The new study, published in the Journal of Activity, Sedentary and Sleep Behaviors, drew on five consecutive waves of the National Survey of Children’s Health, a nationally representative, parent-reported survey administered by the U.S. Census Bureau in partnership with the Maternal and Child Health Bureau. Researchers analyzed responses covering 135,309 children and adolescents aged six to seventeen, a weighted sample representing roughly 48.4 million young Americans. The data spanned 2018 through 2022, a window that captures life before the COVID-19 pandemic, the disruption of lockdowns and remote schooling, and the partial return to normalcy that followed.

The framework behind the analysis is the concept of 24-hour movement behaviors, an increasingly influential idea in pediatric health research. Rather than treating physical activity, sedentary screen use, and sleep as separate concerns, the approach recognizes that these behaviors are locked in a zero-sum relationship: every hour devoted to one is an hour taken from another. Under the relevant guidelines, children and adolescents should accumulate at least sixty minutes of moderate-to-vigorous physical activity daily, limit recreational screen time to two hours or less per day, and sleep between nine and eleven hours per night for children aged six to twelve, or eight to ten hours for adolescents aged thirteen to seventeen.

The pooled results paint a stark picture. Across all five years combined, just 20.8 percent of young people met the physical activity guideline, 49.6 percent met the screen time guideline, and 64.7 percent met the sleep guideline. Only 9.7 percent managed all three simultaneously. Because meeting multiple guidelines together is associated with the strongest health benefits, from cardiometabolic risk factors to mental well-being, that last number may be the most consequential in the entire analysis.

The trend lines are what make the findings genuinely alarming. Using robust Poisson regression models adjusted for age, sex, race and ethnicity, household income relative to the federal poverty level, metropolitan status, and weight status, the researchers calculated predicted prevalences for each guideline in each year. Every combination of guidelines showed significantly lower adherence in 2022 than in 2018, with sleep the lone exception, remaining stable across the period. Screen time adherence fell from 52 percent in 2018 to 47 percent in 2022, while physical activity adherence dropped from 21 percent to 17 percent. Concurrent adherence to all three guidelines slipped from 9 percent to 7 percent. Cochran-Armitage tests for trend confirmed statistically significant downward trajectories across the board.

The single most dramatic shift occurred between 2019 and 2020, when screen time guideline adherence plummeted from 52 percent to 40 percent, a twelve-percentage-point collapse in a single year. The timing points unmistakably to the COVID-19 pandemic, when quarantine policies, remote learning, and the disappearance of structured routines reshaped children’s daily lives. Intriguingly, screen time adherence crept back upward in each year after 2020, though it never returned to its pre-pandemic level. The researchers interpret this partial recovery as evidence that screen behaviors are modifiable and responsive to environmental change, a potentially encouraging signal that schools reopening and routines resuming can pull behavior back toward healthier patterns.

Sleep tells a different story. Adherence to sleep duration guidelines held essentially steady across the five years, even rising slightly between 2018 and 2021 before dipping in 2022. The authors suggest several possible explanations: sleep duration may be biologically regulated and less sensitive to external disruption, parental control over bedtimes tends to be strong, and the pandemic may have produced offsetting effects, with the loss of early morning commutes and extracurricular commitments potentially allowing some children to sleep longer even as stress and disrupted routines eroded sleep quality. The researchers caution, however, that the guidelines measure only duration, not sleep quality, consistency, or timing, all of which influence health. Stable duration should not be read as evidence that sleep health went untouched.

The analysis also revealed persistent disparities that did not narrow over time. Girls showed significantly lower adherence than boys to the physical activity guideline and to every combination involving it, while showing higher adherence to screen time guidelines. Children fared better than adolescents on nearly every measure, a gap the authors attribute in part to the transition to secondary school, which brings heavier academic demands, more homework, and extended evening screen use, as well as the growing autonomy of adolescence, which brings less parental oversight, more device access, and shifting chronotypes that push bedtimes later while school start times stay fixed. Young people with overweight or obesity had significantly lower adherence to every guideline than those without, a bidirectional relationship the authors note cannot be untangled with cross-sectional data but which prior research suggests runs in both directions.

The public health stakes are considerable. Meeting these guidelines is linked to cognition, academic achievement, motor skills, mental health, and the risk of non-communicable diseases including obesity and diabetes. A generation that increasingly fails to meet them faces elevated risks of chronic disease and added strain on an already burdened healthcare system. The authors argue the findings support multi-level interventions tailored to the subgroups at greatest risk, and they make a pointed structural recommendation: unlike Canada, Australia, and several other countries, the United States still lacks integrated 24-hour movement guidelines, relying instead on separate recommendations for activity, screens, and sleep. Recognizing these behaviors as a single, co-dependent cycle, they argue, could set the stage for the widespread adoption and promotion that individual guidelines have so far failed to achieve. With fewer than one in ten young Americans currently clearing all three bars, and the trend moving in the wrong direction, the case for treating the whole day as one health target has rarely been clearer.

Subject of Research: Trends in adherence to 24-hour movement behavior guidelines among U.S. children and adolescents from 2018 to 2022

Article Title: Five-year trends in U. S. child and adolescent 24-hour movement behavior guideline adherence, 2018–2022

Article References: Pfledderer, C. D., Mullane, E. J., Brown, D. M. Y., Burkart, S., Hunt, E. T., Johnson, A., Parker, H., & Salvo, D. (2025). Five-year trends in U. S. child and adolescent 24-hour movement behavior guideline adherence, 2018–2022. Journal of Activity, Sedentary and Sleep Behaviors, 4(1), Article 16. https://doi.org/10.1186/s44167-025-00086-8

Image Credits: AI Generated

DOI: 10.1186/s44167-025-00086-8

Keywords: 24-hour movement behaviors, physical activity, screen time, sleep, children and adolescents, National Survey of Children's Health, COVID-19 pandemic, public health, obesity, health disparities, pediatric health, behavioral interventions