Television and media violence

INTRODUCTION — Violence continues to be a major cause of death and disability for American children. Exposure to television/media violence is an important and ubiquitous risk factor for youth violence [1,2]. A 60-year literature review of screen violence and youth behavior found compelling evidence that violent screen media constitutes a causal risk factor for increased aggression [2]. Although the violence depicted is "virtual" in that the child does not witness it in person, the violence often affects real people (eg, news reports) [3]. Pediatric care providers and caregivers can work together to decrease the exposure of children to media violence (primary prevention) and, if exposed, to mitigate the effects (secondary prevention).

In broad terms, the impact of any influence on health behaviors is the product of the number of persons exposed and the magnitude of the effect of the exposure. This review first explores the ubiquity of exposure of children to television and media violence, then reviews studies that have established the negative consequences of this exposure, and concludes with suggestions for clinical interventions. Much of the research reviewed was conducted in the 1980s and 1990s, when the influence of media exposure on children was first established. Since then, the variety of media available has exploded, although there is no reason to believe that the exposure to media violence has decreased.

The association between viewing violence and subsequent violent behavior and prevention of the consequences of media violence are reviewed here. Other types of violence are discussed separately:

●(See "Peer violence and violence prevention".)

●(See "Intimate partner violence: Epidemiology and health consequences" and "Intimate partner violence: Childhood exposure".)

●(See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)

QUANTITY OF MEDIA VIOLENCE EXPOSURE — Children ≥8 years of age and adolescents in the United States spend an average of >2 hours per day watching television, and at least six hours per day when all types of media are included (eg, movies, videos, digital music, video/computer/mobile games, social media, digital devices, etc) [4]. Children's television is the most violent genre of programming. Whereas violent acts (acts intended to injure or harm others) appear 8 to 12 times per hour on prime-time television, cartoons often show 25 to 50 violent acts per hour [5,6].

Movies are another source of violent content, and viewing gun use in movies may increase interest in guns in the real world [7]. In a review of 77 movies from 1999 and 2000 that were rated PG-13, nearly 90 percent had violent content, and firearms were used in nearly one-third [8]. Overall, 2251 acts of violence were observed, 47 percent of which were of lethal magnitude. Seven movies contained more than 100 acts of violence. In another review of 61 G- and PG-rated movies released between 1998 and 2002, 28 percent included characters with guns, 48 percent depicted gun threats, and guns were discharged in 15 percent [9]. However, the consequences of gun use (injury and death) were rarely portrayed. Depictions of gun violence in the top grossing PG-13-rated films have increased since 1985, and since 2009 have been as frequent or more frequent than in the top-grossing R-rated films [10,11]. A survey of 6522 United States adolescents aged 10 to 14 years in 2003 indicated that 12.5 percent had seen at least 1 of 40 movies that were rated R for violence [12]. (See 'Media violence is without consequence' below.)

Music videos and video games are additional sources of violent content. In a review of 518 music videos broadcast on television, 462 acts of overt interpersonal violence were portrayed [13]. Content analysis of 81 randomly selected video games for teenagers found that 98 percent involved intentional violence, 90 percent rewarded or required the player to injure other characters, and 69 percent rewarded or required the player to kill [14]. However, the data associating video game use with actual violent behavior remain controversial [15]. A 2016 statement from the American Academy of Pediatrics Council on Communications advises that most experts in the field agree on the potential harms of exposure to all forms of screen violence and states that "first-person shooter games, in which killing others is the central theme, are not appropriate for any children" [16].

The average American child who spends two-thirds of his or her television time watching prime-time television programs and one-third watching cartoons views 10,000 to 12,000 violent acts per year [17,18]. American children see an estimated 8000 murders and 100,000 acts of violence by the time they finish grade school and twice that many by the time they reach 20 years of age [19].

A random survey of 1051 families conducted in 2005 by the Kaiser Family Foundation demonstrated the continued early and consistent use of television by American families. Over 40 percent of infants less than one year old watch television daily; this proportion climbs to 80 percent by age two years [20]. More recent survey data indicate that regular screen use is initiated at age four months, and children younger than two years average over one hour of screen time daily [21]. In a 2020 report, 35 percent of three- to five-year-old children had their own smart phone or tablet, and average daily use was nearly two hours [22].

PROBLEMATIC CHARACTERISTICS OF MEDIA VIOLENCE — The effect of viewing violence depends upon the amount, the context in which it is seen, and the social message that accompanies the presentation. Although violence is portrayed in other media (eg, song lyrics, music videos, movies), television violence is best studied. On-demand television and video streaming over the internet have increased the availability of media access. Regardless of how it is delivered, television/media violence is understandable to preverbal and preliterate children because it does not rely on verbal or written language. Television/media violence differs from real violence in ways that affect its impact on children and adolescents.

Media violence is socially acceptable — Violence is used more often than patience, negotiation, or compromise to resolve conflict in the media. It is portrayed as an effective, socially acceptable, and normative way to solve problems, is used by heroes as well as villains, and often is rewarded [6,14,23]. In the study of music videos described above, for example, the protagonist of the video was the aggressor in 80 percent of the violent acts [13].

Media violence is without consequence — Violence in the media has a variety of dramatic functions but is rarely seen as painful. In cartoons, violence is meant to be funny; the victim, however seriously injured, reappears intact after the commercial break. In other programs, heroes typically are spared the effects of violence, and villains, even if they are killed, rarely suffer. In the National Television Violence Study, for example, only 16 percent of violent programs showed long-term negative outcomes; 73 percent of violent acts were unpunished [24]. In G- and PG-rated movies, injuries and deaths related to firearms are rare [9]. This portrayal of violence without pain is internalized by children and adolescents.

ASSOCIATION BETWEEN VIEWING VIOLENCE AND VIOLENT BEHAVIOR — Childhood television viewing is associated with increased risk of subsequent violence. Despite their limitations, multiple studies have demonstrated this effect; taken together, they meet the epidemiologic criteria for causality [17]. These criteria include [25,26]:

●A temporal relationship between variables

●Consistency of the association on replication

●Strength of association

●Specificity of association

●A coherent explanation that accounts for the findings

Temporal relationship — Several studies describe the temporal relationship between viewing of violence and subsequent violent behavior.

●A meta-analysis of field studies of children in controlled environments (eg, boarding school) who were assigned to view films that were violent or nonviolent and then monitored for a period of time by trained observers for aggressive or violent behavior demonstrated a clear and consistent association between the viewing of violent films and short-term violent or aggressive behavior [27,28].

These field studies do not show which children are particularly vulnerable to the effect of viewing violence, the duration of the effect, the effect of television viewed in private, or a dose-response relationship.

●A cohort of eight-year-old children from a county of New York State were followed for 22 years [29,30]. The socioeconomic status, caregiver styles, size of family, and the quantity and quality of television viewing were among the variables studied. Compared with their peers, boys who were reported to view and prefer violent television programming at age eight were approximately twice as likely to be arrested for a violent crime by age 30 years. A weaker association was found between viewing television violence at age 18 years and subsequent violence history by age 30, suggesting that eight-year-old children are more susceptible to media violence than are 18-year-old adolescents. No relationship was found between aggressive behavior at age 8 and subsequent viewing of television violence at age 19.

This study is limited by the lack of randomization and experimental manipulation and the inability to control for potential confounding variables.

●Population studies examined homicide trends in the American, White South African, and Canadian populations before, during, and after the introduction of television in each country [31,32]. The homicide rate doubled in each of these countries 10 to 12 years after the introduction of television.

These studies are limited by their inability to control for other contemporary trends or events (eg, the Vietnam War, the struggle over apartheid) that might also account for the homicide trends.

●In a controlled trial, third- and fourth-grade children at one school received an 18-lesson, six-month curriculum to reduce television, videotape, and video game use [33]. Compared with control children, children in the intervention school had decreased verbal aggression and decreased peer ratings of aggression. This study demonstrates the efficacy of television reduction as a violence prevention strategy, lending further support to the causal role of television in youth violence.

Consistency of association — Nearly every study examining the relationship between television or other media violence (including violent video games) and subsequent violent behavior has demonstrated a positive association [17,27,34-47].

Strength and specificity of association — In most studies, the association of television violence and subsequent violent behavior is significant and persists when a variety of other variables known to influence violent behavior are controlled [17,36,37,45].

The specificity of the association is supported by experimental studies demonstrating an association between reduced television viewing and reduced aggression in school-age children [33,48]. In addition, in a randomized trial, preschool children whose caregivers were encouraged to substitute high-quality/educational programming for aggression-laden programming (without reducing total screen time) and to watch the programs with their children for six months had a higher mean Social Competence and Behavior Evaluation score [49]. Finally, in observational studies, use of violent video games has been associated with a rise in salivary cortisol levels, as well as aggressive behavior [50-52].

Coherent explanation — The explanation to account for the association between viewing violence and subsequent violent conduct has two components. The first one is based upon the ways in which children learn how to behave. The second one is related to the desensitization to and normalization of violence.

Imitation and reinforcement — Social learning begins at an early age through imitation and positive or negative reinforcement of behaviors. As described above, several aspects of televised violence render its imitation appealing to children:

●The effectiveness

●The rewards that heroes receive for its use

●The lack of consequences

Support for this explanation comes from an early experimental study of preschool children who were shown one of three versions of a short film in which an actor hits and kicks a clown doll [53]. In the first version, the film ends after the violence; in the second, the actor is rewarded after the attack; and in the third, the actor is punished after the attack. The children were led to a room containing an identical clown doll after they viewed the film. The children who saw the first and second versions of the film tended to attack the doll in the same way that the actor had. The children who saw the third version did not attack the doll as often.

Additional support is provided by comparison of the portrayal of violence in American and Japanese television. In Japan, where violence more often is perpetrated by the villain and the consequences of violence (eg, suffering for the hero) are emphasized, society is less violent than in the United States [54,55].

Desensitization — Media violence, including violent video games, systematically desensitizes young people to violence [56]. The combination of ubiquitous violence and the successful use of violence by heroes in the media desensitize American children to the horror of killing.

The normalization of and desensitization to violence has three effects [57]:

●Increased likelihood of aggression

●Increased likelihood of being a victim

●The bystander effect

Children who are exposed repeatedly to media violence accept violence as a normal part of life and a way to solve problems. They learn that objecting to violence may lead to more serious violence. They may resign themselves to violence, fail to seek help, and become more susceptible to becoming victims. Bystanders who feel that physical violence is a normal part of life encourage others to fight or refrain from intervening to prevent a fight [58]. In contrast, when children learn sanctions against aggression, aggressive behavior decreases [59].

MODULATORS OF EFFECTS OF VIEWING VIOLENCE — Individual qualities of the viewer interact with the violence that is portrayed to produce a particular outcome in behavior [1,19]. Some individuals are strongly affected by certain program elements, whereas other elements have no effect. The circumstances that increase the likelihood that television violence will have behavioral consequences include [1,60]:

●The violence works for the protagonist

●The violence is justified

●The violence is pertinent to the viewer's life circumstance (eg, the perpetrator is similar to the viewer)

●The viewer is susceptible (eg, viewer is angry or provoked before the viewing)

The effect on individuals is influenced by temperamental and environmental variables [61]. Children who identify with violent media characters are likely to use aggression in their lives [36]. To the extent that children who witness aggressive solutions to interpersonal problems identify with the aggressive character, they fantasize about the aggressive behavior and remember the aggressive characters that they observe. The aggressive behavior then becomes habitual and interferes with social and academic success, leading to more regular television viewing, thus perpetuating a cycle of aggression, academic and social failure, violence viewing, and aggressive fantasizing.

Caregivers may be able to mitigate the negative effects of childhood media use. In a meta-analysis of observational studies, watching media with children and discussing the content ("active monitoring") was associated with decreased aggression, whereas simple media restriction was not [62]. In a subsequent cross-sectional survey of children age 10 to 18 years, active monitoring that supported the child's autonomy was associated with less aggression [63].

EFFECTS OF MEDIA VIOLENCE

News media — Although news media coverage is primarily directed at adults, children and adolescents may view or hear coverage of violent news events, and children may be deeply affected by such vicarious trauma. The impact of viewing acts of terrorism has been most directly studied and has been associated with symptoms of posttraumatic stress, anxiety, and conduct problems [64,65]. In an observational study, caregiver mediation reduced the effects of terrorism-related news [66]. Although there have not yet been published studies of the effects of media coverage of racially and ethnically linked violence and hate speech, or the mass shooting at an elementary school in Uvalde, Texas, anecdotal reports of anxiety and fear have been reported and related to both traditional and social media coverage. As with terrorism-related violence, it is reasonable to assume that school and caregiver interpretation and mediation may reduce anxiety and trauma-related symptoms following exposure to news reports of racially and ethnically linked violence or hate speech [67,68]. The American Academy of Pediatrics provides tips to help caregivers discuss racial, ethnic, and other forms of discrimination and violence with children.

Other types of media — Television violence produces several types of harmful effects on viewers [58,69-72]:

●An increased tendency for viewers of large amounts of television to behave violently toward others (aggressor effect) [73]

●An increased fearfulness of becoming a victim of violence, with a resultant increase in self-protective behavior

●An increased tendency to view the world as a hostile place, which leads to increased aggressive behavior [74]

●An increased callousness and desensitization toward actual violence (bystander effect)

●A cycle in which aggressive children who watch television violence identify with violent characters, act like those characters, and seek out more and more violent programming

Repeated exposure to television violence produces subtle shifts in how adult Americans view the world and contributes to a pessimistic perspective. Adults who watch large amounts of television are more likely to view the world with feelings of danger, mistrust, intolerance, gloom, and hopelessness than do adults with less television exposure [75]. Similar results are found in preschool children [76].This pessimistic world view has implications for policy making and individual actions. As an example, more Americans now own handguns than did in the past, despite the well-documented increased personal risk of injury or death associated with handgun ownership and the decline in the overall rate of violent crime [77,78].

Additional studies have focused on the use of violent video games. In addition to the passive effects of witnessing violence, video games enlist the user in the active roleplay of violent actions. Studies of the effects of violent video games on aggressive behavior have inconsistent findings. In a randomized trial, children who played or watched violent video games were more likely to touch a disabled handgun and to shoot at themselves or others [79]. One meta-analysis of observational studies evaluating the effects of violent video games concluded: "The evidence strongly suggests that exposure to violent video games is a causal risk factor for increased aggressive behavior, aggressive cognition, and for decreased empathy and prosocial behavior" [43]. However, a subsequent meta-analysis of observational studies argued that the effect size is minimal after appropriately controlling for covariates and, in particular, called on experts to refrain from blaming mass shootings on video game use [80].

ADVOCACY — Pediatric care providers can address the problem of media violence and associated violent behavior at three levels: the family, the community and school, and the legislative and regulatory approaches.

Family and individual — Pediatric care providers discuss caregiver practices and offer anticipatory guidance at most health supervision visits. The provision of advice regarding television/media fits well into this practice.

The television/media history has three main questions:

●Where are the televisions/computers located in the household?

●How much television does the child watch or media does the child use after school, after dinner, and on weekends?

●What are some of the child's favorite shows and digital activities?

Caregivers should be educated about the adverse consequences of television/media use (eg, exposure to violence, obesity, and decreased school achievement) [41,81-87] and then advised about ways to decrease the exposure and the effects of media violence. Specific and efficient advice maximizes the effect [16,17,85-89]:

●Avoid media use in children younger than 18 months (except for video chatting with relatives)

●Limit media time to less than one hour per day for children age 18 months tho 5 years (except for video chatting with relatives)

●Remove television sets and computers from children's bedrooms and recommend that children not sleep with other devices (eg, smartphones) in their bedrooms

●Discourage television and screen media use (except for video chatting) for children younger than 18 months

●Monitor the shows that are viewed and digital games that are played by children and adolescents; avoid violent content for children younger than five years

●View media with children and discuss the content:

•Is this real or pretend?

•Is this how we do things at home?

•What do you think would happen if you did that?

●Play digital games with children and adolescents to better understand what the games entail

●Use controversial programming to initiate discussions about family values, violence, sexuality, and drugs

●Encourage alternative entertainment for children (eg, reading, athletics, hobbies, and creative play)

●Use devices to block unauthorized television/media if necessary (eg, a lock for the television's electrical plug)

●Develop a "family media plan" (the American Academy of Pediatrics provides tips and additional resources)

Medical care settings should set an example for the above recommendations [90-92]. Reading programs using volunteers should be implemented in waiting rooms and inpatient units. Televisions in hospitals, offices, and clinic waiting areas should be tuned to nonviolent programming and display a sign that says: "This television is tuned to a public television channel so that children can watch nonviolent shows."

School and community — Pediatric care providers who are consultants to schools, hospitals, or caregiver groups should emphasize the importance of diminishing the exposure of children to televised violence [91,92]. As an example, pediatric health care providers can support community-based "television turn-offs" and media literacy programs to teach children critical viewing skills [90].

Legislation and regulation — The long-term goals of legislative and regulatory advocacy include decreased frequency and different characterization of violence (eg, with consequences) and the promotion of alternative strategies for conflict resolution.

Pediatric care providers should be aware of policies and proposed policy changes in government and industry regulation and should try to focus their advocacy efforts on simple measures that do not impinge on the First Amendment rights of broadcasters. Pediatric care providers should work with the entertainment industry to encourage responsible programming and compliance with the major broadcast networks' standards regarding television violence. These standards proscribe [16,90,93]:

●Gratuitous or excessive depictions of violence

●Depictions of violence as glamorous

●Depictions of violence as an acceptable solution to human conflict

●Depictions of violence designed to shock or stimulate the audience

●Scenes showing excessive gore, pain, or physical suffering

In addition, the standards urge that the consequences of televised violence be portrayed and that portrayals of callousness or indifference to suffering experienced by the victims of violence be avoided.

The Children's Television Act of 1990 and the Revision of Programming Policies for Television Broadcast Stations called for an increase in the quality of children's programming [94,95]. In the past, broadcasters were required to air educational and informational programming at least three hours per week, to limit the amount of advertising during children's programming, and to label the shows E/I (educational and informational) on the screen. These regulations were substantially relaxed in 2019 [96]. Pediatric advocates can use the provisions of these acts to work with their local broadcast stations to develop violence-free programming [90,97].

The Telecommunications Act of 1996 gave the broadcasting industry an opportunity to establish voluntary ratings for programming that contains sexual, violent, or other content that caregivers may consider inappropriate for children [98]. Although caregiver and industry raters may disagree on what is appropriate viewing for children of various ages [99], the rating system is a first step in helping caregivers choose programming for their children. The rating system and the "v-chip" enable caregivers to prevent certain programming from entering their homes.

The United States Federal Communications Commission has adopted rules requiring all new television sets with screens larger than 33 cm to be equipped with v-chips. However, reports indicate that less than half of purchasers of these televisions are aware of the v-chip, and only a tiny minority use them [100]. So, for the time being, caregiver, rather than electronic, controls will mediate the exposure of children to television violence.

SUMMARY

●Quantity of media violence exposure – Children ≥8 years and adolescents in the United States spend an average of six hours per day watching television, playing video games, or using computers. Children's television (particularly cartoons), movies, music videos, and video games are potential sources of violent content. (See 'Quantity of media violence exposure' above.)

●Problematic characteristics of media violence – The effect of viewing violence depends upon the amount, the context in which it is seen, and the social message that accompanies the presentation. Televised violence differs from real violence in ways that affect its impact on children and adolescents. Media violence often is perceived as socially acceptable and without consequence. (See 'Problematic characteristics of media violence' above.)

●Association between viewing violence and violent behavior – Despite their limitations, multiple studies have demonstrated that childhood television viewing is associated with increased risk of subsequent violence by demonstrating a temporal relationship; consistency, strength, and specificity of the association; and a coherent explanation for the association. (See 'Association between viewing violence and violent behavior' above.)

●Modulators of effects of viewing violence – Individual qualities of the viewer interact with the violence that is portrayed to produce a particular outcome in behavior. Some individuals are strongly affected by certain program elements, whereas other elements have no effect. The effect on individuals is influenced by temperamental and environmental variables. (See 'Modulators of effects of viewing violence' above.)

●Adverse effects of media violence – Adverse effects of increased exposure to media violence may include (see 'Effects of media violence' above):

•Increased tendency to behave violently toward others (aggressor effect)

•Increased fearfulness of becoming a victim, with a resultant increase in self-protective behavior

•Increased callousness and desensitization toward actual violence (bystander effect)

•A cycle in which aggressive children who watch television violence identify with violent characters, act like those characters, and seek out more and more violent programming

●Advocacy – Pediatric care providers can address the problem of media violence and associated violent behavior at three levels: the family, the community and school, and the legislative and regulatory approaches. (See 'Advocacy' above.)