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CLINICAL SYNTHESIS   |    
Understanding Technology Use Throughout Development: What Erik Erikson Would Say About Toddler Tweets and Facebook Friends
Tristan Gorrindo, M.D.; Anne Fishel, Ph.D.; Eugene V. Beresin, M.D.
FOCUS 2012;10:282-292. doi:10.1176/appi.focus.10.3.282
View Author and Article Information

Author Information and CME Disclosure

All authors are affiliated with Division of Child and Adolescent Psychiatry, Massachusetts General Hospital Department of Psychiatry, Harvard Medical School.

All authors report no competing interests.

Address correspondence to Tristan Gorrindo, M.D., MGH Child Psychiatry – Yaw 6A, 55 Fruit St., Boston, MA 02114 E-mail: tristan.gorrindo@mgh.harvard.edu

Abstract

Abstract  The seismic changes brought on by technology in the last decade have far outpaced clinicians’ knowledge about how these changes are affecting children and their parents. While there is still much that isn’t known about the impact of technology usage on the developing brain and on family relationships, applying a developmental framework, such as Erikson’s epigenetic model, is a helpful place to start. From infancy through emerging adulthood, children are using technology in different ways, depending on their stage of development. At each stage, technology can facilitate or inhibit development. In infancy, technology can disrupt early attachment and help with new parents’ isolation. For toddlers, it can augment or replace traditional fantasy play. School-aged children find themselves required to use technology for school, but are also drawn toward video games at the expense of outdoor time. While teens and emerging adults may be prone to misusing technology as part of their identity formation and separation from parents, technology can also facilitate peer relationships. For each developmental stage, the authors offer a vignette, a description of media use, a developmental interpretation of technology use, and guidance for clinicians.

Abstract Teaser
Figures in this Article

From infancy through emerging adulthood, children are using technology in different ways, depending on their stage of development. Clinicians who work with children and families benefit from having a basic understanding of the different ways that children are using technology, and how such usage supports or undermines the tasks of each developmental stage. The seismic changes brought on by technology in the last decade have far outpaced clinicians’ knowledge about how these changes are affecting children and their parents. Many clinicians are somewhat stunned by the usage statistics, that suggest, for example that children are spending more time looking at screens than sleeping and eating combined (1). While there is still much that isn’t known about the impact of technology usage on the developing brain and on family relationships, applying a developmental framework is a helpful place to start.

Erikson’s epigenetic model of development can be useful organizationally to understand the possible impact of technology on development. Erikson’s stages, which span from infancy through adulthood, describe challenges for the individual based on cognitive, emotional, and interpersonal/social issues. Erikson posed these challenges as a dialectic—a series of developmental crises of opposing forces that place the individual in a situation requiring the acquisition of newfound positive and growth promoting knowledge, skills and attitudes, or conversely, ones that may lead to personal distress and dysfunction. Each developmental crisis typically takes place at certain ages, depending on the biological, psychological, environmental, and social potentials of each individual. Indeed, development is highly personal. For the purposes of this discussion of developmental tasks, we should assume that the challenges apply as broad generalities and that there is a wide spectrum of differences among individuals. For example, biological factors, such as brain development, temperament, and medical problems may interfere with normal development. In turn, social and environmental variables may also obstruct development. The thrust of the developmental tasks in this paper will consider the basic features of each stage using clinical vignettes with an emphasis on the ways in which technology may enhance or detract from optimal development.

Katie, a mother of a 6-month-old baby, strolls through the neighborhood chatting on her cell phone with a friend and texts her husband to remind him to pick up fish for dinner. Later, while nursing on the park bench, she checks a nursing app to log the time of day and length of this breast-feeding. Once home, she checks in with an online community of mothers, and uploads photos to Facebook from her walk so that all the aunts, uncles, cousins, and friends can stay updated. Soon, it's time for the baby to take a nap. Katie remembers to record the time of her baby's nap on an app so that she can track his napping patterns and get tips on his sleep. Exhausted, she also lies down to take a nap and sets a sleep app to wake her up at a time during her sleep cycle that will maximize her alertness. Later, after her husband comes home from work, he pulls out his iPad and reads Good Night Moon. When the baby touches the screen, objects talk back to him.

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Technology use

Katie's story highlights many of the reasons why new parents use technology: to fight the isolation associated with being the parent left at home during the day; to get parenting information they might have sought in an earlier time from relatives; to document their babies' development with online albums and logs; and to find websites for music and books to entertain their baby. The dramatic rise in ‘mommy’ blogs and community listservs suggest that parents of young children are certainly turning online for advice and support. Further it is estimated that 92% of U.S. children have some type of online presence by the time they are 2 years old (2), largely consisting of photos or videos being published on social media sites. National surveys, such as The Digital Family Project (www.thedigitalfamily.org), seek to understand the ways in which technology is influencing early attachment. Data, however, about the role that technology plays in early attachment, are still forthcoming.

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Developmental task

The first stage of Erikson’s theory is called Basic Trust versus Mistrust and corresponds to infancy and up to two years of age. In this period the child depends on the parent for “consistency, continuity, and sameness” (3). As children are able to “trust” in others, they also are able to find their own sense of trustworthiness and begin to explore the environment. The infant needs to believe that she/he can trust that the parent will provide basic needs, such a food, comfort, safety, and that the parent is dependable.

Naturally, in infancy, the child is just beginning a rudimentary sense of trust in the reliability of the world to present what is needed. The child from birth to 2 years old is nearly fully dependent on the parent. In this context, if a parent is preoccupied with digital media, multitasking and not paying full attention to the child, there may be dangers in the child not feeling fully attended to. Moreover, the parent requires direct interaction with the child’s subtle verbal and nonverbal cues to really appreciate the child’s needs in the moment. Good parents are those who tune in to their babies' needs for play, sleep and feeding, and take their cues from babies about when to look away. When the process goes in the reverse direction and babies have to work or fuss to reengage a parent who has looked away to text or post on Facebook, the connection may go awry. Digital media may well interfere at times with such an important and subtle task.

On the other hand, many parents feel isolated and alone in their new role. To the extent that technology may stave off the isolation and blues that can come from many hours cut off from adult companionship, technology is a real help. We know that happy parents make the best parents. And, technology can also help new parents with self-care, offering advice and tips about sleeping and eating.

Further, the use of online discussion boards and other digital resources may be of invaluable help in answering many of the anxious questions new parents struggle with.

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Guidance for clinicians

Clinicians should explain attachment and remind parents of the importance of attachment formation during the first year of life, and raise awareness about the ways that technology might interfere with that process. At the same time, clinicians should encourage parents to leverage technology to nurture their own self-care and to enhance personal, supportive relationships, and particularly to use it to stave off feelings of isolation that can be a harbinger of depression.

The American Academy of Pediatrics has clearly recommended that children under the age of 2 should not watch television (4) and more recently they have extended this recommendation to all screens (5). This assertion is aimed at dissuading parents from using television as a baby sitter, and leaving the child alone, actions that might undermine the baby’s development of a secure attachment to the parent.

When Caleb, a 3-year-old boy wakes up crying in the morning, his mother hands him her iPhone. He easily finds the app to start playing Koi Pond and immediately settles down. While eating breakfast, his father flips on Sesame Street to amuse Caleb while he reads the newspaper. On the car ride to preschool, Caleb starts to protest having to go to school. His mother again hands him her iPhone to distract him. This time, he finds the music app and sings along to “The Wheels on the Bus.” Once he arrives at preschool, he heads for the water table and enjoys some spirited pouring and splashing. After a few minutes, it’s time for a media-rich curriculum, using video viewing of PBS programs, aimed at learning early literacy skills that will prepare him for kindergarten. After lunch, Caleb spends time on the playground riding on a tricycle and climbing on a jungle gym. When he returns home, he spends an hour or two watching PBS TV, while he has a snack, and his mother prepares dinner. At dinner, his parents are both monitoring their incoming emails on their phones, and Caleb, is clamoring to have a phone to play with. After dinner, he has a bath, and then sits on his mother’s lap, flipping through the digital pages of Yertle the Turtle.

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Technology use

The use of technology in this age group largely consists of digital analogs, that is, activities that were once thought to be typical play for a child this age have been reincarnated in a digital format. With the increasingly popularity of tablet touch-based screens, there are a large number of apps and computer programs which are easy to navigate by a child. Children like Caleb can “finger paint” on a touch-screen computer, create balloon animals on a mobile phone, or interact with digitally enhanced versions of classic books which will make noises or animate in parts. Even mundane trips to a pond to look at swimming fish have found a digital analog.

From an epidemiologic view point, little is known about the absolute usage of technology by kids in the age-group. As early as 2006 it was estimated that 80% of children age three to six watched TV every day and 15% played video games on a daily basis (6). Almost a third of 2- to 3-year-olds have a TV in their bedrooms (7). The number of children using technology on a daily basis has likely increased given societies overall increased use of media, and in particular, as the use of smartphones and tablets has become popular.

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Developmental task

Erikson called the stage of development children ages two to four Autonomy versus Shame and Doubt. This phase relates to the challenges of the child taking control over his own body. The role of the parent in this stage is to foster autonomy, positive self-esteem and a sense of curiosity in venturing out into the environment. Erikson considers this a time when the child learns to “stand on his own feet” (3). As the child grows older, age’s four to five, Initiative versus Guilt are the processes that dominate this phase. In this phase, the child is quite egocentric, and has not developed the cognitive capacity to process external reality.

Imaginative play is the most important work of children this age since it becomes the means for children to test ideas, challenge their fears through displacement, and work through their competitive and guilty feelings. They replay important life scenarios in order to feel they've mastered a skill, perhaps imagining themselves as doctors giving shots or a parent doling out treats. Pretend play also gives kids a chance to share, take turns and to put themselves into someone else's shoes–to learn empathy. Play spurs the imagination and gives kids a way to work out their worries. Digital play–including computer games, smart phones and other handheld devices; peek-a-boo while Skyping with grandparents; watching funny video clips–is the new kid on the block.

Digital play is different from pretend play with a parent or friend because, for the most part, digital play isn't self-generated. In other words, technology-based play is limited by the actual design of the game or device. When children play pretend, it involves give and take often with other children; only the players can determine how their actions evolve. Technology can't duplicate this, but it is still fun, and most young kids are drawn to it.

The role of children’s use of fantasy in the digital world is still unfolding. We can only wonder how a child may use digital media to create avatars, make-believe cities, and play with others, using online fantasy to create new ways of dealing with conflict and with pretend play. If digital media is rigid, however, and does not allow for input from the child, it may thwart the developmental process. A similar criticism was leveled years ago at the impact of movie-watching on a child’s imagination. A number of developmental theorists argued that watching Snow White or Hansel and Gretel was not the same as hearing the story and allowing the child to “make up” the evil characters. If children still have room for real-time personal interaction with a parent, and can start and stop the action, there is likely a place for digital fantasy play just as there is for watching fantasy on film. Developmentally designed technology for this age group needs to create room for fantasy, creativity, and an ability to start and stop the game for spontaneous conversation.

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Guidance for clinicians

The American Academy of Pediatrics recommends a limited media diet for children in this age group, not to exceed more that 1-2 hours per day (4, 5), even if it is child-approved programming like PBS-kids. Screen time should focus around educational content that is enriching and age appropriate. Parents should be active participants in this process, using screen content to learn letters, practice naming objects, or as a jumping off point for the development of fantasy play. Left unanswered by the AAP guidelines is what to do with the digital analogs. Is finger painting on a touch-screen monitor different than finger painting on paper? Is flipping through the iPad version of Good Night Moon different from reading the paperback version? Given that preschoolers learn about their environment and develop fine motor skills through the manipulation of objects, digital analog play is not going to carry the same benefits as hands on play.

There are also interesting implications for those who treat children in this age group using play-therapy based techniques (8). Will play therapy start to involve more technology? In an environment where the child sets the agenda, will we allow them to use technology to share digital doodles or create narratives using iPad photo and movie clips? And if we don’t, what content are we not inviting into the session?

It should also be noted that there is little known about the effect of technology exposure on neurodevelopment (9). One could reasonably argue that early exposure to attention craving technology could affect the differential reinforcement of various neural pathways (10). Early exposure to numerous simultaneous sensory stimuli may result in children who are better at multitasking or in children who have difficulty sustaining attention to a single task.

Molly is an 11-year-old girl whose day begins by checking her Facebook page on her cell phone, which her parents got her for emergencies, but is used throughout the day. While getting dressed in the morning, she watches a rerun of Hannah Montana on the TV in her bedroom. At school, Molly is required to use the computer during her math class and enjoys her afternoon elective time in “Tech Ed.” During car pool, Molly and her friends sit in the back seat and watch a silly DVD about the adventures of three teenage girls. After school, her mother asks Molly if she’d like to play basketball with her in the nearby park, but Molly wants instead, to play a videogame. Her mom demurs, saying that she doesn’t really know how to play. Her mother doesn’t think to ask what the game rating is on the video game, nor does she use a V-chip on the TV to protect Molly from adult content that might be frightening to Molly. As the day winds down, Molly goes up to her bedroom to call a friend on her cellphone, watch TV, and check her Facebook page; her mother has no idea who she is talking to nor what she’s viewing.

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Technology use

According to data from the Kaiser Family Foundation (1), technology use begins to accelerate for children in this age group. On average, 8- to 10-year-olds spend 3:41 hours per day watching TV, 1:08 hours listening to music, 0:46 minutes playing on computers, and 1:01 hour a day playing video games. When multitasking is taken into account, the total media exposure is 7:51 hours per day, that is compressed typically into 5:29 hours (Figure 1). Although there aren’t data specific to children Molly’s age, in a broader examination of 8-18 year-olds, age, 65% have handheld videogames, 71% have a TV in bedroom, and 37% have media systems in the car.

 
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Figure 1.Media Use by Age, 2010

This information was reprinted with permission from the Henry J. Kaiser Family Foundation (1). The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a nonprofit private operating foundation, based in Menlo Park, California.

Technology use for this age group largely centers on TV watching and video games, often done outside of parent supervision. Many parents and clinicians are concerned about the role of violent video games in the development of aggressive behaviors. The American Academy of Pediatrics (7) in its Policy Statement on Media Violence points to meta analyses based on 2000 research reports linking media violence and aggressive behavior conducted by the Center on Media and Child Health at Harvard: “The strength of the association between media violence and aggressive behavior in a meta-analyses is greater than the association between calcium intake and bone mass [loss], lead ingestion and lower IQ, and condom nonuse and sexually acquired HIV infection, and is nearly as strong as the association between cigarette smoke and lung cancer.” The connection between media use and violence may be particularly true for children under eight who still engage in primary fantasy play.

Data suggest that heavy media exposure is associated with bullying, but it’s unclear how to understand the causality here. Perhaps, children who spend more time online simply make themselves more available to cyber-bullies. Conversely, children who spend time online may be somewhat socially awkward (and therefore more vulnerable to bullying) and thus naturally gravitate toward the faux-safety of internet based interaction.

Although there is less longitudinal data about how video games are linked to violence, some longitudinal studies out of America, Japan, Germany, and Finland suggest high exposure to violent video games increase physical aggression (7). The converse may also be true: prosocial games can increase prosocial attitudes and behavior. There have been studies suggesting that playing sports videogames increases interest in active sports and in learning athletic skills, as opposed to keeping kids off the playing fields (11).

Meta-analytic studies have also suggested that the link between video games and violence may not be as strong as the popular media would have us believe. Ferguson and Kilburn (12) considered the impact of violent TV imagery and video games on aggressive behavior. The results suggest that the overall effect for exposure to media violence is less than 1% (r=0.08), concluding that their results “do not support the conclusion that media violence leads to aggressive behavior.” Others also argue that the data linking violence and video games is flawed and fraught with complex methodological issues (13). Without a clear link between violence and media, guidance for parents based in moderation is warranted. In the same way that a healthy diet may include fruits, vegetables, and an occasional dessert, kids should consume a diet of play which includes exercise, imaginative activities, social engagement, and media–all in moderation.

Many children this age are more facile with computers than their parents. They are starting to see technology not only as a means of entertainment, but also a resource for studying, completing homework, organizing social activities and club events, and staying connected with parents and peers. It becomes difficult for parents to enforce technology-abstinence policies across the board as their children are required to use technology as part of their normal academic curriculum.

Although some children, like Molly, are already on Facebook, it should be noted that this is not only a violation of Facebook’s terms of use, but also against the law. Children under the age of 13 are prohibited from participating in many popular social networking websites, such as Facebook. This has as much to do with the Children’s Online Privacy Protection Act (14), as it does with the maturity of the child and the potential content that he or she may encounter (15). Sites such as PBS kids have been engineered to comply with the strict data privacy requirements, but sites like Facebook are inherently built on the idea of sharing information and thus don’t comply with the legislation.

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Development

For school-age children ages 6 to 12, the crisis posed by Erikson was “Industry vs. Inferiority.” It is an age in which children learn fundamental knowledge, attitudes and skills through experience to gather, organize and use their time productively – in school, at home and with friends. Children at this age are developing the “tools” according to Erikson to carry them into the adult world as workers. The days of fantasy play are redirected to the ways in which the child may be responsible, act as a team player, and do things “right.” Hence rule orientation and learning the proper ways of doing things are very important. Children at this age are studying cause and effect, and means of accomplishing tasks effectively and efficiently. These are critical years in developing positive self-esteem and the confidence to take on increasingly difficult tasks. Children discover their special interests and talents, and they are motivated to learn skills in sports, music, or, indeed, computers. At the same time there is increasing awareness of how they fit in to the social order. Girls and boys at this age tend to form separate groups, and in that context learn fundamental principles about group norms.

A challenge for Molly is to acquire the organizational skills and the executive functioning needed for developing academic and extracurricular skills, and still have time to play. While many of these skills may be learned using digital media, the fundamentals of writing, organizing and developing interpersonal skills are even more important. The challenge is to allow the necessary time for learning outside the digital world, without being consumed by the increasing pull of technology. Another challenge is for parents to limit access to those websites that are inappropriate for Molly’s level of emotional maturity, and to help their child have adequate time for school, friends and extracurricular activities. Unfortunately, few parents have been trained to monitor or control access to digital media.

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Guidance for clinicians

Clinicians should routinely ask parents, “How much entertainment media per day is your child or teenager watching? Is there a TV set or internet connection in the child’s bedroom?” Additionally, clinicians should be empowering parents to set limits on media use and technology time. A 2010 study from the Kaiser Family Foundation (1) looked at a number of simple parenting interventions aimed at limiting technology and screen time. The results of the study suggested that no one intervention is better than the other, and that any intervention reduced screen time. Simple interventions such as not putting a TV in the bedroom and not leaving the TV on during meals, dramatically decreased screen time. Parents should be asked to explore what might be interfering with limit-setting. Parents should also be encouraged to use V-chip technology and video game rating scales in an effort to limit exposure to violent or otherwise adult content.

Clinicians should also be urging parents to start talking about cyber-safety. This begins with helping parents to become literate about the very basics of the internet. Websites such as Common Sense Media and Facts for Families (16) provide basic and reliable information (Table 1). Although children in this age group generally are not the primary targets of cyberbullying, it is important to start a dialogue with children this age about the things that might happen online and what they should do if they feel unsafe, scared, or threatened. In much the same way we train children before heading off to preschool about what to do if approached by a stranger, here we are focusing on prevention.

 
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Table 1.Resources for Parents and Clinicians

Parents also need to be aware of their children’s video game use. Most parents do not have any idea of the scenarios in videogames, some of which, when told, they later find quite horrifying. This requires parents to be vigilant and use productive websites that have reviews of games and their content. Better (and often not done) is to play games with their children (11).

Clinicians should additionally urge parents to set a good example, especially during this time when children are so rule-bound. If handheld video games are prohibited at the dinner table, then parents should not take work phone calls or send texts during the meal. Additionally, a powerful intervention is for families to implement technology free “vacations.” This may be as simple as a Sunday afternoon during which everyone in the house puts away digital devices. A key element, however, needs to be parent participation and appropriate modeling. When parents tell their children to put away digital devices, parents need to be ready to model this same behavior.

Eliza is a 15-year-old high school sophomore who is proud to have 500 Facebook friends. During the course of her day, she will spend almost 11 hours doing a combination of checking her Facebook wall for new messages on her cell phone, listening to music while she does her homework, watching TV shows on her computer, and texting her friends. When she gets home, her mother calls her over several times for some, “Hey, look at this,” moments. Later, her father asks for her help setting up Google alerts so he won’t miss any Van Morrison concerts. While he felt a bit clueless having to ask for help, he knows that his daughter knows so much more about the online world and he’s grateful for her assistance. Before bed, Eliza sends a text to a friend that was meant to be funny but was received as snide and sarcastic. Eliza is trying to correct her intent, but as she does this she quickly fires off a few messages in frustration that she later regrets. She wishes she could take them back. She tosses and turns as she worries about seeing her friend in school and worries about who else already knows about her misfires.

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Technology use

Pew (17) found that 63% of all teens say they exchange text messages every day with people in their lives, including their parents, and nearly half of all teens send and receive text messages with friends daily. An estimated 93% of youth use the internet regularly (18), and a Common Sense Media Poll (19) revealed that 22% of teens log onto social media sites greater than 10 times a day, with more than 50% logging on more than once a day (20). At least 75% of teens have their own cell phones, with 25% of them using their phones for social media and 54% using them for texting (20).

“Sexting” or the text messaging of sexually explicit photos is another problem within the teenage group. According to the Crimes Against Children Research Center, 20% of teens, ages 13 to 19, including 18% of teen boys and 22% of teen girls, had sent or posted nude or semi‐nude pictures or videos of themselves on the Internet or through a cell phone (21). Teens have little awareness of the dangers of this kind of behavior, including possible criminal charges for distribution or possession of child pornography. Nor do many realize that sending such material even to a significant other may “go viral” and be sent to countless viewers globally.

Social networking websites, such as Facebook, are extremely popular among teens. Pew estimates that 95% of all teens ages 12-17 are now online and 80% of those online teens are users of social media sites (22). And while 69% of social media-using teens think that peers are mostly kind to each other on social network sites, a startling 88% of social media-using teens have witnessed other people be mean or cruel on social network sites. A 2007 study of 500 profiles on the social networking website MySpace revealed that 24.0% of profiles referenced sexual behaviors, 41.0% referenced substance use, and 14.4% referenced violence (18). It is unclear what the meaning is for displaying such health risk behaviors on one’s website or what the impact might be on peer relationships.

Data from the Kaiser Family Foundation (1) show that overall media use accelerates during the early teen years (11-14 years old). The average teen is exposed to almost 11 hours of media daily, mostly video games, television and movies (Figure 1). Kaiser also noted differences in media use in relation to race, even after controlling for other demographic characteristics. Hispanic and African-American youth average about 13 hours of media exposure daily, as compared with their white peers who are consuming 8 1/2 hours. This difference seems to be primarily driven by television and music time. Children who are heavy media users are more likely to report getting fair or poor grades (47% of heavy users report bad grades). Heavy use is defined as those consuming more than 16 hours of media in a day (21% of the 8-18 year sample).

As part of the separation/individuation process, teens can find themselves in vulnerable online situations and may be reluctant to engage parents or adults for help. Cyberbullying, where a teen is harassed or intimidated online, can be particularly hurtful because comments can be made anonymously and are often made in a public forum where peers can see and chime-in on the harassment. Using Pew data of 935 teens (23), results showed, “the risk of youth being bullied is higher for adolescents who have an active profile on social networking sites and participate in chat rooms but not in playing games online.” Unlike in traditional bullying where the parent or school can implement physical barriers to separate a child and bully (i.e. driving the child to school instead of making him take the bus), most parental mediation techniques are not protective.

Given the independence of teens in this age group, it can be particularly difficult to set limits on technology use. Teens often require computer access for school projects or extracurricular activities, and over a quarter of teens have access to the internet on their cellphones (17).

It should also be noted that there is no consistent definition of “internet addiction” in this population. Internet addiction typically implies some egodystonic or distressing use of technology in an excessive or poorly controlled manner (24). The term, “problematic internet behaviors,” is increasingly used to describe the problems associated with high media use in this age group. It is not clear how these definitions apply to an adolescent population in which high levels of media consumption are egosyntonic and normative when compared with peers. In addition, there are data which suggest that video-game and internet use may affect neuroplasticity and reward/attention circuitry in both positive and negative ways (2527), but the long-term impact of these digital media on learning, memory, and productivity have yet to be determined.

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Development

Adolescence for Erikson was considered the stage of “Identity vs. Role Confusion.” For him, with the advent of puberty and accelerated cognitive development, childhood comes to an end. Cognitively, teenagers are able for the first time to consider abstract, existential questions. They are thinking about the meaning of life, who their parents and family are, and who they wish to be when they leave home. Preparation for separating from family and achieving independence is an important theme. But just as they are forming an internal sense of their personal identity, there is tremendous self-consciousness and consideration of how they are perceived by others.

Despite these advances in adolescence, the relative immaturity of the adolescent’s brain leaves them at risk for emotionally driven, impulsive, risky behavior. There is a sense of grandiosity and invulnerability that accompanies this stage, despite advances in cognition and more sophisticated problem solving ability. There is an ongoing struggle to become increasingly responsible, mature and independent, and yet simultaneously, live in the moment.

This situation puts adolescents at risk in the digital age: Meeting strangers online, sexting, posting pictures, poems, or diatribes on Facebook or Twitter may feel right in the moment, but often have dire consequences. And the overwhelming use of digital media to stay in touch by texting, surfing the web, downloading apps and music, not to mention playing videogames, sometimes Massive Multiple Online Role Playing Games (MMOPRGs) is incredibly tempting and may take precious time away from academics, sports, and real-time interpersonal relationships.

Although not empirically tested, social networking technology may be of benefit to some kids in nurturing social relationships and separation from parents. Adolescents with shy or anxious temperaments can begin to negotiate social interactions and friendships with peers through websites and texts. Even normal adolescents may benefit from the “distance” provided by digital media. They may be able to ask difficult questions about morality, sexuality, identity, or other aspects of complex social behavior with less worry of shame. In short, the media may bridge totally anonymity with much scarier face-to-face contact and confrontation. A successful, “breaking of the (virtual) ice,” with peers may subsequently foster more direct face to face communication. The concern, however, is that virtual interactions become a substitute for real-life interactions. And if such substitutions become overly relied upon, real-time communication skills may be weakened or be less likely to progressively develop.

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Guidance for clinicians

At a minimum, providers should be asking about media usage during initial evaluations and during routine clinical care. Additionally, providers should screen for comorbidities such as depression, ADHD, social anxiety, or adjustment disorders when they see internet usage in excess of what peers are using (28).

Technology also provides psychiatrists with a window to understanding the social world of an adolescent patient. Having a patient walk a therapist through his or her Facebook page or favorite YouTube clips is revealing of themes related to social connectedness, self-esteem, and identity formation.

Clinicians need to facilitate parents’ development of a more ambivalent stance toward technology. An “all or nothing” approach is not realistic in a digitally connected educational setting, nor does it prepare teens for the real-life challenges of balancing technology use within their personal life. Parents should be empowered to set technology-free times and should impose reasonable practices related to usage and monitoring. Particularly, for younger teens, it is appropriate for parents to have access to their children’s Facebook pages, either by being a “friend” or by having their child’s password.

Clinicians can also adapt traditional cognitive behavioral therapy (CBT) strategies to fit media usage. As one example, we have adapted a mindfulness strategy into the form of a mnemonic (Table 2) to help teens evaluate in a structured way whether or not something belongs on the Internet. W.A.I.T. also provides clinicians and parents with a structured conversation tool to engage teens in discussions about what they are posting online. The role of parent involvement cannot be underestimated either. We are currently developing a group treatment paradigm which contains two tracks – one for teens and one for parents. Using CBT strategies with youth is helpful in “complicating their thinking,” around issues of internet use, but it is also important to educate parents about the issues concurrently. For example, during a session in which a child is learning skills to help him or her decide what should be posted online and what should be kept private, parents are simultaneously learning about social networking websites and how to evaluate their child’s privacy settings. The treatment concludes with the parent and child working together to develop a media-use contract which takes a balanced view toward acknowledging the usefulness of internet technologies, while also defining appropriate limits.

 
Anchor for Jump
Table 2.Example Strategy for Working With Teens: W.A.I.T. Mnemonic

As Sam walks from one college classroom to another, he calls his mother so that he doesn’t appear aimless and lonely as he passes by his peers, almost all of whom are also on their cell phones. As soon as he arrives, he tells his mother he has to get off. During class, he takes notes on his laptop, but has several screens open—he’s checking the latest sports news, posting a message on his Facebook wall, and checking for airfares for his trip home for the holidays. He may send a few texts during class, the first of about 40 he’ll send and receive during the day. After class, Sam had planned to go to the library, but decides instead to play a videogame with his roommate. When he does go to the library, he is able to access the assigned readings on his computer. While there, he manages to text his friends, do his economics reading and watch a video clip. He easily makes plans to meet a dozen of his friends from his Google Circle for dinner at a local restaurant. When it’s time to go to bed, he’ll place his cell phone right next to his pillow, so that he will be sure to hear any incoming texts or calls during the night.

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Technology use

Young adults are using more technology than any other cohort. 84% have a social networking profile and 97% have cell phones (29). Those who attend college have the highest technology usage and are likely to be on line, using social networking sites, watching and posting videos, texting and playing videogames.

Modern technology complicates the process of separation as young adults are moving away from home. With technology, it has never been easier to stay in touch. Text messages, cell phones, social networking websites, video chats and e-mail, have all made constant contact simple and expected. But at times it can go too far. Clinicians report stories of parents who call each morning to wake their child up for class; parents who panic if they don’t get at least two text messages a day from their child; or, even parents who require that their child parade new college friends in front of a Skype camera before granting permission for their teen to befriend them.

Some universities have seen the harmful effects of so-called “Helicopter parents” being deeply involved in the day to day details of their children’s lives and have created curricula to help parents and kids set appropriate limits for contact.

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Development

Erikson considered the next crisis in development to be “Intimacy vs. Isolation.” Adolescents making the transition to adulthood are just at the beginning of this phase, in which the young adult moves through intimate relationships and finds a partner. Prior to marriage, however, the individual increasingly has to find a means to become independent of the family, and self-sufficient. This requires an even greater sense of identity, and a vision of one’s career, values and social network. For many it starts in college or in the workplace. Much greater responsibility is expected of young adults in time management, economic independence and learning the social skills to manage relationships in social settings and in academia or at work.

While this constitutes the period of greatest challenge in terms of independence, it also paradoxically requires the greatest degree of mentorship and guidance. It is not unusual for young adults to rely on teachers, coaches, older friends, siblings, therapists, and parents for discussing life’s challenges.

As one component of this period, parents may help the young adult deal with the lure and pressures of digital media. At no point previously has there been such a great distracter or ally than media for individuals at this age. Emerging adults make their own schedules. They are free from the imposed structure of high school or home. They have wide latitude when it comes to deciding how much time they want to spend using technology. We can only hope that they will appreciate the tremendous value of social networking, while not allowing it to dominate their time and possibly thwart their developmental needs.

About half of this age group (ages 18-24) attends college, while others are often living at home and working. This is a developmental stage in which young adults and their parents are still connected to one another, but the cord between them stretches further as the children make more decisions independently and take more responsibility for managing the day to day tasks of living.

Mental health issues, level of maturity, past experiences with living apart from family will all inform the amount of contact that young adults want or need with their parents. In addition, young adults’ comfort and reliance on technology means that connecting with family has never been easier. Gone are the days when college age kids were expected to call once a week from a phone in a public dorm corridor. In a recent Pew study, 80% of young adults had talked to their parents during the previous day (30).

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Guidance for clinicians

Clinicians can be helpful in facilitating a dialogue about how often young adults and their parents will be in touch and by which means (texting, phone, video chat). The best time for such negotiation is before a child departs for college, preferably before both parent and child are deep in separation anxiety. Young adults should take the lead in anticipating the amount and type of contact they think they will want, with the caveat that these patterns can be renegotiated once the separation is underway. Parents and their children will need to agree on what constitutes a reasonable response time for youth to respond to their parents’ communiqués. Parents should be cautioned not to manage the details of their children’s lives as a significant task of young adulthood is learning to handle more of daily challenges on their own.

The first generation of digital kids is now old enough to be parents themselves. This is the millennial generation, born between 1980 and 2000, who grew up on video games, had access to e-mail in grade school, to cell phones in high school, and Facebook in college. If it's true that people resemble their times more than they resemble their parents, will this early exposure to and immersion in technology, lead to defining characteristics, as they become parents?

There is much about this new generation of parents that we don't know. How will their comfort and ease with technology affect the way in which they parent? We assume that having grown up in a digital world, these digital natives will be able to set better media limits with their own children. Data from a Kaiser study (1) of older parents revealed that parents often don't set limits because they are so perplexed by what their kids are doing online. If a digitally savvy parent feels comfortable navigating the web with their children, they may also be able to better protect their children from cyber-bullying, sexting, and the ills of problematic Internet behaviors. These digital native parents may also be more likely to turn to the Internet or app for parenting advice, rather than to their own parents. When a child has a fever they may blast an e-mail to a community parent list-serve, before trying to navigate the phone tree of their local pediatrician's office.

The relationship between technology, clinicians, patients, and parents is constantly evolving and mutating. And, just when clinicians and parents finally feel competent to provide appropriate guidance to children and adolescents about technology use, technology will likely have changed again, presenting another set of challenges. Clinicians and parents should expect that they will always be one step behind the younger, digitally connected generation. But this does not mean that parents are powerless to help. Using tried and true skills of empathic listening, being curious, complicating a child’s thinking about an issue, and flagging behaviors that seem unsafe or inappropriate, are ways that adults can guide children, even if children know more about technology. Parents and clinicians don’t need to understand all the intricacies of what children are doing online in order to be helpful.

Rideout V, Foehr U, Roberts D. Generation M2: Media in the Lives of 8- to 18-Year-Olds. Menlo Park, CA: Henry J. Kaiser Family Foundation, January 20, 2010.
 
Business Wire: Digital Birth: Welcome to the Online World. Amsterdam2010 [cited 2012 March 29]; Available from: http://www.businesswire.com/news/home/20101006006722/en/Digital-Birth-Online-World.
 
Erickson  E:  The Eight Ages of Man,” Childhood and Society .  New York,  Norton, 1963
 
Committee on Public Education: Children, adolescents, and television. Pediatrics 2001; 107:423-426
 
Council on Communications and Media. Media use by children younger than 2 years. Pediatrics 2011; 128:1040-1045
 
Vandewater  EA;  Rideout  VJ;  Wartella  EA;  Huang  X;  Lee  JH;  Shim  M-s: Digital childhood: electronic media and technology use among infants, toddlers, and preschoolers. Pediatrics 2007;119:e1006-e1015
 
Council on Communications and Media. Media violence. Pediatrics 2009;124:1495-1503
 
Allison  SE;  von Wahlde  L;  Shockley  T;  Gabbard  GO:  The development of the self in the era of the internet and role-playing fantasy games.  Am J Psychiatry 2006; 163:381–385
[PubMed]
[CrossRef]
 
Small  GW;  Moody  TD;  Siddarth  P;  Bookheimer  SY:  Your brain on Google: patterns of cerebral activation during internet searching.  Am J Geriatr Psychiatry 2009; 17:116–126
[PubMed]
[CrossRef]
 
Small GW, Vorgan G: iBrain: Surviving the Technological Alteration of the Modern Mind. 1st ed. New York, Collins Living, 2008
 
Kutner L, Olson CK: Grand Theft Childhood: The Surprising Truth About Violent Video Games and What Parents Can Do. New York, Simon & Schuster, 2008
 
Ferguson  CJ;  Kilburn  J:  The public health risks of media violence: a meta-analytic review.  J Pediatr 2009; 154:759–763
[PubMed]
[CrossRef]
 
Sherry  J:  Violent Video Games and Aggression: Why Can’t We Find Effects? in  Mass Media Effects Research: Advances Through Meta-analysis . Edited by Preiss  R.  Lawrence Erlbaum Associates, 2007, pp 231–248
 
Children's Online Privacy Protection Act, 15 U.S.C. §§ 6501–6506 (1998).
 
New York Public Radio (WNYC): Parents helping kids lie online: transcript. 2011; Available from: http://www.onthemedia.org/2011/nov/04/parents-helping-kids-lie-online/transcript/.
 
American Academy of Child and Adolescent Psychiatry. Children Online. Facts for Families [serial on the Internet]. 2011: Available from: http://www.aacap.org/cs/root/facts_for_families/children_online.
 
Lenhart  A:  Teens, Smartphones & Texting .  Washington, DC,  Pew Internet & American Life Project, 2012
 
Moreno  MA;  Parks  MR;  Zimmerman  FJ;  Brito  TE;  Christakis  DA:  Display of health risk behaviors on MySpace by adolescents: prevalence and associations.  Arch Pediatr Adolesc Med 2009; 163:27–34
[PubMed]
[CrossRef]
 
Media CS: Is Social Networking Changing Childhood? A National Poll. San Francisco2009.
 
O'Keeffe GS, Clarke-Pearson K, Council on communications and media. Clinical Report—The Impact of Social Media on Children, Adolescents, and Families. Pediatrics. 2011 March 28, 2011.
 
Lounsbury  K;  Mitchell  K;  Finkelhor  D:  The true prevalence of “sexting” .  Durham, NH,  Crimes Against Children Research Center, University of New Hampshire, 2011
 
Lenhart  A:  Teens, Kindness and Cruelty on Social Network Sites .  Washington, DC,  Pew Research Center, 2011
 
Mesch GS. Parental Mediation, Online Activities, and Cyberbullying. CyberPsychology & Behavior. 2009 08/01;12(4):387.
 
Weinstein  A;  Lejoyeux  M:  Internet addiction or excessive internet use.  Am J Drug Alcohol Abuse 2010; 36:277–283
[PubMed]
[CrossRef]
 
Ko  CH;  Yen  JY;  Yen  CF;  Chen  CS;  Chen  CC:  The association between Internet addiction and psychiatric disorder: a review of the literature.  Eur Psychiatry 2012; 27:1–8
[PubMed]
[CrossRef]
 
Li  RW;  Ngo  C;  Nguyen  J;  Levi  DM:  Video-game play induces plasticity in the visual system of adults with amblyopia.  PLoS Biol 2011; 9:e1001135
[PubMed]
[CrossRef]
 
Weinstein  AM:  Computer and video game addiction-a comparison between game users and non-game users.  Am J Drug Alcohol Abuse 2010; 36:268–276
[PubMed]
[CrossRef]
 
Pridgen  B:  Navigating the internet safely: recommendations for residential programs targeting at-risk adolescents.  Harv Rev Psychiatry 2010; 18:131–138
[PubMed]
[CrossRef]
 
Quitney Anderson J, Rainie L: Millennials Will Benefit and Suffer Due to Their Hyperconnected Lives. Washington, DC, Pew Research Center Report, 2012
 
Taylor R, Keeter S: Millennials: Confident. Connected. Open to Change. Washington, DC, Pew Research Center Report, 2010
 
References Container

Figure 1. Media Use by Age, 2010

This information was reprinted with permission from the Henry J. Kaiser Family Foundation (1). The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a nonprofit private operating foundation, based in Menlo Park, California.

Anchor for Jump
Table 1.Resources for Parents and Clinicians
Anchor for Jump
Table 2.Example Strategy for Working With Teens: W.A.I.T. Mnemonic
+

References

Rideout V, Foehr U, Roberts D. Generation M2: Media in the Lives of 8- to 18-Year-Olds. Menlo Park, CA: Henry J. Kaiser Family Foundation, January 20, 2010.
 
Business Wire: Digital Birth: Welcome to the Online World. Amsterdam2010 [cited 2012 March 29]; Available from: http://www.businesswire.com/news/home/20101006006722/en/Digital-Birth-Online-World.
 
Erickson  E:  The Eight Ages of Man,” Childhood and Society .  New York,  Norton, 1963
 
Committee on Public Education: Children, adolescents, and television. Pediatrics 2001; 107:423-426
 
Council on Communications and Media. Media use by children younger than 2 years. Pediatrics 2011; 128:1040-1045
 
Vandewater  EA;  Rideout  VJ;  Wartella  EA;  Huang  X;  Lee  JH;  Shim  M-s: Digital childhood: electronic media and technology use among infants, toddlers, and preschoolers. Pediatrics 2007;119:e1006-e1015
 
Council on Communications and Media. Media violence. Pediatrics 2009;124:1495-1503
 
Allison  SE;  von Wahlde  L;  Shockley  T;  Gabbard  GO:  The development of the self in the era of the internet and role-playing fantasy games.  Am J Psychiatry 2006; 163:381–385
[PubMed]
[CrossRef]
 
Small  GW;  Moody  TD;  Siddarth  P;  Bookheimer  SY:  Your brain on Google: patterns of cerebral activation during internet searching.  Am J Geriatr Psychiatry 2009; 17:116–126
[PubMed]
[CrossRef]
 
Small GW, Vorgan G: iBrain: Surviving the Technological Alteration of the Modern Mind. 1st ed. New York, Collins Living, 2008
 
Kutner L, Olson CK: Grand Theft Childhood: The Surprising Truth About Violent Video Games and What Parents Can Do. New York, Simon & Schuster, 2008
 
Ferguson  CJ;  Kilburn  J:  The public health risks of media violence: a meta-analytic review.  J Pediatr 2009; 154:759–763
[PubMed]
[CrossRef]
 
Sherry  J:  Violent Video Games and Aggression: Why Can’t We Find Effects? in  Mass Media Effects Research: Advances Through Meta-analysis . Edited by Preiss  R.  Lawrence Erlbaum Associates, 2007, pp 231–248
 
Children's Online Privacy Protection Act, 15 U.S.C. §§ 6501–6506 (1998).
 
New York Public Radio (WNYC): Parents helping kids lie online: transcript. 2011; Available from: http://www.onthemedia.org/2011/nov/04/parents-helping-kids-lie-online/transcript/.
 
American Academy of Child and Adolescent Psychiatry. Children Online. Facts for Families [serial on the Internet]. 2011: Available from: http://www.aacap.org/cs/root/facts_for_families/children_online.
 
Lenhart  A:  Teens, Smartphones & Texting .  Washington, DC,  Pew Internet & American Life Project, 2012
 
Moreno  MA;  Parks  MR;  Zimmerman  FJ;  Brito  TE;  Christakis  DA:  Display of health risk behaviors on MySpace by adolescents: prevalence and associations.  Arch Pediatr Adolesc Med 2009; 163:27–34
[PubMed]
[CrossRef]
 
Media CS: Is Social Networking Changing Childhood? A National Poll. San Francisco2009.
 
O'Keeffe GS, Clarke-Pearson K, Council on communications and media. Clinical Report—The Impact of Social Media on Children, Adolescents, and Families. Pediatrics. 2011 March 28, 2011.
 
Lounsbury  K;  Mitchell  K;  Finkelhor  D:  The true prevalence of “sexting” .  Durham, NH,  Crimes Against Children Research Center, University of New Hampshire, 2011
 
Lenhart  A:  Teens, Kindness and Cruelty on Social Network Sites .  Washington, DC,  Pew Research Center, 2011
 
Mesch GS. Parental Mediation, Online Activities, and Cyberbullying. CyberPsychology & Behavior. 2009 08/01;12(4):387.
 
Weinstein  A;  Lejoyeux  M:  Internet addiction or excessive internet use.  Am J Drug Alcohol Abuse 2010; 36:277–283
[PubMed]
[CrossRef]
 
Ko  CH;  Yen  JY;  Yen  CF;  Chen  CS;  Chen  CC:  The association between Internet addiction and psychiatric disorder: a review of the literature.  Eur Psychiatry 2012; 27:1–8
[PubMed]
[CrossRef]
 
Li  RW;  Ngo  C;  Nguyen  J;  Levi  DM:  Video-game play induces plasticity in the visual system of adults with amblyopia.  PLoS Biol 2011; 9:e1001135
[PubMed]
[CrossRef]
 
Weinstein  AM:  Computer and video game addiction-a comparison between game users and non-game users.  Am J Drug Alcohol Abuse 2010; 36:268–276
[PubMed]
[CrossRef]
 
Pridgen  B:  Navigating the internet safely: recommendations for residential programs targeting at-risk adolescents.  Harv Rev Psychiatry 2010; 18:131–138
[PubMed]
[CrossRef]
 
Quitney Anderson J, Rainie L: Millennials Will Benefit and Suffer Due to Their Hyperconnected Lives. Washington, DC, Pew Research Center Report, 2012
 
Taylor R, Keeter S: Millennials: Confident. Connected. Open to Change. Washington, DC, Pew Research Center Report, 2010
 
References Container
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Sample questions:
1.
Over the past few decades, a major factor increasing the burden on families of chronically ill children has been:

See Smith and Kaye, Introduction, p 255
2.
An often unrecognized psychological dynamic with the parents of chronically ill children is guilt over:

See Smith and Kaye: The Psychological Experience of Parents and Caregivers, p 256
3.
Diagnostic overshadowing is a frequent problem for mental health professionals assessing individuals with severe IDD. Which of the following best describes this problem?

See Barnhill and McNelis: Epidemiology and Natural History, p 300
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