Screen Extremes: Children and Digital Addictions

Youth media use has become near-ubiquitous. How do you know if behaviors around technology use have become problematic or classifies as an addiction? In this #AskTheExperts webinar, a panel of child and adolescent psychiatrists, researchers and a parent with her own lived experience discussed current knowledge of digital addictions, including definitions, prevalence, and related disorders, and provided tips for assessing children’s media use, prevention and intervention for digital addictions, and developing healthy family media habits.

00:00 Introduction

Kris Perry, MSW, Executive Director of Children and Screens: Institute of Digital Media and Child Development, kicks off the panel by welcoming the moderator, Marc Potenza, MD, PhD, MD, Albert E. Kent Professor of Psychiatry, Child Study and Neuroscience at the Yale University School of Medicine.

03:03 Elaine Uskoski

Elaine Uskoski, parent coach, speaker, author of Seeing Through the Cracks and Cyber Sober, and Canada Clinical Partnership Specialist for Intenta Clinical Training for Gaming Disorders, tells a personal story about discovering her son’s gaming addiction and supporting him through his recovery. She provides tangible tips for preventing screen addiction, including setting limits, and emphasizes how important it is for parents and caregivers to be emotionally available. She concludes by offering warning signs parents can look for if they’re worried their kid’s behavior may be problematic.

19:45 Naomi Fineberg, MBBS, MA, MRCPsych

Naomi Fineberg, Professor of Psychiatry at the University of Hertfordshire and Consultant Psychiatrist at Hertfordshire Partnership University NHS Foundation Trust, defines problematic internet use and shares common symptoms to look out for. She stresses the need for more research to understand the clinical boundaries of these disorders, support clinicians, and standardize diagnosis. Next, she shares her work on the Boosting Social Adaptation and Mental Health in a Rapidly Digitalizing, Post-Pandemic Europe (BOOTSTRAP) project, which seeks to understand who is most at risk (and why) and to discover harm-prevention strategies.

36:35 Jason Nagata, MD, MSc

Jason Nagata, MD, MSc, Associate Professor of Pediatrics at the University of California, San Francisco, summarizes findings from the Adolescent Brain Cognitive Development (ABCD) study, a large longitudinal study of brain development and child health in the US. Dr. Nagata shares findings concerning gender differences in problematic use, its relation to mental health effects over time, and parental media use behaviors. At the end of his presentation, he offers practical tips for adolescents and parents to sustain healthy media habits like implementing screen-free times, role modeling healthy screen behavior, and creating a family media use plan.

45:47 Clifford Sussman, MD

Clifford Sussman, MD, Child, Adolescent, and Adult Psychiatrist; Internet and Gaming Addiction Specialist, presents constructive interventions and treatments for youth struggling with problematic usage. Based on his clinical experience, he recommends youth seek balance between high dopamine activities (like video gaming) and low dopamine activities (like playing an instrument). He also suggests parents and caregivers find a balance between setting limits on screen time and teaching their children to self-regulate and manage their digital use. Dr. Sussman discusses some treatment approaches, but concludes by emphasizing that no treatment is one-size-fits all and any treatment will depend on what works best for that child and family.

01:01:19 Discussion and Q&A

Moderated by Dr. Potenza, the panel comes back together to answer audience submitted questions. The panelists discuss when and how to find professional help, family media use plans, what parents can do for younger children, and how the science of digital addictions translates to practice. In the final minutes of the webinar, the experts emphasize the importance of healthy non-judgemental communication for preventing and supporting youth with problematic internet use.

[Kris Perry]: Hello and welcome to today’s Ask the Experts Webinar “Screen Extremes: Children and Digital Addictions.” I am Kris Perry, executive director of Children and Screens: Institute of Digital Media and Child Development. Just last week we hosted a webinar about smartphones and the most common questions were about excessive screen time and what to do if a child becomes addicted to their phone. That is precisely what we are going to learn more about today. How do you know when device use has become problematic? Is tech addiction real? As a caregiver or educator, what can you do when you start to notice signs of dependance? Today, you’ll hear an expert panel of child and adolescent psychiatrists, researchers and even a parent with lived experience. Together they’ll discuss tips for assessing children’s media use, prevention strategies for digital addiction, and best practices and treatments for helping youth who have developed an unhealthy and damaging relationship with digital media. Without further ado, I would like to introduce you to today’s moderator, Dr. Marc Potenza. Dr. Potenza is a board certified psychiatrist with subspecialty training in addiction psychiatry. Currently, he is an Albert E Kant Professor of Psychiatry, Child Study, and Neuroscience at the Yale University School of Medicine, where he is the director of the Yale Division of Addiction Research, the Center of Excellence in Gambling Research, the Women and Addictive Disorders Core of Women’s Health Research and the Yale Research Program on Impulsivity and Impulse Control Disorders. He is on the editorial boards of 15 journals, including editor in chief of Current Addiction Reports, and has received multiple national and international awards for excellence in research and clinical care. He has consulted to the Substance Abuse and Mental Health Services Administration, National Registry of Effective Programs, National Institutes of Health, American Psychiatric Association, and the World Health Organization on matters of addiction. He has also participated in two DSM five research workgroups and six annual W.H.O. meetings relating to internet use and addictive behaviors in the ICD 11, addressing topics relating to gambling, gaming, impulse control and addiction. Welcome, Marc.

[Dr. Marc Potenza]: Thank you, Kris. And thank you for having me and organizing this, and delighted to have a very diverse and well-established panel of individuals here to present on this topic. First, our first panelists, several years ago, Elaine Uskoski faced one of the biggest crises of her life when she learned her youngest son, Jake, was addicted to video gaming. She chronicled her experiences in her book, Seeing Through the Cracks and now shares her powerful message of hope and awareness through her work as a coach for parents and families and as a speaker. Elaine’s second book, Cyber Sober: A Caregiver’s Guide to Video Game Addiction, has now also been published. She is a Canada Clinical Partnership Specialist for Intenta Clinical Training for Gaming Disorders, and has been featured by many media outlets, including CTV, W5, CBC’s The National, McLean’s Magazine, CHCH TV, Global News, National Geographic, The Wall Street Journal and CBC Radio. So she is here to present on the topic of lived experience with a child’s gaming disorder.

[Elaine Uskoski]: Thank you for the introduction, Marc, and thank you to everyone who is here joining us today. My story began on October 31st, 2014, when I received an S.O.S. email from my then 19 year old son, Jake, who was attending university an hour away from where we lived. I was living in residence, and although I say that this letter came as a shock it also didn’t because I’d had this spidey sense that something wasn’t right with my son I just couldn’t put a finger on what it was. And he was in trouble, and he was very fragile sounding in the letter. I know it was difficult for him to confess, but he had not been attending classes for two months. He instead had been holed up in his resident’s room. He’d been gaming up to 16 hours a night until he would literally pass out. And then in the morning he would wake, sorry not in the morning, he would sleep all day and then that night he would wake and start that process again. The university caught up with him and they had said that the locks were being changed in his dorm and that he had three days to move out. So he reached out to me and my first reaction was, thank goodness he trusted me enough to reach out because I know he could have made a different decision. So I picked up the phone and I said, “What do you need?” Of course, he burst into tears and said, “I want you to make this okay. Tell me this will be okay.” I said, “I would.” I didn’t know what that was going to look like. I got in my car and I drove to the university and it was the longest hour of my life. He sounded so fragile in the email and he sounded so fragile on the phone that I thought he might take his life in shame before I got there. When I arrived, he opened the door and I opened my eyes. There stood my six foot two son, and he had dropped to 127 pounds. He had facial tics. He had tremors. His eyes were dilated. His skin, which was normally squeaky clean, was a mess of acne. His hair was greasy. He’d been wearing the same clothes for days and days, and he smelled horrific. And he looked terrible. My heart broke. I just hugged him and hugged him and hugged him. We both cried so much. And then I brought him home and a lot of things were unraveled as we came home. And I started realizing that the video gaming was a problem. I’d seen signs before he left for university and I ignored them. But it was clear to me that he had a problem with video games. And so I told him that I was going to detox him from gaming while we sorted out school. I took him to the doctors to make sure he was healthy. He was diagnosed with very low vitamin D levels, I guess because he’d been in the dark for so long and severe anxiety and depression. He did not want to do medication, but he agreed to see a counselor. And so we started the detox process and it was incredibly painful for him. He had headaches. It was difficult to get back on a regular sleep cycle. It was like going through jet lag. So the next couple of weeks, he mourned the loss of his online friends because he wasn’t making friends at university. He felt agitated. He felt more depressed. I got him exercising. I got him eating right, hoping that that would help elevate his mood. And he started counseling. During that time, we learned also that during the first year, he’d also failed three courses. And so rather than him be two years behind in school, we decided together that after his eight weeks of counseling, he would go back for the second semester and he would pick up those three courses that he failed. And so we did. And I got that awful spidey sense once again after I released him to his residence, and I only heard once from him that week, it was 3:00 in the afternoon on Monday, and he said, survive day one. And then I didn’t hear from him again. So that weekend my husband and I drove back to the university to check on him and when he opened the door, I realized immediately he’d relapsed again. It took some time for him to admit that, but I said, If you want help, you need to be transparent with us, otherwise we can’t help you. And so he was brought home once again, and we had a long discussion. And I asked him if he still wanted to be in university. Of course he said he did, but he didn’t think he had a gaming addiction. He thought he had a time management issue and he thought gaming was just getting in the way of him getting his degree. So once again, I asked him what he needed. Sky’s the limit. I will put my business on hold. I will do whatever you need. And he thought about it and he said, I need you to drive me to school and walk me to class until I can do it on my own. If you leave me alone, I think I will still game. And so that’s what I did. I did that for several weeks until he felt he could be on his own at school. And then he was required to send me photographs of himself in the lecture hall and in the classrooms to prove that he was actually attending. He had to come home on every weekend to be monitored. It was a long, hard process. It was a painful process. He relapsed many, many times. And then two and a half years in, before I could finish, I did go to the university and get him some help. I did ask for him to see a counselor and he had a peer support person and he had a special needs advisor at the school. So he had extra support there. So I wasn’t handling this totally on my own. He never did get addiction counseling. There wasn’t a lot available in 2014 for video gaming addiction, and so he made use of the counseling at school. He worked through self-esteem issues and how to handle the program. And how to manage his life in a healthier way. And after two and a half years of relapse and detox, he finally came to the conclusion that video gaming was going to destroy his life, that he would have no opportunity to get a job once he got his degree. And so he made a commitment to stop gaming. That was six years ago this summer. And he did, with a lot of help, get his degree in his fifth year of university. My husband and I sold our home and we moved to the city that his university was in so he could live with us and have a typical university year where he could join things on the weekends, attend parties, make friends and create a new community rather than the online community that he had found solace in for all of those years. Today, he is living on his own in Toronto. He is a software engineer. He’s very successful with his work. He has found so many wonderful other activities to do to fill his life. He has lots of friends. He’s still very close to his family and I’m really proud of him. When he can, he sometimes speaks with me, and any time that he can help another person overcome their addiction, he’s really pleased.

[Dr. Marc Potenza]: Thank you for sharing your experiences. This is very valuable to hear. Very heartbreaking to hear as well. But I think valuable for us, for the audience, for everyone to understand what it’s like as a parent to witness this in one’s child. So thank you for sharing that. From a perhaps both personal and global perspective, it raises the question about ways in which we might prevent screen addictions, particularly to video games with respect to guiding children, limiting or restricting behaviors, as well as allowing them to have opportunities to grow and develop and be social in ways in which youth may connect. So I was wondering if you could share your thoughts about how we might best prevent the problems such as those that you’ve experienced with Jake?

[Elaine Uskoski]: Yeah, that’s such a great question. It’s a question all parents want to know. How do we not have this happen to us? And I think, first of all, for me to be emotionally available to your child because the addiction is a symptom of something else that’s going on in their life, something much deeper that’s emotional. And I, of course, missed those cues. I didn’t realize how much my son was struggling emotionally. And so we need to be, you know, very open minded and non-judgmental and really listen to our children and understand what they’re going through in their lives. I think what’s secondly most important is that we make sure our children have lots of other activities they’re doing other than gaming and spending time on their phones. So many kids that I work with say I don’t have anything else. I’ve never done anything other than play video games and  then that’s difficult to find ways to fill those gaps when you are trying to stop the gaming addiction or the screen addiction. I think when you are in your home, you need to be setting timelines of when it’s acceptable to be gaming and when it’s not. Rules in the house about, you know, no phones at the table and no phones while we’re playing games together, when we’re having meals together, and when your child is gaming, it’s important that they have an activity that follows because it’s so easy if they have nothing else to do for them to say, but I have nothing else to do so I want to just keep gaming. And usually if we have a physical activity they can move to, that’s even better because they’ve been sitting and they’ve been sedentary with their screens. Allow your children to be bored. You know, that opens up the imagination for creativity. And we’ve become so used to being entertained by our digital devices that we don’t like to sit and ruminate in our heads and be alone. And I think it’s important that children learn that boredom is not a terrible thing, that you can you can really be creative in your boredom. And I think it’s also really important for parents to model their own screen use in the home because, you know, our children are watching us and they’re paying very close attention to that. Yeah, I think and also I think we need to be aware that children are spending money on games when they’re online. And, you know, don’t give your children your credit card, first of all, and think about whether or not you think your child can handle a little bit of spending if they are purchasing things on a game and then give them gift cards instead of a credit card so that they can learn to budget and and have a specific amount that they’re allowed to to use on a weekly or monthly basis.

[Dr. Marc Potenza]: Now, thank you for sharing those very helpful comments and suggestions based on your experiences with Jake and your larger experience throughout this process. Another question that arises is if a parent has identified a child with a gaming addiction and has helped the child go through a detoxification, can there be healthy limits set later? What are your thoughts on that?

[Elaine Uskoski]: Yeah, I never go hardcore detox for every child that has a problematic gaming issue. I generally start with the harm reduction. Where we just reduce the time and we try to introduce other activities in their life and maybe talk about what the issue is. That’s why they’re numbing out with the gaming, why they’re using it as an escapism. And sometimes a detox is required to heal the brain for a little time and then yes, we can reintroduce gaming at a moderated amount afterwards for sure.

[Dr. Marc Potenza]: And one last question before we move on to the next presenter. You had mentioned in your what you shared with us that you felt at one point that something may have been a bit off with Jake and that his behavior may have changed, or was there were there specific warning signs that you’ve identified now in hindsight that you could share?

[Elaine Uskoski]: Sure. Yeah. In grade 12, I started noticing he was fatigued a lot and his grades started to slip. When he went off to university for the first year. He wasn’t communicating a lot. If I did have to go pick him up for an appointment or to come home for a holiday, I’d tell him I was going to arrive at two and then I’d get there and he wouldn’t answer my text, and then I’d find him in his dorm room and it would be blacked out and he’d be sound asleep. So he was sleeping during the day. In second year, and then summer between first and second year he was gaming an enormous amount and I approached him about it and he became very angry with me. He said, you know, I’m in a co-op program and I just want this last summer to play because after this I’m going to either be in school or I’m going to be working. And I didn’t feel right about that either. And then when he went into second year, I didn’t hear from him hardly at all. And when I did see him, he did look like he’d been losing some weight. He did have a body odor, but he seemed to always have an answer for everything. You know, second year is harder than first year. And, you know, yeah, I’ll eat mom. I’ll find time to eat and, yeah, I’m answering your texts at 3 a.m. because I’m up late doing an assignment. Yeah, yeah, I’ll take a shower. But you know, I don’t have a lot of time this year because it’s so much harder. So that’s why it was so easy for him to hide it from me, because he seemed to just cover his tracks so well.

[Dr. Marc Potenza]: Thank you for sharing what sounds like it was a really, really difficult experience and that you’re now using that experience to share with people and to help others. So much appreciated.

[Elaine Uskoski]: Thanks, Marc.

[Dr. Mark Potenza]: And so we’ll move on to our next presenter, Dr. Naomi Fineberg, who is a Professor of Psychiatry at the University of Hertfordshire, and a consultant psychiatrist at the Partnership University there and the NHS Foundation Trust, where she leads the NHS England highly specialized service for obsessive compulsive and related disorders. She currently chairs the World Psychiatric Association, Anxiety and Obsessive Compulsive Disorder Scientific Session. Coordinates the Horizon Europe Network for problematic usage of the Internet, and is Secretary of the International College of Obsessive Compulsive Spectrum Disorders. She is also editor in chief of Comprehensive Psychiatry. And today she’s going to present on how to define and classify digital addiction and problematic internet users researching problematic Internet use in children and adolescents.

[Dr. Naomi Fineberg]: Thank you, Marc. It’s a great pleasure to be here. Thank you children and screens. I’m going to talk a little bit about diagnosis and a little bit about research. So when we talk about problematic use of the internet, what do we really mean? Well, it’s an umbrella term. It covers a lot of different behaviors that have become problematic in relation to or relation to screens. And it ranges from gaming, pornography, viewing, gambling, shopping and buying, video streaming, social media, cyberchondria, that’s the online searching for medical information and I don’t think it will surprise you to know that there’s still a critical scarcity of reliable scientific evidence or information on many key issues related to this, despite the impact it’s having on society and on children and young people. So we don’t know very much about the clinical boundaries of these problems. We’re not entirely sure how they link up with addiction and with other mental health issues. We’re starting to understand something about the brain based biology and the sociohealth economic impact. We still know very little about how to treat these problems when they arise, either to prevent them developing or to treat them once they’re established. In order to understand better some of these issues, we need reliable research, which in turn depends on standardized definitions of these disorders and standardized measurement tools. So we all know when we researching something what it is we’re measuring and how. So we can we can compare like with like. Now when you look at the problematic Internet use behaviors, they do look very much like addiction in the main. So addiction coming from the Latin addicere, to be enslaved, and these are the cardinal features of addiction. First is impaired control. So you try to stop doing it and you can’t. Strong craving and motivational preoccupations to do it. As a result of prioritizing that behavior, you can neglect important other areas of your life, like sleep or your education or your work or your relationships. And you continue to engage, even though you know it’s risky and even though you know it’s damaging, you know, apart from gambling disorder, which can be an online disorder, we’re much less certain as to whether you see more physiological or biological features of tolerance. In other words, becoming desensitized to screen use. So you have to just use it more and more and more, or withdrawal, which is very common in substance addictions and gambling, where you feel moody, your sleep disrupted, you’re very agitated. It’s less clear whether those symptoms of addiction occur across the broad range of Internet use disorders. Not only that, but when you dig a bit deeper and look at some of these other disorders, aside from gambling and gaming, they might look like other disorders, maybe more than addictions. So, for example, online shopping and buying or pornography viewing may be closer to impulse control disorders, where you get this irresistible urge to do it, even though you know it’s going to be harmful later. Whereas checking emails or digital hoarding or the cyberchondria, searching all the time for health information, or fitspiration, being obsessed with fitness and exercise, that’s a bit closer to OCD, where you’re doing it repetitively to avoid feeling bad or avoid bad consequences. And then excessive social media use may be more linked to social anxiety disorder, where people feel more comfortable in online situations that they’re avoiding in-person experiences. Well, maybe related to this fear of missing out the need to be up to date with absolutely nothing new to fear of shame and disgrace. So when it came to diagnosis and Kate mentioned the World Health Organization and Marc’s role in this, the World Health Organization is the international body responsible for the international standardization of disease classification and diagnosis. And the most up to date revision is the 11th revision of the international classification of disease, the ICD 11, and will help World Health Organization grappled with problematic use of the Internet because in order to give a diagnosis, they have to be sure that these entities really exist. That principle is based on the overarching public health need so that they would take the approach that to diagnose this would be reasonable if there’s good evidence that in creating a new diagnosis, it would prevent harm, either harm related to mental disorder or harm related to addiction. So through a great deal of consultation and discussion, they they took up the challenge of looking for diagnoses in the field of problematic use of the internet. They faced a number of controversies, a lot of questions about whether the scientific basis for diagnosis for these disorders is so new was strong enough. How did we differentiate them for profitability? It was considered really important not to stigmatize non problematic behaviors. But on the other hand, as I’ve said, the World Health Organization takes very seriously the importance of recognizing something if it really is a problem in order to be able to research and treat it. And as a result of all these discussions, they came up with these solutions. So we now have a new brand new section, ICD 11 of disorders due to addictive behaviors, which, if you like, matches the disorders due to substances of addiction, and they gave to new disorders, diagnoses, in this category, gambling disorder and gaming disorder. And there’s a residual category as well for other disorders that may not that are not gambling and gaming, but have the same characteristics. They included the Internet as a diagnostic specifier. So you can have online or offline gambling or gaming. And they included a new diagnosis called Compulsive Sexual Behavior Disorder that includes compulsive pornography viewing, which may occur online, which they didn’t put with addictions they put it in the impulse control disorder section. And I thought I’d just show you the diagnosis for gaming disorder so that you can see what the behaviors that define this disorder are. So it’s a persistent pattern of gaming that is characterized by all of the following and principally it’s impaired control, just as we’ve heard talked about today, it’s not being able to control starting, stopping the frequency and duration of the gaming. So it’s not the amount of time you’re gaming, it’s whether you can control it or not that’s key. And then the rest all falls out of that. You’re giving too much priority to gaming over other interests and activities. You continue to game or escalate gaming despite negative consequences and it has to result in significant distress or impairment that’s demonstrable in either personal family or other areas of your life. And if any of you are interested, as Marc mentioned, I chair Horizon Europe. So European network for problematic use of the internet. There is this free popular ebook available online that you can diagnose from our website. The www.internetandme website that covers all the other different forms of play. How to define them and gives practical tips on how to manage them. So do feel free to download this. It’s there to be used. It’s also translated into other languages, including Spanish. I’d just like to finish with a couple of slides on some new research because I’ve said there’s very little information. So what are we doing about it? Well, you may be pleased to hear that the European Union has invested several billion euros in this program, which is called bootstrap. And I’m privileged to lead this program. It’s based on the principle that healthy Internet use is important for health and well-being and that a subset of young people is harmed by Internet use. So not everyone, but just a subset. And so we work with young people aged 12 to 16 years, their parents and their teachers, in order to find out who is most at risk and why that might be. And you can see in the little diagram that you have, the the young person using the Internet is a subgroup, depending on various factors, societal factors, their individual factors, a subgroup will shift to the problematic and mentally unwell category. So we want to know who these people are and then we want to discover some harm prevention strategies, both at the level of the individual. So self management techniques they can use to prevent harmful use. And then at the level of politicians and policy makers to see if there are new social and health policies that we can introduce that makes it harder for at risk young people to be addicted. And the idea is that this will boost mental health and wellbeing across Europe. So just to drill down into more detail of what we’ll do, we’re going to recruit several thousand teenagers for schools across Europe. We’re going to use a bespoke app on their phones to explore how they use the Internet and to identify which behaviors, following them up over time, to identify which behaviors lead to harm. Then we’re going to devise some strategies to tackle it. We’re going to test them in a randomized control trial to see if we can identify self management interventions. Young people can use themselves to prevent these harms developing. At the same time, we’re going to use the evidence that we’ve derived from the assessments and observations to meet with politicians and see if we can develop some more rational policies about Internet use. So we’ve sent out fliers to schools. We’re asking them to join the digital revolution so that we can start recruiting. We’ll actually recruit next July. So we’re in the process of interacting with the public about the design of the project. I’ll be very interested to hear your comments to make sure that it is user friendly, particularly for parents and children. In summary then, healthy Internet use is important for health and wellbeing. A subset of young people can be harmed. Some forms of problematic internet use involve loss of control and are recognized now as mental disorders. And this new research is going on, which I think is well-placed to advance harm prevention and boost mental health and wellbeing amongst young people. So I’d just like to thank you for your attention and I’m more than happy to answer any questions and join this very interesting discussion.

[Dr. Marc Potenza]: Thank you very much, Dr. Fineberg. We have time for one quick question now and we’ll have more in the discussion. But you mentioned the Bootstrap Initiative. There’s also the Adolescent Brain cognitive development study here in the United States. What would you see as the benefits or any concerns? And would you wish, for example, to have a teenage, if you had a teenage child, what would your thoughts be about your child’s participation in such a study?

[Dr. Naomi Fineberg]: Well, that’s a really good question, Marc, and that’s something that that we’re grappling with. The research team are grappling with. The advantages of taking part in this research is that A) you’ll contributing for the first time really in these projects. that are pioneering projects. Were they’re contributing new knowledge to understand those personal factors in our children that might render them vulnerable to problematic use, getting hooked on the Internet. So on the face of it, it’s a no brainer. Why? Why wouldn’t you get involved as all of us have heard stories and are worried that our young children might be vulnerable. But on the other hand, the nature of the research is very personal and involves careful scrutiny of individuals into that use habits and young children might not want to be assessed in that way. We view it as them donating their data, but we will be monitoring their internet use no more than the internet providers, Google, etc. already do on their mobile phones. But we will be transparently looking to see what time they are on the internet at how long they’re on for. We won’t be able to look at the content, but will be able to know what kinds of websites they’re visiting. And people may feel that tyearhat’s intrusive and also they may not. They may alter that behavior. They know that they’re being assessed, they may alter their behavior. As a result, we may not get an accurate representation. So I think people might be cautious. I think parents might be cautious if they think that their child may be assessed and we might find a problem that they didn’t know about. So that suddenly becomes a problem that could feel a bit scary. So in this nine months that we have before we really gear up, we want to consult with parents and children, to hear any concerns that they may have, so that we make sure that when we when we kick off the project everyone’s on side and everyone feels confident that this really is a good thing to be doing. Because I think without this kind of research, we’re never going to really know those factors that determine your illness.

[Dr. Marc Potenza]: Thank you for that very thoughtful response and for the important work that you are leading and conducting. So I’d like to move on to our next presenter, Dr. Jason Nagata, who is an associate professor of pediatrics at the University of California, San Francisco, where he is specializing in adolescent and young adult medicine. He researches health consequences of adolescent digital media use, and he has published over 250 articles in academic journals. And his research has been covered by national media, including the New York Times, NBC News, NPR, and CNN. He co-founded the International Association for Adolescent Health Young Professionals Network, and he is the recipient of the American Academy of Pediatrics Emerging Leader in Adolescent Health Award, and the International Association for Adolescent Health Young Professionals Prize. Today, he’ll be talking about some ABCD, adolescent brain cognitive development, findings related to prevalence, predictors, and outcomes of problematic media use in adolescents.

[Dr. Jason Nagata]: Thank you so much for having me and for covering this really critically important topic. As mentioned, I have been analyzing data from the Adolescent Brain and Cognitive Development study over the last several years and wanted to share some of the findings related to problematic screen use from that study. So overall, the objectives today are to describe the prevalence and sociodemographic associations and prospective health associations, as well as parent media practices and those associations related to problematic screen use in young adolescents who have participated in the Adolescent Brain and Cognitive Development Study in the US. So just as a little bit of background about the ABCD study, in short, it’s the largest long term study of brain development and child health in the United States, which started in 2016 to 2018, which was baseline when the children were 9 to 10 years old and occurred across 21 different study sites throughout the United States, representing all the different regions, and followed about 12,875 nine to ten year olds with annual data collection. The study measures, problematic screen use, as well as mental health, physical health and a number of other related factors. So just as an overview of the data collection and study design of the ABCD study, there are actually several different measures of screen use that have been collected, but specific measures of problematic screen use were started in the second year of the study when the participants were about 11 to 12 years old. So still relatively young or early adolescents, and then those questions have been continued subsequently. So the measures of problematic screen use that the ABCD study used were across three different modalities: video games, social media and mobile phone. And for the video games, the video game addiction questionnaire was used. This consisted of six questions that assessed problematic video game use, covering areas such as mood modification, tolerance, withdrawal, conflict and relapse. And this was based on the Bergen Facebook addiction scale, and a very similar questionnaire was used for social media. And then the mobile phone involvement questionnaire was eight questions that assessed problematic mobile phone use. So just as an example of some of the questions that were assessed and some of the frequency of responses, in terms of mobile phones from this early adolescent sample, again, these are 11 to 12 years old at the time that they answer these questions among people who had mobile phones about or nearly half said that they lost track of how much they’re using their phones 31% said that they interrupted whatever else they were doing whenever they were on their phone. 11% said the thought of being without my phone makes me feel distressed. In terms of social media, 22 and a half percent said that they spent a lot of time thinking about social media or planning use of social media apps. 18% said that I use social media so I can forget about my problems. Almost 16% said they’ve tried to use social media apps less but can’t. And then in the area of video games, about 41% said I spend a lot of time thinking about playing video games. 21% said we need to play video games more and more and 24% said I play video games so I can forget about my problems. And again, this is a large national sample of young adolescents. Overall we also looked at general trends with sociodemographic factors that were associated with problematic screen use and we sort of assigned each participant an overall score for problematic use. And then that did differ a little bit by modality. So overall boys reported higher problematic video game usage, whereas girls reported higher problematic social media and mobile phone use. There are also disparities by race, ethnicity. Where Native American, Black and Latinx adolescents reported higher scores across all of the problematic screening modalities compared to non Latinx white adolescents. We also found that lesbian, gay and bisexual youth reported higher problematic screen use across all the measures. We then analyzed health outcomes one year after the initial reporting of problematic screen use. So we looked at the problematic screen use when it was assessed that 11 to 12 years old and then followed their mental health symptoms one year later when they were 12 to 13 years controlling for their baseline mental health. Across the three modalities of phone use, social media and problematic video game use, problematic screen use was associated with depressive problems, attention deficit symptoms, oppositional defiant problems, although effect sizes were generally small, and it was also associated with shorter sleep duration. We also found that problematic screen use is associated with suicidal behavior and sleep disturbance and substance use. In particular problematic phone and social media use was associated with future marijuana, tobacco and alcohol use. Finally, parents of adolescents in the ABCD study were also asked about their own media parenting practices, and we examined how these media parenting practices were associated with problematic use in the adolescent. Overall, we found that the greater parental screen use and parents allowing or having meals, mealtime, screen use or bedtime screen use was associated with greater problematic use across the different modalities. And parents while monitoring was associated with lower problematic social media and mobile phone use and parental restriction of screen use was associated with low or lower problematic use across the three modalities. Again, these are again with very young adolescents. So overall from these studies, I do think that this supports some of the guidance from the American Academy of Pediatrics to have potentially screen free times like bedtime and family meals to role model screen behavior and to have restrictions and monitoring as appropriate. I just wanted to thank the participants and investigators from the ABCD study, as well as our lab team members and a number of funders. Thank you.

[Dr. Marc Potenza]: Thank you Dr. Nagata. We have time for a quick question. ABCD is a longitudinal study which will provide very important information. What do we know now about the long term effects of different levels of screen media activity in children and adolescents as they go through development?

[Dr. Jason Nagata]: Yeah, that’s a really great question. I think one of the unanswered questions. We do have some preliminary data, as I showed, of some weaker associations between problem screen use at 11 to 12 and then some mental health, shorter sleep and substance use problems one year later, but this I would say I one of the hopeful promises of the ABCD study and other studies is that as they follow these early teenagers through middle adolescence and later adolescence, even into young adulthood, we’ll all be able to determine some of the longer term effects beyond even a year.

[Dr. Marc Potenza]: Thank you. Thank you for your presentation and sharing this important work. We’ll move on to our next presenter, who is Dr. Clifford Sussman, who’s been in private practice in psychiatry for children, adolescents and young adults in Washington, D.C. since 2008. He is an expert on Internet and video game addiction whose work has been featured in The New York Times, HBO Real Sports, Parents Magazine and Time magazine for Kids. He also treats patients with comorbid conditions such as ADHD and Autism Spectrum Disorder. He is dedicated to helping people achieve a more balanced relationship with digital technology use. Today, he will be presenting on interventions and treatments for youth struggling with digital addictions and problematic uses of the Internet, and will be presenting on what caregivers should know.

[Dr. Clifford Sussman]: Thank you very much. Thanks to children and screens for having me. Thanks for all these great presentations and thank you, Dr. Potenza, for your excellent job as moderator. So I’m a child psychiatrist and I really focus on this in my clinical practice. I focus on screen news related problems, and I see some of the most extreme cases in my and my practice. But what I’m going to try to do today in my limited time is focus in on my clinical perspective and some practical tips that all parents should hopefully be able to benefit from. So what you see here is a digital device. And what is it about digital devices that are so tempting to our kids? What is it that makes our kids prefer them so much over real life activities? You could see the digital device as a virtual shortcut, because digital devices do a lot of the same things that we do in the real world. They give you virtual versions that are much faster. They give you, it’s not that they give you better versions of what you want, it’s that they give you what you want right away. So that’s a really key concept because it turns out that the reward system of the brain’s blue dopamine pathways. Now dopamine is the chemical that’s released when we get what we want, when we wanted. And dopamine release is actually much more based on,and that’s the reward neurotransmitter, it’s much more based on the speed at which we get what we want than what we’re actually getting. So we’re on, we’re going to get that, not only are we getting what we want, but we’re getting it quickly and continuously. And so once we’re on our devices, it’s unlikely that we’re going to get off. But to get off, we need our brakes to kick in. Our brakes are in the prefrontal cortex, where you see these red arrows. And unfortunately, in our teenagers and in our kids, their brakes are not as developed as when they get older. So when you have underdeveloped brakes and you’re on your screen, what can happen is that you just keep going and you don’t get off and when you’re on for long enough, that’s when you start to have problems. But you’re not just having problems because you’re losing all the time to the screen. You’re also having problems because when you finally do get out, you’re still craving that, especially if you’ve been on for hours and hours and days and days. And so because these kids are still buying their dopamine, they may start to have a lot of these residual problems like irritability and, you know, going to all sorts of lengths to get back on their screen. They may have had defiance or aggression and they may have all sorts of different seeking behaviors, some of which have been described already. And so that’s when you start to get problems for parents. Again, the problems from being on too long and the problems from the residual effects of being on to them. And so for parents, you want to be looking for, you know, what the key definition of addiction is, which is described in our psychiatric manuals, actually is use disorders. And it’s been talked about already, but, you know, with addiction, you want to look for the problems caused by the use, not just the use itself. So are there social problems, are there academic problems? Are there health and are there psychological problems? So what I try to do, you know, my approach to treating this and to dealing with it is to try and not just eliminate screen use altogether, because that would be very impractical in today’s day and age. I mean, we’ve gotten very dependent as a society, our digital technology for functioning. So what I do is really focus on trying to get a balance between what I refer to as high dopamine activity and low dopamine activity. And the goal of treatment is really to help my patients balance the two. So by high dopamine activity, what I’m talking about is activities that are instantly and continuously stimulating, like playing a video game or being on TikTok. Whereas a low dopamine activity is an activity that requires more patience, where we have to put more effort in to get what we want, where there’s more delay in our gratification such as doing homework or doing exercise or maybe playing a musical instrument. And the reason I don’t just separate it into screen activities and non screen activities is because you can actually do a load over the activity on a screen. You know, doing coding, for example, or making these PowerPoints could be a low dopamine activity that you do on a screen. The problem is if you’re doing a lot of your low dopamine activity time on a screen, you’re also going to have all these other temptations on the screen. We are going to have such easy access to the Internet and everything else that’s on that abstract device. And so it’s kind of like drinking water in a bar now, that brings me to this point I wanted to bring up, which is that your home kind of looks like this bar to your kids. If it’s filled with devices and screens everywhere and if you’re using your devices too. When, and so that the brain starts to release dopamine even before it gets what it wants from the cues that it’s about to receive what it wants. So cues are a big factor. In fact, when someone with alcoholism walks into a bar, they get all the sight, smells and sounds of the bar, and that’s what causes their brains to release dopamine before they even had their first drink. So a lot of the work I do with kids and families is about adjusting the cues in the house and trying to separate high dopamine cues from low dopamine cues. And so that’s a big part of my strategy as well. Now, not only am I trying to help my patients balance the high and low dopamine activities in terms of their time and their schedule, I’m also trying to help parents balance their approach to how to deal with this problem, because I find that, you know, parents have trouble finding a balance between knowing what limits to set and what sort of natural consequences to put in place and encourage their kids to self-regulate and be more independent and set their own limits. And I find that some parents will settle into one extreme approach or another sometimes because maybe it’s more comfortable for them. Like, for example, during the the lockdowns, during the pandemic, a lot of parents just sort of gave up completely on trying to set limits so you could see this sort of extreme of just not setting any screen time limits at all. You could see it as enabling because a lot of these parents are the ones who, you know, when their kids are missing many days of school or not turning in assignments, maybe covering for them. So you can see that as, excuse me, you can see that extreme is sort of an enabling approach, whereas you can see the extreme limits setting, you know, as the parents who try to control and regulate everything almost like the screen police. So you could see that as micromanaging. And so really what I’m trying to help parents do is find a balance. And maybe as their kids go from younger to older teenagers, I’m trying to help them go start out with more limit setting and go gradually towards more self-regulation, because even if you can police and micromanage your kids perfectly to the point where, you know, maybe they get into this awesome college, then you know what happens when there they’re and they basically don’t have you there to micromanage them. And, you know, you could maybe hear a little bit of that in Elaine’s story, and in fact in my practice, even before the pandemic, I was getting a lot of patients who were college first year college dropouts. Who just didn’t know how to handle the lack of structure and the lack of guidance. So this is just a little bit of like the tip of the iceberg. I do a lot more specific interventions and treatments with my patients, but, you know, in the time we had I just wanted to give you a taste of some of the things that that I learned that are helpful for parents. You can find a lot more resources on my website, cliffordsussmanmd.com, if you click on the link: Internet and video game addiction information, you’ll have access to a lot of free videos and podcasts and other information. So and with that, I’m happy to take questions. Thank you.

[Dr. Marc Potenza]: Thank you very much for that very helpful presentation of your clinical experience. And this is, I think, of interest to many people and oftentimes youth with problematic use of the Internet may have other concerns going on. We heard from Elaine about perhaps affective conditions like depression, but also a number of parents and individuals have reported other concerns like attention deficit hyperactivity disorder and antisocial and autism spectrum disorder, and was wondering, with children with these different needs and variety of different presentations, how do you best help youth manage a digital environment?

[Dr. Clifford Sussman]: Yeah, I mean, that’s a really good question. There’s all sorts of differences in kids and parents may have to adjust that balance that I was talking about based on those differences. So one of the examples you brought up was autism. And I work with a lot of kids on the autism spectrum in my practice. So, you know, and they perhaps may not be as independent as other kids or neurotypical kids of the same age. So they may need some more limited setting. But one thing I think in general just to know about kids who aren’t neurotypical and ADHD kids as well, is that some of the standard interventions that I endorse for parents such as additional structure of having good routines, having a schedule, like a very specific schedule, and doing things like that, are they they’re even better and more important for kids with things like ADHD and autism and with kids on the spectrum one of the keys is that they really want things, they tend to really want things to be predictable. They really want to know what’s happening. And so a great way to prevent power struggles and aggression and all sorts of issues is to really let them know ahead of time not only what their schedule is, but exactly how much time is going to get on the screen to let them know exactly what the consequences would be if they don’t get off when it’s time. So the more predictable things are to them, the better. Sometimes even a five minute warning prior to 2:00 ending can prevent aggression or a power struggle. So these are some of the interventions that are really good for autism. And I think that also just preventing power struggles in general is really key. So sometimes you just have to avoid them. If you just have to wait until things calm down to be safe.

[Dr. Marc Potenza]: Yes, and preventing the occurrences is really important as a lot of parents struggle, particularly with youth with autism spectrum disorder, but also individuals without may become upset, perhaps escalating into violence and aggression. So in addition to trying to prevent, are there ways of de-escalating once I’d say a power struggle becomes more severe?

[Dr. Clifford Sussman]: Well, a general rule of thumb for de-escalating is to just try to see if you can avoid all physical types of interventions and just sometimes you just have to get away until the risk of aggression has subsided. But, you know, I may need to work with families on very specific types of approaches for de-escalation. You know, sometimes there’s there’s medication options as well that can prevent those escalations from happening in the first place. Other times, there’s therapeutic options that can that can help individual psychotherapies. But, you know, there’s there’s a, again, the more that they know it’s going to happen and the more that parents have sort of prepared and plan for these things. I think one of the main things for parents is just to kind of know that it comes with the territory and kind of almost anticipate it and so they’ve got a bunch of strategies in place to do this already.

[Dr. Marc Potenza]: That sounds very helpful and so delighted that we have this whole panel here of experts looking at the the concerns from different perspectives and so I’d like to bring some questions from the audience to the group. So one of the questions is how can parents or youth find help when they realize that there is a problem? What programs exist and how do individuals know when it’s time to seek professional help? I’ll put that out to the panel. And maybe I’ll direct that to you Dr. Sussman.

[Dr. Clifford Sussman]: Well, as far as seeking professional help, I mean, I think that if, again, you want to look at just how dysfunctional the behaviors have become, you know, what’s what’s happening to them across the board in terms of the problems it’s causing. You know, it’s it’s difficult because you have to make sure that even kids who don’t say they have a problem or don’t admit they have problems are in denial still get the help they need. So sometimes it’s better to err on the side of seeking help. It’s very standard for kids to be ambivalent about it. And in fact, all people with any types of compulsive use problems tend to be ambivalent, which means there’s a part of them that kind of knows they’re having a problem. But another part that really wants to keep doing what’s the problem is they really wants to keep using screens heavily. So it’s you know, it’s very typical for parents to get resistance when they’re trying to get help. But, you know, again, if you’re having these types of problems, I think it really is important to call a professional, psychologist or psychiatrist to try to schedule an intake appointment. You can’t do it with the information you have by yourself.

[Dr. Marc Potenza]: Elaine, might I direct the same question to you? Because I think you’ve lived through the experiences of your son, perhaps not immediately being open to seek treatment, even though you felt like it may have been helpful to him?

[Elaine Uskoski]: Yeah, in my case, there wasn’t a lot of help available at that time in terms of video gaming addiction. I mean, the most difficult thing about addiction is that those who are addicted will isolate and, you know, they don’t want to be around the people that are going to tell them it’s bad for them or that it’s not good. So they can, you know, hang on to that need for a fix and get it. And the most difficult thing about video gaming addiction is that even if they isolate from you, they still have this built-in online community that they communicate with. So they don’t feel isolated whatsoever. And that was a big problem for Jake. And so building new community outside of online gaming was probably the most important step for him. So that he could realize that he could leave his room, he could spend time with people, and it could be just as meaningful as it was online. I mean, we have to be careful not to be calling these online friends not real. I hear that from a lot of parents. That’s not their real friends. But to these children, those are their real friends. My son was bullied in middle school, and so he gravitated to online gaming to find community and feel accepted and be with children that, you know, were like him. Unfortunately, a lot of them were all, you know, emotionally in trouble as well. So that wasn’t particularly helpful. And so, you know, I mean, it always starts in the home and creating better communication if you want to reach your gamer, you know, they tend, I hear things like they don’t want to eat at the table with us, you know, they take their their food to their console to eat. And that’s generally because every time they come to the table, you want to address the problem of gaming. And so if you want to, you know, build that alliance with your child again, stop talking about the problem and then just start having light, you know, interesting conversation and get to learn, you know, what they’re struggling with and who they are. You know, there are lots of, you know, therapists to take your children to. And you don’t necessarily have to go with the problematic gaming. You can just start working on whatever the core issue is first and then, you know, maybe that becomes a point of discussion. That’s certainly what happened with Jake. As long as he was able to speak to the counselor at school about, you know, his self-esteem issues and and, you know, the bullying past history and the fact that he just really felt small at school. You know, he was a gifted kid in a in a program with very few other children. And so he felt like a big fish in a small pond. And he got to university and discovered there’s lots of smart kids. And he suddenly felt like a tadpole in an ocean. And it really severed his ability to feel he could handle the program as well. And so that was one of the other reasons that he gravitated to gaming. So we just have to be really aware of what’s going on for our kids first and try to reach them in that way I think. I often tell parents to just sort of plant seeds and talk to your kids about what you miss, you know, what are you missing now that they’re locked in their rooms? And, you know, you don’t necessarily have to say if you weren’t gaming, you know, we could be spending more time together. But you can say, you know, I miss our times together and I miss seeing you light up when when we go out together.

[Dr. Clifford Sussman]: Elaine, you make you make a really good point about, you know, when you’re addressing your kids behaviors, how they if you try to just sort of take it head on attack directly, they may just sort of run the other way. And that’s the nature of ambivalence. And it’s much better if you can get it to tell you what problems they’re having than you telling them what problems they’re having and what they need to do, because they’re often going to do the opposite of what they feel an authority figure is telling them to do. And so in my therapy, a lot of these the motivational interviewing approach where I try to have kids become their own authority figure and I try to just really listen and be reflective and try to really hear what’s going on, what problems they’re having to try and give them more insight.

[Dr. Marc Potenza]: Thank you both for that. And the practical information and the clinical approach information is really helpful to hear. And I was curious with what you were sharing, Dr. Fineberg, you had mentioned the learning how to deal with problematic usage of the Internet e-booklet that was generated through the cost initiative, and I believe that book has a number of practical pieces of information or practical approaches that people can use. Maybe you could share with us some of that information. You’re muted.

[Dr. Naomi Fineberg]: Sorry. Absolutely. So do feel free to download it. I’m sure Kate and the team will send the link. And there are the sorts of generic issues and generic approaches that we’ve been talking about that we discuss in the book, which is around, you know, I love Dr. Sussman’s description of the need for balance. It’s about this great emphasis on balance and making sure that your lifestyle is well balanced with your children, that there’s plenty of social interaction and exercise and all those other things going on, as well as allowing screen time, but within in reasonable limits and it may be quite appropriate to set some rules in the household, as we’ve discussed about, you know, not having your mobile phones at the table through negotiation and discussion. But but the key, again, as Dr. Sussman and Elaine were saying, I think the key is, is to parents, as we say in the book, for parents and children to be communicating with one another, the parents need to understand what’s going on on the Internet. They need to understand these games. Very often we don’t, but we need we need to put some effort in. We need to find out what these games are. We can talk about them with our children so that they become an interactive activity rather than an isolated activity. And then we talk more specifically, if you think your child is starting to run into problems, then, you know, with the limited setting taking the point that that Dr. Sussman says about being predictable, not just impulsively instituting a rule, explaining in advance why and what you’re trying to do, but also if you know the game, having a dialogue with the child. If they’re playing a game that’s important, that they finish a certain game and they’re on it with all their friends across the world, and if you make them stop in the middle of the game, that’s just never that’s never going to work. Yeah, negotiate that with your child and let them get to the end of the game before stopping and similar interactions like that. I’m trying to say, trying to diffuse the tension and it’s going to involve compromise. But the more the parents can be involved and again, we emphasize very strongly that Dr. Sussman said, modeling parents behavior. If you’re on your mobile phone at the table or when you’re talking to your child, you know, you can’t be surprised if they’re going to prioritize that behavior as well. So try and practice what you preach. So those are some of the tips that we offer on the phone on the book.

[Dr. Marc Potenza]: Thank you. Dr. Feinberg. Dr. Nagata, your thoughts, particularly with respect to how to make a family use plan?

[Dr. Jason Nagata]: Yeah, I was just going to add that the American Academy of Pediatrics also has a helpful resource on family media use plans. And it very much echoes all the discussion that we’ve had. But there are different areas and it’s an online kind of interactive tool. So just highlighting what everyone has said, like I think there’s not a one size fits all solution for every family, for every child. And so this sort of goes through the different domains like having a discussion with your child, you know, potentially screen free times like bedtime, meals. Screen free zones, maybe in bedrooms or bathrooms, digital privacy and safety, and then balancing, you know, media time with other, you know, physical activity and other activities. So it just has all of those things laid out and I think can be a helpful resource. And I would also just encourage if you are having any concerns, you know, one person you could talk to is like your pediatrician or primary care doctor as sort of a first step. Oftentimes they are supposed to be assessing for media use and like well-child checks or physical exams. But if you have any concerns, I think that could be a good place to start. And they may be able to make initial referrals. 

[Dr. Clifford Sussman]: I’d like to make a comment on what you were talking about. The family use plan, a family media use plan is that I think if you’re going to use a tool like that, one thing I caution parents about is not using it like some kind of contract where if it’s broken, you failed as a parent, rules are going to be broken. That’s something you have to understand as a parent. And, you know, you have to kind of when you put in place a plan, you can have you can set up rewards for following the rules. You can set up, you know, very reasonable, logical consequences for breaking them so it doesn’t have to be like a contract. It would just be like, these are the house rules that we follow. And this is what happens if you if you follow them and this is what happens if you break them.

[Dr. Marc Potenza]: Thank you. And thank you for all the useful information from all the panelists. One question that comes to mind is we’re still at a stage of understanding and initiatives like ABCD or Bootstrap are going to be really helpful for understanding relationships between types and patterns of screen media activity and concerns that may arise, as well as potential benefits from utilizing Screen Media. One question that arises is that ABCD starts at 9 to 10 years old, Bootstrap starts at 12 years of age, but youth are beginning to interact with digital media at increasingly earlier ages and getting smartphones in higher proportions at earlier ages. So what are the thoughts about early childhood development and patterns of screen media activity? What can parents do as their children that are at earlier stages than, say, ABCD or Bootstrap may cover? And I’ll ask Dr. Nagata or Dr. Fineberg to begin, since I frame this with Bootstrap.

[Dr. Jason Nagata]: Yeah, I think it’s a really great question and I do think that part of this lack a bit like lack of one size fits all solution is that, you know, as kids develop like there are so, so many rapid changes like obviously a one year old is going to be different than a five year old is going to be different than a ten year old. And you have to have very different types of rules and perhaps more concrete rules, especially for the younger ages. So I do think that you really have to take into account developmental stage and appropriateness. I’ll just highlight that the current American Academy of Pediatrics media use guidelines and again, you they may not be like hard and fast, but their general guidance is that for under 18 to 24 months that you actually avoid digital media use all together unless it’s for like video chatting or interactive kind of calls like with grandparents or their family members. And then for 18 to 24 months, if you are going to introduce digital media to really just choose high quality programing like PBS Kids or, you know, something that’s really geared towards educational content for children and while avoiding, you know, maybe more fast paced programing or social media and stuff like that. Then from 2 to 5 year olds, they recommend limiting to under an hour again of high quality use and then above five there actually is no there are no like specific time guidelines. They used to recommend less than 2 hours a day. But since so many, so many children, now you get more than that and there are so many different contexts that have sort of been abandoned for this family media use plan, which is to make it a little bit more individualized for your household. But I do think it’s really complicated. And as you mentioned, like kids are exposed to screens at very early ages now. And to some extent you can’t completely avoid them. But I do think that taking into account developmental appropriateness is very important.

[Dr, Marc Potenza]: Thank you very much, Dr. Nagara. Dr. Fineberg.

[Dr. Naomi Fineberg]: Yes, I agree with everything that you said that Jason. That all makes sense of the difficulty in investigating very young children is that the models for investigating the children because as I started to go to, has said, the brain is at a different developmental stage. So the instruments that we use to measure developmental, how people are manipulating information, mood states and so on changes hugely as you go through childhood and adolescence. So the tools that we have, the limited tools that we have at the moment, are really geared towards older children, adolescents, and adults. And so we don’t really have the instruments available to measure very young children and the effects of Internet on them in a very reliable way. It’s also harder to conduct research in younger children. It’s just more difficult practically to do. When we devised the bootstrap, we were wondering how low we should go in terms of age, and we settled on the age of 12 because everybody would be in a second, in Europe, we call it a secondary school. Maybe you call it the high school in America. So the easiest to get the children. Be easy to work with the with the teachers that have more autonomy. And the brain mechanisms were relatively developed to a certain level that we can make some predictions, whereas we are much less able to do so in the younger age group. Having said so, a lot of the research in the young group relies a lot of it relies on parental reports as to how the children are doing at the ages of one, two, three and four. Just to say that there is some new research that’s just come out from Japan, I think Japan, which did seem to show that screen time at the age of one year old, did equate with some developmental changes at the ages of two, three and four years old. Now, that’s not to say cause and effect. It’s not to say the more screen time you have at the age of one, the poorer your development in very specific areas, not across the board, but particularly inhibitory in being able to stop things. But it did seem to hint that controlling, that the American Pediatric Association guidelines may make a great deal of sense and that children at a very young age are not immune to these problems and if they spend too long on the Internet, may have some developmental problems in later early childhood. But these are still very preliminary. I think we need to crack how we research that in the next few years.

[Dr. Marc Potenza]: Yes. And I think.

[Dr. Clifford Sussman]: Sorry, I was I was just going to add like some practical side to this. I think we were talking about the devices as a virtual shortcut machine. And I think parents should be asking themselves, like, what shortcuts are we getting from the machine? Are we using it as a virtual babysitter? Our babysitter is using it as a virtual babysitter or, you know, are we using it to help distract our babies while we feed them? You know, there’s so many apps and so many apps on our devices that are designed to get the very youngest and most vulnerable. You see really little kids endlessly watching YouTube of people opening chocolate eggs. And you’re like, how could they be watching that? Well, you know, they they’re getting similar types of reinforcement that a gambler gets, when they’re online gambling or playing a video game, for that matter.

[Dr. Marc Potenza]: Yeah. So I think that this bridge between science and how do we take the science and translate it into practical, useful health promoting information is still an active area and is moving into earlier stages of development. And there is a new study called the Healthy Brain Child Development Study HBCD, which is starting at earlier ages than ABCD, and I’ve encouraged some of the leaders of that initiative to include screen media activity measures in the developing children so that we can understand brain behavior relationships over over time. Which I think will help us address this knowledge gap in this rapidly changing environment. And what I’d like to do is to, even though I would like to continue at this discussion, this very important dialogue, we are running short of time. So I’d like to thank all of our panelists for a really complimentary group of presentations that synergistically covered this very important topic. So thank you all for bringing your areas of expertise and your experience and thoughts and knowledge together and sharing this information with the larger group of people. I’m viewing this online presently and perhaps down the road as well. So I’d like to turn things over to our organizers.

[Kris Perry]: Thank you, Marc. And before we close, I want to thank all of our panelists today for those informative presentations and the enlightening discussion. Thank you also to our zoom audience for attending this session and to learn more about digital media and child development or the work of the institute, check out our website at childrenandscreens.com. Follow us on these platforms and subscribe to our YouTube channel. We will be taking a brief season hiatus in the month of September as we host the Digital Media and Developing Minds International Scientific Congress in Washington, D.C. We hope you will join us when the Ask the Experts Webinars resume on Wednesday, October 4th, with Anxiety: Youth Mental health and Digital Media. This will be the first of a two part series addressing the current youth mental health epidemic and the relationship with technology and digital media use. Thank you.