Autism Spectrum Disorder and screen time during lockdown: an Italian study.

Introduction

The lockdown imposed to contain the Covid-19 pandemic introduced strict restrictive measures to avoid the spread of the virus (Government, 2020). The adopted measures included a stay-at-home order and the closure of schools and educational facilities. Literature reported that during lockdown, parents of children faced serious difficulties in the organization of the children’s free time (Ozturk & Yalçin, 2021). This plight was even more challenging for families of children with developmental disabilities. One specific and wide subgroup of these families and children, are children with Autism Spectrum Disorder (ASD). The latest revision of DSM American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (APA, 2013), adopted the umbrella term Autism Spectrum Disorder with two features: difficulties in social communication and social interaction; and restricted and repetitive behavior, interests or activities. These two sets of symptoms have a wide range of severity levels, which may be different for each child with ASD (Lord et al., 2020). ASD symptomatology presented additional challenges for children to cope with during the COVID-19 pandemic, for instance the disruption of routines. Literature reported a worsening of the ASD core symptoms as an increase of behavioral problems, mannerisms and stereotypes, worsening in the area of sleep regulation, intensification of self and other-directed aggressive behaviors, increases in sensory motor agitation and restlessness (Di Renzo et al., 2020; Colizzi et al., 2020), and higher levels of anxiety and emotional dysregulation (Amorim et al., 2020). Furthermore, due to their children’s often difficult behavior, parents may have allowed more screen time (such as tablets, smartphones and television) during lockdown as a means of regulating their children (Thompson & Christakis, 2005), for its calming effect, and as a respite from the challenges posed by them (Nally et al., 2000). Literature shows that many children with ASD used electronic devices more often and for longer periods of the day, with it becoming an absorbent interest and that they found it difficult to switch from one activity to another (Istituto Superiore di Sanità [ISS], 2020). In fact, because of their deficits in impulse control and response inhibition, and because of their lower engagement in social and physical activities, children with ASD preferred screen use over other leisure activities, rendering them more prone to problematic screen use. However, no studies have focused on the relationship between the activities performed by children during lockdown (from March to May 2020) and any modification, either worsening or improvement, of ASD core symptoms. In this study we focus on a very common set of activities “screen time activities”. The aim of this brief report is to investigate the possible relationships between the amount of screen time and modification of the ASD core symptoms during lockdown, in children with ASD.

Methods

Results

Discussion

During lockdown, the closure of school and educational facilities, the loss of psychological and rehabilitation services, and the general stay-at-home orders, all led to more time spent at home, as well as daily spare time increasing considerably. Furthermore, any activities were more limited and mostly carried out either alone or with a parent. Children with ASD are highly attracted to screens and this kind of activity increased substantially during lockdown (Olive et al., 2020). The aim of his study was to investigate the relationship between the amount of screen time and the modification of the ASD symptoms during lockdown. Focusing on the ASD symptoms modification during lockdown our results showed a slight worsening of some core symptoms in the “restricted, repetitive patterns of behavior, interests, or activities” cluster. As previous research showed (i.e., Colizzi et al., 2020; Di Renzo et al., 2020), the lost support from school could have intensified the symptoms in these areas of ASD, and the increased worry of parents further exacerbated children's psychological well-being and increased their behavioral problems (Zhang et al., 2020). On the other hand, the improvements in the “social communication and social interaction area” may be explained because those skills acquired before the lockdown period, when supported by the parents, were not lost (Di Renzo et al., 2020). Indeed, attunement improved between parents and children, so children had more direct stimulation from more stable and even more emotionally positive reference.

Our data show that children spent more time watching television and playing video-games than using social networks and playing online with friends. This evidence is confirmed in literature. In fact, children with ASD tend to have higher rate of solitary screen time, such as video game and television, than social interactive media (Mazurek et al., 2012). Considering the loss of school social interactions, the high rate of solitary use of social media appears to be an ulterior risk factor for the children wellbeing because makes them unavailable to learn through home social interactions, boosting an addiction to screens (Wetsby et al., 2020).

The present study shows a relation between the more time children spent with screen during lockdown, and the worsening of ASD core symptoms. The social withdrawal hypothesis proposes that increased screen time may limit social interactions with family members (Varni et al., 2011) which are crucial for language, communication, and socioemotional skills, heightening the difficulties in social communication and social interaction (Mazurek et al., 2012). Furthermore, high screen use leads to sleep disorders, emotional dysregulation, increases stress and anxiety and produces overstimulation (Wallenius et al., 2010) and ADHD-like behaviors (Ra et al., 2018). This can lead to an increase in behavioral problems and restricted and repetitive behaviors, interests or activities (Wetsby et al., 2020).

However, the current study is not without limitations. This study relied on a parent’s evaluation of children’s ASD symptoms modification, so responses are potentially flawed due to social desirability. However, studies have found that parent concerns and reports accurately reflect the child’s ASD symptomatology (Ozonoff et al., 2009; Richards et al., 2016).

In the light of the profound changes that lockdown brought to the daily lives of children with ASD, the results of this study highlight the importance of considering the impact that prolonged screen time activities may have on the wellbeing of children. Considering that we live in a world surrounded by screens, that children with ASD are highly attracted to screens, and that we still live in a time of restrictions, it’s important to underline that high screen time represents a risk factor for the wellbeing of children with ASD. Increased awareness of the risk factors in this population in this unprecedented event is needed to prevent them in the short and long terms. Future research should deepen this argument enlarging the range of screen tools and ASD wellbeing topics. This study may help to increase attention of parents of children with ASD and health care providers and enable healthcare providers to coach parents in more suitable forms of play for children with ASD, both during the pandemic as well as after it ends.

Data availability statement