Five-year-old Kristy gets to watch TV for an hour or so during lunchtime and for about two hours during dinner.
"After dinner, her 'reward' is at least 11/2 hours of time on an Apple iPad before she washes up for bed. Then, we take her through some educational apps or games before she sleeps," said her mother, Mrs D Lee, 39, who holds an office job.
"It is effective as a babysitting tool as long as we set the rules. We will warn her before we take back the iPad. She knows that if she doesn't cooperate, it will be confiscated for a couple of days."
Mrs Lee said she first allowed Kristy to play with the tablet when she was around two, but the time spent on it was a lot shorter.
"It's really a case of bo pian (Hokkien for no choice) now as I have a three-month-old baby. Otherwise, I will go mad. She'll keep bugging me and I have to express milk most of the time."
Mrs Lee is aware of the possible dangers of too much "screen time" but is not overly worried.
Screen time is the time spent on any media device with a screen, such as television, computers, video game consoles and handheld screen devices, including mobile phones and tablets.
She is among the many parents today who whip out their smart devices to entertain their children.
Indeed, a recent study by students from the Yong Loo Lin School of Medicine, National University of Singapore (NUS) called Project iBaby found that nine out of 10 children in the 18 to 24 months age group are exposed to screen devices.
As part of a community health project, the fourth-year students interviewed parents of 800 children in February to find out how often young children use screen devices and the attitudes, practices and beliefs of their caregivers towards such use.
How to manage screen time
Screen time should not compromise parent-child interactions, say doctors.
Here is some advice from paediatricians and Project iBaby researchers on how parents can manage their children's screen time.
1. Discourage children below the age of two from using screen devices.
2. For children above two years old, limit the time spent on screen devices to no more than one or two hours a day.
3. Review the content that your child is watching and watch it with him.
4. Make and enforce rules to limit screen time.
5. Encourage other interactive activities which promote proper brain development, such as playing and reading.
6. Watch TV or use other devices in the living room only and not in the children's bedroom.
SCREEN TIME OVERLOAD
What is of concern is the amount of screen exposure young children are experiencing. The Project iBaby study discovered that almost half of these children under the age of two spend an hour or more on screen devices a day.
The study also found that there was a lack of parental knowledge when it came to the subject matter of screen time exposure. Eight in 10 parents were unaware of any guidelines put forth by professionals regarding screen time for young children while four in 10 parents failed to supervise their child's screen usage all the time.
"This is the first time in Singapore that screen viewing behaviour of very young children has been investigated comprehensively," said Dr Falk Mueller-Riemenschneider from the NUS Saw Swee Hock School of Public Health, who is the supervisor of Project iBaby.
"Our findings highlight that exposure to screen devices is highly prevalent and that awareness about the detrimental health effects is limited."
The excessive use of screen devices can be harmful.
It can cause speech delays and behavioural issues in young children, and attention problems in school-going children, apart from the possible weight gain that can accompany sedentary behaviour.
Mr Readon Teh, 23, the student-in-charge of Project iBaby's results, said: "We also found out that kids below the age of two, who are exposed to screen time, are more likely to have less than the recommended 13 hours of sleep a day."
IMPACT CAN DEEPEN
Early and heavy screen-time exposure can result in a higher rate of attention deficit when a child is of school-going age and result in language delays if parent-child interactions are compromised as a result of screen time, said Dr Jennifer Kiing, consultant, division of neurodevelopmental and behavioural paediatrics at the department of paediatrics, National University Hospital.
"There is also a link between screen violence and aggressive behaviour in children," she said.
In older children and adults, those who show addiction-like behaviour on their smartphone use can exhibit social effects such as declined performance in work or study and neglect of family or important relationships or social engagements, said Dr Tan Hwee Sim, a specialist in psychiatry and consultant at Raffles Counselling Centre.
They can also be affected psychologically. For instance, they may feel anxious when they are unable to access their devices, or depressed when they read negative remarks on social network sites.
Furthermore, their health may be affected as they could suffer from sleep disturbances, eye strain and neck pain, said Dr Tan.
It is not only young children who are at risk of becoming too attached to smart devices. Older children and adults can become hooked on such devices too.
The main difference between a heavy smartphone user and a problematic smartphone user is that for the former, the use does not interfere with his work, relationships or life, said Dr Tan Hwee Sim, a specialist in psychiatry and consultant at Raffles Counselling Centre, who has clinical interests in addictions.
"There is no universal agreement as to the specific criteria for 'smartphone addiction', whether it is a mental disorder or, indeed, whether it is a disorder at all," she said.
As smartphone addiction is not an established mental disorder, the criteria for substance use disorder can usually be applied to problematic smartphone use, she said.
- The person using the device more than he intended to. For instance, he would tell himself that he would spend only an hour on the device but ends up spending the whole night on it.
- Showing a desire to cut down on or control how much he uses the device but is unable to.
- Craving the use of the device.
- Continuing to use the device despite negative consequences, such as deteriorating academic results.
- Neglecting important activities, such as schoolwork or housework, because of time spent using the device.
- Using the device in situations in which it is physically hazardous, for example, when driving or crossing the road.
- Experiencing withdrawal symptoms, such as anxiety or irritability, when withdrawing from the use of the device.
NIP IT IN THE BUD
Dr Tan suggested the following ways to help parents stem problematic use of smartphones.
1. Recognise that the usage is out of control
"Some people are able to modify their behaviour once they have an insight into the negative consequences that their behaviour causes," said Dr Tan.
"If there is any underlying issue that may cause or support the problematic usage, it needs to be addressed. Examples include depression, anxiety, stress or self-esteem and social skills issues."
A formal consultation may be needed to assess what issues are involved, she said.
2. Modify usage
By keeping a log on how much time is spent using a device for non-essential activities, a person can set goals to reduce such usage.
3. Set rules
Lay down some guidelines for not using the smartphone in certain situations. For example, when driving, eating, spending time with the family or when in the bedroom.
4. Eliminate data plan
If a person is still unable to control his usage despite these efforts, he should consider using a device with no data plan, so he cannot surf the Internet on it, in order to break the habit.
Problematic use can even cause long-standing issues such as family break-ups and poor academic results, she added.
One reason why the parents of Angeline (not her real name), 16, took her to see Dr Tan recently was because her academic results had deteriorated. She was also highly irritable and her relationship with her parents was strained. "It turned out that she had been spending increasing amounts of time on her smartphone: watching videos, following updates on various social media sites and playing games," said Dr Tan.
Her anxiety about her poor results had led her to use her smartphone even more to escape from her problems.
Dr Tan assessed Angeline and ruled out any underlying mood or anxiety disorders. She then counselled her and roped in her parents when she devised a plan to help the student gradually reduce her smartphone use.
Problematic smartphone use often occurs in the context of other underlying conditions, such as anxiety and depression, said Dr Tan.
That is why it is still not clear whether "smartphone addiction" is truly a separate disease entity or a manifestation of other issues, she said.
She added that there is currently no consensus among psychiatrists, although some want it to be formally recognised as a disorder here.
Those who are vulnerable to addiction-like behaviour are people with poor social skills, low self-esteem, or are suffering from negative emotions, such as anxiety, depression and anger, and who have limited coping skills, she said.
The students who took part in Project iBaby have developed educational materials, such as brochures and posters, as well as held baby fairs at KK Women's and Children's Hospital and National University Hospital to raise awareness of harmful effects of too much screen time.
But more needs to be done. Dr Mueller-Riemenschneider said more widespread and comprehensive approaches, involving childcare centres and teachers, the health-care sector and other institutions, will be needed to raise awareness on a larger population level, as well as to overcome misperceptions about the beneficial effects of screen viewing in the very young.
Some parents believe that certain TV programmes or apps will benefit their children cognitively but, in fact, there is no evidence to show that these are beneficial for very young children below two, he said.
"There also remains a need to better understand why so many children engage in excessive amounts of screen viewing behaviour and what the barriers to reducing such behaviour in children are," said Dr Mueller-Riemenschneider, whose area of speciality is in public health.
There are currently no official guidelines on the length of screen time children should be exposed to in Singapore, but several health-care organisations in the United States have discouraged media use by children up to the age of two.
For years, the American Academy Of Paediatricians (AAP) has been recommending that TV and other entertainment media be avoided for infants and children under the age of two, and that older children and teens should engage with entertainment media for no more than one or two hours per day.
Experts say children under the age of two learn best through real-life interactions and not through videos.
In general, children under the age of two are more likely to have speech delays and behavioural issues if they are exposed to excessive media screen exposure before they turn two, said Dr Tan Kuanyang from Thomson Paediatric Centre.
That is why the general stand of paediatricians is to discourage the use of media devices below the age of two, he said.
The recommendation also applies to educational apps. "An app speaks to you and does not require you to interact, resulting in speech and behavioural issues," said Dr Tan.
Mrs Lee said she will monitor Kristy's behaviour. If there are any issues, she will "moderate Kristy's time with the iPad".