A healthy media use intervention in preschool-aged children, aimed at replacing violent content with age-appropriate, educational, and prosocial content, led to improved sleep in the intervention group as compared with the control group. The lack of significant effect modification by baseline sleep problems suggests that health media choices may help treat existing behavioral sleep problems and be a useful preventive measure. The observed trend toward effect modification by baseline levels of violent media exposure, coupled with the fact that the intervention targeted content rather than quantity and had no effect on mean daily usage, suggests that the intervention effects at reducing violent media use may have been the initial mechanism by which the intervention improved child sleep outcomes. Although effect sizes were similar at both 6 and 12 months after the initial intervention encounter, there was a trend toward a decrease in effect by the 18-month follow-up. Given that the intervention itself ended at 12 months, the potential decay at 18 months suggests that families may need supportive maintenance after the active intervention or that the intervention protocol may need to be revised to ensure that families are mastering the skills needed to continue making healthy media choices as their child continues to grow older and media options evolve.
Although an intervention to change the child’s media diet positively impacted sleep, it remains unknown how this relationship is mediated; the fact that the intervention targeted content choices rather than quantity of use, and in fact had no impact on total minutes of daily use, suggests that content indeed plays a key role. In our previous article describing the relationship between media use and child sleep at baseline in this study, we found not only that evening media use was associated with increased sleep problems but so was violent media use earlier in the day.2
If the intervention affected child sleep by reducing violent media consumption across the day, the effects may have been mediated by decreases in factors such as fears and state anxiety,20
arousal state at bedtime, or hyperactivity.
This study has a number of limitations that warrant mention. First, the sleep measure used was only a brief excerpt from a validated measure, because the study was designed primarily to examine outcomes of the healthy media use intervention around aggression and prosocial behaviors. The use of such a rough measure increases the chances of misclassification of child sleep problems, with both false-positive and false-negative results; however, we would expect this misclassification to be nonselective in nature, and to therefore bias our findings toward the null. We hope that future studies will be able to replicate these findings by using more robust measures of child sleep, such as sleep diaries or actigraphy. Second, it is not possible to blind the subjects of behavioral intervention studies; however, the study was presented to the parents as targeting media and aggression, not children’s sleep, so there is no reason to expect that social desirability or response bias would have led to differences in the sleep measure between study arms beyond that due to the intervention alone. Third, we drew our sample from clinics in a single urban area; however, because the children were eligible for inclusion regardless of whether they had been seen in the clinic over the past year, the study more closely approximates a population-based sample than a clinical sample. Still, the extent to which the results can be generalized to children from other communities is unknown. Finally, we did not have enough case managers to examine the degree to which interventionist characteristics may have impacted the effects observed in their panels and may not have had sufficient sample sizes of some subpopulations (such as low-income children or those with a television in the bedroom at baseline) to adequately test for effect modification by these factors. Perhaps future studies will be able to selectively target and oversample these populations and explore the potential for effect modification.
Despite these limitations, the findings have 2 important implications. First, these results in the context of a randomized controlled trial suggest that the previously reported relationship between media use and child sleep problems is indeed causal in nature. Second, clinicians and parents should be mindful that healthy media use choices could be a valuable strategy in treating and preventing child sleep problems. Given that early childhood sleep problems have been associated with a range of deleterious outcomes, both acute and long-term, including increased injuries, behavioral and emotional problems, difficulties in school, and obesity, the availability of useful, feasible strategies is critical.