Children, adolescents, and television

Children,

Adolescents, and Televis’ion William H. Dietz, MD, PhD Victor C. Strasburger, MD

Children in the United States spend more time watching television than they do in any activity other than sleep. As shown in Table 1, children in 1988 aged 2 to 5 years watched approximately 25 hours of television per week, children aged 6 to 11 years watched 23 hours per week, and adolescents viewed approximately 22 hours per week.r Considered on an annual basis, these figures indicate that children spend more time in front of the television set than they do in school. The average American 2-year-old child spends 60 days a year in front of the television; by the time that child finishes high school, almost 3 years will have been spent watching television. Based on the current mix of programs that children watch, the average child annually sees 12,000 violent acts2 and sees or hears 14,000 references to sex.3 It is hardly surprising that thousands of American children spell relief “ROLAIDS,“4 or that children in a Maryland suburb identified more brands of beer than American presidents.5 Because children in the United States spend so much time watching television, and because television significantly influences a variety of health-related behaviors, it is crucial for pediatricians to familiarize themselves with the effects of television on children. The pervasive influence of television suggests that pediatricians begin to include counseling on television as part of anticipatory guidance and continue their efforts to affect the regulation and function of this industry. In this review, we will consider the implications of the time that children spend watching television and the commercial relationship of television to children. We will then consider how television affects children. We will review appropriate recommendations to famDr Dietz is Director, Clinical Nutrition Program, Boston Floating Hospital and Associate Professor of Pediatrics, Tufts University School of Medicine, Boston. Dr Strasburger is Chief, Division of Adolescent Medicine, Assistant Residency Training Director, and Associate Professor of Pediatrics and Family Practice, University of New Mexico School of Medicine, Albuquerque.

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ilies for altering television viewing behavior in children, and finally, we will consider appropriate interventions within the regulatory and legislative arenas. Although much of the information that we will consider has a scientific basis, much does not. Nonetheless, given our understanding of how children learn and the role that television plays within our culture, logical conclusions can be drawn that provide the basis for how we should respond to families, and at the community and national levels to attempt to alter the impact of television on children.

Time Spent Watching

Television

The most widely used estimates of time spent viewing television are provided by the A.C. Nielsen Company and are based on a confidential sample of 4,000 households in 17 metropolitan areas of the United States.6 The percentage of the audience that is watching a program during the “sweeps” months of November, February, and May determines what the networks can charge for commercials on their programs. As a result, the networks tend to air programs designed to attract the greatest number of viewers during these months. Until the introduction of “people-meters” in 1987, A.C. Nielsen monitored only whether the television was on and the station to which the set was tuned. A “people-meter” is a hand-held push-button apTABLE 1 Time Spent Age Group

Watching

Television

in the United

Time Spent Watching (hoursminutes)

States* Television

27:49 2-5 year olds 6-11 year olds 23:39 21:16 Teenage boys Teenage girls 22:18 29:18 18 + -year-old men 18 + -year-old women 33:40 *From AC Nielsen Company: N&en Report on TeZezGon2990. Northbrook, IL: Nielsen Media Research, 1990. Used by permission.

paratus that not only records what is being viewed, but permits a specific record of who is watching. Such data enable the networks to establish the demography of the viewing audience on a program-by-program basis so that commercials can be targeted more precisely to the audience most likely to purchase the product that is promoted. Despite the revenues and prestige attached to the Nielsen ratings, surprisingly little is known about the representativeness of the Nielsen sample. For example, approximately 50% of those asked to participate as a Nielsen people-meter household agreed to do so 6, 7 raising the possibility of selection bias in the sample population. In addition, because the composition of the households and the variability in the use of the people-meter are unknown, the reliability of estimates of shifts in viewing time is unknown. Finally, because the sample is only composed of major metropolitan areas of the country, the adequacy with which the entire population of the country is represented is unclear. In 1989, Nielsen data showed that 88.6 million households owned at least one television set, and 66% of all households owned two.* Peak viewing, or prime time, occurred nightly from 8:00 A.M. to 10:00 P.M.; audiences were larger in winter than in summer. Children tended to watch equal quantities of daytime and prime-time television, but even after lo:30 P.M., children comprised 6% of the viewing audience. Afterschool viewing appears to be a particularly important viewing time for children aged 2 to 11 years. During these hours, older children tend to watch sitcoms, followed by unisex animation programs with. human stars, and unisex animation with animal stars.8 According to Nielsen data,i the average household television set was turned on for 6 hours and 55 minutes per day in 1988, and increased with household size. Households with three or more people used their televisions 60 hours and 47 minutes per week. Usage declines slightly as socioeconomic class increases, increases with the use of cable, and is increased in households with children. Older women (more than 55 years old) watch more than 41 hours of television per week, and see more television than any other segment of the population. Changes in weekly viewing time over the past two decades are shown in Figure 1. Because explicit details regarding the size of the Nielsen sample and the confidence intervals for each age group have not been published, it is not clear whether the recent decline in viewing among 2 to 5 year olds and 6 to 11 year olds represents a true decline, the increased use of video games such as Nintendo, or an increased reliance on videotapes. A second problem with the interpretation of the Nielsen data is the assumption that if a child is in front of the television set, television viewing is their prin-

I:

;:

14

t

FIGURE 1 Weekly duration of television viewing by children and adolescents in the United States over the past two decades, based on annual A.C. Nielsen reports1 from the past 20

years.

cipal activity. An alternative possibility is that the child is in the room with the television on, but that television viewing is an activity that is secondary to other activities. Several sources of data suggest that the time that children report that they are watching television differs considerably from the national data when the time spent watching television is collected with diaries.9-12 In some cases, the discrepancy between the national and self-reported estimates may differ by as much as 10 hours per week.9 Furthermore, observational studies of children suggest that they frequently enter and leave the room during the course of a program. Recent estimates suggest that up to 30% of the time spent in front of the television by school-aged children may be devoted to activities other than watching television.iO However, the percentage of time that children spend looking at the television set when the set is on increases from 6% in 1 year olds to 40% in 2 year olds, 67% in 3 to 4 year olds, and 70% in 5 to 6 year olds.r3 Perhaps the most difficult issue, and the most important, is why the population of the United States spends so much time viewing television, and what the effects on the culture are. Few data are available on this issue. It is not clear whether television actually-attracts viewers, or whether the quality of life is such that our population has opted for television as an escape from more direct and interactional experience. The advent of all the viewing options offered by cable television, and the likelihood that hundreds of channels may soon be available from satellite feeds to relatively inexpensive receivers suggests that viewing in American homes may increase even further. The challenge that we have not yet faced is whether the trend toward increased television viewing is reversible. Whether the withdrawal from direct experience or the recognition of the consequent effects of excessive

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television viewing will have a sufficiently powerful effect on our culture to reduce television time remains to be seen.

Television

and Cognitive

Development

Although it is widely believed that television has an adverse effect on learning and cognitive development, a careful review of the evidence provides a less convincing perspective. Television clearly promotes learning in young children and may have some beneficial effects on school performance among selected groups of older children. Nonetheless, the data showing an association of school performance and television viewing are frequently confounded by a variety of other variables that appear to exert an effect similar in direction and magnitude to that exerted by television. The effect of television viewing on cognitive development in young children was extensively reviewed in a recent report to the U.S. Department of Education.9 The report examined the existing data concerning the “mesmerizing effects of television,” the level of children’s comprehension and lack of thought associated with television programs, the displacement by television of other more beneficial activities, and the dampening effect of television on creativity and imagination. Although a thorough review of each of these topics could deservedly serve as the focus of a separate review, a brief review of the conclusions of this report is warranted. As discussed earlier, the majority of children are frequently involved in activities other than watching television when they are in front of the television set. Attention to what is portrayed on television is an enormously complex phenomenon, and may be increased by children’s voices, peculiar voices, sound effects, and visual movement, and decreased by the presence of toys, the presence of a friend, or men’s voices.9 These observations suggest that the notion that television has a mesmerizing influence may be overly simplistic. Observational studies of young childreni3f r* have indicated that a rich series of learning interactions occurs in front of the television set. In a characteristic study of children between the ages of 6 months and 3 years,r3 the content of the child’s speech while he or she was viewing television indicated that television led to extensive verbal interactions. Some of the speech was directed toward naming the objects on the screen. Other categories of speech included questions about the content of the program, repetition of the program dialogue or the parents’ comments about the program, and spontaneous descriptions of program content. The verbal content of the parent’s speech while viewing television tended to parallel that of the child. Studies such as these emphasize strongly that television can be a highly interactive experience for young children,

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and that television can be a source of abundant material for learning names and conceptualizing activities.13, l4 An appropriate analogy for the effects of television on young children may be that of a “talking picturebook.“13 The issue of whether television displaces other activities may be judged from natural experiments in which television was introduced into communities where previously none existed. Two sizeable studies of this phenomenon have been performed in Australiar5 and in Canada.r6 In both locations the introduction of television did not appear to alter the number of activities available. However, in both locations the participation of children and adolescents in outdoor activities or sports diminished. Furthermore, within the Canadian community that previously lacked television, the introduction of television was accompanied by a reduction in community activities by both adolescents and the elderly,17 suggesting that television may affect the degree of age segregation within a community. Displacement may not be the best term to describe this phenomenon, because the process appears to be a reorganization of leisure time rather than a substitution of one activity for another.r5, r7 WilliamsI suggests that television may more easily displace other activities because it is so readily available and because children require no thought or effort to select television viewing as an activity. In the same Canadian study,r6 the effects on creativity were assessed with a comparison of towns that already had television with one that acquired it. Prior to the acquisition of television, children in the town without television scored higher on measures of creativity than children in towns with one or more television stations.r* Following the acquisition of television, creativity scores by children who previously lacked television decreased to the levels found in children who already had televisions. No evidence was found to suggest that television viewing varied according to creativity scores prior to the advent of television, nor was any evidence found that television significantly improved vocabulary or spatial ability. The effects of television on imaginative play remain unclear. An extensive study of a variety of factors related to imagination and imaginative play in yo g children failed to reveal strong clear-cut effectsY of television.19 Television may be used as a source of themes for play by young children who may adopt plots or character roles based on what they see on television.20, 21 In at least one respect, television viewing may enhance play among preschoolers. When children incorporate televised characters into their play, other children are more likely to join the play.z Television may therefore provide a common experience from which children may draw.9 Although television may contribute to imaginative play among

young children, no studies have examined whether these effects persist in older age groups. Furthermore, whether the themes of play initiated by television are more restricted than those initiated spontaneously cannot be readily determined. Finally, the long-term effects of television viewing in childhood on imagination in adults cannot be specified. The effects of television viewing on academic performance have been intensively investigated. Although American students spend more time watching television than doing homework,23 there is no indication that the amount of time spent doing homework would increase if television time decreased. Standardized test scores in several states have shown a negative correlation with television viewing,24, 25 suggesting that television may have a direct and adverse effect on school performance. However, test performance also correlates with intelligence quotient (IQ), socioeconomic class, and prior test performance.26-28 For example, a study of children in the sixth through ninth grades showed a significant negative relationship for both IQ and test performance with television viewing. However, when the effect of IQ on test performance was controlled, the effect of television on test performance was substantially reduced and considerably less uniform. 26 We27 and others28 have made similar observations. Using the same data sets that we used to examine the relationship of television viewing to obesity, we examined the effects of television viewing on the Wide Range Achievement Test (WRAT) reading and arithmetic scores of adolescents. Although a significant inverse relationship existed between WRAT scores and television viewing in the cross-sectional samples, the effects disappeared when the samples were controlled for prior test score, region of the country, population density, parental income, and parental education. Because children with poor test scores at earlier ages tend to watch more television as adolescents, failure to control for variables such as socioeconomic class and IQ probably accounted for the early studies that demonstrated a relationship between test performance and television viewing. In summary, despite the widespread belief that television affects cognitive development, few data support that bias. Children learn effectively from television, which provides a rich source of material for verbal interactions with their families. Television viewing appears to be an active rather than a passive activity. Although television viewing reduces time spent in sports, there are no data that suggest that it substantially displaces schoolwork or affects performance on standardized tests. These observations do not exclude the possibility that television has a more subtle impact on public events. In 1983,40% of American adults obtained their

information about current events from the televised network news, which contains less information than one newspaper page.29 This percentage has probably increased. Newspaper circulation has declined, and the number of young adults who read newspapers decreased to 55% from 71% between 1967 and 1988.30 Political campaigns increasingly rely on television, but between 1968 and 1988 the average length of a politician’s quote declined from 42.3 seconds to 9.8 seconds. Therefore, despite clear evidence for an effect of television on cognitive development, television may have an impact on the level of intelligence regarding political and international issues.31 These effects are difficult to measure with precision.

Commercialism and Children’s Television Television is a business. It therefore follows that children’s television is designed to attract child viewers so that the broadcasters can market advertising to sell products to children. The debate about whether the use of television to sell products to children is in their interest, or whether other needs of children supersede their role as consumers has been the historical division that has characterized the debate about children’s television. The Historical Perspective The use of television to sell products to children began with such early programs as the “Mickey Mouse C1ub.“32 Since then, broadcasters have claimed that it is their right to use the airwaves to promote products, and that the shows that they produce should legitimately be designed to attract the viewer at whom those products are aimed. In 1969, Mattel produced a program known as “Hot Wheels” which involved stories about fast cars and trucks. Not coincidentally, Mattel released a product line of small cars and trucks, known as “Hot Wheels” at the same time the show was aired.33 A rival toy company complained that since the toy and program used the same name, the show constituted a Mattel commercial, and therefore violated the Federal Communications Commission (FCC) limit on commercial time during children’s programming (16 minutes/ hour at the time). In response to this complaint, the FCC reviewed the program and concluded that “Hot Wheels” was “disturbing,” but before the FCC ruled on the matter, the show was discontinued.33 In 1974, the FCC subsequently cautioned broadcasters against “practices in the body of the program itself which promote products in such a way that they may constitute advertising.“33 Furthermore, the FCC required that broadcasters clearly differentiate commercials from programs during children’s programming.34 This requirement led to the message ‘We’ll be right back after

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these messages” that occurs during Saturday morning television. In 1982, Mattel introduced another full-length toybased program known as “He-man and the Masters of the Universe.” Due to the deregulatory approach of Ronald Reagan and of Mark Fowler, chairman of the FCC, the FCC re-interpreted the ban on program length commercials and then eliminated it completely.32 This ruling was followed by a glut of toybased programs 35-37that effectively eliminated almost all other forms of television programming specifically designed for children. By the end of 1987, over 75 such shows had been produced and aired.38 The toy companies were often the co-producers of toy-based programs, and the marketing side of the toy industry was often responsible for the production of the cartoons.32, 39 The more appropriate term to describe these programs is a “program length commercial” because the show is designed to sell a toy rather than to educate or enrich the lives of children. Additional characteristics of these programs leave much to be desired. The quality of the cartoons is low because the production of a series of one half-hour segments may cost as much as a 30-second commercial for the toy. Second, most of the toys are designed for boys, and generally center around violence or war. In the latter category, the most extreme examples are “Rambo,” and “GI Joe,” both of which have been consistent best sellers. Not surprisingly, in the 1986 Christmas season, 11 of the top 20 best selling toys had program-length commercials that promoted them, and promoted themes of violence or war.38, 4o Finally, many of the shows were supported by a series of kickbacks. For example, a toy manufacturer would offer the cartoon to a television station, often an independent, with the assurance that they would also purchase a negotiable number of commercial spots.32, 41 In these circumstances, the only risk to the broadcaster was that the other spots might not sell. Some manufacturers, such as the makers of “Thundercats,” granted local stations a share of the profits for the toy that was promoted.42 Because few other program options were available, American children watched program-length commercials and bought the toys they promoted. Although the total number of such programs has decreased, programs such as the “Teenage Mutant Ninja Turtles” still appear. Originally developed as a parody, this program has spawned over 70 products, a breakfast cereal, and a movie. “Interactive Programs” The most recent development, initiated by Mattel in 1987, is the “interactive toy.” These are toys that are activated by an inaudible signal contained within the

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Current Problems in Pediatrics / January 1991

program, or allow the child to “interact” with the program.“Interactive” clearly is a misnomer, because the process lacks a mutual exchange. The child is affected by the television but the television is not affected by the child. A more appropriate term to describe these toys is “television-activated toys.” Mattel’s television-activated toy was a laser gun that could be fired at characters in the program “Captain Power .” The villains in the program wore reflective chest protectors that reflected the laser from the gun. If the laser was reflected back into the gun, the gun would register a hit. It is not clear how successful the program was, perhaps because during a Congressional hearing even the vice-president of Mattel had difficulties registering hits when he was 2 feet away from the television set (W.H. Dietz, personal observation). Despite or perhaps because of the extensive publicity that attended the introduction of these proadditional programs have not yet been grams, introduced.

Whittle Communications In 1989, Whittle Communications, now a subsidiary of Time-Life, introduced a novel approach to advertising directed at children and adolescents.4 Whittle’s approach, known as Channel 1, was a current events program designed to be shown in schools. Six school districts received $50,000 of video equipment including a satellite, videocassette recorder, and televisions for every classroom. The schools were required to record a program transmitted by satellite, and to air the program, which included 3 minutes of commercials, during the school day. In return for the use of the equipment, the schools were required to broadcast the program.47 We have argued@ that the use of the video equipment constituted a bribe designed to persuade schools to deliver a captive audience to advertisers. Furthermore, as outlined, children already see large quantities of television. It is not at all clear that they will attend to televised information as they would to the samkinformation delivered in other formats. Finally, as discussed earlier, use of television rather than print media may only extend the limited understanding of world events that students already have. Subsequently, the program was banned from schools in New York and California.49 Cable Network News (CNN) also announced a plan to provide similar programming to schools without the advertising50 and the “free” video equipment. Although Whittle has refused to release additional information regarding the number of subscribers, CNN reported that over 7,000 schools had enrolled in their program and over one-half were actually using the broadcast.5*

Obesity and Physical Fitness Over the past 20 years, the prevalence of obesity among children and adolescents has increased,52 and physical fitness has declined.53 Television viewing appears to affect both fatness and fitness. Using data collected during cycles II and III of the National Health Examination Survey (NHES), we have shown that television viewing in children appears to be one cause of childhood obesity. 54 These surveys provided representative samples of the population of noninstitutionalized children of the United States. Cycle II of the NHES sampled 6,965 children between the ages of 6 and 11 years of age, and cycle III examined 6,671 children and adolescents 12 to 17 years of age. The sample of adolescents studied during cycle III included 2,153 subjects who had previously been studied during cycle II when they were 6 to 11 years old. Therefore, these surveys provided one prospective and two cross-sectional samples of children and adolescents. Each sample included information about time spent watching television, as well as time spent in other leisure activities such as playing with friends, playing sports, listening to the radio, or reading. In both cross-sectional studies, the prevalence of obesity was directly and significantly correlated with the time spent watching television (Figure 2). In both surveys, the relationship persisted when controlled for other variables known to affect the prevalence of obesity, such as season, region, population density, parental age, income, family size, or birth order.. No signif-

24 2 5 2 %

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HOURS OF TV / DAY FIGURE

2

Relationship of daily television viewing to the prevalence of obesity and superobesity in adolescents aged 12 to 17 years studied in the National Health Examination Survey. Obesity is defined as a triceps skinfold greater than the 85th percentile, and superobesity (shaded area) is defined as a triceps skinfold greater than the 95th percentile. Numbers in bars represent sample size for each viewing category. (Data from Dietz WH, Gortmaker SL: Pediatrics 1985; 75:807-812.)

icant differences existed between obese and non-obese children with respect to any other leisure time variable. Among adolescents, the prevalence of obesity increased by 2% for each additional hour spent viewing television. In the prospective sample, after controlling for obesity at age 6 to 11 years, the amount of time spent viewing television at ages 6 to 11 years was the most powerful predictor of the onset of obesity at ages 12 to 17 years. Both the specificity of the association of television viewing with obesity and the temporal relationship of television to obesity suggested that obese children and adolescents did not watch more television as a consequence of their social isolation. The relationship between television viewing and obesity is not confined to the pediatric age group. For example, obesity occurred twice as frequently among cohorts of middle-class adults who watched more than 3 hours of television per day than among those who watched 1 hour or less.55 Observations of employees of the Harvard School of Public Health indicated a similar trend.56 In both populations the associations persisted when controls for variables such as smoking and activity were introduced. The association between television viewing and obesity can be explained by the effects of television viewing on activity and food consumption. Although specific measures are lacking, television viewing is probably a less energy-expensive activity than bikeriding or playing outside with friends. As indicated earlier, television viewing displaces active involvement in sports.17 The finding that adolescent boys who watched less than 2 hours of television daily were significantly more fit than their counterparts who watched more than 4 hours of television per day57 further supports this hypothesis. Nonetheless, the view that television viewing is a completely passive activity is contradicted by the observation that a significant number of children exercise while watching exercise programs, or imitate the activities of their televised heroes.s* Use of video games may not have the same effect as television on activity, because children may be more active. For example, calorimetry of young adults playing a popular video game revealed caloric expenditures similar to those achieved while walking (K. Segal, personal communication). Although extensive data are lacking, the acquisition of a new video game appears to have only a transitory effect on other leisure activities.59 Television viewing also directly affects food consumption. Breakfast cereals, snacks, and fast foods are among the most heavily advertised products on television programs aimed at children,60 and tend to have a higher caloric density than other products such as fruits or vegetables that are less frequently advertised.

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The amount of time spent viewing television directly correlates with the request, purchase, and consumption of foods advertised on television.58t 61,Q Furthermore, snacking while viewing television relates directly to the amount of television viewed.58 At least in part, the association between television viewing and food consumption can be explained by the frequent references to food or the consumption of food that occurs during both commercials and programs.63 Finally, obesity occurs among televised characters far less frequently than in the general population.63 Because the characters on television eat or talk about food so frequently, the implicit message may be that it is possible to eat frequently and remain thin. Likewise, the paucity of obese characters on television may contribute to the notion that the ideal body type is that of the women and adolescents shown and may contribute to the culture-wide obsession with thinness. The data linking television viewing with obesity fulfill all of the criteria necessary to demonstrate a causal relationship. The relationship between television viewing and obesity was observed in both crosssectional and longitudinal studies, persisted after controls for a variety of variables known to affect the relationship were introduced, a dose-response relationship existed between television viewing and obesity, and in the prospective study, the time spent viewing television was the most powerful predictor of the development of obesity over a 5-year period. Furthermore, the relationships between television viewing, activity, and food consumption offer several logical mechanisms that would explain how television viewing could cause obesity. Together, these data suggest that reductions in television time could provide an effective mechanism for the prevention and therapy of childhood obesity.

Television

Violence

If parents could buy a package of psychological influences to administer in regular doses to their children, I doubt that many would deliberately select Western gun slingers, hoppedup psychopaths, deranged sadists, slap-stick buffoons and the like, unless they entertained rather peculiar ambitions for their growing offspring. Yet such examples of behavior are delivered in quantity, with no direct charge, to millions of households daily. Harried parents can easily turn off demanding children by turning on a television set; as a result, today’s youth is being raised on a heavy dosage of televised aggression and violence.@

American children watch over 1,000 rapes, murders, armed robberies, and assaults every yearvicariously, sitting in their living rooms watching the television set.& American television contains the most violence of any Western country. The amount of violent content has not changed appreciably in the

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Current Problems in Pediatrics / January 1991

past decade (Figure 3), despite increasing public awareness and concern about it. American children are more likely to be shot than children in any other country (Figure 4), and guns kept at home are far more likely to injure a family member than an intruding criminal.66-68 Unfortunately, cartoon shows and prime-time programming alike glorify the use of guns and the use of violence as an acceptable and justifiable solution to complex problems.

Understanding the Research Over 1,000 studies and reviews,69 reports from the Surgeon General, 7o and the National Institute of Mental Health,71 attest to a significant link between heavy exposure to television violence and subsequent aggressive behavior. 69 Objections to various programming practices can also exist on “purely aesthetic, humanistic, and philosophical grounds,” even if the studies or data are not unanimous in their conclusions. 73 Much of the problem in deciphering the effects of television lies in the complexity of communications research. Television is such a ubiquitous medium that distinguishing its behavioral effects from confounding variables is difficult. Content analyses have consistently shown that violence is frequently contained in Saturday morning and in prime-time programming.@j Nonetheless, such analyses merely count what is being shown; they cannot implicate television violence in a cause-and-effect relationship with aggressive behavior. Early laboratory experiments documented that children will frequently imitate what they view on the television screen, particularly if the behavior depicted is either rewarded or is modeled by an attractive figure.74 However, such experiments have been criticized for being too constrained and artificial. Field experiments have not produced uniform results, mainly because the many variables involved in human behavior cannot be easily manipulated in real life.73, 75,76 In the 197Os, correlation studies surveyed large numbers of children to determine if those who watched more television were more prone to aggressive behaviors than infrequent viewers. For example, 2,300 Maryland junior and senior high school students were asked to list their four favorite shows, which were then assessed for their violence content. More aggressive or deviant behavior as determined by self-reports, peer reports, and teachers’ assessments was directly related to the violence content of the student’s favorite shows.n In 1978, a study of over 1,500 teenage men in London78 showed that those who watched large amounts of television violence committed more antisocial and criminal acts than matched peers who were light viewers. Less serious forms of aggression also correlated with the television diet.

association at all ages between exposure to television violence and aggressive or antisocial behavior, regardless of the measures used. Furthermore, exposure to violent programming appeared associated with higher levels of aggressive behavior and lower levels of positive or altruistic behavior.“, 85

FIGURE Annual periods as “any Gerbner

through School

3 rates of televised violent acts per hour in several time during the past two decades. Violence was defined overt act or threat to hurt or kill a person.” (From G, Gross L, Morgan M, et al: Violence Profile 1967 1988-89: Enduring Patterns. Philadelphia, Annenberg for Communication, 1990. Used by permission.)

Other forms of media (e.g., comic books, films) were faithful to this pattern as we11.78 Other studies in the 1970s yielded similar results.79-81 Nonetheless, these studies failed to demonstrate whether viewing television violence causes aggressive behavior or whether aggressive children choose to watch violent programming. Naturalistic experiments, longitudinal correlation studies, and meta-analysis helped clarify this problem. In the first type of experiment, communities were assessed before and after the introduction of television. The most recent study, done in a Canadian town in which television was introduced,16 found that children in the no-television town (“Notel”) displayed an increase in aggressive behaviors after television was introduced into their community (Figure 5). Several unique longitudinal studies have provided the strongest incriminating evidence. In the longest and best study,82, 83 875 third graders were studied in 1963, 460 were studied again at age 19, and another sub-sample was studied again at age 30, 22 years after the initial observations. The relationship between viewing television violence in the third grade and aggressive behavior 10 and 22 years later was highly significant while aggressive behavior in the third grade did not predict a preference for violent programming later in life (Figure 6). These data suggest that aggressive behavior is learned early in life and is resistant to change. Finally, several meta-analyses (a technique in which the individual studies become data) have now been performed,@ 85 one of which examined 67 different experiments involving close to 30,000 subjects. 85 A majority of studies demonstrated a positive

How Television Promotes Aggressive Behavior Social learning theory. Children model their behavior after adults. Television provides children and adolescents with attractive adult role models. In particular, when children see someone rewarded for a behavior, they are more likely to imitate that behavior. Social learning theory holds that humans learn behavior from observing others directly in real life and vicariously through the mass media%, 87; the easiest way to teach children a desired behavior is to demonstrate the behavior and have the children model it. Bandura demonstrated the power of social learning in his classic 1963 experiments74 with nursery school children and a Bobo doll (a punching bag with a sand base and a red nose that squeaked). One purpose of the experiments was to investigate the circumstances under which novel aggressive acts could be learned and imitated. Each child was first introduced to a room full of attractive toys and then mildly frustrated by the removal of the toys. Children in the control group were then separated from the experimental group, and the experimental group was shown a filmed sequence on television: The film began with a scene in which [an adult male] model walked up to an adult-sized plastic Bobo doll and ordered him to clear the way. After glaring for a moment at the noncompliant antagonist the model exhibited four novel aggressive responses each accompanied by a distinctive verbalization. First, the model laid the Bobo doll on its side, sat on it, and punched it in the nose while remarking, ‘Tow, right in the nose, boom, boom.” The model then raised the doll and pommeled it on the head with a mallet. Each response was accompanied by the verbalization, “Sockeroo stay down.” Following the mallet aggression, the model kicked the doll about the room, and these responses were interspersed with the comment, “Fly away.” Finally, the model threw rubber balls at the Bobo doll, each strike punctuated with “Bang.” This sequence of physically and verbally aggressive behavior was repeated twice.74

Children in the experimental group were then subdivided into three different groups: a model-rewarded group in which the bully was shown being rewarded with candy, a model-punished group in which the bully was shown being reprimanded, and a neutral group which saw no further film. When brought into an experimental room containing many toys, including the Bobo doll, children who had seen the model either rewarded or treated neutrally displayed a large number

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Figure 4A FIGURE

Figure 4B

4

A, trends in mortality and B, deaths from firearms among U.S. white boys aged 15 to 19 years. (From Fingerhut LA, Kleinman JC: Firearm Mortality Among Children and Youth. National Center for Health Statistics Advance Data no. 178, 1989. Used by permission.)

of imitative behaviors. Children who had seen the bully punished and control children displayed little imitation. According to social learning theory, all of the children in the experimental group had learned the aggressive behaviors and could perform them if the circumstances were conducive.ss, 89 In addition, further studies showed that children could learn novel aggressive responses as easily from a cartoon figure, “Cat Lady,” as from a human adult,74 and that preschool children viewing violent television programs during their breaks were more aggressive on the playground than children viewing nonviolent programs.gO In addition to learning and copying from models, generalization of the response may also occur. A violent program could lead to the display of other responses, similar to the behaviors being modeled. For example, observing violence that is justified may be more likely to “cue” aggressive modeling in the viewer. The likelihood of imitative behavior may also be enhanced by the televised depiction of violence as necessary and committed or endorsed by the law. Protracted viewing may eventually affect the viewer’s perception of the world. Gerbner’s studies of the “Mean World Syndrome” in adults reveal that heavy viewers consistently view the world as it is portrayed on television, dramatically overestimating the amount of violent crime or the number of criminals in society.91, 92

Catharsis theo y.

One theory of television’s effects that has essentially been discredited is the catharsis theory. In Aristotle’s Poetics, he suggested that spectators could

16

Current Problems in Pediatrics / January 1991

be vicariously purged of their feelings of grief, fear, or pity. Nevertheless, the preponderance of data suggest that no catharsis occurs among television viewers of any age.69, 83, 93-95

Size of the Effect The magnitude of the contribution of televised violence to aggressive behavior has been estimated. One recent epidemiologic study compared homicide rates in the United States, Canada, and South Africa before and after the introduction of television.96 Homicide rates in the United States and Canada doubled within 20 years of the advent of television, suggesting that television may be a leading cause of homicide and that 10,000 homicides a year could be averted if television did not exist.” Because other simultaneous changes occurred, these figures may be overestimates. A study that combined 18 separate estimates of effect size found that the range of violence accounted for by television was approximately 5% to 15%.97 Lack of a reliable measure of television viewing may attenuate the magnitude or increase the imprecision of the estimate. Nonetheless, even the lower measure is socially significant.

Sexuality The advanced cognitive abilities and sophistication of adolescents about the modern world belies their reliance on television as an important source of infor-

schools and back in the educational ~v.101

NOTEL

UNITEL

MULTITEL

FIGURE 5 The figure shows comparable Canadian communities with no television (Notel), one channel (Unitel), and multiple channels (Multitel) after the introduction of television in Notel. After television was introduced into a community which never had it previously, a significant increase in the number of aggressive behaviors was demonstrated. (From Williams Th/l (ed): The Impact of Telezkion. A Natural Experiment in Three Communities. New York, Academic Press Inc, 1986. Used by permission.)

mation about sex, drugs, and the adult world. Furthermore, television may play an important role in the etiology of significant adolescent problems such as teen pregnancy, drug abuse, and suicide.98 As indicated earlier, Nielsen data indicate that teenagers view slightly less television than younger children.l However, among Michigan ninth and tenth graders, the average teenager reports three television sets at home, two thirds reported having a set in their own room, 78% had cable television, 68% had Home Box Office or another pay channel, and 34% had a videocassette recorder.99 When television time included cable stations and movies, the overall viewing figures rose to an average of 6.2 hours per day (2.6 hours between the time they arrive home from school and dinner, and 3.6 hours after dinner).9 Because of their unique psychology, teenagers may be particularly susceptible to portrayals of “normal adult behavior” that they witness on television.ioO [Teenagers], if they’ve watched Dallas, already have a working familiarity with lust. They learned about impotence from Donahue. Love, Sidney taught them about homosexuality, and one hopes, tolerance. Kojak told them all about the street names for prostitution and prostitutes. Soap operas offer daily classes in frigidity, menopause, abortion, infidelity and loss of appetite. If they’ve watched more than one made-fortelevision movie, they know about rape. Johnny Carson gives graduate courses in divorce and Jerry Falwell has already spoiled all of it with his class-“An Overview of Sin 101.” Parents should probably view television as a blessing; after all, it took television to finally get sex education out of the

home,

where

it belongs.

Call

it

Such information is certainly not limited to sexual matters. Compared to the television of the 195Os, today’s shows give teenagers new insights into the formerly secret world of adult behavior in general.102 Adult drinking behavior, business practices, leisure activities, marriage and divorce, patterns of friendship, and materialism are all accessible to anyone with a television set. The United States has the highest teenage pregnancy rate in the Western world, despite the fact that the rate of sexual activity among American teenagers is no different than among Western European or Canadian teens.ro3 Each year, over one million American teenage girls become pregnant.iM In the past decade, the pregnancy rate among 15 year olds and younger continued to increase, despite a plateau among older teens.lo5 Although the causes of adolescent pregnancy are multifactorial, the effects of the media, especially television, are clearly implicated?, lo7 American television ranks as one of the most sexually suggestive media in the world, and there are indicationsros that it is becoming even more permissive (Table 2): American teenagers seem to have inherited the worst of all possible worlds regarding their exposure to messages about sex: movies, music, radio and TV tell them that sex is romantic, exciting, titillating; premarital sex and cohabitation are

TV violence watched m the third grade

TV violence watched at age 19

Aggressive behavior in the third grade

Aggresswe behavior at age 19

FIGURE 6 Effect of television viewing and aggressive behavior in children in the third grade and the same effects 10 years later. Television viewing at the younger age clearly affects aggressive behavior, whereas early aggressive behavior has no

effect on subsequent television choices. (From Liebert RM, Sprafkin J: The Early Window- Effects of Television on Children and Youth, ed 3. New York, permission.)

Current

Problems

Pergamon

in Pediatrics

Press, 1988. Used by

I January

1991

17

TABLE

2

Changes in the Frequency of Sexual Behaviors Portrayed on Television Over a 13-Year Period* Average Acts/Hour Behavior

1975

1988

Kissing Hugging

3.3 2.6

6.6 7.6

Suggestiveness Physical Verbal Sexual intercourse Discouraged practices

0.8 1.2 0.0 -

3.7 5.2 1.9 1.8 L, et al: Sexual Material on American Network

*Adapted from Harris Television during the 1987-1988 Season. New York, Planned Parenthood Federation of America, 1988; and Sprafkin J, Silverman LT: Sex on prime-time, in Schwartz M (ed): 7’Vand Teens. Reading, MA, Addison-Wesley, 1982, pp 130-135.

visible ways of life among adults they see and hear about. . Yet, at the same time, young people get the message good girls should say no. Almost nothing they see or hear about sex informs them about contraception or the importance of avoiding pregnancy. For example, they are more likely to hear about abortions than about contraception on the daily TV soap opera. Such messages lead to an ambivalence about sex that stifles communication and exposes young people to increased risk of pregnancy, out-of-wedlock births, and abortions.109

Although the average teenager views nearly 14,000 sexual references and innuendos per year, less than 150 of the references deal with birth control, selfcontrol, or abstinence.llO As an example, during the early 1989 season, CBS launched a replacement sitcom entitled, “Live-In,” about an Australian au pair girl imported by a middle-class New Jersey family. One prominent TV critic described the show this way: By an unwritten law of television, domestic sitcoms must have a randy, hyperglandular teen-age boy in the house. In this case, the kid’s name is Danny. . When Danny is not salivating or making suggestive remarks, a moronic friend called Gator does it for him. “So, did you boff her yet?” Gator asked on the first show. When Danny said he hadn’t made it to first base, Gator scoffed, “The chick is obviously frigid.” Seeing Lisa “naked” then became the project du jour; the boys drilled a hole in a wall so they could watch her undress. As irony will have it, Lisa looked through the hole and saw Danny naked instead. Later, she made mocking reference to his genitals, summoning the image of a baby carrot and remarking, “Immature things are usually small.” This was in front of the rest of the family at the dinner table. Good clean fun? Or pandering puerile pap?*ll

The show aired at 8 P.M., a prime viewing time for most children and adolescents and was viewed in 12.6 million American homes.’ On the soap operas, extramarital sex is portrayed eight times more commonly than sex between

18

Current Problems in Pediatrics I January

1991

spouses.rr2 Sex is frequently portrayed as being impersonal and exploitative, r13 and mention or use of contraception is rare. 114Sexually transmitted diseases rarely occur in anyone who is not a prostitute or homosexual.1*s Teenage girls are particularly avid viewers of soap operas,l and the sexual content of soap operas has increased by 103% since 1980.rr6 Television’s influence must be inferred from a knowledge of normal adolescent psychology, content analyses of what is portrayed on American television, adolescents’ heavy consumption of the medium, and studies that demonstrate television’s importance in their lives. For instance, several studies have demonstrated that television is one of the leading three sources of information for teens about sex.l17, lls Even though parents and peers represent more frequent sources, much of their information may also have been learned from the media. Adolescents perceived television equally or more encouraging about sex than either their best male or female friends.*r9 When college students were asked to identify models of responsible and irresponsible sexual behavior, they selected primarily media figures. Those who selected media figures as models of sexual responsibility had higher rates of sexual activity and more permissive attitudes.uO~ lzl Pregnant teenagers were twice as likely than nonpregnant teenagers to think that television relationships are “real” and that television characters would not use contraception if involved in a sexual relationship.rz Four small studies have examined the relationship between early onset of sexual intercourse and television viewing. Among 75 adolescent girls, half of whom were pregnant, the pregnant girls watched more soap operas before becoming pregnant, were less likely to think their favorite characters would use birth control, and were more likely to think that television relationships are “real.“lz3 Adolescents who selectively viewed more television with sexual themes and those with a preference for MTV124 were more likely to have begun having sexual intercourse. Boys who watched television the most had the highest prevalence of sexual experience, and teenagers who watched television apart from their parents had a rate of sexual intercourse three to six times higher than those who viewed with the family.12s Despite widespread portrayals and references to sex, the three major networks still refuse to air contraceptive advertising. Their refusal is surprising, because a majority of Americans of all religions clearly favor birth control advertising on television (Table 3), and most American adults acknowledge the importance of television in influencing adolescent sexual behavior (Table 4). The American Academy of Pediatrics has supported contraceptive advertising on the major networks.126

TABLE 3 The Acceptability of Television American Public* t

Advertisements

to the

Advertisement

Yes

No

Political candidate Hemorrhoid treatments Tampons Contraceptives Feminine hygiene sprays Beer and wine Erotic lingerie X-rated movies

77%

20%

71% 63% 60%

27% 33% 37%

58% 53% 27% 12%

39% 45% 69% 86%

*Adapted from Harris L, et al: Attitudes About Television, Contraception Advertising. New York, Planned Parenthood tion of America, 1987. t n = 1,250 adults.

Sex, and Federa-

Accidents, homicides, and suicides represent the three leading causes of death among teenagers.rz7 Approximately half of all accidental deaths are alcohol-related, and many homicides and suicides involve alcohol use.1o4 A clear link between advertising and increased alcohol consumption is suggested by the $900 million annual budget of the beer and wine industry.128-130 Since 1960 there has been a 50% per capita increase in alcohol consumption in the United States,131 although more recently the consumption of liquor has declined.ls2 Sweden, which banned all beer and wine advertising in the mid-1970s, experienced a 20% per capita decrease in alcohol consumption.133 The average American teenager views between 1,000 and 2,000 beer and wine commercials per year.lN Sports stars and rock idols frequently appear in such ads, and the underlying messages are clear: “real men” drink beer; beer drinkers have more fun, more friends, and more successful relationships; and consuming alcohol is the norm rather than the exception.135 Alcohol advertising appears in close juxtaposition to ads for performance cars (Table 5) and may convey an implicit message that drinking and driving mix. In the past, alcohol was the most common beverage consumed on television.lX Virtually all prime time dramas and situation comedies contained alcoho1.137 In soap operas, alcohol was typically portrayed as an important social lubricant, or a means of resolving personal crises. 138Rarely were the true consequences of alcohol use or alcoholism shown.136, 138 In the past 6 years, Hollywood has made significant progress in reversing this trend. In 1983, the Hollywood Caucus of Producers, Writers, and Directors issued guidelines for the industry, suggesting that they avoid gratuitous alcohol use (e.g., pouring a drink

as a mechanism for getting a character from one scene to the next), glamorized drinking, showing excessive drinking without consequences or miraculous recoveries from alcoholism, or depicting alcohol use in a macho context .139 As a result, Thomas Magnum of “Magnum P.I.” switched from beer to milk as his favorite drink, and the amount of alcohol consumption on prime time has diminished. More recently, the Harvard Alcohol Project has joined with major television networks and Hollywood studios to develop programming that will attack the problem of drinking and driving.r40 The Partnership for a Drug Free America (PDFA) has produced many clever anti-drug ads (e.g., “This is your brain. This is drugs. This is your brain on drugs. Any questions?“), but their ads are limited to either marijuana or cocaine, not alcohol. In addition, the average teenager will view 25 to 50 beer and wine ads for every PDFA ad they see.134

Suicide Suicide accounts for 8% of all deaths in adolescents.14’ Several studies in the United States and Europe have demonstrated a possible link between television programming or news reports about suicide and an increase in teenage suicide. IQ-, 143 Suicidal behavior increases within a newspaper’s readership area after prominent coverage of a suicide, particularly after the suicide of someone who is seen as “attractive.“14 A significantly greater number of suicide attempts and completions occurred after the broadcasts of four made-for-TV films about suicide (Figure 7).145 These studies suggest an increased risk of imitative suicidal behavior in certain susceptible teenagers. Imitative suicides are consistent with the theory that most human behavior is learned through modeling. The

TABLE 4 Responses of the American ceptive Advertisements* t

Public

to Televised

Contra-

Question

Yes

No

Should characters on TV shows be shown using birth control?

59%

34%

32%

64%

60%

37%

42% 82%

52% 14%

Is contraception too controversial to be mentioned on TV shows? Are you in favor of advertising birth control on TV? Would birth Encourage Encourage

control advertising teenagers to have sex? teens to use contraceptives?

*Adapted from Harris L, et al: Attitudes About Television, Contraception Advertising. New York, Planned Parenthood tion of America, 1987. t n = 1,250 adults.

Current Problems in Pediatrics i January 1991

Sex, and Federa-

19

TABLE 5 Frequency of Commercials During Televised Sports (1986)*

351 n

Suicide

0 Attempt

NBA Championship

Product Beer Cars Network *William

15.7% 15.7% 16.9% H.

Dietz,

unpublished

World Series

Pro Football

15.7% 15.0%

11.4% 29.5%

18.9%

18.1%

observations.

attractiveness of the role model and the rewards associated with the observed behavior are important factors in whether the modeled behavior is acquired or imitated.14z, 146 Music Videos Music videos are part television and part rock ‘n’ roll in which the visual impact of the musical themes predominate. Without the video, the impact of the lyrics is often lost. For example, only 30% of teenagers know the lyrics to their favorite songs (40% if they are heavy metal fans).147 Even if they know the lyrics, children may not comprehend their meaning, particularly at younger ages. For example, only 10% of fourth graders could correctly interpret Madonna’s “Like a Virgin,” and nearly 50% of college students thought that Bruce Springsteen’s “Born in the U.S.A.” was a song of patriotism, not alienation.147 Teenagers’ motivation, experience, and knowledge are crucial factors in their ability to interpret lyrics. Children and adolescents frequently miss the sexual themes in lyrics. Whereas adults see such themes as sex, drugs, violence, and satanism in current rock music, teenagers interpret their favorite songs in terms of themes of ‘love, friendship, growing up, life’s struggles, having fun, cars, religion, and other topics that relate to teenage life.“*@ Although teenagers may not hear or understand rock lyrics, they cannot miss the provocative and often violent images of music videos on the television screen, usually involving many of their favorite performers. In addition, Music Television (MTV) appeals to adolescents who might not ordinarily be heavy consumers of television. In one study of over 900 San Jose teenagers, those who had access to MTV watched an average of up to 2 hours per day.149 Music videos are divided almost equally into concept videos, which tell a story, and performance videos, in which the band is merely playing. The latter are of slight concern, although Elvis Presley gyrating his hips has been replaced by David Lee Roth masturbating on stage with a giant inflated phallus. However, content analyses of concept videos reveal that 75% contain sexually suggestive material, 56% contain violence, and much of the violence is committed against women. 150,lsl The only behavioral study

20

Current Problems in Pediatrics / January 1991

FIGURE 7 Number of completed suicides and suicide attempts by adolescents in the Greater New York area 2 weeks before and after made-for-TV movies about suicide aired. (From PhiUips DP, Carstensen LL: N Engl] Med 1986; 315:685. Used by permission.) to date in this area demonstrated that violent music videos desensitized young people to violence immediately after viewing. 152 Videos may be selfreinforcing: if listeners hear a song after seeing the associated video, they immediately “flash-back” to the visual imagery in the video.150 Stereotypes The Programs In the most thorough analysis of the portrayal of characters on television, Barcus assessed the characters who appeared during 38 hours of children’s television in 1983.153 More than 75% of the 1145 characters who appeared were men. Women were more likely to be portrayed as human, whereas the men were often cast in animal or non-human roles. The only category in which women were a majority was among grandparents. However, only 3% of all women and 0.6% of all men were portrayed as elderly. Whites constituted almost 90% of all characters, blacks comprised 6%, other minorities were 6%, and 1% of all characters were indeterminate. Most characters whose role could be determined were in the upper and lower middle classes. Seventy percent were in professional or technical occupations. As emphasized before, few of these characters were overweight.63 Cartoons are a particularly rich source of stereotypes. The enemies in such programs generally speak with foreign accents and have non-white features.154

Most attack the compassionate American may promote an “us v. them” attitude.

heroes and

The News A recent study 155 found that only four women were among the reporters who appeared on the network evening news. Women tended to appear five times more frequently as anchors than as reporters, although men were more frequently anchors, and minority groups were underrepresented in both categories. During the period surveyed, only two Hispanics, and no Asians or blacks were represented in the top 50 reporters. Adolescents Stereotyped sex roles extend to adolescents. A review of 200 episodes of programs that featured adolescent characters revealed that the appearance of teenaged girls was portrayed as being more important than their intelligence. 156 Intelligent girls were sometimes depicted as being social misfits. Teenaged girls were more passive than their male counterparts and were obsessed with shopping, grooming, and dating rather than initiating serious conversations with adults or peers about academic interests or career goals. Ninetyfour percent of teenage girls on television were middle class or wealthy.156 Medicine One of the most important stereotypes shown on television is the stereotypic portrayal of medicine and the people who work in medicine. Physicians are overrepresented on television. During prime-time television, the average viewer sees almost 12 doctors a week, including three in major roles.157 In the soap operas, 68% of all professionals worked in medicine,15* and 80% of the men were doctors.159 Because the American public generally spends more time in front of the television set than it does in the company of doctors in practice, it appears logical to suggest that the public’s perception of medicine may be affected by how the practice of medicine is portrayed on television. Doctors on television are omnipotent and successful. When televised physicians must choose a therapy, 40% of the time they perform unusual highrisk procedures, or, if presented with a sure-safe approach or a risky but potentially curative therapy, physicians on television choose the latter.i@ Television doctors invariably resolve medical or personal crises for the benefit of alll’jo The portrayal of illness is also unrealistic. The majority of televised illnesses are acute rather than chronic.161 Almost 70% of the time, diseases on television respond to a short-term biomedical treatment.161 Much of the health information on television is inaccurate or misleading,162 and most messages promote

pills rather than other remedies.162 Learning how to live with a disease, reintegrating into society, or accepting imperfect therapy are rarely considered. Such televised portrayals ignore the indecision, uncertainty, hypothesis testing, chronicity, and lack of resolution that often accompany the diagnosis and treatment of patients in the settings in which we work. In contrast to the televised image, physicians tend to be conservative, and select well-established treatments where the risks are known. Experimental or untested interventions are used only when all else has failed. As we know all too well, despite appropriate therapy, seriously ill patients may suffer residual handicaps after they recover, or they may die. In contrast to doctors on television, we are often unable to resolve all medical or personal crises for the benefit of all. Televised medicine may create expectations on the part of the families that we treat that cannot be fulfilled. It therefore seems appropriate to contrast with families the reality of medicine with its televised portrayal when we are confronted with a seriously ill patient.

Interventions Counseling Families To counsel families effectively, pediatricians and nurse practitioners must understand what is being shown on children’s television, and how it is likely to affect children. Perhaps the most difficult requirement is to spend time watching television aimed at children. Saturday morning cartoons represent the most intensive exposure for children. Surprisingly enough, Saturday morning fare for children has recently improved. However, most program-length commercials are carried on the independent networks and are generally aired when pediatricians are still in their offices. The only recourse may be to tape these programs for viewing at a more opportune time. The control of the television set should become a standard aspect of anticipatory guidance. Because television viewing habits are probably easier to form than they are to change after viewing habits have become established, guidance about the control of television and the review of what children watch should begin when children begin to watch television, or at approximately 1 year of age. Because so many of the effects of television on children depend on the amount of time that they spend viewing television, the most important focus of counseling should be the reduction of television time. Afterschool television appears to be a critical time to exert such controls, because 80% of children cite television as an important after-school activity. Effective counseling in this area depends on effective teaching of the

Current

Problems

in Pediatrics

I January

1991

21

effects of television on children, and helping parents to understand that television is a poor substitute for more direct experience of the world. American parents have assumed, with few arguments to the contrary, that their children should avoid boredom. In this context, television is seen as an activity that keeps their children from being bored. The same parents also want their children to become creative and self-reliant. It may be helpful to remind parents that boredom is one of the conditions that helps children to develop creativity and self-reliance. Based on the arguments outlined, it may be better for a child’s development to let him be bored than to let him watch television. An ingenious solution is a device that locks the plug on the television set, so that the set can only be used if the plug is unlocked.163 Parents should also be urged to use television appropriately. Many parents use television as a diversion or as a babysitter. Among families that use television as a diversion, children tend to watch more television than children in families that use television for entertainment or educational purposes.164 For such families, use of a babysitter analogy may be helpful. For example, few families would permit a babysitter to urge their children to buy food and toys or to promote violence and sex. When possible, parents should preview the programs they propose to let their children view and should exercise control over the programs that their children watch. With the advent of videocassette recorders, it is possible for even young children to screen rapidly through a variety of programs with a remote device. The remote device increases the likelihood that children who use it may inadvertently tune into IvlTV or a station carrying adult material. Lockout devices may make it impossible for such children to stumble into the wrong theater. For those families who can afford them, the use of the videocassette recorder offers the opportunity to create a library of appropriate programs for use at times when their children want to watch television. Parents should also watch television with their children. Television provides a wealth of human experience. However, because television consists of visual rather than cognitive material, what children see may not be adequately or appropriately incorporated into a cognitive context. Discussion about what children see may not only provide an appropriate frame of reference for what is viewed, but may also allow parents to compare and contrast their values with what their children see. Parental interpretation of a program can make the worst program one of the best learning experiences. Similarly the best program viewed without an appropriate context may be of no value to the children, because they are unable to interpret what they see. Because co-viewing may actually increase the

22

Current

Problems

in Pediatrics

/ January

1991

time that children spend viewing commercial television and reduce the quantity of time that children watch public broadcasting, it may be useful to explore what programs are currently being watched as a family, and to counsel accordingly. Use of the AAP brochure, entitled Television and the Family, offers a concise summary to parents about the effects of television on children and how parents can act to control viewing habits. Use of Office Videos The use of office videos offers new possibilities to educate parents and children about the effects of television on children and to provide anticipatory guidance. An increasing supply of videotapes on a variety of subjects is gradually becoming available. Some of these, such as “Baby Alive,” and “Breastfeeding, the Art of Mothering” have been developed either by or in collaboration with the AAl?.l@ Others are available from independent producers and are reviewed by an AAP publication entitled the Video Resource Guide165 that is updated on a semiannual basis. The technology is now available to allow pediatricians to develop their own videos on almost any subject or to take videos that have been developed by others and adapt them for office use. Such materials can often be personalized, using interspersed discussions by the pediatrician or “voiceovers” where the pediatrician’s voice is taped over visual material. Such material may be more effective for subjects such as home safety than a brochure or direct communication, because the corrective action can be demonstrated directly. Major commercial and non-commercial efforts are being made by industry and the AAP to develop videos that cover a wide range of problems related to health and development. However, families may watch office videos in much the same way that they view television. Because the medium is visual, a verbal directive may be necessary to put the message in a cognitive context. Schools Those involved in the education of children are logical allies, particularly in the development of curricula to educate children about the effects of television. For example, a highly educational discussion could be initiated after viewing a sequence of beer commercials. Appropriate questions for children might include a count of the number of men and women in such commercials, and a contrast of their respective roles. Children could be asked to describe the circumstances shown in the commercials, and what that implies about the product that is being sold. Children could also be asked to keep track of the advertisements during sporting events, and what message is delivered by the juxtaposition of beer and performance car advertisements.

A similar approach could be developed with respect to violent cartoons, or the interpersonal relationships shown on the soaps. Several curricula have been developed for childrenI@-l@ to reduce the belief that the programs represent reality, to increase the ability of children to compare what they see with their impressions derived from other sources of information, to decrease the veracity of television by an improved understanding of its mechanics, and to evaluate television’s content by making use of these skills. An experimental curriculum aimed at reducing violence significantly decreased the aggressive behavior of children and altered their attitudes about violence.l’j9 A curriculum has also been developed for high school students that is designed to develop critical viewing skills. I70 This approach begins with an analysis of how television news programs are made, particularly with respect to the choices of what to film and what quotes to tape. Additional lessons cover politics, documentaries, and advertising. Such approaches help students to understand the limitations of the medium, how the creation of a program reflects a perspective, and by example, the other perspectives that are neglected. A final approach that deserves further evaluation is the television turnoff. The most widely publicized of these occurred in Farmington, Connecticut in 1984. A review of that experience has been developed as a kit.171 The program involved the schools and the library and was sponsored by the Board of Education. The Library Council estimated that 25% of the population of Farmington either reduced or eliminated television for the month of the turnoff. Teachers reported less aggressive behavior on the playground and improved classroom performance, and families found that they were doing more together. Although longterm outcome data are lacking, the discussion of the effects of turning off the television set prior to, during, and following the turnoff were probably as important as any long-term reduction in television usage that occurred.

Action for Children’s Television The most effective lobby on behalf of children’s television over the past 20 years has been Action for Children’s Television (ACT). In part, the strength of ACT derived from its president, Peggy Charren, whose vision and articulate comments on the state of children’s television have been instrumental in the institution of reform. Ms. Charren has been able to respond quickly and cogently to controversial issues regarding children’s television, and the publicity generated by her comments has constituted a potent force for change. In addition, ACT’s demonstrated ability to

change television practices has reflected a comprehensive understanding of broadcast regulation, and the responsiveness of the FCC and the FTC to requests for rulemaking initiated by ACT. With the advent of deregulation introduced by the Reagan administration, the focus for change shifted from the regulatory agencies to the Congress.

The American Academy of Pediatrics In many respects the activities of the AAP complement those of ACT. In contrast to ACT, pediatricians have direct contact with parents and children and may therefore be in a better position to change viewing habits than ACT. In addition, the AAP has a greater capacity to lobby for legislation on behalf of children. Nonetheless, the television industry changes rapidly, and responsive public positions on the issue of children and television must be enunciated quickly to foster debate and form public opinion. It is not yet clear whether the AAP will be able to maintain public visibility on this issue without the capacity for instant comment that characterizes ACT. The earliest documented involvement of the AAP with the issue of children’s television occurred in 1956.l” At this time, a television, radio, and movie committee of the Southern California Chapter was formed to attempt to reduce violence on television and in movies because of its effect on children. Meetings with three major television networks resulted with the suggestion from the networks that parents learn how to turn the television set off. Members of the Academy subsequently testified on behalf of children at hearings of the FCC in 1971 on the subject of commercials aimed at children. At that time, the Academy proposed that half of primetime television consist of programs developed specifically for children, and that commercials be restricted to the end of programs. In 1978, a short-lived Task Force on Television and Advertising recommended a ban on advertising to children under 12 years of age because such children lacked the cognitive ability to assess the meaning and intent of commercials. Members of the Task Force subsequently proposed these limits to the Federal Trade Commission (FTC) as part of the FTC Rule Making in 1978 (&role King, personal communication). In 1983, in an effort to understand the effects of television and to develop a cohesive response to the multiple issues raised by children’s television, the Academy empaneled a Task Force on Children and Television. Members of ACT were instrumental in their advice to the Academy regarding the composition of the Task Force. The Task Force’s initial findings were released as a policy statement in 1984173 that focused on the effects of television on children, and outlined

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an agenda for the education of pediatricians and families and the development of legislative activities and liaisons with other organizations. When the Task Force was terminated in 1986 and the locus of the Academy’s activities on children and television was moved to the Provisional Committee on Communications (now known as the Committee on Communications), many of these goals had been achieved. Education of pediatricians was promoted through symposia and plenary sessions at national meetings, and a brochure for use in pediatricians’ offices was developed. The Academy had increased its visibility on legislative issues, and the institutionalization of the Academy’s commitment to these activities appeared assured by the inclusion of the Task Force in the Committee on Communications. Subsequent policy statements from the Academy’s committees included support for a ban on alcohol advertising, 174 promotion of condom use,lz6 promotion of limits on program-length commercials,175 and increased discretion and restraint in record lyrics and the production of music videos.176 The 1984 statement of the Task Force has recently been revised.in The Academy also produced two public service announcements165 that were estimated to have reached 50 million- households (Michelle Hurwitz, AAP, personal communication). The first, entitled “Couch Potato” was designed to illustrate the effects of protracted television viewing on obesity and food intake. The second, entitled the “Shocking Adventure of Casual T. Cat,” produced by Will Vinton Productions, the agency that developed the California Raisins commercial, was intended to illustrate home electrical safety. Despite the efforts initiated in 1956, the Academy has been unable to develop,a working relationship with the television networks. In part, this failure may be attributable to the criticism that the Academy has directed at current network practices. In addition, the networks asserted that they already had the expertise and process necessary to review programs and to moderate their effects on children, and that these mechanisms were already working effectively (i.e., “if you think things are bad now, think what they would be like if we weren’t here”). The recent reductions in the program practices divisions of the networks have made this argument moot, ,and the advent of deregulation, discussed as follows, has made it possible for the networks to respond only to commercial considerations. The Use of Television for Counter-messages The most common approach to the use of television for health promotion has been the development of Public Service Announcements (PSAs). As indicated earlier, the Academy has developed two PSAs directed at families and children that have been widely aired.

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Other PSAs, such as those developed by the Partnership for a Drug-Free America, have helped to focus attention on the avoidance and effects of drug use. However, PSAs occupy a small fraction of television time. Although they are relatively inexpensive to produce, they are shown to audiences at times determined by the networks. As discussed earlier, even widespread PSAs that promote behaviors such as condom use will not likely counter the effects of the many subtle messages in programs that promote unprotected sex. Several recent initiatives have approached the potential effects of television on health from novel directions. In 1988, Dick Schultz, the executive director of the National Collegiate Athletic Association (NCAA) proposed to ban beer commercials during the NCAA basketball tournament.178 As indicated earlier, such commercials account for approximately 15% of the ads on sporting events, and their elimination would cause a loss of revenue of approximately $150 million annually. 179 Although a complete ban on alcohol advertising was averted, the NCAA negotiated a reduction in the time allotted for beer commercials from 90 seconds to 60 seconds beginning in 1991.rso Furthermore, Anheuser Busch, which negotiated the reduction to avert a ban, agreed to broadcast an equal number of advertising spots that would promote responsible and moderate drinking.lBO A second approach is that initiated by the Center for Health Communications of the Harvard School of Public Health, known as the Harvard Alcohol Project. The Harvard Alcohol Project seeks to change American norms that relate drinking and driving by the promotion of alternative behaviors, such as refusing to ride in a car with a driver who has been drinking, or by the appointment of a designated driver.rB1 The Project grew out of a relationship with the broadcasting industry, initiated by Frank Stanton, a former CBS president, and a member of the Advisory Board of the Harvard Center for Health Communications. As a result of this relationship, the networks developed and aired a number of PSAs that promoted the concept of a designated driver. 182,ls3 Furthermore, a number of televised series included an episode or vignette that dealt with the issue of drinking and driving.184 The Project has argued that the increase in the frequency with which a designated driver is appointed by the young adult men at whom the program is aimed reflects its success.rgl, Is5 Two approaches aimed at children have also been developed. In December 1989, Home Box Office developed and aired a program entitled “Buy Me That. “ls6 “Buy Me That” attempted to show children the differences between what the advertisements of toys showed, and the reality of a toy’s performance. The program also demonstrated how difficult toys

were to play with, in contrast to how easy the games appeared on television. A second program, entitled “Cartoon All-Stars to the Rescue” enlisted 20 popular television cartoon characters to help rescue a 14-yearold boy from drug use. ia7 The program was televised simultaneously on almost all channels on a Saturday morning without commercials and on donated air time. Although these last two initiatives appear highly promising, it is unclear whether programs such as “Buy Me That” can counter the widespread commercial advertising on children’s television. Nonetheless, both approaches are unique and deserve substantial support. The use of the broadcast media to promote health behaviors has been extensively reviewed by the Harvard Center for Health Communication.188 Successful use depends on a well-defined target audience, extensive research to ensure the development of welldesigned campaign materials, messages that build on the current level of knowledge, a media plan that assures access to the target audience, and messages that meet that audience’s needs.is8 Although it is arguable that the success of the Harvard Alcohol Project was due to unique access to the media, the Project fulfilled all of these criteria. Other projects that have relied on a similar approachlg9, 190 appear equally promising. Nonetheless, whether the commitment of television broadcasters, producers, directors, and writers to such a project will endure for more than a single season remains to be determined. Federal Communications Commission (FCC) The Federal Communications Commission was initially established as the Federal Radio Commission (FRC) by the Radio Act of 1927.191 The Radio Act was replaced in 1934 by the Communications Act that established the FCC. The Commission consists of seven members who each serve a 7-year term. They are appointed by the President and are confirmed by the Senate. The FRC, and later the FCC, was charged with the regulation and licensure of radio stations to prevent stations from competing for or interfering with the use of specifically assigned broadcast frequencies.19* In return for licensure powers, the Commission was also empowered to revoke the license of stations. The same legislation was subsequently applied to television stations. In 1928, the Davis amendment to the National Radio Act further allocated the FRC the responsibility to issue, revoke, or renew a station’s license based on whether that station has acted in “. . . the public interest, convenience, or necessity.“192 This directive, and the FCC’s subsequent attempts to define it, has become known as the Public Interest Standard. Although it is clear that the FCC is empowered to act on behalf of the public’s interest, the definition of what constitutes the public interest has been subject to the

political forces that direct the appointment of the seven FCC commissioners. Competing political forces led to an FCC Chairman in 1961 who declared that television was a “wasteland,” and urged forcefully that broadcasters act on behalf of children,193 and later, to a Chair in 1984 who believed that television was no more subject to regulation than other home appliances. In accordance with this latter perspective, television has been deregulated. Recommended limits on advertising minutes per hour were eliminated, and programs featuring toys were not declared commercials. Furthermore, although the FCC has stated that broadcasters must consider the needs of children in their programming, the Commission broadened the definition of children’s programs to include “family-oriented” shows such as situation comedies.194 In 1987, an Appeals Court found that the FCC ignored its own guidelines in its 1984 deregulation of children’s programming and remanded the issue to the FCC.195 Additional decisions from the FCC on this issue have not been forthcoming. Furthermore, the lack of an FCC that actively defended the special needs of children was the principal reason that legislation has evolved. A second regulatory guideline relevant to the interest of children is the Fairness Doctrine. Because of their public obligation to serve the public, broadcasters were obligated to air both sides of controversial issues.196 The Fairness Doctrine was subsequently upheld by the Supreme Court. In 1967, the FCC ruled that the networks were obliged to present both sides of the cigarette smoking/lung cancer controversy, and suggested that a ratio of three cigarette commercials to one anti-smoking advertisement was appropriate.” The failure of the networks to adhere to this ratio generated a proposal by the FCC for Congressional legislation to ban cigarette advertising completely. Subsequent legislation to this effect was opposed by a coalition of the broadcast and tobacco industries, but was passed as the Public Health Cigarette Smoking Act and signed by the President in 1970. Because the FCC ruled in 1974 that the Fairness Doctrine did not apply to commercial products, 72 this approach can no longer be used to promote counteradvertising against products such as alcohol. The prior application of both the Public Interest Standard and the Fairness Doctrine to children’s needs and health issues provides the justification for many of the proposals aimed at the revision of current broadcast practices. The AAP has stated that the use of the airwaves to sell products to children is not in the public interest.175 Because the Fairness Doctrine no longer applies to commercial products, the AAP has sought legislative alternatives to ban alcohol advertising on television. An unexplored but potentially viable alternative is to use the Fairness Doctrine to argue for contraceptive advertising, by arguing that the broadcast

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of unprotected sex represents a controversial practice, and that the alternative must be shown. Obviously, action on this approach would require a responsive FCC. In the past, the FCC regulated the time allocated to commercials. Under guidelines promoted by the National Association of Broadcasters, commercials on children’s television were limited to 12 minutes/hour on weekdays, and 9.5 minutes/hour on weekend days.197 However, in 1984, the Commission ruled that “commercial levels will be effectively regulated by marketplace forces.“197 A legislative attempt to limit commercial time to 12 minutes/hour on weekdays and 10.5 minutes/hour on weekends was subsequently vetoed by President Reagan. Subsequently, commercial time on children’s television rose well above these limits on both children’s38 and prime-time198 television.

Federal Trade Commission (FTC) The Federal Trade Commission was established in 1914 to deal with “unfair methods in competition of commerce,“196 a task which was subsequently modified to include the regulation of deceptive advertising as unfair competition. The Commission consists of five commissioners appointed to staggered terms by the President. Because the bill that established the FTC did not define “unfair” or “deceptive,” the FTC developed criteria by which to judge whether advertising violated these standards. The Commission does not need to prove that an advertisement deceives consumers; advertisements that have the capacity to deceive may be considered deceptive.196 In 1976, in response to a complaint by ACT, the FTC acted to prohibit the advertising of Spiderman Vitamins to children in comic books or on daytime television and to stop using hero figures to induce children to buy the product.199 The Commission stated that “Children are unqualified by age or experience to decide for themselves whether or not they need or should use vitamin supplements in general . . .” and added that any advertising of this product to children constituted “an unfair practice.“199 The FTC subsequently modified this position. In response to petitions filed in 1977 by ACT and the Center for Science in the Public Interest to ban the advertising of highly sugared products,72 the FTC proposed that the Commission should determine whether it should: 1. Ban all televised advertising for any product which is directed to, or seen by, audiences composed of a significant proportion of children who are too

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young to understand the selling purpose of, or otherwise comprehend or evaluate, the advertising. 2. Ban televised advertising directed to or seen by audiences composed of a significant proportion of older children for sugared products, the consumption of which poses the most serious dental health risk. 3. Require that televised advertising directed to, or seen by, audiences composed of a significant proportion of older children for sugared food products not included in number 2 be balanced by nutritional and/or health disclosures funded by advertisers.” Despite its prior judgment, the FTC terminated the rulemaking action with the statement “. . . we cannot justify sacrificing other important enforcement priorities to its continuation.“7* This position has subsequently dominated the attitude of the FTC toward children’s advertising. Until the appointees to the FTC change, it appears likely that children’s television will continue to treat children as consumers rather than to nurture their potential for growth.

Legislation In 1989 and 1990, two major legislative efforts were passed to address the content and effects of television for children. The first of these efforts was legislation introduced by Senator Paul Simon (D-IL). In 1983, a federal court ruled that the actions of the National Association of Broadcasters to produce voluntary standards that regulated commercial time and the content of programs’constituted a violation of the federal antitrust standards and were therefore unconstitutional. Senator Simon’s bill exempted the networks from the antitrust legislation for a 3-year period to allow them to initiate discussions about how to reduce the negative impact of programmed violence on television.2m Prior to passage, the Senate bill was amended to enable broadcasters to discuss ways of reducing the portrayals of sexually explicit episodes and drug use.*Ol The House passed similar legislation that provided only for the discussion of violence. Later in the legislative session, the Senate bill was stripped of the sex and drug use amendments, and became law. Although the networks have reacted to this legislation by arguing that such discussions would violate their first amendment rights to free speech,*OO the Simon bill required only that they initiate discussions. The broadcasters have also argued*OO that their program practices divisions, which are assigned the responsibility to oversee the quality and effects of programs, made the Simon bill unnecessary. However, as the percentage of network viewers and advertising

revenues have declined over the last several years, the program practices divisions have usually suffered the most severe staff reductions.202 The AAP strongly supported the Simon bill. A second bill, originally introduced in the House by Congressman Markey (D-MA), required that broadcasters identify and air programs specifically designed to serve the educational and informational needs of children under the age of 12.38 At least in part, the Markey bill responded to the lack of quality programs for children that resulted from the earlier FCC decisions. In addition, because a significant percentage of the population lacks cable television, many children have no alternatives to network television. The bill also proposed to limit commercial time to 12 minutes/hour on weekdays and 10.5 minutes/hour on weekend children’s television, The strongest aspect of the bill required that the broadcasters’ adherence to this guideline be considered at the time of and as a condition for license renewal. This bill was passed by both houses of Congress and vetoed by President Reagan in 1988 because he believed the bill restricted the freedom of expression of broadcasters.203 Parallel but stronger legislation204 was subsequently introduced in the Senate by Senators Hollings (D-SC) and Inouye (D-HA). The principal difference from the Markey bill was that the broadcasters were required to identify such programs in advance of the program and immediately prior to the program. In addition, the bill sought to review and restrict the broadcast of program-length commercials. The broadcasters argued that the Markey legislation represented an intrusion by government into programming. 38 The AAP believes that such legislation is consistent with the Public Interest Standard. Furthermore, the AAP testified that the needs of children deserved protection, that such legislation would foster television that would enrich the lives of children, and that program-length commercials constituted unfair and deceptive advertising because there is no distinction between the program and the commercial when the programs are designed to market products.38 The strength of both bills was reliance on a review of programming at the time of license renewal. Because television licenses are costly and provide broadcasters with the frequency they use to broadcast, it is unlikely that networks would jeopardize their licenses by failing to comply with this legislation. This bill was also passed at the close of the 1990 Congressional session and has now become law. At the time of passage, the bill incorporated a third television bill that authorized $6 million for a National Endowment for Children’s Educational Television. More recently, Senator Gore (D-TN) and Representative Kennedy (D-MA) introduced legislation that

requires health warnings in television, print, or outdoor advertising for alcohol in a fashion similar to the warnings on cigarette labels.205 As indicated earlier, the AAP has in the past supported legislation that proposed to ban alcohol advertising and also favors this legislation.

Summary As we have indicated, children’s television has either a documented or probable effect on a variety of healthrelated behaviors in children and adolescents in the United States. Studies of cognitive development indicate that television provides a stimulus for learning and that children learn from television. The adverse effects of television appear related to both the time spent watching television and the content of the programs that are viewed. The reviewed observations suggest that a variety of initiatives are warranted to alter the time children spend watching television, the content of programs, and the types of programs for children and adolescents that are produced and broadcast. These initiatives require the development of effective techniques and materials for counseling parents, as well as continued political and legislative activities at the local and national level. We must promote the conviction that time spent in activities other than television viewing will provide our children with the values necessary to understand and interact with an increasingly complex world. Effective governmental action on behalf of children to change television will require a reaffirmation and enforcement of the Public Interest Standard. For half a century, the broadcast media have been licensed to use the airwaves in the public interest. The diversity and magnitude of the adverse effects of television on the health of children strongly suggest that the use of television has not been in the public interest. Although cable television offers multiple alternatives, less than 60% of American households receive cable.206 Broadcast television still represents the only alternative for 40% of American children. Substantial regulatory change by the current administration is unlikely. Therefore, legislative activity to mandate broadcast practices responsive to the needs of children appears the most appropriate national approach.

Acknowledgment The authors gratefully acknowledge Nancy F. Dietz, whose wisdom and guidance led to the success of the Task Force on Children and Television, Peggy Charren, whose lead we have tried to follow, and the other members of the Task Force: Jim Holroyd, Norm Sherry, Frank Palumbo, Jim Harisiades, and Nancy Witty. Carole King provided a helpful history of the AAP’s involvement. Pamela Peak’s assistance in the preparation of this manuscript was invaluable.

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