Digital Media and Developing Brains: Concerns and Opportunities.

Purpose of Review: The incorporation of digital technologies and their use in youth's everyday lives has been increasing rapidly over the past several decades with possible impacts on youth development and mental health. This narrative review aimed to consider how the use of digital technologies may be influencing brain development underlying adaptive and maladaptive screen-related behaviors. Recent Findings: To explore and provide direction for further scientific inquiry, an international group of experts considered what is known, important gaps in knowledge, and how a research agenda might be pursued regarding relationships between screen media activity and neurodevelopment from infancy through childhood and adolescence. While an understanding of brain-behavior relationships involving screen media activity has been emerging, significant gaps exist that have important implications for the health of developing youth. Summary: Specific considerations regarding brain-behavior relationships involving screen media activity exist for infancy, toddlerhood, and early childhood; middle childhood; and adolescence. Transdiagnostic frameworks may provide a foundation for guiding future research efforts. Translating knowledge gained into better interventions and policy to promote healthy development is important in a rapidly changing digital technology environment.

Beliefs and Motivations Regarding Early Shared Reading of Parents From Low-Income Households: A Qualitative Study.

OBJECTIVE: Parent-child "shared" reading is a catalyst for development of language and other emergent literacy skills. The American Academy of Pediatrics recommends that parents initiate shared reading as soon as possible after birth. Persistent disparities exist in reading resources, routines, and subsequent literacy outcomes, disproportionately impacting low-income households. We sought to understand beliefs, motivations, and experiences regarding shared reading during early infancy among parents from low-income households. METHODS: In this qualitative exploratory study, parents of infants aged 0 to 9 months from low-income households who had initiated shared reading ("readers") and those who had not ("nonreaders") were purposefully recruited to participate in individual semistructured virtual interviews. These interviews were coded using inductive thematic analysis by a 3-member team with diverse backgrounds. RESULTS: A total of 21 parents participated (57% readers, 86% mothers). Infants were 86% African American/Black, with a mean age of 3 months. Barriers noted by readers and nonreaders were i) competing demands on time, ii) lack of resources, and iii) parental mental health. An additional barrier noted solely by nonreaders was iv) it's too early/baby is not ready. Two benefits of reading were noted by both groups: 1) parents as child's first teachers and 2) reading catalyzes the child's development. Benefits noted exclusively by readers included 3) reading begets more reading, 4) bonding, 5) "it works," and 6) "two-for-one" shared reading (other children involved). CONCLUSIONS: This study provided insights into barriers and benefits regarding shared reading by socioeconomically disadvantaged parents of infants and has the potential to inform reading-related guidance and interventions.

Neuroimaging of brain connectivity related to reading outcomes in children born preterm: A critical narrative review.

Premature children are at high risk for delays in language and reading, which can lead to poor school achievement. Neuroimaging studies have assessed structural and functional connectivity by diffusion MRI, functional MRI, and magnetoencephalography, in order to better define the "reading network" in children born preterm. Findings point to differences in structural and functional connectivity compared to children born at term. It is not entirely clear whether this discrepancy is due to delayed development or alternative mechanisms for reading, which may have developed to compensate for brain injury in the perinatal period. This narrative review critically appraises the existing literature evaluating the neural basis of reading in preterm children, summarizes the current findings, and suggests future directions in the field.

Shared reading with infants: SharePR a novel measure of shared reading quality.

BACKGROUND: The AAP recommends "shared" reading from early infancy for healthy development. However, many families are uncertain how to read most enjoyably and effectively with infants, especially from underserved backgrounds. Shared reading quality (interactivity) moderates benefits yet is challenging to measure. SHARE/STEP is a new model of shared reading quality at this age incorporating evidence-based behaviors. OBJECTIVE: To test the SharePR parent-report measure of caregiver-infant reading quality. METHODS: This study involved mother-infant dyads in two unrelated trials in an obstetric (0-2 months old) and pediatric (6-9 months old) clinic. SharePR is a 10-item measure based on the SHARE/STEP model. Analyses involved descriptive statistics, measures of psychometric integrity, and correlations with home literacy environment (HLE). RESULTS: There were 99 dyads in the younger (1.2 + 0.5 months) and 108 dyads in the older groups (6.6 + 1.1 months). A majority were of non-white race (73%, 96%) and low-socioeconomic status (56%, 44% in-poverty). SharePR administration time was under 2 min and scores were normally distributed at each age. Psychometric properties were strong in terms of internal consistency and reliability. Scores were positively correlated with HLE for the older group (p < 0.05). CONCLUSIONS: SharePR may be an efficient tool to quantify shared reading quality with infants, warranting further investigation. CLINICAL TRIALS: Data for these analyses were collected via two unrelated trials led by the lead author (J.S.H.). For the younger cohort, this is registered on the ClinicalTrials.gov website, ID# NCT04031235. For the older cohort, this is registered on the ClinicalTrials.gov website, ID# 2017-6856. IMPACT: The AAP recommends caregiver-child ("shared") reading beginning in infancy, yet many families are uncertain how to do so. Verbal and social-emotional interactivity during shared reading ("quality") moderates benefits and is often low in families from disadvantaged backgrounds, yet is challenging to measure. SharePR is a 10-item parent-report measure of shared reading quality based on a novel conceptual model incorporating evidence-based behaviors (SHARE/STEP). SharePR exhibited promising psychometric properties in two separate samples of mothers of younger and older infants. SharePR is a potentially useful measure of shared reading quality at this formative age, for research and to frame early reading guidance.

Associations between digital media use and brain surface structural measures in preschool-aged children.

The American Academy of Pediatrics recommends limits on digital media use ("screen time"), citing cognitive-behavioral risks. Media use in early childhood is ubiquitous, though few imaging-based studies have been conducted to quantify impacts on brain development. Cortical morphology changes dynamically from infancy through adulthood and is associated with cognitive-behavioral abilities. The current study involved 52 children who completed MRI and cognitive testing at a single visit. The MRI protocol included a high-resolution T1-weighted anatomical scan. The child's parent completed the ScreenQ composite measure of media use. MRI measures included cortical thickness (CT) and sulcal depth (SD) across the cerebrum. ScreenQ was applied as a predictor of CT and SD first in whole-brain regression analyses and then for regions of interest (ROIs) identified in a prior study of screen time involving adolescents, controlling for sex, age and maternal education. Higher ScreenQ scores were correlated with lower CT in right-lateralized occipital, parietal, temporal and fusiform areas, and also lower SD in right-lateralized inferior temporal/fusiform areas, with substantially greater statistical significance in ROI-based analyses. These areas support primary visual and higher-order processing and align with prior findings in adolescents. While differences in visual areas likely reflect maturation, those in higher-order areas may suggest under-development, though further studies are needed.

Psychometric properties of the ScreenQ for measuring digital media use in Portuguese young children.

AIM: Digital media use is prevalent among children and linked to potential developmental and health risks, but validated measures of children's digital media use are lacking. The aim of this study was to validate the Portuguese version of the ScreenQ with three distinct children's age groups. METHODS: Parents of children living in Portugal completed an online survey including the 16-item version of the ScreenQ and items related to home activities and digital media use. A combination of classical and modern theory (Rasch) methods was used for analysis. RESULTS: A total of 549 mothers and 51 fathers of 325 girls and 322 boys from 6 months to 9 years and 11 months old responded to the survey. Point-measure correlations were all positive and endorsement of item values were within acceptable ranges. Cronbach's coefficient α was acceptable for a new measure, and test-retest reliability was high. Statistically significant correlations were found between ScreenQ total scores and relevant demographic, play-related, parenting and digital media use items. CONCLUSION: The Portuguese version of the ScreenQ exhibited sound psychometric properties, including internal consistency and concurrent validity referenced to external items. Higher ScreenQ scores were correlated with higher digital media multitasking, lower parent-child interaction, and higher concerns regarding child's learning and behaviour.

Exploratory Mixed-Methods Study of a Primary Care-Based Intervention Promoting Shared Reading During Infancy.

Parent-child "shared" reading can be a rich source of language exposure. Clinic-based programs, notably Reach Out and Read (ROR), are intended to enhance this. However, ROR has been traditionally introduced at 6 months and only recently expanded to younger ages. This study explored efficacy of an intervention delivered during pediatric well visits promoting shared reading prior to 6 months old, in terms of home reading attitudes and routines. The intervention group received children's books and anticipatory guidance about benefits of shared reading, whereas the control group received general age-related anticipatory guidance. Surveys were administered at the child's newborn (pre-intervention) and 6-month (post-intervention) well visits. Significant findings at 6 months included more frequent shared reading (P = .03), greater comfort reading at this age (P = .01), and greater importance attributed to shared reading (P = .04) in the intervention group relative to controls. These support the expansion of early literacy interventions such as ROR into early infancy.

Shared Reading and Risk of Social-Emotional Problems.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends literacy promotion as well as routine developmental surveillance during well-child visits to improve academic, relational, and health outcomes. In this study, we examined the possible association between shared reading and social-emotional problems among young children. METHODS: We conducted a retrospective review of longitudinal records for children aged 30 to 66 months presenting for visits to an academic pediatric primary care center between July 1, 2013, and February 1, 2019. The outcome was evidence of social-emotional problems, defined by an Ages and Stages: Social Emotional Questionnaire (ASQ:SE) score above the established cutoff. The predictor was caregiver-reported frequency of shared reading (most = 5-7 days per week, some = 2-4 days per week, rarely = 0-1 days per week) at a previous visit. Generalized linear models with generalized estimating equations were used to assess the association between the longitudinal outcome and predictor, adjusting for child demographics and needs reported on routine social history questionnaires. RESULTS: Analyses included 5693 children who completed at least 1 ASQ:SE (total of 7302 assessments) and had shared reading frequency documented before each ASQ:SE assessment. Children were predominantly Black (75%) and publicly insured (80%). Sixteen percent of ASQ:SE scores were suggestive of social-emotional concerns; 6% of caregivers reported sharing reading rarely. Children with rare shared reading had a higher risk of an ASQ:SE above cutoff compared with those with shared reading on most days (adjusted risk ratio, 1.62; 95% confidence interval, 1.35-1.92). CONCLUSIONS: Less-frequent caregiver-reported shared reading was associated with higher risk of social-emotional problems in young children presenting for primary care. This highlights potential relational and social-emotional benefits of shared reading.

Maternal depression is associated with decreased functional connectivity within semantics and phonology networks in preschool children.

INTRODUCTION: Maternal depression is characterized by a lack of emotional responsiveness and engagement with their child, which may lead to the child's decreased cognitive, and language outcomes all related to the child's future reading outcomes. The relations between maternal depression and functional connectivity in neural circuits supporting language in the child was explored. METHODS: Eleven 4-year-old girls completed language abilities assessment and resting-state functional magnetic resonance imaging scan. Their mothers completed the Beck's Depression Inventory (BDI) to examine maternal depression when the child was 12 months old and at the age of 4. Functional connections within the child's resting-state phonology, semantics, language networks were correlated with maternal BDI scores at the age of 4 years. RESULTS: Higher maternal depression was associated with the child's decreased within the semantic and phonological networks connectivity during rest. Higher maternal depression at 4 years moderated the relationship between early depression scores and functional connectivity within the phonological network. CONCLUSIONS: Maternal depression in the first year of life is related to functional connections of phonological processing and enhanced by current maternal depression levels. We conclude that after a mother gives birth, resources should be provided to minimize depressive symptoms and interventions should be applied to support their child's language development for future reading acquisition.

Randomized Trial of a Mobile App Introduced During Well-Visits to Enhance Guidance for Reading With Young Children.

OBJECTIVE: To estimate feasibility, usability and efficacy of a mobile parenting app (Rx for Success; RxS) to enhance reading guidance provided to parents of young children during well-visits. METHODS: This trial was conducted at a clinic serving primarily families of Hispanic ethnicity and low-socioeconomic status (SES) where Reach Out and Read (ROR) is standard practice. It involved 252 parent-child dyads in 2 age groups (~6-months old, ~18-months old) randomized during well-visits to receive RxS or a children's book modeling alternatives to screen time (Control) by research coordinators. RxS involves videos, activities and "push" messages. Follow-up assessments were conducted approximately 6 months later, including impression and use, shared reading behaviors, child language and screen time. RESULTS: A total of 217 dyads completed both visits (110 RxS, 107 Control). Time to introduce RxS was under 3 minutes and 32% of parents experienced largely minor performance issues. Parent impression of RxS was favorable for both age groups at baseline and follow-up, though use was infrequent, attributable to a desire for more relevant and updated content. Significant findings favoring RxS included shared reading as a favorite activity, more frequent shared reading reported at 12 months and higher language scores at 24 months. Screen time was equivalent between cohorts, exceeding American Academy of Pediatrics guidelines. CONCLUSIONS: A mobile app introduced to parents of young children from low-SES backgrounds was feasible during well-visits, rated as helpful, and effective to enhance shared reading at younger and language at older ages. While a potentially impactful enhancement to ROR, features needing improvement were identified.

Development of an Eco-Biodevelopmental Model of Emergent Literacy Before Kindergarten: A Review.

Importance: Literacy has been described as an important social determinant of health. Its components emerge in infancy and are dependent on genetic, medical, and environmental factors. The American Academy of Pediatrics advocates a substantial role for pediatricians in literacy promotion, developmental surveillance, and school readiness to promote cognitive, relational, and brain development. Many children, especially those from minority and underserved households, enter kindergarten unprepared to learn to read and subsequently have difficulty in school. Observations: Emergent literacy is a developmental process beginning in infancy. Component skills are supported by brain regions that must be adequately stimulated and integrated to form a functional reading network. Trajectories are associated with genetic, medical, and environmental factors, notably the home literacy environment, which is defined as resources, motivation, and stimulation that encourage the literacy development process. Eco-biodevelopmental models are advocated by the American Academy of Pediatrics, and these models offer insights into the neurobiological processes associated with environmental factors and the ways in which these processes may be addressed to improve outcomes. Emergent literacy is well suited for such a model, particularly because the mechanisms underlying component skills are elucidated. In addition to cognitive-behavioral benefits, the association of home literacy environment with the developing brain before kindergarten has recently been described via neuroimaging. Rather than a passive approach, which may subject the child to stress and engender negative attitudes, early literacy screening and interventions that are administered by pediatric practitioners can help identify potential reading difficulties, address risk factors during a period when neural plasticity is high, and improve outcomes. Conclusions and Relevance: Neuroimaging and behavioral evidence inform an eco-biodevelopmental model of emergent literacy that is associated with genetic, medical, and home literacy environmental factors before kindergarten, a time of rapid brain development. This framework is consistent with recommendations from the American Academy of Pediatrics and provides insights to help identify risk factors and signs of potential reading difficulties, tailor guidance, and provide direction for future research.

Validation of The Reading House and Association With Cortical Thickness.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends literacy and school readiness promotion during well visits. The Reading House (TRH) is a children's book-based screener of emergent literacy skills in preschool-aged children. Vocabulary, rhyming, and rapid naming are core emergent skills, and reading abilities are associated with thicker cortex in the left hemisphere. Our objective was to expand validity of TRH relative to these skills and explore association with cortical thickness. METHODS: Healthy preschool-aged children completed MRI including a T1-weighted anatomic scan. Before MRI, TRH and assessments of rapid naming (Comprehensive Test of Phonological Processing, Second Edition), rhyming (Pre-Reading Inventory of Phonological Awareness), vocabulary (Expressive Vocabulary Test, Second Edition), and emergent literacy (Get Ready to Read!) were administered. Analyses included Spearman-ρ correlations (r ρ) accounting for age, sex, and socioeconomic status (SES). MRI analyses involved whole-brain measures of cortical thickness relative to TRH scores, accounting for covariates. RESULTS: Seventy children completed assessments (36-63 months old; 36 female) and 52 completed MRI (37-63 months; 29 female). TRH scores were positively correlated with Comprehensive Test of Phonological Processing, Second Edition (r ρ = 0.61), Expressive Vocabulary Test, Second Edition (r ρ = 0.54), Get Ready to Read! (r ρ = 0.87), and Pre-Reading Inventory of Phonological Awareness scores (r ρ = 0.64; all P < .001). These correlations remained statistically significant across age, sex, and SES groups. TRH scores were correlated with greater thickness in left-sided language and visual cortex (P-family-wise error <.05), which were similar for higher SES yet more bilateral and frontal for low SES, reflecting a less mature pattern (P-family-wise error <.10). CONCLUSIONS: These findings expand validation evidence for TRH as a screening tool for preschool-aged children, including associations with emergent skills and cortical thickness, and suggest important differences related to SES.

Encouraging Parental Reading for High-Risk Neonatal Intensive Care Unit Infants.

OBJECTIVE: To assess whether a citywide structured book-sharing program (NICU Bookworms) designed to promote reading to infants while admitted in the neonatal intensive care unit (NICU) would increase parental reading behaviors (≥3-4 days/week) in the NICU and after discharge home, including high-risk parents who do not themselves enjoy reading. STUDY DESIGN: The NICU Bookworms program comprised staff training, parent education, and building a literacy-rich environment. In this quasi-experimental intervention study, parents of medically high-risk NICU graduates <6 months of age were administered a questionnaire at their first NICU follow-up clinic visit. The survey incorporated questions from the StimQ-I READ subscale to assess home reading environment and shared reading practices. RESULTS: A total of 317 infants were enrolled, 187 in an unexposed comparison group and 130 in the intervention group. Parents exposed to Bookworms were significantly more likely to read ≥3-4 days per week while in the NICU (34.5% vs 51.5%; P = .002; aOR, 2.2; 95% CI, 1.2-4.0), but reading at home did not differ (67.9% vs 73.1%; P = .28; aOR, 0.99; 95% CI, 0.5-1.8). However, among parents who did not themselves enjoy reading, frequency was significantly higher both in the NICU (18.4% vs 46.1%; P = .009; aOR, 5.0; 95% CI, 1.2-21.5) and at home (36.9% vs 70%; P = .003; aOR, 3.7; 95% CI, 1.1-12.9). A qualitative thematic analysis found that Bookworms decreased parental stress, enhanced bonding, and supported positive parent-infant interactions. CONCLUSIONS: A book-sharing intervention in the NICU increased parent-reported reading aloud during hospitalization and among parents disinclined to read for pleasure, both in the NICU and following discharge. This change may have been mediated by enhancement of parent-infant interactions.

A novel, composite measure of screen-based media use in young children (ScreenQ) and associations with parenting practices and cognitive abilities.

BACKGROUND: Screen-based media use is prevalent in children and is associated with health risks. American Academy of Pediatrics (AAP) recommendations involve access to screens, frequency, content, and co-viewing. The aim of this study was to test the ScreenQ, a composite measure of screen-based media use. METHODS: ScreenQ is a 15-item parent report measure reflecting AAP recommendations. Range is 0-26, higher scores reflecting greater non-adherence. With no "gold standard" available, four validated measures of skills and parenting practices cited as influenced by overuse were applied as the external criteria, including expressive language, speed of processing, emergent literacy, and cognitive stimulation at home. Psychometric analyses involved Rasch methods and Spearman's ρ correlations. RESULTS: Sixty-nine families were administered ScreenQ. Child age ranged from 36 to 63 months old (52 ± 8; 35 girls). Mean ScreenQ score was 9.6 (±5.0; 1-22). Psychometric properties were strong (rCo-α = 0.74). ScreenQ scores were negatively correlated with CTOPP-2 (Comprehensive Test of Phonological Processing, Second Edition) (rρ = -0.57), EVT-2 (Expressive Vocabulary Test, Second Edition) (rρ = -0.45), GRTR (Get Ready to Read!) (rρ = -0.30) and StimQ-P (rρ = -0.42) scores (all p ≤ 0.01). CONCLUSIONS: ScreenQ shows potential as a composite measure of screen-based media use in young children in the context of AAP recommendations. ScreenQ scores were correlated with lower executive, language and literacy skills, and less stimulating home cognitive environment.

Reading in children with drug-resistant epilepsy was related to functional connectivity in cognitive control regions.

AIM: This study aimed to define whether individuals with drug-resistant focal epilepsy also used regions related to cognitive control to facilitate reading. METHODS: We focused on patients with drug-resistant focal epilepsy in 2011-2014, who were aged 8-20 years and were being treated at the Cincinnati Children's Hospital, USA. They performed a verb generation functional magnetic resonance imaging task known to involve language and cognitive control, as well as a formal reading assessment. The reading scores were correlated with functional connectivity of the anterior cingulate cortex (ACC) using seed-to-voxel analysis. RESULTS: There were 81 potential patients and 13 (seven females) met the inclusion criteria. Their age at seizure onset was 0-13 years, and they had a mean age of 12.66 ± 3.17 years at the time of the study. Individuals with epilepsy demonstrated average intelligence and word reading ability. Their reading scores were positively correlated with functional connectivity between the ACC and regions related to emotional processing (right amygdala), learning and language processing (left cerebellum) and visual processing. CONCLUSION: Our results support the role that the ACC plays in proficient reading among children with drug-resistant epilepsy, even in those with epileptogenic foci in areas related to language.

Associations Between Screen-Based Media Use and Brain White Matter Integrity in Preschool-Aged Children.

Importance: The American Academy of Pediatrics (AAP) recommends limits on screen-based media use, citing its cognitive-behavioral risks. Screen use by young children is prevalent and increasing, although its implications for brain development are unknown. Objective: To explore the associations between screen-based media use and integrity of brain white matter tracts supporting language and literacy skills in preschool-aged children. Design, Setting, and Participants: This cross-sectional study of healthy children aged 3 to 5 years (n = 47) was conducted from August 2017 to November 2018. Participants were recruited at a US children's hospital and community primary care clinics. Exposures: Children completed cognitive testing followed by diffusion tensor imaging (DTI), and their parent completed a ScreenQ survey. Main Outcomes and Measures: ScreenQ is a 15-item measure of screen-based media use reflecting the domains in the AAP recommendations: access to screens, frequency of use, content viewed, and coviewing. Higher scores reflect greater use. ScreenQ scores were applied as the independent variable in 3 multiple linear regression models, with scores in 3 standardized assessments as the dependent variable, controlling for child age and household income: Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2; Rapid Object Naming subtest); Expressive Vocabulary Test, Second Edition (EVT-2; expressive language); and Get Ready to Read! (GRTR; emergent literacy skills). The DTI measures included fractional anisotropy (FA) and radial diffusivity (RD), which estimated microstructural organization and myelination of white matter tracts. ScreenQ was applied as a factor associated with FA and RD in whole-brain regression analyses, which were then narrowed to 3 left-sided tracts supporting language and emergent literacy abilities. Results: Of the 69 children recruited, 47 (among whom 27 [57%] were girls, and the mean [SD] age was 54.3 [7.5] months) completed DTI. Mean (SD; range) ScreenQ score was 8.6 (4.8; 1-19) points. Mean (SD; range) CTOPP-2 score was 9.4 (3.3; 2-15) points, EVT-2 score was 113.1 (16.6; 88-144) points, and GRTR score was 19.0 (5.9; 5-25) points. ScreenQ scores were negatively correlated with EVT-2 (F2,43 = 5.14; R2 = 0.19; P < .01), CTOPP-2 (F2,35 = 6.64; R2 = 0.28; P < .01), and GRTR (F2,44 = 17.08; R2 = 0.44; P < .01) scores, controlling for child age. Higher ScreenQ scores were correlated with lower FA and higher RD in tracts involved with language, executive function, and emergent literacy abilities (P < .05, familywise error-corrected), controlling for child age and household income. Conclusions and Relevance: This study found an association between increased screen-based media use, compared with the AAP guidelines, and lower microstructural integrity of brain white matter tracts supporting language and emergent literacy skills in prekindergarten children. The findings suggest further study is needed, particularly during the rapid early stages of brain development.