The rapid digitalization of daily life, accelerated by the coronavirus disease 2019 (COVID-19) pandemic, has led to a substantial increase in screen time (ST) across all age groups, particularly during lockdown periods. Home confinement often required work-from-home parents to adopt more permissive attitudes toward their children's smartphone use, affecting children from early childhood through adolescence [1]. The convenience and widespread availability of digital media have further contributed to the sharp rise in ST exposure among children [2].

Although the use of computers and smartphones has been associated with improved cognitive and academic skills [3], it is also linked to negative social and psychological consequences. Excessive screen exposure may result in social isolation, reduced participation in social activities, and constraints on social development [4,5], ultimately contributing to depression and loneliness [6]. Increased ST can also limit time spent with parents, potentially impairing parent-child interaction, slowing language development, and affecting self-regulation and academic performance [7,8]. Exposure to violent games or shows has been shown to heighten anxiety and foster a perception of violence as an acceptable means of resolving conflict among school-going children [4].

High screen use is also associated with behavioral problems in children [9,10], though the mechanisms underlying these associations remain incompletely understood. One potential pathway involves the impact of ST on sleep quality. Environmental, behavioral, and biological factors all contribute to how increased screen exposure leads to sleep disturbances [11]. Screen-based activities often delay bedtime and shorten total sleep duration [12]. The content of media can produce psychological arousal that disrupts relaxation and hampers sleep initiation [13]. In addition, the light emitted by screens can alter circadian rhythms and increase alertness, providing a biological explanation for these effects [14].

Prolonged screen exposure may impair children’s behavior and attention, potentially through sleep disturbances that negatively influence developmental processes. Although many studies have addressed this issue, much of the existing research has focused on a single screen type, particularly television. This study seeks to bridge this gap by examining a broader range of digital devices, including smartphones, tablets, and gaming consoles. This observational cross-sectional study evaluates the prevalence of neurobehavioral disorders in school-going children (aged 6 to 18) and explores associations between ST (types and content) and problem behaviors, as well as their relationship with outdoor activity.

The study included 776 children, with 446 in the pre-adolescent group (group A) and 330 in the adolescent group (group B). The mean±SD age of all participants was 11.74±3.5 years, with corresponding means of 9.12±1.68 years in group A and 15.29±1.59 years in group B. Male participants accounted for 66% of the sample, resulting in an overall male-to-female ratio of 1.94:1. The ratio was 2.33:1 in group A and 1.54:1 in group B, indicating a more pronounced male predominance among younger children.

The average daily ST for the total cohort was 6.57±2.02 hours. Group A had a mean ST of 6.98±1.86 hours, whereas group B averaged 6.02±2.34 hours. Although younger children demonstrated higher mean ST, the difference between the two age groups did not reach statistical significance.

While ST includes various forms of digital media, mature-rated video games constitute a specific category characterized by violent or adult content, making separate analysis essential to understand their distinct neurobehavioral effects. Use of mature-rated video games was significantly more common in group B than in group A (P<0.05). Among group A, 59% of children had never engaged with such games, compared with 47.3% in group B.

In this study, 22.9% of pre-adolescent children (group A) reported sleep-related difficulties, compared with 15.2% of adolescents (group B), a statistically significant difference (P<0.05). Table 1 summarizes sleep disorders, defined as the presence of any sleep-related problem. Overall, 152 children (representing 19.6% of the study population) experienced one or more sleep disturbances.

The mean±SD CBCL T-score for all participants was 59.6±17.3. Group A demonstrated a significantly higher mean score of 60.9±18.2 compared with 57.8±15.8 in group B (P<0.001). The CBCL includes eight syndrome scales categorized into internalizing (anxious/depressed, withdrawn/depressed, somatic complaints) and externalizing (rule-breaking behavior, aggressive behavior) domains, with social problems, thought problems, and attention problems forming mixed/other domains contributing to total problems. Table 2 compares the distribution of participants across the three CBCL ranges (normal <65, borderline 65-69, clinical ≥70) for each syndrome scale in both groups. Preadolescents (group A) exhibited higher proportions in the borderline or clinical ranges for most scales (P<0.05).

Overall, 79% of children fell within the normal category, 14% were classified as borderline, and 7% exhibited clinically significant neurobehavioral problems. Correlation analysis revealed that playing mature-rated video games, having any sleep-related difficulty, and engaging in ST ≥7 hours were each positively associated with neurobehavioral problems.

For the analysis of neurobehavioral difficulties, the total CBCL score was used as the primary variable. This score provides a comprehensive index of emotional, behavioral, and social problems as reported by parents, serving as a standardized measure of neurobehavioral functioning. In group A, all three factors showed significant correlations with neurobehavioral problems, while in group B, the association with mature-rated video games, although positive, did not reach statistical significance (Table 3). Logistic regression analysis further evaluated these associations, and the model demonstrated good fit based on the Hosmer-Lemeshow test, yielding a predictive accuracy of 78.7%.

This study aimed to identify lifestyle factors, particularly ST and sleep-related disturbances, associated with neurobehavioral problems in children aged 6 to 18 years. Findings indicate a statistically significant association between prolonged ST, sleep issues, and the development of behavioral concerns among school-going children.

Children who engaged in any form of screen-related activity for extended periods showed increased rates of social problems, thought disturbances, rule-breaking behaviors, and aggression, consistent with the findings of Stiglic and Viner [16]. Video gaming, especially mature-rated video games, was significantly correlated with problem behaviors such as social withdrawal and internalizing difficulties. Several studies have also described associations between ST and anxiety or depression in children [17,18]. Additionally, exposure to blue light from screens disrupts sleep patterns, thereby compromising overall sleep quality [19].

Some studies have reported no adverse effects or even potential benefits of increased ST [20], which has been interpreted through the displacement hypothesis. This hypothesis suggests that increased screen engagement displaces other beneficial activities, including outdoor play, social interaction, and adequate sleep, which may in turn contribute to neurobehavioral problems. In this study, exposure to mature-rated video games demonstrated a significant association with higher overall CBCL Total Problem scores, indicating a notable rise in behavioral difficulties. Importantly, significant associations between mature-rated video game use and neurobehavioral problems were observed only in group A (younger children aged 6-12 years), whereas such relationships were not significant in group B (adolescents). This subgroup-specific pattern highlights the heightened vulnerability of younger school-going children to the neurobehavioral effects of mature-rated game exposure. Prior studies have similarly shown an increase in externalizing tendencies among children frequently exposed to violent or mature-rated video games [21]. Collectively, these observations suggest that mature-rated video game exposure may contribute to broader behavioral dysregulation in school-going children.

Sleep problems of any type demonstrated an independent association with behavioral patterns in this study, consistent with previous research showing that such difficulties are linked with higher internalizing and externalizing symptoms. Younger children generally require longer sleep duration and may be more susceptible to environmental and behavioral disruptions, including evening screen exposure. Excessive ST has consistently been associated with shortened sleep duration, delayed sleep onset, and reduced sleep quality in children, partly due to the circadian-disrupting effects of blue light and the arousing nature of stimulating content. These sleep disturbances negatively influence emotional regulation, behavior, and cognitive performance. Recognizing these risks, the American Academy of Sleep Medicine recommends screen-free environments in children’s bedrooms and a minimum 30-minute break from screens before bedtime.

The COVID-19 pandemic further intensified ST and its behavioral consequences by providing school-going children with unprecedented access to smartphones and by reducing opportunities for social interaction [22]. According to the World Health Organization, nearly 1.5 billion children worldwide were confined at home during the pandemic. Studies have shown that children aged 10-17 years reported an average of 138.6 minutes of gaming per day after lockdown, a considerable increase from 79.2 minutes in 2019.

Although ST in this study was documented separately for online classes, video games, entertainment videos, and television viewing, these components were combined to calculate total daily screen exposure. This strategy aimed to estimate overall digital engagement; however, it does not capture potential qualitative differences between educational and recreational screen use. Prior research suggests that academic or passive screen exposure may exert less influence on behavioral and sleep outcomes than interactive or emotionally stimulating content such as gaming or social media. Thus, future studies should evaluate the distinct contributions of screen categories to child mental and behavioral health.

Research indicates that effective interventions to reduce ST among children include parental education about screen-related risks, the establishment of clear daily limits, and structured device-free periods, particularly during the hour before bedtime. Parental controls, monitoring tools, and family media-use plans can assist in regulating exposure. Encouraging outdoor activities, sports, hobbies, and regular social interactions provides healthy alternatives to excessive screen use. School-based programs may also support children by incorporating digital literacy and balanced media-use guidelines. Importantly, consistent parental role modeling and open communication about media habits significantly strengthen intervention outcomes. Together, these strategies can meaningfully reduce excessive screen exposure and promote children’s emotional and behavioral well-being.

Despite its strengths, this study has several limitations. The evaluation of sleep disorders relied exclusively on parental questionnaires without objective measures such as actigraphy, which may introduce reporting bias and reduce accuracy. Additionally, some parents found the checklist lengthy or sensitive, potentially affecting their responses. As an observational cross-sectional study without follow-up, causal relationships cannot be determined. The higher prevalence of sleep disturbances among younger children should be viewed as multifactorial, involving both ST and developmental sleep characteristics. Future prospective research is warranted to clarify the etiology of neurobehavioral disorders in school-going children.

This study demonstrates that ST, sleep disturbances, and exposure to mature-rated video games are significantly associated with neurobehavioral problems in school-going children. Preadolescents exhibited higher daily ST, more frequent sleep-related difficulties, and greater behavioral challenges than adolescents. These findings underscore the need for age-specific strategies to regulate screen use and strengthen sleep hygiene, particularly in younger children, to mitigate negative behavioral outcomes. Further longitudinal studies are needed to explore these relationships and assess the impact of targeted interventions on child mental well-being.