Young adults, Problematic Online Behaviors, and 21st Century Communications Technology. Ann Hackman, MD Liwei Hua, MD, PhD Tristan Gorrindo, MD

1. Young Adults, Problematic Online
Behaviors, and 21st Century
Communications Technology
Ann Hackman, M.D.
University of Maryland (co-chair)
Liwei L. Hua, M.D., Ph.D.
University of Michigan (co-chair)
Tristan Gorrindo, M.D.
Massachusetts General Hospital

2. Outline
• Examine changes in communications technology
over the past decade, with consideration of
psychiatric literature (Dr. Hackman)
• Consider teens/young adults, their use of
communications technology, and characteristics
unique to these age groups (Dr. Hua)
• Discuss application of DBT/CBT skills to the
treatment of problematic internet behaviors (Dr.
Gorrindo)
• Review case vignettes

3. Objectives
• Become familiar with current trends in use of
communications technology in teens/young
adults
• Consider approaches in evaluating this patient
population when they present with or engage in
risky or problematic use of technology
• Discuss application of CBT and recovery-
oriented skills to the treatment of problematic
technology use
• Contemplate the role of this technology in our
own youth patient population

4. YOUNG ADULTS, PROBLEMATIC
ONLINE BEHAVIORS & 21ST
CENTURY COMMUNICATION
TECHNOLOGY
Ann Hackman M.D.

5. DISCLOSURES
 I have no conflicts of interest or disclosures.

6. 21ST CENTURY COMMUNICATIONS
TECHNOLOGY
 The concept of e-mail came about in the 1970s and
it was possible to e-mail from an IBM PC in the mid
1980s
 Internet with its origins in the 1980s and
commercialization in the 1990s
 Text messaging first occurred in the early 1990s; by
2007, 74% of all mobile phone users worldwide (2.4
billion out of 3.3 billion users) were texting

7. TECHNOLOGY CONTINUED
 Social media began in 1997. Facebook
launched in February 2004 and as of July
2011 had more than 800 million active users
 Skype was started in 2003. By April 2006,
the number of registered users reached 100
million
 Twitter launched in July of 2006 and had
200 million users as of 2011 generating over
200 million tweets and handling over 1.6
billion search queries per day

8. IMPACT ON PEOPLE WITH SERIOUS
MENTAL ILLNESS
 Adults with serious mental illness have been
left behind in the explosion of information
technology. A 2009 article (Borzekowski et al)
indicates that from a sample of 100 adults in
CMHC treatment (79% > 40 years old)
- only about 1/3 had cell phones or internet
access
- less than 30% had a computer in the
home

9. IN ADOLESCENTS AND YOUNG ADULTS
 According to the US Census on Internet Access
and Computing
 By 2003, 55% of American homes had internet access;
95% of all households earning >$100,000
 By 2003, 76% of all school aged children in the US had
access to a home computer and 83% had used a PC at
school
(http://maisonbisson.com/blog/post/11088/us-census-on-internet-access-
and-computing/ accessed 10/14/11)

10. MORE ADOLESCENTS AND YOUNG
ADULTS
 According to Harris Interactive poll of 2089
teens in July of 2008
 4 out of 5 (17 million nationwide) teens carry a
“wireless device”
 57% view their cell phone as key to their social
life
 52% view it as a form of entertainment
 42% report that they can text with their eyes
closed
(http://www.marketingcharts.com/interactive/cell-phones-key-to-
teens-social-lives-47-can-text-with-eyes-closed/ accessed
10/14/11)

11. MORE ADOLESCENTS AND YOUNG
ADULTS
 Asof 2009, according to a study of
eighteen year olds (Archives of Pediatrics and Adolescent
Medicine; Moreno MA et al 2009)
 90% of adolescents had internet access and
about half used social networking sites
 Of 500 who used social networking sites
 270 (54.0%) revealed risk behavior information
 120 (24.0%) referenced sexual behaviors
 205 (41.0%) referenced substance use
 72 (14.4)% referenced violence

12. But people have been communicating
forever….. Where are the problems?
 21st century communication technology is faster,
bigger, more access, easier to pass on
 According to Facebook, the average user has 135
“friends”. (I have 168 “friends”. Dr. Hua has 188
“friends”. My 17 year old has 603 “friends” and one
of her acquaintances has 3007 “friends”).
 Tweespeed indicates an average of more than
10000 tweets per minute. It’s not clear how many
of those are being “re-tweeted”
 When adolescents post something or have
something posted about them, the information can
be conveyed instantly to hundreds of people

13. Recent Headlines
 “Rutgers Student Commits Suicide After Sex Tape”
 “Internet addiction linked to ADHD, depression in
teens”
 “Flash Mob Takes Violent Turn In Philadelphia”
 “Cyberbullying Continues After Teen’s Death”
 “Girl Texts Boy Her Naked Photo, Boy Gets
Arrested, Held in Juvenile Detention”

14. Some clinical examples of problems
 19 year old woman with new onset schizophrenia
(symptoms including auditory hallucinations) and a
recent hospitalization
 Socially isolated in terms of in-person interactions but
using the internet and social media
 Making connections with people who are engaged in
activities which may place her at risk
 Conveying information about her illness which may
render her more vulnerable

15. More clinical examples
 21 year old man with schizophrenia paranoid type
who, following a hospitalization, has quit school and
spends 8-12 hours a day engaged in the on-line
game “World of Warcraft”
 18 year old man with schizoaffective disorder
whose symptoms have led to a year including an
arrest and 56 days in jail as well as three extended
psychiatric hospitalizations. He reports the worst
part of this experience was “I could not have my cell
phone”

16. More clinical examples
 23 year old man with psychotic illness and religious
delusions, supporting his belief that the world is
coming to an end by spending considerable time on
end-of-days internet sites
 18 year old arrested for stalking after becoming
increasingly convinced that a high school classmate
whom he had “friended” on Facebook was his
soulmate. Spent hours on her site, checking
multiple times a day then began making unwanted
calls and visits. Pointed to information from her
social media site as evidence of their relationship.

17. Adolescents and
Communications Technology
Liwei L. Hua, M.D., Ph.D.
Clinical Assistant Professor
University of Michigan
Department of Psychiatry, Child and Adolescent Section

18. Disclosures
• I have no conflicts of interest or disclosures.

19. Outline
• Present benefits and risks of use of
communications media
• Examine trends in technology use

20. A Task of Adolescence
• Social and emotional developmental task:
– Emotional separation from parents
– Further development of personal/peer group
identities
– Exploration of sexuality and romantic
relationships
• Dilemma:
– With the availability of “new” technology, how
do we allow teens to explore their sexuality and
yet keep them safe?

21. Benefits of Communications Technology
• Socialization and communication
– Connecting with friends and family
– Chance to express thoughts/feelings that they might be
uncomfortable expressing in person
– Broadening of friendship base/interests
• Education/information
– Enhanced creativity (blogs, podcasts)
– Anonymity
– Accessing health resources (information on medical
illnesses, STIs, signs of mental illness)

22. Risks of Communications
Technology
• Cyberbullying
• Sexting
• “Facebook depression”
• Internet addiction
• Difficulty understanding consequences due to
“safety” of anonymity
• Subject to sexual predators
• Physical health: obesity, metabolic syndrome

23. Normal Behavior?
• Kaiser Family Foundation survey of > 2000
3rd to 12th graders (2010):
– Spending over 7.5 hrs/day on phone, computer,
television
– Additional 1.5 hrs/day text messaging (ave 118
texts/day)
– Additional 30 minutes talking on phone

24. Normal Behavior? Internet
• Estimated 93% of U.S. teens (12-17 y.o.) regularly use
the internet (Pew Internet and American Life report in
2009)
• 34% with some kind of exposure to cybersex (wanted or
unwanted) (Wolak et al 2007)
• 73% of American teens online use social networking sites
(as opposed to 65% in 2008 and 55% in 2006) (Pew)
• > 50% log on to social media site(s) at least once daily;
22% of teens log on > 10 times/day (Common Sense
Media 2009).
• 31% of online teens search health, dieting, physical
fitness info; 17% search drug use and sexual health
information (Pew)

25. Technology Teens Use
Percentage
Blog 14%
Webcam 22%
Game system with chat 27%
Instant Messaging 60%
Social Networking Profile 72%
Cell phone 73%
Email 91%
0 20 40 60 80 100
Adapted from Cox Communications Internet and Wireless Safety Survey 2009

26. Online Activities of Teens in Past
Month
Percentage
Blogged 12%
Webcam use 13%
Talked to someone in a chat room 20%
Shopped online 31%
Played online video game 47%
Sent IM 52%
Updated online profile 58%
Posted or viewed photos/videos 63%
Looked at someone's profile 67%
Research for school 73%
Emailed 80%
0 10 20 30 40 50 60 70 80 90
Adapted from Cox Communications Internet and Wireless Safety Survey 2009

27. Normal Behavior? Cell phones
• 75% of teens (12-17) have cell phones: 25% use for social
media; 54% use for texting (Pew Internet and American
Life Project 2009)
• Almost all teens have texted; of the 54% of daily texters,
1/3 send > 100 text/day (Pew)
• 20% of teens and young adults have engaged in sexting
(Sex and Tech survey)
• 2/3 teen texters say they are more likely to text than talk
on cell phone (Pew)
• Unknown what percentage of these teens have comorbid
psychiatric disorders

28. Critical Questions
• When patients present with misuse/excessive
use of this technology, given the widespread
use, how can clinicians help:
– Evaluate and formulate using an open-minded
approach that does not necessarily pathologize
the behavior?
– Keep this population safe and help guide their use
of this technology?
– Intervene if there are underlying psychiatric
conditions that are driving their behavior?

29. Ideas for clinicians
TRISTAN GORRINDO, MD
Department of Psychiatry
Division of Child and Adolescent Psychiatry
Massachusetts General Hospital
Harvard Medical School

30. Dr Gorrindo has no conflicts of interest to disclose as related to the current
presentation.
30 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

31. Definitions
Screening
Treatment
31 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

34. Don’t forget to look for the Excessive
usual suspects: Usage
ADHD
Social Phobia
Depression Impulse
Mania Control
OCD
Functional
Impairment
34 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

36. 1. Stay on-line longer than intended
2. Neglect house-hold chores to stay on-line
Never Sometimes Always
3. Form new relationships with fellow on-line users
4. Others complain about how long you stay on-line
5. Grades or school work suffer because of the amount of time spent on-line
6. Check your email before something else you need to do
7. Job performance or productivity suffer because of the internet
8. Become defensive or secretive about when anyone else asks you what you do on-line
9. Block out disturbing thoughts about your life with soothing thoughts of the internet
10. Find yourself anticipating when you will go online again Presumed
11. Do you fear that life without the internet would be boring, empty, and joyless
PIB Score
12. Snap, yell, or act annoyed if someone bothers you while you are online
13. Lose sleep due to late night logins range
14. Feel preoccupied with the internet when off-line or fantasize about being online
15. Find yourself saying “just a few more minutes” when online
16. Try to cut-down the amount of time you spend online and fail
?
17. Hide how long you have been online
18. Choose to spend more time online over going out with others
19. Feel depressed, moody, or nervous when off-line, which goes away when you are back online
20. Prefer the excitement of the internet to intimacy with your boyfriend or girlfriend
36 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL
Source: Modified from Young’s Internet Addition Test in Widyanto, Cyberpsychology & Behavior, 2004:7:4:443

37. In this first section, we are interested in learning about how your Thoughts and Urges to use the internet impact your life.
1. I spend _____ (pick
one) thinking about
T 0 hr/day 0-1 hr/day 1-3 hr/day 3-8 hr/day >8 hrs/day
using the
h internet/technology
o 2. Interference due to None Mild
Definite but Substantial
Incapacitating
manageable Impairment
u 3. Distress associated Moderate but Near constant,
g with
None Little
manageable
Severe
disabling
h 4. Resistance Always Much Completely
Some resistance Often yields
t associated with resists resistance yields
s 5. Degree of control Complete
Much control Some control Little control No control
over control
Now we are interested in learning about how Internet -related Behaviors impact your life.
B 1. Time occupied by 0 hr/day 0-1 hr/day 1-3 hr/day 3-8 hr/day >8 hrs/day
e 2. Interference due to None Mild Definite but Substantial Incapacitating
manageable Impairment
h
3. Distress associated None Little Moderate but Severe Near constant,
a with manageable disabling
v 4. Resistance Always Much Some resistance Often yields Completely
i associated with resists resistance yields
o 5. Degree of control Complete Much control Some control Little control No control
over control
r
s
37 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL
Source: Modified from Goodman, Arch Gen Psychiatry, 1989; 46:1006-1011

38.  Asks parents to rate:
 The ways in which PIB impact various
activities of teen’s daily life
 The impact on parents work/social
life/ability to parent
 Various measures of family
functioning
38 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL
Source: Modified from Stewart’s OCD Family Function Scale

40.  Treatments to date
 Medication
▪ SSRI, stimulants, and others
 CBT
▪ Adults 12 session protocol
 Residential Treatment
 Family therapy
▪ Study of Families in Taiwan showed high adolescent-
parent conflict
40 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

42. Teens
• Complicate their thinking
• Practice Skills
• Feedback from peers
42 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

43. Basic Tenants Rational
of Mind
Dialectic Emotional
Mind
Behavioral Wise
Therapy Mind
(DBT)
43 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL
Source: Linehan, The American Journal on Addictions, 8: 279–292.

44. W •Wide-audience
A •Affect
I •Intent
T •Today?
44 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

45. Parents are here Kids are here
DIGITAL DIVIDE

46. Parents
• Education
• Develop ambivalent stance
• Facilitated conversation
46 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

47. Multi-layered Approach
Teen Skills
Parent
Education
Homework
Dialogue
47 MASSACHUSETTS GENERAL HOSPITAL
HARVARD MEDICAL SCHOOL

48. 1 "Online struggles"
Teen Reviewing problematic internet behaviors
"What are they doing?"
2 Parent Describing internet behaviors of the modern teen
"What's a friend?"
Teen
3a 3b
"Social Networking Demystified"
Parent
"Public vs Private"
Teen
4a 4b
"Understanding Privacy Settings"
Parent
"How much is too much?"
Teen
5a 5b "Setting appropriate media rules"
Parent
6 "Staying happy on- and off-line"
Teen
"Moving Ahead"
48 MASSACHUSETTS GENERAL HOSPITAL
7 Teen and Parents Partnership Agreement and Final Questions
HARVARD MEDICAL SCHOOL

49. Parents are here Kids are here
DIGITAL DIVIDE

50. Clinicians are here Kids are here
DIGITAL DIVIDE

51. Clinicians are here Kids are here
Psychotherapy
Parent Empowerment
Complicate Thinking
Screening for other disorders

53. Case 1
• 17 y.o. WM with no formal psychiatric
history
• Referred to psychiatric outpatient clinic by
adoptive mother due to concerning Facebook
posts, such as “Game over”
• Motivation: “sad”, “wanted some attention”

54. Case 2
• 20 y.o. WF, in long-term outpatient
psychiatric care, no history of
hospitalizations, for Tourette’s disorder and
mood disorder, NOS
• When asked about sexting, she said,
“Everyone does it.”
• When asked about consequences, she said,
“Oh, you would only send pictures if you
trusted the person.”

55. Case 3
• 18 y.o. WM, recently diagnosed with bipolar
disorder
• Mood stabilized, compliant with and doing
well on medication
• Active in school tennis and with church
• Mom concerned he is less social with friends
“live”; instead, stays up late chatting with
friends on Facebook/ChatRoulette.

56. Case 4
• 14 y.o. WF with no prior psychiatric history,
referred to Child Psychiatry C/L service after
acetaminophen overdose
• Reported feeling more “depressed” after moving to
current location with family two years ago, difficulty
making friends
• Charged a year ago with child pornography after
posting a “sext” message her friend had forwarded
to her of a naked teenage boy on her MySpace page,
thinking it would be “funny”
• Recent arrest for attempted theft of alcohol from a
store with same friend, prompting suicide attempt

57. Case 5
• 14 y.o. WF hospitalized after father discovered her
exposing herself online
• “Very depressed” since mother’s death several years ago
• Father remarried, had less time with her
• Responsible for caring for younger sibling, which limited
time with friends; overweight with poor self-esteem;
“lonely” and “stressed out”
• Discovered an Internet chat room where men talked to
her via WebCam
• Upon request, took off clothing; felt “beautiful” and
“loved”

58. Case 6
• 13 y.o. WF, adopted at 7 y.o., with history of
ADHD, PTSD, mood disorder, and 3
psychiatric hospitalizations in last 3 months
• Mood improved after last hospitalization a
month ago
• Acutely destabilized after birth mother
discovered her on Facebook and tried to
make contact with her, triggering renewed
feelings of abandonment and resentment

59. Case 7
• 16 y.o. WF presents to psychiatric ED with
superficial scratches to forearm after
argument with friend
• Reports that her friend texted her that she
was going to see a movie with another friend
• Patient felt excluded and accused her friend
of “always leaving her out”
• Mom reports patient has a history of mis-
interpreting social cues

60. TAKE HOME POINTS

61. Take home points
• Physicians need to ask about use of
technology, given the widespread use among
teens/young adults
• Not all that seems excessive or pathological
is; developmental norms must be considered.
• These issues can be addressed/treated with
skills that clinicians already have, although
they may need to be applied more creatively.