Nagata et al.

BMC Public Health (2024) 24:2686 BMC Public Health

https://doi.org/10.1186/s12889-024-20102-x

RESEARCH Open Access

Screen time and mental health: a prospective

analysis of the Adolescent Brain Cognitive
Development (ABCD) Study
Jason M. Nagata1*†, Abubakr A.A. Al-Shoaibi1†, Alicia W. Leong2, Gabriel Zamora1, Alexander Testa3, Kyle T. Ganson4
and Fiona C. Baker5,6

Abstract
Background Despite the ubiquity of adolescent screen use, there are limited longitudinal studies that examine the
prospective relationships between screen time and child behavioral problems in a large, diverse nationwide sample
of adolescents in the United States, which was the objective of the current study.
Methods We analyzed cohort data of 9,538 adolescents (9–10 years at baseline in 2016–2018) with two years
of follow-up from the Adolescent Brain Cognitive Development (ABCD) Study. We used mixed-effects models to
analyze associations between baseline self-reported screen time and parent-reported mental health symptoms using
the Child Behavior Checklist, with random effects adjusted for age, sex, race/ethnicity, household income, parent
education, and study site. We tested for effect modification by sex and race/ethnicity.
Results The sample was 48.8% female and racially/ethnically diverse (47.6% racial/ethnic minority). Higher total
screen time was associated with all mental health symptoms in adjusted models, and the association was strongest
for depressive (B = 0.10, 95% CI 0.06, 0.13, p < 0.001), conduct (B = 0.07, 95% CI 0.03, 0.10, p < 0.001), somatic (B = 0.06,
95% CI 0.01, 0.11, p = 0.026), and attention-deficit/hyperactivity symptoms (B = 0.06, 95% CI 0.01, 0.10, p = 0.013).
The specific screen types with the greatest associations with depressive symptoms included video chat, texting,
videos, and video games. The association between screen time and depressive, attention-deficit/hyperactivity, and
oppositional defiant symptoms was stronger among White compared to Black adolescents. The association between
screen time and depressive symptoms was stronger among White compared to Asian adolescents.
Conclusions Screen time is prospectively associated with a range of mental health symptoms, especially depressive
symptoms, though effect sizes are small. Video chat, texting, videos, and video games were the screen types with
the greatest associations with depressive symptoms. Future research should examine potential mechanisms linking
screen use with child behavior problems.

†
Jason M. Nagata and Abubakr A.A. Al-Shoaibi contributed equally
to this work.
*Correspondence:
Jason M. Nagata
jason.nagata@ucsf.edu
Full list of author information is available at the end of the article

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Nagata et al. BMC Public Health (2024) 24:2686 Page 2 of 13

Keywords Screen time, Adolescents, Depression, Anxiety, Oppositional defiant disorder, Conduct disorder, ADHD,
Somatic, Social media, Video games, Television, Digital technology, Digital media

Introduction represent both a cause and manifestation of behavioral

Globally, mental disorders are significant contributors and emotional symptoms [24].
to disease burden and the leading cause of disability in This positive association between screen time and
adolescents (10–19 years) [1]. Research has documented poorer mental health symptoms has prompted calls for
the rising prevalence of adolescent mental health con- guidelines to limit screen use among adolescents [25].
cerns in the United States. Adolescents are 50% more Some intervention studies, conducted primarily among
likely to experience a major depressive episode today adults, have shown that reductions in digital media use
than in the early 2000s [2]. Between 2000 and 2018, sui- are associated with improvements in mental health out-
cide rates increased by 30% in this population [3]. Inter- comes, but other studies have also found no effect or
nalizing (e.g., anxiety, depression) and externalizing negative consequences for well-being [26, 27]. A recent
(e.g., aggression, inattention) problems in childhood or cluster randomized controlled trial found that adults who
adolescence have been linked to substance use and cog- were allocated to reduce their household recreational
nitive, psychosocial, and physical health impairments digital screen use to less than three hours per week per
later in life [4–7]. Given that the peak and median age person reported significantly improved mental well-being
at onset for any mental disorder worldwide is 14.5 and and mood at two-week follow-up [28]. Another random-
18 years, respectively [8], underlying factors contribut- ized controlled trial found that reducing smartphone
ing to the development of mental health problems dur- social media use in undergraduate students aged 16 to
ing this developmental period may be important to target 24 years yielded significant improvements in appearance
in interventions. Furthermore, the COVID-19 pandemic esteem and anxiety symptoms over four weeks [29].
led to worse mental health among adolescents, with 42% However, the field has relied largely on cross-sectional
of high school students reporting persistent feelings of and correlational data, with much of the conversation on
sadness or hopelessness, a 50% increase from 2011 [9]. screen time and mental health treating adolescents as a
Despite the increasing prevalence and burden of mental relatively uniform category without recognition of the
health problems in adolescents, these factors are com- potential differential impacts of screen time based on fac-
plex, intertwined, and poorly understood [1, 10]. tors such as digital media modality, sex, and race/ethnic-
An increase in the amount of time spent on screen- ity [20]. Furthermore, a more detailed investigation of the
based technologies has been hypothesized to contrib- associations between screen time and specific domains
ute to observed increases in the prevalence of mental or even disorders of adolescent psychopathology is
health problems and suicide among adolescents [11–13]. needed to provide more targeted recommendations and
Smartphones, tablets, television, and other screen-based strategies.
technologies have become increasingly ubiquitous and The Child Behavior Checklist (CBCL), one of the most
embedded into family life [14]. On average, 8- to 12-year- widely used and investigated tools for detecting emo-
olds spend 5.5 h per day using screen media, excluding tional and behavioral symptoms in children and adoles-
time spent online for educational and homework pur- cents [30], provides a dimensional assessment of child
poses. For teenagers aged 13 to 18 years, screen time psychopathology [31]. The CBCL includes Diagnostic
rises to 8.5 h per day [14]. Screen time in adolescents and Statistical Manual of Mental Disorders (DSM)-ori-
rose by 52% on average during the pandemic [15, 16]. ented scales, which were developed based on expert con-
Some research has demonstrated a link between self- sensus to be consistent with diagnostic categories from
reported screen time (total amount of time spent on the DSM [32]. The DSM-oriented scales are as follows:
screens; default measure of digital technology use in affective/depressive, anxiety, attention-deficit/hyperac-
most studies to date) and poor mental health outcomes tivity (ADHD), somatic, oppositional defiant (ODD), and
[17–20]. Increased screen time may be a possible reflec- conduct symptoms [31]. Studies have demonstrated an
tion of problematic screen use, including difficulty self- acceptable correspondence between the DSM-oriented
regulating use and consequent personal, familial, social, scales and DSM diagnoses [33–40]. Although the scores
and school-related functional impairments. Studies have in the clinical range for specific DSM-oriented scales of
linked increased screen exposure to decreased inhibitory the CBCL are not directly equivalent to the correspond-
control neurologically and behaviorally [21, 22]. Prob- ing specific diagnosis [41, 42], the CBCL’s DSM-oriented
lematic screen use has been shown to be associated with scales for depression, anxiety disorders, ADHD, somatic
poorer mental health in adolescents [23]. However, it symptoms, ODD, and conduct disorders can be used in
should be noted that higher levels of screen exposure can clinical settings for screening for psychopathology based

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Nagata et al. BMC Public Health (2024) 24:2686 Page 3 of 13

on the DSM classification system and enhancing diag- between screen time and somatic symptoms have not
nostic assessment [40]. been published.

Depression Conduct disorder and oppositional defiant disorder

Of the disorders included in the CBCL’s DSM-oriented Similarly, previous cross-sectional studies have found
scales, depression has been the most investigated in potential associations between screen time and symp-
association with screen time. More screen time has toms of conduct disorder and ODD among adolescents
been associated with depressive symptoms among chil- [67–72]. One study of 151 adolescents at risk for mental
dren and adolescents in several systematic reviews [11, health symptoms found an association between average
12, 43–50]. In a systematic review of longitudinal stud- daily digital technology use and more conduct disorder
ies examining the relationship between screen time and symptoms both on the same day and 18 months later
internalizing mental health symptoms, Tang et al. (2021) [73]. Consistent with these findings, our group has previ-
found a small but significant correlation between screen ously found higher screen time to be prospectively asso-
time and subsequent depressive symptoms among ado- ciated with higher odds of conduct disorder and ODD
lescents aged 10 to 24 years. at one-year follow-up, based on longitudinal data from
a larger (n = 11,875), national cohort of adolescents who
Anxiety participated in the ABCD Study [74].
In contrast to depressive symptoms, there are relatively
few cross-sectional studies and even fewer longitudinal Gaps in prior literature
studies examining the association of screen time with Certain methodological issues, such as sampling strate-
anxiety, ADHD, somatic symptoms, ODD, and con- gies and cross-sectional design, limit the generalizabil-
duct disorders among children and adolescents [12, 51]. ity of results across studies. For instance, few existing
Some studies support a positive cross-sectional and lon- studies feature longitudinal time frames and account
gitudinal association between screen time and anxiety for additional demographic factors, particularly race/
symptoms in adolescents [52, 53], but others found no ethnicity and sex [12, 75, 76]. Accounting for potential
significant association between screen time at baseline moderators (e.g., sex and race/ethnicity) on the impact
and changes in anxiety over time [54, 55]. Given the lim- of screen exposure on adolescent mental health could
ited number of studies with mixed findings, systematic help explain the heterogeneity seen across study findings.
reviews have deemed the existing literature insufficient to Additionally, investigating these potential moderators
draw conclusions [12, 45]. may improve the identification of at-risk populations and
aid in the development of more targeted interventions
Attention-deficit/hyperactivity disorder [51, 76]. Prior studies have identified sex differences in
Synthesizing data from eight cross-sectional and three the relationship between screen time and mental health
longitudinal studies, a systematic review from 2015 con- outcomes, but this evidence remains inconsistent across
cluded that there was strong evidence to support a posi- studies [11, 12, 51], calling for additional longitudinal
tive association between screen time and hyperactivity/ analyses to provide further insight into the moderat-
inattention symptoms in children and adolescents [56]. ing effect of sex. The moderating effect of race/ethnic-
A more recent review evaluating the longitudinal asso- ity in the relationship between screen time and mental
ciations between digital media use and ADHD symptoms health has not been as extensively studied, although
found reciprocal associations between digital media use there are documented disparities in screen use [77–79]
and ADHD symptoms [57]. and mental health outcomes [80–83] across race/ethnic-
ity in children and adolescents. For instance, data from
Somatic symptoms the ABCD Study showed that, compared to White ado-
Somatic symptom disorder is a psychiatric condition lescents, Black adolescents reported greater total screen
characterized by a significant focus on one or more time use and Asian adolescents reported lower screen
physical symptoms, such as pain in different locations of time use [77]. The same analysis found that, while male
the body, weakness, dizziness, nausea, and shortness of adolescents reported higher overall screen time than
breath [58, 59]. Prior cross-sectional studies have exam- female adolescents, female adolescents reported higher
ined the relationship between screen time and somatic daily use of social networking, texting, and video chat-
symptoms in children, adolescents, and young adults ting [77]. Such differences by sex and race/ethnicity could
[60–66], with the majority finding a positive associa- be reflected in differences in associations between screen
tion between screen time and somatic symptoms. To our time and mental health outcomes which warrant further
knowledge, analyses of the longitudinal associations investigation.

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Nagata et al. BMC Public Health (2024) 24:2686 Page 4 of 13

Few studies examining longitudinal links between received from the University of California, San Diego,
screen time and mental health symptoms have included and the respective IRBs of each study site. Written assent
large national cohorts of adolescents in North America. was obtained from participants, and written informed
In a recent systematic review and meta-analysis on screen consent was obtained from their caregivers.
time and internalizing and externalizing behaviors among
children and adolescents aged 12 years or younger [84], Variables
only three North American studies included a national Independent variable: screen time
cohort with a sample size of 10,000 or more [62, 85, 86]. Screen time was obtained from the ABCD Youth Screen
Further, all three studies featured a cross-sectional study Time Survey [92]. Participants were asked to answer
design and did not investigate the longitudinal relation- questions about the number of hours per weekday/
ship between screen time and internalizing and external- weekend day they spent on six different screen modali-
izing behaviors in adolescents. The cross-sectional design ties (excluding school use), including watching/streaming
of the majority of these studies limits the ability to estab- TV shows or movies, watching/streaming videos [e.g.,
lish causal and temporal effects. Longitudinal studies YouTube], playing videogames, texting, video chatting
provide more robust data and enable the examination of [e.g., Skype, Facetime], and social media [e.g., Facebook,
correlations over time [12]. Instagram, Twitter]. Total screen time was calculated
Furthermore, it remains unclear whether specific separately for weekdays and weekend days, based on a
modalities of screen time (e.g., device type, digital media previously validated measure [93–95]. The following for-
type, and specific websites and applications) are differ- mula was used to calculate the weighted average: [(week-
entially associated with adolescent mental health out- day average x 5) + (weekend average x 2)/7] [62]. The
comes, prompting a call for researchers to conduct more weighted average of total screen time was reported as a
nuanced measurements and analyses of screen use that continuous variable.
focus on the contents, contexts, and environments in
which digital media exposures occur [11, 51, 87–90]. To Dependent variables: Child Behavior Checklist (CBCL)
address such methodological limitations in existing stud- The CBCL is a screening tool consisting of 112 items
ies, we aim to examine the longitudinal relationships asking a parent/caretaker about multiple behavioral,
between screen time (total aggregate screen time and emotional, and mental health symptoms in children
specific types of screen time) and mental health symp- and adolescents aged 4 to 18 years [96, 97]. The CBCL
toms measured by the CBCL’s DSM-oriented scales in a included six DSM-oriented scales, including depressive,
national cohort of adolescents in the United States [85]. anxiety, somatic, attention-deficit/hyperactivity, opposi-
Participants in the current analysis were 9 to 10 years old tional defiant, and conduct symptoms. Parents/caretak-
at baseline and were followed for two years. We hypoth- ers responded to statements about their child’s behavior
esized that higher screen time would be prospectively using a scale from 0 (not true) to 2 (very true/often true)
associated with higher scores on all CBCL DSM-oriented over the past six months. T-scores were calculated based
scales (anxiety, affective/depressive, somatic, ADHD, on the CBCL scoring rubric. The CBCL has high test-
ODD, and conduct symptoms) at one- and two-year retest reliability (ICC = 0.95), strong validity (ability of
follow-up. all items to discriminate significantly p < 0.01) [98], and
acceptable internal consistency with alphas ranging from
Methods 0.63 to 0.79 [99]. Confirmatory factor analysis results for
Study population the DSM-oriented scales indicated good fit (Comparative
We used longitudinal data from baseline to Year 2 from Fit Index [CFI] of 0.96 and Root Mean Square Error of
the Adolescent Brain Cognitive Development (ABCD) Approximation [RMSEA] of 0.045 [100, 101].
Study (4.0 release). The ABCD Study is an ongoing pro-
spective cohort study of health and cognitive develop- Confounders
ment including 11,875 participants (ages 9–10 years at The following variables were used in statistical mod-
baseline in 2016–2018) from 21 recruitment sites across els as potential confounders of the association between
the U.S. The ABCD Study participants, recruitment, pro- baseline screen time and CBCL measures including age
tocol, and measures are described in detail elsewhere (years), sex (female, male), race/ethnicity (White, Latino/
[91]. Among 11,875 participants, 2,337 had missing data Hispanic, Black, Asian, Native American, and other),
for total screen time and confounders, especially in Year household income (U.S. dollars, six categories: less than
2, leaving 9,538 participants for the current analysis. $25,000, $25,000 through $49,999, $50,000 through
Appendix A shows sociodemographic characteristics of $74,999, $75,000 through $99,999, $100,000 through
participants who were included versus excluded from the $199,999, and $200,000 and greater), highest parent
current analysis. Institutional review board approval was education (high school or less vs. college or more), and

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Nagata et al. BMC Public Health (2024) 24:2686 Page 5 of 13

study site. Because the two-year follow-up data collec- Physical activity was measured based on adolescent
tion period (2018–2020) coincided with the COVID-19 reports of the number of days in the last 7 days of spend-
pandemic, which affected both screen time and men- ing at least 60 min per day physically active (the recom-
tal health, we controlled for the data collection period mended daily level for children and adolescents from the
(before or during the COVID-19 pandemic, using March Physical Activity Guidelines for Americans) [91, 103].
13, 2020 as the start date of the COVID-19 pandemic in
the US) in the analyses of the Year 2 data. In addition, Statistical analysis
sleep and physical activity could mediate the association We used total screen time and each of the six screen
between screen time and mental health, as more time on time components at baseline as the primary independent
screens could displace time for sleep and physical activ- variable. The dependent variables were repeated mea-
ity, which are both beneficial for mental well-being. Sleep sures from CBCL DSM-oriented scale scores derived as
duration was measured by parent report based on an repeated measures of t-scores at each year, from base-
item from the Sleep Disturbance Scale for Children [102]. line to Year 2. We used mixed-effects models with ran-
dom effects to assess the association of baseline screen
Table 1 Sociodemographic, screen time, and mental health time with each CBCL DSM-oriented scale. Model 1 was
characteristics of 9,538 Adolescent Brain Cognitive Development unadjusted. In Model 2, the outcomes were CBCL DSM-
(ABCD) Study participants at baseline (2016–2018)
oriented scale t-scores from Year 1 and Year 2, adjusted
Sociodemographic and behavioral characteristics Mean
(SD) / %
for baseline CBCL DSM-oriented scale t-scores and the
Age (years), mean (SD) 9.9 (0.6)
following confounders at baseline: age, sex, race/ethnic-
Sex (%)
ity, household income, parent education, data collection
Female 48.8% period, and study site. We also conducted a supplemental
Male 51.2% analysis adjusting for sleep and physical activity in addi-
Race/ethnicity (%) tion to age, sex, race/ethnicity, household income, par-
White 52.4% ent education, data collection period, and study site. We
Latino / Hispanic 20.1% tested for effect modification by sex and race/ethnicity
Black 17.3% in the association between screen time and CBCL DSM-
Asian 5.5% oriented scales. We present results stratified by sex or
Native American 3.2% race/ethnicity for behavioral outcomes where there was
Other 1.5% evidence of effect modification by sex or race/ethnicity,
Household income (%) respectively (p for interaction < 0.05). P-values < 0.05 were
Less than $25,000 18.1% considered to indicate statistical significance. Data analy-
$25,000 through $49,999 20.7% ses were performed using Stata 18.0 (College Station,
$50,000 through $74,999 18.0% TX) and applied propensity weights based on the Ameri-
$75,000 through $99,999 15.6% can Community Survey [104].
$100,000 through $199,999 20.9%
$200,000 and greater 6.7% Results
Parent with college education or more (%) 79.7% Characteristics of the 9,538 participants are shown in
Recreational screen time variables Table 1. The mean age at baseline was 9.9 ± 0.6 years;
Total screen time, hours per day, mean (SD) 4.0 (3.2) 51.2% of the participants were male, and 47.6% were
Television shows/movies, hours per day, mean (SD) 1.3 (1.1) non-White. The average total screen time at baseline was
Videos (e.g. YouTube), hours per day, mean (SD) 1.3 (1.2) 4.0 ± 3.2 h per day, with most time spent watching tele-
Video games, hours per day, mean (SD) 1.2 (1.1) vision shows/movies (1.3 ± 1.1 h/day), watching/stream-
Texting, hours per day, mean (SD) 0.2 (0.6) ing videos (1.3 ± 1.2 h/day) and playing video games
Video chat, hours per day, mean (SD) 0.3 (0.7) (1.2 ± 1.1 h/day). Furthermore, somatic symptoms had
Social media, hours per day, mean (SD) 0.1 (0.1)
the highest t-score (55.4), among the CBCL DSM-ori-
Mental health symptoms (Child Behavior Checklist
ented scales (Table 1).
t-score)
Table 2 shows the unadjusted (Model 1) and adjusted
Depressive symptoms 53.9 (6.1)
Anxiety symptoms 53.6 (6.3)
(Model 2) models for associations between total screen
Somatic symptoms 55.4 (6.6)
time and CBCL DSM-oriented symptom scale t-scores.
Attention-deficit/hyperactivity symptoms 53.2 (5.6)
Higher total screen time was associated with all DSM-
Oppositional defiant symptoms 53.4 (5.4) oriented scales in adjusted models (Model 2), and the
Conduct symptoms 52.9 (5.4) association was strongest for depressive symptoms
Propensity weights were applied to yield representative estimates based on (B = 0.10, 95% CI 0.06, 0.13, p < 0.001), conduct symptoms
the American Community Survey from the US Census. SD = standard deviation (B = 0.07, 95% CI 0.03, 0.10, p < 0.001), somatic symptoms

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 Nagata et al. BMC Public Health

Table 2 Prospective associations between screen time and its subtypes with mental health symptoms in the Adolescent Brain Cognitive Development (ABCD) Study
Depressive symptoms Anxiety symptoms Somatic symptoms
Attention-deficit/hyperac- Oppositional defiant Conduct symptoms
tivity symptoms symptoms
Model 1: Unadjusted Coefficient (95% CI) p Coefficient (95% CI)p Coefficient (95% CI)p Coefficient (95% CI) p Coefficient (95% CI) p Coefficient (95% CI) p
Total screen time 0.18 (0.14, 0.22) < 0.001 0.12 (0.06, 0.17) < 0.001 0.10 (0.05, 0.14) < 0.001 0.27 (0.22, 0.31) < 0.001 0.21 (0.15, 0.27) < 0.001 0.28 (0.21, 0.36) < 0.001
Television shows/ 0.32 (0.15, 0.48) 0.001 0.19 (-0.02, 0.39) 0.428 0.17 (-0.003, 0.36) 0.055 0.50 (0.32, 0.69) < 0.001 0.43 (0.27, 0.57) < 0.001 0.57 (0.32, 0.82) < 0.001
(2024) 24:2686

movies
Videos (e.g. YouTube) 0.50 (0.37, 0.64) < 0.001 0.36 (0.22, 0.51) < 0.001 0.34 (0.22, 0.47) < 0.001 0.56 (0.46, 0.65) < 0.001 0.42 (0.29, 0.55) < 0.001 0.52 (0.41, 0.65) < 0.001
Video games 0.48 (0.37, 0.60) < 0.001 0.30 (0.16, 0.44) < 0.001 0.19 (0.07, 0.32) 0.003 0.61 (0.50, 0.72) < 0.001 0.48 (0.32, 0.63) < 0.001 0.53 (0.38, 0.68) < 0.001
Texting 0.22 (0.06, 0.37) 0.008 0.04 (-0.15, 0.22) 0.690 0.18 (-0.19, 0.54) 0.331 0.46 (0.27, 0.65) < 0.001 0.38 (0.11, 0.66) < 0.001 0.75 (0.37, 1.13) < 0.001
Video chat 0.29 (0.07, 0.51) 0.012 0.02 (-0.22, 0.28) 0.536 0.07 (-0.21, 0.36) 0.589 0.51 (0.29, 0.74) < 0.001 0.43 (0.07, 0.80) 0.023 0.80 (0.43, 1.17) < 0.001
Social media 0.44 (0.24, 0.64) < 0.001 0.08 (-0.19, 0.37) 0.536 0.28 (-0.04, 0.60) 0.078 0.68 (0.40, 0.96) < 0.001 0.71 (0.44, 0.98) < 0.001 1.15 (0.86, 1.46) < 0.001

Model 2: Adjusted for sociodemographic factors and baseline mental health

Total screen time 0.10 (0.06, 0.13) < 0.001 0.05 (0.01, 0.09) 0.029 0.06 (0.01, 0.11) 0.026 0.06 (0.01, 0.10) 0.013 0.04 (0.01, 0.07) 0.011 0.07 (0.03, 0.10) < 0.001
Television shows/ 0.13 (0.01, 0.26) 0.036 0.06 (-0.09, 0.21) 0.397 0.04 (-0.09, 0.16) 0.559 0.11 (-0.01, 0.24) 0.067 0.10 (0.01, 0.19) 0.032 0.11 (-0.01, 0.22) 0.063
movies
Videos (e.g. YouTube) 0.22 (0.13, 0.31) < 0.001 0.17 (0.08, 0.25) 0.001 0.19 (0.09, 0.29) 0.001 0.09 (0.004, 0.17) 0.042 0.07 (-0.02, 0.15) 0.114 0.10 (0.02, 0.18) 0.018
Video games 0.20 (0.03, 0.37) 0.022 0.08 (-0.02, 0.17) 0.099 0.13 (-0.001, 0.27) 0.05 0.11 (0.05, 0.18) 0.001 0.07 (-0.01, 0.15) 0.07 0.10 (0.05, 0.16) 0.001
Texting 0.26 (0.09, 0.44) 0.005 0.10 (-0.07, 0.27) 0.231 0.19 (-0.04, 0.42) 0.101 0.18 (-0.02, 0.39) 0.080 0.12 (-0.04, 0.28) 0.151 0.33 (0.11, 0.56) 0.006
Video chat 0.35 (0.19, 0.51) < 0.001 0.12 (-0.06, 0.30) 0.189 0.05 (-0.21, 0.31) 0.683 0.22 (0.03, 0.41) 0.022 0.11 (-0.09, 0.33) 0.246 0.35 (0.14, 0.57) 0.002
Social media 0.14 (-0.09, 0.33) 0.230 0.004 (-0.24, 0.25) 0.971 0.11 (-0.16, 0.38) 0.421 0.04 (-0.31, 0.39) 0.805 0.07 (-0.19, 0.33) 0.617 0.22 (-0.02, 0.47) 0.071
Models represent the abbreviated outputs from mixed effects models examining associations between screen time and its subtypes (independent variable at baseline) and mental health symptoms (dependent variable
at one- and two-year follow-up based on the Child Behavior Checklist [CBCL]). Propensity weights from the ABCD Study were applied based on the American Community Survey from the US Census
Model 1 is unadjusted
Model 2 includes random effects adjusted for age, race/ethnicity, household income, parent education, study site, baseline CBCL score, and date of CBCL administration

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Page 6 of 13
Nagata et al. BMC Public Health (2024) 24:2686 Page 7 of 13

w(B = 0.06, 95% CI 0.01, 0.11, p = 0.026), and attention- time at baseline, when participants were 9 to 10 years old,
deficit/hyperactivity symptoms (B = 0.06, 95% CI 0.01, was 4.0 ± 3.2 h per day. While the digital and in-person
0.10, p = 0.013). Supplemental analyses adjusting for socialization landscape during the study’s baseline period
sleep and physical activity in addition to the covariates (2016 to 2018) is distinct from that of the contemporary
adjusted for in Model 2 showed similar results although context, the average total screen time of this study’s sam-
some associations were slightly attenuated (Appendix B). ple is comparable to more recent national statistics for
We stratified results by race/ethnicity for outcomes average screen time among children and younger adoles-
where there was evidence of significant effect modifica- cents aged 8 to 12 years in 2021 (5.5 h per day) [14].
tion by race/ethnicity on the associations between total The present study adds to the current literature on the
screen time and CBCL DSM-oriented symptom scales. relationship between screen time and adolescent mental
In adjusted models (Table 3), screen time was associated health by assessing the longitudinal impact of different
with higher depressive (B = 0.13, 95% CI 0.09, 0.17), atten- screen time modalities on specific domains of adoles-
tion-deficit/hyperactivity (B = 0.07, 95% CI 0.02, 0.13), cent psychopathology that have clinical relevance. Recent
and oppositional defiant (B = 0.05, 95% CI 0.01, 0.10) reviews and meta-analyses have concluded that the liter-
symptom scores in White adolescents but not among ature on the mental health impacts of screen time among
Black adolescents. The association between screen time adolescents presents mixed findings that are difficult to
and depressive symptoms was stronger among White collectively interpret [75, 105, 106], highlighting the need
compared to Asian adolescents. There was no evidence of to consider different modalities of screen time [11, 51,
effect modification of screen time by sex for any of the 87, 89, 90], control for demographic variables and other
outcomes (p for screen time*sex interaction > 0.05). potential confounders [107], and include more longitudi-
nal perspectives [75, 108, 109].
Discussion Consistent with previous analyses, which have included
In a demographically diverse, nationwide, longitudinal longitudinal data and larger cohorts other than the
cohort of 9,538 early adolescents in the United States, ABCD Study cohort, we found weak but significant cor-
the current study found that higher total screen time was relations between screen time and adolescents’ internal-
prospectively associated with higher scores on all DSM- izing and externalizing behavior symptoms, including
oriented scales of the CBCL at both one- and two-year depression, anxiety, ADHD, somatic, ODD, and con-
follow-up, even after adjusting for confounders. These duct symptoms [12, 57, 84, 110, 111]. There are vari-
results were held after adjusting for CBCL DSM-oriented ous factors to consider when interpreting the small
scores at baseline. The specific DSM-oriented scale most effect sizes. While some have suggested that the small
strongly associated with total screen time was depres- effect sizes suggest a small or even negligible impact of
sive symptoms. In this study, the average total screen increased screen time on the prevalence of mental health

Table 3 Prospective associations between total screen time and mental health symptoms in the Adolescent Brain Cognitive
Development (ABCD) Study, stratified by race/ethnicity
Stratified by race/ethnicity
White subsample Black subsample Asian subsample Native American subsample

Coefficient p Coefficient p pa Coefficient p pa Coefficient (95%p pa

(95% CI) (95% CI) (95% CI) CI)
Depressive symptoms 0.13 (0.09, 0.17) < 0.001 0.02 (-0.04, 0.09) 0.387 0.003 0.02 (-0.08, 0.13) 0.882 0.034 -- -- --
Anxiety symptoms -- -- -- -- -- -- -- -- -- -- --
Somatic symptoms 0.10 (0.04, 0.16) 0.001 -- -- -- -- -- -- -0.17 (0.32, -0.01) 0.036 0.003
Attention-deficit/hyper- 0.07 (0.02, 0.13) 0.015 0.01 (-0.04, 0.06) 0.604 0.017 -- -- -- -- -- --
activity symptoms
Oppositional defiant 0.05 (0.01, 0.10) 0.024 -0.02 (-0.07, 0.03) 0.395 0.019 -- -- -- -- -- --
symptoms
Conduct symptoms -- -- -- -- -- -- -- -- -- -- --
Models represent the abbreviated outputs from mixed effects models examining associations between screen time (independent variable at baseline) and mental
health symptoms (dependent variable at one- and two-year follow-up based on the Child Behavior Checklist [CBCL]). Models include random effects adjusted for
age, household income, parent education, study site, baseline CBCL score, and date of CBCL administration. Propensity weights from the ABCD Study were applied
based on the American Community Survey from the US Census. Results stratified by race/ethnicity are only presented for mental health symptoms where there was
evidence of effect modification by race/ethnicity
a
P-value for the screen time*race/ethnicity interaction term coefficient

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Nagata et al. BMC Public Health (2024) 24:2686 Page 8 of 13

symptoms among adolescents [12], others have suggested old). Thus, participants on average reported spending the
that the consequences of screen time at a population level least screen time on social media, out of all the screen
are likely meaningful despite small effect sizes [84, 112]. types assessed.
Regarding the interpretation of longitudinal effect sizes,
it has been argued that even small associations may be Moderating effect of race/ethnicity in the prospective
of importance when controlling for baseline levels [113]. relationship between screen time and mental health
Controlling for stability effects often attenuates the mag- The present study investigated the impact of race/ethnic-
nitude of effect size coefficients in longitudinal designs. ity as a moderator in the association between screen time
It is thus misleading to apply the same guidelines for and mental health symptoms, demonstrating a signifi-
interpreting longitudinal effect size coefficients in mod- cant association between total screen time and depres-
els that control for stability effects versus cross-sectional sive, ADHD, and ODD symptoms in White adolescents,
effect size coefficients in analyses that control for con- but not in Black adolescents. This suggests that the lon-
founds, but not stability effects [113]. Further, the effect gitudinal associations between screen time and several
sizes reported are for each hour of screen time; given that mental health symptoms are significantly weaker among
average screen time for adolescents rose to nearly eight Black adolescents than White adolescents. In addition,
hours per day during the COVID-19 pandemic, these the association between total screen time and depres-
effects could be magnified [16]. These effect sizes per sive symptoms was stronger among White compared to
hour of screen time are similar in magnitude to the effect Asian adolescents. The extant literature on the impact of
sizes previously reported on screen time and nutrition as screen exposure on the psychosocial outcomes of racial
measured by the MIND (Mediterranean-DASH [Dietary and ethnic minority adolescents in the United States is
Approaches to Stop Hypertension] Intervention for Neu- sparse [122–124]. However, it is possible that adolescents
rodegenerative Delay) diet score [114]. from racial/ethnic minority backgrounds who might
In this study, the specific DSM-oriented scale most experience isolation, bullying, or discrimination in per-
strongly associated with screen time was depressive son may use screens to connect with others with simi-
symptoms. These findings may be explained, in part, by lar backgrounds, which could buffer from depression,
some combination of various media effects theories that anxiety, and other symptoms of poor mental health [125].
have been proposed [115], including the displacement Further research is needed to further elucidate potential
hypothesis [116, 117]. The displacement hypothesis pos- differences by race/ethnicity. Other possible explanations
its that screen time may replace time adolescents spend include cultural variability in symptom presentation,
engaging in physical activity, sleep, in-person interac- which may not be comprehensively captured by the diag-
tions, and other beneficial pursuits demonstrated to help nostic classification system [126]. Furthermore, as par-
reduce depression and anxiety symptoms [118–120]. ents complete rating scales in the CBCL, they may make
Studies have also shown that higher levels of screen time implicit comparisons to a culturally-based standard for
were associated with reduced sleep duration and more how children should behave or to their child’s local peers
sleep disturbances, which were in turn associated with [127]. Internalized stigma about mental health may dis-
internalizing, externalizing, and peer problems [62, 121]. suade individuals from reporting symptoms or seeking
The weaker but still significant associations between help and services [126].
screen time and depressive symptoms, along with the
other assessed CBCL DSM-oriented scales found after Strengths and limitations
adjusting for sleep and physical activity (i.e., displace- Strengths of this study include the longitudinal data
ment hypothesis) in Appendix B suggest that displace- spanning two years of follow-up in a large, nationwide
ment theory partially accounts for, but does not fully sample of adolescents in the US that was diverse, allow-
explain, the relationship between screen time and early ing the examination of moderation of effects by sex and
adolescents’ mental health symptoms. race/ethnicity between screen time and mental health
The specific screen types with the greatest associations symptoms. Limitations should also be noted. Screen
with depression include video chat, texting, videos (e.g., time was based on self-report which could be subject to
YouTube), and video games. Of note, there was not a response, recall, and social desirability bias. Screen time
statistically significant association between social media does not capture the content or context of screen use,
and depression or any of the mental health outcomes, which could be examined in future research [20, 128].
although the coefficients were all in the positive direc- The current analysis was limited by the availability of
tion. This may be due to the fact that participants’ age data from the ongoing ABCD Study and could only fol-
during the data collection period for social media screen low adolescents for two years, starting from age 9 to 10.
time (9–10 years old) is younger than the minimum age However, given that digital technology use among chil-
requirement to have a social media account (13 years dren increases with age, particularly during adolescence

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Nagata et al. BMC Public Health (2024) 24:2686 Page 9 of 13

numbers U01DA041022, U01DA041025, U01DA041028, U01DA041048,

[129, 130], it is important to continue characterizing the U01DA041089, U01DA041093, U01DA041106, U01DA041117, U01DA041120,
relationships between digital technology use and mental U01DA041134, U01DA041148, U01DA041156, U01DA041174, U24DA041123,
health over time. Although we examined the prospec- and U24DA041147. A listing of participating sites and a complete listing of
the study investigators can be found at https://abcdstudy.org/principal-
tive association of screen time leading to mental health investigators.html. ABCD consortium investigators designed and implemented
outcomes, there is the possibility of inverse causality. the study and/or provided data but did not necessarily participate in the
Bidirectional associations between screen time and men- analysis or writing of this report.

tal health could be supported by the self-perpetuating Author contributions

feedback loop model [131], whereby screen use leads to Jason Nagata - conceptualization, analysis, writing-original draft and revisions,
worsening mental health and poor mental health leads to supervision Abubakr Al-shoaibi – conceptualization, data analysis, writing –
original draft and revisions Alicia Leong – conceptualization, writing –original
increasing reliance on screens to cope [132]. Although we draft and revisions Gabriel Zamora – conceptualization, writing –original
controlled for age, sex, race/ethnicity, household income, draft and revisions Kyle Ganson, Alexander Testa – writing -critical revisions
parent education, and study site, there is the possibility of Fiona Baker - conceptualization, data acquisition, writing-original draft and
revisionsAll authors approve of the final submitted version.
unmeasured confounders. The effect sizes were relatively
small. Funding
J.M.N. was funded by the National Institutes of Health (R01MH135492 and
K08HL159350) and the Doris Duke Charitable Foundation (2022056).
Conclusion
Our longitudinal study identified several important pro- Data availability
spective associations between screen time and DSM- Data used in the preparation of this article were obtained from the ABCD
Study (https://abcdstudy.org), held in the NIMH Data Archive (NDA).
oriented symptoms in a national sample of adolescents, Investigators can apply for data access through the NDA (https://nda.nih.
most notably depression and conduct symptoms. These gov/).
findings can help to inform developmentally appropriate
guidance related to screen use, especially for adolescents Declarations
and their parents. The American Academy of Pediatrics
Ethics approval and consent to participate
advocates for a Family Media Use plan for children 5 to Written informed consent and assent were obtained from the parent/
18 years old [133], which could be individualized for ado- guardian and adolescent, respectively, to participate in the ABCD Study. The
lescents based on some of the associations noted in the University of California, San Diego provided centralized institutional review
board (IRB) approval and each participating site received local IRB approval:
current study, and nuances in some associations by sex •Children’s Hospital Los Angeles, Los Angeles, California.
and race/ethnicity. Education, prevention, and interven- •Florida International University, Miami, Florida.
tion efforts may be particularly important in early ado- •Laureate Institute for Brain Research, Tulsa, Oklahoma.
•Medical University of South Carolina, Charleston, South Carolina.
lescence given that depression and other mental health •Oregon Health and Science University, Portland, Oregon.
conditions increase in mid- to late-adolescence; there- •SRI International, Menlo Park, California.
fore, acting of modifiable behaviors in early adolescence •University of California San Diego, San Diego, California.
•University of California Los Angeles, Los Angeles, California.
could be protective. Future research could examine lon- •University of Colorado Boulder, Boulder, Colorado.
ger-term associations with additional years of follow- •University of Florida, Gainesville, Florida.
up as the ABCD Study cohort ages through mid-to-late •University of Maryland at Baltimore, Baltimore, Maryland.
•University of Michigan, Ann Arbor, Michigan.
adolescence. •University of Minnesota, Minneapolis, Minnesota.
•University of Pittsburgh, Pittsburgh, Pennsylvania.
Abbreviations •University of Rochester, Rochester, New York.
ABCD Adolescent Brain Cognitive Development Study •University of Utah, Salt Lake City, Utah.
ADHD Attention-deficit/hyperactivity •University of Vermont, Burlington, Vermont.
CBCL Child Behavior Checklist •University of Wisconsin—Milwaukee, Milwaukee, Wisconsin.
CFI Comparative Fit Index •Virginia Commonwealth University, Richmond, Virginia.
DSM Diagnostic and Statistical Manual of Mental Disorders •Washington University in St. Louis, St. Louis, Missouri.
IRB Institutional review board •Yale University, New Haven, Connecticut.
ODD Oppositional defiant All methods were carried out in accordance with relevant guidelines and
RMSEA Root Mean Square Error of Approximation regulations.

Consent for publication

Supplementary Information Not applicable.
The online version contains supplementary material available at https://doi.
org/10.1186/s12889-024-20102-x. Role of the funder/sponsor
The funders had no role in the design and conduct of the study; collection,
Supplementary Material 1 management, analysis, and interpretation of the data; preparation, review,
or approval of the manuscript; and decision to submit the manuscript for
publication.
Acknowledgements
The authors thank Anthony Kung, Jonanne Talebloo, Sean Kim, Zain Memon, Competing interests
and Richard Do for editorial assistance. The ABCD Study was supported by The authors declare no competing interests.
the National Institutes of Health and additional federal partners under award

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Nagata et al. BMC Public Health (2024) 24:2686 Page 10 of 13

Author details 17. Herman KM, Hopman WM, Sabiston CM. Physical activity, screen time and
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