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Relationship between screen use and internalizing/externalizing problems among preschoolers: the mediation of circadian rhythm

Pediatric Research volume 98, pages 1331–1338 (2025)Cite this article

Abstract

Background

Circadian disruption has been proposed as an etiological mechanism for psychopathology, yet its role in the relationship between screen use and emotional and behavioral problems remains under-investigated. This study aimed to examine the mediating effect of circadian rhythm in this relationship among young children.

Methods

This cross-sectional study analyzed data from 1111 children aged 2 to 7 years recruited from six kindergartens between March 2022 and June 2024. Parents reported children’s screen time and use before sleep. Parents and teachers assessed internalizing and externalizing problems using the Strengths and Difficulties Questionnaire. Circadian rhythm, including chronotype and midsleep on free days corrected for sleep debt (MSFsc), was measured using the Children’s ChronoType Questionnaire. In a subsample, MSFsc was also measured using actigraphy and sleep diaries.

Results

Screen use was significantly associated with parent-reported internalizing and externalizing problems. Chronotype significantly mediated the relationships between screen use and parent-reported outcomes, whereas the results were not reproducible using MSFsc derived from survey, actigraphy and sleep diaries.

Conclusion

The mediation of delayed circadian phase in the relationship between screen use and internalizing and externalizing problems in young children may be negligible. Future research should explore the role of other circadian parameters in this relationship.

Impact statement

Circadian disruption has been suggested as a potential mechanism linking screen-based media exposure to psychopathology. Using a triangulation approach that combined multiple data sources—survey, actigraphy, and sleep diaries—we found that the mediating effects of delayed circadian phase in the relationships between screen use and internalizing and externalizing problems were minimal in children aged 2 to 7 years. Future research should explore alternative circadian pathways and examine the long-term developmental effects of screen use during early childhood.

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Fig. 1: Flowchart of subject recruitment and participation in the study.
Fig. 2: A pathway diagram of a mediation model with observed variables represented as rectangles.

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Acknowledgments

We thank all the participants, parents and teachers for their participation. We also acknowledge the staff teachers in the kindergartens for their help in participant recruitment and data collection, and the research assistants for their help in data collection.

Funding

This study was funded by the National Natural Science Foundation of China (32100877). The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Author information

Authors and Affiliations

  1. School of Nursing and Rehabilitation, Shandong University, Jinan, Shandong Province, China

    Jia Zhao, Naixue Cui & Yinjun Hao

  2. Kindergarten of Huaiyin District, Jinan, Shandong Province, China

    Yan Li

  3. Department of Developmental and Behavioral Pediatrics, Pediatric Translational Medicine Institute, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Guanghai Wang

  4. Department of Sleep Monitoring and Treatment, Shandong Mental Health Center, Jinan, Shandong Province, China

    Shunpeng Hu

  5. School of Nursing, University of Pennsylvania, Philadelphia, PA, USA

    Jianghong Liu

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  1. Jia Zhao
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Contributions

Dr Naixue Cui had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Furthermore, Dr Naixue Cui conceptualized, obtained the funding, designed the study, oversaw and managed the project, collected and analyzed the data, drafted the initial manuscript, and critically reviewed and revised the manuscript. Jia Zhao collected data, carried out the initial analyses, drafted and revised the initial manuscript. Yinjun Hao collected data, especially the actigraphy data, cleaned data and managed dataset. Yan Li recruited participants, collected data, provided feedback to the kindergartens and participating parents, and supported the study administratively, technically, or materially. Drs Jianghong Liu, Guanghai Wang, and Shunpeng Hu critically reviewed the manuscript. Dr Naixue Cui contributed equally to the manuscript with Jia Zhao and is considered as co-first author.

Corresponding author

Correspondence to Naixue Cui.

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The authors declare no competing interests.

Consent statement

Informed consents were obtained from all participants and the study obtained approval from the Ethics Committee of the School of Nursing and Rehabilitation of Shandong University (Ref no. 2021-R-014).

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Zhao, J., Cui, N., Li, Y. et al. Relationship between screen use and internalizing/externalizing problems among preschoolers: the mediation of circadian rhythm. Pediatr Res 98, 1331–1338 (2025). https://doi.org/10.1038/s41390-025-03944-y

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