Review on screen time among children and adolescents and impact on mental health
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摘要: 目前电子产品使用的普遍化和低龄化已成为全球趋势, 多数儿童青少年每天视屏时间超过指南推荐(< 2 h)。研究综述了视屏时间对儿童青少年身心健康的影响及其与儿童青少年心理障碍的关系, 发现视屏时间过长对儿童青少年的身心健康存在负面影响, 且视屏时间与抑郁焦虑、情绪异常、社会适应障碍、行为障碍、自伤行为、危险行为存在正相关。目前相关研究主要集中在视屏时间过长与儿童青少年心理健康的相关性上, 缺少对其作用机制、影响因素的研究, 有待开展相关研究, 并探索有效的干预措施, 为提高儿童青少年健康水平提供依据。Abstract: The popularization of the use of electronic has become a global trend, and children are exposed to devices at younger ages. A large proportion of children and adolescents spend on screen time more than 2 h which is recommended in most guidelines. The paper reviews possible effects of screen time on physical and mental health, as well as mental disorders in children and adolescents. It is found that excessive screen time showed negative impacts on mental health, including depression, anxiety, mood disorder, social adaptational problems, behavioral disorders, self-injurious behaviors, and health risk behaviors. Much attention has been paid on the association between excessive screen time and mental health of children and adolescents, while possible mechanisms and influencing factors are lacking. Effective intervention studies are needed to provide a basis for child and adolescent health promotion.
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Key words:
- Fixation, ocular /
- Time /
- Mental health /
- Child /
- Adolescent
1) 利益冲突声明 所有作者声明无利益冲突。 -
儿童青少年视屏时间指3~18岁人群使用手机、电脑等电子设备的时间[1]。随着信息科技的发展、电子产品普及率的提高及网络资源的日益丰富，儿童青少年的视屏行为变化极大。儿童青少年视屏时间增加，视屏行为低龄化在全球范围内形成趋势[2-3]。视屏行为的改变可能对儿童青少年的心理健康产生影响，本文通过查阅文献，探究儿童青少年视屏时间变化与心理健康的关系，为相关研究提供参考。
1. 儿童青少年视屏时间现状
儿童青少年的视屏时间应该受到限制，这一观点为国内外共识。2017年发布的《中国儿童青少年身体活动指南》、美国儿科学会、澳大利亚卫生部和加拿大儿科学会都建议儿童青少年每日视屏时间限制在2 h以内[4-6]。然而，随着电子产品普及，儿童青少年电子产品使用率增长，视屏时间过长的现象越来越突出。1999—2009年，美国青少年日均电视使用时间从3.8 h增加到4.5 h[4]。我国新疆乌鲁木齐市3~6岁儿童日平均视屏时间和周末日平均视屏时间超过2 h的比例分别为28.3%和39.6%[7]；北京市海淀区儿童周末日平均视屏时间为(2.6±2.5)h[8]。随着年龄增长，视屏时间随之增加，视屏时间超过2 h的儿童所占比例也在上升，中国7个省会城市的调查显示，男生的周末视屏时间在7~14岁年龄段呈上升趋势，14岁时达到最高峰3.0 h/d，女生的周末视屏时间在7~15、17~18岁年龄段均呈增加趋势，且2个峰值都超过了建议的2 h[7, 9]。澳大利亚8和16岁儿童日均视屏时间超过2 h的比例分别为45%和80%[4]。
在视屏时间的分配上，美国青少年主要活跃于电子游戏及社交媒体网站[4]。国内调查显示，学龄前儿童更偏好于看电视，其次为使用平板电脑[7]。北京市学龄前儿童主要的视屏内容是学习(64.6%)、看视频(63.0%)、聊天(27.0%)、玩游戏(27.0%)和拍照或录视频(19.1%)[10]。8~16岁青少年最常使用的为社交类APP，其次是学习类、娱乐类、生活方式类[11]。
2. 新冠肺炎疫情背景下儿童青少年视屏时间的变化
由于新冠肺炎疫情，国内外儿童青少年视屏时间明显增加。据估计，新冠肺炎疫情期间，中国共有1.8亿中小学生和4 700万幼儿园儿童受到疫情影响而接受线上教学方式[12]。学习场所以及方式的改变对儿童的生活产生了巨大影响。国内疫情初期，年轻人的视屏时间可达5.1 h/d，平均每周总视屏时间延长了大约30 h，44.6%的学生每天在线学习的视屏时间超过5 h，76.9%的学生反映疫情期间视屏时间明显增加，其中城市地区学生视屏时间和增长速率均较高[13-15]。国外，智利儿童视屏时间在疫情时期增加到了3.0 h/d，约为疫情前的1.7倍[16]；土耳其71.7%的儿童青少年视屏时间增加到(6.4±3.1)h/d[17]。
3. 视屏时间和青少年心理健康
本文心理健康的定义为5个标准：智力发育正常，情绪稳定、情绪反应适度，乐于与人交往、人际关系融洽，行为统一和协调，性格特征良好[18]。视屏时间过长会对儿童青少年的心理健康产生影响。
3.1 抑郁、焦虑情绪异常
儿童青少年视屏暴露可能会增加其出现抑郁、焦虑问题的风险。多项研究显示，在各地区、各年级，视屏时间过长与儿童青少年抑郁、焦虑等不良心理现象的发生相关，每天视屏时间超过2 h的青少年心理健康状况较差[19-23]。
值得一提的是，体育活动似乎可以削弱儿童青少年视屏时间过长与心理障碍发生之间的相关性。研究显示，体育活动水平较高(相比于较低)的青少年基于屏幕的久坐行为与情绪障碍症状之间的关联较弱[24]。与之相反，当过长的视屏时间与大强度体力活动不足相关联时，儿童青少年的焦虑、抑郁症状发生率增加[25]。
3.2 社交障碍
视屏时间过长会对儿童青少年的社交造成影响，甚至导致社交障碍[26]。儿童较长的视屏时间与较差的社交技能存在关联，视屏时间>2 h/d的青少年社会适应困难的发生率更高[27]。可能是电子游戏会干扰识别面部情绪的能力，尤其会延迟对快乐表情的识别，影响情绪和社交智力导致[28-29]。同时，视屏时间的延长可能意味着社交活动、面对面交流的减少，导致社会孤立，进而影响儿童青少年的社交技能与动力[30]。
3.3 注意力缺陷多动障碍(attention deficit and hyperactivity disorder，ADHD)
ADHD是一组儿童期常见的精神神经障碍性疾病，表现为难以集中注意力、不合时宜地多动、情绪过激[31]。研究显示儿童青少年过长的视屏时间与ADHD症状水平呈正相关[32]。可能是由于视屏过程中重复的注意力转移和多任务处理导致大脑执行功能受到损伤[30]。
3.4 危险行为
危险行为指会对儿童青少年的健康状况甚至成年后的健康及生活质量造成直接或间接损害的行为, 如吸烟、暴力伤害、网络成瘾等[33]。许多危险行为与频繁使用电视、计算机或视频游戏相关[34-35]。深圳市一项调查显示，视屏时间过长的儿童青少年更容易遭受校园欺凌，也更容易参与欺凌[36]。与儿童青少年危险行为发生关联的主要视屏因素是赛车、漂移等网络游戏，且问题游戏的严重程度和游戏持续时间与暴力危险行为存在关联[37-38]。
3.5 视屏时间与儿童青少年心理障碍关系的双向性
目前儿童青少年视屏时间与心理障碍间的因果关系并不清楚。儿童青少年视屏时间与心理障碍可能具有双向性。对于有情绪问题的儿童青少年，汲取必要的动力、精力和社交技能参与社交活动更困难，因而更倾向于选择低能量的基于屏幕的久坐行为，如看电视作为享受的主要来源，他们的视屏时间更长，首次接触电子设备的年龄也更早[24, 39-42]。
3.6 视屏时间影响儿童青少年心理健康的可能机制
视屏时间过长对儿童青少年生活习惯的影响主要体现在睡眠、久坐、饮食三方面。在睡眠方面，视屏时间过长可能使神经高度兴奋而导致入睡困难、睡眠时间被压缩、睡眠质量降低，导致儿童青少年睡眠不足，进而影响身心健康[43]。久坐行为指在清醒状态下，包括视屏行为在内的所有在坐位、斜靠或平躺姿势下进行的能量消耗在1.0~1.5 METs的行为，与不健康的饮食习惯形成、骨骼异常发育有关[43-45]。儿童青少年视屏时间过长往往伴随运动时间缩短以及久坐行为加剧，导致超重和肥胖，影响其自尊以及社会交往，对心理健康造成不良影响。
在神经活动方面，视屏时间过长会影响儿童青少年的大脑发育，影响情绪调节、奖赏系统、抑制控制相关脑区的功能和结构，使儿童青少年更难控制自己的行为、情绪，导致ADHD、抑郁症、焦虑症等症状的产生[46]。如网络信息，尤其是以快节奏为主要特点的娱乐新闻、游戏或短视频，所带来的重复的短期快乐会导致用户频繁寻求更高的唤醒水平，阻碍学习、课堂活动等需要长时间注意力且更能刺激认知能力的活动，加重ADHD症状[43]。儿童青少年的心智发育还不成熟，自控能力不足，视屏时间过长带给他们的影响会更加突出。
4. 建议与展望
随着电子设备深入到生活中的各个方面，未来青少年的视屏时间将表现出持续增长趋势，而视屏时间过长会影响儿童青少年心理健康，甚至出现抑郁、焦虑、社交障碍、危险行为等问题，必须引起家长、学校、政府相关部门的重视。
目前关于视屏内容对儿童青少年心理健康影响的研究不足。研究表明，相比于以看电视为主的视屏行为，以电子游戏为主的视屏行为与重度抑郁症、广泛性焦虑症、恐慌症和社交恐惧症状呈正相关[47]。同时，相比于玩低暴力游戏者，参与高暴力游戏者抑郁症状更明显[48]。Tang等[49]也发现，总视屏时间对抑郁、焦虑症状的预测作用很弱，而电脑游戏、互联网的使用时长与抑郁、焦虑症状的相关性大于其他视屏方式(电视、社交媒体等)。不同视屏内容对儿童青少年心理健康产生影响的差异可能是由互动介导的，过度视屏会使儿童青少年与他人的互动频率减少，但看电视、社交媒体等视屏行为可能由孩子和他人共同进行，反而增加了相互间的互动[22-23]。未来需要进一步探讨儿童青少年视屏行为特征、影响因素，以及有效的干预措施，为提高青少年健康水平提供依据。
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