Abstract
Background: Recent studies have demonstrated the association between early screen time exposure and autism spectrum disorder. device use can change. The aim of this study was to determine the impacts of reducing screen time and parent-child interaction training on autism symptoms, repetitive behaviors and EEG spectral power in young children.
Methods: This study was conducted using the quasi-experimental design and consisted of 12 children with ASD (33,33 + 9.95 months) whom excessive exposed to digital devices. Digital devices were reduced from the child’s life for two months and parents were trained to intensive interaction with their child. Autism Treatment Evaluation Checklist, Repetitive Behavior Scale, and 19-channel EEG recording were administered.
Results: It was determined that after the reducing screen time and tow month intensive interaction, the severity of autism spectrum disorder and repetitive behaviors reduced and absolute power of alpha and beta bands and relative power of delta, theta and beta bands significantly changed.
Conclusion: Our findings highlight the importance of communicative and high-quality caregiving environment for children with ASD, particularly for children excessive exposed to digital devices, for treating autism and promoting healthy brain development.
Key Words: Autism spectrum disorders, Screen time, Parent-Child Interaction, EEG
1. Introduction
Autism spectrum disorder is defined by persistent deficits in social communication and social interaction across multiple contexts as well as restricted, repetitive patterns of behavior, interests, or activities(American Psychiatric Association, 2013). Autism spectrum disorders have increased dramatically in prevalence in recent years (Baio et al., 2018). Recent studies have seen the role of environmental factors in the etiology of autism more important than the past (Chaste & Leboyer, 2012; Hallmayer et al., 2011; Sandin et al., 2014) and reveals interest in environmental factors and their potential causal impact on ASD by interfering with neural synchronization and epigenetic regulation (Deth, Muratore, Benzecry, Power-Charnitsky, & Waly, 2008; Hall & Kelley, 2014). Consistent to the high rate of ASD in recent years, children use of digital devices such as TVs, DVDs, smartphones, tablets, and computer games become significant increase. Duch et al. (2013) also reported that 68 percent of children under the age of 3 use digital devices daily, such as TVs, DVDs, and Video games (Duch, Fisher, Ensari, & Harrington, 2013). Kabali et al (2015) study show that approximately 97 percent of 0-4 years old children use the smart phone (Kabali et al., 2015). Chang et al. (2018) also found that about 39 percent of Korean children 2 to 5 years watching television almost every day (Chang, Park, Yoo, won Lee, & Shin, 2018). Ruest et al. (2018) also reported that about 17 percent of children use digital devices for about 6 hours a day (Ruest, Gjelsvik, Rubinstein, & Amanullah, 2018). Literature suggests that the healthy development of children depends on interaction with the others and environment experiences (Hart & Risley, 1999; Tamis‐LeMonda, Bornstein, & Baumwell, 2001; L. Vygotsky, 1978). A child who spent most of his waking hours on digital devices during brain development critical periods will lose the cognitive, emotional and social learning positions (D. Anderson & Pempek, 2005; Lyall, Schmidt, & Hertz-Picciotto, 2014; Mazurek, Shattuck, Wagner, & Cooper, 2012; Pempek, Demers, Hanson, Kirkorian, & Anderson, 2011).
American Academy of Pediatrics (2003) has recommended that children under two years old should not use digital devices (American Academy of Pediatrics, 2003), because, at the early years, high-quality environmental experiences play a vital role in the child healthy development (E. L. Anderson, Steen, & Stavropoulos, 2017; Bradley, McKelvey, & Whiteside‐Mansell, 2011; Piaget, 1964; L. S. Vygotsky, 1980). Whereas, previous studies have shown that the use of digital devices leading to reduces the quantity and quality of the parent-child interactions and deprives the child of the social environment (Courage, Murphy, Goulding, & Setliff, 2010; Kirkorian, Pempek, Murphy, Schmidt, & Anderson, 2009; Pempek et al., 2011). Indeed, when the digital devices are on, parents are less responder, sensitive, and engaging with their child and on the other hand, the child’s attention is also attracted to the attractive visual and auditory effects of these devices (Courage et al., 2010; Pempek et al., 2011; Skaug, Englund, Saksvik‐Lehouillier, Lydersen, & Wichstrøm, 2018). Mendelsohn et al. (2008) have shown that childhood exposure to digital devices reduces parent-child verbal interaction (Mendelsohn et al., 2008). Nathanson and Rasmussen (2011) studied the impact of watching television compared to the book reading and toy games on the interaction between mother and child in the ages of 16 to 72 months and they showed that the mother-child interaction reduced during watching television compared to reading books and playing with toys (Nathanson & Rasmussen, 2011). Despite the parents beliefs, children at an early age after birth due to the lack of symbolic skills, attention, and memory cannot learn through digital devices as much as learning from their caregivers and transfer knowledge from digital devices to daily life is difficult for them (Barr, 2013). So, it seems that digital devices have more funny functions rather than education and learning functions (Radesky & Christakis, 2016; V. Rideout & Hamel, 2006; V Rideout, Saphir, Pai, & Rudd, 2013; Schmidt, Pempek, Kirkorian, Lund, & Anderson, 2008). In the early ages, environmental experiences and parent-child interactions are very important because the development of prefrontal cortex and cognitive abilities are directly related to these experiences (Fay‐Stammbach, Hawes, & Meredith, 2014; Greenough, Black, & Wallace, 1987; Holmes et al., 2018; Kolb et al., 2012; Lam, Chung, & Li, 2018; Lewis & Carpendale, 2009; Sale, 2016; Seidel, Poeggel, Holetschka, Helmeke, & Braun, 2011; Sethna et al., 2017; Sosic-Vasic et al., 2017). Nelson et al (2008) had shown that the peak in the formation of new synapses is about 15 months and survival or pruning of these nerve connections is determined by the frequency of their activation (Nelson, Thomas, & DeHaan, 2008). In this age, children’s extreme use of digital devices may be like environmental deprivation during critical periods and hinders whole brain integration and development of the frontal lobe(Lin et al., 2012), reduced connectivity and atrophy of gray matter in the frontal lobe(Weng et al., 2013) and have correlation with gray matter volume in frontal cortex(Takeuchi et al., 2015). The parent-child interaction also affects the prefrontal cortex of the brain that are bases of executive functions skills (Helmeke et al., 2009; Kolb et al., 2012; Seidel et al., 2011). Also,
It seems that there is the relationship between the use of digital devices in recent years, decreased social interactions and increased prevalence of autism (Heffler & Oestreicher, 2016; Mazurek et al., 2012; Sigman, 2009; Waldman, Nicholson, & Adilov, 2006). Recent studies have seen the role of environmental factors in the etiology of autism more important than the past (Chaste & Leboyer, 2012; Hallmayer et al., 2011; Sandin et al., 2014) and reveals interest in environmental factors and their potential causal impact on ASD by interfering with neural synchronization and epigenetic regulation (Deth et al., 2008; Hall & Kelley, 2014). Hermawati et al (2018) demonstrated the relationship between early electronic screen exposure and autistic-like behaviors (Hermawati, Rahmadi, Sumekar, & Winarni, 2018; Pouretemad, Rahmati, & Sadeghi, 2017). The autism causation model of Heffler & Oestreicher (2016) is a new model that attempts to explain how digital devices can cause autism spectrum disorder (Heffler & Oestreicher, 2016). According to this model, infant attracted to digital devices and its audio and video stimuli, which offer the naive infant no social relevancy. During the critical period of brain development and neuroplasticity, excessive exposure of infant with digital devices causes specialization of brain pathways that process audio and visual stimuli in a non-social manner. These specialized sensory pathways interfere with attention to social stimuli and disrupt the development of social brain specialization. The lack of attention to the caretaker and the social scene contributes to global developmental delay and risk of autism (Heffler & Oestreicher, 2016). Past studies demonstrated that the use of digital devices in young children with autism symptoms is more than normal children. For example, Chonchaiya et al (2008) have shown that young children with autism spectrum disorder spent more time watching television and began to watch television significantly earlier than children with typical development(Chonchaiya & Pruksananonda, 2008). Mazurek et al (2012 & 2013) demonstrated that the rates of media use (especially non-social media) are higher more in children with autism spectrum disorder (Mazurek & Engelhardt, 2013a, 2013b; Mazurek et al., 2012; Mazurek & Wenstrup, 2013). Stiller and Mößle (2018) systematic review study showed that screen media is a preferred leisure activity for children with autism spectrum disorder(Stiller & Mößle, 2018). While previous studies determined the high rate of digital devices use in children with autism spectrum disorder, but previous studies did not investigate the effects of reducing screen time and parent-child interaction among children with autism spectrum disorder. In this study, we investigated the effects of reducing screen time and parent-child interaction on the severity of autism symptoms and EEG absolute and relative power in the children’s who were excessively exposed to screen time and have ASD.
2. Method
2.1 Participants
This study sample included 12 children that they age range were 2–4 years (M= 33.33month, SD=9.95). Children were diagnosed by a highly-experienced licensed clinical psychologist at the Ava Autism Center (Tehran, Iran), where training sessions took place. Children used digital devices in more than half their waking time (0/50 plus waking time using digital devices). Inclusion criteria included lack of psychiatric, neurologic and metabolic disorders as the comorbid diagnosis. Exclusion criteria also included parent failure to reducing child screen time, failure to attend parent-child interaction training sessions and receiving drug or other interventions simultaneously with the present study.
2.2. Procedure
After selecting each subject, parents were invited to a meeting and explained the research for them. Parents provided informed consent to have their children participate in this study. The study was approved by the Shahid Beheshti University ethical committee. Parents also completed demographic information, lifestyle checklist, Autism Treatment Evaluation Checklist, Repetitive Behavior Scale. The questionnaires were completed by parents three times (pre-test, post-test, and follow-up). The follow-up period was two months. Child EEG data were recorded at two times (pre-test and post-test) in Tehran pediatric hospital. The training included parent training to remove any screen device from child life and doing intensive interaction with child. The parent-child interaction training intervention is a child-centered program aimed at increasing the quantity and quality of parent-child communication activities while reducing the use of screen devices by the child (Pouretemad, 2000; Rahmati, 2017). The principles of this intervention are: (A) Increasing the hours of parent-child interaction through enjoyable games, productive games, caring activities (such as feeding, bathing, and hugging), reciprocal imitation and any the interactive activity that is pleasant for the child and parent, (B) arousing the child to communicate with people (instead of objects), (C) Prevention (not confronting) of lonely and repetitive activities and the removal of any a digital device that interferes with the parent-child interaction and encourages the child to be alone with objects and (D) apply the intervention at all hours of child waking. This intervention has three levels: joining parents to child and develop emotional bond between parents and child (first level), parent’s interaction with the child (second level), and bilateral interactions between parent and child (third level). This intervention was taught to parents for two months (8 sessions and each session was 1.30 hours, individually weekly sessions). The sessions were carried out by licensed PhD-level clinical psychologist who had several years of experience working with children with ASD.
2.3 Measures
Life Style Checklist. To assess children’s lifestyle, we compiled a checklist that parents should record every 5 minutes what child is doing. With this method, we measured the amount of sleep, wake, child use of all types of digital devices and child interactions in three times (pre-post and follow-up).
Autism Treatment Evaluation Checklist (ATEC). The Autism Treatment Evaluation Checklist (ATEC) is a questionnaire that was developed by the Autism Research Institute to evaluate the treatment efficacy in autistic individuals(Rimland & Edelson, 2000). The ATEC is suitable for ASD children 2 years of age and older. It consists of four subscales labeled: Speech/ language/ communication, sociability, sensory/cognitive awareness, and health/physical/ behavior. The four subscale scores can be used to calculate a total score (total scores can range from 0 to 180). The higher the scores, the higher the ASD symptoms. ATEC is designed to allow the examiner to assess the outcomes of any treatments used in patients with ASD (Geier, Kern, & Geier, 2013). In this study, ATEC scores were calculated for all participants before and after the intervention and in the follow-up.
Repetitive Behavior Scale. The Repetitive Behavior Scale-Revised (RBS-R) (Bodfish, Symons, Parker, & Lewis, 2000) is a 43-item informant-based rating scale intended to assess 6 dimensions of repetitive behavior in individuals with ASD. These are (1) Stereotyped Behavior, apparently purposeless movements or actions that are repeated in a similar manner; (2) Self-Injurious Behavior, movements or actions that cause or have the potential to cause redness, bruising, or other injury to the body, and that are repeated in a similar manner; (3) Compulsive Behavior, behavior that is repeated and performed according to a rule or involves things being done “just so”; ( 4) Ritualistic Behavior, performing activities of daily living in a similar manner; (5) Sameness Behavior, resistance to change, insisting that things stay the same; and (6) Restricted Behavior, limited range of focus, interest, or activity. Items are rated on a four-point Likert scale ranging from (0) “behavior does not occur” to (3) “behavior occurs and is a severe problem”. The RBS-R is scored by calculating the ‘Number of subscale items endorsed’ (number of items in a subscale rated 1, 2, or 3). The sum of the ratings for all of the items in a subscale gives the ‘Overall Score’.
EEG recording. 19-channel EEG-1200 (Neurofax, Nihon Kohden, Tokyo, Japan) was used to collect electrophysiological data. Data recorded in sedate mode with 500 Hz sampling rate and 22 electrodes (Fp1, Fp2, F7, F3, Fz, F4, F8, T3, C3, Cz, C4, T4, T5, P3, Pz, P4, T6, O1, O2, A1 and A2), which were placed on the skull according to international 10–20 system electrode placement. In the present study, the average of A1 and A2 electrodes was reference. In pre-test and post-test subjects were sedated with Clonidine. The following frequency bands were utilized: Delta (1–3 Hz), Theta (4–8 Hz), alpha (9–13 Hz), and beta (14–30 Hz).
2.4 Analytic Plan
Subjects were assessed three times (pretest, post-test and follow up) by behavioral tools and assessed twice (pre-test-post-test) by EEG. Behavioral data were analyzed by repeated measures analysis of variance with SPSS-22 software (Corp, 2013). Also, EEG data were pre-processed and processed by MATLAB 2013 software (Release, 2013) and the EEGLAB plugin (Delorme & Makeig, 2004) and analyzed using paired t-test in MATLAB 2013 software
This study investigated the effects of reducing screen devices and parent-child intensive interaction on the severity of autism symptoms, repetitive behaviors and EEG absolute and relative power in the children’s with ASD whom were excessive exposed to screen devices. The results suggested an improvement in the children’s ASD symptoms (speech/language/ communication, sociability, sensory/cognitive awareness, and health/physical/behavior) and repetitive behaviors. In addition, the results also showed that delta relative power (C4, F8, P7) decreased and increased in theta (F3, T8, C4) and beta bands (F4, Fz, O2, F8, P3, T7, Pz, P7, Fp2, C3, T8, P8 & F7). Also, after reduced screen time and increase parents-child interactions the absolute power of alpha (F3) and beta (F3, Fp2) increase. As a secondary outcome of this study, the durations of parent-child interactions improved after two months. Consistent with the findings of previous studies, which found that autism and excessive digital devices use is correlated (Hermawati et al., 2018; Pouretemad, 2000; Pouretemad et al., 2017), removing digital devices from children life and replacing it with parent-child interaction decrease ASD symptoms and repetitive behaviors. This findings supports the idea that excessive using of digital devices makes the child unavailable for social interaction or learning and hinders development of social and communication skills that this lifestyle impacts may be as trigger for children who have a genetic predisposition and subthreshold symptoms (Chaste & Leboyer, 2012; Hallmayer et al., 2011; Sandin et al., 2014). Also, this could be associated with the fact that parents play an important role in the children healthy development (Hart & Risley, 1999; Tamis‐LeMonda et al., 2001; L. Vygotsky, 1978). The results obtained in the current study indicate that limited digital devices use in children and decrease children interactions can effects on brain electrophysiological activities. These findings are similar to other studies that demonstrated the importance of early experiences and child digital devices exposure in brain development (D. Anderson & Pempek, 2005; Lin et al., 2012; Lyall et al., 2014; Mazurek et al., 2012; Pempek et al., 2011; Takeuchi et al., 2015; Weng et al., 2013). One explanation for this finding is presented in Heffler & Oestreicher (2016) autism causation model (Heffler & Oestreicher, 2016). According to this model, excessive exposure to digital devices in genetically susceptible infants stimulates specialization of non-social sensory processing in the brain and developed neuronal pathways compete with preference for social processing, negatively affecting development of social brain pathways and causing global developmental delay.
The results of this study also showed that parent-child interaction improvement and reduce children screen time has led to a significant increase in absolute power of alpha and beta EEG band in the brain frontal area of children. This finding is consistent with the findings of previous studies that have shown that parent-child interactions affect the children brain (Helmeke et al., 2009; Holmes et al., 2018; Kolb et al., 2012; Seidel et al., 2011; Sethna et al., 2017; Takeuchi et al., 2015). This increase in the alpha and beta in the frontal area of the brain is coincident with the positive changes seen in the children’s executive function skills in this study. In this ages that appear critical periods in brain development and environmental experiences are very influential on brain development, intensive parent-child interaction and environmental enrichment can effect on the brain and especially frontal area. Frontal lobe rather than the other parts of the brain has more long-term maturation (Kolb et al., 2012). Long period of frontal development makes it possible that human being acquisition complex cognitive abilities through experience and on the other hand, the brain becomes vulnerable to inappropriate experiences that may cause abnormalities. Reducing children screen time and increase parent-child interactions also had significant influence and decreased relative power of delta band. This finding is consistent with previous studies that demonstrated individuals with ASD show reduced relative(Cantor, Thatcher, Hrybyk, & Kaye, 1986; Coben, Clarke, Hudspeth, & Barry, 2008) and absolute (Chan et al., 2011; Chan, Sze, & Cheung, 2007; Elhabashy, Raafat, Afifi, Raafat, & Abdullah, 2015; Pop-Jordanova, Zorcec, Demerdzieva, & Gucev, 2010; Stroganova et al., 2007) power in delta band. Increased theta power after intervention in children is consistent with some previous research on children that showed theta band power is decreased in children with autism compered to normal children (Dawson, Klinger, Panagiotides, Lewy, & Castelloe, 1995; Machado et al., 2015; Shephard et al., 2018). According to many previous studies that showed beta band is decreased in children with ASD (Coben et al., 2008; Daoust, Limoges, Bolduc, Mottron, & Godbout, 2004), we found that after removing digital devices and increase parent-child interactions, relative power of beta increased. In the end, we can say the results of the QEEG analysis are consistent with the behavior finding and autism treatment. It seems that, children brain electrophysiological activities goes towards normalization. Although, it should be remembered that QEEG findings are more heterogeneous in ASD.
In the early age, when the child is exposed to various environmental experiences, such as sensory stimulation and social experiences (parents and peer relationships with the child), his/her frontal cortex developing in healthy styles. So, enriching the parent-child relationship at an early age can cause useful changes in the brain frontal area that is more flexible than other parts of the brain.
In the conclusion, Previous research has revealed high rate use of digital devices in children with ASD that excessive digital devices use is correlated with autistic symptoms in children; findings from this study support the efficacy of removing digital devices and parent-child interaction to reduce children’s autism symptoms. This study is unique in that it began intervention to change lifestyle of young children (2-4 years) with autism symptoms and excessive exposed to digital devices. In conclusion, this study demonstrated the importance of communicative environment and negative effects social deprivations such as excessive exposure to digital devices during a critical period of infant’s development. Positive effects of early environment manipulation on ASD and brain outcome of children who excessive exposed to digital devices suggest that excessive exposure to digital devices as an environmental insult may be cause of autism that not be neglected by this clinicians and treatments.
In our study, the most important limitation was the lack of a control group that would help us evaluate the effect development effects on EEG and ASD symptoms changes. This study has Also, the small sample size certainly restricts the conclusions.
Conflict of interest
None of the authors have potential conflicts of interest to be disclosed.
2018-10-27-1540606135