Digital Devices Use and Fine Motor Skills in Children between 3–6 Years

(1) Background: The principal aim of our research was to explore the relationship between digital devices use and fine motor skills in children aged three to six years and to explore the effect of some socio-demographic factors. (2) Methods: we enrolled 185 children aged between three to six years. The parents of all the participants fulfilled a questionnaire to explore the digital device use, and their children performed a standardized test to assess fine motor skills (APCM-2). We performed the Spearman correlation test to explore the relationship between different variables. (3) Results: the children spent an average of 3.08 ± 2.30 h/day on digital devices. We did not find a significant association between the time of use of digital devices and fine motor skills (p = 0.640; r = −0.036). The youngest children experienced digital tools earlier than older ones (p < 0.001; r = 0.424) and they were also the ones who used digital tools more time afterwards (p = 0.012; −0.202). The children who had working parents spent more time on digital devices (p = 0.028; r = 0.164/p = 0.037; r = 0.154) and used digital devices earlier (p = 0.023; r = 0.171). (4) Conclusions: This data suggest that it would be useful to monitor the use of digital tools, especially in the very first years of life. Future studies are needed to further explore this topic.


Introduction
In recent years, digital technologies have progressively become an integral part of the life of children and adolescents as indispensable tools for communication, relationships, and learning [1][2][3][4].
In particular, the "intuitive" technology of the new digital tools (e.g., smartphones and tablets) is very attractive and greatly stimulates the curiosity of younger children, that, with a single gesture of the finger, can access screens, images, videos, and sounds [5].
The COVID-19 pandemic and its social consequences have widened digital device use and further lowered the age of those that access digital technologies, reinforcing a trend already underway in recent years [14][15][16][17][18].
Digital tools offer children many growth opportunities, but, at the same time, they can lead to risks. Some authors suggested that the use of digital tools constitutes a "passive" video viewing, etc.). Furthermore, high-quality learning apps would be preferable, and co-viewing by an adult is very important to mediate the use of the device in order to improve the child's learning experience.
Based on this evidence, the principal aim of our research was to evaluate the relationship between fine motor skills and digital device use in children aged three to five years. The secondary aim was to explore the modality of use of digital tool in this age group and to evaluate how some socio-demographic variables can affect the relation between fine motor abilities and digital device use.

Participants
Our cross-sectional observational study explored digital devices use and fine motor abilities in children, recruited from four kindergartens of the city of Salerno (Italy).
We included all the children aged between 37-72 months; the exclusion criteria were: (i) medical or neuropsychiatric diagnoses that could affect neuropsychomotor development (autism spectrum disorder, intellectual disability, language disorder, psychomotor development delay), (ii) poor child compliance to perform neuropsychological evaluation, and (iii) poor parental compliance.
The parents of all the participants had a preliminary meeting with a child neuropsychiatrist, who informed them about the methods and the purpose of the study. Written informed consent was collected for all the participants.
All the parents that took part in the study completed the Digital Devices Questionnaire, a non-standardized tool that investigated the frequency and the modality of digital device use by their children.
Our study was conducted in agreement with the Helsinki declaration and was approved by the Campania Sud Ethics Committee (number of the protocol = 0033986 of 5 March 2019).

Questionnaire on Digital Device Use
The questionnaire on digital devices is composed of two sections: a first part, in which general data, socio-demographic information, and medical history (age, sex, household members, siblings number, parents' educational background and employment, pregnancy, childbirth, psycho-motor progression, and medical conditions) were collected, and a second part examining the use of digital devices in children, based on 12 items, as follows:

APCM-2-Abilità Prassiche e Della Coordinazione Motoria-2a Edizione
The test "Abilità Prassiche e della Coordinazione Motoria (Praxic and Motor Coordination Skills)-2nd Edition" (APCM-2) is an Italian test developed and validated by Sabbadini [46]. This test aims to assess motor and praxis skills in children aged between 2-8 years. This tool includes 6 forms, divided into different by age subgroups: 24-36 months (short version and complete versions), 37-48 months, 49-60 months, 61-72 months, and 6.1-8 years. This test includes the evaluation of two scales: (a) motor strategies (eye motions, movements of hand and fingers, balance and coordination, sequencing), and (b) adaptive cognitive processes (symbolic gestures, constructive praxis abilities, manual skills, graphomotor skills, dynamic coordination). In our research, we considered only the last scale mentioned. Raw scores were converted into weighted scores and percentiles scores (a score <5 • percentile was considered under the norm).
The standardization sample comprised 261 children aged from three-eight (54% = boys, 46% = girls). Internal consistency for both scales (motor strategies and adaptive cognitive processes) was higher than 0.75.

Statistical Analysis
We expressed the continuous variables as mean ± standard deviation and categorical variables as proportions/percentage.
We performed the Shapiro-Wilk normality test to verify the data distribution. Due to the presence of data with non-normal distribution, we employed non-parametric tests for our analysis. We performed a Spearman correlation test and multivariate regression analysis in order to explore the relationship between the different variables; p < 0.05 was considered statistically significant.
Statistical Package for Social Science, version 23.0 (IBM Corp, 2015) was employed to analyze all data.

Sample Characteristics
We recruited 185 children (105 males = 57%; 80 females = 43%) aged between 37-72 months (mean = 55.02 ± 9.50). All kindergarten children were recruited (except two children with certified disabilities). All the subjects recruited agreed to participate in the study. All parents filled in the questionnaires, and all children had good compliance with the APCM-2 test, so there was no missing data.
The socio-demographic features of the sample are reported in Table 1.
In our sample, the children spent a total mean time on digital device of 3.08 ± 2.30 h/day, preferring television (1.57 ± 1.22 h/day) and smartphone (0.88 ± 1.02 h/day).
In our sample, the parents reported that most of the children used the digital devices with their parents (119/185, 64%) or brothers/sisters (21/185, 11%) or with parental control (31/185, 18%), and an amount of 11% of children used digital devices alone (21/185).
Some parents reported absorbent behaviors in their child when they used digital devices. In particular, some children did not respond when called (10/185, 5%), did not

Relation between Digital Devices Use and Fine Motor Skills in Children
We did not find statistically significant relationship between the APCM-2 scores and digital device daily time use (smartphone, tablet, personal computer, videogames) ( Table 3). Table 3. Spearman correlation test between fine motor skills and use of digital device. p < 0.05 are in bold. We found a positive significant relationship between start age of use smartphone/tablet and the APCM-2 weighted score (Table 3; Figure 1).

Relation between Digital Devices Use and Fine Motor Skills in Children
We did not find statistically significant relationship between the APCM-2 scores and digital device daily time use (smartphone, tablet, personal computer, videogames) ( Table  3). We found a positive significant relationship between start age of use smartphone/tablet and the APCM-2 weighted score (Table 3; Figure 1). To exclude the effect of age on this relationship, we performed a multivariate regression analysis. Adding age as a covariate the relationship between start age of use and the APCM-2 weighted score is no longer statistically significant (smartphone p = 0.109, ß = 0.239; tablet p = 0.056, ß = 0.393; total p = 0.297, ß =0.178).
We found that total daily time of digital device use, daily time of smartphone use, and daily time of television use were negatively related to age to start using digital device (Table 4; Figure 2).
Daily time of smartphone use was positively related to the mothers' and fathers' jobs and negatively related to the fathers' degree (Table 4).
Daily time of personal computer use was negatively related to the mothers' degree (Table 4). Daily total time of all digital device use was positively related to the mothers' and fathers' jobs ( Table 4).
The age of start to use all digital device was positively related to the age of child, except for television (Table 5; Figure 3). To exclude the effect of age on this relationship, we performed a multivariate regression analysis. Adding age as a covariate the relationship between start age of use and the APCM-2 weighted score is no longer statistically significant (smartphone p = 0.109, ß = 0.239; tablet p = 0.056, ß = 0.393; total p = 0.297, ß =0.178).
We found that total daily time of digital device use, daily time of smartphone use, and daily time of television use were negatively related to age to start using digital device (Table 4; Figure 2).  The age of starting use of tablets was positive related to the fathers' and mothers' degrees (Table 5). The age of starting use any digital device was positive related to the fathers' job (Table 5). Table 5. Spearman correlation test between age of start to use digital device and other sociodemographic characteristics. p value < 0.05 are in bold. Daily time of smartphone use was positively related to the mothers' and fathers' jobs and negatively related to the fathers' degree (Table 4).

Start
Daily time of personal computer use was negatively related to the mothers' degree (Table 4).
Daily total time of all digital device use was positively related to the mothers' and fathers' jobs ( Table 4).
The age of start to use all digital device was positively related to the age of child, except for television (Table 5; Figure 3).    . Relationship between children age and age of start using smartphone (r = 0.424; p < 0.001).

Start Age of Use DD
x axis = children age (in months); y axis = age of start using smartphone (in months).

Discussion
The principal aim of our research was to explore the digital devices use in children aged between three to five years and their relationship with fine motor abilities. We considered a sample of 185 typically developing children (57% male; mean age = 55.02 ± 9.50 months; Table 1) that performed a standardized test that assessed fine motor abilities (APCM-2), while the modality of use of digital device was explored through a questionnaire addressed to their parents.
Regarding the first question of our study, we did not find a significant relation between time of digital device use and fine motor abilities in our sample (Table 3). In particular, the time spent on digital devices was not significantly associated with neither an improvement, nor a deterioration, of performance in grapho-motor skills and manual coordination. We must underline that we have not performed qualitative analyses on the modality of digital device use (use of "educational" applications, "active" or "passive" use of digital tools, and possible parent/caregiver involvement during the use).
We found a relationship between the first age of use of digital device and fine motor skills (Table 4) (the children who used digital tools early had worse fine motor performance). However, this result cannot be considered significant because it is affected by the effect of the age of children on this relationship.
We also found that some socio-demographic characteristics were associated with the daily time of use of digital tool, such as the age of first use (Table 4). Interestingly, the correlation analysis showed that children who used digital devices earlier were those who spent more hour/day with them. It would be interesting, in future studies, to explore the relationship between the first age of use of digital tools by children and the time spent with them in the school age and in adolescence, in consideration of the growing phenomenon of "digital addiction".
In addition, we found that the start age of use of digital device was also related to the age of the child (Table 5), confirming the phenomenon of "digital anticipation", because younger children use digital technologies more and more precociously [1][2][3][4].
Another significant correlation was found between the daily time on digital devices/age of start to use digital device and the parent's job. The children who had working parents spent more time on digital devices (Table 4) and used digital devices earlier (Table 5). In this regard, we must not forget the fundamental role played by parents in digital device exposure [12,13].
Finally, the correlation analysis did not show significant differences between males and females in the modality and in times of use of digital devices, except for video games, which were preferred by males (Tables 4 and 5).
Our research agreed with the cross-sectional study of Moon and colleagues (2019) [37]. The authors enrolled 117 children between three to five years, divided into three age groups, and administered to their parents a questionnaire to evaluated the relationship between smart device use and language, as well as motor and social skills. In children aged three years, the authors found that smart device use was positively related with fine motor skills and negatively associated with language, but no significant relationship was found for children aged four to five years.
Contrary to our study, there is some evidence of both negative and positive correlation between digital device use and fine motor abilities.
The review of Arabiat and colleagues [37], which considered 53 studies on children under seven years, concluded that children's use of interactive digital tools was positively associated with language abilities and negatively associated or unrelated to motor skills. Furthermore, the authors highlighted that the measurements of intensity and duration of digital device exposure were often imprecise.
The study of Zheng and Sun (2021) [41], which involved 877 children aged three-six years, concluded that the time spent on digital tools negatively predict fine and gross motor skills of children (particularly the passive use was negatively associated to school performance and fine motor abilities). Kiefer et al. (2015) [38] considered 23 preschool children divided into two groups, the first group of 11 children using the keyboard and the second of 12 children using handwriting, with the aim of determining whether there was a difference between the two groups in writing skills. The authors found that the handwriting group had better writing skills. Lin et al., (2017) [39] monitored 40 preschool children who used tablets for more than 60 min per week for 24 weeks, comparing them to 40 age-and gender-matched children participating in a hand skills program. The authors found that motor performance improved only in the control group.
In another study by Lin (2019) [40], the authors compared 36 tablet-using children and 36 non-tablet-using preschoolers, showing that the children in the non-tablet group performed significantly better in fine motor tasks.
Some studies also found some benefits in fine motor abilities of children using an iPad [42] or notebook application [44]. On the contrary, Axford et al. (2018) [42] suggested no benefits for children that use an iPad over 30 min/day.
The cross-section study of Souto et al. (2020) [45] considered 78 children aged between 24-48 months, divided into two groups: frequent use of tablet (n = 26) and no experience of tablet use (n = 52). The Bayley Scale of Infant Development III was performed to explore the relationship between fine motor abilities and interactive tablet use. Most of the children performed both active and passive activities, usually accompanied by their parents, not exceeding the recommended times. The major finding of the study was that the children using tablet performed slightly better than the other group.
This apparent discrepancy between our results and those found in the literature may be due to the fact that, in our study, we only considered the total time of digital device use, but we did not consider other factors, such as the employing of "educational" applications and the role of parents while children used the digital tools.
Analyzing the digital device questionnaire, we found that all the children used at least one of the digital tools (smartphones, tablets, television, personal computers, or videogames) ( Table 2). These data agree with the recent literature studies, according to which the use of digital tools in pre-school age has greatly increased, reflecting both the increasing use of digital tools by families and contemporary society [1,4].
The children preferred television (72%), smartphone (71%), and tablet (41%) ( Table 2). Comparing these data with our previous research, we can observe an increase in the preference for the Tablet in children aged three to five years vs. children under three years [6].
The digital tool used first by children was television (mean age of first use = 17.15 ± 8.99 months), followed by smartphone (29.56 ± 13.30 months), tablet (31.66 ± 12.41 months), PC (34.90 ± 16.74 months), and videogames (43.71 ± 16.88 months) ( Table 2). These results, compared to those of children under the age of three, show that, in younger children, there is an increasingly precocious exposure to digital devices (for example, in children between the ages of three to five, the first use of the smartphone was at 29.56 ± 13.30 months, while, in children under three, it was 15.6 ± 5.8 months). This "anticipation" phenomenon had already been underlined in several previous studies [6,47,48].
The parents reported that the mean daily use of digital device was about 3 h/day, according to many recent survey [1][2][3][4] ( Table 2). The most commonly used digital tools are television (1.57 ± 1.22 h/day), the smartphone (0.88 ± 1.02 h/day), and the tablet (0.43 ± 0.71) ( Table 2). It is important to underline that, compared to children under the age of three, children in our sample spent an average of one hour more a day using digital tools [6], exceeding the limits recommended by scientific societies [30,31].
An amount of 64% of children used digital devices with parent/caregiver or siblings (11%), but 11% and 18% of them used digital tools alone or with automatic parental control, respectively ( Table 2).
The parents allowed their children to use digital devices to entertain (70%), during mealtime (30%), to calm down (25%), and to let the children sleep (13%), suggesting that the parents mainly using these tools as "peacekeeper" while they are engaged in other activities [12,13,49] (Table 2).
Some parents reported atypical behaviors in their children during the digital device use: the children did not respond when called (5%), they did not interact (2%), and they appeared frustrated when the digital tool was take away (7%) ( Table 2). This result confirms that digital devices use in some children can compromise social interaction and lead to an emotional deregulation [36,37].
In our sample, sleep problems were reported in 19% of children (Table 2). A relationship between sleep problems and excessive digital media use by children had already been highlighted [50,51].
An amount of 43% of parents say they are concerned about the digital devices use on their child's health. However, only 18% of them asked pediatricians for advice on this topic ( Table 2).
This study has several limitations. First of all, the use of parental questionnaires to monitor the modality of use of digital tools is not free from possible bias. Furthermore, the study only included children aged three to five years, which limits the generalizability of its findings to other age groups. Additionally, the study did not investigate all potential confounding factors that could influence the relationship between digital device use and fine motor skills. Finally, we did not consider other environmental factors that could impact childrens' digital habits, such as time spent on digital devices by their parents, as well as the use of "educational apps", and we did not differentiate between "active" or "passive" co-viewing. We, therefore, propose to explore these aspects in future research.
The strength of our work is the sample size and the use of standardized and direct neuropsychological tests to assess fine motor skills in children.
The results of our study have several practical implications, as they help to better define the possible impact of digital devices on the psychomotor development of children. Based on our results, it would be useful to monitor the time spent by children on digital tools, the age of first use, but also the modality of digital device use in order to ensure the most correct use possible. Our results highlighted, also, that most parents are concerned about the effect of digital tools on their children's health, but only few of them ask for the support of pediatricians. Therefore, it would be important to implement the communication on this topic through information campaigns. In the future, it would be interesting to perform prospective studies that allow us to monitor the relationship between the digital devices use and other development skills (academic skills, as well as emotional and social-relational skills) during school age and adolescence, also with the aim of prevent the phenomena of digital addiction.

Conclusions
In our study, the children spent an average of about three hours a day on digital devices. We did not find a significant relationship between the time of use of digital devices and fine motor skills.
The youngest children experienced digital tools at an earlier age, and they were also the ones who used digital tools more time afterwards. This trend should be monitored over time in order to prevent the phenomenon of "digital addiction", especially in adolescents.
Future studies are needed to confirm these data and further explore the relationship between digital device use and fine motor skills, taking into account other aspects, such as content of digital device.
In the meantime, parents and pediatricians should be aware that the use of digital devices in children can bring both risks and benefits. Therefore, it is important not to exceed the time of use, to prefer active co-viewing with parents, and to encourage the use of quality educational applications.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Campania Sud Ethics Committee (protocol number = 0033986; det. N. 32-05 March 2019).

Informed Consent Statement:
Written informed consent has been obtained from the parents of the participants to publish this paper.

Data Availability Statement:
The data presented in this study are available upon request from the corresponding author.