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9 Oct 2018

Beyens I et al. Proc Natl Acad Sci U S A 2018; 115: 9875-9881

Reports suggest there has been a significant increase in the incidence of ADHD among children and adolescents over the past 40 years (Akinbami et al. 2011; Visser et al. 2014; Nigg 2006). It has been suggested that this increase could be linked to the violent and fast-paced nature of screen media entertainment. Despite this, a comprehensive view of the literature is limited, as much of it is dispersed across different fields of research. In an effort to consolidate the evidence base, the authors performed a review to investigate the relationship between children and adolescents’ screen media use and ADHD-related behaviours.

In this review, the authors first compared the results of two meta-analyses, performed by Nikkelen et al. and Ferguson, on media use and ADHD-related behaviours (Nikkelen et al. 2014; Ferguson 2015). The authors reported small but statistically significant pooled zero-order correlations between screen media use and ADHD-related behaviours, with effect sizes of r+ = 0.12 and r+ = 0.10 yielded by Nikkelen et al. and Ferguson, respectively. The authors stated that these findings were consistent with other meta-analyses assessing media effects, which typically reported effect sizes ranging from r+ = 0.10 to r+ = 0.20. The authors noted that there were clear differences between the two meta-analyses. First, the meta-analysis by Nikkelen et al. was based on studies assessing the effects of television (38 studies) and video games (17 studies), whereas that by Ferguson was based on video games only (9 studies). Second, there was a difference in the conceptual approach between the two studies; Ferguson incorporated background variables (such as sex and age) as controls, whereas Nikkelen et al. treated the same background variables as moderators. The authors stated that there has been some concern that the approach employed by Nikkelen et al. could mask the true media effects for some subgroups of children. On the other hand, the authors postulated that the conceptualisation of background variables as moderators, rather than controlling for them, may promote better understanding as to which children are susceptible to media effects as a cause of ADHD-like behaviour, and, equally important, which children are not.

Next, three propositions provided by the Differential Susceptibility to Media effects Model (DSMM)* were used to examine the limitations associated with the current literature base, and to provide potential directions of future research.

Indirect media effects: mechanisms underpinning the screen media–ADHD relationship

The first proposition of the DSMM postulates that media effects can be explained by a combination of three types of response states:

  • Cognitive – the attention to and processing of certain media content
  • Emotional – affective reactions such as fear and joy while watching and playing
  • Excitative – physiological arousal while or after watching or playing.

In line with the DSMM, most explanatory hypotheses in the current literature conceptualise cognitive, emotional and excitative response states as the underlying mechanisms in the screen media–ADHD relationship. Research has also been conducted to determine whether the fast pace and violent nature of screen media may play a role in children’s media-induced response rates, which could increase the likelihood of ADHD-related behaviours:

  • Effects of programme pacing: the authors’ review of the literature showed that studies on the effects of pacing on ADHD-related behaviours have yielded inconsistent results. The authors suggested that this could be due to multiple factors. First, fast pace is often linked to action and/or violence in popular children’s entertainment. Although researchers may remove this element from fast-paced stimuli to ensure the ecological validity of their experiments, this may render the materials too dull to evoke a true response. Second, ethical constraints mean that it is impossible to expose children to age-inappropriate content; therefore, the stimuli used in experiments may differ substantially from the favourite programmes typically watched by a particular age group, which could reduce the ecological validity of an experiment. Finally, programme pacing was conducted using a number of different approaches across studies (e.g. changes in camera angle, scene or voice), which could complicate valid comparisons between studies.
  • Effects of violent media content: the authors’ review of the literature demonstrated that several studies indicated a positive correlation between exposure to violent television and gaming and ADHD-related behaviours. However, the majority of studies were correlation surveys, which meant that a conclusion could not be made regarding the direction of the relationship between media use and ADHD-related behaviours.

Conditional media effects: susceptible individuals in the screen media–ADHD relationship

The second proposition of the DSMM is that any media effect can be modulated by specific person-based or environmental factors. In line with this, several media-effects theories propose that some individuals are more susceptible to the effects of screen media than others. Studies have been performed to determine if the use of screen media on ADHD-related behaviours may be linked with developmental, dispositional and social factors:

  • Developmental susceptibility: a review of the literature found that although a number of theories suggest age differences in the relationship between screen media and ADHD-related behaviours, research to date has not provided consistent evidence for such differences. Some studies suggest that compared with older children and adolescents, younger children may be more susceptible to media-induced arousal and subsequent ADHD-related behaviours; however, more research is needed before these findings are considered conclusive.
  • Dispositional susceptibility: a number of person-based characteristics have been investigated for their role in susceptibility to media effects, including gender, level of aggression and genetic disposition. The authors’ review of the literature suggested that boys may be more susceptible to the effects of media on ADHD-related behaviours than girls, which may also apply for aggressive adolescents. More research is required to establish the role of gender as a potential moderator, as well as the effect of other dispositional variables.
  • Social susceptibility: the authors noted that only a handful of studies have investigated the role of social susceptibility in the relationship between screen media and ADHD-related behaviours. Results from these studies have suggested that parenting style, demographic factors and parental well-being may enhance the effects of children’s media use on ADHD-related behaviours. However, further studies are needed to develop a more robust evidence base.

Transactional media effects: the directional nature of the screen media–ADHD relationship

The third proposition of the DSMM is that many media effects are transactional or reciprocal. Despite the fact that transactional effects are likely for outcome variables such as ADHD-related behaviours, the authors’ review of the literature found that only a small number of studies have actually considered transactional effects and, furthermore, these studies reported inconsistent results.

The authors concluded that there is a statistically small relationship between screen media use and ADHD-related behaviours among children and adolescents. However, review of the literature base demonstrates that although there are many media-effects hypotheses to explain how and why media use and ADHD-related behaviours may be linked, empirical research to support these arguments is somewhat lacking. The authors, therefore, stated that there is a clear need for further research to establish the causality, underlying mechanisms and differential susceptibility to the effects of screen media use and ADHD-related behaviours, as well as the direction of the relationship.

Find out more about screen media use and ADHD here


*The DSMM is an integrative model that aims to improve understanding of media effects, distinguishing three types of susceptibility to media effects: dispositional, developmental and social susceptibility (Valkenburg and Peter 2013)

Akinbami LJ, Liu X, Pastor PN, et al. Attention deficit hyperactivity disorder among children aged 5–17 years in the United States, 1998–2009. NCHS data brief, no 70. Hyattsville, MD: National Center for Health Statistics. 2011.

Beyens I, Valkenburg PM, Piotrowski JT. Screen media use and ADHD-related behaviors: four decades of research. Proc Natl Acad Sci U S A 2018; 115: 9875-9881

Ferguson CJ. Do angry birds make for angry children? A meta-analysis of video game influences on children’s and adolescents’ aggression, mental health, prosocial behaviour, and academic performance. Perspect Psychol Sci 2015; 10: 646-666.

Nigg JT. What causes ADHD? Understanding what goes wrong and why. New York, NY: The Guilford Press, 2006.

Nikkelen SWC, Valkenburg PM, Huizinga M, et al. Media use and ADHD-related behaviors in children and adolescents: a meta-analysis. Dev Psychol 2014; 50: 2228-2241.

Valkenburg PM, Peter J. The differential susceptibility to media effects model. J Commun 2013; 63: 221-243.

Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry 2014; 53: 34-46.e2.

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