Young Adults, Problematic Online Behaviors, and 21st Century Communications Technology Ann Hackman, M.D. University of Maryland (co-chair) Liwei L. Hua, M.D., Ph.D. University of Michigan (co-chair) Tristan Gorrindo, M.D. Massachusetts General Hospital
Outline• Examine changes in communications technology over the past decade, with consideration of psychiatric literature (Dr. Hackman)• Consider teens/young adults, their use of communications technology, and characteristics unique to these age groups (Dr. Hua)• Discuss application of DBT/CBT skills to the treatment of problematic internet behaviors (Dr. Gorrindo)• Review case vignettes
Objectives• Become familiar with current trends in use of communications technology in teens/young adults• Consider approaches in evaluating this patient population when they present with or engage in risky or problematic use of technology• Discuss application of CBT and recovery- oriented skills to the treatment of problematic technology use• Contemplate the role of this technology in our own youth patient population
YOUNG ADULTS, PROBLEMATICONLINE BEHAVIORS & 21STCENTURY COMMUNICATIONTECHNOLOGYAnn Hackman M.D.
DISCLOSURES I have no conflicts of interest or disclosures.
21ST CENTURY COMMUNICATIONSTECHNOLOGY The concept of e-mail came about in the 1970s and it was possible to e-mail from an IBM PC in the mid 1980s Internet with its origins in the 1980s and commercialization in the 1990s Text messaging first occurred in the early 1990s; by 2007, 74% of all mobile phone users worldwide (2.4 billion out of 3.3 billion users) were texting
TECHNOLOGY CONTINUED Social media began in 1997. Facebook launched in February 2004 and as of July 2011 had more than 800 million active users Skype was started in 2003. By April 2006, the number of registered users reached 100 million Twitter launched in July of 2006 and had 200 million users as of 2011 generating over 200 million tweets and handling over 1.6 billion search queries per day
IMPACT ON PEOPLE WITH SERIOUSMENTAL ILLNESS Adults with serious mental illness have been left behind in the explosion of information technology. A 2009 article (Borzekowski et al) indicates that from a sample of 100 adults in CMHC treatment (79% > 40 years old) - only about 1/3 had cell phones or internet access - less than 30% had a computer in the home
IN ADOLESCENTS AND YOUNG ADULTS According to the US Census on Internet Access and Computing By 2003, 55% of American homes had internet access; 95% of all households earning >$100,000 By 2003, 76% of all school aged children in the US had access to a home computer and 83% had used a PC at school (http://maisonbisson.com/blog/post/11088/us-census-on-internet-access- and-computing/ accessed 10/14/11)
MORE ADOLESCENTS AND YOUNGADULTS According to Harris Interactive poll of 2089 teens in July of 2008 4 out of 5 (17 million nationwide) teens carry a “wireless device” 57% view their cell phone as key to their social life 52% view it as a form of entertainment 42% report that they can text with their eyes closed (http://www.marketingcharts.com/interactive/cell-phones-key-to- teens-social-lives-47-can-text-with-eyes-closed/ accessed 10/14/11)
MORE ADOLESCENTS AND YOUNGADULTS Asof 2009, according to a study of eighteen year olds (Archives of Pediatrics and Adolescent Medicine; Moreno MA et al 2009) 90% of adolescents had internet access and about half used social networking sites Of 500 who used social networking sites 270 (54.0%) revealed risk behavior information 120 (24.0%) referenced sexual behaviors 205 (41.0%) referenced substance use 72 (14.4)% referenced violence
But people have been communicatingforever….. Where are the problems? 21st century communication technology is faster, bigger, more access, easier to pass on According to Facebook, the average user has 135 “friends”. (I have 168 “friends”. Dr. Hua has 188 “friends”. My 17 year old has 603 “friends” and one of her acquaintances has 3007 “friends”). Tweespeed indicates an average of more than 10000 tweets per minute. It’s not clear how many of those are being “re-tweeted” When adolescents post something or have something posted about them, the information can be conveyed instantly to hundreds of people
Recent Headlines “Rutgers Student Commits Suicide After Sex Tape” “Internet addiction linked to ADHD, depression in teens” “Flash Mob Takes Violent Turn In Philadelphia” “Cyberbullying Continues After Teen’s Death” “Girl Texts Boy Her Naked Photo, Boy Gets Arrested, Held in Juvenile Detention”
Some clinical examples of problems 19 year old woman with new onset schizophrenia (symptoms including auditory hallucinations) and a recent hospitalization Socially isolated in terms of in-person interactions but using the internet and social media Making connections with people who are engaged in activities which may place her at risk Conveying information about her illness which may render her more vulnerable
More clinical examples 21 year old man with schizophrenia paranoid type who, following a hospitalization, has quit school and spends 8-12 hours a day engaged in the on-line game “World of Warcraft” 18 year old man with schizoaffective disorder whose symptoms have led to a year including an arrest and 56 days in jail as well as three extended psychiatric hospitalizations. He reports the worst part of this experience was “I could not have my cell phone”
More clinical examples 23 year old man with psychotic illness and religious delusions, supporting his belief that the world is coming to an end by spending considerable time on end-of-days internet sites 18 year old arrested for stalking after becoming increasingly convinced that a high school classmate whom he had “friended” on Facebook was his soulmate. Spent hours on her site, checking multiple times a day then began making unwanted calls and visits. Pointed to information from her social media site as evidence of their relationship.
Adolescents andCommunications Technology Liwei L. Hua, M.D., Ph.D. Clinical Assistant Professor University of Michigan Department of Psychiatry, Child and Adolescent Section
Disclosures• I have no conflicts of interest or disclosures.
Outline• Present benefits and risks of use of communications media• Examine trends in technology use
A Task of Adolescence• Social and emotional developmental task: – Emotional separation from parents – Further development of personal/peer group identities – Exploration of sexuality and romantic relationships• Dilemma: – With the availability of “new” technology, how do we allow teens to explore their sexuality and yet keep them safe?
Benefits of Communications Technology• Socialization and communication – Connecting with friends and family – Chance to express thoughts/feelings that they might be uncomfortable expressing in person – Broadening of friendship base/interests• Education/information – Enhanced creativity (blogs, podcasts) – Anonymity – Accessing health resources (information on medical illnesses, STIs, signs of mental illness)
Risks of Communications Technology• Cyberbullying• Sexting• “Facebook depression”• Internet addiction• Difficulty understanding consequences due to “safety” of anonymity• Subject to sexual predators• Physical health: obesity, metabolic syndrome
Normal Behavior?• Kaiser Family Foundation survey of > 2000 3rd to 12th graders (2010): – Spending over 7.5 hrs/day on phone, computer, television – Additional 1.5 hrs/day text messaging (ave 118 texts/day) – Additional 30 minutes talking on phone
Normal Behavior? Internet• Estimated 93% of U.S. teens (12-17 y.o.) regularly use the internet (Pew Internet and American Life report in 2009)• 34% with some kind of exposure to cybersex (wanted or unwanted) (Wolak et al 2007)• 73% of American teens online use social networking sites (as opposed to 65% in 2008 and 55% in 2006) (Pew)• > 50% log on to social media site(s) at least once daily; 22% of teens log on > 10 times/day (Common Sense Media 2009).• 31% of online teens search health, dieting, physical fitness info; 17% search drug use and sexual health information (Pew)
Technology Teens Use Percentage Blog 14% Webcam 22% Game system with chat 27% Instant Messaging 60%Social Networking Profile 72% Cell phone 73% Email 91% 0 20 40 60 80 100 Adapted from Cox Communications Internet and Wireless Safety Survey 2009
Online Activities of Teens in Past Month Percentage Blogged 12% Webcam use 13%Talked to someone in a chat room 20% Shopped online 31% Played online video game 47% Sent IM 52% Updated online profile 58% Posted or viewed photos/videos 63% Looked at someones profile 67% Research for school 73% Emailed 80% 0 10 20 30 40 50 60 70 80 90 Adapted from Cox Communications Internet and Wireless Safety Survey 2009
Normal Behavior? Cell phones• 75% of teens (12-17) have cell phones: 25% use for social media; 54% use for texting (Pew Internet and American Life Project 2009)• Almost all teens have texted; of the 54% of daily texters, 1/3 send > 100 text/day (Pew)• 20% of teens and young adults have engaged in sexting (Sex and Tech survey)• 2/3 teen texters say they are more likely to text than talk on cell phone (Pew)• Unknown what percentage of these teens have comorbid psychiatric disorders
Critical Questions• When patients present with misuse/excessive use of this technology, given the widespread use, how can clinicians help: – Evaluate and formulate using an open-minded approach that does not necessarily pathologize the behavior? – Keep this population safe and help guide their use of this technology? – Intervene if there are underlying psychiatric conditions that are driving their behavior?
Ideas for cliniciansTRISTAN GORRINDO, MDDepartment of PsychiatryDivision of Child and Adolescent PsychiatryMassachusetts General HospitalHarvard Medical School
Dr Gorrindo has no conflicts of interest to disclose as related to the currentpresentation. 30 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
Definitions Screening Treatment31 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
Don’t forget to look for the Excessiveusual suspects: UsageADHDSocial PhobiaDepression ImpulseMania ControlOCD Functional Impairment 34 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
1. Stay on-line longer than intended 2. Neglect house-hold chores to stay on-line Never Sometimes Always 3. Form new relationships with fellow on-line users 4. Others complain about how long you stay on-line 5. Grades or school work suffer because of the amount of time spent on-line 6. Check your email before something else you need to do 7. Job performance or productivity suffer because of the internet 8. Become defensive or secretive about when anyone else asks you what you do on-line 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. Do you fear that life without the internet would be boring, empty, and joyless PIB Score 12. Snap, yell, or act annoyed if someone bothers you while you are online 13. Lose sleep due to late night logins range 14. Feel preoccupied with the internet when off-line 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 off-line, which goes away when you are back online 20. Prefer the excitement of the internet to intimacy with your boyfriend or girlfriend 36 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOLSource: Modified from Young’s Internet Addition Test in Widyanto, Cyberpsychology & Behavior, 2004:7:4:443
In this first section, we are interested in learning about how your Thoughts and Urges to use the internet impact your life. 1. I spend _____ (pick one) thinking about T 0 hr/day 0-1 hr/day 1-3 hr/day 3-8 hr/day >8 hrs/day using the h internet/technology o 2. Interference due to None Mild Definite but Substantial Incapacitating manageable Impairment u 3. Distress associated Moderate but Near constant, g with None Little manageable Severe disabling h 4. Resistance Always Much Completely Some resistance Often yields t associated with resists resistance yields s 5. Degree of control Complete Much control Some control Little control No control over control Now we are interested in learning about how Internet -related Behaviors impact your life. B 1. Time occupied by 0 hr/day 0-1 hr/day 1-3 hr/day 3-8 hr/day >8 hrs/day e 2. Interference due to None Mild Definite but Substantial Incapacitating manageable Impairment h 3. Distress associated None Little Moderate but Severe Near constant, a with manageable disabling v 4. Resistance Always Much Some resistance Often yields Completely i associated with resists resistance yields o 5. Degree of control Complete Much control Some control Little control No control over control r s 37 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOLSource: Modified from Goodman, Arch Gen Psychiatry, 1989; 46:1006-1011
Asks parents to rate: The ways in which PIB impact various activities of teen’s daily life The impact on parents work/social life/ability to parent Various measures of family functioning 38 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOLSource: Modified from Stewart’s OCD Family Function Scale
Treatments to date Medication ▪ SSRI, stimulants, and others CBT ▪ Adults 12 session protocol Residential Treatment Family therapy ▪ Study of Families in Taiwan showed high adolescent- parent conflict 40 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
Teens• Complicate their thinking• Practice Skills• Feedback from peers 42 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
Basic Tenants Rational of Mind Dialectic Emotional Mind Behavioral Wise Therapy Mind (DBT) 43 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOLSource: Linehan, The American Journal on Addictions, 8: 279–292.
W •Wide-audienceA •AffectI •IntentT •Today? 44 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
Parents• Education• Develop ambivalent stance• Facilitated conversation 46 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
Multi-layered Approach Teen Skills Parent Education Homework Dialogue 47 MASSACHUSETTS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL
1 "Online struggles" Teen Reviewing problematic internet behaviors "What are they doing?" 2 Parent Describing internet behaviors of the modern teen "Whats a friend?" Teen3a 3b "Social Networking Demystified" Parent "Public vs Private" Teen4a 4b "Understanding Privacy Settings" Parent "How much is too much?" Teen5a 5b "Setting appropriate media rules" Parent 6 "Staying happy on- and off-line" Teen "Moving Ahead" 48 MASSACHUSETTS GENERAL HOSPITAL 7 Teen and Parents Partnership Agreement and Final Questions HARVARD MEDICAL SCHOOL
Clinicians are here Kids are here DIGITAL DIVIDE
Clinicians are here Kids are here Psychotherapy Parent Empowerment Complicate ThinkingScreening for other disorders
Case 1• 17 y.o. WM with no formal psychiatric history• Referred to psychiatric outpatient clinic by adoptive mother due to concerning Facebook posts, such as “Game over”• Motivation: “sad”, “wanted some attention”
Case 2• 20 y.o. WF, in long-term outpatient psychiatric care, no history of hospitalizations, for Tourette’s disorder and mood disorder, NOS• When asked about sexting, she said, “Everyone does it.”• When asked about consequences, she said, “Oh, you would only send pictures if you trusted the person.”
Case 3• 18 y.o. WM, recently diagnosed with bipolar disorder• Mood stabilized, compliant with and doing well on medication• Active in school tennis and with church• Mom concerned he is less social with friends “live”; instead, stays up late chatting with friends on Facebook/ChatRoulette.
Case 4• 14 y.o. WF with no prior psychiatric history, referred to Child Psychiatry C/L service after acetaminophen overdose• Reported feeling more “depressed” after moving to current location with family two years ago, difficulty making friends• Charged a year ago with child pornography after posting a “sext” message her friend had forwarded to her of a naked teenage boy on her MySpace page, thinking it would be “funny”• Recent arrest for attempted theft of alcohol from a store with same friend, prompting suicide attempt
Case 5• 14 y.o. WF hospitalized after father discovered her exposing herself online• “Very depressed” since mother’s death several years ago• Father remarried, had less time with her• Responsible for caring for younger sibling, which limited time with friends; overweight with poor self-esteem; “lonely” and “stressed out”• Discovered an Internet chat room where men talked to her via WebCam• Upon request, took off clothing; felt “beautiful” and “loved”
Case 6• 13 y.o. WF, adopted at 7 y.o., with history of ADHD, PTSD, mood disorder, and 3 psychiatric hospitalizations in last 3 months• Mood improved after last hospitalization a month ago• Acutely destabilized after birth mother discovered her on Facebook and tried to make contact with her, triggering renewed feelings of abandonment and resentment
Case 7• 16 y.o. WF presents to psychiatric 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• Patient felt excluded and accused her friend of “always leaving her out”• Mom reports patient has a history of mis- interpreting social cues
Take home points• Physicians need to ask about use of technology, given the widespread use among teens/young adults• Not all that seems excessive or pathological is; developmental norms must be considered.• These issues can be addressed/treated with skills that clinicians already have, although they may need to be applied more creatively.