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Effects of Reducing Children's Television and Video Game Use on Aggressive Behavior
A Randomized Controlled Trial
Thomas N. Robinson, MD, MPH;
Marta L. Wilde, MA;
Lisa C. Navracruz, MD;
K. Farish Haydel;
Ann Varady, MS
Arch Pediatr Adolesc Med. 2001;155:17-23.
ABSTRACT
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Context The relationship between exposure to aggression in the media and children's
aggressive behavior is well documented. However, few potential solutions have
been evaluated.
Objective To assess the effects of reducing television, videotape, and video game
use on aggressive behavior and perceptions of a mean and scary world.
Design Randomized, controlled, school-based trial.
Setting Two sociodemographically and scholastically matched public elementary
schools in San Jose, Calif.
Participants Third- and fourth-grade students (mean age, 8.9 years) and their parents
or guardians.
Intervention Children in one elementary school received an 18-lesson, 6-month classroom
curriculum to reduce television, videotape, and video game use.
Main Outcome Measures In September (preintervention) and April (postintervention) of a single
school year, children rated their peers' aggressive behavior and reported
their perceptions of the world as a mean and scary place. A 60% random sample
of children were observed for physical and verbal aggression on the playground.
Parents were interviewed by telephone and reported aggressive and delinquent
behaviors on the child behavior checklist. The primary outcome measure was
peer ratings of aggressive behavior.
Results Compared with controls, children in the intervention group had statistically
significant decreases in peer ratings of aggression (adjusted mean difference, -2.4%;
95% confidence interval [CI], -4.6 to -0.2; P = .03) and observed verbal aggression (adjusted mean difference, -0.10
act per minute per child; 95% CI, -0.18 to -0.03; P = .01). Differences in observed physical aggression, parent reports
of aggressive behavior, and perceptions of a mean and scary world were not
statistically significant but favored the intervention group.
Conclusions An intervention to reduce television, videotape, and video game use
decreases aggressive behavior in elementary schoolchildren. These findings
support the causal influences of these media on aggression and the potential
benefits of reducing children's media use.
INTRODUCTION
VIOLENCE IS pervasive in television, movies, and video games. Children's
television programming contains even more violence than prime-time programming;
it has been estimated that by the age of 18 years, US children witness 200 000
acts of violence on television alone.1
The relationship between media violence and aggressive behavior has
been the focus of more than 1000 studies. Exposure to violent media appears
to produce 3 effects on children: (1) direct effects, in which children become
more aggressive and/or develop more favorable attitudes about using aggression
to resolve conflicts; (2) desensitization to violence and the victimization
of others; and (3) beliefs that the world around them is mean and scary. Evidence
for these effects comes from laboratory experiments,2, 3, 4
field experiments in which children's aggression was monitored after exposure
to violent media,5, 6 natural experiments
that monitored levels of aggression after the initial introduction of television
into a community,7 retrospective, cross-sectional
and prospective observational studies,8, 9
and ecological studies.10, 11 Reviews
of the literature come to a consensus that exposure to media violence increases
children's aggressive attitudes and behaviors.1, 12, 13
Despite substantial evidence that exposure to violent media is associated
with increased aggression, few potential solutions have been evaluated. In
the current multimedia, multichannel, remote control environment where heavy
media use is the norm, a question of great clinical, practical, and policy
importance is: Will reducing television, videotape, and video game use decrease
aggressive behavior? Therefore, we conducted a randomized, controlled, school-based
trial of reducing third- and fourth-grade children's television, videotape,
and video game use to assess the effects on aggressive behavior and attitudes.
We hypothesized that, compared with controls, children exposed to the intervention
would decrease their levels of aggressive behavior, as measured by peer, parent,
and observational measures of aggression, and decrease their perceptions of
the world as mean and scary.
SUBJECTS AND METHODS
All third- and fourth-grade students in 2 public elementary schools
in a single school district in San Jose, Calif, were eligible to participate.
Schools were sociodemographically and scholastically matched by district personnel.
School principals and teachers agreed to participate prior to randomization.
Parents or guardians provided signed written informed consent for their children
to participate in assessments, and for their own participation in telephone
interviews. One school was randomly assigned to implement a program to reduce
television, videotape, and video game use. The other school was assigned to
be an assessments-only control. Because only 2 schools were randomized, this
may also be considered a quasi-experimental design. All assessments were performed
by trained staff, blinded to the experimental design, at baseline (September
1996) and after the completion of the intervention (April 1997). Participants
and school personnel, including classroom teachers, were informed of the nature
of the intervention and assessments, but aggression was only one of several
outcomes assessed. The beneficial effects of this intervention on adiposity
in this same trial have been previously reported.14
The study was approved by the Stanford University Panel on Human Subjects
in Research (Palo Alto, Calif).
INTERVENTION
The intervention was based on Bandura's social cognitive theory,15 and has been previously described.14
It consisted of eighteen 30- to 50-minute classroom lessons taught by the
regular third- and fourth-grade classroom teachers (trained by the research
staff) as part of the standard curriculum in the intervention school. The
majority of lessons were taught during the first 2 months. Early lessons included
self-monitoring and reporting of television, videotape, and video game use
to motivate children to want to reduce the time they spent in these activities.
These lessons were followed by a TV Turnoff16
during which children were challenged to watch no television or videotapes
and play no video games for 10 days. After the turnoff, children were encouraged
to follow a 7 hour per week television, videotape, and video game budget.
To help with budgeting, each household also received an electronic television
time manager (TV Allowance, Miami, Fla). Additional lessons taught children
to become "intelligent viewers" by using their viewing and video game time
more selectively. Several final lessons enlisted children as advocates for
reducing media use. Parent newsletters were designed to motivate parents to
help their children stay within their budgets, and suggested strategies for
limiting television, videotape, and video game use for the entire family.
We allowed parents to decide whether to include computer use in their child's
budget. The intervention targeted media use alone and did not address aggressive
behavior.
CHILD SELF-REPORT MEASURES
At baseline and posttest, on the same days in both schools, children
completed self-report questionnaires during a 40-minute class period on 2
days, Tuesdays through Fridays. A research staff member read each question
out loud and students were instructed to follow along together. Classroom
teachers did not participate in assessments.
Demographics and Media Use
Children reported their date of birth, age in years, sex, number of
televisions in their home, the number hooked up to a VCR, the number of video
game players hooked up to a television, the number of portable video game
players, and their hours of television, videotape, and video game use.14
Peer Ratings of Aggressive Behaviors
On the second assessment day at each time point, children responded
to a peer nomination survey, modeled after the instrument developed by Eron
et al17 and Walder et al.18
These instruments have been demonstrated to be highly reliable and to have
criterion, construct, and predictive validity.17, 19, 20
Children were asked to respond to 15 questions about the behavior of their
classmates. The first question was a "warm-up" (Who sits next to you in class?).
The next 14 questions included 10 aggressive behavior items (eg, Who often
says "Give me that"? Who starts a fight over nothing? Who pushes or shoves
children?) interspersed with 2 popularity items (eg, Who are the children
you would like to have for your best friends?) and 2 prosocial items (eg,
Who helps other children?). Questions were read aloud and each page was color
coded and contained a single question at the top, so data collection staff
could be sure that every child was on the correct item. Below each question
there were 2 columns of names, one listing all the boys in that classroom
and the other listing all of the girls in that classroom. Each list also contained
an option for "no boy" or "no girl." Children were instructed to choose as
many students as they wanted to answer each question, by marking the box next
to the name, but not to nominate themselves. Responses are scored as the number
of times a student is nominated divided by the number of other students completing
the survey. In this study sample at baseline, internal consistency was high
for the aggression items (Cronbach  = .97), and aggressive behavior
scores were inversely correlated with popularity and prosocial scores (r = -0.21, P = .002 and r = -0.39, P<.001, respectively).
Perceptions of a Mean and Scary World
Children responded to 12 items assessing their perceptions of a mean
and scary world (eg, Do you think most people are mean or most people are
friendly? How important is it to know how to fight? Are you scared of being
hurt by a criminal?) with dichotomous answer options. These items were adapted
from instruments previously demonstrated to correlate with the amount of television
viewing among young adolescents21 and children.8, 22 In this sample at baseline, internal
consistency was moderately high (Cronbach = .61).
PLAYGROUND OBSERVATION OF AGGRESSIVE BEHAVIORS
A 60% random sample of participating children was selected from class
lists for direct observation of aggressive behaviors during free play on the
school playgrounds during recess. The protocol was based on the procedure
used by Joy et al.7 At both baseline and posttest,
observations of the same children occurred over the same 10 days in both schools.
A total of 8 trained observers, blinded to the experimental design, were each
randomly assigned to 1 of the 2 schools on a daily basis (4 per school). Observations
occurred during morning and after-lunch recesses. Each observer was given
a different random order of children. For each child, observers categorized
all aggressive acts during a 1-minute period according to specific classification
criteria for verbal and physical aggression. Every 15th child for each observer
was a duplicate observation to assess interrater reliability. At baseline,
this protocol produced 886 one-minute observations of 109 children (range,
3-13 observations per child), of which 78 were co-observations. At posttest
there were 1050 one-minute observations of 101 children (range, 5-17 observations
per child), of which 126 were co-observations. Interrater reliability for
co-observations was high at both baseline (percent agreement = 0.96 and 
= 0.88 for physical aggression; percent agreement = 0.83 and = 0.65
for verbal aggression) and posttest (percent agreement = 0.94 and
= 0.60 for physical aggression; percent agreement = 0.87 and = 0.50
for verbal agreement) and intrachild stability between observations was also
high (baseline intraclass Spearman r = 0.89 for physical
aggression, r = 0.70 for verbal aggression; posttest r = 0.61 for physical aggression, r
= 0.51 for verbal aggression).
PARENT MEASURES
Parents were interviewed by telephone at baseline and posttest by trained
interviewers, following a standardized protocol. At least 10 call attempts
were made at various times of day and up to 3 messages were left on answering
machines before classifying a parent as a nonrespondent. Mothers or female
guardians were requested for telephone interviews, but fathers or male guardians
were interviewed if mothers were not available. All parent interviews were
completed within a 23-day period at baseline and a 36-day period at posttest,
with more than 85% of interviews completed during the first 16 days of each
assessment period.
Demographics and Media Use
Parents reported the ethnicity of their child, highest level of education
completed for all parents or guardians living in the household, marital status,
child's typical school day and weekend television, videotape, and video game
use,14 and overall household television viewing
patterns.23
Parent Reports of Children's Aggressive and Delinquent Behaviors
The parent report form of the Child Behavior Checklist24
is widely used to assess behavioral problems and social competencies of children
aged 4 through 16 years. It has strong psychometric properties and has been
the subject of many empirical studies. For this study, parents responded to
the 33 items that make up the Delinquent Behavior and Aggressive Behavior
subscales. The developers have reported 1-week test-retest reliabilities of
0.86 for delinquent behaviors and 0.91 for aggressive behaviors, and interparent
agreement of 0.78 and 0.77, respectively.24
STATISTICAL ANALYSIS
Baseline comparability of treatment and control groups was assessed
using nonparametric Wilcoxon rank sum tests for scaled variables and  2 tests for categorical variables. The primary objective of this study
was to evaluate the effects of the intervention on aggressive behavior. Because
of its strong psychometric characteristics, including predictive validity,17, 18, 19, 20 and
its potential availability on all eligible children in both schools, peer
ratings of aggressive behavior were identified a priori as the primary outcome
measure of aggression. Additional measures were considered secondary outcomes:
playground observation of physical and verbal aggression, which assesses aggression
at school, and parent ratings of aggressive and delinquent behavior, which
would be expected to reflect behavior in the family context. Assessing multiple
measures from different sources has been recommended to examine whether the
findings replicate across the measures despite the flaws and limitations of
each.25, 26 Perceptions of a mean
and scary world were measured with a single scale.
Randomization was by school. Because subjects within a school may have
correlated responses, we used a mixed model analysis of covariance approach
(SAS MIXED procedure, SAS version 6.12; SAS Institute Inc, Cary, NC), which
adjusts for observed between-subjects correlations within schools.27 To test the primary hypotheses, we used an analysis
of covariance with the posttest measure as the dependent variable, the intervention
group (intervention vs control) as the independent variable, and the baseline
measure of the dependent variable, age, and sex as covariates. Each outcome
was also tested for treatment x age and treatment x sex interactions.
Intraclass correlation coefficients ranged from -0.004 to 0.006 for
all outcome measures (as would be expected from random variation). Confirmatory
analyses using standard analysis of covariance (not adjusting for between-subjects
correlations within schools) produced the same results, indicating that intraclass
correlation coefficients were approximations of 0. All analyses were completed
on an intent-to-treat basis, such that all students were analyzed in their
schools as randomized, regardless of their participation in or compliance
with the intervention or their school at posttest, and all available data
were included in the analyses. All tests of statistical significance were
2 tailed with = .05. With an anticipated sample size of approximately
100 participants per group, and the above analysis, the study was designed
to have 80% power to detect an effect size of 0.20 or greater.28
RESULTS
The study design and participation are illustrated in Figure 1. Baseline and posttest peer ratings of aggression were
available for 100 (95.2%) of 105 eligible children in the intervention school
and 118 (98.3%) of 120 eligible children in the control school. Eighty-eight
children (83.8%) in the intervention school and 89 children (74.2%) in the
control school completed the mean and scary world surveys, at both baseline
and posttest assessments. Self-reports were excluded in the analysis for 11
children, across both schools, whose teachers classified them as having limited
English proficiency or a significant learning disability. Intervention and
control participants were comparable in age (mean [SD] = 8.9 [0.6] years vs
8.9 [0.7] years; P = .80), sex (48.0% vs 51.7% girls; P = .59), mean (SD) number of televisions in the home (2.7
[1.3] vs 2.7 [1.1]; P = .59), mean (SD) number of
video game players (1.5 [2.3] vs 1.6 [1.7]; P = .44),
and percentage of children with a television in their bedroom (43% vs 43%; P = .98).
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Study design and participant flow.
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Fifty intervention schoolchildren and 51 control schoolchildren were
observed for physical and verbal aggression during recess for at least 3 one-minute
periods at both baseline and posttest. Observed intervention and control children
were comparable in age (mean [SD] = 9.1 [0.6] years vs 9.0 [0.7] years; P = .72), sex (40.0% vs 49.0% girls; P = .36), mean (SD) number of televisions in the home (2.8 [1.5] vs
2.9 [1.1]; P = .29), mean (SD) number of video game
players (1.4 [2.7] vs 1.2 [2.1]; P = .96), and percentage
of children with a TV in their bedroom (46% vs 47%; P
= .95).
Baseline and posttest telephone interviews were completed by 68 (71.6%)
and 75 (72.8%) of the parents of participating children in the intervention
and control schools, respectively. Among this subsample of parents who completed
interviews, intervention school parents reported greater maximum household
educational levels than control school parents (45% vs 21% college graduates; P = .01) but did not differ significantly in ethnicity
(80% vs 70% white; P = .19), sex of respondent (82%
vs 88% female; P = .33), or marital status (77% vs
67% married; P = .22).
PARTICIPATION IN THE INTERVENTION AND CHANGES IN MEDIA USE
Intervention participation and effects of the intervention on media
use have been previously reported.14 To summarize,
teachers reported teaching all lessons, 95 (90%) of 106 students in the intervention
school participated in at least some of the TV Turnoff, and 71 (67%) completed
the entire 10 days without watching television and videotapes or playing video
games. During the budgeting phase of the intervention, 58 (55%) of the students
stayed under their budget for at least 1 week. Forty-four parents (42%) returned
slips reporting they had installed the TV Allowance system and 29 families
(27%) requested 1 or more additional TV Allowance systems. In response to
the intervention, children in the intervention school significantly decreased
their television viewing, compared with controls, according to both child
and parent reports (relative reductions of about one third). Intervention
children also reported significantly greater reductions in video game use
than controls, and had greater, but not statistically significant, decreases
in parent reports of children's video game use, parent and child reports of
videotape viewing, and parent reports of overall household television viewing.
There were no significant group x sex or group x age interactions
for any of the media use outcomes.14
EFFECTS OF THE INTERVENTION ON AGGRESSIVE BEHAVIOR AND PERCEPTIONS
OF A MEAN AND SCARY WORLD
Results are presented in Table 1.
At baseline, intervention and control groups were comparable on peer ratings
of aggression (P = .34), observed physical aggression
(P = .98), observed verbal aggression (P = .89), parent reports of aggressive behavior (P = .89), and parent reports of delinquent behavior (P = .86). However, control children reported greater perceptions of
a mean and scary world than intervention children at baseline (P = .02). Effects of the intervention are presented as differences
between intervention and control groups at posttest (treatment minus control),
adjusted for the baseline level of the dependent variable, sex and age, with
95% confidence intervals. There were no significant treatment x sex
or treatment x age interactions for any of the outcomes, so main effects
of the intervention are presented for boys and girls together, adjusted for
sex and age. The results did not change when parental educational level was
included as an additional covariate for the subsample of children with completed
parent interviews.
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Aggressive Behavior and Attitudes*
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As shown in Table 1, compared
with controls, children in the intervention group had statistically significant
decreases in peer ratings of aggression, the primary outcome measure, and
observed verbal aggression on the playground. In addition, although not statistically
significant, the direction of the differences favored the intervention group
for all other outcome variables except parent reports of delinquent behaviors,
which were very rare in both groups.
Equivalent Cohen effect sizes (the differences divided by the within-group
SDs) were 0.29 for peer-nominated aggression and 0.53 for observed verbal
aggression, generally considered small to medium and medium effects, respectively.29 The nonsignificant differences represented Cohen
effect sizes of 0.18 for observed physical aggression, 0.17 for perceptions
of a mean and scary world, 0.18 for parent reports of aggressive behavior,
and 0.06 for parent reports of delinquent behavior.
Although the sample size was insufficient to formally test for effects
within subgroups, it was desirable to further characterize the effects of
the intervention on participants with varying levels of aggression at baseline,
with a descriptive analysis. To do so, we compared intervention and control
group changes within strata defined by baseline levels of the outcome measures.
In general, effects of the intervention occurred across the entire distribution
of baseline values for all outcomes, with greater intervention vs control
differences among those children who had medium and higher aggression levels
at baseline.
COMMENT
In this study, an intervention to reduce television, videotape, and
video game use decreased aggressive behavior in third- and fourth-grade schoolchildren.
Because the intervention targeted reduction of media use alone, without substituting
alternative behaviors or activities, these results are also additional evidence
for the causal effects of these media on children's aggressive behavior.30 Aggressive behavior is determined by complex interactions
between biological and socioenvironmental influences.31
This intervention attempted to mitigate only one of those influences, modeling
of aggressive behavior in television, videotaped movies, and video games.
Cognitive social learning explanations of aggression suggest that exposure
to aggressive acts in the media provides opportunities for children to learn
aggressive behaviors and to develop beliefs about the potential utility and
consequences of using aggression to resolve conflicts.15, 32
Consistent with this model, our findings demonstrate that reducing exposure
to media results in reductions in children's aggressive behaviors.
In response to the intervention, children had statistically significant
decreases in peer ratings of aggression (the primary outcome measure) and
directly observed verbal aggression, compared with controls. The peer-nomination
measure used is often considered the primary measure of aggression in studies
of childhood aggression because of its exceptional psychometric properties.17, 19, 20 We also included
observations of aggression on the playground because of their appeal as direct
assessments of actual behavior. Despite the fact that observations were performed
on a much smaller sample, the intervention effects on verbal aggression (an
average intervention-control difference of 0.1 act per minute per child) were
large enough to be statistically significant. There was a similar average
intervention-control difference in the number of physically aggressive acts
per minute, but the variation in this measure was larger and the difference
was not statistically significant.
The lack of statistically significant effects for parent reports of
aggressive and delinquent behaviors may suggest that the intervention, and
the influences of media exposure, are more specific to aggression at school
than at home. However, the direction of the differences in parent reports
of aggression did favor the intervention group and the effect size was similar
to that for observed physical aggression on the playground. As a result, this
finding could also be explained by insufficient statistical power, due to
the lower reliability and sensitivity to change of parent report measures.
It is also possible that parents have fewer opportunities to see their children
act aggressively than their peers, or that parent ratings are less sensitive
to change. Parent reports of delinquent behaviors were very rare in both groups
in this study, so it is not surprising that we did not find an intervention-control
difference for this variable. Although intervention-control differences in
perceptions of a mean and scary world also favored the intervention, this
difference also was not statistically significant. Again, however, this study
may have been insufficiently powered to detect small changes in this measure.
This study has several limitations. First, because this study involved
children in only 2 elementary schools, we cannot completely rule out the possibility
that the results were due to differences in the intervention and control groups
that were unrelated to the intervention. This possibility is made less likely,
however, because the schools were in a single school district and participants
were comparable at baseline on almost all measured variables. Second, the
intervention targeted all television, videotape, and video game use, instead
of just violent media. In addition, we did not assess specific exposure to
violent media so we do not know whether violent media exposure was reduced.
As a result, it may be argued that we have not sufficiently tested the causal
relationship between violent media and aggressive behavior. However, we decided
on the present design for practical reasons: in the current multimedia, multichannel,
remote control environment, actual exposure to violent content is extremely
difficult to assess accurately; the definition of what constitutes violent
media is not necessarily straightforward; requiring parents and children to
differentiate violent media from other types of content would make the intervention
less likely to be adopted and less generalizable; and reduction in aggressive
behavior is only one hypothesized benefit of reducing media use. However,
because the intervention did not target just violent media, potentially diluting
intervention effects, others may argue that our findings are even stronger
evidence of the benefits of reducing media use on aggressive behavior.
Strengths of this study include the randomized controlled trial design;
blinding of students, parents, and teachers to the specific study hypotheses;
blinding of data collectors to experimental assignment; the use of multiple
measures of aggression from different sources, including the highly reliable
and valid peer nomination measure and playground observations with good interrater
reliability; the use of a potentially generalizable intervention delivered
by the regular classroom teachers; and the analysis approach, which appropriately
accounted for the design with the school as the unit of randomization.
Despite substantial evidence linking violent media with increased aggression,
there have been few previous studies of approaches to reduce this effect.30 This small study indicates that reducing television,
videotape, and video game use may be a particularly promising approach to
reducing children's aggressive behavior. Furthermore, even small and medium-sized
effects may produce large benefits when applied to a population in a public
health intervention.33 The effects of this
intervention occurred throughout the entire sample, although reductions in
aggressive behavior were generally larger among children who were more aggressive
at the beginning of the study. Although the analysis was limited by the small
sample size, there was no evidence that the intervention was differentially
effective in boys and girls. It will now be important to replicate this study
with larger and more sociodemographically diverse samples and longer follow-up
to confirm these findings and to evaluate the generalizability of this approach.
Studies of the mechanisms by which this intervention influences aggressive
behavior will also improve our understanding of the relationships between
exposure to aggression in the media and subsequent aggressive behavior. In
addition, to inform public policy, future studies should be designed to identify
whether subgroups of children are more or less likely to respond to the intervention,
and the elements of the curriculum and implementation most closely linked
to reductions in children's aggression.
AUTHOR INFORMATION
Accepted for publication August 23, 2000.
This study was funded by grants from the American Heart Association,
California Affiliate; grant RO1 HL54102 (Dr Robinson) from the National Heart,
Lung and Blood Institute, Bethesda, Md; the Children's Health Research Fund
at Lucile Packard Children's Hospital at Stanford, Palo Alto, Calif; and a
Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award.
We are indebted to Joel D. Killen, PhD, Helena C. Kraemer, PhD, Dina
L. G. Borzekowski, EdD, Sally McCarthy, Connie Watanabe, MA, Melissa Nichols
Saphir, PhD, and the students, teachers, and administrators who participated
in this project.
From the Departments of Pediatrics and Medicine (Dr Robinson), Stanford
Center for Research in Disease Prevention (Drs Robinson and Navacruz and Mss
Wilde, Haydel, and Varady), Stanford University School of Medicine, Palo Alto,
Calif.
Corresponding author: Thomas N. Robinson, MD, MPH, Department of
Pediatrics and Center for Research in Disease Prevention, Stanford University
School of Medicine, 1000 Welch Rd, Palo Alto, CA 94304 (e-mail: tom.robinson{at}stanford.edu).
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