child & youth Mental Health Series · •Attention deficit hyperactivity disorder (ADHD): Individuals with ADHD tend to be sensory seeking, which leads to the attraction of screens

Today’s topic: Technology Overuse: Helping Patients and Families to Reconnect and Unplug

Speaker: Michael Cheng, Psychiatrist, CHEO

child & youth

Mental Health Series

Thu, Apr 20, 2017

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Declaration of conflict

Speaker discloses a unrestricted educational grant from Lundbeck/Otsuka via uOttawa Brain/Mind Research Institute for development of the website eMentalHealth.ca/PrimaryCare

Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.

Technology Overuse: Helping Patients and Families to Reconnect and Unplug

CHEO MH Rounds

Thu, Apr 20, 2017, 1200-1300 hrs

Dr. Michael Cheng, Psychiatrist, www.drcheng.ca Children’s Hospital of Eastern Ontario (CHEO)

http://www.drcheng.ca/

Schedule

1200-1245 Talk (45-min.)

1245-1300 Questions (15-min.)

When I was a kid…

• My parents wouldn’t get us an Atari, because my parents thought that it would rot my brain…

• For years, I resented them for that…

• And now…

• Every day I am telling parents to cut back on their kids’ technology…

Objectives

• By the end of this session, participants will be able to: • List the elements for mental wellness,

• List ways in which technology overuse impairs this,

• List strategies to • Reconnect children/youth to healthier attachments such as parents and

nature

• Disconnect children/youth from technology overuse

Objectives

• Note • This presentation is a “Part 2” that complements earlier “Part 1” lectures on

technology given by Dr’s Gandy and Cheng.

• Whereas previous sessions focused on the evidence that technology overuse causes problems, this session will focus more directly on clinical interventions with the patients that we see.

Now that I’m an adult…

• Now I’ve become my parents…

• Every day, I tell parents to reduce their kids recreational screen time…

Let’s start with a case…

• Dave is a 16-yo teenager

• Referred to see you for inattention, irritability, and depression

Image: Boggett Photography

Case

• Your assessment with Ryan shows… • Depressed mood

• Sensory sensitivities

• 7.5 hrs a day on video games!


Q. What is the secret to happiness, i.e mental wellness?

a) The latest first person shooter video game

b) Lots of money

c) Lots of friends

d) A sense of belonging (including secure attachments), meaning, hope and purpose

Q. What is the secret to happiness, i.e mental wellness?

a) The latest first person shooter video game

b) Lots of money

c) Lots of friends

d) A sense of belonging (including secure attachments), meaning, hope and purpose

What Do People Need for Wellness? • Purpose in daily life, e.g. education,

employment, care giving, cultural activities

• Hope for the future • Belonging and connectedness within

one’s family, community and culture • Sense of meaning in one’s life

First Nations Mental Wellness Continuum Framework, 2014

In normal development, people connect to things which give hope, meaning, belonging and purpose such as…

Deep connections to people, in particular family

Nature

Other meaningful things such as community, culture, spirituality, etc...

At a brain level, studies show that these healthy connections provide optimal amounts of dopamine/adrenaline and oxytocin

Secure attachment to people oxytocin

Nature exposure dopamine / adrenaline


NEED REFERENCES


Nature

If someone is depressed, then at some level, they have been disconnected from that which would provide purpose, belonging, hope and meaning…



Nature

Such as overconnection to technology, peers and values that don’t bring meaning…


Technology

Hedonism, materialism, consumerism…

Peers

Getting back to our case

Epidemiology

How common is technology overuse?

• The average American teenager has 7.5 hrs/day of recreational screens (Pew Internet Study, 2011)

Pathophysiology

How does technology overuse impact the brain?

• Today’s technology is far more addictive and immersive than early video games

• MRI brain studies confirm this

• The human brain is not designed for the level of sensory stimulation that today’s modern video games provide

• As a result, sensory overload makes the brain feel it is under threat, at a sub-cortical, polyvagal level

• It triggers your body’s alarm that something is not quite right…

Screens give us “easy dopamine”

“Easy dopamine”, i.e. provides lots of dopamine, adrenaline with little effort

When your brain gets used to “easy dopamine”, its harder to do things that provide less dopamine, that are ‘boring’ like: • Going for a walk • Homework • Face to face contact • Driving • Looking at your child…

Screens are overstimulating: Part 1

• This is the type of sensory stimulation our brains are designed to handle

• Numerous studies confirm nature provides optimal sensory experience, leading us to have optimal brain waves and feel calm, relaxed, refreshed

• Nature sounds are more soothing than even other things thought relaxing, e.g. classical music


Screens are overstimulating: Part 2

• Although it gives our brains a rush of adrenaline / dopamine, it is actually not calming nor refreshing, and can trigger fight/flight responses

• Especially in those with brain conditions, e.g. seizure disorders, sensory processing issues, issues that affect filtering such as psychosis, or anxiety

• Multi-tasking just makes this worse…

Image credit: Fair Use Policy

With excess screen use…

• With excess screen use over time, the body is under chronic alarm, i.e. stress • Blood flow shifts from frontal (developed brain) to the

more primitive parts of the brain • Thus, one can see problems with regulation, attention,

creativity, social behaviour • Body makes cortisol, a stress hormone

• High cortisol impairs memory (from hippocampus), disturbs sleep, disturbs concentration, causes weight gain

• Electronic Screen Syndrome (ESS) • Signs of an overloaded brain can mimic any psychiatric

disorder • E.g. inattention • E.g. mood/anxiety problems

Dunckley, 2014

Clinical Presentation

Excessive screen time has been associated with numerous issues including • Impaired function

• School, work and relationships • Preoccupation with technology

• Physical symptoms • Insomnia • Physical complaints, including repetitive strain syndrome in texting or video gaming

• Neurovegetative symptoms • Mood problems • Attention problems • Hallucinations

• REFERENCES

Assessment

Digital Media History

• Ask parents / youth together, and separately • What types of technologies does your child use?

• How many hours a day on weekdays? Weekends?

• What’s the worst thing that has happened online? • Done anything that you’ve regretted, e.g. sexting, posting certain comments, etc.?

• Any cyberbullying?

• Ask parents • Any rules around the technology use?

• Any conflicts that arise from the use?

Activities / Attachments

• Ask parents / youth • “Walk me through a typical day… How do you spend your day?”

• “What are the activities that you spend time on every day?”

• “Who are the people that you are the closest to?”

• With technology overuse, may show that • Several hours of day on technology

• Very few hours on non-electronic activities, or face-to-face time, or nature time, or other things which give purpose, belonging, hope and meaning

Diagnostic Issues

DSM-5 Internet Gaming Disorder

Repetitive use of Internet-based games, often with other players, that leads to significant issues with functioning. Five of the following criteria must be met within one year:

1) Preoccupation or obsession with Internet games.

2) Withdrawal symptoms when not playing Internet games.

3) A buildup of tolerance – more time needs to be spent playing the games.

4) The person has tried to stop or curb playing Internet games, but has failed to do so.

5) The person has had a loss of interest in other life activities, such as hobbies.

6) A person has had continued overuse of Internet games even with the knowledge of how much they impact a person’s life.

7) The person lied to others about his or her Internet game usage.

8) The person uses Internet games to relieve anxiety or guilt–it’s a way to escape.

9) The person has lost or put at risk and opportunity or relationship because of Internet games.

If “screentime” was substituted for “internet-games / gaming”… Repetitive use of screentime, often with other players, that leads to significant issues with functioning. Five of the following criteria must be met within one year:

1) Preoccupation or obsession with screentime.

2) Withdrawal symptoms when not playing screentime.

3) A buildup of tolerance – more time needs to be spent on screentime.

4) The person has tried to stop or curb screentime, but has failed to do so.

5) The person has had a loss of interest in other life activities, such as hobbies.

6) A person has had continued overuse of screentime even with the knowledge of how much they impact a person’s life.

7) The person lied to others about his or her screentime.

8) The person uses screentime to relieve anxiety or guilt–it’s a way to escape.

9) The person has lost or put at risk and opportunity or relationship because of screentime

Differential Diagnosis of Technology Overuse

• Technology overuse can: • Occur on its own, without any other psychiatric conditions and mimic a psychiatric

condition (such as ADHD, mood/anxiety problems), in which case, symptoms should resolve with screen detox.

• Worsen an underlying psychiatric condition such as ADHD, mood/anxiety disorder, or sensory processing disorder, in which case, symptoms should improve with screen detox.

• If the ADHD or mood/anxiety is primary, then there will hopefully be a history of symptoms preceding screen time use

• Unfortunately, with earlier and earlier use of excess technology, it is becoming increasingly difficult to ascertain which is primary or secondary

• The good news: when properly done, screen detox is a safe way to find out (i.e. safer than a medication trial for example!)

Comorbidity

• Certain conditions may be associated with a higher risk of technology overuse, such as: • Attention deficit hyperactivity disorder (ADHD): Individuals with ADHD tend to be

sensory seeking, which leads to the attraction of screens. • Autism spectrum disorder (ASD): Individuals with ASD may have troubles connecting

with people, and as a result, technology offers an easy distraction in the short run. The problem however, is that especially with ASD, their brains need exposure to face-to-face social interaction to help wire their brains, which is lacking with screens.

• Anxiety and depression: Individuals with anxiety and depression may struggle to socially connecting with others, and hence turn to technology such as social media to try to connect. It can then become a vicious cycle as excessive social media use worsens mood.

• Sensory processing disorders (SPD): Individuals with SPD are easily overloaded by sensory input such as sound, touch, or smell. As a result, individuals with SPD are even more sensitive to having sensory overload from using recreational screens.

Comorbidity: Sensory Processing Disorders

• Sensory processing disorders • In my anecdotal experience, those with sensory processing issues are

particularly sensitive to technology overuse

• More likely to become irritable, frustrated, angry

• Pattern where their meltdowns has led them to be suspended from regular school, and they may be in Section 23 programs

• Yet in Section 23 (or regular) school, schools often reward positive behaviour with screentime

• So it becomes a catch 22 where if they can have meltdowns, they are rewarded with something which promotes more meltdown

Personal communication, Dr. M. Cheng

Comorbidity: Other Processing Problems

• Auditory processing problems, e.g. ‘auditory processing disorder’

• Visual processing problems, e.g. • Visual stress

• Previously known as Irlen or scotopic sensitivity

• Classic symptoms • Child/youth has troubles with reading

• Reports that words move on the page

• Symptoms are treated by colored filters, such as colored overlays or prescription colored glasses

• Increasing use of screens at school (e.g. Smart Boards, tablets, screens) may also be contributing

Personal communication, Dr. M. Cheng

Physical Exam / MSE

• Non-specific findings anecdotally reported: • Problems with weight due to physical inactivity.

• Fatigue from sleep deprivation.

• Child/youth using devices in the waiting room, as opposed to talking with each other.

• Child/youth that can’t put down the device even during the office visit, e.g. wanting to continue playing or texting with others.

• Repetitive stress injury from excess texting or video game use

Diagnostic Testing

• There are no diagnostic tests for technology overuse in clinical practice

• Anecdotally, red flag would be “I’m bored” sign • Child/youth who is unable to tolerate even short periods of time without

using a device of some sort

How much is too much?

How much is too much? 20-hrs a day is definitely too much… • Studies show that children who play video games more than 20-hrs a

week begin to have brain changes that resemble drug addiction. “[Children playing video games more than 20-hrs a week] showed increased glucose metabolism in the right obitofrontal gyrus, left caudata, and right insula after play. Decreased metabolism was seen ... while at rest. These patterns were similar to those seen in drug addicts ... suggest[ing] that online gaming may be addictive to the genetically vulnerable.” (Burke, 2010).

• It is for this reason that 20-hrs/week (i.e. 3-hrs a day) may be too much, and if anything, probably the less the better.

Is there a number of hours/day limit?

• Newer guidelines on screen use from American Academy of Paediatrics (AAP) suggest not so much a fixed number, but rather other factors • How is the technology used?

• Is it recreational vs. creative?

• Does the child have impairment from the use?

Is there a number of hours/day limit?

• In our clinical context • Everyone coming to our tertiary care clinics is coming because they have

impairment of some sort

• Most patients are coming because lower tier interventions (e.g. community-based mental health services, medications) have not been successful

• Sleep disorders specialist recommend “query sleep disorder” for cases of treatment-resistant depression

• Perhaps we should recommend “query technology overuse” for cases of treatment-resistant depression as well…

Management of Technology Overuse

Evidence for technology restriction for technology overuse

• Various studies have looked at the effects of technology restriction on various problems.

• For depression: • One study showed that stopping social media use led to impovements in

mood (REFERENCE REQUIRED)

• For social skills • In children with social skills problems, five days at an outdoor education camp

without screens improved their non-verbal skills (e.g. reading facial expressions) (Uhls, 2014).

Treat any treatable DSM-5 conditions

• Interventions for any mental health conditions such as ADHD, social anxiety, autism spectrum disorder (ASD) • Untreated ADHD with inattention, high need for stimulation and lack of

impulse control may make it harder for a child to detach from technology and thus, treating ADHD may help

• Untreated social anxiety disorder, with an avoidance of live social contact may similarly make it hard for such a child to connect with people

• A child with ASD who has no other social contacts or interests is possibly more likely to be overconnected with a device; hence, appropriate interventions with ASD may be able to help connect a child to healthier attachments

Psychoeducation for Parents

• What children/youth need above all, is healthy connections with parents

• Technology is no replacement for genuine human interaction

• Ensure you have a close relationship with your child that is nurturing and caring • Spend 1:1 time with your child • Be sure that you are the primary influence in your child's

development rather than technology, to protect yourself against negative influences from television, media, video games

• Be close so that your child can turn to you to meet their core needs rather than technology

Technology Overuse: Psychoeducation for Parents

• Thank you for bringing in your child, who has troubles with mood, attention, and low frustration tolerance

• At some level, your child’s brain is overloaded

• One of the main factors right now, may be the several hours of recreational screentime that your child is getting

Motivational interviewing and stages of change

• What stage of change are they at? • Clinician to youth: “Any

concerns about your technology use?”

• Clinician to parent: “Any concerns about your child’s technology use?”

Precontemplation

Contemplation Action

Maintenance

Parent Responses and Stage of Change

Stage of Change Parent Response

Pre-contemplative “We don’t have any problem with tech overuse”

Contemplative “Yes, we have a problem, but we’re not ready/able to change right now… • Lack of alternative activities: “Screentime is the only thing that keeps them

occupied so that I can get dinner done.” • Worry about child’s reaction: e.g. “I’m worried my child will get depressed, or have

a tantrum.” • Peer concerns, e.g. “How will my child fit in with peers? They only connect through

technology these days.

Action “Yes, we have a problem, and we are open to whatever you suggest!”

If pre-contemplative…

Stage of Change What the clinician might say

Validation “I appreciate, that at this point, you don’t feel a need to make changes.” “How else can I support you?”, e.g. you can work on other goals together with the family, such as improving family communication, etc. ”In the meanwhile, can I just ask you a few other questions…”

Cost-benefit analysis “What would be the advantages of cutting back?” E.g. improved mood/concentration; less need for medications or therapists “What would be the challenges with cutting back?” E.g. how to occupy their time? ; how else to connect with peers?

Identifying other support (or lack of support)

“Any people that could helpful to help you in cutting back on screen use?” “Any people that might be an obstacle for cutting back on screen use?”

If parents agree…

• Consider meeting with youth / parents together • To the teen:“You have told me as well, that you are having troubles with your

mood and feeling tired all the time. • Would you be interested in some ideas on how we can help your mood,

energy and concentration?

• Focus with the youth on increasing healthy activities, and de-emphasize cutting back on electronics • Getting more nature time • Going to bed earlier • Special 1:1 time with each parent

If parents agree…

• It will naturally happen that there will be less technology time as this happens

• Avoid telling the youth that it is the technology that is the key problem, as this may lead the youth to feel threatened, and resist

• Rather, the problem is that there is a lack of 1) outdoor time, 2) face-to-face time, 3) etc.

• Don’t target the youth • When parents set technology rules, try to set them as new guidelines that

you believe will be healthy for the whole family

If parents agree…

• Don’t target the youth, but rather set rules as family rules

• Set rules for the whole family • When parents set technology rules, try to set them as new guidelines that

you believe will be healthy for the whole family

• Parent might say, “We used to eat together as a family, and go out for after-dinner walks together. And we used to have board game night. Let’s start that up again!”

Screen detox

• Theory of technology overuse (i.e. too much recreational screens) is to reduce the recreational screens to ZERO hours/day, followed by a “detox” period of a few weeks

• For mild to moderate overuse, stopping ‘cold turkey’ can be tried. • For example, the family tells the child they are going away on a 1-week family trip,

and it just so happens that there is no internet • Anecdotally, these include camping trips, trips to Cuba, and cruises

• For moderate to severe overuse, a more gradual reduction might be recommended. • For example, over a period of weeks, parents gradually reduce the amount of

allowable screen time • The goal is to reach a 3-4 week period of “screen detox” without any electronics.

Stopping cold turkey is not recommended for moderate to severe technology overuse

• There have been documented instances in the media where parents have suddenly cut off video games from youth, with catastrophic results • E.g. youth with ASD who ran away and died

• From an attachment perspective, it is better to work on connection before direction • I.e. connect the child to healthy adults and non-electronic activities prior to

cutting off the technology

Co-constructing a plan with the parents

• With parents first, map out the daily schedule for the child for the next few weeks

• Week 0 • 7.5 hrs recreational screen time / zero nature time / zero family time

• Week 1 • 7 hrs recreational screen time / 30-min. outside with dad

• Week 2 • 6 hrs recreational screen time / 30-min. outside with dad / 30-min. non-electronic

activity with mom, e.g. board games

• Week 3 • 5 hrs recreational screen time / 45-min. outside with dad / 45-min. non-eletronic

with mom, etc…

Resources

• Consider 1) Dr. Dunckley’s “Reset Your Child’s Brain”, which has a four-week ‘electronic detox’ protocol for parents

2) Going to http://www.drdunckley.com and signing up for the “Save Your Child’s Brain” mini course – 4 newsletters that summarize the electronic detox protocol

http://www.drdunckley.com/

Prevention of Technology Overuse

American Academy of Pediatrics (2013)

• Have a family plan with reasonable but firm rules

• Limit total screen time to < 1-2 hrs/day

• Keep screens out of the bedroom

• Monitor what media children are using

• Enjoy with children and discuss

• Enforce mealtimes & bedtime “curfew”

Principles

• Be a role model for others on healthy technology use

• Don't use technology to meet a child’s needs that should be met by a human being

• E.g. don’t give a toddler a device to soothe, but instead, pick up the child and co-regulate yourself

• If a child is complaining of boredom…

• Involve them with chores, or

• Let them be bored so that they can then experience creativity

• Limit electronic toys

• Use natural toys, e.g. wood


Principles

• As a parent, be a role model for your kids

• Have rules/limits about technology • E.g. no video games / consoles in bedrooms

• Have tech-free times so that family can connect

• E.g. All family members (including parents) should put devices into a basket when they come in through the door, and only retrieve them at a pre-designated time, e.g. after dinner

• Limit technology during times when people should be connecting • E.g. dinnertime (i.e. ideally no TV), in the car

Principles

• Find alternatives to screen time • Encourage non-electronic activities such

as reading, sports, crafts, nature, etc.

• Create rather than consume • Encourage technology to create (e.g.

writing a story, making a movie, etc.)

• Discourage technology that is just about ‘consuming’, e.g. playing a violent video game, binge watching TV…


Recommendations

• If there is screen time, ensure this is balanced by non-screen time • For every 1-hour of screen time, 1-hr of

restorative nature time is needed (Louv, 2005)

• For adults, every 90-min. of technology, give 10-min. rest (Rosen, 2014)

• For children, every 1-min. of technology needs 5-minutes doing non-tech (Rosen, 2014)


Recommendations for age 0-2

• No technology • No TV

• No handheld devices

• No video games • No non-violent

• No violent games

• This includes background exposure • Background TV shown harmful for language

development

Canadian Paediatric Society (CPS) Technology Guidelines



• Less than 1-hr a day of screen time

• Less is better!

Canadian Paediatric Society Guidelines



• Some technology

• Some non-violent TV

• 1-hr daily max

• No handheld devices, e.g. no smart phones, no iPads

• No video games • No evidence that video games (even educational video games) improve

child development

• “Positive studies” show improvements in isolated measures such as eye-hand coordination but not in development overall

• Less is better!


• Some technology • Weekdays:

• No gadgets at all

• No screen time

• No video games

• No screen time in bedroom

• * Exception is computer use for schoolwork

• Weekends

• Up to 2-hrs screen time (i.e. non-violent TV) under parental supervision

• No screen time in bedroom at all

Dr. Kimberly Young

Recommendations for aged 9-12

• Up to 2-hrs screen time / day

• No use outside of parental supervision, and no access to online games such as multiplayer games

• Permitted technology: Internet under supervision.

Dr. Kimberly Young

Recommendations for aged 12-18

• Age 12-18

• Child must have responsibilities such as school, and home chores

• Child must have healthy activities such as friends, peers

Dr. Kimberly Young

Consider sending your child to a nature-based school • Nature-based education has deep roots in

many European countries (e.g. Waldorf movement from Germany; nature schools from Scandinavia, especially Finland)

• There is growing interest in Canadian school boards in adopting more nature-based education in order to optimize brain development

• Examples • Trille des bois, French public board, Ottawa • _____ (name to be determined), French

Catholic Board, on Main Street, Ottawa • Forest School movement (private school) in

Gatineau and West of Ottawa http://www.nytimes.com/2011/10/23/technology/at-waldorf-school-in-silicon-valley-

technology-can-wait.html?pagewanted=all

Getting back to our case…

Case

• You meet alone with Dave, and you ask him what makes it hard to connect with his mother

• He explains that his mother lectures him, gets upset…


Case

• You resist the urge to tell him that all parents get upset from time to time…

• Instead, you provide radical empathy that of course, it would feel difficult talking to mother if she gets angry and upset…

Case

• You review his attachment with his mother, focusing on • What makes him disconnect from her

• What would make him want to reconnect with her

• You review his attachment with his technology, focusing on ‘stages of change’ • What does he get out of it

• What other alternatives might their be


Case

• You provide education to the mother about the importance of connection to things that give belonging (i.e. attachments), purpose, hope and meaning

• You show mom that he is overly attached to technology and materialism, and not attached to parents and others

• You stop mother from starting by cutting off the internet

• You help mother start by reconnecting to him first

• You help mother with unconditional acceptance, by teaching her the skills of (radical) empathy, validation and acceptance


Case

• Eventually, you notice this change in the waiting room with them, as they reconnect with each other


Resources

Parent Handout: Unplug and Connect

Available from • www.cheo.on.ca • www.eMentalHealth.ca Aussi disponible en français

http://www.cheo.on.ca/

http://www.ementalhealth.ca/

Resources for Gamers

• Cam Adair’s Game Quitters website, as featured on TED talk

Books: Advice on how to (Re)Connect

Detox protocol for tech addicted youth

Attachment-informed parent strategies

Resources for General Audience

• Numerous TED talks on technology including tech addiction • Escaping video game addiction, Cam Adair

• What you need to know about internet addiction, Dr. Kimberly Young

• What you are missing while being a digital zombie, Patrik Wincent

• Why I don’t use a smart phone, Ann Makosinski

• A year offline, what I have learned, Paul Miller

Book Readings: How Society Disconnects Us

Acknowledgments

• Special thanks to • Dr. Mireille St-Jean, family physician, uOttawa

• Kayla Sims, uOttawa Medical Student, Class of 2017

• Stock photo models Kim Surette, Richard Voss and Ryan Letourneau

Thank you for your attention!

Image: Adobe


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Documents

child & youth Mental Health Series · •Attention deficit hyperactivity disorder (ADHD): Individuals with ADHD tend to be sensory seeking, which leads to the attraction of screens