I hear so many people blaming the ills of this world on screens but I honestly think they can’t be all bad, however, as a parent of 3 teenagers I desperately want to ‘get it right’. So, for the second time my Mental Elf blog is delving into a meta-analysis of screen use in an attempt to untangle the complexities of its relationship with mental health.

My last blog was concerned with screen use and wellbeing concluding that as ‘screen time’ was so broad and the data, in some cases, quite old (pre-snapchat) it was difficult to establish a cause and effect. In his blog, David Turgoose summarises research with much the same findings: research is sparse, not always of good quality and it is hard to infer cause and effect.

In the technological parenting maze that we live in, it would be good to understand exactly what constitutes problem use. Parents don’t want to raise ‘well-adjusted outcasts’ but are concerned about the negative impact of phones on the health and wellbeing of their children.

Mobile phones have become ubiquitous over the last 10 years or so. According to Ofcom’s 2019 report, digital independence (i.e. mobile phone ownership) doubles from 25% of 9 year olds to 50% of 10 year olds, and by 15 years old almost all children own one. Although most parents feel ‘the benefits of the internet for my child outweigh the risks’, the proportion who agree with this statement has declined in the last 4 years from 65% to 55%. Parental concerns range widely from online bullying, seeing damaging content, grooming, the time children spend gaming…so it goes on.

This paper focuses on Problematic Smartphone Use (PSU) (Sohn et al, 2019). The aim of the meta-analysis was to establish the prevalence of PSU in young people and to consider the links between Problematic Smartphone Use and 4 variables:

• Sociodemographics
• Mental health outcomes
• Sleep
• School performance.

However, the starting point for this is to establish what we mean by Problematic Smartphone Use. Currently there is no formal diagnosis in the ICD-11 (2011) or DSM V (2013) – clearly smartphones were not around whilst they were being compiled. In general, PSU is considered to consist of four main components, which map onto the criteria for gaming disorder – DSM-V & ICD-11 (Lin et al., 2016):

• Compulsive behaviours
• Tolerance
• Withdrawal
• Functional impairment.

There are a range of scales that measure PSU and are utilised in the studies included in this meta-analysis. It is worth noting that it is not screen time per se that is thought to have an impact on mental health but the pattern of use – gaming, communication or social media. It is this discrepancy in the way that we measure screen time and phone use that may lead to some of the conflicting findings in the literature.

Methods

This meta-analysis searched 8 databases for publications from 1st January 2011 (n.b. This is still pre-snapchat and only 3 months after the launch of Instagram) to October 2017. The studies were assessed for methodological quality using a modified Newcastle-Ottawa scale, and for quality of evidence using GRADE (Guyatt et al., 2011), ensuring that the reader understands how robust the research used is.

Problematic Smartphone Use was defined as:

smart phone use associated with at least some element of dysfunctional use, such as anxiety when the phone was not available, or neglect of other activities.

The study complies with PRISMA guidelines and was registered at PROSPERO. This ensures the meta-analysis is carried out without bias and is a good representation of the research available. After protocol registration the additional outcomes of suicidal ideation and associated psychological factors were included.

Results

A total of 924 studies were identified, of which 41 met the inclusion criteria. Of these 22 were judged as being of poor methodological quality and 19 of moderate quality. Research was from Europe (n=9), Asia (n=30) and America (n=2). The total number of participants was 41,871 of which 55% were female. Those reporting PSU also reported their preferred use being social networking. Communication was the most frequent type of smartphone use.

Prevalence & sociodemographics

31 of the studies found PSU to be between 10 and 30%, the median being 23.3% (i.e. 1 in 4 young people). Sociodemographic factors that seemed to play a role in PSU were age and gender. The highest incidence of PSU was found in females (13 studies; n.b. 4 studies found the opposite) aged 17-19 years old. There was also the suggestion that males and females use their phones differently: males tended to use media applications and gaming, where females used them for social networking and communication. Positive correlations were also found between PSU and monthly cost of living; family income and high socioeconomic status.

Problematic smartphone use (PSU): mental health outcomes

20 of the 41 studies measured the relationship between PSU and various mental health outcomes:

• 8 studies looking at depression and PSU reported a significant positive association;
• 7 studies investigated anxiety, 6 found a positive association and one found a negative association;
• Of the 5 studies investigating stress, 4 found a positive association and the 5th found no significant relationship;
• 6 out of 7 seven studies reported a positive association between PSU and poor sleep, the 7th finding no significant association;
• In terms of educational attainment, 4 out of 6 studies reported a significant relationship, one reported no association and the final one did not evaluate the statistical significance of the relationship;
• One study reported increased odds of suicide with PSU, but this was assessed through a single screening question, so should be considered with caution.

The psychological factors associated with PSU were both high risk-taking (e.g. low self-control & impulsivity) and risk avoidance (e.g. perfectionism and avoidance). In addition, insecure attachments, loneliness and low self-esteem were also associated with PSU.

Conclusions

The authors conclude that ‘those with PSU had an increased risk of poor mental health, wellbeing and day-to-day function’ (p6) and that this is fairly widespread in young people. Not only this but there is compelling evidence to suggest that PSU is also linked to wider issues such as school performance.

Strengths and limitations

This meta-analysis does suggest compelling evidence that PSU is an issue for young people and that it has worrying effects on their wellbeing and mental health. It also looks at studies from a range of cultures that suggests similar patterns are found around the globe.

The study selects 41 papers to analyse, none of which are of high quality (22 were poor quality and 19 were moderate). This begs the question: where is the high-quality research in this field? It was also challenging to compare studies due to the lack of clarity in defining PSU; with no formal diagnostic criteria, studies rely on self-report so it is possible that these are not as objective and as comparable as one might like.

Finally, these studies look at associations not causation so it is not clear if PSU causes issues with mental health or if it is triggered by existing mental health problems, or if the interaction between variables is more complex than this.

Implications for practice

It is clear that more high-quality research needs to be done. In particular around the assessment tools used to measure PSU, and establishing (if they do indeed exist) causal links between smartphone use and mental health outcomes.

According to Yang et al. (2019) there are differences in the way young people from different cultures use mobile phones. Whilst there is compelling evidence that PSU and its impact on wellbeing is an issue, if young people from different cultures are using the technology in different ways this will have an impact on any interventions that may be used to support them.

I still don’t feel any closer to really understanding the issues underlying the link between PSU and mental health. It is clear that there are links and that they are widespread. The lack of high-quality research is frustrating, when this is such an important issue, and the speed at which technology develops continues to race ahead of the pace of research.

So as a parent for now I err on the side of caution and frustrate my children with limits and parental controls, whilst encouraging behaviours I know promote wellbeing.

Statement of interests

None.

Links

Primary paper

Sohn, S., Rees, P., Wildridge, B. et al. Prevalence of problematic smartphone usage and associated mental health outcomes amongst children and young people: a systematic review, meta-analysis and GRADE of the evidence. BMC Psychiatry 19, 356 (2019). https://doi.org/10.1186/s12888-019-2350-x

Other references

Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G., Brozek, J., … & Jaeschke, R. (2011). GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. Journal of clinical epidemiology, 64(4), 383-394.

Lin, Y. H., Chiang, C. L., Lin, P. H., Chang, L. R., Ko, C. H., Lee, Y. H., & Lin, S. H. (2016). Proposed Diagnostic Criteria for Smartphone Addiction. PloS one, 11(11), e0163010.

Ofcom (2019) Children and parents:Media use and attitudes report accessed 30/6/20

Yang, Z., Asbury, K. & Griffiths, M.D. Do Chinese and British University Students Use Smartphones Differently? A Cross-cultural Mixed Methods Study. Int J Ment Health Addiction 17, 644–657 (2019). https://doi.org/10.1007/s11469-018-0024-4

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