2  Introduction

2.1 Preface to the introduction

Children are social beings. They develop in a massive dependence on their environment. We shape their biography, physical, mental and intellectual development (see §35 SGB Mental Health), significantly through our actions. With the rapid development of digitalization, the respective facts must be supplemented by a professionally competent assessment of future developments and their consequences for the health of children. This guideline is therefore based on the basic principle of “acting with insight”. The form, functionality and nature of the rooms and objects, the socio-cultural environment characterized by love and goodwill and the mental alertness, agility and worldview of fellow human beings have an initially very direct and later more indirect effect on the brain structures, habits, abilities, wishes and interests of the child. Education and relationships are the variables that determine human health. At the same time, every child also has an innate, free development potential that is astonishingly strong in some children and that in itself means that they can develop to the highest level even under the “most unfavorable” conditions. When assessing and advising on media education, one can fall into the trap of blaming the parents and overlooking the role played by the characteristics of the child on the one hand and the social conditions on the other. A phenomenological, unbiased observation and advice on the overall situation with a “positive bias” and in the knowledge that almost all parents want the best for their children is necessary. By focusing primarily on the real resources of children and adults and promoting and strengthening them, the danger of removing digital resources creating a void that, in the worst case, is filled with something even more unhealthy is avoided. Really profound changes in life come about primarily through inner insights, not just through rules and structures. In a family context, this also means reflection and awareness of one’s own role model function. The main thing for this guideline will therefore be to generate insight and motivation to implement the initially abstract recommendations. This guideline is aimed at people who work with parents, children and young people on the subject of “screen media” as part of their professional activities. This requires communication materials, dialogic processes and creative solutions. We need negative examples and warnings, but above all “best practice” examples that are inspiring and infectious and take into account the individual inclinations of each child. It is crucial that parents learn to understand the “language of their child” better and better . Parents need suggestions to be able to assess their child’s vitality. Knowing when the child is tired, happy, hungry or dissatisfied is of central importance in order to decide which type of interaction is useful or necessary at the time. It should be emphasized that the child has a personality that develops in interaction with and together with the parents. Readers should also know the importance of general sensory care. This includes a sense of one’s own well-being, one’s own movements, one’s own thoughts and a sense of the “you” of the other person. Parents who have a good perception of their child’s expressions of life, are aware of their role model function and devote time, attention and sensitivity to their parenting tasks every day can enable healthy growth in today’s media landscape and also counteract “slip-ups” that can be found in every area of education and find ways to compensate. It is important for adults to be aware that children, regardless of age, are not small adults. It must be taken into account that in the first three years of life, important processes of neuronal maturation and structuring of the child’s brain take place and are also completed in many areas, especially in sensorimotor development. Children need ample opportunity to be creative in the three-dimensional world and to have a variety of real experiences with all of their senses. The less practice children have in creating their own inner images, the more difficult it is for them to develop their imagination [1]. Small children perceive the world differently, so that parents and children may be in the same environment , but they experience and perceive things very differently. Children have needs that often do not correspond to those of adults. Children therefore need, above all, a great deal of attention and sensitive appreciation. The well-being of children requires parents who are prepared to embark on a constant path of learning and further training in order to understand their children and who take time for their children. As a counterbalance to the generally required media competence, analogue future competence should represent another social goal. Children in particular should learn and experience from their parents that the time not spent on screen media counts in life. The time children spend with screen media means they are not able to acquire analog skills (speaking, social behavior, motor skills, etc.). This guideline provides a formal basis for education on how to deal with screen media . The recommended materials may help to identify and prevent behaviors that are detrimental to development on the part of educators at an early stage.

“Man becomes an I through the You.” (Martin Buber)

2.2 Background

Most experts agree: On average, young children spend too much time with screen media [2, 3], and the trend is increasing [4]. Accelerated by the Corona crisis, screen media are taking on an unprecedented importance in everyday life. Lessons are being moved to virtual classrooms, kindergarten children are following digital play groups on the screen. Adults and children alike are finding more ways to pass the time with digital communication, films and computer games than ever before. According to a recent survey in Germany, adults now spend around a third of their lives online [5] . Despite all the opportunities and potential that screen media has, we must not forget that there are downsides: the younger the person and the more persistent the use, the more pronounced the downsides.

Building on these considerations, the following overarching and summary principles can provide guidance for balancing the opportunities and potential of screen media exposure in childhood and adolescence on the one hand, and the risks on the other. Mößle formulates six rules of thumb for balancing the opportunities and risks of children’s screen media use [6], which therefore depends on the following factors:

  • the age of the user: the younger, the worse
  • on the duration of use: the longer, the worse
  • of everyday vs. laboratory/school setting: Better in experiment/school, worse in everyday use
  • from the period of recording consequences: better in the short term, worse in the long term
  • of processing aids: Unsupervised child use of poor
  • on the type of learning performance: Procedural knowledge better than fact-based knowledge

Screen media has a more negative impact on children’s health than on adults [7, 8]. In particular, the “time displacement hypothesis” [6] – that screens act as time thieves and a child who spends more time on a screen has less time to spend on developmentally beneficial activities in the real world – can be cited as a key explanation here. During early childhood, excessive use of screen media, both by parents and by the children themselves, is associated with numerous negative health effects (e.g. regulatory and attachment disorders [9, 10], developmental disorders [11], particularly language and cognition [12, 13]), although the data initially appears controversial. In fact, negative findings are more common in high-quality studies, e.g. B. Longitudinal studies, however, positive findings are mainly found in experimental studies in which an educationally intended use of screen media is examined or in studies in which only a few intervening variables are recorded [14].

There is much evidence to suggest that the long-term effects of dysregulated screen media use are associated with significant costs for the health system, but due to the lack of randomized trials, there are only estimates [15]. In particular, a further differentiation between receptive and interactive screen media is necessary in future studies on media effects research, as well as further distinctions in the type and manner of use: It is necessary that detailed usage profiles of children and adolescents are taken into account in further research processes (e.g. does screen use take place at home/on the go? How long are the time windows NOT interrupted by looking at the smartphone or other devices? Are the screen media used for further education or for private pastimes/out of boredom?). In studies on screen media consumption in the context of educational institutions, so far only the effects on learning performance are recorded [16, 17], but not the short- and long-term effects on physical and psychosocial development. There are also no studies to date that examine the influence of screen media use in educational institutions by professionals on the professional-child interaction, similar to the investigation of “technoference” in studies on parental use.

We can only speculate about the effects on vital skills such as ingenuity, action skills, manual dexterity, artistic, sporting and musical abilities and inclinations. However, it is to be feared that there will be significant effects [1]. Reducing exposure to screen media in the first years of life, on the other hand, is associated with positive effects in numerous developmental domains (including executive functions, fine motor skills [3], attention, prosocial behavior [18]). Students who do not use their cell phones in lectures take notes 62% more information and can remember more detailed information from class [19]. In the USA, reducing screen time, even for young children, is a national health goal [20]. China, which is considered a pioneer in the field of screen media, describes online games as “mental opium” and “electronic drugs”, and has therefore recently limited online video game time for children and young people to three hours per week! German statements from associations and health organizations (BVKJ, DGKJ, DGSPJ, BZgA, klicksafe.de, schau-hin.info and bildschirmfrei-bis-3.de) recommend keeping children under 3 years of age away from screen media altogether.

In order to implement recommendations such as these in health care, cost-effective interventions that can be scaled into routine care are necessary. This guideline is intended to make a theoretical contribution to this.

2.3 Screen media

Since the middle of the last century, the growing availability of television sets – probably the first digital screen medium, with ever longer broadcast times and an increasing number of programs – has brought about profound changes in the way people spend their free time. The spread of the Internet, mobile devices and software developments, for example in the communications or computer games sector, is now having an enormous impact on society [21]. The rapid technological progress in this area in recent years has led to screen media being firmly integrated into everyday life [22]. A distinction must be made here between voluntary or optional use for entertainment purposes, compulsory use (e.g. in the work context) and use that has become “quasi-compulsory” for the individual consumer due to the dismantling of analogue alternatives by higher-level actors. With regard to screen media, a distinction can be made between traditional screen media and new screen media. With traditional screen media, such as the television, content is consumed passively. New media, which include interactive and social media, offer users the opportunity to use existing content and applications (apps/games) passively or interactively, or to actively produce their own content or even applications [23]. The term “social media”, a term that is somewhat euphemistic, is often used as a generic term for various types of interactive media, which have a wide variety of properties and objectives [24]. In Germany, too, the use of social media is the top priority [25]. Mothers, fathers, caregivers and those responsible for raising children and young people of all ages are increasingly uncertain about the voluntary and externally determined consumption of screen media [26]. A conscious approach is required in order to keep an eye on opportunities and risks and to be critical in the selection of screen media. Media literacy, i.e. the ability to use digital media in a targeted manner, but also to be able to do without it and to critically evaluate the content, should be promoted among parents/caregivers. In this context, the intended media literacy, as the opposite of media addiction, must be distinguished from media competence. Although the term media competence is often understood in academic discourse [27] not only as the ability to use media and its content in accordance with one’s own goals and needs, and a broader understanding is formulated that approximates the above-mentioned understanding of media literacy, in public discourse media competence is often reduced to the ability to use technical devices. Among other things, the Children’s Commission of the German Bundestag advocates a graduated educational concept of media literacy that takes into account the age and living environment of children and young people: “The aim of media education in schools is general media literacy in the sense of a critical understanding of the media and the ability to use it confidently and responsibly. An”overall concept of media education” is needed that involves schools, parents and non-school actors in a professional and pedagogical manner and is structured in an age-appropriate manner” [28]. Experts are also increasingly calling for an intensive discussion of the ongoing media revolution and for media-literate students and teachers [29]. The social pressure exerted on children and young people who do not consume certain media and/or are not “in the know” about current trends is particularly important here. Media literacy, which also includes the current renunciation of media use, must not lead to exclusion.

2.4 Definition of dysregulated screen media use

The strongest predictor of emotional or social problems related to screen media use is the role that these media play in the family structure, both the functions they perform from the parents’ perspective and the way children use the devices, not just the amount of time family members spend using them. Below you will find a selection of warning signs which, even if they occur individually, indicate a dysregulated Screen media usage [30]:

  • Loss of control: The child/young person finds it difficult to stop using screen media.
  • Loss of interest: Screen media is the only thing that seems to motivate the child/teenager.
  • Worrying preoccupation: The child/young person seems to only think about screen media.
  • Psychosocial consequences: The child/adolescent’s use of screen media interferes with family activities.
  • Serious problems caused by use: The child/young person’s use of screen media causes problems in the family.
  • Withdrawal: The child/young person is frustrated when he/she cannot use screen media.
  • Tolerability: The amount of time the child/adolescent wants to use screen media is becoming longer and longer.
  • Deception: The child/young person secretly uses screen media.
  • Escape/mood enhancement: When the child/teenager has had a bad day, screen media seems to be the only thing that helps them feel better.
  • Decline in academic performance: Difficulty concentrating, lack of sleep and days off school by the child/young person endanger their academic development.

2.5 Use of digital media in childhood and adolescence

Children today are exposed to more technology than in previous decades. They also have access to more screen media, which is accompanied by an increase in screen time [31] . The influence of traditional media is increasingly being replaced and supplemented by the use of interactive digital media [4, 23, 32] . Since the introduction and spread of tablets and smartphones, more and more activities in the home are connected to screen media [23] , such as shopping or information about household-related activities. Younger children and children from families with a lower socioeconomic status increasingly use mobile media devices for entertainment purposes rather than for educational purposes [33, 34]. There is evidence of an educational gradient in the relationship between entertainment and educational use of mobile media devices [34]. Device development has also changed user behavior with regard to screen media. While in 1970 children began watching television regularly at around the age of 4, today children in the USA often come into contact with screen media as early as 4 months of age [23]. The possibility of making video games available on mobile devices means that they are being integrated into everyday life to a greater extent [23] . The simultaneous use of several media at the same time is normal for many young people and can now even be observed in children under 4 years of age [35] .

In 2020, the proportion of children who consumed moving images at least once a day via the respective device was over 70% for television among 3- to 10-year-olds and around 20% for tablets and smartphones. From the age group of 11 to 13 years, the proportion for television is only 60% or less, whereas the proportion of smartphone use increases to over 50% [36].

In 2020, television was the most relevant leisure activity among children and adolescents. 70% of all children said they watched television every day or almost every day. Screen time in front of the television was around 58 minutes of television per day [37] . In Germany, according to the miniKIM study, television is still the leading medium until the end of kindergarten age [4] . Television is the medium most likely to be used alone among children and adolescents, with the proportion increasing for each age group. While 39% of 6- to 7-year-olds surveyed in 2020 said they watched television alone, the proportion among 12- to 13-year-olds was 58%. In this age group, television was no longer the medium most frequently used alone. Priority was given to surfing the Internet (74%), mobile games (67%) and looking for information on the Internet for school (64%) [37].

Televisions, internet access and smartphones are present in almost all households. In 2020, around half of children between the ages of 6 and 13 had their own cell phone or smartphone, and around 49% had a games console. Computers can be found in more than 80% of households. According to the Children’s Media Study (KIM), the frequency of ownership of electronic devices increases with age. As early as 2018, 17% of 6-year-olds owned their own cell phone or smartphone, and by the age of 13, this figure had risen to 92% [38].

In terms of social media usage, WhatsApp is the most popular product among all age groups between 10 and 18 years old. It is followed by Instagram in the age group between 12 and 18 years old, closely followed by Snapchat. However, among children aged 10 to 11 years, Tik Tok is in second place. Facebook and Twitter are still particularly popular among older teenagers. News is consumed by 10 to 18 year olds primarily through moving images [39].

2.6 Use of digital media in times of pandemics and isolation

The corona pandemic and the accompanying measures to contain it have increased the development of behavioral addictions [40, 41]. Factors such as the loss of alternative offers, social isolation and forced inactivity as well as the increasing importance of online offers contributed to this. Essential social contacts such as contact with grandparents and friends as well as sports, etc. could only take place via the screen for weeks and months. At the same time, technology made it possible to maintain social contacts. In a Forsa survey commissioned by DAK-Gesundheit at the beginning of the corona pandemic in 2020, adolescents stated that the main reasons for gaming and social media use were to combat boredom, maintain social contacts, reduce stress and forget worries. During the first lockdown in 2020, gaming usage times on weekdays increased by an average of 75%, from 79 to 139 minutes a day. Likewise, the time spent using social media increased by 66% from 116 to 193 minutes [42] . Another study confirms the significant increase in the frequency and duration of use of games and social media during the lockdown [43, 44]. At the same time, as a result, the severity of media use disorders that already existed before Corona has increased and the chances of remission have decreased [45] . An increased risk of relapse can also be assumed [46].

2.7 Digital distance learning

In digital distance learning, teaching content is provided via platforms on digital screens and/or lessons are conducted using video conferencing techniques in virtual classrooms. Children who are taught via digital lessons therefore spend many hours a day in front of screen media due to compulsory schooling. A review that summarizes international study results shows that students in Germany did not learn during the first lockdown, but rather unlearned things. The effect on learning performance was comparable to that of holidays [47]. Things did not look much better in the second lockdown [48]. When the device is running, the temptation to play games, surf the Internet, and the like at the same time as the lesson is very tempting. It is also unclear in all educational levels how much of the work was done independently by the student and how much by parents/siblings, etc.

It must be assumed that the sum of screen media use for school and leisure time taken together is decisive for an assessment of the health risks. Especially for younger children who have not previously had their own internet-capable digital devices, the availability of these devices poses the risk that their leisure time use will increase significantly beyond school use . On average, the usage times of children with their own device are about twice as high as those without, and contact with content that is not age-appropriate increases sixfold [6]. There are good reasons to assume that digital teaching brings with it the same symptoms as traditional office work or screen work: headaches, nervousness, irritability, musculoskeletal disorders and eye diseases. A large proportion of children do not have access to fully equipped PC workstations and therefore follow digital lessons on mobile devices. Not least because many schools have started to buy tablets in large quantities or receive them as gifts from industry and lend them to students in order to ensure digital teaching. This development is worrying, as the Federal Institute for Occupational Safety and Health advises that tablets and smartphones should only be used for short periods of time due to the increased risks of physical strain [49]. In addition, the use of screen media and further developments in communication are increasing the associated flood of information, which can lead to increased expectations of the individual’s work pace and workload and consequently to psychological overstrain. Therefore, in addition to the classic ergonomic design of computer workstations, factors such as work organization, self-management and communication skills are increasingly becoming relevant. Last but not least, study results indicate a negative effect of school closures on student performance, particularly among younger students and students from families with a low socioeconomic status, and that measures must be taken to mitigate these negative effects [47]. In summary, it can be said that digitalization, although important, is not a savior for all educational challenges, and that technology should sensibly be subordinated to interaction between people [16].

2.8 Role model function in dealing with screen media

Promoting parental self-efficacy or changing parenting styles may be promising approaches to reduce screen time in young children [50]. In the field of eating behavior, it is known that parents modeling healthy behavior is an important method of influencing children’s diet quality, possibly even more than the actual quality of parents’ diet [51, 52]. Parents should serve as an important mechanism for changing children’s health status by improving their own health-related behavior [53]. Siblings also have a special significance with regard to screen media usage behavior, as they have a lasting influence both as peers and as family members.

In Western countries, most siblings live together for long periods of time, communicate daily, and spend a lot of time together. They are likely to spend more time together than with their parents [54], as they tend to have the longest-lasting relationships among family members – even longer than parent-child or spouse relationships [55]. Reviews of correlates of screen time in preschool children have found no association between the presence of siblings and sedentary activities, including television or electronic media viewing [56, 57]. Nevertheless, the child development literature contains ample empirical evidence that siblings have a positive impact on each other’s cognitive, social, and emotional development [54]. For example, for every hour a child spends watching television without siblings, the amount of time the child spends interacting with siblings decreases. And not just by one hour, but by about one and a half hours. For every hour of television viewing, interaction with parents decreases, as does the time spent on homework and creative play [58]. It therefore seems sensible to take the role model function into account within the recommendations of this guideline.

2.9 Youth Protection Act

The regulations on age ratings for films and computer games for child and youth media protection were fundamentally modernized with the reform of the Youth Protection Act on May 1, 2021 and offer more reliable and comprehensible guidance for parents, professionals and children and young people themselves. Online-based film and game platforms must also provide their offerings with age ratings that have been created on a transparent basis. To the extent that they significantly shape the age suitability of a medium, interaction risks, such as chat functions, are also included in the age rating. The same applies to purchase incentives (in-game and in-app purchases) and gambling-like elements. By including all relevant elements in age labeling, users, parents and professionals should be enabled to make a safe decision regarding suitability.

2.10 Risks of dysregulated use of screen media

Although media use at school age offers advantages, such as the exchange of information, the stimulation of creativity [59] (although no studies are known to prove a long-term creativity-promoting effect of screen media use!), the exchange with like-minded people [60] or opportunities for communication regardless of geographical distance [61], it is also associated with various incalculable risks. The operation of tablets and smartphones is highly intuitive and therefore “child’s play”, so that children under the age of three are already able to carry out simple activities such as swiping and unlocking on these devices – and do so regularly [62] . When it comes to regulating the use of screen media by children, not only parents but also daycare centers and schools have a role to play, as the children themselves do not yet have sufficient regulation options [63]. Of particular importance for the “ability to regulate” is the fact that, unlike, for example, children with screen media cannot regulate their own behavior. For example, when eating, where children can tell when they are full, and when exercising, where children receive immediate feedback on risky behavior through small accidents and pain, the health risks of excessive screen media use are not immediately experienced. For many people, these only become apparent several years or decades later. “Learning from mistakes” is therefore not possible. In addition, the long-term consequences of content often only become apparent later, such as content that endangers privacy: once an image or video has been posted on the Internet, it cannot be deleted.

According to Mall & Paulus, interaction is one of the most important factors in child development, with emotional attachment and the availability of trusted people being particularly important [21]. Interactions between parents and children during screen media use are very important in order to promote positive, meaningful and independent usage behavior [64]. The content of screen media, the context of games on the screen and the extent to which adults accompany children during screen time are more important in their impact on children than the amount of time spent in front of the screen [65] . Heavy use of mobile devices by parents is associated with less verbal and non-verbal interaction with their children [66] and probably with increased parent-child conflicts [10].

In general, excessive television viewing is associated with conflicts in the family [67]. Children aged 2 years are more likely to perceive inappropriate content via “background media” than older children [68]. Children and young people are increasingly exposed to a wide variety of advertising via screen media [69]. This is made much more individualized by profiling the respective user behavior [70]. Another study shows that children consume content via YouTube or Netflix to a greater extent than educational programs or learning apps [33].

Since children often come into contact with the Internet actively and passively at a young age and are often more competent than adults in their environment, for example in the area of using social media, new demands arise for education [71]. With mobile use of the Internet via smartphone, parents generally have little insight into the Internet content used by their children, which is why technical solutions for child protection, especially on smartphones, are absolutely necessary. These block, for example, content that is not suitable for children, but can be removed by older children with little know-how and thus represent a questionable restriction or prevention. Surprisingly, the fewest restrictions exist when it comes to playing on smartphones: only 62% of educators whose children play on smartphones set guidelines regarding the length of time they can use their smartphones. Two thirds of parents do not use any technical child protection options [25]. The small devices are underestimated.

2.10.1 Obesity

Various studies have shown a link between media use and obesity [61]. Commonly suspected mechanisms include reduced physical activity, increased calorie intake from eating in front of the screen, the effects of advertising presented there, and reduced sleep duration [72]. For children aged between 4 and 9 years, daily TV consumption of more than one and a half hours is a risk factor for the development of obesity [73]. The results of another study with children aged 2 years found a link between an increase in BMI for every hour of media consumption per week [74]. Sisson et al. note that it is not the amount of television consumption alone that is a significant factor in the development of obesity [75]. Another study suggests that the combination of the presence of a TV in the bedroom and an increased number of hours of television viewing is most strongly associated with the development of obesity [76].

2.10.2 Sleep disorders

Several studies show that increased digital media use leads to a higher risk of sleep disorders [77]. The causes for this are often cited as replacing sleep time with time in front of the screen, psychological stimulation due to the media content and effects caused by the light emitted by the devices [78]. Increased media use and the presence of digital screen media devices in the bedroom is associated with reduced sleep duration in childhood [79]. A larger number of screen media in the bedroom is associated with poorer sleep quality [77]. The use of screen media in the evening hours is also associated with shorter sleep duration in children [80]. In addition to sleep disorders, screen media use around bedtime is also associated with negative effects on school performance [81]. The use of screen media before bedtime is associated with depressive symptoms in adolescents [82–84]. The use of electronic media during the day can also be associated with insufficient sleep [85].

2.10.3 Eye diseases

The dangers of blue light from screen media have been the subject of numerous publications [86]. Prolonged smartphone use, especially in children, increases eye diseases, including myopia (the eyeball is still growing until about 4 years of age), asthenopia and ocular surface diseases [87]. Myopia is the eye disease with the fastest increasing prevalence worldwide and develops with a peak in incidence between the ages of 13 and 15 years. Although the cause of myopia is complex, in addition to genetic predispositions, lifestyle factors in childhood , such as little time outdoors and work close to the eyes, such as reading and smartphone use, are suspected to be risk factors [88].

2.10.4 Developmental disorders (fine motor skills, gross motor skills, language)

The exchange between doctors, educators and other experts during the creation of this guideline showed that many are convinced that development suffers considerably more in many dimensions than studies have so far been able to prove. Various studies confirm a connection between television consumption in childhood and later delays in cognitive [89], linguistic [13, 22, 56], social and emotional development [90] as well as hyperactivity [91]. Children under 30 months of age had difficulty learning from content presented in two dimensions because they were unable to transfer it to the three-dimensional world to the necessary extent. This is attributed to the fact that, compared to adults, their skills in symbolic thinking, attention control and memory flexibility are not yet fully developed [92]. In children between 2 and 3 years of age, a positive connection between screen time and a lower developmental status at the age of 5 was demonstrated [12]. Another study found a negative association between the amount of television viewing in infancy and later gross motor skills [93].

2.10.5 Attachment disorder

The period after birth is of great importance for the establishment and development of a secure attachment relationship between the infant and the caregiver. During this phase, parent-child interaction should be characterized by as few interruptions as possible and by increased parental sensitivity [94]. In particular, parental sensitivity and the reliable response to the child’s needs in the form of physical contact, eye contact and attention are a challenge and are made even more difficult by the simultaneous use of digital screen media [95]. An analogous paradigm for the effect of the reduced reaction and interaction of parents to the child’s needs is shown by the “still face task”. In this task, the caregiver is asked to freeze in their facial expressions and gestures when interacting with the child. The child reacts increasingly stressed, irritated and unsettled to the frozen facial expressions and gestures, and demands a resonant response from the caregiver through gesticulations and facial expressions, even crying [96]. Similar reactions in the child are triggered by the absence of attention from the parents due to digital devices [97], also known as “phubbing” [98]. It has also been shown that the use of screen media is associated with an increased risk of injury in distracted parents, reduced parent-child interaction and reduced attention [95]. Accordingly, parents are less concerned with the needs of their children when using screen media and also show unreliable reactions to the child [97]. This puts a strain on the parent-child relationship and has an impact on further relationships with other people. These early relationship experiences, characterized by less interaction and less reliable responses to the child’s needs, affect the ability to empathize and also influence the development of further interpersonal relationships [7]. The less empathy skills can be developed through parent-child interaction, the more difficulties potentially arise in building human relationships [7]. These unfavorable bonding relationships and a lack of empathy training particularly encourage an increased withdrawal into the digital world, even leading to pathological use of screen media [99].

2.10.6 Behavioral disorders

The prevalence of behavioral disorders associated with screen media in German children and adolescents was estimated at 3 - 5% even before the pandemic. Behavioral disorders associated with screen media arise due to dysfunctional learning processes in combination with general and specific risk factors [100]. Significant correlations are increasingly being found between depictions of violence in the media and aggressive behavior in children [59]. However, although violent media consumption has an impact on short-term propensity to violence (state aggression), it has less of an impact on long-term propensity to violence (trait aggression). Current models assume that violent media consumption leads to a loss of empathy, so that in critical situations, violent acts continue instead of being inhibited. The depiction of health-damaging behavior in screen media can also make this appear normative or desirable in adolescents [101]. For example, the exposure of adolescents to the topics of alcohol consumption [35], tobacco consumption [102] or sexuality [103] via screen media is associated with an earlier onset of these behaviors. Early onset of media use, higher media usage time, and lower quality content are associated with reduced impulse control, reduced self-regulation, and lower mental flexibility in preschool children [104]. Although the available evidence suggests a link between media and ADHD-related behaviors such as attention and concentration problems, impulsivity and hyperactivity [105], there is also evidence that individual differences between children such as gender and aggression traits influence this association [106].

The use of entertainment media while doing homework can also have a negative impact on learning [107] and creativity [1] in children and adolescents. Negative effects of low socioeconomic status on their executional functions in preschool children are intensified by the combination of inappropriate media content and inadequate media regulation by parents [108]. Increased use of screen media by parents harbours the dangers of emotional and social maldevelopment in children [59]. Studies as well suggest that in families with low socioeconomic status, a combination of inappropriate media content and inadequate media regulation by parents exacerbates the negative effects on executive functions in preschool children [109]. Moreover, studies suggest a connection between role stereotypes presented on TV and the development of self-esteem in children [110]. The use of social media is associated with reduced satisfaction and well-being [111]. Following the user profiles of strangers on social media, in combination with an increased tendency towards social comparison, is associated with depressive symptoms [112].

2.10.7 Internet usage disorders (Internet addiction)

Excessive use of online media by children poses the risk of developing problematic internet behavior [109]. Likewise, heavy use of video games is associated with an increased risk of internet behavior disturbances [113]. International studies show that 4 to 8% of children and adolescents exhibited problematic internet behavior as early as in 2014 [114]. Even before the pandemic, figures from Germany showed a significant increase in the prevalence of internet use disorder among adolescents aged 12 to 17 years, from 3.3/3.0% (girls/boys) in 2011 to 8.6/6.7% in 2019 [115]. Symptoms occur in connection with problematic internet behavior and disturbed online gaming behavior that are also known from other forms of addiction. According to the characteristics for behavioral addictions in the ICD-11, in which computer gaming disorder was acknowledged as a known illness, these symptoms include a loss of control over when, how often, how long and in which contexts the behavior is practiced, as well as an increasing priority of this activity in the life of the person involved, and a continuation of the behavior despite the negative consequences involved. A further criterion is that an impairment due to media use behavior must be present for the diagnosis to be valid [116]. In the DSM-5, other characteristics are listed for Internet Gaming Disorder, such as being taken in, withdrawal symptoms, tolerance development, dysfunctional emotion regulation, and concealing the actual extent of the behavior [117]. Consequences of the disorders can include conflicts with parents and other people, neglect of tasks, social contacts, job, school and hobbies, as well as a drop in performance, loneliness and health detriments. Mental disorders such as anxiety or depression often occur together with Internet usage disorder, and can precede it or result from it. A number of assessment instruments have been developed for such disorders, which detect either specific behavior (use of computer games or of social networks) or general Internet use disorder. For the latter area, the Compulsive Internet Use Scale (CIUS) has proven practical, although there is only limited validation for adolescents (long version from 14 years of age). The CIUS is a self-test consisting of 14 statements about private Internet use that measures the extent of an Internet use disorder [118] and that, if necessary, can serve as an indication that parents and doctors should consider professional help. There is also a short form validated in Germany with 5 criteria [119]. This is available at the dia-net.com website (www.dia-net.com/screeningDiagnostik.html#scrB4H). A fully standardized diagnostic interview can also be conducted on this website (www.dia-net.com/screeningDiagnostik.html#scrB6H).

2.10.8 Bullying and sexual harassment

In Germany, 5% of 6 to 13-year-olds had already come into contact with discriminatory (e.g. sexist, racist) media content in 2018, and 4% had encountered frightening content. Boys tended to come into contact with content inappropriate for their age earlier than girls. In general, the risk of being exposed to inappropriate Internet content increases with age [25]. Internet bullying is another risk and is associated with negative social, academic and health outcomes [120]. The problem with Internet bullying is that the victim can be reached at any time as soon as online media is used. Victims of Internet bullying show higher levels of suicidal thoughts and suicide attempts [61]. As far as social media is concerned, these always carry the risk of violations of privacy and unwanted distribution of private content, which is subsequently difficult to remove [121]. The Internet also poses the risk for children to be exposed to sexual harassment in the context of social networks, chat rooms or online games [122]. There are large inter-individual differences among adolescents regarding the understanding of privacy protection measures within the media. Even a large proportion of adolescents who have a high level of understanding often do not implement the possible protective measures [123].

2.10.9 Gambling

While gambling is prohibited for minors in Germany, there is simulated gambling, particularly on the Internet, which has much higher payouts and is permitted for children and adolescents. With the feeling that gambling can be controlled, children and adolescents switch to inadequately protected access to “real” gambling, including on social media [124]. Children and adolescents are susceptible to gambling due to their developmental and cognitive naivety and their sensitivity to peer pressure and marketing. In-game or in-app offers are often difficult for children to recognize. Purchases result in unintentionally high mobile phone bills, and there are subscription and cost traps. The prevalence of online gambling is increasing among children and adolescents, with some adolescents who gamble developing a gambling disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), pathological gambling behavior is present when four of nine identifying criteria are met within a period of 12 months [125]. Although gambling is prohibited for adolescents, the prevalence of the disorder among 14- to 17-year-olds was already higher than that of adults in 2015, according to a representative study from Germany [126]. Adolescents who have gambling problems tend to have lower self-esteem and a history of hyperactivity and impulsivity, are more likely to have parents who are gamblers, report less parental supervision and consume more alcohol than their peers [127]. Studies show that gender, parental behavior and extensive Internet activity are among the best predictors of online gambling [124]. Parental safety practices often have no influence on the extent of online gambling, which shows the need for specific measures to combat this phenomenon, since providing simple information about the dangers is not enough here. The effective management of gambling disorders in children and adolescents requires close cooperation with families [124, 127]. Since prepaid contracts only allow access to the credit that has been loaded, they can help limit costs and support effective management of gambling disorders by limiting access to paid offers. However, inappropriate purchases of prepaid credit can be uncontrollable, especially among older teenagers. Prepaid contracts that allow top-ups and debits to be viewed in a user account are helpful in these cases.

2.10.10 radiation

Due to the widespread presence of mobile phones and other wireless networks, most people are constantly exposed to high-frequency electromagnetic radiation. The effects of this radiation on human health are still unclear. Reliable research results, mostly from animal experiments, indicate that cellular changes and even tumors are promoted by electromagnetic fields [128]. The extent to which this is transferable to humans is a matter of scientific controversy, and no clear connection with diseases such as cancer, depression, sleep disorders, addictive behavior, infertility or electrohypersensitivity has been demonstrated [129]. However, risks to human health, especially in children, cannot be ruled out based on the current state of research, which is why the International Agency for Research on Cancer, a WHO organization, classifies high-frequency electromagnetic fields as possibly carcinogenic to humans (Group 2B). This is a category used when a causal relationship is considered credible, but coincidence, distortion or confusion cannot be excluded with sufficient certainty [130]. The Scientific Advisory Council of the German Federal Government on Global Environmental Change classifies mobile communications as a risk technology [131]. The German Federal Office for Radiation Protection advises minimizing exposure to high-frequency electromagnetic radiation, especially for children and young people, as their health may be more sensitive [132].

2.11 Screen media during pregnancy

Pregnant women use the Internet to seek social support from other pregnant women, to research specific problems, to get advice or find information on home remedies, to participate in discussion groups, and to find information on prenatal tests [133, 134]. It is assumed that the majority of all pregnant women use at least one, if not several, pregnancy apps on their smartphone [135]. However, the excessive use of screen media can lead to health problems, depending on the dose: It is assumed that digital media have both a direct and an indirect influence on parents, children, their relationships and their living environment even before birth [136]. A connection has already been shown between maternal use of mobile phones during pregnancy and an increased risk of behavioral problems, particularly hyperactivity, in children [137]. In a survey published in 2008, mothers’ use of mobile phones during pregnancy was associated with a 50% increased probability of behavioral problems in their children at the age of 7 [138]. Mothers also have their smartphones near them while they sleep. Mothers surveyed could imagine using screen media less and, for example, talking more with their unborn child [135]. A bibliographic analysis of publications from the last 15 years dealing with the use of screen media during pregnancy showed that there is still a large need for research [139].

2.12 Screen media and children with special needs

Screen media have the potential to open up new opportunities for children with special needs in various areas of life. For people with disabilities, computers are widely accepted and institutionally supported as tools to manage activities of daily living at home and in the workplace. Screen media are making their way into the daily activities of adults with disabilities in two ways: Firstly, screen media provide support for traditional offline tasks such as communication or orientation. Secondly, due to their ubiquity in every single social subsystem (education, politics, economics, health, etc.), screen media establish new access to social offerings and discourses [140, 141]. There are currently no publications on the importance of screen media in children’s daily lives, but it is not unreasonable to assume similar mechanisms [142, 143]. This shift in social interaction to digital networks supports the participation of people with disabilities, since it reduces certain restrictions. At the same time, however, new barriers are also emerging (accessibility, skills, etc.). It must be taken into account that competent use of screen media is very relevant today, especially with regard to later professional advancement. A lack of access to or skills in using screen media can jeopardize social participation. In addition to the opportunities and barriers, screen media also pose tangible risks, especially for people with cognitive impairments. If digital content cannot be understood or classified correctly, the risk increases that content will be disturbing or that users will become victims of fraud and abuse. Another risk lies in the (in)ability to make decisions regarding private and public content and the associated risk of unwanted exposure [144]. Thus the challenge for parents and caregivers is to shape the contact of people, especially children with disabilities or special needs, when dealing with screen media, in such a way that they benefit from it, that they can exercise their rights in the same way as other people, and that their safety is guaranteed.