Presented at the MGH Primary Care Pediatrics Conference in Boston December 4, 2013

1. Tweets, texts, and twerks:
A framework for understanding
problematic internet behaviors in
children and adolescents
Tristan Gorrindo, MD
Principal Investigator, The Digital Family Project
Managing Director, The Clay Center for Young Healthy Minds
Assistant Professor of Psychiatry, Harvard Medical School
www.pathstodream.org

2. Disclosures
Dr. Gorrindo has no disclosures
to report.
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3. Objectives
• Define Problematic Internet
Behaviors
• Screening and Recommendations
• Working with Teens and Parents
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4. WHAT IS A PROBLEMATIC
INTERNET BEHAVIOR?
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5. Case 1
• Elaine is a 16 y/o WF with no past psychiatric
history. Presents to ED with superficial
scratches to forearm after argument with friend.
• Reports that her friend texted her that she was
going to see a movie with another friend.
• Had exchanged >60 texts with the friend over
the course of the day, and became distraught
when the last text she received from her friend
was a simple text saying, “k” (short for “okay”).
• Mom reports patient has a history of misinterpreting social cues.
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6. Case 2
• Rory is a 15 y/o WF with history of mood disorder,
NOS, and SIB, living with father and stepmother.
• Reported to be “addicted to technology”: staying up
late at night on computer and texting; history of
sexting.
• Parents feel unable to control use; whenever
restrictions are imposed, patient acts out/selfharms, requiring hospitalization.
• Recently admitted to inpatient unit after posting on
Facebook, “What would you do if I killed myself?”
and becoming suicidal after other kids posted, “Just
do it.”
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7. Case 3
• Greg is a 17 y/o WM with no past psychiatric history.
Adopted at 2 y/o, recently “came out” as gay; quite
introverted.
• Joined Neutral Zone, a youth-driven teen center; felt
more accepted, but still had difficulty forming
romantic relationships; patient based self-worth on
this.
• Brought to outpatient clinic after Neutral Zone
counselor told mother that Greg had posted “Game
over” on Facebook.
• Greg endorsed depressed mood and poor selfesteem, but denied true SI with plan or intent. No
history of suicide attempt or self-injurious behaviors.
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8. What is a Problematic Internet Behavior?
Don’t forget to look for the
usual suspects:
ADHD
Social Phobia
Depression
Mania
OCD
PDD
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Excessive
Usage
Impulse
Control
Functional
Impairment
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9. SCREENING
FOR
PROBLEMATIC
INTERNET
BEHAVIORS
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10. Internet Addiction Screening
• Chinese (or Chen) Internet Addiction Scale (CIAS) (S. Chen et al.,
2003)
• Compulsive Internet Use Scale (CIUS) (Meerkerk et al., 2009)
• Generalized Problematic Internet Use Scale (GPIUS) (Caplan,
2002)
• Internet Addiction Scale (IAS) (Nichols & Nicki, 2004)
• Internet Addiction Test (IAT) (Young, 1998)
• Internet-Related Addictive Behavior Inventory (IRABI) (Brenner,
1997)
• Internet Related Problem Scale (IRPS) (Armstrong et al., 2000)
• Online Cognition Scale (OCS) (Davis et al., 2002)
• Pathological Internet Use Scale (PIUS) (Morahan-Martin &
Schumacher, 2000)
• Problematic Internet Use Questionnaire (PIUQ) (Demetrovics et
al., 2008)
• Use, Abuse and Dependence on Internet (UADI) (Gnisci et al.,
2011)
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11. Young’s Internet Addiction Test
Never
Sometimes
Always
1. Stay online longer than intended
2. Neglect household chores to stay online
3. Form new relationships with fellow online users
4. Others complain about how long you stay online
5. Grades or school work suffer because of the amount of time spent online
6. Check your email before something else you need to do
7. Job performance or productivity suffers because of the internet
8. Become defensive or secretive when anyone asks you what you do online
9. Block out disturbing thoughts about your life with soothing thoughts of the internet
10. Find yourself anticipating when you will go online again
Presumed
11. Fear that life without the internet would be boring, empty, and joyless
12. Snap, yell, or act annoyed if someone bothers you while you are online
PIB Score
13. Lose sleep due to late-night logins
range
14. Feel preoccupied with the internet when offline, or fantasize about being online
15. Find yourself saying “just a few more minutes” when online
16. Try to cut down the amount of time you spend online and fail
17. Hide how long you have been online
18. Choose to spend more time online over going out with others
19. Feel depressed, moody, or nervous when offline, which goes away when you are back online
20. Prefer the excitement of the internet to intimacy with your boyfriend or girlfriend
?
Source: Modified from Young’s Internet Addition Test in Widyanto, Cyberpsychology & Behavior, 2004:7:4:443
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12. How do you define abnormal?
• 8-10 y/o : 8+ hours per day
Teens: >11 hours per day
• 84% of teens have internet
access; 75% have cell
phones
• 88% of teens text (3364 texts
per month)
• 20% adolescents sent/
received sexually explicit
content
Source: Pediatrics 2013;132:958–961
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13. AAP Screening Guidelines
1) How much recreational
screen time does your child
or teenager consume
daily?
2) Is there a TV set or an
internet-connected
electronic device
(computer, iPad, cell
phone) in the child’s or
teenager’s bedroom?
Source: Pediatrics 2013;132:958–961
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14. AAP Screening Guidelines
1) How much recreational
screen time does your child
or teenager consume
daily?
2) Is there a TV set or an
internet-connected
electronic device
(computer, iPad, cell
phone) in the child’s or
teenager’s bedroom?
Source: Pediatrics 2013;132:958–961
www.pathstodream.org
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15. AAP Screening Guidelines
• Take a more detailed media
history with children or teenagers
who demonstrate aggressive
behavior; are overweight or
obese; use tobacco, alcohol, or
other drugs; or have difficulties in
school
• Examine your own media use
habits; pediatricians who watch
more TV are less likely to advise
families to follow AAP
recommendations
Source: Pediatrics 2013;132:958–961
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16. Screen Positive, Dig Deeper
• Excessive Use
–
–
–
–
–
Depression
ADHD
Increased alcohol use
Truancy
“Academic troubles”
• Cyberbullying
–
–
–
–
–
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Low self-esteem
Depression
Suicidal ideation
Delinquency
Substance use
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17. TREATMENT OF
PROBLEMATIC
INTERNET
BEHAVIORS
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18. Treatment of Problematic Internet Behaviors
Medication
• SSRI
• Stimulants
Others
CBT
• Adults 12 session protocol ~Good outcome at 6 mo.
Residential Treatment
• China ~75% had axis I co-morbidity
Family Therapy
• Study of families in Taiwan ~high adolescent-parent
conflict
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19. Treatment of Problematic Internet Behaviors
Working with Teens
•Complicate their thinking
•Practice skills
•Feedback from peers
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20. Before you post, “W.A.I.T.”
W
•Wide-audience
A
•Affect
I
•Intent
T
•Today?
Source: Gorrindo T, FOCUS: The Journal of Lifelong Learning in Psychiatry. 2012;10(3):282-92
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21. www.commonsensemedia.org
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22. Parents are here
Kids are here
DIGITAL DIVIDE
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23. Treatment of Problematic Internet Behaviors
Working with Parents
• Education
• Develop ambivalent stance
• Facilitated conversation
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24. Treatment of Problematic Internet Behaviors
• Education
– Limit entertainment screen time to <2 hours per
day
– No screens for children <2 years
– Monitor websites, video games, and TV
– Model active parenting
 Media curfew
 TV and internet out of the bedroom
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25. Treatment of Problematic Internet Behaviors
•
94% of parents of 0-2 year olds
use technology to cope with
the stress or loneliness of
being a new parent.
•
Among parents of 0-2 year
olds, 54% think it is appropriate
for children under 2 to spend at
least one hour per day in front
of a screen.
•
79% of new parents have felt
distracted from their baby's
needs because of time spent
using technology.
•
58% of parents use protective
settings to limit the websites
their elementary schooler (6-11
year old) visits.
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26. Treatment of Problematic Internet Behaviors
• Ambivalent Stance
– Technology is not all good or all bad
– Moderation
– Encourage curiosity
• Avoid hypocrisy
Source: Pediatrics 2013;132:958–961
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Allow tech at the
dinner table:
18% of kids
34% of parents
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27. www.pathstodream.org
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28. Conclusions
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29. Take Home Points
• Screen at each well-visit
• Remember psychiatric co-morbidities
• Complicate thinking
• Educate and empower parents
• Stay educated
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30. www.pathstodream.org
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