Part 1: Adolescent Tech Use and Mental Health: Expert Roundtable

It is estimated that 95% of youth aged 13 to 17 years across all demographic groups use smartphones, with near-constant internet use reported by 45% of teenagers.¹ The current generation of adolescents spends less time in person with peers compared with previous generations, and technology influences their identity and socialization in numerous ways.²

The use of technology is also transforming the mental health landscape, with significant implications for clinicians who work with adolescents in particular. As 1 of many examples, teenagers often hide online activity from parents, but may share it with mental health providers, and this can present various ethical and clinical challenges. In addition, among the ever-increasing number of mental health apps, very few are evidence-based, and some of these sell user data.²

“Given its powerful influence on mental health and behavior and the importance of parental modeling and limit-setting, technology is a vital topic for clinicians working with adolescents and families,” according to a paper published in October 2018 in Current Psychiatry Reports.² “Ethical considerations in clinical work with youth are uniquely complicated by the developing capacities of the ever-maturing patient, the need for a dual alliance with patients and legal guardians, and the importance of working with the systems in which teens are embedded (e.g., schools).”

Based on a review of the literature regarding adolescent mental health and technology use, the authors noted the following findings and other relevant points.

Clinical implications

• Incorporating a “tech history” into routine evaluations is recommended, with questions “addressed to both the adolescent and caregiver to obtain a thorough understanding of the role of media in the psychological and social-emotional world of the patient,” they wrote.² If the clinician reviews a patient’s social media content, this should ideally be done in session with the patient, rather than without them.
• Clinicians should also be educated about the role of social media as it pertains to the specific adolescent populations they treat. Some patients with autism spectrum disorders, for example, may prefer electronic vs face-to-face communication.
• Although the use of technology can become compulsive and possibly addictive, there is no consensus definition for problematic internet use or internet addiction, which has also been referred to as “internet use disorder,” and it is unclear how such use may affect brain development in adolescence.
• Screening tools for problematic internet use in adolescents include both the 18-item Problematic and Risky Internet Use Screening Scale and the shorter 3-item version.

Effect on adolescent mental health

• Technology use in adolescents can increase creativity, identity development, social group connection, and improvements in self-esteem and well-being. However, there are numerous potential risks, such as cyberbullying, sending sexual content, excessive use, and compromised privacy.²
• Emerging research indicates an association between increased technology use and higher depression rates among adolescents, and connections between internet use and increased self-harm and suicidal behavior.^2,3
• Other studies have found associations between increased use of electronic communication and reduced psychological well-being, as well as between problematic Facebook use and psychological distress.²
• An extensive body of research has linked youth exposure to violent media with increased fear and anxiety, a greater frequency of aggressive thoughts and violent behaviors, and desensitization to violence in general.² “Parents can mitigate these effects by heightening exposure to prosocial video games, discussing the difference between on-screen and off-screen violence, and promoting empathy-building civic experiences,” wrote the current authors.²
• In a survey of teenagers in the United States, 24% of respondents reported a mostly negative effect of social media on their lives, whereas 31% indicated mostly positive effects and 45% reported that the effect had been neither positive or negative.¹
• “Although a platform for disseminating successes and upbeat images, social media also engenders feelings of self-doubt and dissatisfaction and can leave youth vulnerable to affective disorders,” as explained in the recent review.² A 2015 Pew Research Study found that 21% of teenagers felt worse about their lives because of exposure to friends’ social media posts, and superficially positive content can make them feel lonely and excluded.⁴
• However, 56% of teenagers have reported feeling lonely, anxious, or upset in the absence of their phone.⁵

“As clinical work expands into the new frontier of digital media and other technologies, complying with relevant established professional recommendations constitutes good ethical and good clinical care,” the authors of the current study stated.² Clinicians should apply these principles in a manner appropriate to the patient’s developmental stage.

To learn more about the implications of technology on mental healthcare among adolescents, Psychiatry Advisor interviewed the following experts:

Elias Aboujaoude, MD, MA, clinical professor of psychiatry and behavioral sciences, director of the Stanford OCD Clinic, and author of “Virtually You: The Dangerous Powers of the e-Personality”; Joseph F. McGuire, MA, PhD, assistant professor of psychiatry and behavioral sciences in the division of child and adolescent psychiatry at Johns Hopkins University School of Medicine; and Brenda L Curtis, PhD, MSPH, assistant professor of psychology in psychiatry at the Perelman School of Medicine at the University of Pennsylvania. (Dr. Curtis’s interview will appear in Part 2 of this article.)

Psychiatry Advisor: What are some of the potential ethical dilemmas that clinicians face regarding adolescents’ use of technology?

Dr Aboujaoude: Much of mental health treatment unfolds in the context of strictly defined relationship boundaries, whether between therapist and patient or between patient and other players in his or her life. Treatment often involves highlighting boundaries between provider and client and protecting the individual from boundary violations by others. Social media and online life overall, in contrast, defy boundaries. The result can be privacy violations, the extent of which are absolutely unprecedented and that the clinician must respond to.

Dr McGuire: There are several ethical dilemmas that clinicians may face when working with adolescents that surround balancing therapeutic trust and patient safety. This can be challenging, as adolescents are often the primary patients, but their parents are the legal guardians. It can be particularly difficult when adolescents are using technology in an inappropriate manner. These instances might include excessive gaming, picking on peers over social media, posting inappropriate pictures on Instagram, and/or having online relationships with people that they have never met.

Psychiatry Advisor: What are the ethical responsibilities of clinicians in this context, and how can they best address these issues?

Dr Aboujaoude: The universal ethical principles governing care, including beneficence, nonmaleficence, confidentiality, and justice, have not changed. What has changed considerably are the platforms where patients’ lives play out and where symptoms manifest. Therefore, the ancient principals have to adjust to the peculiarities of the digital age and to the needs of a specific population, adolescents, that is highly reliant on new technologies.

Dr McGuire: It is challenging because clinicians need to balance the patient’s needs with legal and safety concerns. It is important to assess technology use in any patient, and to address any unsafe behaviors in a collaborative manner.

Psychiatry Advisor: What are other treatment implications or recommendations for clinicians regarding adolescents and technology?

Dr Aboujaoude: Abstinence is not an option or a realistic target. Instead, the goal should be to help adolescents achieve a balance between a level of technology use that enhances well-being but that still allows them to feel content, productive, entertained, and “normal” when offline.

Dr McGuire: It is important to remember that not all technological use is bad. Given children and adolescents’ interest and reliance on technology, it can serve as a useful tool to disseminate therapeutic information and engage youth in treatment through apps or other novel approaches such as therapeutic video games, for example.

Clinicians should inquire about adolescents’ technology use and understand the function of technology usage in the adolescent’s life. For instance, they may use technology for information purposes and seek advice about their mental health online. As such, it can be important for a clinician to direct the patient to appropriate online resources rather than the adolescent relying entirely on Google.

Similarly, the adolescent may be spending many hours a day using technology such as internet and video games. By assessing the function of technology usage, a clinician can clarify whether this use serves to avoid difficult life situations or whether it serves as source of positive friendships in the adolescent’s life.

Psychiatry Advisor: What should be the focus of future research regarding the effects of technology use on adolescent mental health?

Dr Aboujaoude: Clearly, more research is needed to understand how principles that in some cases date back to Hippocrates translate to the age of Instagram storylines.

Dr McGuire: Unfortunately, there has been limited research on the important topic of technology in adolescence. With regard to ethical dilemmas, an initial first step might be to survey clinicians to identify common concerns around technology use in the treatment of adolescents and to evaluate challenges, ethical, logistical, or otherwise, surrounding this topic. This could eventually lead to consensus regarding strategies among clinicians to address problematic use of technology by adolescents. Regarding treatment, there is a need to better understand how technology can be integrated into evidence-based care to engage youth in an accessible and familiar manner.

References

1. Anderson M, Jiang J. Teens, social media & technology 2018. Pew Research Center; May 2018. http://assets.pewresearch.org/wp-content/uploads/sites/14/2018/05/31102617/PI_2018.05.31_TeensTech_FINAL.pdf. Accessed December 7, 2018.
2. Sussman N, DeJong SM. Ethical considerations for mental health clinicians working with adolescents in the digital age. Curr Psychiatry Rep. 2018;20(12):113.
3. Marchant A, Hawton K, Stewart A, et al. A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: The good, the bad and the unknown. PLoS One. 2017;12(8):e0181722.
4. Lenhart A, Smith A, Anderson M, Duggan M, Perrin A. Teens, technology and friendships. Pew Research Center. 2015 http://www.pewresearch.org/wp-content/uploads/sites/9/2015/08/Teens-and-Friendships-FINAL2.pdf. Accessed December 7, 2018.
5. Jiang, J. How teens and parents navigate screen time and device distractions. Pew Research Center; August 2018. http://assets.pewresearch.org/wp-content/uploads/sites/14/2018/08/21153052/PI_2018.08.22_teens-screentime_FINAL.pdf. Accessed December 7, 2018.

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Part 2: Adolescent Tech Use & Mental Health: Expert Perspective features an interview with Brenda L Curtis, PhD, MSPH, assistant professor of psychology in psychiatry at the Perelman School of Medicine at the University of Pennsylvania, whose principal research focuses on “big data” generated from social networking sites, technology-based interventions for substance use disorders and related issues, and Internet research ethics.