Featured topic and speakers
Melissa Garretson, MD, member of the American Medical Association Board of Trustees, and Alex McDonald, MD, of the Southern California Permanente Medical Group, explore the challenges adolescents face online and how physicians can support their overall health. From screen time to sleep deprivation, Dr. Garretson shares strategies to help manage unhealthy social media use. This episode was created in collaboration with the PermanenteDocs Chat podcast and is hosted by family physician Alex McDonald, MD.
Speaker
- Melissa Garretson, MD, board-certified pediatrician, American Medical Association Board of Trustees
Host
- Alex McDonald, MD, family medicine physician and host of PermanenteDocs Chat, Kaiser Permanente
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Unger: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode is produced in collaboration with the PermanenteDocs Chat podcast. The host, Dr. Alex McDonald, talks with board-certified pediatrician Dr. Melissa J. Garretson about navigating social media’s impact on young people. Together, they’ll discuss the challenges adolescents face online and how physicians can support their overall health. From screen time to sleep deprivation, Dr. Garretson shares strategies to help manage unhealthy social media use. Here’s Dr. McDonald.
Dr. McDonald: Hello, everybody. Welcome to today's PermanenteDocs Chat. Our guest today is Dr. Garretson, who is a pediatric ER physician and among many hats is also a member of the American Medical Association Board of Trustees. So, welcome, Dr. Garretson. We are excited to have you.
Dr. Garretson: It's really great to be here. Thanks so much, Dr. McDonald.
Dr. McDonald: As you can all surmise, probably from the title, we'll be discussing the impacts of social media and the fact that Dr. Garretson is a pediatrician, the impacts of social media on the health of our young people and our teenagers in particular. If you're joining us live, please drop questions in the Q&A box. We'll try to get to as many of those as we can. But these are short, high yield chats, so please get your questions in early and often, and we'll try to get to these as many as we can. So, we're going to jump right in here. Dr. Garretson, in your own words, tell us who you are and what you do.
Dr. Garretson: So, thanks again for having me. I'm super excited to be here. I am Melissa Garretson. I'm a pediatric emergency physician in Fort Worth, Texas. I started out actually in private pediatric practice in a small group. And the thing I always like to say is I trained when there were no computers and there were no social media. That wasn't even a thing. The internet hadn't been invented yet. And so, this is a challenging topic for all of us as parents, when our kids grew up knowing how to do all this to try and outsmart our kids. We're working on it.
Dr. McDonald: Yep, yep. Well, let's start here with the tricks. So, recently, there's been a lot of research coming out, particularly regarding the mental health impacts on young people, regarding this anxiety, depression, sleep disturbances, body dysmorphia. It's really becoming a scary epidemic, quite frankly. And we think that social media plays a role in that, but we're not really sure, I guess from my understanding. Can you tell us what kind of impacts you've seen and what impacts we know about social media having on adolescents and young people?
Dr. Garretson: Well, so, I think the thing we need to acknowledge first is how pervasive it is in terms of its impact on child brain health and development. And you have to look back, I think, to the adverse childhood events data that we have for children under three and that impact that that has on their brain development across their lives. Even as adults, they're at higher risk of death. And so, when you look at that and you look at 95% of 17-year-olds have social media and use it on a daily basis in this country. If that doesn't blow your mind, I don't know what does, because there is nothing else that 95% of adolescents do altogether. Even eight- to 12-year-olds, 40% of kids use online social media. And so, it behooves all of us to start looking at this data to continue to investigate and research the impacts that we have on brain development.
I think the hardest thing about brain development research is we have no easy way to measure neurochemical transmitters in the brain. We're not going to do a brain biopsy. And so, some of this is anecdotal, some of this is self-reporting from kids. But we all know, because you don't have to think that far back how traumatizing adolescence can be. And then you magnify that by everything you're doing, 24/7 being shared with everyone you know. It tends to be an incredibly intense spotlight. And so, we see that in emergency department visits for deliberate cutting, depression and suicide attempts, and a lot of anxiety that we are seeing in a lot of kids. I think initially we all kind of blamed it on COVID. But when you actually look at the data, it actually started back about 2010, which in retrospect is about the time all the social media platforms really got going and really became very robust. And so, you have to wonder if there's very definitely a causal relationship to that.
Dr. McDonald: Yeah. No, I think like many things, COVID just magnified or put a spotlight on some of these preexisting problems and challenges. From my perspective, it's so hard to tease out what is related to social media versus pressures from parents, versus school. So, there's so many different confounding variables when you look at mental health research regarding social media. And we have no control, since 95% of young people are using social media on a daily basis. And so, from my perspective, anytime I think about this or address this with a patient in the exam room or in the hospital, there's just so many factors at play. It's really hard to tease out what's what.
Dr. Garretson: And I think one of the things that we can tease out very well, because we have a lot of data from pilots and stuff like that, is sleep deprivation. So, I think one way that all of us can help our patients, our families, and our loved ones do better around social media, is to acknowledge the impact that screen time can have on sleep. Whether it's you're on your phone, whether it's the light from your phone or the actual discourse that's occurring that causes kids to have difficulty with either falling asleep or staying asleep. We all know that sleep deprivation leads to poor choices, mental instability in terms of how you respond in stressful situations, which is why pilots have to have a regulated amount of sleep. And I think we can apply that to all of our lives.
Dr. McDonald: Yeah, absolutely. I mean, sleep, again, you're talking to a primary care doctor who's constantly preaching diet, sleep and exercise is the key pieces to just a foundation of health regardless of anything else. So, you had me at sleep.
Dr. Garretson: And I say nothing good happens after midnight, so you and I are lockstep.
Dr. McDonald: That's very true. And this is coming from a doctor who often, I assume you do some overnight shifts also. So, you have personal experience.
Dr. Garretson: For 20 years, that's all I did. I was the overnight doc for 20 years. And the number of times I'd walk into a room and the parents' asleep, the kid's on phone texting somebody, it's 2:00, 3:00 in the... I'm like, "Who are you texting? It's 3:00 AM and nobody should be awake." And they're like, "My friends." I'm like, "No, go to bed."
Dr. McDonald: Yeah. No, that's pretty true. Do we have any good studies regarding this or is this all more expert consensus and general themes?
Dr. Garretson: So, a lot of it is review studies. And so, you look at Pew who just recently published their report on the Pew report on social media use and online health. And again, we've got good data that shows an increase in depression and anxiety among social media users. Again, the cause and effect hasn't been established. And again, that's a tough causality to determine. We also have data that shows that suicide attempts have increased and now thankfully maybe plateaued, hopefully longer than just a year. But you do see some definite at-risk communities in online behavior, and increased risk for depression and anxiety, especially in women or girls as the case may be. And then minoritized populations tend to have higher stress regarding this and then the LGBTQ+ community as well.
And again, I think it's intuitive. Women have higher rates of depression in the general population. Minoritized populations have different stressors than traditional populations in our communities. And then you look at the LGBTQ community and understand the stress that they're under, especially in this day and age. It is not something we would doubt that they're under increased stress.
Dr. McDonald: Yeah, no question. And I guess I should give a full disclosure that I'm a parent of two teenage daughters currently. So, I have both my personal and my professional hat here, so I'll try to keep it professional. Can you explain … Or we've heard this concept of social media addiction, can you comment on that? Is that a real thing? And then what are some things that parents and physicians can do to help mitigate that?
Dr. Garretson: I think that's an emerging field that we're just starting to acknowledge being a thing. But 13% of 11- to 17-year-olds say that they're addicted to their social media. So, if the child thinks they're addicted to their social media, you got to know, we would think they're addicted to their social media. And so, one of the things I think that we need to acknowledge is that there are studies that we can do with imaging studies that look at brain stimulation regarding social media. And the amygdala and the prefrontal cortex are two of the things that light up when you're doing some social media interventions and studies with that. And so, the amygdala really controls our emotional well-being and our sense of self. And really the prefrontal cortex we all know is a developmental thing that helps us stop being impulsive and gives us a chance to be who we are as a person, rather than just reacting in the moment.
And when you get distortions in those things, a lot like other addictions, you can develop an addictive type pattern. And so, while I think no one's really quite ready to say absolutely, these are addictions. We are developing that same gaming addiction theory that we have regarding kids. And I think then the thing we do as parents, and that's really what we need to do as parents, is help set limits for our children to help stop that manipulation of their brain. And so many of the algorithms that social media companies use are black box. I don't even know that the social media people who own those platforms even understand the black box implications of those algorithms.
And so, understanding that there is some manipulation going on, there is some feedback loop that goes on that rewards you for continuing to click down the rabbit hole, sometimes in positive ways and sometimes in negative ways. It is one of those things that we need to be aware of and teach our kids. And I always say, we teach our kids to learn how to potty-train, and we teach them how to eat different foods, and how to ride a bike and things like that. We need to teach them how to make smart choices regarding social media and online presence. And I think that's one of the things that we as parents, when we have well-child checks with people, we need to include that in our guidance to them. And it needs to start pretty early since 40% of eight-year-olds and eight- to 12-year-olds are using social media.
Dr. McDonald: Yeah. No, you touched on so many great points that I want to highlight there. One is having a framework over the use of these devices and technology. Encouraging parents to set up guardrails, and boundaries, and set the parental guidance. Even though kids will probably figure out a way around it, at least if you set that standard up front. Just from my own personal experience, my 12- and 14-year-old have phones more for safety. They don't have social media because they're not allowed to have that, and the phone is mine. I clearly explicitly told them when they receive their phones, "This is my phone. I'm allowing you to use it between the hours of 8:00 AM and 6:00 PM." And then the phone shuts off outside of those hours and they can't even use it. So, my wife and I set very clear guidelines and boundaries from the beginning, which I think is much better than trying to crawl it back afterwards.
And so, that's something that I'm often telling my patients and my patients' parents, just from my own personal experience, because I think that's really, really key. And then the second piece also is, my understanding is that there've been studies showing that when you go down that rabbit hole and that someone likes your post, a little blip of dopamine goes off in your brain. And there's a lot of those same neurochemical pathways regarding social media as use disorder, and drug and alcohol addiction. And so, I think we have pretty clear evidence that it's a setup for use disorder just like many other conditions. Is that accurate?
Dr. Garretson: I think that's very true. And I think, again, as we've been having social media now for 14 years, and so we don't have as much robust data as we do for other addictions. But it's really easy to see how that setup and that algorithm is that same thing. "I want to keep you here. The longer you're here, the more I win, the more advertising I can do." It goes from there for sure.
Dr. McDonald: Yeah. So, we have a question in the chat here, which I think directly relates to this. And so, the question relates to, we talk a little bit about strategies the doctors can use with their parents and their kids, but how do doctors advise parents about how to talk to their kids and teens about regulating social media use without just getting a giant eye-roll response? I don't know the answer to that one. That's a tricky one.
Dr. Garretson: No, I think you're going to get an eye roll. I mean, you're a parent, so if you don't get an eye roll at least three times a day, I don't know that you're doing something right as a parent—you should be getting eye rolls. But the thing about it, I think, is that it's the actual conversation. And yes, they're going to be like, "You can't tell me what to do and you can't limit what I do." But yes, you can and you do as a parent. Every day, when you make them get up and go to school, that's an everyday thing we do. But I agree with you, and one of the things that was so effective with my own children is the same thing as yours. Having the ability to have that conversation, doing it upfront and letting them help you set up what the rules are.
So, they've got some buy-in. And there's a website, healthykids.org, that has sample family social media plans. And you can set that up yourself where you and your child go together, select how many hours, what sites, how often can mom and dad look over what you're doing and help you as a parent engage in positive conversations. Social media isn't all bad, but there are pitfalls. And so, again, having that conversation. And I always, with my kids too, because you hear all those horrible things in the news. If you make a mistake and post something online, I promise it's not the end of the world.
You have to tell me so I can help you, but I'm not going to be mad. And you're not going to disappoint me for the rest of your life. And this isn't the end of your life. If you can tell me about it, please, I can help you. And it was a conversation we had all the time, because kids are impulsive and they make poor choices in the moment, and that's why we need to be there to help them.
Dr. McDonald: Yeah. No, that's great advice overall. I like to joke that my daughters, and my wife, have extremely strong extraocular muscles due to their amount of times I make them eye roll every day. So, I wear it as a badge of honor.
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Dr. Garretson: You are doing it well. Good job.
Dr. McDonald: What are the positive benefits of social media? What are some of the fun elements, and how do we use some of the creative benefits of social media to help our children, honestly?
Dr. Garretson: And so, I think that is there are safe spaces that children can go to where they share their likes, share their talents, display some of their artwork in positive ways. And I think, too, surrounding yourself in a friend group in your online presence with people who you are friends with and are supportive of you, can be a nice way to make those connections when you can't see each other, when you're separated by illness or other things. I think, too, there are specific communities that benefit tremendously from that online support as well. I mean, the LGBTQ+ youth group is one of those places where you need as much support as you can get. And it truly does take a village to help raise well-adjusted kids.
I think, too, when you have special talents that you can share that and develop those further. You look at kids with cancer, they're often in the hospital. They're away from their peer groups. They're missing their social connections. Social media allows those kids to connect. It also allows those kids to not feel like they're the only one in the whole wide world with this disease or going through similar things. And you can say that about any chronic disease, especially in children. That lifts them up to understand they're not alone and there is hope. And look, there's somebody who's 15 when they're 11. And you can get there. And there are ways to make it through this disease, and not give up and not lose faith. And so, I think there's tremendous positive opportunities. We as a society and as parents, need to make sure our kids are engaging in those positive experiences and able to identify when something is negative. And that, again, isn't something you're going to naturally know. We have to teach our kids what those things are.
Dr. McDonald: Yeah. I think one piece of advice that I will often give my parents is to model good social media behavior. So, sit with your kid, and flip through Instagram, and make it more of an ... You have trouble interacting with your teen, they won't talk to you. Sit there with the phone, looking at whatever the Instagram feed is or social media feed. And you can comment, and you can help verbalize how images may or may not impact you. And I think that's a way that parents and kids can actually, one, connect and bond, but also parents can model good behavior. For those of you on the call who may be paying more attention, I like to declare that I have SMUD or social media use disorder. It's a term that I'm working on. I don't think it's in the DSM-5 yet.
Dr. Garretson: Not yet.
Dr. McDonald: But I like to use social media as a platform to amplify my own voice as a physician, as a community member and give advice, but also model good behavior at the same time. So, I think as physicians, you have advised your parents in the exam room and in the hospital, but you can also as a parent and as a member of humanity, you can model good social media behavior as well.
Dr. Garretson: Exactly. And I think, too, as a family, you make a commitment. We're not going to have our phones at meals. Well, that means me too. It's not just them. It's me too. And it goes down an hour before bedtime so you don't disrupt sleep as much. Same thing for the adults. We are always like this. My husband accuses me of being like this because my phone is my book. It is my work. That's where I do all my documenting. I mean, it's like all right there. And so, it is a very conscious choice that you have to think, okay, put it down. Put it down. Yes, I totally agree. Modeling that for both our patients and our families is incredibly important too.
And I think just sharing the struggles. In my world, and when my kids were in that middle school, high school thing, I reached out to all of their friends' parents. So, we all had conversations together. And I will tell you, too, there are a number of times when I was the mom that the kids would come to when they weren't necessarily comfortable talking to their own parent about stuff that was making them uncomfortable. And then we could talk through it together. And then I could redirect them back to their parent in a better way that helped them feel more comfortable to do that. Not that I was taking a parent place, but they felt comfortable sharing with me, because I was open in those conversations and that dialogue is critically important.
Dr. McDonald: Yeah. No, I think that makes perfect sense. Here's a question which is actually in the chat, which actually segues nicely to my next question here regarding putting restrictions or guidelines on social media. There's some people that want to legislate the role that government and local elected officials have regarding social media use. But then, also, there's a question here, like particularly with limits on social media being beneficial for two hours or less, are there any sort of guidelines and then is there a mandate or legislative fix that we can put on this?
Dr. Garretson: So, there's lots of talk about legislative fixes. And the Surgeon General called for a warning label on social media platforms back in, what, June of this year. And that would take an act of Congress to do. And I don't know. I mean, I think more so than anything, the fact that the Surgeon General called for that raised the awareness of every parent and every kid that perhaps this is a big issue and we might need to pay closer attention to what our kids are doing online. That's the first thing. I think … and there is a bill, the Children's Online Privacy and Prevention Act. That is a bill that exists, which does seek to perhaps set up on social media companies more responsibility to allow them to open up what their algorithms are, to help us understand what guardrails we can set up within the system, what they do with our kids' privacy data. Which is a critical issue for all of us, because who hasn't been aware of the Change Healthcare debacle and the ability of online nefarious actors to steal data?
That's huge. And so, I think that it does behoove us to take that approach. I don't think setting a—have to be 12 years old, or you have to be 20 years old to use social media is going to work. This is an individual child thing. You raise your child. You're going to have a better feel for when they're emotionally ready to handle some of the stresses and the decision making involved in using social media. And so, the American Academy of Pediatrics really hasn't come down hard on an age before or after you should use social media. It's more so an awareness of when your child is emotionally ready for this. And that's going to be different in every child in each situation.
Dr. McDonald: Yeah. Well, I like to use the example of competency-based training in residency education.
Dr. Garretson: Correct.
Dr. McDonald: Not every resident or medical student is ready for every procedure or treatment option at the same point in their training, their career. And the same thing with children. They all develop very differently at different rates, and some are already at different times than others. One piece here that happened locally at my school, my children's high school, is they decided they would put some guidelines and some policies regarding social media use. And there were some people that wanted to ban cell phones entirely at school, but we took a little bit of a different approach where we would basically ban during instructional time. They could use their phones during passing period. They could use their phones at lunch. And I think by simply banning it that we missed an opportunity to teach our children. Versus if we can, again, model good behavior, and set policies that help them learn limits, and learn how to live and interact with these little devices which are ubiquitous, that's going to help educate them and help them become happier, more well-adjusted adults as well. But again, that's my own personal bias.
Dr. Garretson: Well, I mean, I think that's true. And again, I think there are different situations. And a lot of the conflict over cell phones in schools centers around safety and then lack of learning, because kids are totally on this instead of face forward, looking at the teacher kind of thing. And I do agree with you. I think that is a learning opportunity for all of us, but it also behooves us in a scientific role to help teachers understand ways that they can teach. I mean, they're struggling in the dark just like the rest of us, trying to figure out the best practices for how to use social media and how to identify scary people who really aren't the 15-year-old best friend you thought you had.
Dr. McDonald: Right, exactly. No, it's very true. This has been phenomenal. We could probably go on, and on, and on, but again, we try to keep these short and high yield. So, my last question and my favorite question, what makes you most proud to be a physician?
Dr. Garretson: I think every day when I go to work, it seems kind of funny, saving a life in the emergency department is a big deal. But really helping a family connect with one another when they're at odds and they're struggling with one another, helping them to be able to understand one another and move forward. That's a lifetime kind of change for me and I really do like that. 90% of what I do in the emergency department is primary care pediatrics. It really is. It's helping parents raise their children.
Dr. McDonald: Fair enough. Dr. Garretson, thank you so much for joining us and sharing your insights and expertise today. We really appreciate your time.
Dr. Garretson: I appreciate it very much. Thanks so much.
Unger: Subscribe to the PermanenteDocs Chat podcast to never miss an episode and register to take part in upcoming live chats. Visit permanente.org/amadocschat.
Disclaimer: The views expressed in this podcast are those of the speaker and are not meant to represent the views of The Permanente Federation, the Permanente Medical Groups or Kaiser Permanente, or the views and policies of the AMA.
