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Screen-related discord and dismay in low-income Mexican American families with toddlers: A qualitative study

Published:November 14, 2022DOI:https://doi.org/10.1016/j.pedn.2022.09.009

      Highlights

      • Little is known about screen-related discord in low-income Mexican American families.
      • Findings offer insight into the types of screen-related discord parents experience.
      • Parent-child discord stems in part from parental limit setting.
      • Parent-partner discord reflects disagreement between partners about screen use.
      • Parents experience feelings of ambivalence and dismay about screen use.

      Abstract

      Purpose

      Understanding parental experiences with managing their toddler's screen use is important to inform the design of interventions addressing early childhood screen use, yet current evidence is limited. To enhance our understanding of the context of toddler screen use, this study characterizes the screen-related discord and dismay parents experience in families with toddlers.

      Design and methods

      In-depth interviews were conducted to explore everyday experiences with screen use among low-income Mexican American caregivers of toddlers (21 mothers, 10 fathers, 1 grandmother). Transcripts were content analyzed to identify prominent themes.

      Results

      Three themes were identified. Experiences of screen-related discord and dismay arose (1) between parent and child, (2) between parents, and (3) surfaced as parental internal dissonance about toddler screen use. Parent-child discord resulted from parental limit setting and child reactions to parental screen use, which often included tantrums. Parent-partner discord included patterns of agreeing to disagree and direct disagreement between partners. Parents also reported their own feelings of ambivalence and dismay as they struggled to reconcile their preferences against their toddler's actual screen use, while living in a screen-saturated world.

      Conclusions

      Findings offer insight into types of screen-related discord and dismay low-income Mexican American parents experience as they attempt to manage their toddler's screen use.

      Practice implications

      Although discord in families is normal, the screen-specific discord reported by participants warrants consideration in efforts promoting healthy screen use in families. Providers can tailor their counseling to consider the range of screen-related discord families of toddlers may experience.

      Keywords

      Introduction

      Despite cautions from the World Health Organization and the American Academy of Pediatrics to limit young children's exposure to screen devices, most children begin using screen devices in the first few years of life (
      • Council on Communications and Media
      Media and young minds.
      ;
      • Hish A.J.
      • Wood C.T.
      • Howard J.
      • Yin S.H.
      • Rothman R.L.
      • Sanders L.M.
      • Delamater A.M.
      • Flower K.B.
      • Perrin E.M.
      Infants who watch television become toddlers who watch more television: Screen time patterns in the greenlight study.
      ;
      • Rideout V.
      The Common Sense census: Media use by kids age zero to eight.
      ;
      • World Health Organization
      Guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age: Summary.
      ). Screens, including television (TV) viewing and mobile device use, are a common part of family life, and reasons for use are diverse, including assistance in managing child behaviors, stimulation of child learning, and simple entertainment (
      • Beck A.L.
      • Takayama J.
      • Badiner N.
      • Halpern-Felsher B.
      Latino parents' beliefs about television viewing by infants and toddlers.
      ;
      • Coyne S.M.
      • Shawcroft J.
      • Gale M.
      • Gentile D.A.
      • Etherington J.T.
      • Holmgren H.
      • Stockdale L.
      Tantrums, toddlers and technology: Temperament, media emotion regulation, and problematic media use in early childhood.
      ;
      • Davou B.
      • Sidiropoulou A.
      Family life around screens: Some thoughts on the impact of ICTs on psychological development and the development of relationships.
      ;
      • Elias N.
      • Sulkin I.
      Screen-assisted parenting: The relationship between toddlers’ screen time and parents’ use of media as a parenting tool.
      ;
      • Radesky J.S.
      • Eisenberg S.
      • Kistin C.J.
      • Gross J.
      • Block G.
      • Zuckerman B.
      • Silverstein M.
      Overstimulated consumers or next-generation learners? Parent tensions about child mobile technology use.
      ;
      • Tang L.
      • Darlington G.
      • Ma D.W.L.
      • Haines J.
      • Study, O. B. O. T. G. F. H
      Mothers’ and fathers’ media parenting practices associated with young children’s screen-time: A cross-sectional study [journal article].
      ;
      • Thompson D.A.
      • Polk S.
      • Cheah C.S.L.
      • et al.
      Maternal beliefs and parenting practices regarding their preschool child’s television viewing: An exploration in a sample of low-income Mexican-origin mothers.
      ). Currently, effective interventions supporting parents in the promotion of healthy screen use in this specific age group are lacking. Recommendations for healthy screen use from national and international organizations include limiting screen use to less than one hour a day in 2–5 year old children, not using screen devices in the hour before bedtime, and keeping mealtimes screen-free (
      • Council on Communications and Media
      Media and young minds.
      ;
      • World Health Organization
      Guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age: Summary.
      ).
      One potential reason for the lack of interventions is the limited amount of evidence to inform them. Specifically, little is known about parents' experiences managing screen use in this age group. A focus on toddlers, defined here as ~1 to 2-year-olds, is important as toddlerhood is a unique developmental period in which language use expands exponentially and a desire for independence is clear. Parenting can be challenging as toddlers make their wants and needs more clearly known, and tantrums are common (
      • Daniels E.
      • Mandleco B.
      • Luthy K.E.
      Assessment, management, and prevention of childhood temper tantrums.
      ). Since early screen use behaviors persist throughout childhood, intervening early may be important (
      • Certain L.K.
      • Kahn R.S.
      Prevalence, correlates, and trajectory of television viewing among infants and toddlers.
      ;
      • Thimmig L.M.
      • Cabana M.D.
      • Bentz M.G.
      • Potocka K.
      • Beck A.
      • Fong L.
      • Chao C.
      • Caughey A.B.
      • Wong A.
      • McKean M.
      Television during meals in the first 4 years of life.
      ).
      Over the last decade, average daily screen use has increased for children in low-income households, whereas it has remained stable in children from higher income households. Recent pre-pandemic evidence suggests a nearly 2 h difference in average daily screen use between young children 0–8 years old in low-income versus higher income households (
      • Rideout V.
      • Robb M.B.
      The Common Sense census: Media use by kids age zero to eight.
      ). The same study found that Latino children ages 0–8 years old spend over 1 additional hour each day using screen devices compared to non-Hispanic White children. During the pandemic, screen use in children increased, including in low-income Latino children (
      • Beck A.L.
      • Huang J.C.
      • Lendzion L.
      • Fernandez A.
      • Martinez S.
      Impact of the Coronavirus disease 2019 pandemic on parents’ perception of health behaviors in children with overweight and obesity.
      ;
      • Kracht C.L.
      • Katzmarzyk P.T.
      • Staiano A.E.
      Household chaos, family routines, and young child movement behaviors in the U.S. during the COVID-19 outbreak: A cross-sectional study.
      ). Based on this evidence, a focus on screen use among low-income Latino families is warranted. Outcomes, such as short sleep duration and obesity, that are associated with unhealthy screen-use behaviors (e.g, use before bedtime, high screen use durations), are also more prevalent in Latino children than in non-Latino White children, further supporting this focus (
      • Ogden C.L.
      • Carroll M.D.
      • Lawman H.G.
      • Fryar C.D.
      • Kruszon-Moran D.
      • Kit B.K.
      • Flegal K.M.
      Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014.
      ;
      • Pan L.
      • McGuire L.C.
      • Blanck H.M.
      • May-Murriel A.L.
      • Grummer-Strawn L.M.
      Racial/ethnic differences in obesity trends among young low-income children.
      ;
      • Peña M.-M.
      • Rifas-Shiman S.L.
      • Gillman M.W.
      • Redline S.
      • Taveras E.M.
      Racial/ethnic and socio-contextual correlates of chronic sleep curtailment in childhood.
      ). In national data, 15% of Hispanic 2 to 5-year-old children are obese in the United States compared to 5% of similarly aged non-Hispanic White children (
      • Ogden C.L.
      • Carroll M.D.
      • Lawman H.G.
      • Fryar C.D.
      • Kruszon-Moran D.
      • Kit B.K.
      • Flegal K.M.
      Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014.
      ). Likewise, in children less than 2 years old in low-income households, elevated weight-for-lengths are more common in Hispanic children compared to non-Hispanic Black or White children (
      • Freedman D.S.
      • Sharma A.J.
      • Hamner H.C.
      • Pan L.
      • Panzera A.
      • Smith R.B.
      • Blanck H.M.
      Trends in weight-for-length among infants in WIC From 2000 to 2014.
      ). To address screen use, sleep, and obesity disparities and potentially enhance intervention effectiveness, contextual tailoring of interventions is needed (
      • Whitesell N.R.
      • Sarche M.
      • Keane E.
      • Mousseau A.C.
      • Kaufman C.E.
      Advancing scientific methods in community and cultural context to promote health equity:Lessons from intervention outcomes research with American Indian and Alaska native communities.
      ).
      Given the lack of information regarding screen use among families with toddlers, and especially among low-income Latino families with toddlers, we used qualitative methods to explore the day-to-day management of screen use among low-income Mexican American parents of toddlers. Recognizing the interconnectedness of family members (i.e. children, parents, extended family) and the influence of context (e.g. home, neighborhood) on behaviors, this research was guided by the frameworks of both family systems theory and the social ecological model (
      • Bronfenbrenner U.
      Ecology of the family as a context for human-development - research perspectives.
      ;
      • Minuchin P.
      Looking toward the horizon: Present and future in the study of family systems.
      ). In this paper, we present parents' descriptions of the screen-related discord and dismay they experienced as they managed screen use in their home. Understanding the challenges that arise in families with toddlers while they manage their own and their toddler's screen use on a day-to-day basis may lead to interventions that are better able to support families in their household contexts.

      Methods

      Design

      This qualitative study, based on principles of focused ethnography (
      • Higginbottom G.
      • Pillay J.J.
      • Boadu N.Y.
      Guidance on performing focused ethnographies with an emphasis on healthcare research.
      ), used in-depth interviews in the home setting to explore low-income Mexican American parents' perspectives on their everyday experiences related to their own and their toddler's screen use.

      Sample and setting

      Participants were enrolled between March 2019 and April 2020 by trained study staff recruiting in the waiting room of a general pediatrics clinic located in a federally qualified health center, where ~97% of families served have household incomes at or below 100% of the federal poverty level. Purposeful sampling was used to recruit English- and/or Spanish-speaking adult primary caregivers, specifically those in parenting roles (mothers, fathers, grandparents), with a child 15–26 months old. Participants included 21 mothers, 10 fathers, and one grandmother. All mothers/grandmother self-reported being of Mexican descent, as this was an inclusion criterion for those in maternal parental roles. Fathers can be a hard-to-reach population, and thus were recruited through individuals in maternal parental roles. To enhance participation, fathers were not required to be of Mexican descent, but rather were eligible if they were partnered with a woman of Mexican descent. All but one participating father were of Mexican descent. Additional eligibility criteria included residence in the Denver metropolitan area and having a screen device in the home. Individuals were excluded if they endorsed that they or the focal child had a health condition that interfered with screen use. The amount, appropriateness, and richness of the experiential descriptions offered by participants assured data adequacy (
      • Morse J.M.
      • Clark L.
      The nuances of grounded theory sampling and the pivotal role of theoretical sampling.
      ), and saturation was achieved after 32 participants were interviewed (
      • Morse J.M.
      The significance of saturation.
      ). The study was reviewed by the Colorado Multiple Institutional Review Board.

      Procedures

      After eligibility screening was conducted and informed consent obtained, private, individual face-to-face interviews were conducted by two trained bilingual, bicultural Latina research assistants (RAs) using a brief demographic survey and semi-structured interview guide (See Table 1 for example questions) (
      • Goodell L.S.
      • Stage V.C.
      • Cooke N.K.
      Practical qualitative research strategies: Training interviewers and coders.
      ). Interviews were conducted in the home setting except for the final interview that was conducted by telephone due to a local stay-at-home order implemented in response to the emerging COVID-19 pandemic. This interview occurred within a few weeks of the stay-at-home order.
      Table 1Selected example questions from the interview guide.
      I'd like you to think of a regular day for your child in the last week. Starting with the first thing in the morning, I'd like you to walk me through that day and when your child watched/used a screen device.

      • 1.
        What are the 2 screen devices your child uses most often?


      I'd like you to think about (Screen device #1). I'd like to understand a little bit about what you think about your child watching/using (screen device #1).

      • 2.
        Please tell me what you like about your child watching/using (screen device #1).
      Items repeated for screen device #2



      Now I would like you to think about what you dislike and the disadvantages for both your child (and for you) when your child watches/uses (screen device #1).

      • 3.
        Please tell me what you do not like about your child watching/using screen device #1.
      Items repeated for screen device #2



      I often see children using mobile screen devices when they are not home – like at the grocery store, waiting for an appointment, waiting for something at a store, or when visiting other people.

      • 4.
        When your child is with you or your partner outside your home, tell me about how your child uses screen devices.


      I've heard that parenting is one of the hardest jobs out there. Getting a child to do what you want them to do isn't always easy.

      • 5.
        Thinking specifically about your child's use of screen devices, can you tell me about a struggle you have had with your child about using a screen device?
      In many families, parents agree on some things about caring for their child and they disagree on other things about caring for their child. I am interested in you and your partner's thoughts about screen use.

      • 6.
        Can you tell me about a time when you and your partner agreed about your child using a screen device? In other words, you both wanted him/her to use it, or you both wanted him/her not to use it. I'd like to hear how you worked together in a specific situation.


      • 7.
        Can you tell me about a time when you and your partner disagreed about your child using a screen device? In other words, maybe one of you thought it was a good idea to have him/her use it, but the other one disagreed. That is common—many parents have different ideas about things like this. Can you tell me about a time when you two disagreed?
      Questions in the semi-structured interview guide and related prompts were derived theoretically from family systems theory (
      • Minuchin P.
      Looking toward the horizon: Present and future in the study of family systems.
      ), and the social ecological model (
      • Bronfenbrenner U.
      Ecology of the family as a context for human-development - research perspectives.
      ). Family systems theory recognizes the interconnectedness and interdependence of family members and the emergence of behavior patterns within a family system (
      • Minuchin P.
      Looking toward the horizon: Present and future in the study of family systems.
      ). The social ecological model emphasizes the influence of contextual factors on behavior (
      • Bronfenbrenner U.
      Ecology of the family as a context for human-development - research perspectives.
      ). Following staff training, the interview guide was pilot tested with three mothers who met inclusion criteria to assess understandability of questions and conversational flow. Minor adjustments were made in question structure and order as a result, and the pilot interviews served as additional RA training opportunities (
      • Goodell L.S.
      • Stage V.C.
      • Cooke N.K.
      Practical qualitative research strategies: Training interviewers and coders.
      ). These interviews were not analyzed in final sample. The interview focused on 1) parents' beliefs about the benefits and risks of screen use, 2) experiences managing their child's screen use, including whether they had struggled on this topic with their child or were in agreement or disagreement with their partner; 3) practices implemented to manage their child's screen use; and 4) family and neighborhood contextual dimensions of screen use.

      Data analysis

      Audio recordings were professionally transcribed verbatim in the language of the interview (English or Spanish) and Spanish-language interview transcripts were professionally translated into English. All transcripts were anonymized and then verified by the interviewer, who re-listened to the audio file and verified both the transcription and translation for accuracy. Spanish and English data were presented side by side for analysis, based on best practices (
      • Clark L.
      • Birkhead A.S.
      • Fernandez C.
      • Egger M.J.
      A transcription and translation protocol for sensitive cross-cultural team research.
      ).
      A codebook was developed using qualitative team-based research processes (
      • Guest G.
      Handbook for team-based qualitative research.
      ). Using a directed qualitative content analysis approach(
      • Hsieh H.-F.
      • Shannon S.E.
      Three approaches to qualitative content analysis.
      ), we imported a provisional start list of codes into Atlas.ti (Atlas.ti v8 software) generated through our prior qualitative work on preschooler screen use (
      • Thompson D.A.
      • Polk S.
      • Cheah C.S.L.
      • et al.
      Maternal beliefs and parenting practices regarding their preschool child’s television viewing: An exploration in a sample of low-income Mexican-origin mothers.
      ;
      • Thompson D.A.
      • Johnson S.L.
      • Vandewater E.A.
      • Schmiege S.J.
      • Boles R.E.
      • Lev J.
      • Tschann J.M.
      Parenting and preschooler TV viewing in low-income Mexican Americans: Development of the parenting practices regarding TV viewing (PPRTV) scale.
      ;
      • Thompson D.A.
      • Johnson S.L.
      • Schmiege S.J.
      • Vandewater E.A.
      • Boles R.E.
      • Lev J.
      • Tschann J.M.
      Beliefs about child TV viewing in low-income Mexican American parents of preschoolers: Development of the beliefs about child TV viewing scale (B-TV).
      ). Thereafter, we inductively developed descriptive and values codes in first-cycle coding, followed by focused coding and theoretical coding (
      • Saldaña J.
      The coding manual for qualitative researchers.
      ). Code definitions and exemplars were recorded in a free-standing codebook organized by topic (i.e., parent beliefs, parent practices, child reactions). During iterative transcript analysis, we applied codes to parent interview material, first through line-by-line coding performed independently by each of the two RAs, followed by meetings between the coders and a qualitative methodologist who reviewed the coding and resolved any differences. Next, through team analytic meetings, we developed interpretive insights and theoretical codes through constant comparison with the interview transcripts in an abductive process (
      • Tavory I.
      • Timmermans S.
      Abductive analysis: Theorizing qualitative research.
      ). In analyzing and interpreting coded data, we examined parents' narratives of screen-related interaction and developed integrated, thematic descriptions of salient patterns of discord, dismay, and ambivalence (
      • Elo S.
      • Kyngäs H.
      The qualitative content analysis process.
      ).
      In extreme-case and contrast-case analysis (
      • Morse J.M.
      • Clark L.
      The nuances of grounded theory sampling and the pivotal role of theoretical sampling.
      ), we described and then holistically compared the interview data from parents who discussed few instances and types of discord and dismay with those who described more, to identify dimensions of discord and accord in the interpersonal and intrapersonal domains.

      Results

      Table 2 shows participant and interview characteristics. Among those interviewed were 4 couples (mother and father interviewed separately), so the 32 participants represented 28 households.
      Table 2Participant demographics and interview characteristics for in-depth interviews with parents of toddlers (n = 32 participants).
      Participant characteristics (n = 32)Percent (n) or mean (SD)
      Parental role
       Mother (inclusive of 1 grandmother)69% (n = 22)
       Father31% (n = 10)
      Mean parent age in years29.22 (6.4)
      Education level
       < high school degree28% (n = 9)
       High school degree47% (n = 15)
       >High school25% (n = 8)
      Work outside the home69% (n = 23)
      Home level characteristics (n = 28 households)Percent (n) or mean (SD)
      Partner status
       Partnered75% (n = 21)
      Mean number of people in the home: adults and children4.6 (1.6)
      Mean age of focal child in months19.7 (3.7)
      Focal child in non-parental childcare (e.g., daycare, family member care)43% (n = 12)
      Mean number of children living in the home2.2 (2.3)
      Mean number of screen device types in home, excluding smartphones3.9 (1.7)
      Mean number of smartphones in home2.1 (1.2)
      Mean daily hours of screen use, weekday2.1 (1.4)
      Mean daily hours of screen use, weekend1.7 (1.4)
      Interview characteristics (n = 32)Percent (n) or mean (SD)
      Language of interview
       English56% (n = 18)
       Spanish44% (n = 14)
      Mean duration of interview (minutes)57 (13.2)
      SD = Standard deviation.
      Parents' experiences of discord, ambivalence, and dismay about toddler screen use was prominent across the interviews, with emotive valence and detail about the antecedents and consequences of screen-related conflict. Three main themes were elaborated: discord between parent and child, discord between parents, and internal dissonance reflected in parents' ambivalence and dismay about toddler screen use. Themes and subthemes are outlined below and in Table 3. Parents' words, identified in quoted segments, are used to illustrate the results.
      Table 3Themes and subthemes from in-depth interviews on screen use with parents of toddlers.
      ThemesSubthemes
      1Parent-child discord: Screen devices often ignite parent-child discord.
      • -
        Toddler tantrums in reaction to parental attempts to manage the child's screen use
      • -
        Intense toddler reaction to parent's screen use
      2Parent-partner discord: Discord between parents results from toddler screen use.
      • -
        Separate-worlds approach: Parents agreeing to disagree with their partner
      • -
        Parents in direct disagreement with their partner
      3Internal dissonance: Parental ambivalence and dismay about toddler screen use.
      • -
        Parents struggled with their in-the-moment decision making on screens.
      • -
        Parents felt responsible and expressed guilt about their child's screen use
      • -
        Demands of everyday life contributed to guilty feelings
      • -
        Family interactions contributed to personal struggle
      Theme 1: Parent-child discord - Screen devices often ignite parent-child discord. Typical situations involved a toddler's tantrum in response to a parent's attempt to manage the child's screen use or an intense toddler reaction to a parent's screen use. These conflicts were common and difficult to manage.

      Toddler tantrums in reaction to parental attempts to manage the child's screen use

      Parental attempts to set limits on screen use often elicited a toddler tantrum. Toddlers wanting to use a screen for longer than what parents wanted or allowed was a common observation. Parents reported intense child reactions to such limits:If I tell her no phone, it's like the whole world is falling apart…, so if she has a phone in her hand playing Baby Shark, it's like, yeah! When I tell her that's enough, she just goes ballistic. I never thought in a million years that she'd be like that.
      Many reported toddlers throwing the phone as an expression of anger. For some parents, the child's reaction was so strong that they began to anticipate the behavior: “Because I'm telling you it's like really bad… If I give her my phone, and I take it away, it's like I shouldn't have given it to her in the first place.” The phone was often critical to managing the ensuing conflict: “She gets restless, and we can't calm her. And if we don't give it to her, she throws more of a tantrum.”

      Intense toddler reaction to parent's screen use

      Parents also reported that children often reacted negatively to parental use of a screen device. Child reactions included yelling, crying, and throwing a tantrum. Some children tried to keep their parents from using their smartphone to monopolize their parent's attention. One participant noted, “He puts himself in front of me so that I can't see the phone and see just him instead.” Other child reactions included trying to take the screen device away from the parent so they could use it themselves. In response to parent-child conflict stemming from parent screen use many parents reported altering their screen-use behavior, for example hiding the phone or putting it away. Others opted not to use their smartphone in front of their child:Oh, she'll get mad. Yeah, that's why I try and limit my screen device use when I'm around her, because if she doesn't have my attention and I'm on the phone, she'll start yelling like, “Ma, Ma, Ma, Ma.” Or she'll try to take the phone away and throw it.
      Many reported shifting their attention from their device to their child in response. The child's reaction indicated for some that “…that's when Mommy needs to get off the phone.”
      No families reported an absence of screen-related discord. For a few families, outbursts about screen use were minimal because their child was not very interested in screen use. With these toddlers, sporadic screen time was interspersed with playing and running around, with little need for limit-setting.
      Theme 2: Parent-partner discord – Discord between parents results from toddler screen use. Discord between parents resulting from toddler screen use was also evident. Typical approaches to this included a separate worlds approach or more direct disagreement.

      Separate-worlds approach: parents agreeing to disagree with their partner

      Some parents followed a pattern of agreeing to disagree, espousing a separate worlds approach to screen use. In these separate parental worlds, children encountered different sets of parental screen expectations, with parents managing their child's access to screens differently.I personally don't like to give her my phone because I read in the news how bad it is for the kids. Then their dad is the one that, whenever he gets home from work, he gives her the phone. … Or he tells me to give her my phone. I tell him, “No, I'm not going to do it.” And then he's the one doing it. I don't think there's a benefit [to her]… I don't think that's the right thing to educate a child.

      Parents in direct disagreement with their partner

      Typically, direct disagreements stemmed from one parent believing the other was too lax or strict. Some mothers mentioned fathers who gave in to their child's tantrums with the phone, relenting when the child cried for the phone, or enticing children to eat by offering the phone. Fathers confirmed these points of conflict with their spouses. Fathers seeking their own screen relaxation time or co-viewing time with their child had different viewpoints. As one father said, “I come home from work and ask my little boy, ‘Do you want to watch TV? Want to watch my phone?’” In response, he reported that the child's mother would say, “No, no, no. Don't give it to him. He misbehaved, threw this, threw that. Some mothers commented on the utility of the phone in their care of the child, in direct disagreement with their perception of their partner's views.He doesn't think we should have the phones on at all. Period. I'm just like, [why not? With the phone on] they're not screaming; I'm not ripping my hair out. So they have the phone, so that's what it is. I'm going to do what I'm doing. So, I guess like he doesn't ever agree with me.
      Discord within couples was often situationally sparked and recurrent. One parent's patterned responses to their child's screen use in specific situations remained at odds with the other parent's preference for handling the situation.
      A few families reported low levels of parent-partner discord regarding screen use and appeared to have either low-levels of overall conflict between partners, high trust between partners on the topic of parenting, or family-level schedules that included screen use. Parents said they were “…pretty much on the same page” or had “…other things to disagree about.” A mother reported, “We've never had an argument” about screen devices. In her household, each parent had the latitude to decide what would be most appropriate, indicative of a separate worlds mindset. “If he is taking care of her, I feel like he knows the appropriate amount of time she should be watching TV.” In this case, high trust between parents about screen-use decisions averted conflict.
      Theme 3: Internal dissonance – Parental ambivalence and dismay about toddler screen use. Expressions of ambivalence and dismay about their toddler's screen use were common. Parents struggled with their in-the-moment decision making about screens and felt responsible for giving in or over-riding their own best judgment, expressing culpability about their child's errant screen use. The demands of everyday life and interactions with family often contributed to guilty feelings.

      Parents struggled with their in-the-moment decision making on screens

      Parents struggled to reconcile their preferences for their toddler's screen use against their actual screen use. “I try to lend her the phone the least [amount] possible,” said one mother, suggesting that “trying” to enact her values about limited screen use was not the same as succeeding. Another mother said, “I would prefer for her not to [use the phone] in certain situations, like at the grocery store. It's a mess. [But shopping is] just not happening [without the phone], which is unfortunate.” Another said:I don't think I like anything about [the amount of time my child uses the phone]….It's just a habit. It's just… that it keeps her calm, that's it. Because other than that, I would prefer them not to have any type of devices in their hands.
      The way parents talked about screen use “happening” highlighted the deviation between desired and actual behavior. “I would prefer not,” “I know it's bad, but…” and “I give up!” were refrains from parents regarding the incongruence between their screen-use preferences for their child and the screen use they actually allow their child.
      A few parents did not report this incongruence. Contrast-case analysis suggested that parents with the least amount of ambivalence about their child's screen use were able to maintain congruence between their preferences for screen use and actual child screen use, primarily because their child was uninterested, had limited viewing opportunities, or was in daycare where screens were not part of the daycare routine or parents did not worry about the screen use that was part of the daycare situation.

      Parents felt responsible for and expressed guilt about their child's screen use

      Internalizing intra-personal conflict, parents felt responsible for and expressed guilt about their child's screen use. Expectations about parental control were apparent. One mother said, “I have the ability to control screen use, but I don't. I'm working on it a little bit. I guess I don't do too much to benefit them.” She extrapolated from her child's use of the phone to an overall estimation of failure in making choices that benefit her children. Yet, she was “…working on it,” an indication of her feelings of guilt and commitment to becoming a better parent. Another mother said, “I gave him the phone. He wanted it, I gave it. I blame myself.” Parents' distress reflected unmet expectations to regulate children's screen use in the face of screen-demanding behavior.

      Demands of everyday life contributed to guilty feelings

      Sources of guilty feelings and dismay stemmed from the demands of everyday home life, which diminished parents' control of toddler screen use. “I try to prevent it,” explained one mother. Yet practicalities intervened. Working in the kitchen, with hot oil, knives, and other dangers, warranted use of a screen device for many parents.I'm scared that he will get burned. Get hurt. I would rather let him borrow the phone for a while. Hold on. Don't move. Please, be on the phone. I have to beg him to be on the phone sometimes, and I feel, like, bad in a way. But I'm like, “It's for your own good.”
      Another mother noted, “I'd prefer them not to have any type of devices in their hands, but in that moment, [I'm] either burning down the kitchen or paying attention to her with the phone, so….” Her narrative stumbled as she shared how she had given in to her child's demands: “I'd rather her just. I mean. I would prefer not to have the fighting or the crying or the screaming,” she concluded. At this point in the interview, she realized that she tried to prevent screen use but ultimately relented because cooking and avoiding a tantrum were more compelling as she tried to get her own work done. The tradeoff pitted her own preferred tasks against the child's screen use. “I'm giving it to her because I'm trying to do what I have to get done and not have to worry about her. I'm like, I feel guilty about it, but it's like, So?” Parents often mentioned competing responsibilities as requiring their attention, creating ambivalence about their choice to use screens for instrumental purposes:Sometimes I will feel guilty like on my day off because I have so many things to do … sometimes I sit him there for a like an hour and a half [with a screen] … I feel like that's way too much. He will leave, then come back with his toys and stare at it and then leave and then come back. So, I guess it's a little fly going to the light ….
      Parents' best judgment about screen use was countered at times by their choice to relent in order to accomplish a competing chore. Toddler's persistence, ‘like a little fly going to the light’ of the screen, contributed to their difficulty in maintaining screen use boundaries.

      Family interactions contributed to personal struggle

      Parents struggled to reconcile their preferences for their toddler's screen use with others' screen use in family settings. Screens were seemingly everywhere. Extended family members, in an effort to entertain a child, often would provide a screen device. “Her grandpa will say ‘Here, take the phone,’ and put on YouTube or something. I'll be like ‘Aaargh. I hate YouTube, why are you giving her that?’” Parents also pointed to extended family members as promoting screen viewing. “It scares me. My niece is always on the phone, and she's not very well supervised,” said one parent. Yet parents also realized that screens provided a point of interaction for extended family members. One mother acknowledged the enjoyment and time together that screens offered her son and her father. “’Grandpa, the tiger,’” says her son. “And he wants his grandfather to mimic the tiger. It's some extra time here and there that they spend together.” Recognizing the screen as a nexus through which children connected to others, parents were nevertheless flummoxed by their inability to balance their values regarding limited screen use and upholding family connections.

      Discussion

      Recognizing the widespread use of screen devices in early childhood, this study aimed to understand aspects of the family context around early screen use in low-income Mexican American families. We described screen-related discord and dismay expressed by low-income Mexican American parents with toddlers as they managed both their own and their child's screen use in everyday family settings. The findings suggest that screen-related discord and dismay is salient in these families. They also further underscore the interconnectivity of families, with parents experiencing parent-child discord, inter-parental disagreements, and internal dismay and ambivalence about managing their child's screen use. Although discord and dismay in families is normal, the extent of day-to-day conflict in families around screen-related behaviors warrants recognition in the design of interventions aiming to promote healthy screen use. Consideration of these contextual factors may enhance the effectiveness of provider counseling on this topic.
      We found that screen devices often ignited parent-child discord. Toddler tantrums related to screen devices were reported due to either parent limitations on the child's use or parental use in front of the child. Although tantrums are common during this developmental stage, the interactive and arousing content of screen devices (
      • Garrison M.M.
      • Liekweg K.
      • Christakis D.A.
      Media use and child sleep: The impact of content, timing, and environment.
      ;
      • Hiniker A.
      • Suh H.
      • Cao S.
      • Kientz J.A.
      Screen time tantrums: How families manage screen media experiences for toddlers and preschoolers.
      ), especially mobile devices (
      • Munzer T.G.
      • Miller A.L.
      • Wang Y.
      • Kaciroti N.
      • Radesky J.S.
      Tablets, toddlers and tantrums: The immediate effects of tablet device play.
      ), and possibly the functional use to calm young children (
      • Coyne S.M.
      • Shawcroft J.
      • Gale M.
      • Gentile D.A.
      • Etherington J.T.
      • Holmgren H.
      • Stockdale L.
      Tantrums, toddlers and technology: Temperament, media emotion regulation, and problematic media use in early childhood.
      ;
      • De Decker E.
      • De Craemer M.
      • De Bourdeaudhuij I.
      • Wijndaele K.
      • Duvinage K.
      • Koletzko B.
      • Grammatikaki E.
      • Iotova V.
      • Usheva N.
      • Fernández-Alvira J.M.
      • Zych K.
      • Manios Y.
      • Cardon G.
      • ToyBox-study, G
      Influencing factors of screen time in preschool children: An exploration of parents' perceptions through focus groups in six European countries.
      ), may set the stage in this age group for intense discord related to screen use. This could potentially increase the frequency of tantrums in some toddlers. Mobile devices may be more tantrum-inducing than other objects toddlers interact with. A recent experimental study in toddlers from mainly White, college-educated families reported increased tantrum behaviors in toddlers immediately following the use of a tablet versus a print book, possibly due to ‘engagement-promoting design features’ used in apps (
      • Munzer T.G.
      • Miller A.L.
      • Wang Y.
      • Kaciroti N.
      • Radesky J.S.
      Tablets, toddlers and tantrums: The immediate effects of tablet device play.
      ). Other studies also report on screen-related parent-child discord (
      • Beyens I.
      • Beullens K.
      Parent–child conflict about children’s tablet use: The role of parental mediation.
      ;
      • Hiniker A.
      • Suh H.
      • Cao S.
      • Kientz J.A.
      Screen time tantrums: How families manage screen media experiences for toddlers and preschoolers.
      ;
      • Matthes J.
      • Thomas M.F.
      • Stevic A.
      • Schmuck D.
      Fighting over smartphones? Parents' excessive smartphone use, lack of control over children's use, and conflict.
      ). Hiniker et al. studied parent reports of child transitions away from screen use in a sample of predominantly White, upper income mothers of 1–5 year olds, finding that “painful transitions” away from screen use were routine (
      • Hiniker A.
      • Suh H.
      • Cao S.
      • Kientz J.A.
      Screen time tantrums: How families manage screen media experiences for toddlers and preschoolers.
      ). In an observational study of parents in fast food restaurants, Radesky et al. reported on the attention-seeking behaviors of children in response to parental screen use (
      • Radesky J.S.
      • Kistin C.J.
      • Zuckerman B.
      • Nitzberg K.
      • Gross J.
      • Kaplan-Sanoff M.
      • Augustyn M.
      • Silverstein M.
      Patterns of mobile device use by caregivers and children during meals in fast food restaurants.
      ).
      Outright, prolonged, loud, and sometimes even violent tantrums at awkward times and in unfortunate places are common among toddlers (
      • Daniels E.
      • Mandleco B.
      • Luthy K.E.
      Assessment, management, and prevention of childhood temper tantrums.
      ). These tantrum behaviors are sometimes referred to as ‘difficult’ or ‘painful’ transitions away from screen use and may make it challenging for parents to limit their toddler's screen use (
      • Coyne S.M.
      • Rogers A.
      • Shawcroft J.
      • Reshke P.
      • Barr R.
      • Davis E.J.
      • Holmgren H.G.
      • Domoff S.
      Meltdowns and media: Moment-to-moment fluctuations in young children's media use transitions and the role of children's mood states.
      ;
      • Hiniker A.
      • Suh H.
      • Cao S.
      • Kientz J.A.
      Screen time tantrums: How families manage screen media experiences for toddlers and preschoolers.
      ). In a racially and ethnically diverse sample of parents of older children, Evans et al. reported that parents viewed child outbursts in response to parental limits on screen time as an obstacle to optimal parenting (
      • Evans C.A.
      • Jordan A.B.
      • Horner J.
      Only two hours? A qualitative study of the challenges parents perceive in restricting child television time.
      ). This may be particularly challenging for low-income parents who face higher levels of parenting stress (
      • U.S. Department of Health and Human Service
      The health and well-being of children: A portrait of states and the nation, 20112012.
      ). Limiting screen use, as perceived by the parents in the Evans et al. study, requires time, energy, and money (
      • Evans C.A.
      • Jordan A.B.
      • Horner J.
      Only two hours? A qualitative study of the challenges parents perceive in restricting child television time.
      ). These resources are often limited in low-income families. Research supporting parents, inclusive of low-income parents, in the prevention and management of screen-related tantrums in toddlers is warranted, such as research on tools to help parents transition young children away from screens (
      • Shin H.
      • Gweon G.
      Supporting preschoolers’ transitions from screen time to screen-free time using augmented reality and encouraging offline leisure activity.
      ).
      In addition to parent-child discord, some families in the current study experienced discord between parents as a result of toddler screen use. In these families, screens were a source of discord that was often situational and recurrent. Disagreement between parents related to screen use is known to happen in families (
      • Lindsay A.C.
      • Moura Arruda C.A.
      • Machado M.M.T.
      • Greaney M.L.
      “If you let them, they will be on it 24 hours a day”: Qualitative study conducted in the united states exploring Brazilian immigrant mothers’ beliefs, attitudes, and practices related to screen time behaviors of their preschool-age children.
      ), but further research is needed to understand how to support healthy screen use in families with parents who disagree. Providers need guidance on how to help parents work through such disagreements to advance healthy child-screen use. In some families, parents agreed about children's access to screens. Additional research on low-income Latino families' assets and parent successes in managing screen use may inform helpful, culturally-relevant strategies for other parents to consider.
      We found that parents experienced internal dissonance, ambivalence, and dismay regarding their toddler's screen use. The current screen-saturated environment distresses parents who are concerned about their young child's screen use. As parents reconciled their child's screen use with their preferences and in-the-moment decision making about screens, many parents found themselves struggling with their choices. It is possible that this internal struggle may negatively impact parents' ability to limit screen use, such as their self-efficacy around limiting screen use (
      • Bandura A.
      Self-efficacy: Toward a unifying theory of behavioral change.
      ). Evidence suggests that self-efficacy is associated with screen-related parenting behaviors that support healthy screen use, as shown in studies including low-income Latino parents and racially and ethnically diverse parents (
      • Thompson D.A.
      • Schmiege S.J.
      • Johnson S.L.
      • Vandewater E.A.
      • Boles R.E.
      • Zambrana R.E.
      • Lev J.
      • Tschann J.M.
      Screen-related parenting practices in low-income Mexican American families.
      ;
      • Vaala S.E.
      • Hornik R.C.
      Predicting US infants' and toddlers' TV/video viewing rates: Mothers' cognitions and structural life circumstances.
      ). Increasing parents' self-efficacy regarding screen use could be a focus for intervention efforts (
      • Thompson D.A.
      • Schmiege S.J.
      • Johnson S.L.
      • Vandewater E.A.
      • Boles R.E.
      • Zambrana R.E.
      • Lev J.
      • Tschann J.M.
      Screen-related parenting practices in low-income Mexican American families.
      ;
      • Xu H.
      • Wen L.M.
      • Rissel C.
      Associations of parental influences with physical activity and screen time among young children: A systematic review.
      ). Studies in older children report similar findings. A study of White British parents of older children reported that parents experienced internal tension about their child's screen use (
      • Solomon-Moore E.
      • Matthews J.
      • Reid T.
      • Toumpakari Z.
      • Sebire S.J.
      • Thompson J.L.
      • Lawlor D.A.
      • Jago R.
      Examining the challenges posed to parents by the contemporary screen environments of children: A qualitative investigation.
      ). Parents appeared to be caught between the desire to restrict use and their perception that screen use is the norm, can be educational, and ensures their child is not left behind technologically (
      • Solomon-Moore E.
      • Matthews J.
      • Reid T.
      • Toumpakari Z.
      • Sebire S.J.
      • Thompson J.L.
      • Lawlor D.A.
      • Jago R.
      Examining the challenges posed to parents by the contemporary screen environments of children: A qualitative investigation.
      ). Notably, parents also experience internal tensions around their own screen use, as noted in a study including a diverse sample of parents of 0–8 year old children (
      • Radesky J.S.
      • Kistin C.
      • Eisenberg S.
      • Gross J.
      • Block G.
      • Zuckerman B.
      • Silverstein M.
      Parent perspectives on their mobile technology use: The excitement and exhaustion of parenting while connected.
      ). Social norms supporting screen use, including the pervasiveness of screen devices, the general prevalence of use among toddlers, and encouragement by family members in some instances, probably contribute to this tension (
      • Lindsay A.C.
      • Moura Arruda C.A.
      • Machado M.M.T.
      • Greaney M.L.
      “If you let them, they will be on it 24 hours a day”: Qualitative study conducted in the united states exploring Brazilian immigrant mothers’ beliefs, attitudes, and practices related to screen time behaviors of their preschool-age children.
      ;
      • Thompson A.L.
      • Adair L.S.
      • Bentley M.E.
      Maternal characteristics and perception of temperament associated with infant TV exposure.
      ). Pediatric providers could play a key role in helping parents decide how they want to handle screen devices by building parental self-efficacy to actively manage screen devices and empowering parents to act upon their decisions, possibly against social norms.

      Practice implications

      Early interventions on screen use are important as evidence suggests that trajectories of screen use behaviors are set early (
      • Hish A.J.
      • Wood C.T.
      • Howard J.
      • Yin S.H.
      • Rothman R.L.
      • Sanders L.M.
      • Delamater A.M.
      • Flower K.B.
      • Perrin E.M.
      Infants who watch television become toddlers who watch more television: Screen time patterns in the greenlight study.
      ). These findings highlight the interconnectivity of family members as it relates to child screen use. Interventionists, nurses, and other providers aiming to promote healthy screen use in low-income Mexican American families with toddlers should consider the family as a whole and the range of screen-related discord and dismay they may be experiencing. Anticipatory guidance on tantrum behaviors is a typical part of well-child visits, and guidance about navigating screen-related tantrums could be incorporated into discussions specifically regarding early childhood screen use. Guidance might suggest methods that ease the child's transition when stopping screen use (e.g., offering an alternative activity). Nurses and other providers might also recommend parents consider putting away screen devices during meals, family time, or when not in use. They might also recommend the creation of a family media plan, encouraging families to thoughtfully determine where, when, and how they think media should be used (
      • Council on Communications and Media
      Media and young minds.
      ;
      • Canadian Paediatric Society, Digital Health Task Force, Ottawa, Ontario
      Screen time and young children: Promoting health and development in a digital world.
      ). Although evidence on family media plans in this population are lacking, it seems possible that the process of creating such a plan, perhaps with the help of nurses or other providers and involving all caregivers, may help parents move from feelings of dismay and ambivalence to taking consistent, collaborative action regarding their own and their child's screen use, thereby building their self-efficacy in this realm. When developing such a plan, providers can help families to prepare for how changes in their own or their child's screen use might impact family routines and dynamics (
      • Pratt K.J.
      • Skelton J.A.
      Family functioning and childhood obesity treatment: A family systems theory-informed approach.
      ). Helping families to find healthy alternatives to screen time is important and should consider a family's ongoing needs while also helping to maintain healthy dynamics within the family unit. Consideration of external influences on a family's ability to make changes to their screen use is also important. For example, parents may be limited in their choice of childcare due to affordability, proximity, and/or transportation, and therefore may not prioritize taking action on concerns regarding screen exposure in their child's childcare. Additional research is needed to understand whether any of the above interventions are effective in supporting parents and the promotion of healthy screen use.

      Strengths and limitations

      Although this study has numerous strengths, including its framing in family systems theory and the social ecological model, the focus on a specific subgroup of parents of toddlers in the United States, the inclusion of fathers, and the in-depth interviews conducted in the home setting, study limitations warrant discussion. Parents may have underreported screen-related discord and dismay due to social desirability bias (i.e. the tendency for participants to report socially favorable responses) (
      • Grimm P.
      Social desirability bias.
      ). Despite this, parents reported substantial and distressing screen-related concern and tension that interfered with their parenting preferences. The focus on the family microsystem is narrow; research on the impact of social and environmental factors on screen-related discord and dismay is needed, as well as research on protective factors, including parental strengths. For example, although nearly half of participants had children in non-parental childcare settings, the influence of such settings on family experiences of screen-related discord and dismay was not explored in-depth. An additional limitation is that the findings may over-represent the experiences of the 4 families with both a mother and father participating. To guard against this, both the interviews and analysis of each interview were conducted separately. Finally, more evidence is needed to ascertain whether and how these findings apply more generally across other subgroups of Latino parents or to parents from other socioeconomic, ethnic, or geographic backgrounds.

      Conclusion

      Latino parents are concerned about the possible negative impact of screen use on their children (
      • Common Sense Media
      Zero to eight: children's media use in America 2013.
      ;
      • Thompson D.A.
      • Polk S.
      • Cheah C.S.L.
      • et al.
      Maternal beliefs and parenting practices regarding their preschool child’s television viewing: An exploration in a sample of low-income Mexican-origin mothers.
      ), yet evidence suggests dissemination of child screen use guidelines has failed to adequately reach this population (
      • Common Sense Media
      Zero to eight: children's media use in America 2013.
      ). Given this, the prevalence of unhealthy screen-use behaviors among children in low-income Latino families, and growing evidence identifying health risks associated with aspects of early childhood screen use, culturally and contextually tailored interventions promoting healthy screen use in early childhood are urgently needed (
      • Common Sense Media
      Zero to eight: children's media use in America 2013.
      ;
      • Reid Chassiakos Y.
      • Radesky J.
      • Christakis D.
      • Moreno M.A.
      • Cross C.
      • Hill D.
      • Ameenuddin N.
      • Hutchinson J.
      • Levine A.
      • Boyd R.
      • Mendelson R.
      • Swanson W.S.
      Children and adolescents and digital media.
      ;
      • Rideout V.
      The Common Sense census: Media use by kids age zero to eight.
      ;
      • Thompson D.A.
      • Sibinga E.M.
      • Jennings J.M.
      • Bair-Merritt M.H.
      • Christakis D.A.
      Television viewing by young Hispanic children: Evidence of heterogeneity.
      ). The findings of this study will inform the design of future intervention efforts promoting healthy screen use in low-income Mexican American families.

      Funding

      Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number R01NR017605 (PI: Thompson) and by NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

      CRediT authorship contribution statement

      Darcy A. Thompson: Conceptualization, Methodology, Formal analysis, Data curation, Visualization, Writing – original draft, Writing – review & editing. Jeanne M. Tschann: Conceptualization, Methodology, Formal analysis, Visualization, Writing – review & editing. Andrea M. Jimenez-Zambrano: Investigation, Data curation, Visualization, Writing – review & editing. Suzanna M. Martinez: Visualization, Writing – review & editing. Gabriela A. Reyes: Investigation, Data curation, Visualization, Writing – review & editing. Guadalupe A. Solis: Investigation, Data curation, Visualization, Writing – review & editing. Lauren Clark: Conceptualization, Methodology, Formal analysis, Visualization, Data curation, Writing – original draft, Writing – review & editing.

      Declaration of Competing Interest

      None.

      References

        • Bandura A.
        Self-efficacy: Toward a unifying theory of behavioral change.
        Psychological Review. 1977; 84: 191-215
        • Beck A.L.
        • Huang J.C.
        • Lendzion L.
        • Fernandez A.
        • Martinez S.
        Impact of the Coronavirus disease 2019 pandemic on parents’ perception of health behaviors in children with overweight and obesity.
        Academic Pediatrics. 2021; 21: 1434-1440
        • Beck A.L.
        • Takayama J.
        • Badiner N.
        • Halpern-Felsher B.
        Latino parents' beliefs about television viewing by infants and toddlers.
        Journal of Health Care for the Poor and Underserved. 2015; 26: 463-474
        • Beyens I.
        • Beullens K.
        Parent–child conflict about children’s tablet use: The role of parental mediation.
        New Media & Society. 2017; 19: 2075-2093
        • Bronfenbrenner U.
        Ecology of the family as a context for human-development - research perspectives.
        Developmental Psychology. 1986; 22: 723-742
        • Certain L.K.
        • Kahn R.S.
        Prevalence, correlates, and trajectory of television viewing among infants and toddlers.
        Pediatrics. 2002; 109: 634-642
        • Clark L.
        • Birkhead A.S.
        • Fernandez C.
        • Egger M.J.
        A transcription and translation protocol for sensitive cross-cultural team research.
        Qualitative Health Research. 2017; 27: 1751-1764
        • Common Sense Media
        Zero to eight: children's media use in America 2013.
        Common Sense Media, October 28, 2013 (Retrieved November 29, 2020 from)
        • Council on Communications and Media
        Media and young minds.
        Pediatrics. 2016; 138e20162591
        • Coyne S.M.
        • Rogers A.
        • Shawcroft J.
        • Reshke P.
        • Barr R.
        • Davis E.J.
        • Holmgren H.G.
        • Domoff S.
        Meltdowns and media: Moment-to-moment fluctuations in young children's media use transitions and the role of children's mood states.
        Computers in Human Behavior. 2022; 107360
        • Coyne S.M.
        • Shawcroft J.
        • Gale M.
        • Gentile D.A.
        • Etherington J.T.
        • Holmgren H.
        • Stockdale L.
        Tantrums, toddlers and technology: Temperament, media emotion regulation, and problematic media use in early childhood.
        Computers in Human Behavior. 2021; 120106762
        • Daniels E.
        • Mandleco B.
        • Luthy K.E.
        Assessment, management, and prevention of childhood temper tantrums.
        Journal of the American Academy of Nurse Practitioners. 2012; 24: 569-573
        • Davou B.
        • Sidiropoulou A.
        Family life around screens: Some thoughts on the impact of ICTs on psychological development and the development of relationships.
        Contemporary Family Therapy. 2017; 39: 261-270
        • De Decker E.
        • De Craemer M.
        • De Bourdeaudhuij I.
        • Wijndaele K.
        • Duvinage K.
        • Koletzko B.
        • Grammatikaki E.
        • Iotova V.
        • Usheva N.
        • Fernández-Alvira J.M.
        • Zych K.
        • Manios Y.
        • Cardon G.
        • ToyBox-study, G
        Influencing factors of screen time in preschool children: An exploration of parents' perceptions through focus groups in six European countries.
        Obesity Reviews. 2012; 13: 75-84
        • Elias N.
        • Sulkin I.
        Screen-assisted parenting: The relationship between toddlers’ screen time and parents’ use of media as a parenting tool.
        Journal of Family Issues. 2019; 40: 2801-2822
        • Elo S.
        • Kyngäs H.
        The qualitative content analysis process.
        Journal of Advanced Nursing. 2008; 62: 107-115
        • Evans C.A.
        • Jordan A.B.
        • Horner J.
        Only two hours? A qualitative study of the challenges parents perceive in restricting child television time.
        Journal of Family Issues. 2011; 32: 1223-1244
        • Freedman D.S.
        • Sharma A.J.
        • Hamner H.C.
        • Pan L.
        • Panzera A.
        • Smith R.B.
        • Blanck H.M.
        Trends in weight-for-length among infants in WIC From 2000 to 2014.
        Pediatrics. 2017; 139e20162034
        • Garrison M.M.
        • Liekweg K.
        • Christakis D.A.
        Media use and child sleep: The impact of content, timing, and environment.
        Pediatrics. 2011; 128: 29-35
        • Goodell L.S.
        • Stage V.C.
        • Cooke N.K.
        Practical qualitative research strategies: Training interviewers and coders.
        Journal of Nutrition Education and Behavior. 2016; 48: 578-585 e571
        • Grimm P.
        Social desirability bias.
        in: Wiley international encyclopedia of marketing. 2010
        • Guest G.
        Handbook for team-based qualitative research.
        Rowman Altamira, 2008
        • Higginbottom G.
        • Pillay J.J.
        • Boadu N.Y.
        Guidance on performing focused ethnographies with an emphasis on healthcare research.
        The Qualitative Report. 2013; 18: 1-6
        • Hiniker A.
        • Suh H.
        • Cao S.
        • Kientz J.A.
        Screen time tantrums: How families manage screen media experiences for toddlers and preschoolers.
        in: Proceedings of the 2016 CHI conference on human factors in computing systems, San Jose, California, USA. 2016
        • Hish A.J.
        • Wood C.T.
        • Howard J.
        • Yin S.H.
        • Rothman R.L.
        • Sanders L.M.
        • Delamater A.M.
        • Flower K.B.
        • Perrin E.M.
        Infants who watch television become toddlers who watch more television: Screen time patterns in the greenlight study.
        Pediatrics. 2020; 146: 32-33
        • Hsieh H.-F.
        • Shannon S.E.
        Three approaches to qualitative content analysis.
        Qualitative Health Research. 2005; 15: 1277-1288
        • Kracht C.L.
        • Katzmarzyk P.T.
        • Staiano A.E.
        Household chaos, family routines, and young child movement behaviors in the U.S. during the COVID-19 outbreak: A cross-sectional study.
        BMC Public Health. 2021; 21
        • Lindsay A.C.
        • Moura Arruda C.A.
        • Machado M.M.T.
        • Greaney M.L.
        “If you let them, they will be on it 24 hours a day”: Qualitative study conducted in the united states exploring Brazilian immigrant mothers’ beliefs, attitudes, and practices related to screen time behaviors of their preschool-age children.
        JMIR Pediatrics and Parent. 2019; 2e11791
        • Matthes J.
        • Thomas M.F.
        • Stevic A.
        • Schmuck D.
        Fighting over smartphones? Parents' excessive smartphone use, lack of control over children's use, and conflict.
        Computers in Human Behavior. 2021; 116106618
        • Minuchin P.
        Looking toward the horizon: Present and future in the study of family systems.
        in: McHale J.P. Grolnick W.S. Retrospect and prospect in the psychological study of families. Erlbaum, 2002: 259-287
        • Morse J.M.
        The significance of saturation.
        Qualitative Health Research. 1995; 5: 147-149
        • Morse J.M.
        • Clark L.
        The nuances of grounded theory sampling and the pivotal role of theoretical sampling.
        in: Byrant A. Charmaz K. The SAGE handbook of current developments in grounded theory. Sage Publications, 2019: 145-166
        • Munzer T.G.
        • Miller A.L.
        • Wang Y.
        • Kaciroti N.
        • Radesky J.S.
        Tablets, toddlers and tantrums: The immediate effects of tablet device play.
        Acta Paediatr. 2021; 110: 255-256
        • Ogden C.L.
        • Carroll M.D.
        • Lawman H.G.
        • Fryar C.D.
        • Kruszon-Moran D.
        • Kit B.K.
        • Flegal K.M.
        Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014.
        JAMA. 2016; 315: 2292-2299
        • Pan L.
        • McGuire L.C.
        • Blanck H.M.
        • May-Murriel A.L.
        • Grummer-Strawn L.M.
        Racial/ethnic differences in obesity trends among young low-income children.
        American Journal of Preventive Medicine. 2015; 48: 570-574
        • Peña M.-M.
        • Rifas-Shiman S.L.
        • Gillman M.W.
        • Redline S.
        • Taveras E.M.
        Racial/ethnic and socio-contextual correlates of chronic sleep curtailment in childhood.
        Sleep. 2016; 39: 1653-1661
        • Canadian Paediatric Society, Digital Health Task Force, Ottawa, Ontario
        Screen time and young children: Promoting health and development in a digital world.
        Paediatrics & Child Health. 2017; 22: 461-468
        • Pratt K.J.
        • Skelton J.A.
        Family functioning and childhood obesity treatment: A family systems theory-informed approach.
        Academic Pediatrics. 2018; 18: 620-627
        • Radesky J.S.
        • Eisenberg S.
        • Kistin C.J.
        • Gross J.
        • Block G.
        • Zuckerman B.
        • Silverstein M.
        Overstimulated consumers or next-generation learners? Parent tensions about child mobile technology use.
        The Annals of Family Medicine. 2016; 14: 503-508
        • Radesky J.S.
        • Kistin C.
        • Eisenberg S.
        • Gross J.
        • Block G.
        • Zuckerman B.
        • Silverstein M.
        Parent perspectives on their mobile technology use: The excitement and exhaustion of parenting while connected.
        Journal of Developmental and Behavioral Pediatrics. 2016; 37: 694-701
        • Radesky J.S.
        • Kistin C.J.
        • Zuckerman B.
        • Nitzberg K.
        • Gross J.
        • Kaplan-Sanoff M.
        • Augustyn M.
        • Silverstein M.
        Patterns of mobile device use by caregivers and children during meals in fast food restaurants.
        Pediatrics. 2014; 133: e843-e849
        • Reid Chassiakos Y.
        • Radesky J.
        • Christakis D.
        • Moreno M.A.
        • Cross C.
        • Hill D.
        • Ameenuddin N.
        • Hutchinson J.
        • Levine A.
        • Boyd R.
        • Mendelson R.
        • Swanson W.S.
        Children and adolescents and digital media.
        Pediatrics. 2016; 138e20162593
        • Rideout V.
        The Common Sense census: Media use by kids age zero to eight.
        Common Sense Media, 2017
        • Rideout V.
        • Robb M.B.
        The Common Sense census: Media use by kids age zero to eight.
        Common Sense Media, 2020
        • Saldaña J.
        The coding manual for qualitative researchers.
        Sage, 2012
        • Shin H.
        • Gweon G.
        Supporting preschoolers’ transitions from screen time to screen-free time using augmented reality and encouraging offline leisure activity.
        Computers in Human Behavior. 2020; 105106212
        • Solomon-Moore E.
        • Matthews J.
        • Reid T.
        • Toumpakari Z.
        • Sebire S.J.
        • Thompson J.L.
        • Lawlor D.A.
        • Jago R.
        Examining the challenges posed to parents by the contemporary screen environments of children: A qualitative investigation.
        BMC Pediatrics. 2018; 18: 129
        • Tang L.
        • Darlington G.
        • Ma D.W.L.
        • Haines J.
        • Study, O. B. O. T. G. F. H
        Mothers’ and fathers’ media parenting practices associated with young children’s screen-time: A cross-sectional study [journal article].
        BMC Obesity. 2018; 5: 37
        • Tavory I.
        • Timmermans S.
        Abductive analysis: Theorizing qualitative research.
        The University of Chicago Press, 2014
        • Thimmig L.M.
        • Cabana M.D.
        • Bentz M.G.
        • Potocka K.
        • Beck A.
        • Fong L.
        • Chao C.
        • Caughey A.B.
        • Wong A.
        • McKean M.
        Television during meals in the first 4 years of life.
        Clinical Pediatrics (Phila). 2017; 56: 659-666
        • Thompson A.L.
        • Adair L.S.
        • Bentley M.E.
        Maternal characteristics and perception of temperament associated with infant TV exposure.
        Pediatrics. 2013; 131: e390-e397
        • Thompson D.A.
        • Johnson S.L.
        • Schmiege S.J.
        • Vandewater E.A.
        • Boles R.E.
        • Lev J.
        • Tschann J.M.
        Beliefs about child TV viewing in low-income Mexican American parents of preschoolers: Development of the beliefs about child TV viewing scale (B-TV).
        Maternal and Child Health Journal. 2018; 22: 849-857
        • Thompson D.A.
        • Johnson S.L.
        • Vandewater E.A.
        • Schmiege S.J.
        • Boles R.E.
        • Lev J.
        • Tschann J.M.
        Parenting and preschooler TV viewing in low-income Mexican Americans: Development of the parenting practices regarding TV viewing (PPRTV) scale.
        Journal of Developmental and Behavioral Pediatrics. 2016; 37: 465-474
        • Thompson D.A.
        • Polk S.
        • Cheah C.S.L.
        • et al.
        Maternal beliefs and parenting practices regarding their preschool child’s television viewing: An exploration in a sample of low-income Mexican-origin mothers.
        Clinical Pediatrics. 2015; 54: 862-870
        • Thompson D.A.
        • Schmiege S.J.
        • Johnson S.L.
        • Vandewater E.A.
        • Boles R.E.
        • Zambrana R.E.
        • Lev J.
        • Tschann J.M.
        Screen-related parenting practices in low-income Mexican American families.
        Academic Pediatrics. 2018; 18: 820-827
        • Thompson D.A.
        • Sibinga E.M.
        • Jennings J.M.
        • Bair-Merritt M.H.
        • Christakis D.A.
        Television viewing by young Hispanic children: Evidence of heterogeneity.
        Archives of Pediatrics & Adolescent Medicine. 2010; 164: 174-179
        • U.S. Department of Health and Human Service
        The health and well-being of children: A portrait of states and the nation, 20112012.
        • Vaala S.E.
        • Hornik R.C.
        Predicting US infants' and toddlers' TV/video viewing rates: Mothers' cognitions and structural life circumstances.
        Journal of Children and Media. 2014; 8: 163-182
        • Whitesell N.R.
        • Sarche M.
        • Keane E.
        • Mousseau A.C.
        • Kaufman C.E.
        Advancing scientific methods in community and cultural context to promote health equity:Lessons from intervention outcomes research with American Indian and Alaska native communities.
        American Journal of Evaluation. 2018; 39: 42-57
        • World Health Organization
        Guidelines on physical activity, sedentary behaviour, and sleep for children under 5 years of age: Summary.
        • Xu H.
        • Wen L.M.
        • Rissel C.
        Associations of parental influences with physical activity and screen time among young children: A systematic review.
        Journal of Obesity. 2015; 2015546925