with their children, is
crucial to children’s language production by children
development
Frequent exposure to TV during family
meals was negatively associated with
language scores at every age.
In agreement with other studies on Also, auditive and visual stimulations
TV exposure, the importance of child– may increase children’s and parents’
Our main explanations for these distractions in their family
adult interaction with regard to TV
indings, in line with previous work, environment and increase the
was reinforced when
are that TV during family meals may diiculties for a child to extract
have both a direct efect of distracting phonological and syntactical sounds
a child and an indirect efect by taking from the background noise at home
a parent’s attention away from their
child.

In this study, that increased exposure to TV during family meals at age 2 years was
strongly associated with poorer language at age 5–6 years.
Strenght

relies on the use of

language tests assessed
longitudinal design, Longitudinal analyses of
by trained
large sample size and the associations
psychologists; therefore,
the availability of a wide between TV exposure in
our fndings are unlikely
range of confounding early childhood and
to be afected by social
factors that few past later verbal IQ at age 5–
desirability bias arising
studies 6 years
from parental reporting
only.

Finally, we performed a sensitivity analysis with factors identifed as

potential mediators between TV exposure and language development
Limitation

Lacking these
we measured
EDEN children data, we
children’s
Our study must turned 5–6 years attempted to
Second, we were exposure to
be interpreted in between 2008 control for
notable to screens with
light of some and 2012, when program content
account for the parent-reported
limitations. First, the market of indirectly by
content of questionnaires;
we could not handheld devices including
children’s TV this method is
examine screens was only variables likely to
programs in our relatively
other than TV emerging and be associated
analysis. inaccurate and
and video games, targeted adult with the types of
sufers from social
users. program a child
desirability.
watches

Finally, the three language assessments we conducted were not directly comparable,
which limits our ability to implement models with repeated measures
 Conclusions
In this analysis, we found no
relationship between daily screen
This work consolidates previous
Families need to be better informed time and language development,
results and adds new elements to
about what activities really promote except cross-sectionally at age 2 years
support recommendations, especially
their children’s healthy with a U-shaped relationship where
with regard to the context of TV
neurodevelopment. children exposed to TV for
viewing.
intermediate times had greater
scores.

We found, however, consistent

negative dose–response associations Our fndings encourage scientists and
between frequency of exposure to TV decision-makers to better consider
during family meals and language contextual traits of screen viewing.
development.
Telaah Kritis Jurnal

Exposure To Screens And

Children’s Language
Development In The EDEN
Mother–child Cohort
Pauline Martinot, Jonathan Y. Bernard, Hugo Peyre, Maria De Agostini, Anne
Forhan, Marie‑Aline Charles , Sabine Plancoulaine & Barbara Heude
Umum
NO HAL YANG DINILAI CHECK LIST PENILAIAN YA TIDAK
1 Judul makalah a. Tidak terlalu panjang atau tidak terlalu pendek √
b. Menggambarkan isi utama penelitian √
c. Cukup menarik √
d. Tanpa singkatan, selain yang baku √

2 Abstrak a. Abstrak terstruktur √

b. Mencakup komponen IMRAC (Introduction, √
methods, Results, Conclussion)
c. Secara keseluruhan abstrak informatif √
d. Tanpa singkatan, selain yang baku √
e. Kurang dari 250 kata √
263
kata

3 Pendahuluan a. Ringkas terdiri dari 2 – 3 paragraf √

b. Paragraf pertama mengemukakan alasan √
dilakukannya penelitian
c. Paragraf berikut menyatakan hipotesis atau √
tujuan penelitian
d. Didukung oleh pustaka yang kuat & relevan √
e. Kurang dari 1 halaman √
4 Metode a. Disebutkan design, tempat dan waktu √
penelitian
b. Disebutkan populasi sumber (populasi √
terjangkau)
c. Dijelaskan kriteria pemilihan subyek √
(inklus i& eksklusi)
d. Disebutkan cara pemilihan subjek √
(teknik sampling)
e. Disebutkan perkiraan besar sampel & √
alasannya
f. Perkiraan besar sampel dihitung √
dengan rumus yang sesuai
g. Observasi, pengukuran serta intervensi √
dirinci sehingga orang lain dapat
mengulanginya
h. Ditulis rujukan bila teknik pengukuran √
tidak dirinci
i. Pengkuran dilakukan secara tersamar √
j. Definisi iistilah & variable penting √
dikemukakan
k. Ethical clearance diperoleh √
5 Hasil a. Disertakan tabel karakteristik subjek penelitian √
b. Karakteristik subjek yang penting (data awal) √
dibandingkan kesetaraannya
c. Dilakukan uji hipotesis(statistik) untuk √
kesetaraannya √
d. Disebutkan jumlah subjek yang diteliti
e. Dijelaskan subyek yang dropout dengan √
alasannya
f. Ketepatan numerik dinyatakan dengan benar √
g. Penulisan tabel dilakukan dengan tepat √
h. Semua hasil di dalam tabel disebutkan dalam √
naskah
i. Semua outcome yang penting disebutkan dalam √
hasil
j. Subyek yang drop out diikutkan dalam analisis √
k. Analisis dilakukan dengan uji statistik yang sesuai √
l. Ditulis hasil ujistatistik, derajat kebebasan √
(degree of freedom), dan nilai p
m. Disertakan interval kepercayaan √
n. Dalam hasil disertakan komentar & pendapat
√
6 Diskusi a. Semua hal yang relevan dibahas √
b. Tidak sering diulang hal yang dikemukakan √
pada hasil
√
c. Dibahas keterbatasan penelitian, dan
dampaknya terhadap hasil √
d. Disebutkan penyimpangan protokol, dan
dampaknya terhadap hasil √
e. Diskusi dihubungkan dengan pertanyaan
penelitian √
f. Dibahas hubungan hasil dengan teori/hasil
penelitian terdahulu √
g. Dibahas hubungan hasil dengan praktek klinis
h. Efek samping dikemukakan dan dibahas √
i. Disebutkan hasil tambahan selama diobservasi √
j. Disertakan simpulan utama penelitian √
k. Simpulan didasarkan pada data penelitian √
l. Disebutkan generalisasi hasil penelitian √
m. Disertakan saran penelitian selanjutnya √
TELAAH KRITIS JURNAL

IMPORTAN APPLICABI
VALIDITY
CE LITY
 TELAAH KRITIS JURNAL VALIDITY

1. Apakah awal penelitian didefinisikan dengan jelas ? (pertanyaan penelitian/tujuan

penelitian)?
Ya, pada awal penelitian disebutkan tujuan penelitian yaitu untuk mengeksplorasi
asosiasi screen time harian dan paparan TV selama makan keluarga dengan
perkembangan bahasa anak-anak pada usia 2, 3 dan 5-6 tahun sambil menghitung
untuk berbagai pembaur mapan dan kovariat.

2. Apakah dinyatakan desain penelitian dengan jelas ?

Penelitian Ini menggunakan metode cross-sectional longitudinal
 TELAAH KRITIS JURNAL VALIDITY

3. Apakah pembanding dinyatakan dengan jelas ?

Ya, dibandingkan berdasarkan durasi screen time harian dan paparan TV selama
makan keluarga dengan perkembangan bahasa anak-anak pada usia 2, 3 dan 5-6 tahun

4. Apakah kelompok-kelompok yang dibandingkan sebanding pada

tahap awal penelitian ?
Untuk karakteristik ibu, anak dan rumah tangga dari 1.562 sampel penelitian yang
dianalisis ditunjukkan pada Tabel 1
Table 1. Maternal, child and household characteristics of the participants from the EDEN cohort.
 TELAAH KRITIS JURNAL VALIDITY

5. Apakah follow up dilakukan secara memadai ?

Ya, dilakukan follow up secara memadai. Diikuti sejak masa pranatal, 2002 wanita
hamil terdaftar antara tahun 2003 dan 2006 di unit bersalin masyarakat Poitiers dan
Nancy, Prancis. Sebanyak 1907 anak diikutsertakan dan ditindaklanjuti. Dinilai durasi
screen time harian dan menonton TV saat makan, dan perkembangan bahasa pada
anak berusia 2 tahun, 3 tahun, dan 5-6 tahun.
 TELAAH KRITIS JURNAL VALIDITY

6. Apakah diidentifikasi dengan jelas kelompok dengan prognosis

yang berbeda ?
Ya, dibandingkan durasi screen time harian dan paparan TV selama
makan keluarga dengan prognosisnya yaitu perkembangan bahasa
anak-anak pada usia 2, 3 dan 5-6 tahun.

7. Apakah outcome dinilai dengan kriteria objektif?

Ya, penilaian perkembangan bahasa anak ditentukan dengan
kriteria objektif
Ketika anak-anak berusia 2 tahun, orang tua menyelesaikan MacArthur-Bates
Communicative Development Inventory (CDI) versi Prancis

Penilaian kosakata ekspresif dengan reliabilitas

Dari daftar 100 kata, orang tua menunjukkan kata-kata yang bisa diucapkan anak
mereka secara spontan; dan jumlah itu digunakan sebagai skor.

Pada usia 3 tahun, dua psikolog terlatih (satu per pusat studi) menilai perkembangan bahasa
dengan menggunakan lima subtes neuropsikologis dari Evaluasi Perkembangan du Langage
Oral de L'enfant Aphasique dan A NEuroPSYchological

Pada usia 5–6 tahun. psikolog terlatih menggunakan Wechsler Preschool and
Primary Scale of Intelligence-Third Edition versi Prancis.

Subtes inti dinilai (informasi, kosa kata, penalaran kata) untuk memperoleh IQ
verbal yang disesuaikan dengan usia.
TELAAH KRITIS JURNAL VALIDITY

8. Uraian unsur PICO?

Patient : Anak-anak dari penelitian the EDEN mother–child cohort
Intervention : -
Comparison :
Durasi screen time dan menonton TV saat makan pada usia 2,3, dan 5-6
tahun
Outcome : Perkembangan Bahasa pada usia 2,3, dan 5-6 tahun
 TELAAH KRITIS JURNAL IMPORTANCE

1. Apakah outcome/hasil dipaparkan secara jelas (hasil uji

statistik dengan hasil nilai P) ?
Ya, Hasil/outcome pada penelitian ini berdasarkan uji statistik
(nilai p) dengan nilai ketepatan P < 0.05

2. Seberapa besarkah ketepatan estimasi outcome yang didapat

dengan nilai korelasi 95% CI?
Tabel 3 menunjukkan perbedaan rata-rata dan interval kepercayaan 95%
dari model regresi linier yang menilai hubungan antara paparan layar
dan skor bahasa (Perkembangan Bahasa) pada waktu bersamaan.
 TELAAH KRITIS JURNAL Applicability

1. Apakah karakteristik pasien kita mirip dengan subjek yang diteliti?

Ya, karakteristik subjek yang diteliti mirip dengan pasien-pasien anak
yang mengalami gangguan perkembangan Bahasa yang berobat pada
Poli Anak Pediatrik sosial RSUP Wahidin Sudirohusodo

2. Apakah bukti ini akan mempunyai pengaruh yang penting secara

klinis terhadap kesembuhan pasien kita tentang apa yang telah
ditawarkan / diberikan kepada pasien kita
Diharapkan Keluarga perlu mendapat informasi yang lebih baik tentang
kegiatan apa yang benar-benar mendorong perkembangan saraf anak
mereka yang sehat, terutama yang berkaitan dengan durasi dan konten
saat screen time dan menonton TV.
 TELAAH KRITIS JURNAL Applicability

3. Apakah simpulan tentang hasil studi tersebut berguna bagi pasien

dalam tatalaksana secara keseluruhan?
Ya, menjadi sumber informasi informasi dan edukasi kebijakan screen
time harus lebih memperhitungkan konteks, bukan hanya
berdasarkan durasi dari screen time.
Terimak
asih