With screen time essentially doubling during the pandemic, kids and their parents need guidance to get back to healthier habits. Adolescent medicine specialist Jason Nagata, MD, MSc, presents the data on how electronic pastimes – watching TV, playing video games, scrolling through social media – impact the mental, psychosocial and physical health of young patients, and offers updated screen use guidelines that could help protect them against everything from cyberbullying to sleep deprivation to obesity.
Thanks so much for having me and for the opportunity to speak today. My name is Jason Negada. I'm an associate professor of pediatrics at the University of California, San Francisco. Um, and my specialty is in adolescent medicine, and I have been researching adolescent screen time and social media. And impacts on teens over the last several years. Um, particularly, I got interested in the field because clinically, I specialize in adolescent and young adult eating disorders. Um, and I, uh, attend on our inpatient, uh, eating disorders unit at Benioff Children's Hospital. Uh, and I think You know, even before the pandemic, we, uh, noticed that a lot of our teens, even those who were critically ill and needed inpatient medical stabilization, um, many of them were just glued to their phones and to social media channels. Um, and in fact, um, use social media as a way to To, uh, even try to, um, kind of game the system and get out of the, um, feeding, refeeding protocols. Um, and it just really struck me that, um, so many of our teens, even those who were, um, really struggling with their body image, were still glued to, uh, social media platforms. And Um, this problem really just skyrocketed during the pandemic, and I think that was around the time that I started actually looking into research on the impacts of social media and screen time on teens. Uh, and so for today's presentation, Um, I will actually talk a little bit about some of the research that I've done, um, using data from the adolescent Brain Cognitive Development Study to, um, summarize some of the evidence of what we know on screen use trends in teenagers, um, and then associations between screen use and, uh, different health, uh, outcomes, including mental health. Um, and within uh screen use, I'll be looking at screen time. So that's just, You know, the amount of time that people are spending, as well as different aspects of screen use, um, and particularly problematic screen use, um, which I will describe a little bit later, uh, as well as cyberbullying. Um, and then I'll move on to what we know about screen time and physical health outcomes, um, and conclude with, um, some of the recent guidelines and recommendations from professional organizations like the American Academy of Pediatrics, um, and the Surgeon General. So, uh, just to give you an overview of the methods and study design of the Adolescent Brain Cognitive Development Study, um, which is going to be the, um, cohort study that informs, uh, several of the studies that I referenced, um, throughout the talk. The Adolescent Brain Cognitive Development Study, or known, also known as the ABCD study, is the largest long-term study of brain development and child health in the US. Uh, it started in 2016, um, and so the baseline data collection was collected from 2016 to 2018. Um, and there are 21 sites across the US, um, that have recruited a sample of nearly 13,000, um, teenagers who are now followed every year. Um, and there is ongoing data collection right now, um, with at least, um, 10 years of annual, um, Uh, of data collection. And, you know, the ABCD study, um, includes lots of different measures, but they really have great measures on screen use, um, mental health and physical health, um, which I think makes it a nice, uh, large national diverse, uh, sample to better understand potential, uh, screen effects on various health outcomes. Um, so just to summarize what the ABCD study collects, all of the youth or adolescents who are in the ABCD study every year, uh, have to fill out a screen time questionnaire. Um, which as their total time as well as um specific um context, so like if they're using screens at bedtime, to what extent they've experienced cyberbullying, um, and aspects of problematic screen use. Um, their parents are actually also given a survey, um, so the parents report what they think the teens' screen use is, um, and they also report, um, any monitoring or rules that they have in the household related to screens. Uh, and then they're also, uh, uh, for children who opt into, uh, a mobile phone app, there's actually a mobile phone app called EARS or Effortless Assessment of Risk states that, um, is now actually passively collecting data in, in the background. Um, so in terms of the, uh, when these measures were implemented within the study, um, at baseline, uh, the The children were 9 to 10 years old, um, and then as I mentioned, every year there's data collection and with every year that has passed, there are additional measures related to screen use that have been added, um, and then, um, by the time they're 13 or 14, that's when this, um, passive, um, app is, is started. So I'll mostly be reporting on the self-reported data, but very soon, um, the actual app-based data will be, um, released. So first, I just wanted to talk about some of the screen use trends that we found nationally um in the past 5 or so years. Uh, so at baseline of the ABCD study, again, this is among 9 and 10 year olds, the average screen time that was reported was about 4 hours of recreational screen time. So that doesn't count screens for schools or homework. Um, there were some interesting disparities, uh, in the sample, such that, um, black, um, 9 to 10 year olds reported about 5 hours, which was higher than Asian or white, uh, children. On average, boys reported about 0.75 more hours, so about 45 more minutes um than girls. And this Difference was largely driven by video games. Um, and then also there were socioeconomic disparities, um, such that those from lower income households and those, um, whose parents had lower, higher, uh, lower educational attainment, um, were associated with higher screen time overall. Now, this study, uh, you know, collected annual data through the pandemic. And I think one of the most notable findings was that, um, at the beginning of the pandemic, so around May 2020, um, the, the screen time actually doubled in this same cohort. So as I mentioned at um 2016 to 2018, it was about 4 hours. Um, and by the beginning of the pandemic, it was nearly 8 hours, so nearly a doubling of screen time, um, which was largely driven by streaming videos, and movies or television shows. So that was the most common, uh, screen modality, and then followed by video games, um, both multiplayer and single-player video games. Um, and so, based on the, this national cohort, this is the general trend of screen time, um, from 2016 to 2021, which is the most recent data that's been released. Um, and so you can see that there is quite a large upswing, um, you know, not surprisingly during the pandemic. Um, and then there has now been a little bit of a, um, down, down trend, and it'll be interesting to see how, um, those trends continued to 2023. Um, but the fact that screen time in this national, um, national representative study doubled, um, during the pandemic was, uh, you know, potential cause for alarm. And so, um, the Surgeon General in 2021 initially, um, uh, released this advisory on protecting youth mental health and, um, actually cited, um, our study and the ABCD study, um, as one of the, um, Concerns related to social media and screen use uh among teenagers, um, and it was widely covered, uh, you know, in, in, in media. Um, beyond time, so, uh, what I've reported so far is just what the amount of hours and minutes that, um, teenagers report that they're spending on screens. Um, the ABCD study also, um, measures problematic screen use. And so, this can include elements of screen addiction, such as mood modification, tolerance, withdrawal, conflict, and relapse. And so there's a questionnaire, um, that actually gets at some of these problematic issues amongst Uh, screens for 3 different modalities for mobile phones, for social media, and for video games. Um, and so if you just, you can just see here that some of the, um, interesting findings, again, from this national study are that nearly half of teens say that they lose track of how much I'm using my phone. 31% say I interrupt whatever else I'm doing whenever I'm on my phone. 11% say the thought of being without my phone makes me feel distressed. Um, with regards to social media, uh, 22.5% say they spend a lot of time thinking about social media or planning use of social media apps. 18% say they use social media apps so they can forget about my problems. 16% say I've tried to use my, uh, social media apps less, but I can't. And then for video games, uh, 41% say they spend a lot of time thinking about playing video games, 21% say they feel the need to play video games more and more, and 24% say they play video games, they can forget about their problems. Um, so these are just some examples of the problematic screen use, uh, measures, and as you can see, they're quite common even among this early, uh, uh, sample of young adolescents. Again, these are, um, kids who at this time point are like 10 to 14 years old. Um, so overall in the whole sample, there were kind of similar demographic differences, uh, whereas boys reported higher problematic video game usage, girls reported higher problematic social media and mobile phone use, um, and there were also race-ethnic disparities such that Native American, Black, and Latinx adolescents, um, reported higher problematic screen use scores, um, compared to non-Latinx white adolescents. Um, the survey also asked about cyberbullying, which is the willful and repeated harm by a perpetrator to a victim, um, through the use of computers or electronic devices or cell phones. And so in the ABCD study, uh, again among this early sample, so at the point that they're answering this question, they're 11 to 12 years old. Almost 10% had said that they had, um, experienced some sort of, uh, cyberbullying victimization in their lifetime. Um, you know, there are limits to self-report. So while 10% said they had experienced victimization, only 1% reported perpetration, but, uh, you know, there is probably some response bias and that kids may not want to, um, acknowledge that they have been perpetrating. Um, one I think really notable finding was that gay, lesbian, and bisexual adolescents, um, were nearly 3 times more likely to report, uh, cyberbullying victimization compared to heterosexual adolescents. Um, and boys reported higher odds of cyberbullying perpetration, but lower odds of victimization than girls. Um, so these are just some of the trends that we saw in the ABCD study in the first two years. Um, and I next want to look at, um, what we found with regards to screen use and associations with mental health. Um, So, there have been a lot of studies actually that have looked at screen time and particularly social media and mental health, but a vast majority of the studies have been cross-sectional, which means that they measure screen time and mental health at the same single time points. And so it's very hard to get at um causality or like whether it was the chicken or the egg, you know, is it screen time that leads to worse mental health, or is it that kids who already have mental health issues are just using screens more. Um, and so, one of the advantages of this prospective cohort study is that um we do follow the same children over several years. Um, and so we can, um, identify, you know, an exposure like screen time at baseline and then see how their mental health progresses, um, you know, in the following years. And so, uh, I'll be presenting some of the results of the prospective analysis that we've looked at, um, looking at screen time, um, and then subsequent development of mental health issues over the, um, 1st 2 or 3 years of the ABCD study. Um, so the different screen exposures that I'll talk about our first screen time, so again, the hours per day or minutes per day, um, and then I'll look at the problematic screen use across social media, video games, and mobile phones, um, and then finally, cyberbullying. So in the first study, we looked at um baseline screen time, so when these were 9 or 10 years old, um, and then mental health symptoms um that were uh 1-year follow-up and a 2-year follow-up, controlling for uh any mental health symptoms at baseline. Um, so again, these are all like changes or new onset, um, symptoms of mental health, um, in the ABCD study. And so you can see across the board, Um, this is a 110 item questionnaire that they answered, um, based on the child behavior checklist. Um, and it gets at a number of different, um, mental health issues, uh, including depression, anxiety, somatic problems, um, and somatic symptom disorder is characterized by a significant focus on one or more physical symptoms like pain in different locations of the body or weakness or dizziness or nausea. Um, attention deficit, oppositional defiance, and conduct problems. Um, and so you can see that there are significant perspective associations between screen time and all of these mental health symptoms. But I would say that um if you look at The, uh, effect sizes, so like the coefficients, they're all pretty small, it's like 0.09. They range from 0.04 to 0.09. So there is uh an association, but I would say they're relatively weak associations across the board. Um. And this is pretty consistent with uh prior literature that um when you look at meta-analysis of, you know, the thousands of studies that have looked at screen time and depression, um, typically there has been a significant finding, but the um associations are generally pretty weak. And I think this is, um, pretty consistent with that assessment. Um, we also looked particularly at suicidal behaviors, um, in the cohort. So we looked at screen time again among the 9 to 10 or 11 year olds, and then, um, at 2 years later, um, where those kids with more screen. Uh, exposure or time, um, at higher odds or risk of, uh, of reporting a suicidal behavior, um, two years later. Um, and we did also, we did find that across many of the modalities, there was a higher risk of suicide. Um, but again, the effect sizes were generally small, um, and fortunately, in this cohort, the, um, prevalence of suicide two years later was not super high. I think it was less than 2%. Um, so there was also like a relatively rare outcome. Um, I'm just gonna elaborate a little bit on a few of the specific, um, uh, mental health disorders that we, uh, looked at. The first being obsessive compulsive disorder. Um, so, For this analysis, we found that specifically video games and videos um were the two screen modalities that had the strongest associations um with OCD development two years later. Uh, and again, they were relatively weak effect sizes, but, um, those were the only two modalities that, that we found associations with, um, within the 8 different types of screens. Um, and so some of the mechanisms that might explain links between Uh, screen time and OCD or that, at least for video games, um, there might be increased aggressive or stressful intrusions, and that may lead to obsessions. Um, video games may also promote perfectionism, um, that can lead to compulsions, um, and then also excessive engagement with video games can lead to compulsivity and loss of behavioral control. Uh, and then with YouTube videos, uh, specifically, it was interesting that we did find this association with YouTube videos, but not with traditional television. Um, and part of the thought between the link between, um, YouTube videos and OCD, um, is potentially that with YouTube there are algorithms that, um, are developed such that, you know, if you're looking at one type of content, you will likely be recommended very similar videos or contents, um, and that can then lead to compulsive viewing, um, in a way that traditional television viewing, at least on, um. I, uh, may not have have those same associations because it's not feeding you an algorithm. Uh, another, uh, interesting finding, I think, was that we looked at screen associations with disruptive behavior disorders. So, um, this includes conduct disorder and oppositional defiant disorder. Um, and then, uh, the specific modality associated with conduct disorder was social media or social networking. Um, so each hour of social media was associated with a 62% higher prevalence of conduct disorder. Um, and then, particularly over 4 hours of screen time, um, was the threshold that, um, was associated with higher um conduct disorder. And then for oppositional defiant disorder, um, TV movies, video games, texting, and video chat were all associated with oppositional defiant disorder. Um, but again, the effect sizes were, I would say, relatively small, and 4 hours was also the threshold that was found for, um, both conduct and oppositional defiance. Um Some of the potential mechanisms that link screen time to oppositional defiant or conduct disorder, um, are that, uh, you know, On screens, um, adolescents may be exposed to harmful behaviors and or violent behaviors, and that could normalize those behaviors. Um, also on social media, um, there is often anonymized interactions or people can have fake profiles or fake accounts, um, and there can be more like hateful postings, um, without, uh, seeming to have any consequence, especially if they're anonymous sort of interactions. Um, and then, uh, screens can also displace sleep or physical activity, um, which may exacerbate, um, behavioral disruptions, um, and then also can sort of, um, take away from attention or lead to attention problems that can also then exacerbate argumentative or defiant symptoms. So Those were some of the findings on screen time, again, hours per day. Um, and for this particular analysis, the threshold seemed to be more than 4 hours a day was where we started to see signal. Um, but I next wanna move into the problem screen use measures. Um, so, again, these are the questionnaires that try to measure, uh, the screen addictions or problematic use, um, uh, for specifically, um, phones, social media, and video games. Um, and so we looked at some of the same mental health, um, symptoms from that child behavior checklist. Um, and overall, I would say that there were, uh, uh, prospective associations, and oh, I should clarify that this analysis, um, was 1 year follow-up. So this was, um, problem screen use, um, when they were like 11 to 12 years old, and then, um, new onsets, uh, the, uh, mental health symptoms 1 year later, so when they were like 12 to 13. Um, and I would say that overall with some of these associations, the effect sizes were a little bit stronger than with the screen time. Um, but I would say still generally pretty mild to weak. Um, but as you can see, like previously, I think the, um, magnitudes were like on the 0.04 to 0.09 level, and these do seem to be a little bit stronger, but again, generally weak. Um, also interesting that, um, problem screen use was associated with lower sleep duration, um, across the board. Uh. We also looked at uh substance use outcomes, uh, as well as suicide. Um, and so, especially phone use and social media use, uh, problematic use of either of those modalities was associated with higher suicide and, um, higher substance use across the board, um, alcohol, tobacco, marijuana, um, and then also higher sleep disturbance. And so, part of the um mechanism or thought about substance use is that, uh, oftentimes on social media, um, you know, substance use may be glorified by peers or, uh, some studies have actually see it found that like a vast majority of postings related to substance use in teenagers are, you know, seen in a positive light, so it's kind of a cool thing to do. Um, and technically, there are supposed to be rules, um, that Advertisements are not supposed to be geared towards minors for a substance use, but um if you look at some of the advertisements, they clearly are targeting a younger audience. Um So next, when we look at cyberbullying, um, and this is specifically the experience of cyberbullying victimization, we also see, um, that particularly cyberbullying is associated, um, one year later or with depression, with depressive problems, somatic problems, um, and the attention deficit problems, um, as well as suicide and all the substance use, and particularly marijuana had the strongest association. Uh, so next I wanted to move on to what we know about screen use and physical health. Um, so I'll be talking about sleep, um, body mass index, or weight, um, and related to that physical activity, um, and eating behaviors. So, uh, I think I mentioned that the ABC study actually had a specific questionnaire on bedtime screen use. Uh, and I think what was interesting from that was that overall, um, 63% of teens said that they had an electronic device in their bedroom, um, and about 17% said that they were woken up by notifications in the past week. Um, and then the teens and their parents also filled out questionnaires related to their sleep patterns. Um, and overall, 15% of the teens said that they had some trouble falling or staying asleep in the past two weeks. Um, and there's a 25 item sleep disturbance scale, um, and about, and there's a clinical cutoff for that, and about 28% of the teens had met that clinical cutoff for sleep disturbance. Um, when we look at specific screen use behaviors, um, in association with trouble falling or staying asleep and the overall sleep disturbance, um, we did find that having a screen in the bedroom, leaving the ringer or notifications on overnight, um, receiving phone calls or text messages or emails, And then use of the specific modalities of social media, video games, um, or going on chat rooms, or watching or streaming TV videos, uh, were all associated with, um, both trouble falling or staying asleep and, and overall sleep disturbance. Um, next, we want to look at body mass index and weights. Um, we found that, uh, more screen time at baseline, uh, was associated with higher BMI percentile at one year follow-up. Um, and so for every hour of screen use, it was associated with the 0.22% higher percentile, um, one year later. And again, that effect size does not seem large, but if you think about it, um, if you're The average screen exposure was 4 hours per day. So for the average kid, that's 1 BMI percentile higher the next year. Um, and if that compounds over 10 years, that's, um, 10 percentile points higher. And that's, you know, going from the 75th to 85th percentile, you know, puts you into the overweight range or 85th to 95th percentile puts you from overweight to obese range. So I do think that over time and over several hours, particularly if Um, the adolescent is, um, watching more than 4 hours per day, um, that can add up, uh, cumulatively. Um, so some of the mechanisms that are thought to explain um links between screen time and higher BMI include just um being distracted in front of screens. So, um, when kids are eating in front of screens, they may overeat or snack without realizing it cause they're just focused on whatever program is on. Um, they'll be exposed to food advertisements, um, and then also for the most part, watching screens is sedentary, um, and that may also displace or decrease time for physical activity or, um, or, you know, other health benefit behaviors. Um, and I do think that screen time in itself is not necessarily a bad thing, but um if you think that you only have, you know, if you're, if kids are in school for 8 hours a day, they're supposed to be sleeping for 8 or more hours a day, that really only leaves you, you know, 8 or less hours for additional leisure activities. And if 4 or more of that is spent on screens, um, then that's, you know, time that isn't spent, you know. Doing sports or or other um activities. Um, one thing that I thought was interesting is, in general, we do know that, uh, you know, screen time can be associated with higher weight, as we mentioned, and in general, physical activity can be beneficial for that. Um, We actually looked at combinations of different categories of screen, um, screen time and physical activity as measured by Fitbit. Actually, the, um, children also, um, have Fitbits, um, and so it measures their steps per day. And so one thing that we thought was interesting was we looked at different Combinations of screen and steps. Um, and so, uh, what the main finding here is that, um, and then the outcome here is BMI percentile, so like obesity risk. Um, but one thing that I think was interesting was that for the kids who were in the high screen time category, so if they had more than 8 hours of screen time per day, it didn't actually matter what their steps were, if they had high, medium, or low steps, they were at higher risk of higher BMI or obesity. Um, but if you were sort of in the middle ranges, so if you had 4 to 8 hours of screen time, then having, um, low steps compared to high steps, um, and high steps here is more than 12,000 steps per day, that still can have diff, um, you know, protection for obesity or, or BMI and same with the low screen use group. Um, but when you're at the 8 hour or above screen level, it actually doesn't matter how many steps you have, it doesn't seem to compensate for, um, for that, at least in terms of obesity risk. Um We also found a link to this that screen time was associated with binge eating disorder one year later. So, uh, especially with social media, was associated with 62% higher odds of binge eating disorder. Um, texting was associated with 40% higher, uh, watching TV was 39% higher odds, um, and then total screen time was associated with 11% higher odds. Uh, and so I think that this is also potentially implicated in some of the weight, um, changes that we, uh, mentioned with some of the same mechanisms. Um, and While that study was specifically focused on binge eating disorder, I also wanted to just call out some of the potential linkages between social media in particular and eating disorders in general. Um, and so social media may lead to constant comparisons to unattainable body ideals, um, you know, there's all types of filters, editing, curation, um, and selection. Bias, by which I mean, um, you know, oftentimes the picture or video that a teen posts is like the best or most flattering out of maybe hundreds of photos that they've, um, that they've taken. And so it can lead to a distorted sense of reality, um, that, you know, everybody on social media is like portraying their best life, but in fact, it's not really an accurate representation of reality. Um, and then I think one interesting, uh, difference between social media and the traditional media like television, um, is that, you know, on social media, teens actually are Producing content. So there's a pressure to display their own bodies to gain likes or followers or interact, whereas there's that not, not that same pressure on television, you know, television is more passive. Um, and so I do think that this, uh, new pressure of teens having to create their own content, um, has also, um, created Uh, you know, some of these increased risks or pressures. Um, and then, uh, you know, unfortunately, there is also a lot of eating disorder and weight loss content on social media, um, and, and many platforms. And so, uh, because of the algorithms, if you, uh, look at one type of weight loss thing, then the algorithm often bombards you with a lot of similar content. Um, I also just wanted to point out that, you know, a lot of the media attention on links between social media and eating disorders has really focused on teenage girls, um, and, you know, the Facebook files that were, uh, released, um, through the Facebook whistleblower, Francis Haugen really focused on, um, Teen girls impacts. Um, but I, uh, actually, my specific area of research focuses, um, on eating disorders in boys and men. Um, and so I actually wrote right after the Facebook files were released, um, this op ed in the San Francisco Chronicle, sort of summarizing what we know about social media and boys. Uh, and so, actually, even though I, I think boys are under-recognized in terms of, uh, eating and body image concerns, um, actually, uh, studies on social media content of boys and young men have found that actually boys are more likely than girls to allow for public followings. Um, male selfies are more likely to be full body photos that show their muscles, not just their faces. Um, and the majority of male body image-related Instagram posts depict muscularity and leanness. Um, and the few studies that have looked at social media and behaviors in boys have found that Instagram use, um, in boys and men is associated with meal skipping, disordered eating, muscle dissatisfaction, and Use of anabolic steroids. So, uh, you know, although the initial Facebook files, um, that were released by the Wall Street Journal, um, focused on impacts on teenage girls, they did subsequently do a follow-up on, uh, links to teenage boys. Um, and so I contributed to that article as, um, as I, I think it's important, uh, for primary care providers to just recognize that eating disorders and body concerns, um, affect people of all genders. So in this last section, I just wanted to summarize um some recent guidance, um, uh, particularly that clinicians and primary care providers can um provide for parents and teenagers, um, about how to navigate this, uh, you know, the current screen environments. And I will say that, um, the There is still a lot of room for improvements, but just in 2023, the uh Surgeon General and the American Psychological Association have released for the first time specific um guidance for adolescent social media. Um, so some of this is actually very new, um, which is I think definitely important and a step in the right direction. Um, but I'm gonna first actually summarize the American Academy of Pediatrics media use recommendations. So this is for, uh, screen use in general. It's not specific to social media. Um, and I will just note that, um, you know, this was last updated in 2016, so it is still a little bit, um, dated, but these are the most recent guidelines. They have not, um, updated them formally yet. Um, so, just, um, because I know we have primary care and pediatricians, I wanted to include the recommendations for all the different age groups. Um, so actually for under 18 to 24 months, um, they recommend avoiding digital media use altogether except for video chatting. So if you're like FaceTiming or video chatting with a grandparent or uh um parent or other adults, um, you know, that may be OK cause that could still promote, um, you know, communication and interaction, um, but other types of media use should generally be avoided. Um, and then starting at 18 to 24 months, um, if parents want to introduce digital media, they recommend just Focusing on high quality educational programming, um, and then watching that together with your child, so not, um, letting the child watch it by themselves and making sure it is kind of highly curated educational content like PBS Kids or, or Sesame Street. Um, then, from 2 to 5 years of age, the recommendation is to limit screen use to 1 hour per day of high quality programming, again, co-viewing with children, um, and then trying to help them understand, see, to see what they are seeing. Um, and then above 5, so 5 to 18 years old, um, previously, the recommendation was to limit to less than 2 hours of screen time a day, and I think, um, in 2016, they actually replaced that. And so there is no formal number, um, uh, because I think the American Academy of Pediatrics recognizes that it's not a one size fits all solution, and I think there's a lot of variability between 5 to 18 years old. So the current guidance is um that families should actually make a more individualized family media use plan. Um, and so, um, if you go to the AAP website, there is a resource um that you can refer people to that that's interactive that Um, that can have families, um, check out each of these different aspects of the plan. Uh, but in general, the plan involves regular discussions with family, um, so just making sure that you communicate about, um, you know, what makes sense for your family, what devices you have at the house, and, um, what general rules are, um, people are able to follow. Um, and then there's a section on potentially having screen-free times. So some, um, High, uh, you know, important times that you might consider having screen-free would be like before bedtime. So considering, you know, turning off devices an hour before bedtime because Um, as we looked at earlier, there are impacts on sleep. Um, and then also potentially, um, having screen-free times around family meals so that, um, you know, people can focus on interactions and, um, eating, um, and then that can also maybe, uh, you know, avoid the distracted eating and overeating, um, and some of the eating disorder concerns. Um, there's also a section on potentially having screen-free zones. Um, so that could be like limiting screen use to public spaces or having, um, you know, televisions or other devices like in the living room or kitchen or family room, um, as opposed to bathrooms or bedrooms, so that, you know, parents can observe more easily what their kids are looking at. Um, and so maybe avoiding more of the violent or explicit content, um, that might happen in more private areas. Um, and then, uh, just understanding that, you know, there is a balance that should be, that needs to be struck, and as we mentioned, if there's only a few hours a day of leisure time, um, you know, just reflecting on how much of that time you want to be in front of screens versus, you know, socializing with people face to face or doing physical activity or other activities. Um, and then also having conversations about digital privacy and safety, um, especially for minors. Um, so I did briefly just want to mention that we, uh, there is a parent media practices questionnaire in the ABCD study, um, and so we did actually look at how that related to problematic screen use, um, and we did find that in general, um, parents, um, modeled greater screen use, so they like, um, spent more time in front of screens, in front of their children. Um, that was associated with, um, more problematic screen use. Um, and then also having screens around meals and, and bedtime was associated with more problematic use. So that, um, sort of supports this idea of having screen-free, um, times around meals and, and before bedtime. Um, and then, uh, Interestingly, um, parental control of of screen use, like, so having more trying to implement more controls was actually associated with more video game use, um, you know, and it, I think that's also variable in terms of like the age of the teen, but sometimes, um, you know, having too many controls can can backfire. Um, we also found that more monitoring of screen use, though, was associated with lower problematic social media and mobile phone use. Um, and then actually having more restrictions was also associated with lower problematic, um, screen use across the three modalities. Um, so those were the American Academy of Pediatric Screening guidelines, and I, as I mentioned, they're not specific to social media. Um, but, uh, earlier this year in May 2023, the Surgeon General, um, issued, uh, Specific, um, advisory on social media and youth mental health. And so this advisory actually did have um some additional guidance. Um, and so this is also a good resource, um, uh, and they divide their guidance into what parents and caregivers to do. Um, and a lot of this does reflect the AP guidance, but, um, you know, first, potentially having tech-free zones. Um, having a family media plan that was, you know, covered by the AAP, um, they've also added to like report cyberbullying and online abuse and exploitation, um, trying to teach kids about technology and empowering them to be responsible online participants. Um, you know, modeling responsible, responsible social media behavior. Um, so as I mentioned in our study, we did find that parent modeling was a big predictor of kids' screen use, um, and then also working with other parents to establish shared practices, um, and support programs and policies around social media use. Um, and then in the Surgeon General's advisory, they have a section on what kids and adolescents can do. Um, so, you know, reach out for help as needed, um, create boundaries to help balance online and offline activities, um, develop protective strategies and healthy practices, um, advising them to be cautious about what they share, um, and enable, you know, appropriate privacy and protection for themselves and others. Um, to report online harassment or abuse, and also, you know, not, not to take part in perpetrating online harassment or abuse. Um, the Surgeon General's advisory is a little bit more, um, general, but actually just a few weeks before, uh, the American Psychological Association, um, did have, uh, a set of, uh, uh, guidelines that they put out, um, also. Um, and so, uh, I also just, these are, there are 10 of them, um, and so I just wanted to highlight some of these too because they get, um, a little bit into, into more detail. Um, and so the first recommendation is promoting the use of social media that encourages socialization with peers, companionship, and support. And I think one of the things that the, uh, APA guidelines acknowledge is that not all screen use is bad, um, you know, there are beneficial uses and so it really is about trying to, you know, reap the benefits while minimizing the risks. So, you know, there are, if you are gonna use social media, you know, trying to do it in a way that actually encourages socialization and supports. Um, and then, you know, potentially, um, adapting the functionality and use of select social media sites, um, to be tailored to children and their, um, you know, developmental abilities or age, um, so that's, you know, developmentally appropriate, um, for like younger teens versus older teens. Um. And then particularly for the younger um adolescents, so 10 to 14 years old, uh, you know, potentially having uh coaching for safe use. I think one thing I will note is that technically, um, if you're under 13, you're not supposed to be able to have a social media account. Um, most, um, uh, most platforms require that you be at least 13 years of age, but as of now, there's not really strict age verification. So, um, in the ABCD study, we found that like 20, 25% of Um, the under 13 year olds had accounts, they just lied about their age. So I think this recommendation acknowledges that because there's not robust age verification, um, you know, anyone can have a social media account as of now. Um, but so that for the younger, um, adolescents to really make sure that they have more coaching and guidance, um, and then Uh, really trying to limit the harmful material or contents like illegal activities, self-harm, eating disorders. Um, and as I mentioned, once I think one gets exposed to some of those things, potentially because of algorithms, um, it can really be a vicious cycle. Um, so really trying to avoid, um, getting into those cycles. Um This is, on a related note, limiting a child's access to any form of hateful content like discriminatory social media accounts. Um. Again, that's to try to avoid cyberbullying. Um, 6 is a regular screening for harmful social media use, so it could be like the um problematic social media questionnaire that we had mentioned, um, uh, but yeah, looking out for sort of the red flags of social media use. Um, 7 is trying to prevent, uh, social media usage that worsens sleep or physical activity or displaces those. Um, 8 is, uh, trying to limit social media that encourages social comparison. Again, like that could lead to eating disorders or body dissatisfaction. Um, 9 is that before they reach the age, uh, where they're on social media, um, they should be trained on it and on safety so that they can be, um, digitally literate and savvy. Um, and then 10 is just promoting, um, investments and research on adolescent social media. Um, so I think the APA guidelines have a little bit more detail than, uh, than the AP or Surgeon General. And again, these are all new from the last year. Um, I'll just wrap up by saying that the Surgeon General also had a section on what policymakers can do, um, so like strengthening protections, um, to ensure greater safety, um, ensuring tech, tech companies share data relevant to the health impact of their platforms, um, supporting development, implementation, and evaluation of digital and media literacy. Um, having more funding for research, um, and engaging with international partners. I will also just note that in the US right now, there's a deluge of state and federal policies related to social media. So Utah and several states have actually now, um, passed laws that will, um, require that actually parents be Um, in order for a child to there to get on a social media account, they actually have to have some sort of verification from a parent or guardian. Um, you know, the details of that are, are still being worked out, but it's just to say that there will be more onus on parents, um, in certain states, um, to actually monitor social media use now. Um, and there will, um, need to be more robust age verification, and there are similar federal, um, proposals, uh, legislation that are being discussed now. Um, and then finally, uh, you know, for what tech companies can do, uh, you know, conducting and facilitating transparent assessments and independent assessments, um, sharing data, um, designing, developing, and evaluating platforms and products that foster safe and healthy online environments, prioritizing user safety, um, and then having effective and timely systems to process and adjudicate requests or complaints from young people or families or educators. Um, so, you know, I think also being in the Bay Area, um, you know, we do have a lot of, um, the tech companies, right, as our neighbors. Um, so, just in terms of ABCD study research, I've mostly focused on cardiovascular disease risk and mental health. Um, and the study, as I mentioned, is ongoing for at least 10 years. Um, so right now, we've really focused on the early, early adolescent period, um, but I'm planning on continuing the studies that look, um, through middle and late adolescence, um, which are actually times in which we expect the prevalence of social media use to rise. Um, and so, the overall goal of our research is to continue to inform these individualized guidance, um, and then have, you know, age-specific, um, considerations for guidance, particularly in the adolescent age groups, um, and then also potentially to have guidance for specific modalities and platforms and content. Um, so I just would like to thank, uh, our lab group at UCSF, uh, um, and particularly Jackie He and Anthony Kung who helped with these slides, um, and of course, the adolescent brain cognitive Development study participants and investigators, um, and, uh, funders who have supported this research. Um, these are the references for some of the studies, um, that we've published in the ABCD study that were referenced. Uh, and then these are the guidelines that, um, have good resources that I mentioned, including the American Psychological Association, the Surgeon General, and, and then there's two guidelines from the American Academy of Pediatrics. Um, the first one is on, um, the 5 to 18 year olds, and then the second one is on the under 5-year-olds. Um, so with that, I Uh, I'm happy to pause and take questions.
