Prevalence, Correlates, and Trajectory of Television Viewing Among Infants and

Toddlers
Laura K. Certain and Robert S. Kahn
Pediatrics 2002;109;634
DOI: 10.1542/peds.109.4.634

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/109/4/634.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
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Prevalence, Correlates, and Trajectory of Television Viewing

Among Infants and Toddlers
Laura K. Certain, BA, and Robert S. Kahn, MD, MPH
ABSTRACT. Objectives. Recognizing the negative effects of television on children, the American Academy of
Pediatrics (AAP) recommends that children 2 years and
older watch <2 hours of television per day and that
children younger than 2 years watch no television. However, relatively little is known about the amount of television viewed by infants and toddlers. The objective of
this study was to describe the prevalence and correlates
of television viewing that exceeds the AAP guidelines for
0- to 35-month-olds and to examine the trajectory of a
childs viewing over time.
Methods. Data from the National Longitudinal Survey of Youth, 1990 to 1998, were used to analyze reported
television viewing at 0 to 35 months of age and to follow
the trajectory of a childs viewing from infancy through
age 6. Logistic regression models were used to determine
risk factors associated with greater television viewing at
0 to 35 months and the association of early viewing
habits with school-age viewing.
Results. Seventeen percent of 0- to 11-month-olds,
48% of 12- to 23-month-olds, and 41% of 24- to 35-montholds were reported to watch more television than the
AAP recommends. Compared with college graduates,
less-educated women were more likely to report that
their children watched more television than recommended. Children who watched >2 hours per day at age
2 were more likely to watch >2 hours per day at age 6
(odds ratio: 2.7; 95% confidence interval: 1.8 3.9), controlling for maternal education, race, marital status and employment, household income, and birth order.
Conclusions. A substantial number of children begin
watching television at an earlier age and in greater
amounts than the AAP recommends. Furthermore, these
early viewing patterns persist into childhood. Preventive
intervention research on television viewing should consider targeting infants and toddlers and their families.
Pediatrics 2002;109:634 642; television, infant, children,
longitudinal survey, socioeconomic factors.
ABBREVIATIONS. AAP, American Academy of Pediatrics; NLSY,
National Longitudinal Survey of Youth; HOME, Home Observation for Measurement of the Environment; OR, odds ratio; CI,
confidence interval.

he substantial amount of television watched by

school-aged children1 6 and the associated adverse effects726 are increasingly well documented. Although a few researchers highlight the
benefits of television,1214 the majority link increased
television viewing with higher rates of violence,1517
obesity,18 23 and poor school performance.24 26
Moreover, recent randomized, controlled trials have
shown that decreasing the amount of television
viewed leads to relative decreases in aggression15
and body fat.19,23 Recognizing the adverse health
effects of television, the American Academy of Pediatrics (AAP) recommends that children 2 years and
older limit their time with entertainment media (television, video games, the Internet) to 2 hours per day
and that children younger than 2 watch no television.27,28 Little is known, however, about the amount
of television viewed by infants and toddlers. The
vast majority of research has remained focused on
television viewing in older children.1,29
Delineating patterns of early childhood television
viewing may be important for several reasons. First,
it may provide insight into the earliest behavioral
antecedents of obesity and other health outcomes
linked to excessive television viewing. Second, a description of social differences in early childhood television viewing may illuminate the mechanisms by
which social disparities in these health outcomes
emerge. If school-age television habits begin to develop early in life, then the roots of social disparities
in obesity and violence may be explained in part by
these early experiences. Finally, if indeed very young
children watch substantial amounts of television,
then the findings raise important questions about the
constraints that parents may face in choosing alternative activities for their children.
The present study had 2 objectives. First, we described the prevalence and correlates of television
viewing that exceeded the AAP guidelines for a
national sample of 0- to 35-month-olds. Second, we
examined the trajectory of a childs viewing over
time. Data came from the National Longitudinal Survey of Youth (NLSY).
METHODS

From the Division of General and Community Pediatrics, Childrens Hospital Medical Center, Cincinnati, Ohio.
Received for publication Jun 14, 2001; accepted Oct 15, 2001.
Reprint requests to (R.S.K.) Division of General and Community Pediatrics,
TCHRF 6549, Childrens Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: robert.kahn@chmcc.org
PEDIATRICS (ISSN 0031 4005). Copyright 2002 by the American Academy of Pediatrics.

634

Sample and Design

The NLSY began in 1979 as a national sample of young men
and women aged 14 to 21, oversampled for blacks, Hispanics, and
low-income whites. This original cohort has been surveyed almost
every year since 1979, with 84% of the original respondents still in
the sample as of 1998.30 Data on children of the women in the
cohort have been collected every other year since 1986. This study

PEDIATRICS Vol. 109 No. 4 April 2002

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focused on the 5 child surveys from 1990 to 1998 that included

questions about child television viewing.

Cross-Sectional Design
For determining the prevalence and correlates of television
viewing that exceeded the AAP guidelines, a cross-sectional design was used. Our sample for this objective (the Cross-Sectional
Sample) consisted of children who were 0 to 35 months of age in
any survey year from 1990 to 1998 (N 3556). Because television
viewing is strongly correlated with age, this sample was divided
into 3 subgroups: 0- to 11-month-olds (Youngest), 12- to 23month-olds (Middle), and 24- to 35-month-olds (Oldest). Sibling pairs existed within these subgroups, so we randomly chose
1 child for each mother. Five percent of children were missing
outcome data. Children who were excluded because of missing
data did not differ significantly from those who were included
with respect to maternal education level or survey year. The final
sample sizes were 1084 for the Youngest, 1254 for the Middle, and
1247 for the Oldest. These are not mutually exclusive samples; for
example, a child who was 5 months old at the 1992 survey and 30
months old at the 1994 survey was included in both the Youngest
sample and the Oldest sample.

Longitudinal Design
For examining the trajectory of a childs viewing over time, a
longitudinal design was used. The Longitudinal Sample was a
subset of the Cross-Sectional Sample. Children who were 0 to 23
months of age in 1990 or 1992 were followed for 6 years (until 1996
or 1998); 5% were lost to follow-up. As above, this sample was
divided by age into subgroups: children 0 to 11 months of age at
baseline (n 554) and children 12 to 23 months of age at baseline
(n 666).

Outcome Measure
For both of the designs, the outcome variable was hours of
television per weekday, assessed by maternal response to the
following question: How much time would you say your child
spends watching television on a typical weekday (either in your
home or elsewhere)? A separate question with parallel wording
assessed television on a typical weekend day. Mothers reported
the hours of viewing in whole numbers; watching 1 hour of
television per day was considered equivalent to watching no
television. Following the AAP guidelines, we dichotomized the
outcome variable as 0 versus 1 hour per day for children 0 to 23
months of age and 0 to 2 versus 3 hours per day for children 24
months and older. The Spearman correlation between weekday
and weekend viewing was 0.7 for each age group, and the
average amount of television on a typical weekend day was the
same as on a typical weekday for all ages. Therefore, only the
results for weekday viewing are shown. There was no question
specific to video viewing, so mothers may have included videos in
their estimate of television viewing.

Independent Variables
Because of the limited information available on television viewing among infants and toddlers, we chose predictors based on
other studies of parenting style and home environment.3134 We
calculated the average annual household income across the 5
surveys and divided the resulting value into quintiles. Children
whose household income was missing in 3 or more of the survey
years (11%) were given a missing value. Mothers who reported
working, going to school, or serving in the active armed forces
were considered to be employed out of the home; women who
were on leave from their jobs, unemployed, out of the labor force,
or keeping house were considered in the home; all others
were considered unknown. For the paternal variables, we used
the data for the person whom the mother identified as both a
member of her household and a spouse or partner. The quality of
the home environment was determined by the Short Form of the
Home Observation for Measurement of the Environment (HOMESF).35 Both the total standardized score and the 2 standardized
subscale scores (cognitive stimulation and emotional support)
were analyzed as continuous variables.

Additional Variables
Data on child care, maternal depression, and neighborhood
quality were available only in selected years; therefore, these
variables were analyzed separate from the main analysis.

Child Care
Because child care information was collected retrospectively,
complete data were available for children in 1990 and 1992 only.
Mothers were asked about any regular child care during their
childs first, second, and third years of life. We classified child care
responses as none (besides maternal), in a (private) home, and
in a center/preschool.

Maternal Depressive Symptoms

Maternal depressive symptoms were measured only in 1992
and 1994. In 1992, the NLSY included the full Center for Epidemiologic Studies Depression Scale, a 20-item self-report instrument.36 38 In 1994, the survey included only 7 questions from the
Center for Epidemiologic Studies Depression Scale. The scores for
each year were divided into quintiles for analysis. Within the 1992
data, the Spearman correlation between the full 20 questions and
the 7 questions was 0.9.

Neighborhood Quality
Neighborhood quality was assessed in 2 ways, beginning in
1992. First, mothers were asked the following question: How
would you rate your neighborhood as a place to raise children?
Would you say it is excellent, very good, good, fair, or poor? In
addition, mothers rated the following problems in their neighborhood: lack of respect for rules and laws; crime and violence;
abandoned or run-down buildings; not enough police protection;
not enough public transportation; too many unsupervised children; people keep to themselves, dont care about the neighborhood; and lots of people who cant find jobs. Mothers rated these
problems on a 3-point scale, and the answers were summed into a
composite score.

Analysis
Cross-Sectional
The 2 test and t test were used in the cross-sectional analysis to
examine the associations between the independent variables and
television viewing. Any predictors that were significantly (P
.05) correlated with television viewing in the bivariate analyses
were included in multivariate logistic regression models that examined the odds of viewing 1 hour/d for the Youngest and
Middle groups and 3 hours/d for the Oldest group. In the
longitudinal analyses, a logistic regression model was used to
examine the odds of watching 3 hours of television per day at
age 6. The predictor of interest was television viewing as an infant
or toddler, but models also controlled for maternal education,
marital status, employment, race, household income, child age
and birth order.

Weighting and Design Effects

As recommended when combining data across survey years,30
we did not use sample weights to make our results nationally
representative of children born to mothers who were 14 to 22 years
of age in 1979.30 However, an exploratory comparison of weighted
results to our unweighted results for any given individual year
showed no difference in the amount of television viewed at each
age.
The data were collected through a multistage stratified cluster
random sampling procedure, and consequently the standard errors may be underestimated. The information required to adjust
for such design effects is not in the public use data; however,
respondent movement out of their original sampling units has
reduced such design effects.30 We present significance at the 95%
confidence level, but a conservative approach is to focus on findings significant at P .01.39 All analyses were conducted using
SAS 8.1 for Windows 95 (SAS Institute, Inc, Cary, NC).

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635

48% were reported to watch at least 1 hour per day,

and 22% were reported to watch 3 or more hours per
day. In the Oldest sample, 41% were reported to
watch 3 or more hours per day, and 16% were reported to watch 5 or more hours per day.

RESULTS
Cross-Sectional Results

Approximately 25% of the mothers were black,

20% were Hispanic, 75% were married, 10% had not
finished high school, and 20% to 25% had finished 4
years of college (Table 1). The median household
income was $41 000/y.
Seventeen percent of the Youngest sample were
reported to exceed AAP television viewing guidelines, watching at least 1 hour of television on a
typical weekday (Fig 1). Among the Middle sample,
TABLE 1.

Bivariate Results

In bivariate analyses, the most consistent correlates of increased television viewing were black maternal race, lower maternal education, and having an
unmarried mother (Table 2). For example, 51% of

Description of the Cross-Sectional Sample*

Characteristic

Total sample
Gender
Female
Male
Maternal race
Black
Hispanic
White/other
Maternal education
12 y
12 y
1315 y
16 y or more
Household income
$22 000/y
$22 00035 000/y
$35 00047 000/y
$47 00066 000/y
$66 000/y
Maternal age at delivery
2225
2630
3135
3640
Maternal employment
Out of the home
In the home
Marital status
Formerly married
Never married
Married
Birth order of child
First
Second
Third or higher
Number of children in house
1
23
4 or more
Paternal education
12 y
12 y
1315 y
16 y or more
No father figure in house
Paternal employment
Employed
Unemployed
No father figure in house
Survey year
1990
1992
1994
1996
1998

Youngest

Middle

Oldest

1084

100.0

1254

100.0

1247

100.0

537
547

49.5
50.5

640
614

51.0
49.0

604
643

48.4
51.6

283
223
578

26.1
20.6
53.3

310
236
708

24.7
18.8
56.5

333
252
662

26.7
20.2
53.1

112
423
272
273

10.4
39.2
25.2
25.3

137
491
310
312

11.0
39.3
24.8
25.0

137
541
299
266

11.0
43.5
24.1
21.4

181
195
197
196
201

18.7
20.1
20.3
20.2
20.7

220
205
228
228
236

19.7
18.4
20.4
20.4
21.1

217
231
242
216
187

19.9
21.1
22.1
19.8
17.1

33
453
494
104

3.0
41.8
45.6
9.6

72
624
499
59

5.7
49.8
39.8
4.7

158
646
401
42

12.7
51.8
32.2
3.4

499
572

46.6
53.4

710
535

57.0
43.0

698
530

56.8
43.2

123
151
809

11.4
13.9
74.7

146
156
952

11.6
12.4
75.9

163
166
917

13.1
13.3
73.6

292
377
415

26.9
35.8
38.3

368
449
437

29.3
35.8
34.8

377
452
418

30.2
36.2
33.5

276
616
144

26.6
59.5
13.9

341
728
157

27.8
59.4
12.8

294
767
162

24.0
62.7
13.2

100
316
202
256
193

9.4
29.6
18.9
24.0
18.1

116
366
213
307
228

9.4
29.8
17.3
25.0
18.5

110
389
214
264
250

9.0
31.7
17.4
21.5
20.4

833
33
192

78.7
3.1
18.1

960
41
228

78.1
3.3
18.6

938
39
249

76.5
3.2
20.3

324
267
200
167
126

29.9
24.6
18.5
15.4
11.6

375
319
258
166
136

29.9
25.4
20.6
13.2
10.8

339
317
244
207
140

27.2
25.4
19.6
16.6
11.2

* Number of women responding to individual questions may vary.

636

TELEVISION VIEWING AMONG INFANTS AND TODDLERS

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Fig 1. Reported hours of television

viewed on a typical weekday. Percentages
may not sum to 100 because of rounding.

mothers who had not graduated from high school

reported that their 2-year-olds watched at least 3
hours of television on a typical weekday, compared
with only 27% of college graduates (P .0001). Although maternal education was associated with television viewing, paternal education was not.
Lower HOME scores were associated with increased television viewing in some children (data not
shown). In the Oldest group, the average HOME
score for children who exceeded AAP television
viewing guidelines was a third of a standard deviation worse than the average score for children who
were within the guidelines (95.0 vs 99.4; P .0001);
in the Youngest group, the average score for those
who exceeded the guidelines was a quarter standard
deviation better (100.6 vs 97.0; P .007). There were
no differences in HOME scores for the Middle group
(97.0 vs 97.5; P .6).
Of the variables that were available only in selected years, none were consistent correlates of television viewing. Child care was significantly associated with television viewing for the Oldest sample
only; children in center-based child care were the
least likely to watch more than the AAP recommends
(P .02). Similarly, increased maternal depressive
symptoms were significantly associated with increased television viewing for the Oldest sample
only (P .02). Poor neighborhood quality was significantly associated with increased television viewing in the Youngest and Oldest samples (P .05 for
both neighborhood assessments).
Multivariate Results

In logistic regression models, maternal race, maternal education, and child age were consistent predictors of high television viewing (Table 3). A black
mother was twice as likely as a white/other mother
to report that her 2-year-old watched at least 3 hours
of television per day (odds ratio [OR]: 2.0; 95% confidence interval [CI]: 1.4 2.8). A woman who had not
graduated from high school was almost 4 times as
likely as a woman who had graduated from college
to report that her 0- to 11-month-old watched at least
1 hour of television per day (OR: 3.7; 95% CI: 1.77.7).
Survey year was also a significant predictor of child

television viewing, particularly for the Youngest

sample. Infants in 1998 were more likely to watch
television than infants in preceding years. The
HOME score was significant for the Youngest children only; higher total and subscale scores were
associated with increased viewing.
In separate regression models for the variables that
were available only in selected years, child care and
neighborhood retained significance but maternal depression did not. Compared with children in centerbased child care, 2-year-olds with no formal child
care were more likely to watch more than the AAP
recommends (OR: 1.6; 95% CI: 1.0 2.6; P .04), as
were 2-year-olds who were cared for in a private
home (OR: 1.6; 95% CI: 1.0 2.6; P .05). Compared
with a mother who rated her neighborhood as excellent for raising children, a mother in a poor
neighborhood was more likely to report that her
infant watched at least 1 hour of television per day
(OR: 3.6; 95% CI: 1.5 8.3; P .003), adjusting for
covariates. Using the composite scale, infants in the
worst quartile of neighborhoods were twice as likely
as infants in the top quartile to watch at least 1 hour
per day (OR: 2.2; 95% CI: 1.1 4.5; P .03).
To determine whether neighborhood quality confounded the relationship between television viewing
and race or education, we looked for changes in the
-coefficients for race and education on entering
neighborhood quality in the model. Including neighborhood quality did not substantially change the
coefficients of either, suggesting that perceived
neighborhood quality was not a confounder of these
associations.
Longitudinal Results

The trajectory of television viewing with age is

shown in Fig 2. Daily television viewing increased by
roughly 1 hour per year during the first 3 years of
life, then leveled off. Differences between children of
less-educated mothers and children of well-educated
mothers were significant at an early age and became
more pronounced as the children got older. By age 4,
children of less-educated mothers were watching an
additional 2 hours of television per day, on average,
a nearly 2-fold difference.

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637

TABLE 2.
Percentage of the Youngest, Middle, and Oldest Children Reported to Exceed the AAP
Guidelines for Television Viewing (1 Hour, 1 Hour, 3 Hours, Respectively)
Characteristic

Youngest
N

Total sample
Gender
Female
Male
Maternal race
Black
Hispanic
White/other
Maternal education
12 y
12 y
1315 y
16 y or more
Household income
$22 000/y
$2235 000/y
$3547 000/y
$4766 000/y
$66 000/y
Maternal age at delivery
2225
2630
3135
3640
Maternal employment
Out of home
In home
Marital status
Never married
Formerly married
Married
Birth order of child
First
Second
Third or higher
Number of children in house
1
23
4 or more
Paternal education
12 y
12 y
1315 y
16 y or more
Paternal employment
Employed
Unemployed
Survey year
1990
1992
1994
1996
1998

Middle

Oldest
%

189

17.4

603

48.1

516

41.4

93
96

17.3
17.6

298
305

46.6
49.7

248
268

41.1
41.7

68
32
89

24.0
14.4*
15.4

184
108
311

59.4
45.8*
43.9

189
109
218

56.8
43.3*
32.9

32
77
43
37

28.6
18.2
15.8*
13.6

74
243
153
131

54.0
49.5
49.4
42.0

70
247
127
71

51.1
45.7
42.5*
26.7

35
39
34
37
21

19.3
20.0
17.3
18.9
10.5

123
97
98
109
109

55.9
47.3
43.0
47.8
46.2

115
114
98
78
54

53.0
49.4
40.5*
36.1
28.9

10
67
93
19

30.3
14.8
18.8
18.3

31
298
245
29

43.1
47.8
49.1
49.2

75
262
165
14

47.5
40.6
41.2
33.3

90
96

18.0
16.8

323
276

45.5
51.6

275
234

39.4
44.2

33
28
128

21.9
22.8
15.8

100
78
425

64.1
53.4*
44.6

89
84
343

53.6
51.5*
37.4

50
53
86

17.1
14.1
20.7

190
208
205

51.6
46.3
46.9

139
187
190

36.9
41.4
45.5

46
110
26

16.7
17.9
18.1

178
332
80

52.2
45.6
51.0

111
320
74

37.8
41.7
45.7

19
52
32
34

19.0
16.5
15.8
13.3

49
158
105
144

42.2
43.2
49.3
46.9

43
163
87
84

39.1
41.9
40.7
31.8

132
4

15.9
12.1

437
21

45.5
51.2

361
17

38.5
43.6

47
41
34
30
37

14.5
15.4
17.0*
18.0
29.4

152
158
136
86
71

40.5
49.5
52.7
51.8
52.2

132
128
106
95
55

38.9
40.4
43.4
45.9
39.3

* P .01.
P .05; 2 test for any difference between categories.

Given the varying trajectories for different subgroups, we investigated whether early factors, particularly early television viewing, were associated
with television viewing at school age (age 6). We
found that television viewing at 24 to 35 months
predicted school-age television viewing, but television viewing at 0 to 11 months did not, adjusting for
maternal education, race, income, marital status, and
employment. Children who watched at least 3 hours
of television per day at age 2 were almost 3 times as
likely as other children to watch at least 3 hours per
day at age 6 (OR: 2.7; 95% CI: 1.8 3.9; P .0001).
638

Maternal education was also a significant predictor

of television viewing at age 6, controlling for viewing
at age 2. Children of high school graduates were
more than twice as likely as children of college graduates to watch more television than the AAP recommends (3 hours per day) at age 6 (OR: 2.3; 95% CI:
1.4 3.9; P .002).
DISCUSSION

This study presents the first national data on the

prevalence, correlates, and trajectory of television
viewing habits for infants and toddlers. Seventeen

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TABLE 3.
Odds of Exceeding the AAP Guidelines for the Youngest, Middle, and Oldest (N 939,
N 1091, and N 1114, Respectively)
Characteristic

Age (mo)
Maternal race
Black
Hispanic
White/other
Maternal education
12 y
12 y
1315 y
16 y or more
Household income
$22 000/y
$2235 000/y
$3547 000/y
$4766 000/y
$66 000/y
Maternal employment
In the home
Out of the home
Marital status
Formerly married
Never married
Married
Birth order of child
Third or higher
Second
First
Survey year
1990
1992
1994
1996
1998
HOME-total score

Youngest

Middle

Oldest

OR

95% CI

OR

95% CI

1.16*

1.101.24

1.16*

1.121.20

1.04

OR

1.001.08

95% CI

1.60
0.75
1.00

1.002.56
0.441.28

1.88*
1.14
1.00

1.302.71
0.801.63

2.01*
1.38
1.00

1.442.81
0.981.93

3.66*
1.45
1.28
1.00

1.747.70
0.842.51
0.712.29

1.84
1.49
1.41
1.00

1.093.11
1.032.16
0.962.07

2.18*
2.00*
1.69
1.00

1.283.71
1.362.92
1.122.55

0.91
1.28
1.34
1.65
1.00

0.431.89
0.652.51
0.692.61
0.873.14

0.87
0.84
0.84
0.95
1.00

0.521.45
0.531.34
0.551.29
0.621.44

1.45
1.55
1.19
1.22
1.00

0.872.42
0.962.48
0.751.87
0.771.93

1.18
1.00

0.791.74

1.35
1.00

1.031.77

1.11
1.00

0.861.44

1.58
1.31
1.00

0.882.84
0.732.34

1.42
1.77
1.00

0.902.22
1.122.81

1.02
0.97
1.00

0.691.52
0.631.49

0.79
0.67
1.00

0.481.30
0.411.09

0.60*
0.74
1.00

0.420.85
0.541.03

0.84
0.99
1.00

0.601.19
0.721.37

0.26*
0.37*
0.38*
0.50
1.00
1.02

0.150.47
0.210.65
0.210.70
0.270.92

1.001.03

0.56
0.86
0.96
1.04
1.00
1.01

0.350.90
0.531.39
0.591.56
0.611.76

1.001.02

0.76
0.85
1.03
1.24
1.00
0.99

0.481.20
0.541.35
0.641.65
0.772.02

0.991.00

* P .01.
P .05.

Fig 2. Trajectory of television viewing

over time. The error bars show the
standard error of the mean.

percent of 0- to 11-month-olds, 48% of 12- to 23month-olds, and 41% of 24- to 35-month-olds were
reported by their mothers to watch more television
than the AAP recommends. Less-educated mothers
reported that their children viewed more television;
29% of mothers with 12 years of education reported that their infants watched television, com-

pared with only 14% of college graduates. These

differences, apparent at an early age, increased as the
children grew older. Both early television viewing
and maternal education had significant, independent
effects on television viewing at school age.
Children in our study were reported to watch
slightly more than those in a national cross-sectional

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639

study, in which the average 1-year-old watched 6

hours per week and the average 3-year-old watched
13 hours per week.6 Children in our study watched
slightly less than children surveyed in 2 pediatric
clinics.40 These differences are probably attributable
to differences in sample composition, data collection
methods, and the inclusion of videos. For example,
the national study used diaries to determine the
amount of time spent with television, and the clinic
study separated television from video viewing.
Children of black and less-educated mothers
watched more television at all ages. These social
gradients in television viewing were our most persistent findings and were consistent with studies of
older children1,18 and adults.29 Because it is unlikely
that race and education directly influence television
viewing, there must be other contributing factors.
For example, it has been suggested that concerns
about safety might present a barrier to childrens
going outside to play and that blacks are more likely
to live in neighborhoods perceived as unsafe.18 Surprisingly, adding perceived neighborhood quality to
our regression models did not change the estimates
for race or maternal education, perhaps because the
questions in the NLSY did not capture the relevant
neighborhood characteristics.41,42 In addition to
neighborhood quality, other factors potentially related both to television viewing and to race or education need to be considered, such as residential
stability,42 wealth,43 and the accessibility of playgrounds, museums, and libraries. Our results can
speak only indirectly to the many constraints that
disadvantaged families and their children may face
in pursuing beneficial alternatives to television.
Our longitudinal analysis indicates that greater
television viewing in early childhood is associated
with greater viewing at school age. The persistence
of this behavior pattern may reflect continuing environmental influences, the development of child preferences or habits, or, most likely, an interaction
between the 2. Regardless, prevention research directed at much younger children and their families is
warranted, especially because successful preventive
intervention studies by Robinson and colleagues15,19
and Gortmaker et al23,44 strongly suggest a causal
relationship between school-age viewing and obesity
and aggression. Our analyses also indicate that, like
television viewing in general, the social gradients in
television viewing emerge at an early age, increase,
and persist into childhood. These viewing gradients
may be among the earliest antecedents of social disparities in health, offering potential insight into predisease pathways45 and suggesting earlier opportunities to address these disparities.
Surprisingly, child care, maternal employment,
and marital status were not among the strongest
independent predictors of increased television viewing, which runs counter to the notion that television
often serves as a babysitter for busy parents trying
to juggle jobs, children, and taking care of a home.
Similarly, one would expect a measure of the home
environment to capture parenting style and therefore
to correlate with the amount of television watched.
However, the HOME score was not a strong predic640

tor of television viewing. This could be attributable

to 2 factors: first, the HOME-SF may be a less accurate measure of parenting style for children younger
than 346; second, overall parenting style may not
correlate with parental approaches to child television
viewing. If a parent believes that television is beneficial, then letting an infant or toddler watch television may reflect a desire to do what is best for the
child. The surprising positive association between
HOME scores and viewing in the Youngest group
may be reasonably explained by such parental beliefs. Indeed, 1 study found that the majority of parents of 0- to 35-month-olds believed that television
could improve a childs vocabulary,40 highlighting
the need to study parental knowledge about and
attitudes toward television. Future studies should
focus on untangling the interactive effects of the
home environment, parenting style, and child preference on child television viewing.
An important limitation of this study is the reliance on maternal response to single questions regarding weekday and weekend day television viewing. Studies comparing parental estimates with
diaries or with direct observation (video) suggest
that parents may overestimate their childrens time
with television.47 49 However, when we analyzed
children 2 to 11 years of age in 1998 and compared
our (weighted) findings to data collected using the
Nielsen People Meter in 1999,29 NLSY mothers reported only a half-hour more per day, on average, a
difference that may be explained by NLSY mothers
inclusion of videos. In addition, parental estimates of
television viewing in older children were used in the
randomized, controlled trials that linked television
with obesity,19 indicating that parental estimates
have some predictive validity.
Another limitation is that we do not know how
mothers defined watching television for their infants and toddlers. This is particularly an issue for
the Youngest sample. Although 6-month-olds will
attend to television roughly half the time that it is
on,50 qualitative observation of infants in a small
study suggested that they look at television continuously for only short periods of time.51 By 15
months, children can imitate what they see,52,53 and
by 18 months attention to television can last as long
as 30 minutes,51 but more information on the early
development of television viewing is needed. The
maternal estimates are further limited by the fact that
viewing was reported in whole numbers. Any child
who views 1 hour a day was reported as watching
no television, and older children who watch television between 2 and 3 hours per day may have been
reported as 2 hours per day. Both could result in
some underestimation relative to the AAP viewing
guidelines. Additional work, based on both detailed
diaries and direct observation, is clearly needed to
confirm our results.
A final limitation is that the NLSY sample design
makes it difficult to generalize the findings to all
young children. The survey oversampled disadvantaged groups, and the requirements for our sample
meant that no mothers were younger than 22 years at
delivery, and most were older than 30. It is not clear

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whether or in what direction these sample characteristics might bias the results.
This study could not address the content of childrens viewing. The relative consumption by and
effects on infants and toddlers of educational versus
entertainment television are not known. A study of
the relationships between preschool television viewing and adolescent achievement, behavior, and attitudes found that the effects of television depended
on the content of the programs viewed.54 Studies of
elementary school children, however, have shown
positive effects of reducing television without reference to the quality of programs viewed.15,19,23
CONCLUSION

A substantial number of children begin watching

television at an earlier age and in greater amounts
than the AAP recommends. Furthermore, these
viewing patterns persist into childhood, when the
direct adverse effects of television are better documented. Important research questions remain regarding television program content and possible direct effects on infants and toddlers. Nevertheless,
these findings should encourage parents and pediatricians to discuss young childrens television viewing (and beneficial alternatives) and should alert researchers to the potential window of opportunity for
preventive interventions before age 2.
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ARROGANCE ENCOURAGED

I was appalled by the way arrogance and overconfidence were encouraged

during medical training. Indeed, during clinical training I was frequently criticized
for expressing uncertainty and humility to patients or teachers. It struck me as
ironic that awareness of the limits of ones knowledge or data are encouraged in
graduate school (I have a PhD in biology), where the degree of uncertainty is far
less than in clinical practice. Perhaps the level of certainty in professional discourse
is inversely proportional to a professions scientific rigor?

Sender R. Physician, know thy limits. Can Med Assoc J. 2001;165:147

Submitted by Student

642

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Prevalence, Correlates, and Trajectory of Television Viewing Among Infants and

Toddlers
Laura K. Certain and Robert S. Kahn
Pediatrics 2002;109;634
DOI: 10.1542/peds.109.4.634
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