The media is a powerful teacher of children and adolescents, an editorial in JAMA says. But what are they learning, and how can it be modified? "When children and adolescents spend more time with media than they do in school or in any leisure-time activity except for sleeping, much closer attention should be paid to the influence media has on them."

Editorial author Victor C. Strasburger writes:

A kinder, gentler, more responsive public media would be nice but is unlikely. Hollywood has been resistant to any outside criticism, the Motion Picture Association of America ratings have remained closed to scrutiny for decades, and the TV ratings are not understood by most parents. The Internet cannot be regulated. More graphic violence on TV shows and movies, more sexual suggestiveness in primetime shows, and more edgy advertising can be expected in the future. Easier access to media will occur as cell phones are used to download TV shows and movies, and soon a personal Internet device (about the size of a paperback book) will allow instant online access anytime and anywhere. Therefore, the solution to children's exposure to inappropriate media cannot rely on its producers.

There have been a number of studies on the media's influence on its viewers, especially children, and while it's hard to directly correlate the effects of TV viewing on children's actions, the association is definitely there.

Strasburger says physicians underestimate the influence of media on children. On average, kids spend more than 6 hours a day with media (more than they spend in the classroom) - two-thirds of U.S. kids have a TV in their bedrooms, half have a VCR or DVD player, half have a video game console, and almost one-third have Internet access or a computer. This, naturally, makes monitoring media use difficult.
 
The American Academy of Pediatrics has a policy that recommends limiting media use to 1-2 hours per day, but a recent survey (n=365 pediatricians) found that only half agreed with the policy, while half were not interested in learning more about media effects on their patients through media education. Yikes. Considering what the media can influence - sex, drugs, aggressive behavior, obesity, eating disorders, suicide - isn't this something physicians should consider?

Contribution to many health problems

The media are not the leading cause of any pediatric health problem in the United States, Strasburger writes, but they do make a substantial contribution to many health problems, including the following:

Violence. Research on media violence and its relationship to real-life aggression is substantial and convincing. Young persons learn their attitudes about violence at a very young age and, once learned, those attitudes are difficult to modify. Conservative estimates are that media violence may be associated with 10% of real-life violence. Office counseling about media violence and guns could reduce violence exposure for an estimated 800,000 children per year.

Sex. Several longitudinal studies have linked exposure to sex in the media to earlier onset of sexual intercourse, and 8 studies have documented that giving adolescents access to condoms does not lead to earlier sexual activity. The media represent an important access point for birth control information for youth; however, the major networks continue to balk at airing contraception advertisements at the same time they are airing unprecedented amounts of sexual situations and innuendoes in their prime-time programs.

Drugs. Witnessing smoking scenes in movies may be the leading factor associated with smoking initiation among youth. In addition, young persons can be heavily influenced by alcohol and cigarette advertising. More than $20 billion a year is spent in the United States on advertising cigarettes ($13 billion), alcohol ($5 billion), and prescription drugs ($4 billion).

Obesity. Media use is implicated in the current epidemic of obesity worldwide, but it is unclear how. Children and adolescents view an estimated 7500 food advertisements per year, most of which are for junk food or fast food. Contributing factors to obesity may include that watching television changes eating habits and media use displaces more active physical pursuits.

Eating Disorders. The media are a major contributor to the formation of an adolescent's body self-image. In Fiji, a naturalistic study of teenaged girls found that the prevalence of eating disorders increased dramatically after the introduction of American TV programs.

These points, taken from Strasburger's editorial, touch on some of the negatives of media's influence. But what about the positive ways we can use media to teach children?

At the same time, clinicians need to recognize the extraordinary positive power of the media. Antiviolence attitudes, empathy, cooperation, tolerance toward individuals of other races and ethnicities, respect for older people—the media can be powerfully prosocial. Media can also be used constructively in the classroom in ways that are better than traditional textbooks. For instance, middle school students are often assigned to read Romeo and Juliet as their first exposure to Shakespeare. Might it not be more effective, given that Shakespeare wrote his plays to be observed and not to be read, to watch one of the at least 10 different versions available on DVD? Reading Civil War history using a textbook pales in comparison to watching a TV documentary bring history to life. What could be a more entertaining way to teach high school physics than using episodes of Mythbusters? In addition, no drug or sex education program is complete without a media component.

I agree 100% with his idea. While sometimes videos can be a cop-out for lazy teachers, they can also be used as powerful teaching tools. I remember watching movies in class, and then dissecting them to compare history with fiction. My professors also used videos as ways to open up new cultures - we'd have themed days where we would watch a foreign film (or film concerning that culture), cook ethnic food and really try to get a flavor for who the people are. That's much more powerful to me than just reading a chapter in a textbook. On the social side, consider kids' views of homosexuality before and after Will&Grace, Ellen, Queer Eye for the Straight Guy.

Firearms and Smoking

Two research letters published in the same JAMA issue directly address effects of firearms and smoking in movies on adolescent behavior.

Firearms. Tongren and colleagues write that in 2005, 1,453 firearm deaths occurred among children in the U.S. (8.2% of deaths among 1-17 year olds). "Mass media have been reported to influence children's behavior toward violence," the write, and "from 1995 to 2002, 34% of G- and PG-rated movies with the highest U.S. box-office gross revenues depicted use of firearms."

The authors examined movies released 2003-2007 to determine whether the depiction of firearms in movies marketed for children had changed. Of 125 movies, 67 (54%) met the inclusion criteria for the study with 5 G-rated movies (7%) and 62 PG-rated (93%). Eighteen movies (27%) depicted characters with firearms. The study also found that almost all firearm users were adult males, and movies rarely showed the consequences of firearm use, including injury or death.

Smoking. Sargent and Heatherton write that the NCI reports that the "total weight of evidence" from studies "indicates a causal relationship between exposure to depictions of smoking in movies and youth smoking initiation. Attributable risk estimates suggest that movie smoking accounts for one-third to one-half of adolescent smoking onset."j

They examined current (past 30-day) smoking among U.S. 8th graders with smoking in popular movies. The geometric mean for movie smoking was 3.5 occurrences in 1990 and 0.23 in 2007, so portrayal of smokers decreased. Smoking among 8th graders increased in the early 1990s and then declined from a peak of 21.0% in 1996 to 7.1% in 2007.

The authors note that the main limitation of this study "is that it is an ecological analysis and can only demonstrate association. Nonetheless, the downward trend in movie smoking is consistent with an influence on downward trends in adolescent smoking." The increase in the early 1990s could be attributed to a lag in awareness of portrayal of smoking effects in the movie industry, as well as external marketing campaigns by tobacco companies.

Why should we care?

If you don't think media influences children, I'm not sure what will convince you. But think about it this way: if they aren't, why are there so many commercials on TV? Wouldn't that mean advertisers are just throwing money away?

Strasburger suggests pediatricians should ask patients (or their caregivers) if there is a TV in their bedroom, and how many hours per day they spending using media. He also suggests researchers should include media when considering behavioral effects and modifications - we don't exist in a vacuum.

What do you think? Does TV influence children's health behaviors? Should we try to modify content? Should physicians get involved?