Most of you probably saw a wave of news media reports about a recent study showing that television exposure in infancy and early childhood may lead to a delay in language development. In a recent study also published in Pediatrics, a group of researchers from the University college London in the UK examined the effects of television viewing and physical activity on psychological distress among children of various ages. This study is very interesting, not only because of the provocative findings, but because it opens the door for a discussion of the concept of “Prodrome.”

The authors examined data from the Scottish Health Survey, a nationally representative study of multiple psychosocial factors.  The data for this analysis included 1,486 Children age 4 to 12 with a mean age of 8.5, who were assessed in 2003.  The Strengths and Difficulties questionnaire was used to assess for psychological distress. Specifically, the total difficulties score incorporates responses to subscales that examine hyperactivity, emotional distress, conduct problems, and peer problems.  The authors also obtained the parents’ reports of the kids’  total weekly hours of television viewing, and the frequency of sports or active play during the week.  The authors were primarily interested in exploring whether TV viewing and/or activity level were associated with psychological distress.

The results:

  1. On average, kids watched a total of 2.4 hours of television per day
  2. Television viewing was associated with sports activity in that those who watched most television were also those with the lowest level of sports activity.
  3. Those with the highest levels of television viewing also had the lowest level of fruit intake, and the highest levels of sweets and sugar drink intake.
  4. High levels of Television viewing and low levels of physical were both independently associated with psychological distress.
  5. An additive effect was found in that the combination of high television viewing and low physical activity was associated with the highest levels of psychological distress.

We can write entire books and a year worth of blog posts discussing the many possible explanations for these findings. The most salient, but not necessarily correct, is that television viewing likely limits other behaviors that are associated with psychological well-being, and that physical activity also promotes psychological well-being directly (physiologically) and indirectly (through the effects on the kid’s social development). Yet, it is possible that these two findings do not cause distress, but are a reflection of distress.  For example, relatively recently, researchers have began to extend the concept of prodrome from general medicine to psychiatric disorders. Prodrome refers to a conglomeration of symptoms that reflect the disease process at an early stage, usually before it displays the symptoms that we usually associate with the disease. A prodrome is not a symptom that leads to the disease. The prodrome is the disease itself already evolving.

I’m currently working with Dr. Maria Kovacs on a upcoming invited theoretical paper on  prodromes in child depression, and during the writing process I’ve been considering the implications of prodromes to past longitudinal and cross-sectional “predictive” research. That is, how many of the factors that have been found to predict a condition are actually not predictors (causes) of the condition but the condition itself?

Back to the TV viewing/physical activity study; the authors found significantly elevated levels of psychological distress in 4% of the sample. Yet these were not clinical cases with specific diagnoses. It is possible then that the authors were tapping at a subgroup of kids with specific psychiatric problems at the prodrome level (depression for example) which would result in increased levels of anhedonia and reduced motor mobility. This would in turn lead to more ‘just laying on the couch staring at the TV’ and reduced interest in outside sporting events.

The reference:
Hamer, M., Stamatakis, E., & Mishra, G. (2009). Psychological Distress, Television Viewing, and Physical Activity in Children Aged 4 to 12 Years PEDIATRICS, 123 (5), 1263-1268 DOI: 10.1542/

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