Adolescents' screen time, sleep and mental health: literature review

Research Question 5: What existing evidence is there on adolescents' views of how mobile device screen time affects their sleep, and following on from this, their mental health and wellbeing?

Description of studies

Study design, geographical location and setting

The first study, Quante et al (24), was a mixed methods study conducted with participants living in low- and middle-income racially/ethnically diverse neighbourhoods in the USA. Focus groups were used to examine strategies to improve and promote sleep within the population.

The second study, Smahel et al (25) was conducted within the network of the EU Kids Online III project. Focus groups and interviews were used to explore children's perceptions of positive and negative experiences and consequences of using the internet and technology in general.

Sample size and participants characteristics

Quante et al (24) recruited 27 English-speaking participants aged 14-18 with a mean age of 15.7 (SD=1.4). Of these 55.6% were male; 7.4% identified as White, 11.1% as Black, 66.7% as Asian and 14.8% as 'Other'; 22.2% identified their ethnicity as Hispanic. Participants were recruited from one housing location and two youth services located within neighbourhoods within one city, described by the authors as low socioeconomic status and ethnically diverse.

Smahel et al (25) recruited 254 participants to focus groups and 114 to interview across nine countries (Belgium, Greece, Malta, Italy, Portugal, Romania, Spain, United Kingdom and the Czech Republic). Participants were recruited from three age groups (9–10 years, 11–13 years, and 14–16 years), and from a variety of schools or youth centres (e.g. public/ private, city/ suburban/ rural). Information relating to specific demographics were in the original report (34). The number of participants recruited to focus groups in each country ranged from 22 (Portugal) to 36 (Belgium) with five of the nine countries reporting an equal gender split within the sample. For the remaining four, Belgium reported 52.8% females, Malta reported 51.9% females, Portugal reported 54.5% females and Czech Republic reported 40% females. In terms of interviews, the number of participants ranged from 8 (Greece) to 20 (Belgium), with four of the nine countries reporting an equal gender split within the sample. For the remaining four, Belgium reported 55.5% females, Greece reported 62.5% females, Romania reported 54.5% females, United Kingdom reported 46.7% females and the Czech Republic reported 41.7% females.

Data collection methods

Quante et al (24) first provided participants with a survey gathering information relating to demographics, general health habits and sleep patterns. This survey also involved the Epworth Sleepiness Scale, questions from the sleep environment survey and one question from the Horne-Ostberg questionnaire which self-assesses chronotype (the propensity for the individual to sleep at a particular time during a 24-hour period). Following survey completion (approximately 10 minutes), participants were included in one of three focus groups (also described as moderator led discussions). Focus groups lasted up to one hour and used a semi-structured guide to shape discussions. Focus groups and interviews were audio- recorded, transcribed and then coded using a combination of inductive and deductive approaches.

For Smahel et al (25) limited details regarding data collection were included in the paper, instead authors referred to the larger report (34). A common topic guide was used across the nine countries. Focus groups and interviews were then transcribed in the national language, the first stage of coding involved coding condensed descriptions of material in English, next researchers translated relevant paragraphs to determine the 5-10 most interesting passages. These were then coded and analysed. The included study focused only on codes specifically linked to 'health', type of problematic situation and those that related to health issues associated with new media use.

Quality of studies

Both studies were of fairly high quality with most of the criteria checklist fulfilled (see Appendix Table C). The studies were considered poor quality in terms of richness of data, however this may be a by-product of journal word count restrictions. Table 5 provides an overview of the quality rating by criteria of NICE guideline checklist.

Table 5. Quality assessment of studies of adolescent views

Quality appraisal items	Quante et al (2019)	Smahel et al (2015)
Appropriate approach	(G)	(G)
Clear Aims	(G)	(G)
Research design	(G)	(G)
Data collection	(Y)	(Y)
Role of Researcher	(Y)	(Y)
Context	(Y)	(Y)
Methods	(G)	(Y)
Rigorous Data Analysis	(G)	(Y)
'Rich' Data	(R)	(R)
Reliable Analysis	(G)	(G)
Findings- convincing	(G)	(G)
Findings- relevant	(G)	(G)
Conclusions	(Y)	(Y)
Reporting of Ethics	(Y)	(Y)

Green (G)=high quality, Yellow (Y)=unclear, Red (R)=low quality

Findings

Adolescents' perception of screen use and sleep

Quante et al (24) directly asked young people about their perceptions of screen use and the implications of screen use on sleep. Young people, within this study, reported being aware of specific recommendations regarding screen use prior to bedtime, although they may not always follow these guidelines. Quante et al (24) suggested that both genders reported using smartphones in bed, and recognised that it may negatively affect their sleep

'PF1: I'm addicted to my phone. Most of the time, the reason I wake up in the middle of the night is to look for my phone because I fell asleep with it.'

However, boys within the Quante et al (24) study were more likely to report trying to follow guidelines (e.g. putting electronics away one-hour pre bedtime) whilst girls suggested they specifically used their electronics as a tool to aid sleep (e.g. listening to music).

Young people involved in the Smahel et al (25) study tended to report that sleep issues were connected to the content in video games rather than their use.

'And those bad dreams, I think that is the worst, because I cannot sleep. I'm tired and then I am mad because I cannot sleep, because I'm afraid that I will have those bad dreams. Therefore, I do not want to sleep, I'm afraid and then I am so tired''.'

Adolescents' perception of sleep and mental health and wellbeing

Both articles explicitly discussed mental health in relation to sleep, although these discussions were limited in nature. It should also be noted that one study (25) included sleep behaviours (e.g. sleeping problems, nightmares or being unable to sleep alone because of violent games and bad movies) within the broader category of mental health issues (e.g. cognitive salience and aggressive behaviours). Despite the references to mental health, neither study seemed to ask young people directly about their perception of the relationship between sleep and mental health, rather the concept of mental health was attached, by the authors, to comments made by the young people.

Young people within Quante et al's (24) study were prompted to discuss the importance of sleep, with participants commenting on the 'energising, relaxing, stress-reducing and restorative qualities of sleep'. Authors suggested that participants could identify consequences of poor sleep, such as adverse effects on mood and patience. Young people in both studies were reported as clearly articulating the influence of mental health (e.g. anxiety, worries or fear of nightmares) on sleep e.g.

PF2: Yeah. Thinking a lot or you just can't fall asleep. Even when I clear my mind, I can't fall asleep.

PM5: It's like when you're awake but you're sleeping. PM5: When your body is like sleeping but your mind swirls.' Quante et al (2019)

''MOD: You say yes. Why do you have trouble sleeping?

PF1: I think it's because I worry about things, and I keep on thinking about it. So I can't sleep. ' Quante et al (2019)

Adolescents' perception of the three concepts mobile device screen time, sleep and mental health and wellbeing

Neither of the two studies included asked young people explicitly about the connections between screen use, sleep and mental health.

RQ5 Summary

The authors of the studies above suggest that simply being aware of the importance of sleep and sleep guidelines does not necessarily result in behaviour change. Therefore, it is important to identify key components of interventions that may result in behaviour change. Whilst young people seemed to recognise the importance of sleep, within the included studies they rarely reported on physical and mental health problems as interconnected. Where mental health issues were reported they were often seen as being related to screen use (and content) directly rather than via sleep issues. Quante et al (24) reported differences in screen exposure by gender and propose that this suggests a need for tailored interventions.