Autism Spectrum Disorder and Screen Time: Comparison
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There is growing evidence that prevalence rates of autism spectrum disorder (ASD) are increasing. A number of factors appear to contribute to this increase, including excessive screen time. Screen time seems to be linked to the severity of the symptoms of ASD. 

  • autism spectrum disorder
  • repetitive behaviors
  • screen time

1. Introduction

Compared to other neurodevelopmental disorders, the prevalence rates of autism spectrum disorder (ASD) has increased within the last two decades [1], with a rise of up to 500% from 1992 to about 2000 [2]. According to the Salari and Rasoulpoor [3] study, the prevalence of autism spectrum disorders has increased worldwide. Nevertheless, the prevalence of ASD differs by country due to differences in awareness levels, cultural differences in how children’s behavior is interpreted, variability in screening tools, the lack of culture-sensitive diagnostic tools, the evaluation year, and the sample and study populations. Currently, one out of 54 children appears to show symptoms of ASD [4]. Several hypotheses have been proposed to explain the increased prevalence rates, such as expanded diagnostic criteria, increased awareness of ASD, earlier diagnosis, recognition that ASD is a lifelong condition, and alterations in lifestyle [5,6,7][5][6][7] (see also further details below). Further, descriptively, as the prevalence of ASD has increased, the exposure of young children to digital devices (smartphones, tablets, televisions, etc.) has increased in parallel [8,9][8][9]. It has been reported that parental screen time, parental attitudes, parents’ workload, and having a television in the bedroom, as well as the availability of digital devices, are the most important factors influencing children’s screen time [10,11][10][11].

2. Symptoms of Autism SDpectrum Disorder and Exposure to Screens

Associations between ASD and television viewing were further investigated. To illustrate, Waldman and Nicholson [12] concluded that early childhood television viewing was an important trigger for autism; about 38% of ASD diagnoses appeared to be attributable to an excess of television watching. Similarly, Hermawati and Rahmadi [13] observed a statistical association between early electronic screen exposure and autistic-like behaviors (e.g., language delay, short attention span, and hyperactivity) in nine children aged 44 to 78 months. A similar pattern of association was further observed in a child aged 5 years [14]. In a further cross-sectional study Heffler and Sienko [15] investigated the associations between early life social and digital media experiences and the development of autism spectrum disorder-like symptoms. Heffler and Sienko [15] found that, among 12-month-old toddlers, the combination of increased exposure to television or video or both and shorter caregiver-child interactive play duration were significantly associated with more significant ASD-like symptoms, but not with the risk of ASD. Chen and Strodl [16] investigated in their cross-sectional study the relationship between early electronic screen exposure and autistic-like behaviors among 29,461 preschoolers aged 0–36 months and observed that a longer screen time per day was associated with autistic-like behaviors at preschool age. Dong and Wang [17] examined the association between screen time and ASD symptoms in children with ASD. Results showed that a longer screen time correlated with a higher ASD severity and with limited language abilities. The causal associations between screen time and the development of ASD at three years was further investigated among a large cohort of 84,030 children [18], with the finding that a longer screen time at the age of one year predicted symptoms of ASD at the age of 3 among boys, but not among girls.

3. Theoretical and Evidence-Based Explanations for Symptoms of Autism ASDSpectrum Disorder and Exposure to Screens

Seven theories have been proposed to explain the associations between symptoms of ASD and exposure to screens.
First, over-engagement with screen-based media may cause social isolation and deprivation [19,20,21,22][19][20][21][22]. In this view, there is evidence that restricted environments and experiences and early social isolation can cause autism symptoms and repetitive behaviors. To illustrate, children growing up in institutions were at increased risk for “quasi-autistic” patterns of behavior [23[23][24],24], also labelled post-institutional autistic syndrome (PIAS) [25]. Furthermore, Pouretemad and Sadeghi [26] defined Post-Digital Nanning Autism Syndrome (PDNAS) as a condition in which young children develop subclinical autism symptoms due to excessive exposure to digital devices (for more than half of their waking hours). The researchers hypothesized that PDNAS is a new subtype of ASD caused by and associated with the children’s lifestyle and excessive screen time at an early age. In this case, it is assumed that young children’s autism symptoms are probably causally associated with the early excessive exposure to digital devices. Previous studies have indicated that social interaction is very important for toddlers with autism [27]. According to Sadeghi and Pouretemad [28], parent–child interactions decreased children’s autism symptoms and repetitive behaviors and normalized their electrophysiological characteristics. It seems that the increase in social interactions leads to the development of neural circuits of social behaviors and, as a result, this reduces the severity of autism symptoms. In the Dawson [29] model, early behavioral intervention that leads to adaptive interactions between the child and its environment reduces autism symptoms.
Second, a prolonged screen time may contribute to non-social neural circuits formation during critical periods of brain development and neuroplasticity, and a prolonged screen time may inhibit the development of neuronal social networks [15,30,31][15][30][31]. In accordance with this theoretical framework, excessively watching television appeared to unfavorably impact on the typical development of the visual cortex, hypothalamus/septum, and sensorimotor structures in children [32].
Third, interventional studies indicated that reducing young children’s screen time and promoting social interaction reduced autism severity and normalized brain electrophysiological patterns in children with ASD-like symptoms [28,33,34,35][28][33][34][35].
Fourth, while these theories indicated that excessive screen time appeared to be causally associated with higher symptoms of ASD, an inverse direction of influence is also highly conceivable; children, at a very early age, with socioemotional deficits appeared to be more likely to prefer screens to social interactions [36,37,38][36][37][38]. Indeed, among six-month-old toddlers, the diagnosis of ASD was associated with earlier and more intensive preference for and use of screens [39].
Fifth, children with ASD may also intuitively and deliberately use screens as a coping strategy for impulse control and response inhibition [40].
Sixth, and plausibly, difficult children’s behavior may encourage their parents to expose their children to more screen time as a coping strategy [41].
Seventh, and last, longer screen time was associated with higher sleep issues and feeding problems in young children with ASD [42]; in such cases, longer screen time exposure may be understood as a coping strategy.

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