Abstract: Background and Objectives The COVID-19 pandemic led to major changes in children’s daily routines, including increased exposure to digital devices. Concerns have emerged regarding the potential impact of increased screen time (ST) on children’s behavioural development and the possible rise in referrals for suspected Autism Spectrum Disorder (ASD). This study aimed to explore the relationship between ST during the COVID-19 pandemic and the number of first referrals for suspected ASD. Methods A retrospective study was conducted at the Department of Child and Adolescent Psychiatry of CHUSJ. Children referred for a first consultation due to suspected ASD between January 2018 and December 2022 were included. Participants were divided into two groups: pre-pandemic and pandemic. Parents completed a structured questionnaire regarding their children’s ST and behavioural characteristics. Results A total of 52 participants were included (18 pre-pandemic and 34 pandemic). ST increased significantly during the pandemic compared with the pre-pandemic period (p=0.040). Institutional data also showed a progressive increase in first consultations for suspected ASD between 2018–2022. There was no association observed between ST and behavioural characteristics related to ASD in this sample. Conclusions Consultations for suspected ASD increased substantially following the COVID-19 pandemic, accompanied by a significant rise in ST among the children assessed. However, no association was found between ST and behavioural characteristics related to ASD, suggesting that the increase in consultations may reflect broader changes in children’s routines and social context during the pandemic. Therefore, we cannot affirm that there is no link between increased ST and ASD. Keywords Autism Spectrum Disorder (ASD); Screen time (ST); COVID-19; Child psychiatry; Neurodevelopment; Referrals. Authors: Sofia Rodrigues de Ornelas Nunes, Department of Child and Adolescent Psychiatry of Centro Hospitalar Universitário do São João; Alda Múrias Mira Coelho, Department of Child and Adolescent Psychiatry of Centro Hospitalar Universitário do São João.
Introduction
Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent difficulties in social communication and interaction, together with restricted and repetitive patterns of behaviour, interests or activities. To make the diagnosis, symptoms must be present early in development and cause clinically significant impairment in social, occupational, or other important areas of the individual’s present functioning. Because Autism is a spectrum disorder, it can range from very mild to very severe levels – Level 1 “Requiring support”, Level 2 “Requiring substantial support” and Level 3 “Requiring very substantial support” – and occur in all ethnic, socioeconomic and age groups.[1]
Recent epidemiological literature indicates a rapid increase in the prevalence of ASD worldwide, noting a sex ratio where boys are affected about four times more frequently than girls.[2] A variety of factors may explain this rise, including a broader definition of ASD, changes in diagnostic criteria and screening tools, shifts in research methods, and a heightened public and professional awareness of the disorder.
In Portugal, epidemiological data on ASD remains relatively scarce. A landmark study by Guiomar Oliveira in 2005, entitled: “Epidemiologia das Perturbações do Espectro do Autismo em Portugal: prevalência, caracterização clínica e condições médicas associadas numa população infantil” provided some of the first national prevalence estimates. More recently, as part of the European project “ASDEU – Autism Spectrum Disorders in the European Union” (2015-2018), an epidemiological study was conducted in the Central region of Portugal, coordinated by the National Institute of Health Dr. Ricardo Jorge. Interestingly, the prevalence identified by Oliveira et al. (0.125%; 95% CI: 0.096–0.15) was approximately four times lower than the figures reported later by the ASDEU study, reflecting the evolving landscape of ASD identification in the country.
Early diagnosis of autism is crucial for timely intervention and improved long-term outcomes. The benefits of early diagnosis – typically between the ages of two and five – allow early intervention, which has been shown to enhance developmental outcomes in critical domains such as communication, social interaction and movement skills.[3]
The emergence of the COVID-19 pandemic affected all parts of society, imposing unprecedented challenges on global health and social structures. In Portugal the first two cases of COVID-19 were confirmed on 2 March 2020 and the first lockdown as well as the State of Emergency began on 18 March 2020. On 15 January 2021, in response to a new severe wave of the disease, there was a second lockdown. The end of the alert situation was declared in September 2022, marking the end of exceptional pandemic measures in the country. At the beginning of 2023, the World Health Organisation (WHO) declared the end of the pandemic.
A review study demonstrated that pandemics often serve as precursors to a decline in mental health.[4] Evidence of this can be seen in how the COVID-19 pandemic affected the lives of children and adolescents around the world, by the disruption of school routines and social environments, resulting in greater loneliness, distress, social isolation, reduced psychological well-being and increased symptoms of anxiety, depression and stress. The circumstances created by this social isolation acted as a non-normative stressor, increasing the likelihood of developing mental health problems for the first time, as well as exacerbating or triggering the recurrence of pre-existing mental disorders.
People with mental disabilities were especially vulnerable to the physical, psychological, and social effects of the pandemic. The pandemic-induced uncertainty and the sudden disruption of established routines frequently led to increased irritability, social withdrawal, and challenging behaviours in ASD patients.[5] Research has also highlighted a significant escalation in sleep disturbances and circadian rhythm imbalances, which further intensified behavioural symptoms during periods of confinement.
Although electronic devices have taken on an essential role during the COVID-19 pandemic in maintaining school, social and recreational activities, excessive use of screen time (ST) has many negative health effects caused by a multitude of mechanisms, affecting plenty of systems. There has been a 52% increase in ST amongst children and adolescents during the COVID-19 pandemic. Excessive ST is associated with various adverse outcomes, including cardiometabolic disorders as well as sleep disorders, chronic neck and back problems, depression, and anxiety.[6]
It has been well established that excessive ST affects the mental health of youth. Recently, pandemic-related stressors led to decreased physical activity and increased ST, both of which were associated with poorer mental health outcomes. Furthermore, recent findings by Heffler KF et al. documented that while an early onset of ST viewing does not affect the risk for ASD, it increases the risk for “ASD-like symptoms”.
There are still few studies that specifically quantify the evolution of initial child psychiatry consultations motivated by suspected ASD and their possible association with ST during the pandemic period. Thus, this study aims to investigate the possible correlation between ST during the COVID-19 pandemic and whether there was an increase in first paediatric psychiatry consultations for suspected ASD, seeking to understand the impact of this new digital reality at the time of diagnosis. By providing objective data from a major clinical centre (CHUSJ), this research aims to offer essential insights for clinicians to assess environmental factors in neurodevelopmental disorders, ultimately optimizing early intervention strategies in a post-pandemic digital era.
Material and Methods
Study design
This analytical retrospective study aimed to evaluate the potential association between ST during the COVID-19 pandemic and the number of referrals for suspected ASD. The study compared children referred for a first consultation in child and adolescent psychiatry during two distinct time periods: a pre-pandemic period and a pandemic period.
Setting
The study was conducted at the Department of Child and Adolescent Psychiatry of Centro Hospitalar Universitário do São João (CHUSJ), Portugal. Children referred for a first psychiatric consultation due to suspected ASD between January 2018 and December 2022 were considered eligible for inclusion. For analytical purposes, the study period was divided into two groups: a pre-pandemic group, including children whose first consultation occurred between January 2018 and February 2020, and a pandemic group, including children referred between March 2020 and December 2022. March 2020 was used as the cut-off point, corresponding to the onset of the COVID-19 pandemic and the implementation of public health containment measures in Portugal.
The pre-pandemic group served as a comparison group for evaluating changes observed during the pandemic period.
Participants
Children referred for a first consultation due to suspected ASD during the defined study period were identified through clinical records. Parents or legal guardians were invited to answer a structured questionnaire regarding the child’s digital media use and behavioural characteristics. Inclusion criteria consisted of having a first consultation for suspected ASD during the study period, availability of clinical information regarding the consultation, and completion of the parental questionnaire. Responses were excluded if the reported date of the first consultation did not correspond to the predefined study periods or if questionnaire data were inconsistent with the eligibility criteria.
Data sources and variables
Data were obtained from two main sources: retrospective review of clinical records and parental questionnaires. Clinical records provided information regarding referral characteristics and diagnostic classification. The questionnaire collected information on demographic characteristics of the child, including age and sex, as well as the identity of the responding parent. Information regarding daily ST was obtained through parental report and categorised into five levels: less than one hour per day, one to two hours per day, two to four hours per day, four to six hours per day, and more than six hours per day. For children included in the pandemic group, parents reported ST for two time periods, corresponding to the period before the pandemic and the period during the pandemic. Additional variables included the type of digital devices used, such as television, tablet, smartphone, computer and gaming console, as well as the main purpose of screen use, including educational activities, video viewing, gaming, social media or mixed use. Parents were also asked to report perceived behavioural characteristics in their children, including aspects related to social interaction, isolation, verbal and non-verbal communication, repetitive behaviours, restricted interests, irritability, agitation and sleep patterns. ST was recorded using categorical intervals to facilitate parental reporting and statistical analysis. Institutional clinical records were also consulted to determine the annual number of first consultations for suspected ASD during the study period, allowing the evaluation of trends in referrals over time.
Bias
Several measures were implemented to minimise potential sources of bias. The same questionnaire was used for all participants to ensure consistency in data collection, and predefined screen-time categories were employed to reduce variability in parental reporting. Eligibility criteria were applied uniformly to all responses to ensure comparability between the study groups.
Study size
The study sample included all eligible participants who completed the questionnaire during the study period. No formal sample size calculation was performed, as the study aimed to include all available cases meeting the inclusion criteria.
Statistical methods
Statistical analyses were performed using IBM SPSS Statistics 30. Descriptive statistics were used to characterise the study sample. Continuous variables are presented as mean and standard deviation, whereas categorical variables are presented as frequencies and percentages. Comparisons between the pre-pandemic and pandemic groups were conducted using the Mann–Whitney U test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables, as appropriate. Changes in ST before and during the pandemic within the pandemic group were analysed using the Wilcoxon signed-rank test. A significance level of p < 0.05 was considered statistically significant.
Ethical considerations
The study was approved by the Ethics Committee of CHUSJ. Participation was voluntary and informed consent was obtained from parents or legal guardians prior to questionnaire completion. All data were anonymized prior to statistical analysis.
Results
A total of 57 parental questionnaires were initially received. Of these, 18 corresponded to children whose first consultation took place between January 2018 and February 2020 and were assigned to the pre-pandemic group. Thirty-nine questionnaires corresponded to children whose first consultation occurred between March 2020 and December 2022 and were therefore initially classified as belonging to the pandemic group. However, 5 questionnaires were excluded because the reported date of the first consultation did not fall within the predefined study period. After applying the eligibility criteria, the final sample comprised 52 participants, including 18 children in the pre-pandemic group and 34 children in the pandemic group.
Questionnaires received
n = 57
Pandemic group
Questionnaires received
n = 39
Excluded
n = 5 (first consultation outside study period)
Included in analysis
n = 34
Pre-pandemic group
Questionnaires received
n = 18
Excluded
n = 0
Included in analysis
n = 18
Figure 1. Flow diagram of participant selection and inclusion in the study. A total of 57 questionnaires were received. After applying eligibility criteria, 52 participants were included in the final analysis (18 in the pre-pandemic group and 34 in the pandemic group).
Final sample included in analysis
n = 52
The demographic and clinical characteristics of the study population were analysed to assess the comparability between groups (Table 1). The mean age of the overall sample was 8.5 years (standard deviation [SD] = 2.93). Children referred before the pandemic were significantly older than those referred during the pandemic. The mean age in the pre pandemic group was 10.39 years, compared with 7.50 years in the pandemic group. The difference was statistically significant (p < 0.001).
A predominance of male participants was observed in the overall sample. Of the 52 children included in the study, 45 were male and 7 were female and most questionnaires were completed by mothers. The distribution of sex did not differ significantly between the pre-pandemic and pandemic groups (p = 0.399). No statistically significant differences were identified between groups regarding the responding parent (p = 0.495).
Regarding diagnostic status, most children were ultimately classified as having ASD. In the pre-pandemic group, 17 children received a diagnosis of ASD and in the pandemic group 27 children were diagnosed with ASD. No statistically significant differences were observed between the two groups regarding diagnostic outcome (p = 0.273), although the interpretation of this result is limited by the small number of cases in some categories.
|
Variable |
Pre-pandemic (n=18) |
Pandemic (n=34) |
P value |
|
Responding parent – father, n(%) |
4 (22.2) |
5 (14.7) |
0.495 |
|
Responding parent – mother, n(%) |
14 (77.8) |
29 (85.3) | |
|
Age (years), mean SD |
10.39 +- 2.00 |
7.50 +- 2.86 |
<0.001 |
|
Male sex, n(%) |
17 (94.4) |
28 (82.4) |
0.399 |
|
Female sex, n(%) |
1 (5.6) |
6 (17.6) | |
|
ASD diagnosis, n(%) |
17 (94.4) |
27 (79.4) |
0.273 |
|
Non-ASD diagnosis, n(%) |
1 (5.6) |
3 (8.8) | |
|
Diagnostic evaluation ongoing, n(%) |
0 |
4 (11.8) |
Table 1. The sociodemographic characteristics of the sample.
ST prior to the pandemic was subsequently examined (Table 2). The mean category of daily ST before the pandemic was similar in both groups, with a mean value of 1.94 in the pre-pandemic group and 2.06 in the pandemic group. No statistically significant differences were found between groups regarding baseline ST prior to the pandemic, suggesting that both groups had comparable patterns of screen use before the onset of the COVID-19 pandemic (p = 1.00).
|
Screen time category |
Pre-pandemic group (n=18) |
Pandemic group (n=34) |
P value |
|
< 1 hour/day, n(%) |
6 (33.3) |
13 (38.2) |
1.00 |
|
1-2 hours/day, n(%) |
7 (38.9) |
11 (32.4) | |
|
2-4 hours/day, n(%) |
5 (27.8) |
7 (20.6) | |
|
4-6 hours/day, n(%) |
0 (0.0) |
1 (2.9) | |
|
> 6 hours/day, n(%) |
0 (0.0) |
2 (5.9) |
Table 2. Baseline ST before the pandemic according to study group.
The main purpose of screen use before the pandemic was also analysed. Reported uses included watching videos, playing games, educational activities, social media and mixed use. The distribution of these categories did not differ significantly between the pre-pandemic and pandemic groups (p = 0.327).
In addition, the types of digital devices used before the pandemic were evaluated, including television, tablet, smartphone, computer and gaming consoles. No statistically significant differences were observed between groups for any of these devices, indicating similar access to and use of digital devices in both groups prior to the pandemic.
Within the pandemic group, changes in daily ST before and during the pandemic were analysed (Table 3). Before the pandemic, most children were reported to have relatively low levels of daily ST. Specifically, 38.2% of children were reported to use screens for less than one hour per day and 32.4% for between one and two hours per day. During the pandemic, a shift towards higher exposure categories was observed. The proportion of children reported to spend two to four hours per day using screens increased to 38.2%, and 8.8% of children were reported to have more than six hours of daily ST. In the pandemic group, there was a statistically significant increase in ST during the pandemic compared to the pre-pandemic period (p = 0.040).
|
Screen time category |
Before pandemic (n=34) |
During pandemic (n=34) |
P value |
|
< 1 hour/day, n(%) |
13 (38.2) |
10 (29.4) |
0.040 |
|
1-2 hours/day, n(%) |
11 (32.4) |
7 (20.6) | |
|
2-4 hours/day, n(%) |
7 (20.6) |
13 (38.2) | |
|
4-6 hours/day, n(%) |
1 (2.9) |
1 (2.9) | |
|
> 6 hours/day, n(%) |
2 (5.9) |
3 (8.8) |
Table 3. Changes in ST during the pandemic.
Changes in the purpose of screen use before and during the pandemic were analysed using the Wilcoxon signed-rank test. Although a trend towards a change in the purpose of use of the devices was observed between the pre-pandemic and pandemic periods, the difference did not reach statistical significance (p = 0.064). Also, no statistically significant correlations were observed between increased ST during the pandemic and the behavioural variables analysed.
Parental perceptions of behavioural changes during the pandemic were also explored (Table 4). Variables analysed included social interaction, isolation, verbal and non-verbal communication, repetitive behaviours, restricted interests, irritability, agitation and sleep disturbances. Comparisons between the pre-pandemic and pandemic periods did not reveal statistically significant differences in these behavioural variables. The groups presented a similar profile and most behavioural variables assessed in the pre-pandemic period, with a statistically significant difference only in the sleep variable (p = 0.024).
|
Variable |
Before pandemic median (IQR) |
During pandemic median (IQR) |
P value |
|
Social interaction |
3.0 (2.0–4.0) |
3.0 (2.0–4.0) |
0.76 |
|
Isolation |
3.0 (1.0–4.0) |
3.0 (2.0–4.0) |
0.13 |
|
Eye contact |
2.0 (2.0–4.0) |
2.0 (2.0–4.0) |
0.95 |
|
Verbal communication |
4.0 (2.3–5.0) |
4.0 (3.0–5.0) |
0.60 |
|
Non-verbal communication |
3.0 (2.0–3.0) |
3.0 (2.0–3.0) |
0.31 |
|
Reduced communication |
3.0 (2.0–4.8) |
3.0 (2.0–4.0) |
0.41 |
|
Repetitive behaviours |
3.5 (2.0–4.8) |
3.0 (2.0–5.0) |
0.19 |
|
Restricted interests |
3.5 (3.0–4.0) |
3.5 (3.0–4.0) |
0.73 |
|
Resistance to changes in routine |
3.0 (2.0–4.0) |
3.0 (2.0–4.0) |
0.88 |
|
Irritability |
3.0 (2.0–4.0) |
3.0 (2.0–4.0) |
0.73 |
|
Agitation |
3.0 (2.0–4.0) |
3.0 (2.0–4.0) |
0.73 |
|
Sleep |
1.0 (1.0–2.8) |
1.0 (1.0–3.0) |
1.00 |
Table 4. Behavioural characteristics in the pandemic group before and during the COVID-19 pandemic, expressed as median and interquartile range (IQR).
Finally, institutional clinical data were examined to analyse trends in the number of first consultations for suspected ASD over time (Table 5). A progressive increase in referrals was observed during the study period. The number of first consultations rose from 130 in 2018 to 266 in 2022, representing a marked increase following the onset of the COVID-19 pandemic.
|
Year |
Number of 1st consultations |
|
2018 |
130 |
|
2019 |
147 |
|
2020 |
154 |
|
2021 |
218 |
|
2022 |
266 |
Table 5. Number of first consultations for suspected ASD from 2018 to 2022.
Overall, these findings indicate that although referrals for suspected ASD increased substantially during the pandemic period and ST increased among children evaluated during this time, no statistically significant associations were observed between ST and the behavioural variables assessed in this sample. However, we cannot state that there is no link between increased ST and ASD; what may have happened is that these children likely already had these symptoms and did not improve due to the increase in ST.
Discussion
The present study aimed to explore the potential relationship between ST during the COVID-19 pandemic and the number of first referrals for suspected ASD. The findings revealed a substantial increase in first consultations for suspected ASD following the onset of the pandemic. Additionally, ST among children referred during the pandemic increased significantly compared with the period before the pandemic. However, no significant associations were identified between ST and behavioural characteristics related to ASD. These findings underline the complexity of factors influencing referrals for suspected ASD and suggest that increased ST alone may not fully explain the observed rise in consultations during the pandemic period.
The increase in referrals for suspected ASD observed in the present study is consistent with findings reported in another study[7] conducted after the COVID-19 pandemic. The 2024 comparative analysis between the pre-pandemic and pandemic periods found a significant increase in ASD diagnosis during the pandemic period compared to the pre-pandemic one. Several factors may help explain this trend. During periods of lockdown, parents spent considerably more time at home with their children, which may have increased their awareness of developmental and behavioural difficulties. In addition, greater public awareness of the signs and symptoms of ASD may have contributed to a higher number of initial consultations, as parents sought professional evaluation to confirm or rule out concerns regarding their children’s development.
The increase in ST observed in this study is also consistent with findings reported in another study conducted during the COVID-19 pandemic.[8] Restrictions related to lockdown measures, school closures and reduced opportunities for outdoor activities resulted in children spending more time at home and relying more heavily on digital devices for entertainment, communication and educational activities. Previous research has shown that these circumstances contributed to a substantial increase in screen use among children and adolescents during the pandemic.[9]
Despite the observed increase in ST, no significant associations were identified between ST and behavioural characteristics related to ASD in the present study. This finding suggests that increased digital media use alone may not fully explain the rise in referrals for suspected ASD observed in this study. The relationship between ST and developmental outcomes is complex and likely influenced by multiple factors, including family environment, parental involvement, and the type of digital content consumed, and cannot be fully established based on the findings of this study. Previous research has suggested a possible association between ST and autism-related outcomes. However, evidence remains inconsistent and may be influenced by methodological limitations.[10]
Several limitations should be considered when interpreting the results of this study. First, the relatively small sample size may have limited the statistical power to detect more subtle associations between ST and behavioural characteristics. Second, ST was assessed through parental report, which may be subject to recall bias. Additionally, the age difference observed between the pre-pandemic and pandemic groups may represent a potential source of confounding, as patterns of digital media use may vary according to age.
Despite these limitations, the present study contributes to a better understanding of factors associated with referrals for suspected ASD during the COVID-19 pandemic. The findings point out the importance of considering multiple environmental and developmental factors when evaluating children referred for suspected ASD. Increased ST may reflect broader lifestyle changes during the pandemic rather than a direct causal factor underlying the observed increase in referrals.
These findings may contribute to understanding post-pandemic patterns of referral for suspected ASD in similar clinical settings, but should be interpreted with caution, as the study was conducted in a single clinical centre and may not fully represent patterns observed in other healthcare settings.
Conclusion
In conclusion, this study identified a substantial increase in first referrals for suspected ASD following the COVID-19 pandemic, accompanied by a significant rise in ST among children referred during this period. However, no statistically significant association was observed between ST and the behavioural variables assessed in this study. These findings suggest that the increase in referrals may reflect broader changes in children’s daily routines, parental awareness and social environments during the pandemic rather than being solely explained by increased screen use. Clinicians should therefore interpret parental concerns within the broader context of children’s routines, social experiences and environmental changes that occur during this period. Further research with larger samples is needed to better understand the complex factors influencing referrals for suspected ASD in the post-pandemic context.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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