Digital Addiction 101: Signs, Treatment Strategies, and Managing Conflict | Clifford Sussman, MD

[Kris Perry]: Welcome to Screen Deep, the podcast where we decode young brains and behavior in a digital world. I’m your host, Kris Perry, Executive Director of Children and Screens.

Today we’re exploring the science of digital addiction. Why are some children particularly vulnerable? How do you know when screen use has crossed the line from a frustrating habit to a serious problem? And what can families do to help children regain control without turning every interaction into a battle? We’ll discuss the warning signs parents should look for, what the science tells us about dopamine in the developing brain, and strategies for reducing problematic use, managing conflict, and helping children develop lasting self-control.

Joining me is Dr. Clifford Sussman, a child, adolescent, and adult psychiatrist and psychotherapist who specializes in problematic digital media use, including gaming and social media. Dr. Sussman is a Clinical Instructor at the George Washington University School of Medicine and Health Sciences and has extensive experience helping children navigate digital addiction, ADHD, and challenges with self-regulation. Clifford, welcome to Screen Deep.

[Clifford Sussman, MD]: Thank you. Thanks for having me. Always good to talk to you, Kris.

[Kris Perry]: “Is my child addicted to screens?” is a top question on so many parents’ minds in recent years. What are the signs that a child or adolescent’s media use has become an addiction that requires outside help versus just being on screens too much?

[Dr. Clifford Sussman]: Right, well the hours that a – that your child spends on a screen is not exactly related to addiction. You can spend a lot of hours on a screen and still not be addicted. What’s key is the problems that are being caused by the time you’re on screens. And some of those problems may be residual effects from after you’ve binged for many hours on a screen and then get off and then still have trouble paying attention and are still distracted and preoccupied by getting back on a screen. Could even be that, you know, you’ve binged on a screen all weekend and you go into kind of a withdrawal state where you don’t pay attention well on school on Monday. And, you know, that’s called in the literature, “reward deficiency syndrome.”

But addiction has always been defined – even though they keep using different terms for it – it’s always been defined as not being able to stop doing something despite the problems it’s causing in your life, and “the problems” is the key. So what problems are kids having because they’re on screens? Are they doing poorly academically compared to their potential? Are they becoming aggressive when parents try to limit their screen time? Are they threatening suicidality when parents threaten their screen time? Are they spending thousands of dollars of parents’ money to play games without telling the parents? Those are some of the red flags.

[Kris Perry]: What’s the youngest age of a patient you’ve had for digital addiction?

[Dr. Clifford Sussman]: Well, I’ve had kids I would say as young as seven or eight years old. I would say most of the kids who come into my office to sit down and do therapy with me about screen use are probably between thirteen and eighteen, and then I see some young adults. I see a lot of people who’ve dropped out of college or are still living at home in their young adulthood. So yeah, the age range I would say keeps growing of the types of people who are having problems.

But I also speak to the community a lot. I talk to parents at a lot of schools and I know that there’s really young kids struggling. I know that parents are starting to expose their kids to screens when they’re infants, they use screens to distraction-feed babies. I mean, they make apps on, you know, Fisher Price, for example, that are designed to appeal to infants and toddlers. So yeah, I think there’s a very big age range of people who probably need help. I think the parents who are most likely to come in to see me are parents of teenagers.

[Kris Perry]: Are any of those warning signs or problems for screen addiction you mentioned different for younger kids versus adolescents?

[Dr. Clifford Sussman]: Adolescents have more of a need to self-regulate and they have more of a need to be more independent and to successfully launch when they reach a certain age. And also there’s natural developmental stages. Adolescents tend to – the older they get, the less likely they are to share problems with their parents, the more they may be likely to keep things to themselves. Younger kids are more likely to show problems with aggression, with meltdowns. You know, older kids are more likely to keep some problems to themselves, and you may just see their grades being affected, or you may see, you know, their moods being affected in a more clear way than with a younger child.

So yeah, there’s lots of differences and it’s helpful for a parent to know what normal development looks like and to study up on that a little bit so they know what to expect at different ages in terms of behaviors. With younger teens, they start to go into that phase where they’re sort of ambivalent about still needing their parents but also wanting to join with their peers. And so they may appear a lot more defiant towards their parents and get very embarrassed about their parents when they’re online with their friends. As they get older, they may share less with their parents and there may actually be fewer warning signs because they may keep more to themselves. And that’s normal development. And they wanna become, you know, they wanna join with their peers and join that generation and leave the past generation. That happens with every generation.

[Kris Perry]: Can you talk about the neural patterns that underlie digital addiction and why adolescent brains are so susceptible to them?

[Dr. Clifford Sussman]: I like to explain it as the brain being kind of like a car. If you think of the driver of the car, the gas pedal, that would be the sort of primitive dopamine pathways of the brain that all creatures have where we’re motivated by getting what we want as soon as we want it. That sort of instant gratification, that instant reward. And so those are the dopamine pathways. Screens are a giant shortcut machine. They give us everything we want as soon as we want it. We can even take one out of our pocket and immediately get the answer to something we can’t think of. So that’s like stepping on the gas. It produces dopamine and drives our behavior. We’re usually more likely to do something that gives us something right away than to wait and get an even better version of that.

So you have that competing with the brakes of the car, which is the prefrontal cortex. And so the brakes are what allow us to, you know, stop what we’re doing and do some homework. Or, you know, to stop, to be more patient, to put more sustained effort into something, to use executive functioning, to plan our schedule so that we’re not on games all the time. So if you think of that, it’s like the brain is sort of a struggle between the driver and the brakes. And in teenagers, their brakes are not well developed, and their driver is very well developed. So it’s like you have a car with a lot of gas, you know, where somebody’s just slamming on the gas pedal with very weak brakes. And that’s why it’s so hard for kids to get off of their devices, especially teenagers.

[Kris Perry]: You mentioned that parents are using screens with their children at younger ages. And we’ve seen a lot of research that links early screen use to later adolescent use. What are you seeing in your practice with your adolescent patients who are digitally addicted? When did it start for them?

[Dr. Clifford Sussman]: Well, for a lot of them it started during the pandemic. Around those years, you know, 2020, 2021, when they were kept at home for so long without nearly as much structure as they’re used to having, and also much more detached from the real world with their peers. They really became heavily dependent on screens to communicate with each other, to stay in touch, and they didn’t have, you know, enough structured activities, and they even were asked to learn in an environment where they have all these cues telling them, you know, that it’s time to go on my game or go on social media because they were being asked to sit in class on the same device they use for those things.

So I know a lot of parents will tell me that with their teenagers the problems started a lot during the pandemic. But certainly, it’s not unusual for the kids I work with who have had a lot of exposure to screens early on. You know, a lot of them discovered it at, like, let’s say five or six and then, as they kept growing, the problem gradually got worse and worse. So you see that, too.

[Kris Perry]: Yeah, the pandemic really accelerated the use of digital devices for young kids and now that we’re post-pandemic, it’s really hard to go back to the person you were before you had so much exposure. And you pointed out earlier that it’s not just screen time. It’s the kind of kid you are. It might be the age you are, but we also want to make sure to point out that screen time is one of the risk factors in a way, right? The more you’re on, the more you’re raising the odds that you’re gonna have a problem. And COVID really contributed to that.

[Dr. Clifford Sussman]: Yes, it did. And it’s not just the hours per day that you’re on that I think is a risk factor, it’s how many hours at once, like how many hours per session. If you’re on for five hours in a day but they’re all spread out and you’re taking breaks, you know, it shows you both have the ability to stop and start and use that prefrontal cortex, right? And then delay your gratification. But you’re also practicing it every time you do that and you’re making it part of your routine and your schedule. Whereas if you sit down and play for five hours straight until you’re asked to get off, that same five hours, it’s, you know, I think a lot of the research suggests may be more unhealthy than the spread out five hours. That’s why I’m not crazy about saying, “They should have this many hours per day.”

[Kris Perry]: Yep, no, that’s a really subtle difference, and I’m really glad you brought that up. In your practice, what are you seeing in terms of the most prevalent patterns of digital addiction? Are there certain types of media use like gaming or social media that seem to be involved in more of the cases that you see?

[Dr. Clifford Sussman]: Well sure, certainly multiplayer games, games with user-generated content. I mean the social media, you know, there’s more of a blurry line between where gaming ends and social media begins. It’s really – because gaming has become more social and social media has become more gamified. So if they’re on social media they may be watching people play the games that they play or talking about the games they play on Discord, for example. But I see a lot of kids struggling in particular with Minecraft, with Roblox, with Fortnite, these massive multiplayer games where kids don’t just play, they also create. And, you know, a lot of mission-based games where your peers are dependent on you to be in that mission, like Call of Duty. So those are some of the ones I see a lot but I think it’s probably possible to get addicted to most video games because they’re designed to keep you on and, you know, they need to keep you on to profit.

[Kris Perry]: Yeah, I mean it’s as if they’re designed to encourage addictive use. It’s like, yeah, it’s baked into the design and we’ve covered that in so many different ways on the podcast, but it’s really helpful for you to point out the types of games and the features of those games and how they’re designed in different ways to encourage this idea that you’re not a good team player if you leave the game or you’re letting your friends down – those very same qualities of adolescence and childhood that you’re building in a positive way can be leveraged in a way against you as you’re involved in those online activities.

[Dr. Clifford Sussman]: Absolutely. And I grew up, by the way, with single player games with lots of puzzles in them that I loved and they hadn’t evolved the way these games have and I still had a lot of trouble getting off of them. You know? You wanted to finish everything before you got off.

[Kris Perry]: I mean, just solitaire can be kind of hard to put down if you’re waiting for an airplane or something. You can feel it around the simplest of games, much less some of these really complex games. 

Digital addiction is notoriously difficult to treat, especially in adolescents, whose brains are so wired for that reward seeking and dopamine release you just described. How do you go about treating digital addiction? Is it like substance abuse where there needs to be a period of complete abstinence of use?

[Dr. Clifford Sussman]: Well, I certainly take a lot of the research on substance abuse treatment to inform my treatment because there’s a lot more research on substance abuse and, you know, gambling addiction treatment and things like that – other process addictions – than there is specifically on screen use problems, even though, thanks to your organization and others, there will be more and more over time and there has been some good research lately. 

So I definitely do some things differently than if I were treating a substance addiction. For example, I’m not going for complete abstinence. I’m not saying to kids, you know, they have to get off screens entirely, like you might if they were, you know, using cocaine, let’s say. Because, well, there’s several reasons. One is it’s unrealistic. And two is that there’s a lot of benefits from digital use. And three is that there may be some actual benefits to being able to have balance or being able to, again, use those brakes, right? If you’re not getting on and off a screen, you’re not using that prefrontal cortex brakes to stop you and I think that there can be a lot of benefits if you use screens in a healthy way.

So, really, what I’m trying to stop is that binging we were talking about and, you know, using it at inappropriate times and all the problems we were discussing. But I may very well use a therapy that was designed to treat addiction, such as motivational interviewing in my individual psychotherapy. And I definitely think about things like cues, which we talk about a lot in addiction medicine. Like, what are the cues in the environment of the home that are getting the kids, in “I have to game” mode or, you know, “I have to get on a screen” mode?

I like to talk about having a balance between what I call “high dopamine activities” and “low dopamine activities,” with the high dopamine activities being things like using substances but also using things like YouTube and streaming videos and all these games that kids will stay on for a very long time. You can do a low dopamine activity, meaning one that takes more patience and requires more sustained mental effort. You can do one on a screen, you know, like you can write a paper or do some artwork or make a PowerPoint presentation, but that’s a little bit like drinking water in a bar. So again, you have to think about those cues. And then, of course, like I like to have kids try to balance it with low dopamine activities in, you know, off-screen, like playing a musical instrument or, you know – not just productive ones like homework and exercise, but maybe playing the board game version of the video game they like. So I like to have parents think of things in terms of balancing out low and high dopamine activities as well as the kids. 

And also another thing that I will often use – another tool that perhaps does have its roots in substance abuse treatment – is detoxing. I will do a temporary what I call a “dopamine detox.” Now, in a program for this, like a residential center, you might see a one or two month detox. But I found in my outpatient practice that, even if a kid comes in, like, seeking pretty aggressively, that if you just get them to go three days completely without high dopamine activities – maybe it’s because you sent them on a camping trip with no access to tech or they traveled or you just gave them a lot of structure for those three days and just pretty much locked up the devices in a room – parents will report to me that by the third day they’re doing much better. Like, a lot of the behaviors have completely changed and, you know, gone back to a time that the parents fondly remember. So, you know, of course, if you just put them back in the same environment, you’re gonna be back where you started. But first of all, it’s a great reset button to use whenever you need to as a parent. Second of all, it’s not as hard to do as parents think because sometimes it’s actually easier to not let someone into the bar than to let them in the bar, give them a drink, and then cut them off. And finally, it sets them up for the perfect balanced use pattern. If they’re in that, you know, third day or fourth day state where they’re not seeking as aggressively, and then you put them in a situation where they have this balanced use – you know, you have a nice structured schedule with them, and you have some clear and logical rules that you’ve made. You have the devices put into separate high dopamine zones, and you’ve looked a lot at the home environment to make sure they don’t have cues everywhere in their low dopamine zones. You’ve gotten the screens away from the dinner table and the bedroom and things like that, then they’re in, you know, the ideal condition to start to learn balanced use and to have a healthy lifestyle, to have that, you know, ideal balance of high and low dopamine activities, at least for a while, you know, and it certainly can last longer every time you try it and every time you get better at it.

[Kris Perry]: It’s really great to talk about – you and I are talking about dopamine, and low dopamine, and high dopamine, and cues, and environment, and we’re doing that and those terms really carry a lot of meaning and they help you just “mentalize” what it is you want to do. In other words, it helps you be a little bit more thoughtful and intentional about how you might go about your day just by giving some more words to these experiences, these complex neural pathways, right? Let’s just call those high and low dopamine. And this feeling, this sensation you have when you wake up that you want to grab your device, well that’s, you know, that’s something that’s going on inside you, but also there may be something in your environment. So I really love the way that you’re, you know, kind of talking holistically about all the things that are coming at kids from outside and inside themselves that make them want to be online.

And that – I think you’re also flagging that, you know, in order to be better and better over time, you have to practice. And it’s like anything else you’re learning to do for the first time. And it’s also helpful to get a clean start, you know, a fresh start by saying, “Okay, let’s go 72 hours without using screens and then – like a reboot – and then we’re gonna go and we’re gonna – while we’re in that period of time, we’re gonna figure out how to make the environment less triggering and we’re gonna figure out how to build more low dopamine into our day. And you know, you just really, you know, behavior change is so, so difficult. And even as a young person without that many years under their belt can develop some really powerful habits. So it’s really helpful for you to describe different ways to name it, participate and support your child in changing it, and supporting them going forward and paying attention to how they’ve made these adjustments and and really you know, I think, you know, complimenting and celebrating these victories over time, framing things in a positive way really gives the child something to feel proud of. And I’m really glad as a clinician that you see the child within this larger system of the family and how that is part of their recovery from too much use of screens.

[Dr. Clifford Sussman]: That’s right.

[Kris Perry]: You also talked about how important it is to have buy-in from the child or teen before launching one of these detox approaches, even short term. Some clinicians have shared stories about these cold turkey methods causing severe distress for some teens. So how can parents avoid that and support their child in these moments?

[Dr. Clifford Sussman]: Well, you know, my treatment is very customized, you know, because all kids are different and all families are different and you have to customize it to what works for that family and not every approach works for every kid. And I have the benefit of being an individual therapist and working with individual families so I can do a very thorough assessment of how the family does things and how the child’s brain works and, you know, are they in the autism spectrum? Do they have ADHD? You know, is it just a pure addiction? Or in the case of a kid with autism, are they going online because they’re going down fixation rabbit holes and they’re leveling the social playing field and, you know, it may be more than just addiction. And do these kids need more of a warning before you do something like a detox? You know, things have to be more predictable for them. And, you know, you have to have a plan in place where you’re anticipating meltdowns rather than causing them and you’re not just having lots of power struggles.

So I actually have a lot of tools and strategies to avoid that. And also at the very start, I’m trying to psycho-educate these families as much as I can. And, you know, going back to a point you were making about using terminology, I think that parents will often emphasize productivity too much because they don’t understand that much about how dopamine pathways work. So they’ll say, “Okay, you know, if you do your homework first, then you can have screens.” So what’ll kids do? They’ll rush through the homework. So it helps to have them look at how what they’re doing is not working. That’s how I came up, by the way, with high and low dopamine. I was trying to get away from productive activities and unproductive activities.

[Kris Perry]: Well, you mentioned the importance of environmental cues. Isn’t it the case that children get so sensitive to cues for media use that their brain releases the dopamine before the media use even starts?

[Dr. Clifford Sussman]: Yeah, no, you’re describing it correctly. That’s exactly what happens. So if you go into a room filled with the screens you’re usually on, or if you’ve got the device sitting right next to you, you’re anticipating getting on it before you’ve even gotten on it, and that causes dopamine release. Just like when somebody, you know, to go back to the bar analogy, if you walk into a bar and you anticipate that you’re going to drink because of the sight, smells, and sounds, the bartender, the drinks, the people you drink with, all of those things, you start to release dopamine before you’ve even had a drink. And so that’s one of the easiest first steps to work with parents on is to really look at all the cues in the home because that sometimes is more adjustable immediately than the kids’ behaviors.

A good example of that: A lot of parents struggle with using parental controls leading to meltdowns or aggression or, you know, trying to actually get the device out of the kid’s hand when it’s time leading to huge power struggles. Whereas if all the devices are sort of locked in one room and they’re allowed in that room during their “high dopamine time,” as I call it, it may not be easy to get them to leave that room, but if it becomes a part of the regular routine for them to go in and out of that room at regular predictive time intervals, it’s easier to get them to leave a room and leave the devices behind than a lot of those other options that parents typically use, and then you can have other systems in place to prevent power struggles, you know, such as having a system where if the child needs to stay on because they’re in the middle of a mission or, you know, their friends need them, they are allowed to do that, but they’re held accountable. You start a timer when they’re supposed to leave the room and if they’re on for another ten minutes, you know, they have to let you know when they are done and whatever extra time they use, maybe for some families it works to just double that time and add it to the low dopamine block or to take it off the next high dopamine block. So at least they’re being held accountable and, you know, they have to sort of – it’s like a reverse marshmallow test, like, they have to give up more time later to get what they want now.

[Kris Perry]: What you just described to me sounds like something that only an older child could really handle.

[Dr. Clifford Sussman]: Yeah, yeah, that is more of an older child intervention. Although with younger children, you know, it depends on the child. Some of these things might work. With younger children often I’ll try to use positive reinforcement for a kid getting off when they’re supposed to without a fight, you know, maybe they get a hole punched in a card. And, you know, maybe if they fill the card just like, you know, Starbucks or Subway, they can turn it in for something, like choosing where the family goes out to eat. You don’t want a reward with extra screen time, of course. But, you know, it’s good to use positive rewards and to use just logical consequences consistently, especially with the younger kids.

[Kris Perry]: Yeah, those reward systems too. And we’re – ’cause so much of what you’re describing is behavior modification and how to do that in a way that sticks. I think those rewards, whether they’re verbal acknowledgments or something else the child likes to do that’s not digital media, and baking that in, those are all really good suggestions.

[Dr. Clifford Sussman]: And let’s also not forget that parents have to model the right behaviors themselves. And that these younger kids are very susceptible to doing exactly what their parents are doing. I would say older kids, too. Younger kids do need more limits, but they also – they’re much more likely to do what you do than what you say as a parent.

[Kris Perry]: Thank you again for bringing up how big a role the family plays in the child’s use of screens. It might be that you’re inadvertently modeling a lot of screen use by your own behavior, or you’re not taking as seriously the child’s behavior at an early enough stage to be sure you’re trying to create more balance for them. In terms of creating that balance between high dopamine and low dopamine activities – and those can be both online and offline, right? 

[Dr. Clifford Sussman]: And in many cases kids are forced to do their homework online, although I have had to advocate with some families to get their schools to give them paper homework. But, you know, sometimes you just have to do your homework on a computer. So I have to work with families around that, you know, because I do like to count that as a low dopamine block if they’re actually doing their homework, or if they’re actually writing a paper or composing music on a screen or something like that. 

Again, you just have to be aware that the screen is a cue. So it might require more parental intervention, more random checks. Again, I think it’s good to agree to a system ahead of time so you don’t catch your kid by surprise and you’re not being reactive, you know, you’re planning ahead. I think that as your teenagers get older, you know, they can do high dopamine activities off the screen, you know, like smoking marijuana or something like that. So it’s of course as a parent, you know, you want to monitor for that too, because kids who are more prone to one type of addiction are more prone to another type of addiction. And you might often, you know, replace one source of heavy dopamine with another.

[Kris Perry]: Is there a point with a digitally addicted child where families need significant outside support and how would they recognize that?

[Dr. Clifford Sussman]: Well definitely look for the red flags we talked about, any types of self harm or suicidality around screens, complete loss of trust because of their behaviors. You know, like, cases will present to me where the parents can’t trust their child any at all and they’ve spent thousands of dollars of money by taking their credit card right out of their wallet, things like that for the games. The games are always coming first. They’re always seeking the games. It’s always their top priority. And it seems like everything they do is to try and get on again at the expense of everything else. It could be hurting their relationships. It could be hurting not just their family relationships but their peer relationships, as well. You know, again, it could be causing them not just academic problems but sleep problems. You know, they could be staying up all night, they might not be eating. 

So those are the types of red flags where parents I think should reach out for help. Like you said, it’s hard to treat, but it’s even harder without a professional’s help. It’s important to have your child evaluated and even screened for screen use problems, but especially if you see these red flags, you know, you might want to get your kid a psychiatric evaluation.

[Kris Perry]: This is maybe a bit painful. I think a lot of parents of adolescents know how easy it is to have near constant conflict about screen time and stopping screen time and the disruption, the discord, the way it is displacing, frankly, even just sort of calm quiet time, much less like high quality family time. It’s like it’s punctuating the daily lives of families in a way that’s so stressful. How can families navigate regulating screen use and achieving minimum conflict?

[Dr. Clifford Sussman]: You know, I like the way you’re reminding me to say that it’s important for all families to strive for screen balance, not just families that have a kid that, like, is hitting these red flags. And, you know, I think one of the problems is people think of addiction as a black and white, “You have it or you don’t,” binary thing and it isn’t. Really, if you think about the definition I gave before where it’s like, you’re using something and it’s causing problems and you can’t stop, you can have that to an extreme end or you can have it just mildly, right? You can have mild problems or severe problems. And again, like, we were talking about how this technology is designed to keep people on it, it’s designed to be addictive. And so even if you’re not one of those kids who’s really predisposed to it and likely to fall through the cracks, like, every family needs to be paying attention to how much their kids are using screens and what kinds of problems it might be causing for them. You know, you always want to sort of weigh the risks and benefits of things. 

I feel like a lot of parents will go to one extreme or the other where they’ll just be like, “I give up,” and they’ll just let their kids use all the screens they want. A lot of parents did that during the pandemic because they were overwhelmed and they didn’t want to keep them from the only social contact they had. And then you see the other extreme where parents just want to, you know, over-micromanage everything, which becomes more and more inappropriate as the kid gets older and they need to launch and be independent, but they want to, like, look over the shoulder and know everything their kid’s doing online. I think parents need to find a balance, too, just like kids do. And like I was saying before, they wanna look at their own behaviors and what they’re modeling and this is useful, I think, for every family, not just families that are completely falling apart over screen use.

But like you said, you want to pay attention to what your younger kids are getting exposed to and what sorts of behaviors they’re getting into at a young age, which might influence their future behaviors. You may want to err on the side of waiting longer to give your kids devices or having more off-screen structure instead of less.

[Kris Perry]: I’m gonna shift gears just for a minute here because you have a lot of experience with neurodivergent children and their experiences with digital addiction, both autistic children and children with ADHD. We know that there are special considerations when evaluating media use with those children. Can you talk about what these considerations are from how to help foster healthy media habits as well as how to recognize or cope with an addiction?

[Dr. Clifford Sussman]: You know, with ADHD these kids have even weaker brakes because their prefrontal cortex is affected by the ADHD. Their medications may help that temporarily because it provides you with dopamine from the medications, so you don’t need it as much from your environment, but then it wears off. You may crash and need screens even more. The stimulant medications don’t cover you at night when you need to sleep, and that’s when a lot of kids are on their games. And yes, kids with ADHD, they’re always novelty seeking. Like, they’re much more likely to have these problems with screens, and much more drawn to screens and more likely to fall through the cracks. And I also, like you said, work with a lot of kids in the autism spectrum. And as I was alluding to before, these kids have sometimes different patterns of use. They tend to be more repetitive and fixated on the same types of media over and over again, whereas you may see the ADHD kid always needing some kind of new stimulation. So you might notice different patterns and how they’re playing games and how they’re using screens and what they’re using it for.

But I find that it’s – it can be a real struggle with kids in the autism spectrum when they’re using screens too much, because oftentimes the parents see that as maybe the only time they’re having the sort of socializing that they want. Maybe they’re on a lot of social media sites and doing, you know, fan fiction and connecting with other fans about something they may be fixated about. But I think it’s important to remind these parents that socializing online, while I’m not here to say that it’s all a bad thing, it’s a very different thing than socializing in real life. And these kids in the autism spectrum who may already be struggling with, you know, eye contact and reading nonverbal cues and real-world social interactions and may already be lonely because of that, they may not be getting the experience and practice they need off a screen. And that real world connection is also very important. I think it’s, again, important for them to have balance in the type of socializing they’re doing. And if they’re always socializing the same way on a device with the same group of people, that may not be so healthy for them.

[Kris Perry]: We’ve seen some research on how digital use can intensify ADHD symptoms. Is it a chicken and the egg situation or in what ways might screens cause ADHD symptoms? And in what ways are screens maybe exacerbating ADHD traits?

[Dr. Clifford Sussman]: Sure, sure. I mean, as far as chicken and egg goes, you know, I never really claim that screen use causes problems that are always irreversible. I think there’s a lot of bidirectionality, but it tends to be that kids with problems like ADHD are very predisposed to screen use, but if you don’t address the screen use it becomes a barrier to treating all these problems, you know, from the chicken and egg debates, like depression and anxiety and ADHD and autism. So it may be more likely that the biological problems are causing the screen use, but if you don’t address the screen use, you’re not going to have access to treating the biological problems.

Now, you know, you asked about exacerbating ADHD. When you binge and binge on a screen and give the brain all that dopamine, you become more desensitized to dopamine. You go through a process called “dopamine receptor downregulation.” That’s one example of how you’re going to cause at least a temporary exacerbation of ADHD symptoms. That reward deficiency syndrome thing I was describing earlier, you know, that when people become very desensitized to dopamine, they become extremely bored and irritable. And that can last a while. Now, I do believe it’s reversible. Right? Not all of it’s reversible, but some of it might be reversible. I think you know, getting people to have a cue response is less reversible from a lot of repeated use patterns than the actual reward deficiency syndrome, that just intense boredom kids feel when they’ve just been binging for a really long time. I think you can get those dopamine receptors back, which is why I encourage those dopamine detoxifications. So – but that looks very much like an exacerbation of ADHD. If, you know, you binge for long enough that you just –  it takes more stimulation to get you stimulated.

[Kris Perry]: How should parents adjust those strategies we talked about earlier when dealing with a neurodiverse child who also has a media use problem? I mean, do you approach the high low dopamine balance differently?

[Dr. Clifford Sussman]: In some ways, yes. Like, I’ll have parents make whatever interventions they’re doing a lot more predictable. These kids need a lot more time to adjust to whatever the strategy is. These kids need structure even more than the other kids in some cases. 

At the same time, you know, the flip side of that is that a kid in the spectrum may be more likely to want rules that are consistent and be more welcoming of parental intervention because they may feel more secure. They’re sometimes, you know, less socially developed and they sometimes interact with parents more like a younger child would, where they depend on the parent for longer than a neurotypical child would, rather. And so there are some advantages to being in the spectrum. Like, for example, when you do develop a healthy routine. When you have, you know, your schedule of the day laid out and you know exactly when you’re going to be using a screen and when you’re not, and you’ve developed sort of a commuter instinct for how long you do get to be on a screen – maybe it’s 45 minutes each time. You know, maybe you’ve learned to plan it so that you’re done by the end of 45 minutes because it’s happened so many times – the kids in the spectrum tend to keep their routines longer. It’s harder for them to transition into a different routine, so it may be tougher at first. But once they have transitioned into a new routine, they may stay in it longer and not transition out of it. So that might actually be an advantage.

[Kris Perry]: The structure we’ve been talking about between low and high dopamine and environmental cues and the support of your family and sometimes getting outside support, all of those things have just as much, if not more, impact with a child that’s neurodiverse because these very structures you’re talking about, they can be leveraged by any kind of child, but what’s really fascinating from a clinical perspective is that you’ve seen it work even better in some cases with neurodiverse youth. So that’s really a hopeful point and I’m really glad you raised that. 

Actually thinking a little bit more about the high dopamine activities, low dopamine activity balance we were talking about, is there any high dopamine activity that is actually healthy to engage in?

[Dr. Clifford Sussman]: Yeah, absolutely. I mean there’s all sorts of educational software out there. I mean, and I can tell you from personal experience that, like, the puzzle solving adventure games I used to play that were not overly-violent or, you know, that would actually really get you having to think outside the box to solve problems, and solving riddles and, you know, all these strategy games that kids play. I do think they can provide cognitive benefits. I do think that software can be educational. I do think that there can be social benefits to gaming with friends or even family bonding benefits to gaming with your kids. So I’ve never said that technology use is not a good thing as well, it’s about getting too much of a good thing, right? It’s like everything else in life, you need moderation. And because these products are designed to be so addictive and keep you on for so long and they keep evolving to be more so, it gets more and more difficult to use them in moderation. But that’s not to say that you’re not getting any benefits from them, it’s just to say that the risks are outweighing the benefits for some kids.

[Kris Perry]: Yeah. Here we are. It’s an interesting time of the year, right? There have been a number of high stakes, athletic events and there’s an election tomorrow and there are a number of big cultural events always probably going on. Fall is particularly busy. And I think of those as, like, high dopamine events. Like, if you’ve been following your favorite team all season or you suddenly care about a new sport your friend’s interested in or you’re following your local politician or something like that. It seems like there are plenty of other interesting things that go on that are high stakes and competitive – especially an adolescent, right, that can understand what these races are all about, could get more interested in high dopamine both virtually – most of those things you’d probably experience on a screen. But also they might find themselves wanting to try that in real life, right? So get involved in athletics or other kinds of competition like math Olympics and these different things that schools are always trying. You probably are constantly throwing other ideas at families of things they could try that get their child excited.

[Dr. Clifford Sussman]: Right, like maybe “medium dopamine’s” a better way to describe ’cause you’re kind of trying to meet them where they are. Like, okay, your kid likes to game, let them do math Olympics and play a game with other kids. You know, your kid likes to play Madden all the time, let them learn to play real football. But of course it takes a lot more patience to play real football than it does to play Madden. And as far as all those high dopamine events you describe, like, you know, all the politics and everything else, it’s hard to get people off their devices for those things, because you’re getting in the form of AI algorithms and reels that make high dopamine even higher dopamine.

[Kris Perry]: Yeah, medium dopamine.

[Kris Perry]: No, there’s definitely the flip side of the things that I mentioned. And we’ve covered that, you know, gambling and, you know, sort of these blogospheres and all of that, which is why I think it’s really this critical balance between the child, the parents, the family, and how you’re constantly – as the adult with the fully functioning executive portion of your brain online – are in that position of trying to anticipate a way to enhance the child’s experience. So let’s just say, you know, your favorite team is doing really well and they’re getting close to some major playoff or something, trying to figure out how to maybe go in person to something or try to figure these things out so that you bring that experience into the real world. And we know with elections and all these – there are lots of interesting ways to get more involved in the real real parts of that. And I think with younger children it actually seems like it would be less challenging. So if you’re really obsessed with trains or animals or, you know, like, you can probably visit something in your community with where that’s going on.

[Dr. Clifford Sussman]: I love that strategy. Like trying to look for, like, lower dopamine versions of things that your kids are already interested in, ’cause a lot of parents struggle with trying to find activities that their kids are into. Another good example is, like, taking kids to an actual movie theater and have them actually sit through the ads and not bring their phone with them and actually sit and watch the whole movie instead of, you know, it being a thirty second clip online or if they’re watching a series, where they can switch from one to the other at any time.

[Kris Perry]: You’ve been at this for a long time. How did you start working in digital addiction and has there been a personal experience or “aha” moment that led you there?

[Dr. Clifford Sussman]: Well, let’s see. I mean, I’ve been in practice 18 years and I started exclusively seeing people who had this problem as part of their chief complaint – you know, excessive screen use – about 10 years ago, so before the pandemic. I would say as far as “aha” moments go, there were probably several of them, but – I mean, I was always a tech nerd, I was always into computers and video games myself. I did enjoy my addiction rotation and when parents started coming in on a regular basis – which really happened even, you know, before that – I would say for as soon as I started practice in 2008, there were parents coming in and saying, “My kid’s addicted to video games.” Oftentimes they’d been to other clinicians who kind of dismissed it or just said to treat the underlying cause. But when I evaluated these kids, I think my real “aha” moment was saying, “Wow, these are the exact same problems I saw in my addiction rotations.” You know, and seeing that over and over again. And then reaching out to colleagues who are also studying this stuff and writing a review article where I compared imaging studies of the brains of people who use substances with the brains of people who use games excessively, like all of those things were influences on my decision.

[Kris Perry]: What gives you hope in creating a more healthy digital experience for today’s children and adolescents?

[Dr. Clifford Sussman]: Well, I mean, I just see how bright and creative kids are. User-generated content also has a flip side, right? Like, the kids are creating the content and, you know, they’re not just being fed the content. Kids are still into art and music. Kids want to learn about their brain. Every child has ambivalence, meaning that there’s a part of them that wants two different things and is being torn at all times. I mean, we all have that, but teenagers especially, and anyone who’s having a problem with this has ambivalence. There’s a part of them that always wants to change and that sees they’re struggling and having problems, even though you may not see that part because it’s not on the surface. And so, you know, that’s one of the huge rewards of the job for me. And one of the things I’m really passionate about is helping, you know, teenagers explore their own ambivalence. And I think they start to appreciate what real-life interaction is like and some of its advantages. And they want that. On some level they know that, while the internet is meeting a ton of needs for them, it’s not meeting all of them.

[Kris Perry]: Is there one piece of advice you shared today that you think is the most important takeaway for a parent today?

[Dr. Clifford Sussman]: I mean, definitely look at the home environment. Look at the cues in the environment, study them, and study the cues that you’re giving to your kids with your own screen use. I think that’s certainly, of all the things we talked about, one of the things I hope people will really take from this.

[Kris Perry]: Clifford, thank you for helping us better understand the complex nature of problematic screen use and, importantly, what families can do when technology begins to interfere with children’s lives. One of the important takeaways from today’s conversation seems to be that helping children develop healthier digital habits isn’t simply about setting limits. It’s also about balancing their activities and gradually building the skills they need to manage technology independently and providing support along the way. 

For listeners who want to learn more, Children in Screens offers a range of free, evidence-based resources on digital media use, gaming, ADHD, and children’s mental health at ChildrenandScreens.org. If you enjoyed this episode, be sure to subscribe to Screen Deep wherever you get your podcasts and leave us a review. It helps more parents, educators, clinicians, and policymakers discover these important conversations. Thanks for listening. We’ll see you next time on Screen Deep.