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The exposure of American children and adolescents to television continues to exceed the time they spend in the classroom: 15 000 hours versus 12 000 hours by the time they graduate.1 According to recent Nielsen data, the average child and/or adolescent watches an average of nearly three hours of television per day.2These numbers have not decreased significantly over the past 10 years.3 By the time a child finishes high school, almost three years will have been spent watching television.1This figure does not include time spent watching video tapes or playing video games.4
Based on surveys of what children watch, the average child annually sees about 12 000 violent acts,5 14 000 sexual references and innuendos,6 and 20 000 advertisements.7 Children and adolescents are especially vulnerable to the messages communicated through television which influence their perceptions and behaviours.8 Many younger children cannot discriminate between what they see and what is real. Although there have been studies documenting some prosocial and educational benefits from television viewing,9 ,10significant research has shown that there are negative health effects resulting from television exposure in areas such as: violence and aggressive behaviour; sex and sexuality; nutrition and obesity; and substance use and abuse patterns. To help mitigate these negative health effects, paediatricians need to become familiar with the consequences of television and begin providing anticipatory guidance to their patients and families.10 In addition, paediatricians need to continue their advocacy efforts on behalf of more child appropriate television.
In this review, we will describe the effects of television on children and adolescents. In addition, we will make recommendations for paediatricians and parents to help address this significant issue.
Prosocial and educational benefits
Studies from the early 1970s have shown that children imitate prosocial behaviour. These imitated behaviours included altruism, helping, delay of gratification, and high standards of performance when children are exposed to models exhibiting these behaviours. Friedrich and Stein provided evidence that children learned prosocial content of the television programmes and were able to generalise that learning to a number of real life situations.9 In addition, they were also able to show that prosocial programmes increased helping behaviour in situations similar to and different from those shown on television.
With the initiation of Sesame Street, an American educational television programme for children over the age of 3 years, extensive research was performed.10 Many studies showed that children who watched the most learned the most. A two year longitudinal study assessing the impact of viewingSesame Street on the vocabulary of 3 and 5 year old children showed that viewing predicted significantly improved vocabulary scores on the Peabody Picture Vocabulary Test. Another study done in the early 1990s showed that children in Turkey who viewed the Turkish version of the programme Susam Sokagi, showed substantial pre- to post-test gains in overall knowledge.
Violence and aggressive behaviour
Young people view over 1000 rapes, murders, armed robberies, and assaults every year sitting in front of the television set.11 Recently published, the three year, National Television Violence Study examined nearly 10 000 hours of television programming and found that 61% contained violence.12-14Children's programming was found to be the most violent. In addition, 26% (of the 61%) involved the use of guns. Portrayals of violence are usually glamorised and perpetrators often go unpunished. Another venue in which a significant amount of violence is portrayed is in rock music videos, which are viewed heavily by adolescents. In a comprehensive content analysis of these music videos, DuRant et al showed that 22.4% of all rap videos contained violent acts, and weapon carrying was depicted in 25% of them.15
Numerous studies, including longitudinal research,16 ,17have shown a relation between children's exposure to violence and their own violent and aggressive behaviours. Many studies have documented the role of television in fostering violent behaviours among children.18 ,19 Two recent meta-analyses investigating the relation between violence viewed on television and aggressive behaviour in children concluded that exposure to portrayals of violence on television was associated consistently with children's aggressive behaviours.20 ,21
Sex and sexuality
American television, both programming and advertising, are highly sexualised in their content. Each year, children and adolescents view 14 000 sexual references, innuendoes, and jokes, of which less than 170 will deal with abstinence, birth control, sexually transmitted diseases, or pregnancy.22 What has been traditionally described as the “family hour” (8–9 pm) now contains more than eight sexual incidents per hour, more than four times as much as in 1976.23 Nearly one third of family hour shows contain sexual references, and the incidence of vulgar language has increased greatly.24 In addition, soap operas, a genre highly viewed by adolescents, show extramarital sex eight times more commonly than sex between spouses.11 At the present time there have only been four studies examining the relation between early onset of sexual intercourse and television viewing. However, there are numerous studies which illustrate television's powerful influence on teenagers' sexual attitudes, values, and beliefs.25 ,26 Teens rank the media second only to school sex education programmes as a leading source of information about sex.26
Nutrition and obesity
Over the past three decades the prevalence of obesity among children and adolescents has increased and fitness has decreased.27 Television viewing affects both fatness and fitness and multiple studies point to television viewing as one cause of childhood obesity.28-31 Two primary mechanisms for this relation have been suggested: reduced energy expenditure from displacement of physical activity and increased dietary energy intake, either during viewing or as a result of food advertising.
The association between television viewing and food consumption can be explained, in part, by the frequent references to food or the consumption of food that occurs during both commercials and programmes.11 Breakfast cereals, snacks, and fast foods are among the most heavily advertised products on television programmes aimed at children, and tend to have higher energy density than other products such as fruits or vegetables which are less frequently advertised.30 The amount of time spent viewing television directly correlates with the request, purchase, and consumption of foods advertised on television.11
Furthermore, obesity occurs among televised characters far less frequently than in the general population. Because the characters on television eat or talk about food so frequently, the implicit message may be that it is possible to eat frequently and remain thin.32 Likewise, the almost exclusive presence of very thin, particularly female, television characters may contribute to the notion that the ideal body type is that of the women and adolescents shown; this may contribute to the culture wide obsession with thinness.
Tobacco and alcohol use and abuse
Increasingly, media messages and images, not necessarily direct advertising, are normalising and glamorising the use of tobacco, alcohol, and illicit drugs. Tobacco manufacturers spend $6 billion per year and alcohol manufacturers $2 billion per year to entice youngsters into consuming their products. Content analysis has found that alcohol, tobacco, or illicit drugs are present in 70% of prime time network dramatic programmes and half of all music videos.33 The prominence of alcohol in prime time television applies to all characters, including adolescents, where negative characteristics are often applied. However, many adults shown to consume alcohol have positive personality characteristics.34 Popular movies, frequently shown during the “family hour”, often show the lead or likeable characters using and enjoying tobacco and alcohol products.35 ,36 In addition to programming, children and adolescents view approximately 20 000 advertisements each year, of which nearly 2000 are for beer and wine.37 For every public service announcement, adolescents will view 25–50 beer commercials.
Research indicates that the combined 8 billion dollars which the tobacco and alcohol industries use every year to pitch their product to the American public has a significant impact on adolescents' beliefs and attitudes about smoking and drinking and may actually influence their consumption as well. Correlational studies have shown a small but positive relation between advertising exposure and consumption.38-41 Furthermore, advertising exposure appears to influence initial drinking episodes which in turn contribute to excessive drinking and abuse.39 The evidence, however, to increased consumption, is strongest regarding cigarette advertising and promotions.42 ,43 A recent longitudinal study found that an estimated one third of all adolescent smoking could be causally related to tobacco promotional activities.44
Recommendations for parents and paediatricians
As has been shown, there is a significant amount of literature to support the connection between adverse outcomes and exposure to television. There are ways to help attenuate the effects of television “promotion” of harmful activities and substances. They range from controlling the way children and adolescents view television to more effective office counselling and public health activism. The American Academy of Pediatrics, through its policy statements has taken a leadership role in making recommendations for both parents and paediatricians.5 ,6 ,45 ,46
RECOMMENDATIONS FOR PARENTS
Parents are often not familiar with what their children are viewing on television, nor do they control the television which they watch.47 In addition, parents generally underestimate the amount of time their children spend viewing television. A recent study found that 32% of 2–7 year olds, 65% of 8–13 year olds, and 65% of 14–18 year olds have television sets in their bedrooms.3Furthermore, two 1997 surveys, with a sample size of nearly 1500 parents, found that less than half of them report “always watching” television with their children.47 Co-viewing is thought to be an effective mechanism for mediating untoward effects of television viewing: an adult, watching a programme with a child and discussing it with him/her, serves simultaneously as a values filter and a media educator.35 Based on this information, and the data available, the American Academy of Pediatrics5 ,45recommends that parents should:
Participate in the selection of programmes to be viewed
Co-view and discuss content with children and adolescents
Teach critical viewing skills to their children and adolescents
Limit and focus time spent viewing television to less than one to two hours per day
Be good media role models for their children and adolescents
Emphasise alternative activities
Remove television sets from children's and adolescents' bedrooms
Avoid using the television as an “electronic babysitter”.
RECOMMENDATIONS FOR PAEDIATRICIANS
With the known unhealthy effects of media on children and adolescents, it is crucial that paediatricians are aware and become knowledgeable about the media's influence on their patients.9 Paediatricians need to be able to educate their patients' parents and advocate for improved, healthier media.5 As part of health supervision visits, paediatricians also need to begin taking a media history and using the media history form developed by the Academy (table1).45 ,48 This tool enables young people and parents to examine their media habits and allows paediatricians to focus on areas of concern and offer counsel and support.45 In addition, paediatricians can work with patients to help them understand that what they view on television is not “real” and that the purpose of advertisements is to sell them products. These premises of media education have been implemented in programmes with documented success.49 ,50 Review of the available literature has enabled the Academy to make the following recommendations for paediatricians5 ,45 ,47:
Become educated about the public health risks of television exposure and share this information with their patients, families, and the community
Incorporate questions about television use into routine visits including use of the Academy's media history form
Include anticipatory guidance about television to their patients and their families at health supervision visits
Encourage parents to avoid television viewing for children under the age of 2 years
Serve as role models by using television sets and videocassette recorders in their waiting rooms for educational programming only
Advocate for improved media by writing to local stations, national networks, Hollywood studios, and the Federal Communications Commission
Promote media education as a means to help mitigate some of the unhealthy effects of television
Advocate for mandatory media education programmes with known effectiveness in the schools.
Although this review primarily focused on the unhealthy effects of television viewing on children and adolescents, some television programming has been shown to promote prosocial behaviours and have positive educational effects in young children. However, these programmes are in the minority and are mainly targeted to very young children (3–5 year olds). There are effective methods which can be used to lessen the negative influences of television. The primary method, besides turning off the television, is the introduction of media education to patients and their families. This introduction can be accomplished through many settings including the paediatrician's office, the school, and the community. The Academy's Media Matters Campaign is an example of such an integrated initiative to disseminate media education. It is important that paediatricians and parents jointly implement prevention campaigns and strategies. The effect on both children and adolescents, and the community will be much greater with a joint effort.
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