The increasing use of digital devices by children and adolescents worldwide has led to major concerns regarding the impact of screen time on their health (1). Excessive recreational screen time (> 2 h per day as defined by the Sedentary Behavior Research Network) is associated with negative health outcomes, including myopia which is also known as nearsightedness (1–3).

Myopia is the most common refractive error of vision worldwide, with rates increasing during the past decades, in particular among youth (4). A study in Europe showing that nearly half of the present younger demographic of 25 to 29-year-olds being myopic has however raised concerns as early development of myopia increases the chance of high myopia during adulthood (5, 6). High myopia (−6D or stronger) significantly increases the risks of ocular complications leading to blindness later in life (7). Environmental factors in childhood increase the risk of myopia. Well-established risk factors are: prolonged exposure to classroom education, limited outdoor exposure, and continuous near work activities like reading and the use of near screens such as smart phones and tablets (8–12).

Among children aged 9–12, often referred to as “tweens,” the balance between beneficial and detrimental effects of screen time is a pressing issue for parents and health professionals alike (13, 14). Tweens have a significant number of years of ocular growth ahead of them, while at the same time they often already have relatively unrestricted access to (personal) digital screens, a setting that challenges parental management. This makes the development of a potential follow-up intervention for this age group both promising and valuable. Parental behavior plays a critical role in determining how effectively screen time is managed, with various behavioral determinants influencing the strategies parents employ. Parental attitudes toward screen use, self-efficacy in managing children's activities, and the modeling of screen behaviors are key determinants that shape children's screen habits (15).

Parental management has been shown to be effective in the reduction of screen time exposure (16). However, evidence lacks on the specific determinants of parental behavior, including the underlying factors of influence in order to develop more targeted interventions (17, 18). Strong evidence shows that increasing awareness of the risks of near screen use among parents may significantly lower children's screen time (19). Campaigns to increase this awareness, guidelines on screen time, and finding ways to overcome barriers to implementing such guidelines are necessary, but require more evidence on behavioral determinants for their proper targeting (20). The 20-20-2 rule (20 min screen use followed by 20 s gazing in the distance and a minimum of 2 h a day spent outside) is propagated by the Dutch Eye Fund for this purpose (21). However, behavioral change is complex, and implementation remains a challenge.

The aim of the study was to assess near screen use among children and to gain insight into the behavioral determinants that affect parental management skills of child screen use.

The aim of the study was to assess near screen use among children and to gain insight into the behavioral determinants that affect parental management skills of child screen use. Regarding near screen use, the greater part of the children in this study had their own smart phone, and about a quarter of them spent more than 2 h a day on near screens at home.

Our study based on questionnaires is one of the few which shows the time spent on recreational handheld screens and the attitude of parents in the Netherlands regarding screen use, showing 26% of 9–12 years olds to exceed 2 h of screen use/day. WHO advice a maximum of 2 h of screen time a day for children above 5 years of age and this involves all types of screens ranging from TV to smartphones (24). Similarly, various other guidelines also advise recreational screen time to be no more than 2 h a day (24). Our findings evidently show screen time of a significant part of tweens to exceed these recommended daily limits.

Regarding parental management skills, almost two thirds of the parents made an effort to reduce this screen time. Parental knowledge, a high-risk perception of screen use and a negative attitude toward screens, was associated with more efforts to minimize screen time. When it comes to parental knowledge, we found that only few parents were aware of recommended screen time and complementary advice, such as the 20-20-2 rule, even though a majority had knowledge on myopia. This confirms previous findings that knowledge of parents is generally limited when it comes to child lifestyle issues (25). Nevertheless, our study showed that knowledge was associated with more efforts to minimize screen use.

To aid interpretation of the logistic regression results, average predicted probabilities were calculated. Parents who had heard of myopia had a predicted probability of 59.3% to reduce screen time, compared to 35.7% among those who had not. This substantial difference (23.6%) supports the significant odds ratio of 2.62, and highlights the practical relevance of increasing parental awareness about myopia. This confirms findings from other studies showing that parental knowledge and attitudes profoundly affect the health-related behaviors they model and enforce in their children. For instance, one study showed that parents who are knowledgeable about the benefits of physical activity are more likely to encourage outdoor play and limit sedentary behavior like screen time (26). Findings were similar for parental attitudes: parents who had a negative attitude toward technology and entertainment as a goal on screens and who believed that children spent too much time on them were more often strict in their approach than parents who did not have this attitude (27). Parents primarily seem to require a framework defining what constitutes “healthy” and “normal” screen usage in children. The WHO has advised the 0-1-2 rule: no screens until the age of 2 years, maximum 1 h between 2 and 5 years, a maximum of 2 h above 5 years. An optimal approach would be the combination of the Dutch 20-20-2 rule and the German 3-6-9-12 rule (European Journal of Public Health, accepted voor publication) (28). The German rule can be explained as follows: Until the age of 3 years, no screen media exposure; from 3 to 6 years usage limited to a maximum of 30 min a day under parental supervision; from 6 to 9 years a max. of 30–45 min recreation time and between 9 and 12 years maximum recreation time between 45 and 60 min, and own no game console. Recently, the Dutch government has released a guideline (based on consensus and involving parents and professionals) regarding healthy screen use among children. The 20-20-2 has been integrated in this guideline.

We found an association between risk perception and screen use regulation: the higher the parental perception of the risks, the more efforts parents made to reduce screen use. This is in line with other studies reporting that parents who exhibited higher levels of risk perception regarding screen use and greater confidence in their parenting abilities were more proactive in mediating their children's eye care behavior (29).

In our study, higher self-efficacy was associated with less parental efforts to reduce screen time, which is an unexpected finding. However, other studies have shown that the relationship between parental self-efficacy and parenting competence can be moderated by the parent's knowledge of child development (30, 31). Furthermore, several studies demonstrate a negative relationship between parental self-efficacy and parenting competence, especially when self-efficacy is not supported by sufficient knowledge or realistic expectations about parenting (32–34). This negative relationship is especially the case when parents have confidence in their parenting skills but simultaneously lack knowledge, understanding, or competence in their child's development, which can lead to ineffective or even problematic parenting practices (35). This suggests a strong synergy between self-efficacy and knowledge: confidence in parenting is valuable, but without the right knowledge, it can be counterproductive (35). Parents may unintentionally make wrong choices because they rely too much on themselves, without having the proper information or tools to decide effectively (33, 36).

We found no significant relationship between perceived social influence and parental efforts on screen use. In contrast, other studies did find this relationship. One study found that parental perception of social norms, or the opinion of people in their nearby surroundings, about screen use has a profound effect on their behavior and the health outcomes of their children (37). An explanation may be that social influence in our study was assessed by only one question focusing on other families, also expressed as descriptive norms, while it can be interpreted much broader than perceived influence as intended. For instance, cultural beliefs and values can also shape parents' perceptions and strategies to reduce screen time (38).

A strength of this study is, first, that it is one of the few which shows the time spent on recreational handheld screens among 9- to 12-year-olds, with a relatively large study sample. Second, the prevalence of spectacle wear among these children was 18.7% which emphasizes the need to monitor screen use, considering the fact that in another study 11.8% of Dutch children had spectacles at younger ages, i.e., at age 7 years (4).

This study also had some limitations. First, the questionnaire was filled in by children and parents jointly, which could have led to some information bias. A second limitation is that among parents those with a Dutch background, and of middle and higher education were overrepresented. Our findings should thus be confirmed in further research including more parents with a non-Dutch birth background and a lower education.

Our findings on the importance of knowledge regarding myopia and the 20-20-2 rule of lifestyle as determinant of parental behavior imply a need to increase awareness among parents. Evidence shows that parent training and education programs can increase both parents' knowledge and can build confidence, especially for parents who have excessive confidence without the proper knowledge base (33, 36). This would align with the need for parents to gain more insight into normal screen behavior. Enhancing skills could also be done directly or indirectly in collaboration with other professionals as parents have to feel that they can succeed in reducing screen use. Adopting healthy norms and associated emotions strengthen intentions to alter and increase the likelihood of achieving new behavior (39).

Excessive screen time among youth deserves public health attention. Most 9–12-year-olds had an own smart phone and their recreational handheld screentime, extrapolated to the entire day, exceeded the recommended limits. Our findings emphasize the need to address parental knowledge and attitude toward myopia, and the parental ability to reduce screens. Monitoring spectacle wear and initiating mass media campaigns to reduce screen use are warranted. The focus should be on increasing knowledge, influencing attitude, and addressing self-efficacy reaching a diverse public as well as collaboration with other professionals as a part of behavioral change strategies.