Background
The identification of developmental problems in a child’s acquisition of speech is
a core part of clinical observation. Conditions that can account for speech problems
can be divided into primary, those for which no other etiology can be found, and secondary.
Autism spectrum disorders are an example of such a secondary condition, and when a
child is observed with speech delay, it is essential to pay attention to their socially
interactive and communicative skills. In this article, we suggest that early media
overexposure (EMO) is another condition of this sort.
Case Presentation
A 25-month-old boy was observed during a general pediatric visit, following parental
concern over speech delay, feeding, and sleep disorders. He was a first child without
special neonatal history, looked after by his mother at home with scarce outdoors
activities (the pregnancy of a second child occurred when he was only 9 months old
and the mother felt too tired to go outside). Parents reported typical “infantile
anorexia” with a child who refused to eat adequate amount of food for more than 6
months and who lacked interest in food and showed strong interest in exploration instead.
The sleep schedule was erratic with very late sleep onset and many wakes during the
night. Neurological examination was normal, except for the items of language and more
largely social behavior. He presented as sad and restless, and during all adult initiated
interactions, it was difficult to meet his gaze and he had no joint attention. He
neither sought after nor desired adult interactions, but there was a small observable
improvement in his responsivity toward the end of the session, probably due to the
close attention paid to him. Following discussion with his father, it was noted that
he did not engage in structured play, but preferred to “tinker repeatedly with locks,”
suggesting stereotypical repetitive activity. Formal language testing was not possible
as he did not use any verbal language although his parents stated that he would say
a few isolated words at home “water,” when he was thirsty, or “not that.” Parents
commented that he always held a hard object and used to turn the wheels of little
cars close to his eyes. Although there was no evident stereotyped behavior during
examination, parents commented that he sometimes bit himself when he was overexcited.
During the consultation, when asked to draw, he evidently found the close proximity
of adults challenging and started to draw on the table and then on books but not on
the paper presented to him. He did not respond to “don’ts” but did respond to regular
“increase” in volume of voice to “no.” He stopped, suspended his movement, and appeared
to be thinking, which suggested an ability to hear and to be considering those around
him.
He received normal results in the audiogram performed a few days later. Parents were
asked to complete the Ages and Stages Questionnaire, Third Edition (ASQ-3). The ASQ-3
is a widely used, parent-reported screening measure.
1
The ASQ-3 identifies developmental progress in 5 domains: communication, gross motor,
fine motor, problem solving, and personal-social. The questionnaire includes 30 items
scored as yes, sometimes, or not yet on questions asking about a child’s ability to
perform a task. All ASQ-3 results of the child except gross motor measure were below
the cutoff score expected for the age.
Because of the boy’s autism-like symptoms, a diagnostic assessment tool was asked
to an experienced child psychiatrist. The Childhood Autism Rating Scale (CARS) is
a 15-item behavioral rating scale and each item covers a particular characteristic
and behavior, with a first edition validated in French.
2
Scores of less than 29, between 30 and 36, and above 36 on the CARS are considered
indicative of normal, mild to moderate autism, and severe autism, respectively. In
this first examination, the CARS gave a score of 36, which placed this boy in the
“mild to moderate autism” category. None of the 15 items were normal; poor results
were obtained in all the social categories (social relations, imitation, emotional
responses, language) and in “level of activity.” A family screen time questionnaire
revealed that he had been exposed to background all the day long, as well as foreground
television (he watched the TV News with his father after work) since his first 6 months
and that he was habitually watching YouTube Kid alone on the parents’ smartphone for
3 hours a day, especially during mealtime (as he was suffered of feeding disorders).
On the family’s screen questionnaire, his mother reported using her mobile phone herself
for more than 3 hours a day while his father reported essentially watching the TV.
Subsequently, his parents were asked to completely stop any and all screen and media
exposure for all the family (the sister is 6 months old). Written pieces of advices
were provided to the father by the pediatrician to increase outdoors activities, play
with traditional toys (as balloons or truck), and foster social interaction with same-age
peers. A regular schedule for meals and sleep times was also recommended. Two and
a half months later, the parents reported to the pediatrician that, as asked, they
have stopped giving their smartphone and that the television was now only switched
on when their son was asleep. Sleep quantity and quality have improved. At the examination,
the boy was more stable, less agitated, and was now able to remain focused on his
activities for a longer period of time. His language was observed to be somewhat jargonized,
but with intentional prosody, and in which it was now possible to recognize words
and groups of words. His play activities had become more varied. During this interview,
he spoke to the adult and pointed his finger at the waiting room searching for a joint
attention, in an attempt to tell a story in which the words “balloon” and “truck”
appeared. In explanation, his father stated that that they had left a balloon and
a truck in the waiting room. The boy’s language seemed to fulfill its communicative
function. Complex instructions given by his father were well understood and executed.
When he was asked to build a tower of 6 cubes, the boy obeyed, displayed observable
signs of pleasure, and made the activity last, indicating an increased interest in
toys. He made seemingly easy and often sustained eye contact with those around him
and was positively responsive to smiles. The CARS assessed by the same child psychiatrist
gave him a new score of 21, which placed him in the “non-autistic” category. Some
items were categorized as close to or completely normal (body use, nonverbal communication,
and level of activity), and the overarching impression was one of a non-autistic child.
On the other hand, his language remained abnormal. Pieces of advice were repeated
to parents to support the progress, and 6 months later, the child was integrated thanks
to the intervention of the pediatrician in a public day care center.
A new ASQ score is assessed at the age of 3 years: the communication, problem solving,
and personal-social scores are normal. Only the fine motor measure is still under
the cutoff score expected for the age. Screen time is now limited to 20 minutes a
day.
Discussion
There is now evidence that excessive screen time can be harmful to children’s social-emotional,
attentional, and cognitive functions.
3
Some studies have reported autism-like symptoms in the most severe cases, findings
that coincide with the above-described case. Wu found that children exposed to a screen
time of more than 2 hours per day had a significantly increased risk of having emotional
and prosocial problems, as well as behavioral symptoms of autism (using the Clancy
Autism Behavioral Scale).
4
Chonchaiya et al reported that infants aged between 6 and 18 months and who had been
exposed to television since the age of 6 months displayed higher levels of pervasive
developmental problems (using the Child Behavior Checklist).
5
Recently, Yurika et al reported a 5-year-old boy, who, having been exposed to media
during his early development, had later displayed neurobehavioral symptoms that mimicked
autism. She used, as we did, the Child Autism Rating Scale.
6
Similar observations have been reported and discussed by clinicians worldwide.
7
-9
From our discussion of case study as well as previously published studies in this
field, we describe a new condition called “Early Media Overexposure” syndrome. This
syndrome is caused by overexposure to media at an early age. It affects young children
and it associates speech delay with autism-like symptoms. We suggest, however, that
the condition can be reversed by way of a total ceasing of media and screen exposure.
The initial reason for the general practice consultation in our case was speech delay.
The examination found symptoms that could evocate one of autism spectrum disorders
and was confirmed by the Childhood Autism Rating Scale, an accurate instrument for
the screening and diagnosis of childhood autism.
10
During the discussions with parents, the screen exposure was found to have begun early
in the child’s life. The child was found to have been intensely exposed to screens,
with most experiencing the presence of consistent background television, as well as
heavy use of mobile phones. In connection with this, parents were found to be exposed
to their own mobile phones for an excessive amount of time during the time shared
with their child. This may have deeply disrupted family interactions and could explain
the language delay and social disturbances displayed by the child. Background television
indeed has a profound effect on children and families. It diminishes the quality and
quantity of parental communication.
11,12
This “barrier effect” to interactions is related to the broader notion of “technoference.”
13
Furthermore, handheld mobile use by the child and heavy media use by the parents may
have severely aggravated the “barrier effect” between parents and child, challenged
essential interactions, and led to our clinical findings.
14
Klin and colleagues have well described that the context of the infant-caregiver dyad
is the catalyst for subsequent development: initially spontaneous reflex-like responses
transition into remarkably sensitive and contingent social action, all within the
first month of life. Interestingly, these transitions may be disrupted in autism spectrum
disorders.
15
The screens offer no reciprocal social reward such as a returned smile or eye gaze
for looking at the eyes of the projected individual, and no opportunities for joint
attention, turn taking, or the complexities of social engagement. Heffler and Oestreicher
have largely discussed the potential mechanisms by which screen exposure could act
as a potential “environmental trigger” for neurodevelopmental disorders. Because of
the lack of real-life social interaction, and limited multisensory input, the audiovisual
materials developed neuronal pathways compete with preference for social processing,
negatively affecting development of social brain pathways, and causing global developmental
delay. This heightened neural response to the sensory exposure alters the infant’s
behavior, and affects further social and cognitive growth through an aberrant trajectory
of neurodevelopment.
16
The 2-month-long media fast prescribed by the pediatrician after the diagnosis of
“EMO” syndrome, without any other alteration in conditions, led to a rapid improvement.
This is evident through the normalization of the autism score. However, there is a
possibility that the differences between the 2 CARS measures found could be due to
causes other than the abolition of screen time. However, both tests were performed
by the same examiner at a close interval, and during the interview, no alternate intervention
during this period (eg, by a speech therapist or psychologist) was reported by the
parents. It is also clear that some children who are overexposed to screens at an
early age may be children with preexisting autism spectrum disorders, as these children
are known to have a particular predilection for screens.
17
We are convinced, however, that an abolition of screen use should be introduced to
every child displaying the clinical characteristics we note, as the recovery of interactions
between parents and children associated with a media break are of benefit to everyone.
The gravity of these clinical findings confirms the importance of the recommendations
of the American Academy of Pediatrics, who, for a long time, have discouraged screen
exposure for very young children.
18
It is no longer possible to ignore discussions regarding the harmful effects of screens
on young children or for pediatricians, to “understand the evolution of digital technology
without demonizing,” as in some recommendations from pediatrics institutions.
19
What should be encouraged is a sharing of this information by parents. Therefore,
all families should be informed, from maternity unit, about the risks of early exposure
of their child to screens. Our findings show that such overexposure could lead to
symptoms that mimic autism spectrum disorder and that these symptoms can be reversed
or improved by a break from media and screen use. We are convinced that this removal
of media must be thorough and be implemented early on to be effective. In turn, this
could only be done if pediatricians systematically ask parents about screen time exposure
and systematically pay attention to autism-like symptoms.