Adolescents and Development. Brain Areas Involved with Internet Use. Social Media and Children. Internet Use and Family

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1 Adolescents and Development Helping Families Unplug Their Children and Adolescents with Psychiatric Disorders: Understanding Neurocircuitry to Guide Effective Treatment Approaches Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC-APN Clinical Professor of Psychiatry and Nursing Administrative Director Pediatric Mood Disorder Program Institute for Juvenile Research, Department of Psychiatry University of Illinois at Chicago Chicago, Illinois Time where certain stimuli can alter cortical inputs and responses Teen brains are in a state of pronounced developmental plasticity Studies at rest vs in task differ normal vs abnormal Lag between affect and systems of cortical control Heaviest users First adopters Generation M: digital natives or screenagers Between the ages of 8 to 18 spend an average of 7 hours 38 minutes on digital media daily (YouTube, Facebook, games excluding phone use/texting) Multitask more than older populations Dosenbach NU, et al. Science. 2010;329(5997): Lewin T. If Your Kids Are Awake, They Are Probably Online. The New York Times. January 20, Brain Areas Involved with Internet Use Social Media and Children Benefits: Community engagement, individual and collective creativity, growth of ideas, expansion of diverse connections, fostering of one s individual identity and social skills, opportunities Adverse effects: Cyberbullying, Facebook depression, sexting, privacy concerns, online risk-taking behavior Recommendations: Family online use plan, parental supervision, talk to children about use, parents/health care providers must know about social media Choudhury S, et al. Transcult Psychiatry. 2013;50(2): O Keeffe GS, et al. Pediatrics. 2011;127(4): Richards D, et al. J Paediatr Child Health. 2015;51(12): Neuro-alarmism vs Neuro-enthusiasm Internet Use and Family Are we altering our minds because of dependence upon social media? Unempathetic? Intellectually shallow and uncritical? desensitized, depressed, or attention-deficit? Neuroplasticity: The brains constant change in response to environment and to brain s own activity Much of what we know comes from small scale neuroimaging studies Research points to dopamine: Associated with reward driven behaviors in compulsive digital media use Pleasure, euphoria, withdrawal effect from media is blamed on the hook of dopamine Choudhury S, et al. Transcult Psychiatry. 2013;50(2): Weinstein AM. Am J Drug Alcohol Abuse. 2010;36(5): Survey of 222 4th, 5th, and 6th grade Korean children to examine a) Whether children s Internet use influences declines in family time and family communication b) How parental mediation techniques are related to children s online activities Total time using the Internet was related to perceived declines in family time but not related to family communication The influence of the Internet on family time and family communication differed by the type of children s online activities The analysis of the relationship between parental mediation techniques and children s online activities indicated that parents recommendation of useful Web sites and co-using were positively related to frequency of children s educational online activities However, parental restrictions on time and Web sites did not alter children s actual Internet usage Lee SJ, et al. Cyberpsychol Behav. 2007;10(5):

2 Tips for Parents: Social Media Use Are There Upsides to Digital Use? 1. Reinforce positive self-talk and self-acceptance to navigate peer pressure, competition, and negative behaviors. 2. Know what sites your kids are using. Preteens as young as age 9 can be active on accounts without their parents being aware. Check browser history and, more importantly, use the opportunity to communicate with your child. 3. Set up boundaries on what is appropriate or inappropriate for posting. Encourage your child to pause before they post and take a moment to think about how their words might impact someone else. 4. Practice the 3 Cs Control (what you let influence your emotions), Care (how words and actions impact you and others), Confidence (in positive feelings about yourself). 5. Use practical advice and relatable resources when talking to your preteen. Books like Love Yourself a short fictional story about a girl who learns self-acceptance to navigate social media, so her self-esteem isn t based upon the number of likes she gets can be a helpful tool in starting a dialogue about social media with your child. 6. Get to know your child s online friends in the same way you would in person. Check in with them about their online activities, and ask them about their followers 7. Talk with other parents. Compare notes and take a team approach to making the online spaces safe. 8. Talk with your children about their well-being and online dangers (eg, acceptance, risk-taking behaviors, overuse, bullying, personal disconnection). 9. Monitor Internet and social media usage. Use this as an opportunity to create conversation. 10. Recognize some of the positive aspects of the Internet (eg, community engagement, solidifying personal identity, providing a sense of group cohesion) and help guide your child toward prosocial uses. US Psychiatric and Mental Health Congress July 20 at 1:39 PM Going out to catch Pokemon everyday has had a positive impact and players mental health. Read more about how players have been positively motivated by this new mobile app! Pokémon Go Is Having an Unexpected Effect on Players Mental Health This is neat. ATTN.COM BY LAURA DONOVAN National Youth Risk Behavior Survey 2015 Parents, Teachers, Society Survey of 9th to 12th graders using 89 questions on YRBS, N = 15,624 administered across the United States National Data is broken down into state data as it varies: Goals Describe risk behaviors Create awareness Set program goals Develop programs and policies Support health-related legislation Seek funding YRBS = Youth Risk Behavior Survey. Kann L, et al. MMWR Surveill Summ. 2016;65(6) Of the 61.3% of students who drove a car or other vehicle 30 days before the survey, 41.5% said they texted or ed while driving 15.5% were electronically bullied: 21.7% of females > 9.7% of males 27.3% get 8 hours of sleep each night (less in minority youth) Digital Technology, Gaming Brain Activation and Internet Use Americans spend an average of 33 hours/week surfing the Internet (US IDC, 2008) In 2012, more than 1 billion individuals play computer games Massively multiplayer online role playing games World of Warcraft, (46%) of play (reputation, social element, admiration, acquiring status with competition). Social, discovery, escapism. More addictive High comorbidity with psychiatric disorders: Affective disorders Impulse control disorders Substance use disorders ADHD Studies of brain activation when net surfing show disparate results; and can reflect both increased or decreased specialization of a brain region and ability/skill Lack of integrative models that can address functional neuroplasticity lead way to interpretative openness of study results Delineating typical brain development and the sequence of emerging social cognitive abilities may contribute to increased understanding of the effect of increasing social media on the developing brain ADHD = attention-deficit/hyperactivity disorder. Weinstein AM. Am J Drug Alcohol Abuse. 2010;36(5): Choudhury S, et al. Transcult Psychiatry. 2013;50(2): Burnett S, et al. Neurosci Biobehav Rev. 2011;35(8):

3 Studies on Gaming Adolescents Health Risks Decreased blood flow in frontal cortex while gaming Reduction of limbic activity with violent gaming What is normal identity formation, brain, and cognitive formation; and then how does gaming and digital media influence? Use Lifestyle Health Risks Sleep duration was negatively associated with obesity (β = -0.30), which in turn was associated with elevated blood pressure (β = 0.26), low high-density lipoprotein cholesterol (β = -0.18), high triglycerides (β = 0.61), and high insulin resistance (β = 0.39) The model explained 36.2% of the variation in sleep duration, 32.7% of the variation in obesity, and between 12.8% and 28.1% of the variation in cardiometabolic indicators Post-hoc analyses indicated that curtailed sleep is a possible full mediator of the association between videogame addiction, abdominal obesity, and the associated cardiometabolic deficits Mathiak K, et al. Hum Brain Mapp. 2016;27(12): Turel O, et al. PLoS One. 2016;11(5):e Anthropometric and Descriptive Characteristics of the Participants Descriptive Statistics, Correlations, and Reliability Indices Turel O, et al. PLoS One. 2016;11(5):e On the diagonal: Cronbach s Alpha for multiple-item constructs. *P <.05. **P <.01 Turel O, et al. PLoS One. 2016;11(5):e PIU Traditions Use to Addiction As substance Abuse As Impulse Control Disorder An artifact of relational and relationship building resource deficits Depression Loneliness Social Anxiety Excessive Play Problematic Dependence Addiction Self-diagnosis correlates with standardized measures PIU = problematic Internet use. Tokunaga RS, et al. Human Communication Research. 2016;42(2): Kuss DJ. Psychol Res Behav Manag. 2013;6:

4 Risks for Addiction Qualities of Gaming Internet Addiction Neuroticism Aggression and hostility Sensation seeking Some games are more addicting than others: Games online, those with positive reinforcement, enjoyment of particular game content, viewing ones online persona as better than oneself Psychiatric diagnoses: Depression, bipolar disorder, borderline personality disorder Cue induced desire seen in dorsolateral prefrontal, orbitofrontal cortex, parahippocampal gyrus, and thalamic regions Person is preoccupied with gaming Gaming is used to escape reality or create euphoria Tolerance develops Withdrawal symptoms occur: Person feels anxious, depressed, irritable if prevented from playing Person has interpersonal conflict as a consequence of playing; problems with relationships, job, hobbies, and lack of success in abstinence Upon discontinuation, the person experiences relapse Kuss DJ. Psychol Res Behav Manag. 2013;6: Han DH, et al. Compr Psychiatry. 2011;52(1): Griffiths MD. Journal of Substance Use. 2005;10(4): High impulsivity contributes to Internet addiction Use to Addiction Impulsivity/Impaired Prefrontal Impulse Inhibition Ding WN, et al. Behav Brain Funct. 2014;10:20. Kuss DJ. Psychol Res Behav Manag. 2013;6: Individuals context (excessive and addiction) Cultural context: Embeds gamer in community with shared culture and beliefs Similarities with other addictions Scales Used to Measure PIU Compulsive Internet Use Scale (CIUS) consists of 14 items A 5-point scale: 0 = never; 1 = seldom; 2 = sometimes; 3 = often; and 4 = very often Do you experience your Internet use as a problem? Do you feel or have you ever felt addicted to the Internet? Established validity and reliability Meerkerk GJ, et al. Cyberpsychol Behav. 2015;12(1):1-6. Tokunaga RS. Human Communication Research. 2016;42(3): Jelenchick LA, et al. Acad Pediatr. 2015;15(6): Online Cognition Scale (OCS) measures PIU 36 items covering 4 subscales: 1. Loneliness/depression (6 items, 0.74) 2. Diminished impulse control (10 items, 0.82) 3. Distraction (7 items, 0.85) 4. Social comfort (13 items, 0.86 Other Scales DSM-5: Internet Gaming Disorder Social Media Intensity and Use Scale (SMIUS ) The Final 10-Item Scale and Descriptive Statistics Using the Total Sample Item text Mean SD ITC 5a I feel disconnected from friends when I have not logged into Facebook a I would like it if everyone used Facebook to communicate a I would be disappointed if I could not use Facebook at all a I get upset when I can t log on to Facebook a I prefer to communicate with others mainly through Facebook a Facebook plays an important role in my social relationships b I enjoy checking my Facebook account b I don t like to use Facebook (r) b Using Facebook is part of my everyday routine b I respond to content that others share using Facebook Note. n = 552. SD = standard deviation; ITC = corrected item-total correlation. Scale range for items: 1 strongly disagree to 6 strongly agree. (r) item 11 reverse coded. a Social Integration and Emotional Connection subscale. b Integration into Social Routines subscale. Criteria: Preoccupation with gaming Withdrawal symptoms Lack of control Loss of other interests Use despite negative consequences Deception Mood modification Losing a job relationship, or similarly important aspects of life Tokunaga RS. Human Communication Research. 2016;42(3): Jelenchick LA, et al. Acad Pediatr. 2015;15(6): Jenkins-Guarnieri M, et al. Psychology of Popular Media Culture. 2013;2(1): American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Publishing, Inc.; 2013.

5 Treatment of Internet Addiction Moderation for Outcome Variables Addiction: 1.5% to 8.2% of population No significant difference between psychological and psychopharmacologic interventions = where outcome is addiction status, time spent online Difference seen in reduction of depression: psychological Tx > psychopharmacologic Tx No difference between CBT and other psychosocial treatments On addiction status, CBT > other psychosocial treatment for time spent online CBT > other psychosocial treatments for depression CBT = cognitive-behavioral therapy. Winkler A, et al. Clin Psychol Rev. 2013;33(2): Winkler A, et al. Clin Psychol Rev. 2013;33(2): Psychopharmacology Psychopharmacology Limited number of studies Escitalopram Amphetamine Methylphenidate Bupropion Unlike other addictions, ITS benefits are greater than group therapy (may be due to high levels of social anxiety) Culture related differences across studies Methylphenidate N = 62, mean age 9.3, range: 8 12 Young s Internet Addiction Scale (YIAS) OROS methylphenidate 18 mg upward There are no medications FDA approved for the treatment of Internet addiction. Winkler A, et al. Clin Psychol Rev. 2013;33(2): Han DH, et al. Compr Psychiatry. 2009;50(3): Family Therapy Interaction between Group and Stimuli in Response to Affection/Game at Baseline From substance abuse literature (family dysfunction, poor cohesion) Brief 3-week family therapy intervention 15 adolescents with videogame addiction vs 15 normal controls Interventions: Increase family cohesion for > 1 hour/day, 4 days/week fmri pre-post Findings: Improved family cohesion = increased activity of caudate nucleus in response to affection stimuli and inversely correlated with online game playing cues and images depicting parental love Building family cohesion may be important in the treatment of online gaming fmri = functional magnetic resonance imaging. Han DH, et al. Psychiatry Res. 2012;202(2): Han DH, et al. Psychiatry Res. 2012;202(2):

6 Case Presentation How to Help? Andrew (10) Presents with adoptive parents Hx of BD, ADHD Symptoms of illness mostly well treated Tablet and handheld games Transitioning on and off Medications: Methylphenidate patch 15 mg, bupropion XL 150 mg, risperidone.5 mg bid BD = bipolar disorder. Is this overuse? Is this related to his ADHD/BD? What does he think of questions assessing his use? Can he withstand moderation of use or is a break possible? How may his medication be helping? Not helping? What strengths in parents can we use? Family therapy: Increase cohesion, manage transitions, positive reward system, create balance, family sharing of gaming Consider whether medication doses are sufficient or if a change in agents may better address overuse Educate family on risks for addiction in Andrew s case and engage Andrew in collaborative problemsolving Take Aways Reduced dopamine transporter availability and a weakened control circuit linking occipital lobe circuitry through emotion regulation and reward centers may be involved with digital technology addiction and misuse Collaborating with families around parent-child relationship quality, monitoring, and restriction of use, and addressing symptomatology underlying misuse with psychological and psychopharmacologic approaches can result in positive outcomes in mental health settings Digital technology that engages executive functioning and mediates reward circuitry can result in symptom improvements in children and adolescents with some psychiatric illnesses, and using these familiar techniques may assist in recovery efforts