Читать книгу Reset Your Child's Brain - Victoria L. Dunckley MD - Страница 12
ОглавлениеHow ESS Mimics a Wide variety of Psychiatric, Neurological, and Behavioral Disorders
The system of nature, of which man is a part, tends to be self-balancing, self-adjusting, self-cleansing. Not so with technology.
— E. F. Schumacher, Small Is Beautiful 1
For a list of all the ways technology has failed to improve the quality of life, please press 3.
— Alice Kahn
Historically, certain infectious “agents” have become infamous for their capacity to randomly invade a victim’s nervous system, lending them an uncanny ability to mimic various neurologic and psychiatric disorders. In fact, both syphilis and Lyme disease have been nicknamed “the Great Imitator.”2 Not surprisingly, both illnesses are also considered to be sources of misdiagnosis as well as misguided treatment.
Other classes of mental health offenders demonstrate a similar nature. Food intolerances, such as gluten or dairy sensitivity, are capable of inflaming the brain and body and causing symptoms ranging from irritability and hyperactivity to fatigue and brain fog. Abuse of street drugs, like cocaine and methamphetamine, can cause wildly variant presentations; symptoms range from mild anxiety or depression to personality changes and overt psychosis. All of the above offenders — infections, certain food proteins, and illicit drugs — are known to cause widespread dysfunction and wide-ranging symptoms in some, and more “classic” symptoms in others, creating challenges for diagnosis and appropriate treatment.
It is, therefore, not such a stretch to imagine that if screen-time is capable of irritating the nervous system in general, that its corresponding syndrome would be capable of imitating or secretly amplifying more specific conditions. ESS “shape-shifts,” such that clinicians and parents may think they are seeing one thing when in fact ESS is the real villain. To make matters even more confusing, the way ESS presents itself depends not only on a child’s underlying constitution but also on his or her current environment and stage of development, and thus it sometimes morphs into different entities even within the same child. In other words, regardless of the nature of your child’s issues, it pays to be on the lookout for ESS.
The Shape-Shifting Nature of Electronic Screen Syndrome
This chapter categorizes and describes the ways in which ESS can either exacerbate or imitate various mental and neurological health problems. This covers a lot of ground, and you may want to turn first to the sections covering the types of dysfunction that you know apply to your child, and then read the chapter more thoroughly later. I have based these findings on my own and others’ clinical experience with patients, on what we already know about the brain and body, and on relevant, emerging research about electronic media and these conditions. In other words, this chapter presents the sum of what we see, what we know, and what we’re finding out about screen-time’s effects. Note that for some conditions, such as tics or psychosis, there remains a paucity of formal research, but the findings described here are nevertheless supported by peripheral research (for example, by screen-time’s impact on dopamine), published case reports, surveys, therapeutic effects from the fast, and anecdotal reports from patients and parents. No doubt we will improve our understandings in time.
Although pediatric mental health disorders are notorious for symptom overlap across differing diagnoses, for organizational purposes I have grouped symptoms and conditions into six categories: moods, cognitive concerns, disruptive behaviors and social issues, addiction, anxiety, and neurological dysfunction (including tics and autism). Some children exhibit numerous symptoms from different categories, and some only a specific one or two. Some symptoms may be directly related to interacting with electronic screen devices, while others may be indirect as a result of poor sleep or stress reactions. For some symptoms or disorders, ESS may only exacerbate but not mimic; for instance, autistic symptoms would (theoretically) not be mimicked in a typically developing child. But for most disorders, ESS can either mimic or exacerbate them. For example, ESS might mimic the symptoms of ADHD in a child without ADHD, or ESS might exacerbate symptoms in a child who does indeed have ADHD. In spite of these variations, a common ESS combination of symptoms is irritability (mood), attention issues (cognition), and immature or defiant behavior (behavior/social). Hopefully this chapter provides both a “big picture” sense of ESS as well as ways to specifically identify how it may be presenting in your child. Think in themes rather than absolutes, and remember most psychiatric symptoms and diagnoses occur on a spectrum.
Luckily, despite its shape-shifting nature, ESS is relatively simple to diagnose. Like food intolerances, the gold standard is simply to remove the potential offender — in this case, screen devices — and observe the child for symptom and function improvement. While this chapter describes most of the ways screen-time might impact a child, the swiftest and most accurate way to figure out if or how ESS is affecting yours is to follow the Reset Program and observe what happens.
Moods and Meltdowns
Mood symptoms are nearly always present in ESS. They can take the form of irritability, depression, mood swings, an inability to calm down, tantrums, or even outright aggression. These mood changes are likely produced by screen-time’s impact on dopamine and other brain chemicals, sleep, the sensory system, and the stress response. Interestingly, I’ve noticed that some children and even teens with screen-related mood symptoms will destroy a screen device by smashing, throwing, or “drowning” it, as if they know on some level it is hurting them. (Remember Ryan, the eight-year-old son of my work colleague, whom I mentioned in the Introduction? Ryan smashed one device and later drowned another in the tank of a toilet during his spiral into screen-related depression.) As I advise all parents, if a device gets destroyed in the throes of frustration, do not replace it! Your child’s behavior is telling you something.
Figure 4 below depicts how altered physiology from screen interaction can translate into mood symptoms and difficulty functioning, setting the stage for an apparent mood “disorder.”
Figure 4. How screen-time effects translate to mood symptoms
Irritability
Irritable moods — along with attention difficulties — are among the most universal symptoms of ESS. In a younger child, irritability often results in frequent meltdowns or even rages over seemingly minor frustrations. These meltdowns, as we saw with Aiden in chapter 2, can be severe enough to disrupt an activity, an entire day, or even the functioning of an entire family. Severe tantrums or meltdowns are frequently the catalyst that brings a parent to my door, but they can also be what motivates a family to make a drastic lifestyle change.
In teens and young adults, ESS-related irritability can present as mood swings or meltdowns, or it may take the form of defiant behavior, withdrawal from the family, or extreme disrespectfulness. Not surprisingly, determining whether irritability is a problem in a teen can present a dilemma for parents: we expect teens to be moody, withdrawn, and even rude to a certain extent, so how do you know if something’s really wrong? Trust your gut and ask yourself if your teen’s irritability seems out of the norm, chronic, is associated with destructive impulses, or is severe enough to affect daily functioning and quality of life.
Regardless of age, irritable mood is no doubt related to all the factors outlined in figure 4, and most parents can readily appreciate how poor sleep can result in an irritable child. Less obvious, however, is the dopamine connection. When a child is irritable immediately after, for example, video game play, it’s likely due — at least in part — to the rapid rise (during play) and fall (upon stopping play) of dopamine. This is not the natural rise and fall you’d see associated with a healthy stimulating activity, like playing a competitive sport. Rather, it’s similar to the pattern that occurs with older dopamine-releasing medications (short-acting stimulants) that work quickly but wear off in a few hours. When dopamine rises and falls suddenly — whether from game play or short-acting stimulants — the child can become weepy, impulsive, or angry.* It’s as though the sudden fall in dopamine causes the brain to short circuit; every little demand on the child becomes stressful. Since dopamine is needed to execute tasks, when it’s suddenly low, every task becomes overwhelming, setting the stage for a meltdown. No wonder the child fights getting off the device — it’s uncomfortable!
Aside from this “relative withdrawal” of dopamine levels following screen activity, irritability may also be related to dopamine depletion and desensitization of dopamine receptors that studies show develop over time with excessive screen-time.3 Unfortunately, it is literally impossible to “taper” going from screen to no screen, from virtual world to real world, so the transition cannot be gradual and smooth. The rapid and extreme drop in stimulation levels is one reason that even occasional bouts of video game play are capable of causing dysregulation in some children and why moderation doesn’t always work. Our systems simply aren’t meant to handle such extremes.
One teen admitted to me, “You know, I do notice I’m always yelling at my parents when they say anything to me when I’m on the computer. It makes me snappy.” A friend and father of three boys quipped: “We call it ‘game-head’ when the boys are playing video games and then one of them loses it and smacks the other upside the head.” And a grandmother with custody of her two grandchildren related, “When the kids get mouthy, we know it’s the electronics. It’s like it jumbles up their brains, so we remove them when the kids get out of line.” Many parents report crying, emotional sensitivity, and irritability or anger surrounding their child’s or teen’s game play or computer usage, especially when use is prolonged.
Closely related to irritability is difficulty regulating arousal levels. As mentioned in chapter 1, this symptom is one of the hallmarks of ESS. A chronically hyperaroused child may have trouble recovering from being angry or sad, as we saw with Aiden. Instead of experiencing an outburst and then calming down, the child continues to be in a state of distress for a prolonged period. In general, the greater the stimulation — in the form of changing scenes, vivid colors, rapid or sudden movements, multitasking, or multimodal sensory input — and the more often that stimulation occurs, the harder it is to regulate arousal, and the more irritable the child becomes.
Depression
The evidence linking overall electronics use and depression is substantial,4 and virtually all types of interactive screen-time have been implicated: Internet usage is directly correlated with depressed mood, withdrawal or isolation, loneliness, and less parent-child interaction, and the highest users show the most severe symptoms.5 Use of social media such as Facebook is a risk factor for depression and dissatisfaction with one’s life.6 “Light-at-night” studies demonstrate an association between electronics use at or near bedtime and increased depressive symptoms, suicidal tendencies, self-injurious behavior, and physical complaints like headache and leg pain.7 Multitasking and smartphone use have been linked to adolescent depression.8 And excessive gaming is associated with depression, anxiety, and hostility.9 Tellingly, in a large study that followed more than three thousand children over a two-year period, researchers found that youths who became pathological gamers tended to become more depressed and anxious, while those who stopped gaming in a pathological manner became less depressed and more socially competent.10
Note that generally speaking, in children and adolescents depression can present as irritability with or without a depressed mood. In a younger child with screen-related depression, the child may cry a lot, lose interest in activities, become chronically irritable, and withdraw. The child’s parent often says things like, “My son seems to have lost his spark,” or “She’s lost her natural curiosity about life.” In teens and young adults, screen-related depression can become quite serious, as it did for Dan, whose case is described below. Regardless of age, frequently the child will have some underlying social difficulties — due to shyness, odd mannerisms, or a difficult temperament — leading the parents to become overly permissive with screen privileges, which sets the stage for a vicious cycle. Psychologically, the child becomes more and more dependent on screen-time for stimulation or a feeling of connection, or to escape from what is an otherwise boring, unfulfilling, or perhaps even painful life. Eventually, even the thought of living without screen devices may cause the child to feel highly anxious — as though in an existential crisis. Meanwhile, the child’s identity can become so fused with his or her virtual cyber life that normal development is stunted or interrupted; teens who are heavy screen users often make statements such as, “My phone is like my brain. I can’t live without it.” Or, “Being on the computer is the only thing that makes me happy…it’s my life.” In older children and teens, role-playing games may serve as an escape and a place they can control their image and actions, but this can be true for children of any age, who can become obsessed with certain video games or cartoon characters as a substitute for real relationships. As social support erodes, the depression worsens. Studies suggest that children or teens with shyness or social anxiety are at higher risk for screen-related depression.11
Alongside these psychological changes are physiological ones, including dysregulation of dopamine and other neurotransmitters (brain chemicals), compounding depression and a sense of isolation. While dopamine is the “feel good” chemical linked to positive moods, another relevant brain chemical is serotonin. Serotonin is important for socialization, stable mood, a sense of well-being, and coping with stress, and it is low in depression, anxiety, and aggression. Serotonin levels are highest in the mornings, and its production is thought to be boosted by bright morning sunlight and physical activity. Lack of morning light and sedentary daytime behavior may therefore blunt serotonin, contributing to depression, anxiety, aggression, and even suicidality.12 Light-at-night may further depress mood, both because serotonin is made from melatonin (which is suppressed by light), and because sleep disturbance itself is linked to mood issues. As dopamine and serotonin become more and more dysregulated, the child starts to seek out screen stimulation to temporarily boost mood, and screen-time literally becomes a form of self-medication.
Dan: A Curious Case of Depression
Dan was a twenty-year-old young man with mild social anxiety and ADD who — despite a genius-level IQ — was failing out of college. His social life had gone from being fairly active to nonexistent, his sleep-wake pattern was almost completely reversed, and he rarely left his room. Although not actively suicidal, Dan reported he often felt he’d be “better off dead” and didn’t “see much point to life.” What was happening?
Upon graduating from high school, Dan had continued living at home. But without the eight-hour school days and no job to go to, he suddenly found himself with a lot of extra time on his hands. His electronics’ use skyrocketed. Even when his college classes began that fall, Dan continued to spend anywhere from six to twelve hours a day on the computer, playing games, chatting, or reading articles. Dan barely scraped by the first two semesters. By the end of his third, Dan had dropped one class and was getting Fs in the other two. Despite his high IQ, he was struggling to keep up.
He’d also lost a lot of weight, even though he was thin to begin with. Dan’s mother reported that he’d stopped going to the kitchen to get food or water, and he was dependent on her to nag him into eating and drinking. By the time Dan came to me, he was gaunt and pale, and his muscles had literally atrophied from sitting and lying down so much.
To see this in a young male was shocking. Dan complained of fatigue, joint pain, back pain, shortness of breath, depressed mood, trouble sleeping, and feeling “flat.” His mother had made the rounds to numerous medical specialists and therapists — for both physical and psychiatric complaints — but to no avail. By the time I consulted with him, Dan was taking three psychotropic medications plus a pain medication, and he had been tried on numerous other “psych meds” but found them all ineffective. Not one person ever suggested he remove the computer and other devices from his bedroom, despite this being a standard-of-care intervention for sleep disturbance.
Naturally, when I suggested an electronic fast, Dan resisted. As is often the case with youths over eighteen, his treatment providers and his parents had been reluctant to force any screen-time rules upon him, which only escalated the problem. I, however, viewed his situation as an emergency; his behavior was showing us he wasn’t able to care for himself. Fortunately, his mother — who had been suspecting that the computer was part of the problem — readily agreed that imposing the fast was warranted, and she removed all the electronics in the home that same day.
Initially, Dan became even more isolated. Most days, he stayed in bed and didn’t speak much at all. Because he was so depressed, we decided to extend the fast for at least six weeks, and this proved to be prudent. Right around the six-week mark, Dan started coming alive again. He got out of bed each day, made spontaneous conversation with his mom, and began going to class. His interest in physics and history revived, and he joined some academic clubs. Initially, we maintained the fast except for school-related work, but as time went on, his mother and I established strict rules for personal use and continued to actively moderate his usage, in part by requiring his schedule be structured. Dan got a part-time job, made friends, and started getting As and Bs in school. Slowly, Dan put on some weight and started walking and stretching regularly with a family friend. As he regained his strength and energy, it became clear that all Dan’s physical ailments stemmed from deconditioning (being out of shape), depression, and stagnant blood flow — not some mysterious medical disease.
Dan’s case underscores the seriousness of electronics’ role in mood disorders, highlights the risk that social anxiety can bring, and demonstrates some of the physical effects that can occur with electronics overuse. Other individuals at high risk for screen-related depression are those with autism spectrum disorders, particularly after graduating from high school (for more on autism and ESS, see page 99). Suffice it to say, it is not enough to address depression in young people solely with conventional psychotherapy and perhaps an antidepressant. Even if screen-time is not the primary cause, it is virtually always a contributing factor.
Bipolar Disorder
Bipolar illness is a mood disorder characterized by severe high and low mood states. While “low” refers to a depressed mood, “high” can refer to a state of either euphoria or irritability. In adults these swings tend to be relatively discrete episodes, but in children, bipolar episodes are less distinct, and both the “highs” and “lows” can be associated with irritability — making the disease mimic a lot of other mental disorders. Thus, the diagnosis can be missed in those who truly have it, but it also tends to be overdiagnosed in children with other difficulties.
When I first began my “Mental Wealth” blog for Psychology Today a few years ago, I wrote a post entitled “Misdiagnosed? Bipolar Disorder Is All the Rage!” in which I proposed that the large increase in pediatric bipolar disorder diagnosis was due (in part) to children who were overstimulated from video games and other screen-time who raged, and thus “looked” bipolar.13 I received emails from mothers all over the world — including the United States, Europe, Canada, South America, and the Middle East — telling me their child had been diagnosed as “bipolar” because he or she was exhibiting rages. Typically, the email would reveal that the mother had long suspected video games were the real culprit, but that the notion had always been shot down by whoever was evaluating the child. When these mothers read my article, however, the sense of validation they felt prompted them to follow their instincts — and out went the electronics. Story after story poured in about how a child’s rages had resolved or at least become manageable when they followed this simple intervention. Although I’d seen this in my practice hundreds of times, it was validating for me to hear that mothers around the world were using the intervention effectively.
However, behind the satisfaction loomed something more ominous. How many children were receiving psychotropic medication unnecessarily? How many were labeled as “bipolar” when they were simply overstimulated and unable to regulate themselves? As I mention in the introduction, the diagnosis of childhood bipolar disorder has increased dramatically in recent decades, and a new diagnosis was created in 2013 — Disruptive Mood Dysregulation Disorder — precisely out of concern that children are being inappropriately diagnosed with bipolar disorder and receiving unnecessary medication. In my experience, disruptive children are sometimes given a “bipolar” diagnosis by a pediatrician during a routine ten- to fifteen-minute visit, while in other cases a teacher or therapist suggests to parents that their child “might be bipolar” and “might need medication,” or worse, “can’t come back until he’s medicated.” Often, a child need only exhibit aggression or explosive rage to get this label slapped on by a well-meaning but misinformed clinician. In some instances, a mother will read a description of pediatric bipolar disorder, feel her child fits the description, and then convince herself and others that bipolar disorder is the correct diagnosis. Of course, childhood bipolar disorder can and does exist (with or without ESS), and it’s not a diagnosis you want to miss — early treatment improves prognosis. But it is relatively rare, especially if there is no family history of the disease (or no genetic predisposition).
So, what is it about ESS symptoms that prompt this mistake and create what seems to be a bipolar “picture”? In addition to rages and mood swings, ESS symptoms can include severe insomnia, impulsivity, distractibility, and, in certain vulnerable individuals, hallucinations or vague paranoia. Especially together, these symptoms can take on a very convincing bipolar persona. The misdiagnosis of bipolar disorder is even more common in children for whom ESS amplifies other difficulties, such as existing learning disorders, intellectual delays, ADHD, attachment disorder, sensory integration issues, and autism spectrum disorders. These children’s nervous systems are already more vulnerable to environmental assaults of all kinds, and they are more likely to become impulsive or aggressive under stress. For instance, say an eight-year-old boy has learning difficulties and ADHD. Both of these disorders will affect functioning of the brain’s frontal lobe, which governs planning, judgment, prioritizing, and emotional regulation. Now, if this boy is repeatedly overstimulated from electronics, this will further reduce frontal lobe activity, disrupt sleep, shorten attention span, and worsen mood. Now the boy will have even more trouble processing his environment, and very minor frustrations will be experienced as uncomfortable. You can see how a child like this might become explosive and have mood swings, or how he could be calm and loving after getting a good night’s sleep but be a wreck again the following day. His hyperarousal and poor processing might also mean he barely remembers his outbursts, and so he acts as though they never happened. These are all patterns that can occur when ESS compounds or mimics other disorders, and they are the same patterns that contribute to misdiagnosis.
Finally, of course, ESS can and does occur alongside true childhood bipolar disorder. ESS can easily make things worse for such a child, since bipolar illness is exquisitely sensitive to lack of sleep: staying up all night can induce mania, while inducing sleep is an important part of managing acute mania. If a child truly does have a serious mental illness like bipolar disorder, an electronic fast can help clarify the diagnosis, and it may help manage symptoms, both directly (by helping to regulate mood) and indirectly (by improving sleep). Either way, it may help reduce the need for medication.
For parents witnessing serious mood disturbances and dysregulation that appear to take on a life of their own, it may be hard to appreciate the link with electronics, and at first they often dismiss screen-time as a serious or central issue. But a child’s diminished ability to self-soothe or regulate mood due to of ESS will prolong and worsen the episode, all while creating a hair-trigger response to stress. Then, when the usual treatments don’t improve symptoms, parents become even more exhausted — and almost invariably children are allowed even more screen-time. This creates a vicious cycle of stress and dysfunction that can further overshadow the role of electronics. The bottom line is that ESS needs to be both ruled out and addressed before tackling whatever lies underneath.
Lily: When a Smartphone Isn’t Smart
A bright young girl, Lily was sixteen when I met her. By then, Lily had already been kicked out of school because of her rages and emotional instability, and she was being homeschooled. She had also been diagnosed with bipolar disorder, and because of the prescribed medications she was taking, she’d gained nearly thirty pounds. Her mother initially brought her to me for a second opinion on her medication regimen. Instead, as I discovered the amount of computer time Lily devoted to gaming and chatting on anime sites, I suggest that they do the Reset Program.
After much convincing, Lily’s mother agreed, but Lily was furious. During the first few days of the fast, Lily screamed and cried, pleaded, slammed doors, threw things, and generally gave her mother hell. “It was like taking someone off heroin,” her mother told me. “She swore up and down and cursed you and me both.” I told her mother that this behavior was expected, and I encouraged her to hang tight and continue the fast. When Lily and her mother returned to my office several weeks later, Lily was smiling and admitted her mood was better since the fast, even though she was initially “mad as hell” at me. Her mom described Lily as “more even-keeled” and noticed she was sleeping a lot better. Eventually Lily returned to school, and we were able to greatly reduce her medication doses — which in turn helped her lose weight. Because Lily was a lot more pleasant to be around, she began making friends.
Lily continued to improve over the next several months, and we were able to wean her off all her medications with the exception of a mild mood stabilizer that didn’t cause weight gain. During this time, she and her mother decided Lily would try attending a very strict and structured boarding school, which emphasized fitness and developmentally based learning. The school did not allow any electronic screen devices — no cell phones, no television, no computers — and it had a psychiatrist on site who would monitor Lily closely. For the next year and a half, Lily did wonderfully: not only did she lose the thirty pounds she’d gained, but she lost ten more; her mood was relaxed and happy; and her self-esteem and social skills greatly improved.
In April of her second year at school, however, I received a frantic call from her mother stating that Lily’s mood swings had suddenly returned and that she was suicidal and had to be brought home. When Lily came in, I tried to find out what stressors may have triggered a mood episode, but could find none. Lily claimed she hadn’t used any computers, even when she had been home over that recent spring break. On the surface, it looked like Lily was “cycling,” or experiencing a bipolar episode, perhaps because of her reduced medication regimen. But I kept digging — and eventually I uncovered that when Lily had turned eighteen in March, she’d been allowed phone privileges, and her parents had given her a new smartphone.
Lily admitted to texting incessantly, playing electronic games, and accessing the Internet on her phone throughout the day. She also admitted to using her phone at night, texting while in bed, and sleeping with the phone under her pillow. Thus, despite the fact that she was still restricted from television and computer use at school, she had ramped up her interactive screen-time over a very short time period and was exposing herself to light-at-night, which, as mentioned earlier, has been linked to depression and suicidal thinking. Lily’s sleep was disturbed, her mood had become dysregulated, and her grades had fallen.
To me, this was a no-brainer: the culprit was the phone. Although neither she nor her mother agreed that the phone could possibly be the trigger, they agreed to a fresh electronic fast — which included handing over the phone — since they were both reluctant to increase or add medication. Lily quickly stabilized.
As with Dan, Lily was now a legal adult, and some might argue that she had the “right” to own a phone. This may be true, but if excessive smartphone use could put her in the hospital, did we really want her have one? Did she really need it? In the end, her mother bought Lily a simple flip phone with no texting, games, or Internet capabilities, and Lily was able to return to school successfully. My opinion is that Lily was indeed somewhere on the bipolar spectrum, but screen-time clearly dysregulated her already vulnerable brain and made it nearly impossible for her to succeed in life.
Cognitive Concerns
As opposed to mood or behavior, cognition relates to thoughts and thinking. Cognitive problems associated with ESS run the gamut, from trouble concentrating and diminished creativity all the way to paranoia and even hearing voices. The influence of interactive screen-time on cognition is thought to be due to dopamine imbalance, blood flow shifting from higher to lower centers of the brain, mood disturbance, and stress chemicals and hormones associated with hyperarousal (see figure 5). Furthermore, cognitive effects are compounded by screen-time’s effects on sleep. Light-at-night studies confirm that children suffer immediate and lasting impairment of cognition and sleep quality from any amount of interactive screen-time after bedtime.14
Figure 5. How screen-time effects translate to cognitive symptoms
Attention, Executive Functioning, and Learning
Children with attention problems generally have difficulty sustaining and shifting attention, and they have trouble initiating and completing goal-oriented activities — particularly if the activity is experienced as difficult or tedious. Inseparable from the ability to pay attention are two other abilities: executive function — that is, the ability to “get things done,” which includes planning, prioritizing, organizing, revising, strategizing, attending to details, and managing time and space — and working memory, that is, “seeing in the mind’s eye,” or the ability to hold and manipulate incoming information in the mind. Difficulties with attention and executive functioning, which are largely governed by the brain’s frontal lobe, have a profound impact on quality of life — affecting everything from academic and career achievement to the success of relationships.
Attention and executive functioning are largely dependent on dopamine and another brain chemical (or neurotransmitter), norepinephrine. These two neurotransmitters are the same chemicals that attention-deficit drugs seek to increase. Our brains need not just an adequate supply of these chemicals, but they also require them to 1) be active in the appropriate areas, 2) bind to adequately sensitive receptors, and 3) strike a balance with other brain chemicals, such as serotonin. These functions are sensitive to stress of any kind and can also be impacted by lack of proper sleep.
Whether related to ESS or not, what do attention difficulties look like? The child or teen with poor executive functioning …
• has difficulty with multistep directions and executing tasks that require planning and prioritizing, like school projects or applying for college or a job.
• loses homework even when completed or forgets to turn it in.
• has trouble keeping track of things, including time and personal belongings.
• is easily overwhelmed and becomes frustrated by small demands.
• exhibits paralyzing procrastination and avoidance of chores, and will have a “hard time getting started” on homework (especially “busy work”) and paperwork in general.
• has trouble staying on task, perhaps even with tasks or routines he or she is familiar with, like getting ready for school or bed.
• displays a lack of attention to detail, such as completing chores or homework in a sloppy or haphazard manner, keeping his or her room “like a disaster zone,” or shoving everything into a backpack and never cleaning it out.
• appears “lazy” or “unmotivated” and can’t tolerate delayed gratification.
• tends to be impulsive, acts before thinking things through, and disregards consequences of actions.
• often will not perform up to his or her academic potential, particularly in later school years.
It’s critical to understand that anything that impacts attention also impacts executive functioning. Attention difficulties are, of course, the hallmark of attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD*). Because screen-time affects dopamine regulation, frontal lobe activity, sleep, and stress levels, ESS can look exactly like ADD — and will almost certainly worsen ADD if it preexists. Furthermore, children with attention symptoms are drawn to electronics precisely because they are stimulating; I’ve yet to meet a child with attention problems who doesn’t love screen devices. The two tend to go hand in hand.
Here is a very typical example: Suzanne, a friend from high school, once contacted me about her son, Justin. Justin had become moody, was struggling academically, and was disruptive and defiant in the classroom. Suzanne reported that Justin didn’t seem to enjoy playing anything but video games anymore; he had lost his natural “sense of curiosity” and “thirst for knowledge.” Justin’s teacher and his dad both felt Justin had ADHD and wanted him to see a psychiatrist. Suzanne, however, wanted to first get rid of the video games and other electronics before even considering medication, and she convinced his dad to wait while she tried the electronic fast.
Sure enough, within the first week of the fast, Suzanne noticed that Justin’s mood improved. By the end of the month, her son had turned things around at school and was playing healthy activities again, and all discussions about Jason having ADHD were dropped. Eventually, Suzanne let Justin play video games again on a very limited basis, but she learned to immediately pull them back if she noticed mood or attention changes.
Video Games and Learning: The Attention Paradox
Parents often wonder, “Why is it that my child can pay attention to a video game — but to nothing else?!” Likewise, when I tell parents that gaming worsens focus, they often respond, “But I thought video games improved his attention.” Why the confusion?
Attention is interest-based and driven by stimulation. Children with attention issues are drawn to video games and screens precisely because they can focus on them; the games provide sufficient stimulation for a dopamine surge, and thus gaming may be considered “self-medicating.”15 In fact, studies have shown that ADD medications actually curb cravings for and amount of video game play,16 presumably because these medications raise dopamine levels.
But what about using the attention-grabbing stimulation of video games and other screen-based methods to enhance learning in the classroom? The excitement about using electronic media to engage students has led to a rush to implement electronic learning tools, despite their poor track record in studies. Essentially, what teachers are finding is that they work — until they don’t. Soon enough, the novelty wears off, and more and more stimulation is required for focus. Meanwhile, the added stimulation contributes to dysregulation and a worsening of attention in general. When a child reports finding non-screen activities “boring,” this should be a red flag to parents and educators — it means the child’s brain has become used to an unnaturally high level of stimulation.
Further confusing the issue of attention, learning, and gaming is the highly touted finding that gaming can modify visual attention.17 This is different than the executive attention issues we’ve been discussing related to “getting things done.” An example of visual attention would be scanning an environment and visually picking out a target. Both the scientific and lay media have speculated that playing video games could “improve surgical skills,” and that better visual attention skills could perhaps boost the potential to “become a pilot,” “be a sharpshooter,” or “improve driving skills.”
But I would argue that it doesn’t matter if gaming improves visual attention if it also worsens executive attention, impulse control, and frustration tolerance. Overgeneralizing and overemphasizing the visual attention effect is dangerous and misleading. The idea that gaming might improve the driving skills in teenage boys is laughable — not to mention inconsistent with research, which finds that gamers tend to be more reckless drivers.18 And someone who can shoot well but has poor impulse control is not welcome in the military, for obvious reasons. Finally, aside from the fact that pilots and surgeons are a fraction of a percent of the population, you can bet that to persevere in career paths with such long and intense training, pilots and surgeons virtually always have highly superior executive functioning.
There now exists a large body of research implicating screen-time in the development of attention problems, and the earlier the exposure, the stronger the effect.19 Although many of the studies have focused on television, more recently video games and Internet use have been implicated as well.20 As I’ve said, interactive screen-time seems to have a much more potent detrimental effect on attention and executive functioning than passive screen-time, perhaps because the interactivity promotes higher levels of arousal, and because the proximity of the screen causes more severe melatonin suppression and circadian disruption. (EMFs may also be a factor; see the appendix.) Several studies support this distinction. A 2007 study conducted in Germany that allowed children an evening of either excessive television or computer game use found that the gaming group suffered significantly altered sleep patterns and impaired cognition when measured the following day, while the television group showed some sleep inefficiency but no change in cognitive performance.21 Similarly, a large study published in 2010 that followed children over a two-year period found that total screen-time predicted attention problems, but that video game playing was more predictive than television viewing when the factors were looked at separately.22
It is also becoming increasingly clear that the relationship between screen-time and attention problems is one of causation — not mere association or “self-selection.” In a landmark study, researchers followed more than three thousand Singapore children and adolescents over a three-year period and found there was actually a bidirectional relationship between gaming and poor attention.23 In other words, it appears that gaming causes attention problems, and that children who are inattentive are more likely to game. This finding held true even when the researchers controlled for earlier attention problems, suggesting that screen-time as an environmental factor worsened attention whether or not the child had previous genetic-related attention problems. The authors also found that while violent gaming added slightly to the risk, the “dose” or total time spent was more important. Another study found that the association between screen-time and attention issues persists into adulthood.24
Research suggests that screen-time causes immediate effects on attention as well. As mentioned earlier, a 2011 study found that viewing a fast-paced cartoon — in this case SpongeBob SquarePants, a not particularly violent cartoon — for just nine minutes produced deficits in executive function in four-year-old children.25 Another study tested children’s attention before and after playing a video game and found that those with higher levels of daily computer use performed more poorly compared to those with more minimal use.26 In other words, higher levels of overall screen-time appears to potentiate short-term attention effects.
Aside from attention, other aspects of cognition seem to be negatively affected as well. Consistent with “poor time management” complaints heard from parents, a 2006 study demonstrated that players experience time distortion when gaming, whether they’re novices or experts.27 (And who hasn’t lost track of time while on the computer?) Other research suggests decision making is impacted. In 2009, researchers concluded from a series of studies that players exhibited increased risk taking after playing an auto racing game — the so-called Racing-Game Effect.28 This finding lends credence to the concern that gaming can precipitate reckless behavior by glorifying and rewarding risk taking.
As I’ve mentioned, a growing body of research implicates the use of screen devices at night as a negative influence on daytime functioning, cognitive ability, and memory performance.29 Studies also show that light-at-night causes higher nighttime core temperature and heart rate and lower melatonin levels,30 markers associated with poor sleep and high stress. Lastly, numerous studies on multitasking — think Skyping and texting while doing homework — show it reduces efficiency and worsens performance.31 One 2013 study found that students who checked Facebook just once while studying tended to have lower GPAs.32
One of the most compelling studies to date has come out of Denison University, where researchers demonstrated that video game ownership can interfere with reading and writing skills in boys.33 Here, in a move that effectively eliminated any self-selection bias, researchers randomly split sixty-four boys ages six to nine who had never owned a video game into two groups. The children and families in the study were told only that they were receiving a reward for their participation — a video game console. One group received the console at the beginning of the four-month trial, while the control group received it at completion. The two groups were then compared in terms of academic achievement and behavior. The results showed that the boys receiving the console at the beginning of the study tested lower in reading and writing assessments, had more teacher-reported learning problems, and spent less time doing homework. Similarly, a 2010 study examined data collected on 150,000 middle school students in North Carolina and found that introducing a home computer had a negative and persistent impact on reading and math scores.34 The same conclusion was found by another 2010 study on low-income Romanian students, which compared the grades of those who had acquired a new home computer via a government-sponsored voucher program and those who had not.35
Likewise, various experts have made disturbing observations regarding technology’s effect on reading and learning. Dr. Leonard Sax, author of Boys Adrift, notes that in comparison to girls, boys are “falling off the curve” in terms of academic achievement and that the “gap” between boys’ and girls’ reading ability is growing; he cites video games as the second of five major contributors.36 Nicholas Carr, author of the critically acclaimed The Shallows, contends that the Internet is changing the depth of our reading and thinking. Carr writes, “The kind of deep reading that a sequence of printed pages promotes is valuable not just for the knowledge we acquire from the author’s words but for the intellectual vibrations those words set off in our own minds. In the quiet spaces opened up by the sustained, undistracted reading of a book … we foster our own ideas.”37 How can one reflect on or make new associations from written material at the same time one is skimming large amounts of information from the Internet — or having to process excess stimulation, for that matter?
In short, it is not an exaggeration to say that technology is “dumbing us down.” Screen-time makes us less attentive and less able to learn, remember, and think for ourselves.
Cole: Making the Grade
Cole, a young adult patient of mine with learning disabilities and ADHD, provides a dramatic example of screen-time’s effect on attention and learning. When he first came to see me, Cole declared that he wished to work on his reading skills and had recently taken placement tests at a local college. Academically, Cole had tested at a fifth-grade level in both reading and math. Fifth grade, interestingly enough, was the same year his teachers had introduced him to a computerized reading program. “They were all excited about it,” he said, “but then they gave up on me when it didn’t work.” In light of these goals, and because his mood and sleep patterns were dysregulated, I asked Cole if he was willing to give up a handheld video game of his that had practically become a new appendage. After a forty-minute discussion, Cole decided to leave the game in my office. A few days later, Cole’s brother left a voicemail stating that Cole’s mood had evened out almost immediately. Shortly after this (and much to my delight), Cole’s game console at home broke — he was now video game–free. A couple of months later, he was retested at the college for placement.
The results were nothing less than shocking: in math, which he’d always claimed he was good at, Cole now tested at a high school level, and his reading score had climbed four grade levels. I wouldn’t have believed him if he hadn’t shown me the actual testing results. Clearly, screen devices had been hindering this young man for many years, and his brain was now functioning at a level much more representative of his true capacity — making his literacy goals much more achievable. Indeed, as I’ll cover in chapter 11, research shows that screen-time use in general makes literacy achievement more difficult and that reading from a screen hinders reading comprehension.
Green-Time and Attention Restoration: A Cure for Aggression?
Appreciating the link between attention fatigue and tantrums, meltdowns, and more serious aggression is key to putting a stop to this type of unwanted behavior. Children with attention difficulties are at much higher risk for aggressive acts38 — not surprising considering inattention is associated with low frustration tolerance and an inability to check impulses. Meanwhile, restoring a child’s mental capacity for focus reduces risk. Attention restoration theory posits that while stress depletes attention, sensory input or stimulation that lowers the stress response (“easy attention”) restores the ability to focus.39 Studies show green environments reduce aggressive acts and improve attention, impulse control, and academic performance.40 Greenery draws the eye but lowers heart rate and blood pressure, thereby restoring focus and our ability to tolerate stress. Even pictures of greenery and viewing nature out of a window help, but time spent outdoors in nature is most powerful. Thus, in addition to the numerous ways screen-time contributes to aggression via hyperarousal, the fact that time spent indoors reduces exposure to the restorative effects of “green-time” is equally important!
Psychosis
Perhaps the most frightening repercussion of electronic devices is the emergence of psychosis, in which there are abnormal thoughts or thought processes. This can take the form of hallucinations (hearing voices or seeing things that aren’t there), delusions, paranoia, or confused thinking. In the cases I’ve witnessed, psychosis triggered by screen-time has occurred in individuals with underlying vulnerabilities, such as intellectual delays, a mood disorder, autism, or a history of neglect or severe abuse, especially sexual abuse. The vast majority of the time, the psychosis resolves or dramatically diminishes with the electronic fast. Often, in contrast to an individual with an “organic” psychosis, the person often knows what he or she is experiencing is imagined: the voices are heard but don’t feel “real,” the sense that others are talking about them doesn’t jive with reality, the nagging fear that someone is outside the window watching them at night seems silly during the day. Treating these cases can be very rewarding, because in addition to relieving symptoms, antipsychotic medicines can often be avoided, or if they’ve already been started, they can be reduced or even discontinued. This can lead to other pleasant by-products like weight loss and other health improvements.* Additionally, when a person’s psychosis resolves, he or she may suddenly become capable of attending school, holding down a job, or engaging in a romantic relationship.
On the other hand, if an individual is genetically predisposed to psychotic illness, such as schizophrenia or severe bipolar disorder, screen-time may represent the proverbial straw that breaks the camel’s back. It can trigger a “first break” — the initial episode in which an individual experiences a break from reality. In one sad case, a thirteen-year-old boy was allowed a substantial increase in his video game play during the aftermath of Hurricane Sandy. After several weeks of playing up to ten hours a day, the child started acting out scenes from his favorite game, and at times he seemed to believe he was actually in the game. Eventually he began acting out scenes in his sleep — a visible sign his brain was completely imprisoned, not to mention that sleep was not offering any relief. While searching for answers, his mother came across an article I’d written about screen-time and psychosis and promptly removed all video games as well as his computer. When she contacted me for a consultation a couple of months later, the worst of his symptoms had resolved, but the boy was continuing to hear voices, and he wound up requiring antipsychotic medication. In the months that followed, it became clear that the boy had a budding mental illness, likely schizophrenia. There was no family history of the disorder, but the child did have some vulnerabilities — learning disabilities and social problems — that, when combined with excessive gaming, was enough to create a tipping point.
When I first wrote about screen-time-related psychosis in Psychology Today in 2012,41 I received a backlash of criticism and skepticism from several neuroscientists. But the first case report was published in 1993 (involving a Nintendo game), and multiple cases involving computer games and Internet-related psychosis have been reported since.42 More recently, researchers have become interested in how excessive technology use might trigger psychotic symptoms. In 2013, an extensive report was published on so-called Game Transfer Phenomenon, a process in which gamers experience game-related visual hallucinations during real-life situations.43 It may be that these visual hallucinations — thought to be a sensory imprint of sorts — are more “benign” than other forms of psychosis I mention here. They are certainly more common and, for the most part, don’t cause distress. (When the article came out, I was shocked at how many of my male friends admitted to having experienced them after long bouts of gaming.) Nevertheless, gamers and parents should interpret the presence of any psychotic phenomenon as a cautionary red flag.
How might screen-related psychosis occur? One factor likely at play here is dopamine regulation. Drugs and medications that increase dopamine (stimulants) are capable of producing psychosis, and many medications used to treat psychosis block dopamine. As you now know, gaming releases dopamine. Other factors may be sensory overload and the brain’s inability to discern a virtual environment from the real one — especially as gaming environments become increasingly vivid and lifelike. This last factor may particularly be true for a child’s brain and psyche, which are not yet solidly formed. Unfortunately, we are seeing an increased incidence of violent crimes in which young people act out particular video game scenes or role play a video game character. The perpetrator is often in a semi-dissociative state, which has been initiated and perpetuated by repeated exposure to virtual environments for years. Many of these cases don’t “make the news” because the incidents involve minors, but they’re occurring much more often than the general public realizes.
Because the consequences of psychosis can be so dire, parents should take extra screen-time precautions in a child with the vulnerabilities mentioned above, particularly if the child has trouble separating fantasy from reality, has a history of violent behavior, or has a family history of serious mental illness such as schizophrenia. Most physicians and mental health clinicians will not suspect video games or computer use when a patient reports psychotic symptoms, so it’s likely that this screen-related phenomenon is largely under-reported — which is a horrible shame, considering that it’s treatable with strict screen elimination.
Disruptive and Defensive: Behavior and Social Issues
Behavior is essentially the outward manifestation of all the other issues we’ve been talking about. Typically, it’s a child’s behaviors that drive parents and teachers to the edge of the proverbial cliff — leading a parent to seek treatment. Socially, a multitude of important issues exist in relation to electronic media usage, such as identity development, sexting, and cyberbullying, to name a few. Here we’ll look primarily at the impact of electronic media on behavior and social skills in the context of ESS — in other words, at how the physiological effects of screen-time translate to social problems in your child. With its core components of hyperarousal and mood dysregulation, ESS can affect relationships with peers and family, stunt social development, and diminish capacity for empathy and intimacy. Figure 6 below shows how this might occur.
Figure 6. How screen-time effects translate to social dysfunction
Oppositional-Defiant, Argumentative, and Impulsive Behaviors
“I say black and he says white.”
“I could say, ‘The sky is blue,’ and she will start arguing with me.”
“When we ask him to do something, his whining and arguing is so annoying that we just wind up doing it for him.”
“When we enforce a consequence, she becomes so enraged that she wears us down and we give in.”
“He doesn’t listen and just does what he wants.”
These are comments frequently expressed by parents in my office, and research suggests that there’s a link between amount of media consumption and such disruptive behaviors.44 Although “oppositional-defiant disorder” is an actual diagnosis listed in the DSM, in practice these symptoms are virtually always related to something more specific, such as ADHD or trauma.
Opposition and defiance are strategies children will use to exert some control over their environment when they feel stressed or inept in some way — it’s a sign of a disorganized state of mind. These behaviors are often secondary to attentional or learning issues, hyperarousal, overstimulation, or poor sleep. Saying “no!” harks back developmentally to age two, when a child realizes that saying no gives him or her power over caregivers. Even as adults, when we feel overwhelmed, we might interrupt someone with a knee-jerk “no” before the person can even finish the question. Arguing is another common behavior indicative of poor attention or irritable mood* that’s made worse by interactive screen-time;45 arguing is a major source of parental frustration and exhaustion. Arguing may actually be a way for an unfocused child to raise arousal or dopamine and norepinephrine** levels, plus it serves to engage the parent — which can help a disorganized child feel more anchored. When a parent complains that a child is oppositional, argumentative, and irritable, especially if these symptoms seem to be worsening over time, my “index of suspicion” for ESS is very high.
In a classic example, a mother was telling me how her six-year-old twin boys weren’t watching cartoons in the morning anymore; she and her husband had decided to get rid of cable TV to save money, and she knew that cartoon watching could affect attention. But their hectic morning routine had become a daily nightmare when it came to getting the boys ready for school. They’d argue and stall, refusing to dress themselves, put on shoes, or brush their teeth, crying, “I can’t!” — all while refusing any offer of help. Inadvertently, the mother mentioned that because they weren’t getting up to turn the television on anymore, she and her husband were able to sleep in a little longer in the mornings, despite the fact that the kids continued to get up earlier than they did. “So what do the kids do instead of watch cartoons?” I asked. “We let them play on our phones,” she replied. Mystery solved! The boys’ daily fifteen or twenty minutes of phone play was enough to disorganize their nervous systems and set the tone for the day. She and her husband began taking turns getting up early, stopped the phone play, and smoother mornings soon followed.
Another ESS behavioral symptom we’ve already touched on is poor impulse control. Impulsiveness refers to the tendency to act without thinking, such as hitting a sibling without regard for consequences, running into the street without looking for cars, continually interrupting others, and so on. Children with attention problems and hyperactivity are typically impulsive as well, and thus they tend to engage in more risk taking, resulting in more frequent accidents. Consistently, impulsivity has been found to be a risk factor for problematic gaming and Internet use,46 and it seems to be a product of them as well. That is, just as there is a bidirectional relationship between gaming and poor attention, impulsivity and video games have been found to be mutually reinforcing. Violent games may pose an additional risk for poor impulse control.47
Violence and Delinquency
Violent aggression and delinquency are serious behavioral issues that are linked to excessive electronic media, particularly with violent content,48 but also with screen-time in general49 and with disturbed sleep.50 I have already discussed this connection in several places, and how the mood dysregulation, hyperarousal, and attentional fatigue that occur with gaming can lead to meltdowns and aggression. In general, aggression and delinquency are associated with poor frontal lobe functioning, which is a clear consequence of excessive screen-time.
These links have been demonstrated no matter what content is viewed. Importantly, research suggests that total time spent gaming is a stronger predictor of aggression than the level of violence in the games played.51 As with ESS in general, “It’s the medium, not the message.” That said, violent games pose a unique risk, and studies suggest that both violent and competitive games increase the risk of aggression compared to prosocial games.52 This risk is especially strong in violent games where players team up to face a common enemy.53 There’s something about the social nature of these games that makes them risky for both aggression and addiction.
While content is not the most important factor in the development of ESS, because of their highly stimulating nature, violent games are likely to cause more severe ESS symptoms. I used to believe that parents already realized that violent games were harmful, and therefore I didn’t spend much time driving this point home. What I didn’t realize was that many — if not most — video games (including those made for younger children) are violent. More than 90 percent of games rated as appropriate for children ten and older are violent, and the majority of boys play mature, or M-rated, games.54 Parents may be in the dark about how violent games really are, and ratings for video games are unreliable. Furthermore, many video games don’t display any sex or violence on the cover or in their advertisements, masking their true nature. Violent games also often portray female characters in a degrading manner and can contain sexual violence (including rape) and racist content. Thus, it’s advisable that parents watch or even play a game in order to screen it.
At this point, six decades of research have solidified the connection between acts of violence and aggression and exposure to media violence in television and movies,55 while the past decade has seen an explosion of research on violent gaming in particular.56 Do not be fooled by studies claiming there is no connection or that it’s inconclusive; an overwhelming majority of evidence tells otherwise, and there is a strong consensus not only within the medical community but among researchers whose work is unbiased and non-industry-affiliated. Violent video game playing is associated with poor school performance; increased aggressive thoughts, feelings, and behavior; increased physiological arousal; and decreased empathy and prosocial behavior.57 One reason for this is desensitization — that is, a blunting of our mental and physiological aversion to violence, whether real or virtual. Studies of violent video games have documented desensitization by measuring brain, cardiovascular, skin, and empathy responses.58 Disturbingly, one study showed the desensitization response occurred after just twenty minutes of play.59 As one young man explained to me, “I don’t know if I’m addicted, but I tell you one thing, it’s true what they say about violent video games and desensitization. … I don’t feel any reaction at all to seeing violence. … I mean nothing. [Laughs] I could see someone get torn apart by a machete and it’s the same to me as looking at someone walking down the street.”
Children with mental health issues — especially boys — who play violent games and those who have addictive tendencies are at high risk for aggression, as are children who have a poor sense of reality or who have a tendency to attribute hostile intentions to others.60 Newer, more technologically advanced games are more strongly linked to aggressiveness than older games, a trend researchers attribute to more realistic and vivid graphics and heightened “feelings of presence” (the sense that you are actually there).61 Indeed, each generation of games creates higher levels of risk for both aggression and addiction than the one before: lifelike realism creates higher levels of arousal, hyperarousal is linked to both addiction and aggression, and addicted players are more likely to be aggressive.
In regard to other delinquent behavior, studies suggest that excessive screen-time (including smartphone use) in teens and preteens is associated with risky behaviors such as school truancy, experimenting with drugs and alcohol, and having unprotected sex — behaviors consistent with poor impulse control.62 Interestingly, one study found that higher amounts of computer use was a stronger risk factor for delinquent behaviors than high television or video game use.63 Lastly, research shows that poor sleep — which goes hand and hand with technology use — is in itself a risk factor for high-risk behaviors.64
Aside from the obvious safety issues surrounding aggressive acts, aggression is a leading reason why children are placed on psychotropic medication, misdiagnosed as having bipolar disorder, suspended or expelled from school, and charged with criminal activity. Needless to say, it’s important to create environments that reduce this behavior, especially in high-risk populations.
Arrested Social Development
Children who experience social anxiety — feeling discomfort or distress in social situations — or who are socially incompetent are particularly at risk for developing dependence on electronic media. This is true whether the preferred agent be the Internet, video games, or a smartphone.65 The more a child hides behind a screen, the more socially awkward he or she becomes, creating a self-perpetuating cycle. In contrast, a shy child who continually works at overcoming social anxiety is likely to overcome it. In the past, the strong desire to belong to a social group during adolescence helped override resistance to social interaction, which would lessen over time simply due to practice. Nowadays, socially anxious or awkward children and teens aren’t forced to practice face-to-face and eye-to-eye interaction because some of their social needs are met online. Thus, in socially anxious children, the ability to tolerate the physical presence of others never builds, and “walls” are erected instead to keep the child feeling safe. An adolescent with somewhat poor social skills in high school can easily become reclusive as a young adult, spending more and more hours online and less and less time interacting in real life. This pattern makes it increasingly harder to make and keep friends. Relationship problems show up at home, too; research indicates that the more time a child spends using the Internet, the less healthy the parent-child relationship becomes.66 Thus, social incompetence and screen-time represent another bidirectional relationship.
Interacting with young people with screen-related social anxiety can be awkward or even irritating: they tend to make poor eye contact, seem distracted or “not present,” or squirm with discomfort. Often, they seem apathetic and demonstrate passive body language, like a weak handshake. They can take long pauses before answering questions and may be unable to engage in meaningful, reciprocal conversation. When they do open up, they may not be able to follow longer or more nuanced questions because of a shortened attention span, they may not give others the sense of being “heard,” and they often can’t seem to “resonate with” or “mirror” the other person’s emotions.
A few years ago, I had a very enlightening conversation with my then sixteen-year-old nephew about this very issue. We were sitting together at his sister’s high school graduation. The previous time I’d seen him, just six months earlier, he’d been his usual self — friendly, talkative, and high energy, but not able to pay attention to anything for more than a few seconds. If your question was too long, you lost him. Forget about sharing something with him — he wasn’t listening. As we sat there, I was struck by a change in him. We were having a great conversation: he was listening to me, making eye contact, and responding without going off topic. At first I just thought, Wow, he’s really matured. However, as we talked about football, which he’d played that year for the first time, my nephew shared that his coach had instructed the team members to stop playing video games because he felt it affected their ability to focus during games and could negatively impact grades — and therefore their eligibility to play sports. My nephew said at first he only cut back. Then, after realizing the difference it made, he quit completely. He said one of the first things he noticed was that he was suddenly able to talk to adults more easily, and he was speaking up more in class. He said that although he’d felt shy around his peers before, he’d found himself speaking up more in groups. Needless to say I was excited: here was a teen without a psychiatric disorder who’d quit playing video games on his own and was able to verbalize the changes in himself. His capacity for meaningful interaction had expanded dramatically.
Interestingly, my nephew then told me about one of his friends who was diabetic and sometimes faked being sick in order to miss school, either so he could play video games all day or because he’d been up late the previous night playing. (My nephew could “see” online when his friend was logged in to the game.) After quitting himself, my nephew became appalled by his friend’s behavior, especially when he realized that during those long gaming sessions his friend’s blood sugar would go way up. As he finished telling me this story, my nephew said, “His handshake is really weak. It’s like a dead fish.” After imitating it, he said, “I mean, come on, who’d hire a guy like that?”
He’d hit the nail right on the head. Impressions are made in the blink of an eye, and young people with poor social skills will have trouble getting ahead in life. Conversely, as my nephew’s social skills improved, so did his awareness of their impact. This ability to self-reflect is part of what helps children not just survive but thrive.
In school-age children, social impairment related to ESS can manifest as poor sportsmanship when playing games, acting bossy or controlling, or being super competitive. (It doesn’t help that many video games reward competitiveness.) Kids with ESS often have a low frustration tolerance that results in meltdowns and a tendency to blame everyone but themselves. They may also hold grudges or attribute hostile motives to others where there are none, such as assuming a peer purposely bumped into them. All of these behaviors drive other children away.
Because social skills and mood regulation are dependent on good frontal lobe function, children with ESS often act much younger than their years, and they may be teased, bullied, or ostracized because of outbursts. This occurred to Billy, a ten-year-old boy I worked with whose story I tell in chapter 4 (see page 117). In part, this dynamic occurs because screen-time creates a false experience of ease and success: electronic media offers immediate gratification, endless (and effortless) stimulation and entertainment, the ability to control one’s environment or one’s image, and the opportunity to be a hero — features that don’t reflect how things work in the real world. Real life is much more difficult. Screen-time makes children less able to tolerate disappointment and boredom, more entitled, and less willing to work — whether it be for school, at a job, or to improve a relationship.
Disconnected: Empathy and Intimacy Issues
As I’ve already described, both violent gaming and excessive Internet use have been linked to a diminished capacity for empathy. Indeed, brain imaging studies of adolescents with Internet gaming addiction show damage to the insula, an area involved in empathy that helps integrate bodily sensations with emotion.67 Empathy is different from sympathy; empathy is the ability to resonate with another’s state of mind and actually feel what the other is feeling. It helps us bond because the other person “feels felt,” and it fuels compassion and social responsibility by allowing us to feel others’ pain. These characteristics make empathy fundamental to enjoying a fulfilling emotional and social life. But violent gamers and Internet-addicted individuals aside, what about today’s children in general? Does time spent behind a screen impact one’s ability to relate face to face?
Mounting evidence suggests that it does. A study examining empathy score trends of college students from 1979 to 2009 found scores to be falling, with a particularly sharp drop after the year 200068 — right in line with the first generation of children who were born into the age of video games and computers. Much of social competence is learning how to read subtle cues in body language and facial expressions, and studies show face-to-face contact is highly correlated with social well-being, while media use and media multitasking correlate with the opposite.69 I’ve seen this firsthand: children who complete the Reset Program invariably display improved social skills, and their emotional competency grows quickly in the absence of screens. A 2014 study came to the same conclusion: preteens who spent five days at a wilderness camp in which screen media was completely restricted showed an enhanced ability to accurately interpret others’ facial expressions.70 Interestingly, one way we develop empathy is by unconsciously imitating the physical actions of others, so the freedom to move one’s body while viewing others’ bodies — something that being screen-free affords — appears to be important as well.
Eye contact is another element important in determining the quality of our social relationships. Eye contact is an essential part of the bonding process from birth onward. It reflects our capacity for intimacy, and an inability to tolerate sustained eye contact often translates to shallow relationships. Capacity for eye contact is likely related to the amount of an individual’s current screen-time habits, the total years of screen-time, the age at which screen devices were introduced, and the quantity and quality of past and present face-to-face time — which is, of course, related to parental screen-time, too. Note that when a child operates with a defensive nervous system (from frequent fight-or-flight and less face-to-face interaction) on a regular basis, he or she will be less able to tolerate eye contact without unconsciously interpreting it as a threat — much like wild animals do — and will thus avoid it until the absence of screens forces the child to build tolerance.
Nowhere is the capacity for eye contact more critical than in romantic relationships. Although as a parent you may or may not be concerned about your child’s romantic relationship potential at the moment, it’ll be important at some point, usually starting in adolescence. A child’s ability to form close friendships, to be honest and open about feelings, to empathize by putting themselves in another’s shoes, and to communicate during conflict without becoming defensive will dictate the quality of his or her relationships, starting with friends and family and later with romantic interests as well. I see a number of young adult males with screen-time issues in my practice, and many of them want a girlfriend but have no clue about “live” interaction. Others begin relationships only to see them end quickly when their partner senses intimacy limitations and moves on. It takes a lot of hard work and resources to work on these issues as an adult — it’s much easier to prevent them from developing in the first place.
In short, the same stress or fight-or-flight reactions that affect mood and cognitive symptoms also impact social relationships. Extreme shyness, poor sportsmanship, limited empathy skills, and reduced tolerance for intimacy are all made worse when face-to-screen replaces face-to-face. A defensive nervous system in survival mode cannot trust and therefore cannot form close relationships, and a poorly functioning frontal lobe cannot delay gratification, tolerate disappointment, or self-reflect. Aside from predicting relationship quality, these are essential ingredients for becoming a responsible adult with a strong moral compass.
Hijacked: Addiction and Reward Pathways
Addictions occur on a spectrum, and screen addiction is no different. However, when I work with patients, I don’t like to focus on screen or tech addiction per se because it undermines the fact that ESS can be triggered by even “regular” use. Although severely screen-addicted individuals will virtually always have ESS, individuals with ESS aren’t always or even usually addicted to screen-time. Furthermore, teens and young adults often find the term addiction off-putting, which can create roadblocks in treatment. Thus, I feel the most accurate and helpful term is “problematic,” since it includes the child who experiences screen-related symptoms but whose screen habits are not necessarily excessive or addictive in nature. Nevertheless, the terms “pathological,” “excessive,” “overuse,” and “addiction” are all used in the scientific literature, so for purposes of discussion here, they may be used interchangeably.
In reality, if the average school-age child is consuming four to six hours and the average teen is consuming seven-plus hours daily,71 then the majority of children have screen habits that should be considered “excessive” — especially considering that we don’t yet know what the long-term effects will be. Terminology notwithstanding, the findings in screen addiction research dovetail nicely with those observed in ESS, including biological, psychological, and behavioral aspects. If ESS and screen addiction are part of the same spectrum, then addiction research highlights the need for aggressive screen management — to “head it off at the pass.”
Screen addiction or dependence can be psychological (causing anxiety or distress with lack of screen access), physical (causing brain changes and a true “withdrawal syndrome” similar to drug withdrawal), or both. In developed countries worldwide, an estimated 5 to 15 percent of people have screen-time addictions, making it an epidemic.72 The silver lining behind the enormity of the problem is that because the problem is more widely recognized, a robust body of literature now exists that didn’t a decade ago.
As I’ve said, electronics overuse bears a striking resemblance to stimulant abuse and addiction. Like amphetamine abuse, focus and mood may seem — and indeed may be — enhanced by the stimulation of screen-time. However, over time and as usage increases or accumulates, the “user” will begin to experience mood changes, sleep disturbances, shortened attention span, irritability, depression, defensiveness, an inability to tolerate stress, and a general worsening of functioning. Other similarities between screen addiction and stimulant addiction include decreased interest in other activities and feeling anxious if forced to be “without.” Also, as with drug abuse, electronics use or abuse “just on the weekends” can still produce significant issues.
As with drugs, people are drawn to interactive electronic media for its ability to provide immediate gratification and intense stimulation. Marketers exploit these tendencies and thus “up the ante” with every new game, gadget, or application. Each new version becomes more stimulating, titillating, or rewarding — and thus more addicting — and the hijacking begins. Both physiological arousal and “feelings of presence” are factors known to promote and maintain engagement in video game play, and these factors are enhanced with newer games.73
Although there has been considerable media hype about the ways in which technology may be rewiring our brains, the bigger concern is that excessive video game and Internet use is causing actual brain damage. Numerous brain imaging studies have shown abnormalities in both brain structure and function similar to damage caused by drugs, such as in heroin, cocaine, and alcohol addiction. As discussed in chapter 2, research has demonstrated brain shrinkage in processing areas (gray matter), including the frontal lobe; loss of integrity in connection pathways (white matter); reduced cortical thickness (higher brain areas); and more impulsive but less accurate cognitive processing. When video game addicts are shown cues that induce “craving,” their brains light up in the same areas that drug-addicted brains do. Finally, dopamine receptors may become desensitized, effectively requiring larger amounts of dopamine to do the same job.74
Interestingly, one group of researchers summarized the literature on pathological Internet use in a way that described the mood, attention, and behavior traits seen with ESS: “Taken together, these findings indicate that internet addiction disorder is associated with structural and functional changes in brain regions involving emotional processing, executive attention, decision making and cognitive control.”75
