PermanenteDocs Chat on growing up with social media

With up to 95% of young people ages 13 to 17 using social media, the U.S. Surgeon General recently issued an advisory warning of the potential health effects of social media platforms on adolescents. Several leading medical organizations, including the American Medical Association and American Academy of Pediatrics, joined the surgeon general in expressing concern over social media and children. In a generation of TikTok, Instagram, and Facebook, what advice can physicians provide to parents concerned about their children’s screen time and activities on social media. Watch this recent PermanenteDocs Chat as host Alex McDonald, MD, talks with child/adolescent psychiatrist Asha Patton-Smith, MD.

Guest

• Asha Patton-Smith, MD, psychiatrist, Mid-Atlantic Permanente Medical Group.

Watch the full replay video or listen to the podcast above.

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello and good morning, everyone. Welcome to the PermanenteDocs Chat. Thanks so much for joining, wherever you may be watching or listening. My name is Alex McDonald, I’m your host. I practice family and sports medicine here in Fontana, California, as part of the Southern California Permanente Medical Group. Today, I’m looking forward to this chat in particular. We’ll be discussing the convergence of two of my favorite topics: social media and pediatrics. Our guest today is Dr. Asha Patton-Smith, who is a child and adolescent psychiatrist at the Mid-Atlantic Permanente Medical Group. Dr. Patton-Smith, thank you so much for joining us today.

Asha Patton-Smith, MD: Thank you so much for having me. It’s great to see you again.

AM: Likewise. That’s true; you’re a repeat guest here. Thanks for coming back. I tell people, if you join us once on the podcast, you’re brave. If you join us twice, you’re very brave. So, thanks for coming back. If you’re listening live or you’re tuning in on the webinar here, please make sure you drop your questions in the Q&A. We’ll get to as many as we can, but we only have about 20 minutes for these chats. So, get your questions in early, and we’ll try to get to as many as we can. So again, let’s just jump right in. Dr. Patton-Smith, in your own words, tell us who you are and what you do.

APS: I am a child, adolescent and adult psychiatrist. I’m here in Mid-Atlantic. Currently, I’m in my office here in Falls Church, Virginia, and I’ve been with MAPMG since 2006.

AM: Great, sounds good. And you wear a couple of different hats there at MAPMG.

APS: Yeah, Mid-Atlantic Permanente Medical Group. I do a few things. I’m the regional medical director of inpatient psychiatry, assistant chief of psychiatry for NOVA [Northern Virginia]. And I do a lot of media throughout, talking about children, adolescents, and parents — some of your favorite topics and some of mine as well.

AM: Absolutely. Well, let’s jump into the topic at hand. In May, the U.S. Surgeon General issued a new advisory regarding the health effects of social media on youth mental health. What are your thoughts on this? And do you think this new advisory is really going to make a difference in terms of the work that you do, and that I do, and that all of our parents do?

APS: You know, social media in general and screen time in general is always a hot topic. And what this advisory at least brought for some of my patients and families is, “Hey, this is something we need to seriously consider.” So, when I’m in appointments, I say, “Hey, what’s happening with your social media time? How are you doing with your screen time?” And, you know, parents don’t want to rock the boat. Kids are locked into doing what they want to do. This has kind of helped increase the intensity of this is something that we need to talk about.

AM: Yeah, I remember when I was in medical school there wasn’t really much discussion. You talked about screening for bullying at school and substance use and those types of things. But really, in the last several years again, as many of you know, I practice general pediatrics as well as part of my practice in family medicine. And I’ve started integrating the question of, “Do you have social media? Do you use social media? What apps are you using?” “Are you experiencing online bullying?” “How often are you using it?” All these questions open up a Pandora’s box, if you will, of different issues which may come up with our individual patients.

APS: Yes, it can. And so, one of the things that we need to look at is the amount of time kids are using social media, the content, what are they looking at, as you’re talking about. And then, what is it removing them from? Are they having issues with getting to sleep because they’re on social media late at night? Are they not having in any physical activity because they’re constantly on their phones, computers, or iPads? Are they not eating as well because they’re always doing social media stuff and are there some things and content that are preventing them from feeling that they can. These are the 3 major things that I talk to my kids about. So, not just, “Hey, you can’t use it,” or “What are you using?” But how much are you using? What are you looking at, as you said? And what is this removing you from? Do you ever go outside? Do you ever socialize in person with people your age? I mean, these are all things that you wouldn’t think you had to ask. And yes, in my training in medical school and in residency and fellowship, we didn’t. But this is where we are now. It’s just really important to check in.

AM: It makes me think about a time I was at a big family gathering, pre-COVID, and I walked into one of the rooms. Many of the teens and tweens were in this room just sitting on their phones. And I was like, “Guys, what are you doing? Let’s go. Come on. You’re supposed to be at a party.” And they’re like, “Well, we’re talking to each other,” like they’re all just texting each other in the same room. And I was like, “Well, that’s certainly an odd way to communicate, so…”

APS: It’s so interesting, right?

AM: It’s a very different sort of culture that our children are growing up with, with social media. And so how is that going to affect them both in the here and now, but also in the long term as well? I know there have been several studies looking at the impact on development and mental health regarding social media in this tween and teen population. What do you make of some of these studies? And what do you make of some of this research, which seems to be a little bit mixed at this point?

APS: You summarized that well. It is mixed. Especially in behavioral health and psychiatry, we live in that gray area. So we have a lot of mixed results, and part of it is because social media and social media use are hard to isolate and study on their own. There are always other environmental factors that impact things. What I tell parents and kids, especially my teenagers, is ok I can’t give you a study that definitively says social media is horrible. But I also can’t give you a study that definitively says social media is the best thing ever. So, because of that, we need to look at your use, your content, and what it’s taking you away from, because these are the things that we can measure. It’s just important to keep that in mind.

AM: We know that there has been an alarming rise in teen and young adult mental health concerns in general in this nation. I think the CDC put out a report earlier this year which has staggering numbers regarding almost a third of teens have contemplated suicide in the past year. These are staggering numbers. Do you think that social media plays a role here? And if it does, how do you think, it’s a very challenging question obviously, it may impact some of these other greater mental health concerns that we’re seeing?

APS: So we can’t say it doesn’t play a role. So when we can’t say definitively it doesn’t, we really have to look at the fact that there has to be some relationship with social media use. And what we look at, especially certain content, is those reinforcing spirals where you continue to find more and more content, and you go deeper and deeper through the rabbit hole, right? And then the upward social comparison, so that fear of missing out, everyone’s doing something better than me, everyone looks better than me. And when we’re looking at, especially adolescents, which is a pivotal developmental stage, those types of sticky social media situations in a population that is growing and developing can cause overall challenges of depression, with anxiety, with self-esteem, with focus and concentration. So, there is a correlation, even if it’s not direct with some of these issues. The other thing is that for some kids they’re trying to get on social media to fit in. But when content kind of changes and you’re googling depression because you’re concerned about feeling depressed, or you’re on TikTok, and then it talks about other things that become more concerning like suicide, and how to, you know, plan suicide without anyone knowing. That’s the type of thing when we talk about those reinforcing spirals that can sometimes get kids in a lot of trouble. And they don’t have the capacity to really deal with that.

AM: Right? Yeah. I mean, even adults can kind of get stuck in that in that loop as well. And in social media work is curated to raise our interest. And we if we search for one thing, it’s kind of mind boggling how much information these companies have. They know how long we look at different types of posts or pictures, what type of a post, and then it can start feeding you more information similar to that, to keep you on the platform longer. Sounds like there’s a lot of similarities with addiction, quite frankly. Do we know anything about social media and addiction? And how every time somebody likes your post you get a little blip of dopamine in your brain, do we know anything about sort of the neurochemical biology of social media use?

APS: Social media can be addictive, and, as you said, it’s designed to be that way. Video games are the same way. I mean what video gamer would just play it one time and then go to something else. They’re designed to keep playing, to keep looking, to keep watching. And when things are going well, you get this rush like, it’s another like, or I went viral. These are exciting things. So, you have this burst of dopamine. However, especially for my kids that are gaming or excessively using social media those chemicals glom onto the receptors, the neurotransmitters. But there’s a finite amount of neurotransmitter. So, after a while they’re oversaturated. Then what happens? if you don’t take a rest from gaming or social media, you get agitated, you get irritable. You become sad and depressed, and that’s part of the amount of use, right? We have to take these things in short burst and use them appropriately.

AM: Well, then, I think that dovetails perfectly into the next question. What should physicians advise parents and teens about their social media use? You just said it’s not an all-or-nothing type of thing. And if you say no, you can’t use it at all, that’s likely to backlash. So, what do you typically advise your parents and your teens?

APS: American Academy of Pediatrics recommends in the adolescent population 3 hours or less, in 20-minute bursts. Anyone under 2 years old should have no social media, which seems to be something that would make sense, but I see 2-year-olds that are looking at screens all the time when I’m interviewing other patients. And I’m like, “Mom, why don’t we do something else other than have them look at a screen?” For 2 to 5 years old, 1 hour or less. And what I tell my parents is, let’s have an open conversation. If you tell, especially a teenager, “No,” they completely shut down, right? So have a conversation about what the risks are. Show them information about what the risks are, and then try to come to some happy medium on how we can slowly decrease use, and really improve overall just foundationally, sleep, appetite, focus, and concentration.

AM: Yeah, one great piece of advice that I’ve heard recently, and I’ve started telling my patients, is to use social media together with your child or with your teen, so they can kind of learn how to do it. You’re looking at pictures together on Instagram. My 13-year-old and I like playing Wordle together, actually. So, we’ll play Wordle, this app, together. So, there’s some social interaction, and you’re also demonstrating good behavior, if you will. You play it for 20 minutes, or however long, and then you put it down. So you’re leading by example, but you’re doing it with them, so it’s also a social interaction. What are your thoughts on that recommendation?

APS: I think that’s an excellent recommendation. And to that same point, however, parents, you can show them more than you can tell them. So you have to make sure, as a parent or caregiver, that you’re being the correct model and using social media, as far as the time you’re using it, when you’re using it, and if you’re using it appropriately. It goes both ways, right? You can tell your kid, “Hey, you know, don’t be on social media,” or “We need to limit time.” But if you’re always on it as a parent or always on your phone and not present, it becomes this mixed message that’s very confusing for kids.

AM: Yeah, for those of you who have heard me speak before on social media, I always like using the term SMUD. I’m self-diagnosed, but I have social media use disorder. I definitely sometimes need to put it down and learn to step away. And so, I’m working on it. It’s a process, and there are some support groups for this, I think. We have a question here in the chat. There are so many different social media platforms. Are there some platforms that are a little bit more concerning than others? You know, TikTok, Twitter, Instagram?

APS: That’s a great question, and I can’t really answer that question because there are so many social media platforms that my kids — my kids are my patients — are telling me about that I don’t even know. So, I can’t say one or the other. But they’re all very what we call sticky. They have these algorithms that keep coming up on and on and on. So, I’m sure there are some that are more concerning, as far as the content that comes about as you’re continuing to use them. They’re all designed very similarly, and I don’t know all of them. I think it’s just fair to say that, in general, they really need to be monitored, especially in children and adolescents.

AM: They seem to be growing and propagating so quickly it’s hard to keep up, you know? It always tend to be ahead of us. I heard a new term yesterday for when people are using Snapchat. They called it “snapping.” I had never heard that term before. One of my patients used that term. They were like, “Oh, yeah, I snap pretty regularly.” I’m like, “Wait, what?” So sometimes learning the terminology helps us better communicate with our patients. Also, I always try to watch some of the latest cartoons, so I know what the popular cartoons are sometimes, where I can interact with my pediatric patients a little bit better or know what their T-shirt says. I think social media probably is pretty similar. Unfortunately, at the same time, we have to stay up with the lingo.

APS: Yeah. And kids love to teach, right? So, just like you do with your patients, I tell my parents all the time, ask them what the latest is. You know, they love to tell. They love to instruct. They love to be able to give that information, and we can find out a lot of information from our kids as well as our parents.

AM: Another issue which sometimes comes up, and we kind of touched on this a bit before, but I want to go back to it. We live in this society of instant gratification. You order something on Amazon, it shows up on your doorstep a few hours or a day later, and social media seems to be the same, creating this sense of instant gratification, addiction, creating silos, amplification, and reinforcement of your worldview, and narrowing that worldview a little bit as well, particularly for teens and the developing brain. What are your thoughts? How can we combat some of those concerns regarding just how social media seems to impact us as a cultural phenomenon in terms of different aspects, thoughts, or views within society?

APS: I think it’s important to have, and you said that beautifully. I think it’s important to have very open conversations ongoing with your patients and the families that you’re working with because you’re exactly right. Those reinforcing spirals just keep going, and like you said, it just gets smaller and smaller. When I talk to my kids, they usually have very strong opinions, which is very appropriate developmentally in adolescents, right? “This is wrong,” or “I’m being triggered by this.” These are the things that they say, and just having some very open-ended conversations about, what about this perspective, or what do you think about this, and just kind of getting a sense of how they think, and slowly widening that very narrow view in some situations is helpful. It’s not a matter of trying to get adolescents to think differently than what they’re currently thinking because they’ll completely shut down. It’s a matter of just prompting them to open up their line of thinking or creating other scenarios for them to think about differently, which takes time. It’s not a one-conversation or one-question type of situation.

AM: And I imagine getting them off their phones and into the real world, and having a diversity of real-world experiences, potentially could help shape that view as well.

APS: That’s the key, really, and how to do that varies. But it definitely is something that needs to be done. I encourage families to, just as you talked about using social media together, just go outside and walk together, or do a puzzle together, or something together that’s not related to any type of electronics. It can make a world of difference. And the earlier you start, the earlier it just makes it easier. The earlier that changes can be made. Parents have to provide limits and structure. We can’t always be friends with our kids. Sometimes it gets to a point where, in the negotiation phase of this process with social media, it becomes so much where you’re not getting anywhere. There sometimes has to be a time where parents say, “Okay, this particular area is a no-phone zone.” So if you come in here, it’d be the dinner time or the dinner table or the living room, no phone, no social media, nothing, and just start the process of weaning away slowly, for the parents and the kids.

AM: Yeah, that’s actually a perfect point. I was thinking about that as you mentioned not only social media boundaries but technology boundaries in general. We have no phones in their rooms and no phones at the dinner table at our house. That’s the rule and what seems to work well. And there’s obviously not a one-size-fits-all. you have to figure out what works for you. But having clear limits in terms of where you can use your phone, and then also you can set a timer so the phone locks out at 8 pm and they can’t use it after that, which is something we do in our household as well.

APS: Excellent, and the other part to that is, as you talked about addiction and we talked about dopamine, when you start that process, it could increase escalation of behaviors, anger, frustration, arguments, threats. That is just part of the process of pulling away that surge in a way that a lot of times, you know, teens especially won’t like. That’s okay. It will get better.

AM: Yeah. And that actually dovetails perfectly into our next question in the chat, it’s like you were reading ahead or something. Do you have any suggestions regarding handling teens and kids and the pushback when they feel left out in social situations, when they’re not on social media, they’re not texting their friends constantly, or they have those downtime periods within the day?

APS: I wish I had the magic wand, but this is what I do recommend, and most of the time over time it works, if the parent is consistent. One key is open conversations, right? Have the kids understand why and get some sort of buy-in. If they’re using, let’s say, 5 hours a day, let’s take it down to 4, and then build from there, right? The old parenting was “Suck it up, buttercup. You can’t work with everyone. You’re not going to know everything. It’s just the way it is.” That doesn’t work very well with our teens now. There has to be some sort of buy-in. And that is typically talking about, okay, these are some things that you’re concerned about. A lot of my kids have trouble sleeping, and they want something for sleep. Or they say, ‘I can’t focus.’ These are some things that you can do to help that situation, and then we can build from there. And what a lot of times, when they start seeing results like, “Oh, yeah, I mean, I guess I am thinking clearer, or I did get to sleep a little bit later,” it’s part of them separating from that need to always be involved or always know what’s going on. It also trains that we don’t always have to have that instant gratification, right? So, we’re increasing our frustration tolerance, which is something that we need to do as we move through adolescence in general. So, they’re not going to be 100% on board initially, but that’s part of the process. Getting the buy-in is key.

AM: That’s great advice right there, in general for any teens in our lives, and not just regarding phones and social media. Well, this has been such a fantastic discussion. We could go on and on all day, I’m sure, but we do want to keep this pretty high yield and short. So last question here, tell us what makes you most proud to be a Permanente physician?

APS: Oh, gosh! That’s a great question. I think the biggest part to me is being able to have a wide variety of patients from all walks of life and be able to integrate with pretty much every specialty known to man with just the touch of a button, a text, or an email, or even knocking on the door and saying, “Hey, I have this challenging case.” So, it’s the relationships with the other Permanente doctors in addition to my patients and families. That is why I’m here, and why I’ve been here for 17 years.

AM: Wonderful! Well, thank you so much, Dr. Patton-Smith, for joining us again and sharing your expertise. We really appreciate it.