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Tablet vs book learning: Impact on memory, attention and learning skills

Objectives : Textbooks are the major source of instruction, yet many Lebanese schools have partially introduced electronic devices, and have discreetly started to rely on them. Given the reported discrepancies between textbooks and tablets learning in international literature, it is essential to conduct a Lebanese study that compares both entities. Therefore, the objective of this paper was to assess the impact of tablet use at school on memory, attention and learning abilities among Lebanese children. Methods: This cross-sectional study, conducted between January and May 2019, enrolled 566 students aged of 11-13 years. Three schools were chosen conveniently for this study, one of them uses the Tablet and text books for students’ learning whereas the second one uses text books exclusively. Students were randomly chosen from the list given by the school administration. Results : Textbook learning was significantly associated with lower episodic memory score (better episodic memory) and lower visual memory score (better visual memory), lower attention score (better attention), lower processing speed score (better processing speed), lower mathematic skills score (better mathematic skills) compared to tablets and textbook learning. Conclusion : Learning is evolving to another level and forever changing. Many studies should be conducted in order to understand the importance of merging new and old techniques to ensure that the next generations are receiving what can positively affect their cognitive skills and their performance.


Introduction
Education is must. It is a fundamental human virtue, an essentiality for society, and a firm basis for a healthy life 1 . Although education is not limited to schools, the intrinsic important aim of the expansion of human mental capacities starts in schools 2 . As a matter of fact, it is known that education improves the cognitive abilities in children: a meta-analysis done by Jennifer L. Carter et al. in 2019 points out a positive correlation between cognitive skills and education 9 . The cognitive skills of the human brain are very intriguing, yet essential in a healthy human brain to be able to manage his own decisions 3 . The main cognitive skills include memory, attention, and learning capacities, among others. It is mandatory to mention that the thread of the mental development of children depends upon the quality of education that is being transmitted, as well as the process in which the information is received. In this context, many schools have tried to shift from printed texts to electronic ones, while others held on textbooks only. Moreover, the debate whether electronic devices are more effective than textbooks in education or not is still ongoing 4 . Electronic devices are hypothesized to affect several aspects of education, such as memory, attention, learning capacities and academic performance (mathematical, reading and expression skills).
Memory can be divided into short term and long term memory. The short term is responsible of maintaining essential information for immediate purposes, accordingly, this data will be selectively relocated to long term memory 5 . Many types of memory could be highlighted such as the working memory which preserves recent acquired information and is helpful to recall data from the long term memory needed at a specific moment, the episodic memory which is essential to recall specific events, and the semantic memory which elicits objects, facts and concepts 6 . Many previous studies have explored the effect of tablets use on children's memory in comparison to textbooks use and found contradictory results. Wagner and Sternberg determined that students reading texts on tablets were not capable of remembering the details of the text 7 , while Belmore concluded that students who used electronic devices have increased reading speed and comprehension, thus a higher capacity to recall details 8 .
Attention is defined as "a psychological phenomenon that interacts with all other cognitive processes, such as perception, memory, behavioral planning or actions, linguistic production, and spatial orientation" 9 . It implicates several systems of the human brain to be able first, to process all the input acquired, second, to avoid distraction and focus on the selected resources and finally, to switch the attention from one stimulus to the other successfully 10 . According to a study conducted by Kropman et al., tablets use is tiresome compared to textbooks which decreases the attention span in children trying to focus for long periods every day 11 . In addition to that, a study found that 87% of teachers believe that nowadays electronic and digital technologies are generating an easily distracted generation with short duration of attention maintenance, and that tablets in classrooms could conceivably do more harm than good.
Learning capacities largely depend on the way information is received. Many studies evaluated the impact of the electronic use on learning capacities and academic performances. Some studies revealed student's positive learning attitude towards the use of tablets and electronic devices in schooling 4 . The characteristics of tablets, such as unlimited internet access and being easy to carry were helpful 12 and made students more implicated in their learning. A study further showed that tablets' users tended to take notes directly, three times more than students using textbooks 13 . Other papers demonstrated that logical thinking and critical criticism were improved in children using tablets by enhancing their problem solving ability 14 . On the opposite side, some studies showed that tablets negatively affected academic performance and learning skills due to the eyestrain that occurs with excessive use 15 .
Originally, textbooks were the main tool for acquiring information 12 . With time, as technology was implicated in various fields, and access to the internet or to an electronic device was easier and cheaper 16 , it started to replace textbooks. In fact, the methods of instruction employed in Lebanese classrooms are mostly classic. Teachers spend a great deal of time giving lessons and homework to students, as well as reading assignments and correcting exercises finished in class. Students usually play a passive role in the education process. They listen calmly, occasionally question what is presented, and copy texts and information dictated by the teacher. Textbooks are the major source of instruction, yet many Lebanese schools have partially introduced electronic devices, and have discreetly started to rely on them 17 . Given the reported discrepancies between textbooks and tablets learning, it is essential to conduct a Lebanese study that compares both entities. In order to assess the influence of textbooks and tablets on cognition and attention, it is also essential to take the schooling age into consideration. The latter is critical to understand the human brain and cognition as one of the major skills of the mind. Therefore, the objective of this paper was to assess the impact of tablet use at school on memory, attention and learning abilities among Lebanese children.

Participants
This study was a cross-sectional, conducted between January and May 2019. Three schools were chosen conveniently for this study, one of them uses the Tablet and text books for students' learning whereas the second one uses text books exclusively. Students were randomly chosen from the list given by the school administration. Prior to participation, parents were briefed on the study objectives and methodology, and were assured of the anonymity of their participation. Individual participants had the right to accept or refuse participation in the study, with no financial compensation provided in exchange for individual participation. All participants were parents of children aged between the age of 11 and 13 years of age were eligible to participate.

Procedure
The questionnaire was distributed to each student in the classroom to be taken home.
Parents filled it within 25 minutes approximately. The completed questionnaires were collected back and sent for data entry. During the data collection process, the anonymity of the participants was guaranteed.

Questionnaire
The questionnaire used was in Arabic, the native language of Lebanon. The first part assessed the sociodemographic details of the participant's child (i.e. age, gender, grade, and father and mother education level). Questions were also asked about number of hours using the tablet for learning at home and at school, number of hours using screens for electronic use (IPad/cellphone for playing electronic games…), number of hours watching TV programs and number of hours reading books. The second part of the questionnaire included the following scales: The Children's Memory Questionnaire (CMQ) The CMQ is a 36-item questionnaire designed to assess parents' perceptions of their children's memory. The CMQ requires parents to assess their child's memory based on five possible options: 1 = never or almost never happens; 2 = happens less than once a week; 3 = happens once or twice in a week; 4 = happens about once a day; and 5 = happens more than once a day 1 . Three subscales derived from the total scale representing the episodic memory, visual memory and working memory and attention. The higher the scores, the greater the impairment in the cognition domain 18 . In this study, the Cronbach alpha values for the episodic memory subscale was 0.888, for the visual memory was 0.770 and for the working memory was 0.845.

The Clinical Attention Problems Scale
The scale measures the frequency of activity and attention by asking the parent and teacher to respond to a series of 12 statements and their applicability to their child in the morning and afternoon. Response options range from "not true"(0), "somewhat or sometimes true" (1), "very often" or often true (2). The higher the scores, the greater the attention problems exist 19 . In this study, the Cronbach alpha values for the clinical attention problem in the morning and in the afternoon were 0.844 and 0.839 respectively.

Learning, Executive and Attention Functioning (LEAF) Scale
The LEAF is a 55-item self-report questionnaire that assesses executive functions, related neurocognitive functions, and academic skills in children and adults. The LEAF evaluates a broad set of core cognitive abilities as well as related cognitive learning and academic abilities. Cognitive areas assessed by the LEAF include attention, processing speed (including visual-spatial organization skills), and sustained sequential processing to achieve goals (e.g., planning and executing goal-directed behavior), working memory, and novel problem-solving. Also, LEAF includes comprehension and concept formation, declarative/factual memory, and academic functioning. The LEAF contains Academic subscales assessing reading, writing, and math fluency and abilities. A multivariate analysis of covariance (MANCOVA) was carried out to compare multiple measures (each scale was taken as a dependent variable) between the groups of school type (book vs. Tablet learning), taking into account potential confounding variables: age, gender, family monthly income, mother and father education level, number of hours using IPad, cellphone or playing electronic games, number of hours watching TV programs and number of hours reading books. A p < 0.05 was considered significant.

Sample characteristics description
Out of 700 questionnaires distributed, 566 (80.86%) were completed and collected back.
The sociodemographic characteristics of the participants are summarized in Table 1. The mean age was 10.77 ± 1.38 years, with 55.2% males and 48.8% females. More than half of the selected school were using book and Tablet (61.1%). Also, higher education level in parents was found in 58.9% among mothers and 39.4% among fathers. The mean number of hours per day learning on tablet at school was 0.91 ± 0.78, the mean number of hours per day spending using tablet to do homework was 0.44 ± 1.09, the mean number of hours per day using tablet or cellphone playing electronic games was 1.70 ± 2.06, the mean number of hours spending per day watching TV programs for children was 1.42 ± 1.23 and the mean number of hours spent per day reading books was 0.79 ± 1.09 (table 1).

Discussion
This pilot study is the first of its kind in Lebanon that aims to evaluate the association between tablet vs book learning on memory, attention and learning. Overall, the major finding from the study is that the use of textbooks was associated with better results in many aspects that can influence the learning process. The findings elicit that the students that used textbooks had better memory function, which contradicts the study that showed improvement in cognitive learning in people using tablets 13 . Another study concluded that learning from a tablet made the person involved in the process of learning. Many etexts provide the option to highlight text, present with high resolution graphics and not to forget that many e-texts can be saved on the same tablet 12 . Despite these advantages, tablets can cause eyestrain and are a major source of distraction to the learner. Thus, a person reading a book will be focused on the material presented in front of him. On the other hand, a tablet especially connected to the internet can provide endless information that can affect the ability of the learner to retrieve the needed information 12 .
A positive correlation is found between the use of textbooks and the episodic, working, visual and factual memory, which is confirmed in the literature 21 . To be able to understand a textbook or an e-book, the long term and short term memory need to be involved 21 . A previous study conducted in 2012, implied that it is easier to recall information read in books than in tablets due to many factors 22 . For example, tablets present fewer spatial landmarks, smaller screens that can cause eyestrain. In addition to that, scrolling along text can cause distraction 21 . All of that can negatively influence the memory and eventually affect the comprehension. Another study done in 2012 found a better reading comprehension in books compared to e-books 23 , and people noted that ebooks were not clear enough because of the screen and text size, which affects their ability to comprehend the text and the way they perceived the e-book 23 .
As for attention, the results were inconclusive in accordance to other studies that could not find a difference between tablets and books regarding many aspects such as comprehension 12 , and reading skills 4,24 . Books learning was correlated with better cognitive skills especially in memory but did not seem to directly affect the attention: attention was found to be similar in books and in tablets learning. Meaning that people were able to focus on the text and the data regardless of the way it was presented to them. The media used to read and to learn did not seem to affect attention. A study done in 2019 that compared comprehension in reading text in printed books and on a tablet showed that there is no difference in the attention paid in both cases 21 .
Moreover, learning in books was associated with an improved processing speed compared to tablets learning. In a study done by A. Lynne Beal et al in 2016 showed that processing speed is correlated with the improvement of reading and mathematical skills 25 . This paper also showed a positive impact for learning in books on mathematical skills and reading abilities that is in favor of the positive impact on the processing speed in learning: children learning in books will depend more on their basic skills and knowledge to be able to develop their mathematical, reading and writing abilities. They have to memorize the multiplication table to be able to do calculation. In addition to that, they need to be creative in order to write a good sentence. Oppositely, tablets have a "built-in calculator" which is able to do all the complex calculation in a fraction of second. At the same time, there is a reading option dedicated to read a whole text so the child is only passively receiving information, without him trying to improve his reading skills. Furthermore, tablets also provide "predictions" when writing which can negatively affect the creativity of the child compared to books.
Additionally, the level of education of the parents, especially the father influenced on the results. Children with educated fathers showed better scores in reading and written expression skills, mathematic subscale and comprehension and conceptual learning which is a finding not discussed in other studies. According to these findings, we hypothesize that educated parents will be more involved in helping their children learn and be more involved in education 26 .

Limitations
There are some limitations in our study. Since this is a one-time measurement of exposure, it is difficult to derive causal relationships from a cross-sectional analysis. This study type is also prone to certain biases. An under or over estimation of a question could be experienced by the parent, leading to a non-differential information bias; this is expected to drive the results towards the null hypothesis. Selection bias and misclassification due to recall bias could may have also occurred. More than that, attrition bias could have happened when participants don't respond to certain questions.
Furthermore, although the multivariate analysis took into account several potential confounding factors, a residual confounding is still possible. Nevertheless, the overall results are consistent with the study hypothesis and the majority of literature findings, which can be considered as a strength of this study.

Conclusion
The results suggest that tablet learning was significantly associated with worse memory, attention, processing speed, mathematic skills, as well as, worse writing skills, compared

Ethics Approval and Consent to Participate
The Psychiatric Hospital of the Cross Ethics and Research Committee approved this study protocol (HPC-012-2018). A written consent was obtained from the students' parents prior to starting the data collection.

Consent for publication
Not applicable.

Availability of data and materials
All data generated or analyzed during this study are not publicly available to maintain the privacy of the individuals' identities. The dataset supporting the conclusions is available upon request to the corresponding author.
of the kindergarten, Mr Joseph Rassi-Director of the primary cycle as well as the teachers of the primary cycle for their help in the data collection. Special thanks to the parents who participated in this study and for Ms Marine Arisdakessian for her help in the data entry.