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 Nagata. 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 be of 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 used social media as a way 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 impact 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 scr uh screen use, I'll be looking at screen time. So that's just 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 reference. Um throughout the talk, the adolescent brain cognitive development study or known, also known as the ABC D 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 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 ABC D study um includes lots of different measures, but they really have great measures on screen use, uh 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 ABC D study collects all of the youth or adolescents who are in the ABC D study every year, I 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 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 and 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 is 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 released. So first, I just wanted to talk about some of the screen use trends that we found nationally um in the past five or so years. Uh So at baseline of the ABC D study again, this is among nine and 10 year olds, the average screen time that was reported was about four 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 five 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 socio-economic 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 the the screen time actually doubled in this same cohort. So as I mentioned that um 2016 to 2018, it was about four hours. Um And by the beginning of the pandemic, it was nearly eight 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 downtrend 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 in the ABC D study um as one of the um concerns related to social media and screen use uh among teenagers um and 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 ABC D 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 among uh screens for three different modalities for mo 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 ABC D study, uh again on this early sample, so it, 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 three times more likely to report uh cyberbullying victimization compared to heterosexual adolescence. 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 ABC D 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 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 first two or three years of the ABC D 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 this pro 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 nine or 10 years old, um and then mental health symptoms um that were uh one year follow up and a two year follow up controlling for um 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 ABC D study. And so you can see across the board. Um This is a, 100 and 10 item questionnaire that they answered um based on the child behavior checklist, I mean, 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 a, 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 two years later, um were 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 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 O CD 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 eight different types of screens. Um And so some of the mechanisms that might explain links between uh screen time and O CD are 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 pro 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 O CD 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 content. Um And that can then lead to compulsive viewing um in a way that traditional television viewing at least on um is uh may not have ha 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 percent higher prevalence of conduct disorder. Um And then particularly over four 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 four hours was also the threshold that was bound 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 uh findings on screen time again, hours per day. Um And for this particular analysis, the threshold seemed to be more than four hours a day was where we started to see signal. Um But I next want to 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 for a specific the 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 one year follow up. So this was um problem screen use um when they were like 11 to 12 years old and then um new onset uh the uh mental health symptoms one 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 could 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 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, the 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 D 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 is a 25 item sleep disturbance scale. Um And about, and there's a clinical cut off for that and about 28% of the teens had met the that clinical cut off 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 an 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 BM I 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 four hours per day. So for the average kid that's one BM I 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 95 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 four hours per day, um that can add up a cumulatively. Um So some of the mechanisms that are thought to explain um links between screen time and higher BM I 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 because 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 about, but um if you think that you only have, you know, if you're, if kids are in school for eight hours a day. They're supposed to be sleeping for eight or more hours a day that really only leaves you, you know, eight or less hours for additional leisure activities. And if four 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 BM I 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 eight 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 BM I or obesity. Um But if you are 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 BM I and same with the low screen use group. Um, but when you're at the eight hour or above screen level, it actually doesn't matter how many steps you have, it, this 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. Uh 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 biased 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, t 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 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 Hagen really focused on um teen girls impacts. Um But I uh actually, my specific area of research focus is 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 a majority of male body image related Instagram post post 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 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 improvement, but just in um 2023 the 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 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 face timing or video chatting with a grandparent or uh um parents or other adults, um you know, that may be ok because that could still promote um you know, communication and interaction. Um But other types of media 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 one 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 five, so 5 to 18 years old, um previously, the recommendation was to limit to less than two 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 A AP website, there is a resource um that you can refer people to that ha that's interactive, that um that can have families um checked out each of these different aspects of the plan. Uh But in general, the plan in 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 violence 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 kind of 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 ABC D 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 screen 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 a 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 A P guidance but um you know, first, potentially having tech free zones um having a family media plan that was, you know, covered by the A AP 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 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 to 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 A P A 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 it's, you know, development to the 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 it 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 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 ABC D study, we found that like 2025% 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 content 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 Six is 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 Seven is trying to prevent uh social media usage that worsens sleep or physical activity or displaces those um eight is uh trying to limit social media that encourages social comparison. Again, like that could lead to eating disorders or body satisfaction. Um Nine is that before they reach the age uh where they're on social media, um they should be trained on it and on safe safety so that they can be um digitally literate and savvy. Um And then 10 is just promoting um investments in research on adolescent social media. Um So I think the A P A guidelines have a little bit more detail than uh than the A P or A 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 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 at as our neighbors. Um So just in terms of ABC D 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 used 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 U CS F. Uh um and particularly Jackie, her 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 ABC D 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 five year olds. Um So with that, I uh I'm happy to pause and take questions.