Letters

Study concept and design: All authors. time. Six items from the Parent Opinion Survey7 assessed
Acquisition, analysis, or interpretation of data: All authors. parental perceived control regarding their child’s develop-
Drafting of the manuscript: Bona.
Critical revision of the manuscript for important intellectual content: Brosco. ment, social relationships, and behavior. Using multivari-
Administrative, technical, or material support: Brosco. able logistic regression, we modeled the odds of being
Study supervision: Brosco. somewhat/very likely to allow a child to use mobile technol-
Conflict of Interest Disclosures: None reported. ogy in different situations, using the child’s soc ial-
1. Centers for Disease Control. Data and statistics: new data: medication and emotional score on the Baby or Preschool Pediatric Symp-
behavior treatment, attention-deficit/hyperactivity disorder. http://www.cdc tom Checklist as the primary predictor, controlling for all
.gov/ncbddd/adhd/data.html. Published 2015. Accessed September 13, 2015.
covariates whose removal from the model changed odds
2. Evans WN, Morrill MS, Parente ST. Measuring inappropriate medical
diagnosis and treatment in survey data: the case of ADHD among school-age
ratios by more than 10%. We then stratified analyses by
children. J Health Econ. 2010;29(5):657-673. parental perceived control, which was split at the median
3. Hofferth SL, Sandberg JF; Population Studies Center at the Institute for value. Owing to sample size limitations, tests for interac-
Social Research. Changes in American children's time, 1981-1997. http://www tions were not performed.
.psc.isr.umich.edu/pubs/pdf/rr00-456.pdf. Published 2015. Accessed
September 13, 2015.
Results | Caregivers were primarily mothers (81.3%) of non-
4. National Center for Education Statistics; US Department of Education.
Average National Assessment of Educational Progress reading scale scores and
white race (78.7%) and foreign-born (64.0%), with a mean (SD)
percentage distribution of students, by age, amount of reading for school and age of 31.6 (7.2) years (Table 1). Compared with children with-
for fun, and time spent on homework and watching TV/video: selected years, out social-emotional difficulties, children with social-
1984 through 2008. http://nces.ed.gov/programs/digest/d12/tables/dt12_144
emotional difficulties (Baby or Preschool Pediatric Symptom
.asp. Accessed September 13, 2015.
Checklist score ≥9; 58 of 144 children [40.3%]) had a higher
5. US Department of Education. The Condition of Education 2006. Washington,
DC: National Center for Education Statistics; 2006. prevalence of being given mobile technology as a calming tool
6. National Center for Education Statistics; US Department of Education.
when they were upset (61.8% vs 38.1%; P = .01) and to keep
Preprimary education enrollment, fast facts; http://nces.ed.gov/fastfacts peace and quiet in the house (69.6% vs 51.2%; P = .03); how-
/display.asp?id=516. Accessed September 13, 2015. ever, there were no differences during other situations such
as eating, being in public, doing chores, or at bedtime. After
Use of Mobile Technology to Calm Upset Children: adjustment for potential confounders, associations between
Associations With Social-Emotional Development social-emotional difficulties and mobile technology use per-
Although it is known that parents of infants and toddlers sisted (Table 2). Such associations were stronger among par-
with difficult behavior disproportionately use television ents with low vs high perceived control for calming down
and videos as calming tools,1 there are no published data (adjusted odds ratio [AOR], 7.63 [95% CI, 2.07-28.1] vs AOR,
regarding to what degree mobile technologies (such as cell 1.52 [95% CI, 0.45-5.13]) and for keeping peace and quiet in
phones and tablets) are used for this purpose. Previous the house (AOR, 6.48 [95% CI, 1.52-27.7] vs AOR, 2.90 [95%
qualitative work with parents has suggested that parental CI, 0.75-11.2]).
perceived control, defined as feelings of control over chil-
dren’s behavior and development, may determine how par- Discussion | This cross-sectional analysis showed significant as-
ents set limits around screen media use2 and respond to dif- sociations between increased social-emotional difficulties in
ficult child behavior. 3 We therefore sought to further toddlers and the tendency of low-income parents to use mo-
explore this observation by examining associations between bile technology to calm their children or keep them quiet, par-
the social-emotional development of toddlers and mobile ticularly parents who expressed lower perceived control over
media use in a sample of parent-toddler dyads, and to deter- their children’s behavior and development. While reverse cau-
mine whether potential associations are modified by paren- sation can also explain this finding (ie, the exposure to tech-
tal perceived control. nology affecting social-emotional development), we intention-
ally stratified analyses by perceived control in order to explore
Methods | The study was deemed exempt by the Boston Uni- the hypothesis that frustration with the child’s behavior would
versity Medical Center institutional review board. We sur- lead to use of digital media as a coping strategy. However, we
veyed 144 English- or Spanish-speaking parents of healthy recognize that these results are exploratory and are from a mod-
children 15 to 36 months of age who were recruited from an est-sized low-income sample, so they may not be generaliz-
urban primary care clinic and 3 Women, Infants, and Chil- able. Longitudinal studies are needed to understand the trans-
dren nutrition centers. Survey instructions, questions, and actional relationship between the use of digital technology and
answer choices were read to participants by research assis- the developmental trajectories of children.
tants. After collecting demographic information, we
assessed social-emotional development using the validated Jenny S. Radesky, MD
Baby or Preschool Pediatric Symptom Checklist.4,5 Mobile Elizabeth Peacock-Chambers, MD
technology use by children was queried using 6 questions Barry Zuckerman, MD
adapted from prior surveys6 asking about the likelihood of Michael Silverstein, MD, MPH
allowing smartphone or tablet use by children during differ-
ent situations, including to calm them down, keep them Author Affiliations: Division of Developmental Behavioral Pediatrics, Boston
quiet, while eating, in public, to get chores done, or at bed- Medical Center, Boston, Massachusetts (Radesky, Zuckerman); currently with

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 Letters

Table 1. Demographic Characteristics of Participants

% of Participants, Stratified by
Parental Perceived Control Score
% of Below Median Above Median
Characteristic Participants (n = 71) (n = 73) P Valuea
Child
Age, mean (SD), mo 25.1 (6.8) 25.4 (7.0) 24.6 (6.4) .63
Premature
Yes 14.9 15.5 14.3
.84
No 85.1 84.5 85.7
Sex
Male 55.6 52.1 58.9
.41
Female 44.4 47.9 41.1
First child
Yes 38.2 39.4 37.0
.76
No 61.8 60.6 63.0
Siblings at home
Yes 70.8 73.2 68.5
.53
No 29.2 26.8 31.5
Caregiver
Age, mean (SD), y 31.6 (7.2) 30.6 (7.4) 31.2 (6.0) .44
Language
English 65.3 50.7 79.5
.003
Spanish 34.7 49.3 20.6
Race
White non-Hispanic 5.6 0.0 11.0
Black or African American 34.7 33.8 35.6
.01
Hispanic 52.8 62.0 43.8
Other 6.9 4.2 9.6
Sex
Male 12.5 8.5 16.4
.15
Female 87.5 91.6 83.6
Marital status
Married 36.1 38.0 34.3
Single/separated/divorced 38.9 32.4 45.2 .24
Live with partner 25.0 29.6 20.6
Education completed
Elementary/primary school 16.7 18.3 15.1
High school or GED 45.2 52.1 38.4 .11
College or more 38.2 29.6 46.6
Employment
Unemployed 43.8 46.5 41.1
.52
Employed 56.3 53.5 58.9
Receiving public assistance
Yes 81.9 87.3 76.7
.10 Abbreviations: GED, General
No 18.1 12.7 23.3 Education Development;
PHQ-8 Depression Scale score PHQ-8, 8-item Patient Health
Questionnaire.
<10 87.5 90.1 84.9
.34 a
Based on the t test or χ2 test of
≥10 12.5 9.9 15.1
association.

Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Published Online: February 29, 2016. doi:10.1001/jamapediatrics.2015.4260.
University of Michigan Medical School, Ann Arbor. (Radesky); Division of Author Contributions: Drs Radesky and Peacock-Chambers had full access to
General Pediatrics, Boston Medical Center, Boston, Massachusetts all of the data in the study and take responsibility for the integrity of the data
(Peacock-Chambers, Silverstein). and the accuracy of the data analysis.
Corresponding Author: Jenny S. Radesky, MD, Division of Developmental Study concept and design: All authors.
Behavioral Pediatrics, Department of Pediatrics, University of Michigan Medical Acquisition, analysis, or interpretation of data: All authors.
School, 300 N Ingalls St, Ste 1107, Ann Arbor, MI 48108 (jradesky@umich.edu). Drafting of the manuscript: Radesky.

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 Letters

Table 2. Bivariate and Adjusted Associations Between Social-Emotional Difficulties and Likelihood
of Mobile Media Use During Different Daily Situationsa
Social-Emotional Difficulties
Response on B/P-PSC, No./Total No. (%) AOR (95% CI)
To calm down when upset
Not at all/not too likely 21/73 (28.8) 1 [Reference]
Somewhat/very likely 34/66 (51.5) 2.67 (1.26-5.67)
For peace and quiet in the house
Not at all/not too likely 17/58 (29.3) 1 [Reference]
Somewhat/very likely 39/82 (47.6) 3.63 (1.52-8.66)
While eating
Not at all/not too likely 46/113 (40.7) 1 [Reference]
Somewhat/very likely 10/25 (40.0) 0.92 (0.36-2.38)
While in public (eg, riding on public transit)
Abbreviations: AOR, adjusted odds
Not at all/not too likely 34/82 (41.5) 1 [Reference] ratio; B/P-PSC, Baby or Preschool
Somewhat/very likely 21/54 (38.9) 0.81 (0.37-1.75) Pediatric Symptom Checklist.
a
To keep occupied while parent does chores Adjusted for parent’s language
(English/non-English speaking),
Not at all/not too likely 18/47 (38.3) 1 [Reference] education level (college or
Somewhat/very likely 38/94 (40.4) 1.40 (0.60-3.27) more/high school or General
Education Development/
At bedtime elementary school), race/ethnicity
Not at all/not too likely 46/115 (40.0) 1 [Reference] (White non-Hispanic/black/
Hispanic/other), and child
Somewhat/very likely 11/26 (42.3) 1.04 (0.41-2.62)
prematurity.

Critical revision of the manuscript for important intellectual content: COMMENT & RESPONSE
Peacock-Chambers, Zuckerman, Silverstein.
Statistical analysis: Radesky, Peacock-Chambers, Silverstein. Attribution of Concussion-Like Symptoms
Obtained funding: Peacock-Chambers.
Administrative, technical, or material support: Silverstein.
and History of Collision Sports Exposure
Study supervision: Zuckerman, Silverstein. To the Editor It has become fashionable to posit that
concussion-like symptoms result from preexisting mood and
Conflict of Interest Disclosures: None reported.
behavioral disorders instead of traumatic brain injury.
Funding/Support: This study was funded by the Academic Pediatric
Association Maternal and Child Health Bureau Bright Futures Young Investigator Iverson et al 1 have produced a study of impressive size,
Award U04MC07853 (Dr Peacock-Chambers). scope, and statistical depth supporting this thesis. While it
Role of the Funder/Sponsor: The funder had no role in the design and conduct goes to great lengths to establish factors such as substance
of the study; collection, management, analysis, or interpretation of the data; abuse, attention-deficit/hyperactivity disorder, psychiatric
preparation, review, or approval of the manuscript; and decision to submit the
conditions, and migraines as primary predictors of reporting
manuscript for publication.
of concussion-like symptoms in the high school population,
1. Radesky JS, Silverstein M, Zuckerman B, Christakis DA. Infant
self-regulation and early childhood media exposure. Pediatrics. 2014;133(5): it fails to investigate whether these factors are the result of
e1172-e1178. concussions and/or repetitive head trauma earlier in
2. Radesky JS, Kistin C, Eisenberg S, Zuckerman B, Silverstein M. Parent views childhood.2,3 A sample of high school athletes, particularly
about mobile device use around and by young children: implications for those participating in collision sports such as football,
anticipatory guidance. Abstract presented at: Annual Meeting of the Pediatric
includes those who may have started organized play as early
Academic Societies; April 25-28, 2015; San Diego, CA.
as 4 years of age. It would imply that some participants in
3. Guzell JR, Vernon-Feagans L. Parental perceived control over caregiving and
its relationship to parent-infant interaction. Child Dev. 2004;75(1):134-146. the Iverson et al sample may have been exposed to more
4. Sheldrick RC, Henson BS, Neger EN, Merchant S, Murphy JM, Perrin EC. than a decade of repetitive head trauma before inclusion in
The baby pediatric symptom checklist: development and initial validation of a this study. The study does attempt to account for those with
new social/emotional screening instrument for very young children. Acad Pediatr. a history of concussion, but it is well recognized that most
2013;13(1):72-80.
concussions in youth league sports are neither well detected
5. Sheldrick RC, Henson BS, Merchant S, Neger EN, Murphy JM, Perrin EC.
nor documented. 4 This study and numerous previous
The Preschool Pediatric Symptom Checklist (PPSC): development and initial
validation of a new social/emotional screening instrument. Acad Pediatr. 2012; studies5 have demonstrated that those who have had docu-
12(5):456-467. mented concussions are more likely to have future concus-
6. Wartella E, Rideout V, Lauricella AR, Connell SL. Parenting in the age of sions. In that light, clinicians must document not only sex
digital technology: a national survey. http://web5.soc.northwestern.edu/cmhd and preexisting conditions of the patient but also whether
/wp-content/uploads/2014/03/ParentingAgeDigitalTechnology.REVISED
he or she has a history of participating in collision sports.
.FINAL_.2014.pdf. Revised June 2014. Accessed July 28, 2015.
Until sufficient data are gathered, it would be irresponsible
7. Machida S, Taylor AR, Kim J. The role of maternal beliefs in predicting home
learning activities in Head Start families. Fam Relat. 2002;51(2):176-184. to attribute symptoms to conditions that may have been
doi:10.1111/j.1741-3729.2002.00176.x. acquired as the result of mechanical insults to the brain.

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