Hi, welcome to our presentation, Friend, Frenemy, or Foe? The Role of Adolescent Social Media Use in Race-Based Trauma. My name is Stephanie Garialde. I am an APA-APAF Child and Adolescent Psychiatry Fellow and a first-year Child and Adolescent Psychiatry Fellow at the University of Florida in Jacksonville. I will be presenting, along with Asha Martin, who is an APA Diversity Leadership Fellow and a first-year Child and Adolescent Psychiatry Fellow at New York Presbyterian. We have an exciting group of panelists today, consisting of Dr. Katelyn Costello, who is a Program Director at UCSF, Dr. Tresha Gibbs, who is the Medical Director of Outpatient Services at New York City Children's Center at Columbia University, and Dr. Gabrielle Shapiro, who is the APA Chair of the Council of Children, Adolescents, and Their Families and is at Mount Sinai. We have no conflict of interest to disclose today. So our objectives today are to outline the role of social media during periods of heightened attention to police shootings of unarmed black males, describe healthy developmentally appropriate social media use by adolescents and their families in the setting of collective trauma, identify features of problematic social media use in adolescents, which may increase trauma and other negative mental health impact, and finally, practice communicating with youth and their families about patterns of use and identify strategies to mitigate negative mental health impact. So before we get going, it's important that we understand the concept of structural racism. So structural racism is the way in which society perpetuates racial discrimination. This is not necessarily consciously done. This is often historically rooted and then culturally reinforced through things such as laws, education, housing, and so on. An example of structural racism is police brutality. So when we talk about police brutality, we're talking about the excessive use of force of law enforcement officers in situations where it's not appropriate and such as in the shooting of unarmed black individuals. For instance, in November 23rd of 2014, Tamir Rice, who was a 12-year-old black male, was shot and killed in Cleveland, Ohio, by law enforcement officers for just carrying a toy gun. So police brutality is not a new issue. This is something that has been going on for a very long time. But fortunately, through media coverage and social media, this has been something that has been, that we, there's been a lot of awareness on. So social media has really become a tool in which, you know, people can console, educate, share information and, you know, during situations of crisis. So here we have a timeline of police, of events during the police brutality. And it's in the associated social media activism that occurred around that same time. So for instance, when Trayvon Martin was killed, Black Lives Matter hashtag came about and started a movement. So yeah, so that's how this works. Another example of social media activism is the Blackout Tuesday movement. And this started following the death of George Floyd end of May of 2020. And this was initiated by the music industry who wanted to show their support for the victims of the police brutality. And so they wanted the music industry to pause, the music industry to pause. And so they disseminated the information through the show must be paused. And this got adopted by a lot of artists and it spread beyond the music field. And it became adapted to the Blackout Tuesday hashtag, which then got further evolved into the Black Box postings on Instagram. And about 20 million people posted black squares on Instagram. So it's a pretty big movement. So in terms of social media activism, we know that social media has been used to gain followers, to get friends to post about vacations. But when we talk about social media activism, there's really three main purposes. The first is financial. So we talked about Blackout Tuesday, and that was to talk about the importance of the dollar. So the importance of putting the dollar in Black communities and taking it out of large corporations. There's also repost for financial incentives, and the show must be paused or other benefit concerts or things to raise awareness to celebrities and other people that may donate to the movement. There's also we have organizing. So here I have the Instagram account justice for George NYC. And this was huge, at least in New York City, where I'm based during the time of the George Floyd movement. So there wasn't much happening in terms of media coverage, things were happening so rapidly on social media, you needed a source to find out where the protests were going to be happening. And this was just updated live. So if police were in one location, or if it was raining, things would be postponed. And there were just rapid updates for moving and organizing. And this is a photo that I took at one of the protests. And then of course, a big thing is to raise awareness. So to say, this wasn't just an isolated issue. This isn't just the incidence of one bad cop or one bad day. But this is occurring. So we would go on social media, and you're reading about George Floyd. And then you see that months later, the death of Ahmaud Arbery happened or Breonna Taylor. So just spreading awareness and making people know that this wasn't just one bad episode. And along with that, if you look at the data, we see that in 2020, 23% of US adult social media users said that they changed one of their views based solely on social media. And the two most popular views that were changed, were actually on Black Lives Matter and that movement, and also police brutality and the need for police reform. So social media has really been a powerful tool. But of course, there is the other side. So with rapid spread of information, so you're going online, you're looking through the slides, sorry, you're looking through the posts, and then you see all of these deaths, you see all of these murders, there have to be some sort of risk associated with that. And I'll be talking about trauma. So we have collective trauma, that's a psychological stress reaction that's shared by a group that did not necessarily have direct exposure to the traumatic event. So we could think of that as like the US population. And that's saying, as American citizens, we were stressed out, we had the COVID-19 pandemic, increased racial tensions here in the United States, and that was stressful. So that's a collective trauma that we all experienced. And a lot of us weren't directly at that murder that happened. And then we go to race-based traumatic stress. So that's the added stress that minorities have from racism and discrimination. So in addition to the collective trauma, minorities experience unique stressors. And this can range from like PTSD, to even depressive symptoms. When you look at collective trauma and media exposure, most of the research is based on the Boston Marathon attacks. And we know that the response ranges from short-term anxiety to more long-term PTSD and also depression. An interesting thing is that you get increased psychological symptoms with repeated exposure. So the more you're exposed to the media coverage of these events, the more symptoms in terms of psychological distress that you're likely to experience. One interesting thing that I found is that several hours after repeated media exposures were associated with higher acute stress scores than individuals with direct exposure. So those people that were at home watching coverage of the Boston Marathon bombings had higher acute stress than those people that were actually at the bombings themselves. So this just shows how big of an effect social media and other media can have. And exposure to the media was linked to continued worry about ongoing mass violence and just traumatic stress symptoms. We looked at race-based trauma and media. There's two studies that I really like, and it's important to recognize that race-based trauma is thought to be a physiological response, not pathological. And that basically means that it's racism and discrimination that's stressful. It's not that being a Black person or being Black is stressful. It's racism is stressful, discrimination is stressful, and someone that experiences that, that's a normal physiological response to be stressed out by that. So one study was looking at adults living in states where police shootings of unarmed Black residents occurred, and they found a greater number of poorer mental health days. And this was just adults and just occurring in the states where the shooting had occurred. But we know with social media, more people were exposed to media coverage and potential trauma that were living outside of those states. So what I like about this second study, it actually looked nationwide. So it wasn't just restricted to the states where the trauma occurred. And this occurred in adolescents who we know are high social media users. And what it found is that Black and Latinx adolescents with repeated traumatic exposure to online discriminatory content, and they looked at social media specifically, those people showed increased PTSD-like symptoms. And what they also found is girls had more depressive symptoms as did Latinx adolescents. So there is a risk of trauma with repeated social media exposure to race-based discriminatory content. So when we're looking at this, it's really going to be important to think, is social media a friend, a frenemy, or a foe? And Dr. Costello is going to help us decide. Thanks, Sasha. So I'm going to talk a little bit about how do we go about assessing that the comparative risks or benefits for a given teen interacting on social media. And in addition to the race-based trauma and collective trauma that Asha talked about, social media carries a number of potential benefits for adolescents and the number of potential risks. So some additional benefits include general social connections that wouldn't be possible outside of social media. This is, of course, particularly salient in these pandemic times when opportunities to communicate in person are really limited. Overcoming geographical barriers and being able to connect with people who it otherwise wouldn't be feasible to because of lack of proximity. Social media can help link up people to in-person and community activities, and we heard about some of this with how, especially during a pandemic, how were people going to know about protests to join and so forth? And a lot of that communication happens on social media. Social media can facilitate social connections for youth who may be shy or socially anxious. We need to be careful about assessing that because there's also the risk of social media replacing in-person communications because it's easier for someone who might be suffering from social anxiety. Educational collaborative learning. You can connect and enhance each other's learning as well. And then building digital literacy because, of course, this is more and more important as technology purposes. Next slide, please. And then, of course, social media carries a number of risks for young people interacting online. Exposure to cyberbullying, exposure to cyberstalking and online harassment. Texting and sexting carries some potential legal risks, too, with the risk of that being considered child pornography and being exposed to criminal risks. Exposure to online solicitation and predation. Exposure to substance use, and this can come in the form not just of facilitating the logistics of acquisition, but also facilitating substance use through what's called peer injunctive norms, which are what you think your peers think is cool, essentially. And there's some research to suggest that as a mechanism for facilitating exposure to substance use. And there's a broad category that we could call reputation damage. And this is basically posting things that when they're out there on the internet and people can access them forever, it might be detrimental to the reputation of the young person. They're creating a digital footprint that's going to follow them around. Posts can be viewed by unintended audiences. That can have real implications for their futures. Surveys of admissions officers and employers have revealed that some of them do look at social media posts when making those decisions. Next slide, please. Just to illustrate this idea of reputation damage, just one small example. So this was a high school student who tweeted sort of a mild and joking criticism of the school superintendent and then was suspended from school for it. And that might not even be the worst part, because if you Google this teen's name, this is the first thing that comes up. And is this what he wants associated with his name for the rest of his life? It can get worse than that, too. In the current era of worries about school violence, anything that a teen might post in frustration that could be interpreted as a threat can get taken very seriously, not only by schools, but also potentially by police and lead to real consequences for something that the teen never intended to carry. Next slide, please. And then, of course, very salient to what we're talking about today, the effect of social media on mental health. And this relationship is somewhat complicated. So studies have been somewhat mixed, but a large study of over 6,000 adolescents published recently in JAMA Psychiatry found that social media use of over 30 minutes per day, which is not very much social media use for today's teens, was associated with a greater risk of internalizing and comorbid externalizing symptoms. And when they adjusted it for pre-existing mental health and substance use conditions, social media use of three hours per day, which still isn't that much for today's norms, was still associated with those symptoms. Even with that adjustment, it's hard to really establish a true causality because it's complicated there. But we know that social media can pose risks to mental health, and we need to be careful and be assessing that. Next slide, please. So the legal context of all of this is important, too. Essentially, when you click, I agree on the terms of service, you're entering a legal contract with a social site. There are limited legal protections for young people posting online. There's a federal law requiring parental permission, but that only applies to ages under 13. And then there have been some recent legislative efforts to protect all minors under 18, such as California has a law that a site that has customers under the age of 18 has to let those customers delete their posts. But in general, there's really little legal protection for what kids are posting online, in contrast to almost every other area of the law where juveniles under age 18 are considered immature compared to adults. The trend in criminal law is very much towards recognizing the immaturity of juveniles as different from adults. A recent series of Supreme Court cases on juvenile sentencing relied heavily on our evolving knowledge of adolescent behavior and brain development, and really that the immaturity, less sense of responsibility, adolescents are prone to recklessness, impulsivity, risk-taking, they're vulnerable to peer pressure, and they're less able to assess the consequences of their actions compared to adults. Also, in non-online contracts, minors either can't contract in general, or their contracts are avoidable if they want to avoid them, but that doesn't apply to these contracts that they make with social media sites. Next slide, please. This is all happening in the context of just how adolescents make decisions about everything, and knowing a little bit about this has really helped me understand how they're interacting online and what we need to watch out for, and so recent research shows us that the skills for different steps of decision-making reach adult-level maturity at different rates. So again, these are legal decisions that adolescents are making, entering a contract to post online. In other legal decision-making areas, it's been found that juvenile decision-making seems to reach adult maturity sort of around mid-adolescence, around age 15 or 16, but that process of decision-making involving psychosocial maturity appear to develop later, and we'll go into this a little bit. Next slide. So my favorite study to illustrate this was done by Steinberg and colleagues. They looked at young people ages 10 to 30, and they gave them tests of cognitive skills and psychosocial skills, and so the cognitive tests, which are sort of pure cognition, working memory, digit span, verbal fluency, and they found that the older kids did better than the younger kids, but it topped off at about age 16. So the 16-year-old did much better than the 10-year-olds, but in their 20s, they didn't do any better than when they were 16, and this matches up pretty well with kind of lots of other ways that we've tested just sort of pure cognition seems to be fully mature in mid-adolescence around age 16. Next slide. In contrast to psychosocial maturity, and so for that, they tested risk perception, sensation-seeking, impulsivity, resistance to the influence of peers, and orientation towards the future as opposed to towards the presence. We found a pattern increasing skills with age, but they didn't start increasing until age 16, so the 16-year-olds didn't do any better on this than the 10-year-olds, and then they continued to improve such that young people in their older 20s, you know, were doing better than the 18 to 21-year-olds. So really, these kinds of decision-making skills are returning much later, and even in older adolescents are still pretty immature. Next slide, please. So the authors concluded in the context of other research about how adolescents make decisions that it really matters what context are making these decisions in, not only the type of decisions, but the context in terms of how mature an adolescent's decisions are likely to be. So adolescents are likely to be capable of making mature decisions in situations that permit deliberative, reasoned decision-making, where emotional and social influences are minimized, and where the consultation of adults is available. Next slide, please. In contrast, they're likely to make immature decisions in situations eliciting impulsivity, high levels of emotional arousal, or social coercion, or not encouraging expert consultation, and when you think about how adolescents are making decisions about interacting with social media, you know, they're typically not making these deliberatively. They're not usually consulting with adults, and social media is highly emotionally salient, and the social and peer pressure component is really strong, and so this is just a setup for adolescents to be making pretty immature decisions about how they're interacting online. Next slide, please. This just matches up with a lot of the other recent body of literature on adolescent brain development, you know, that shows that the areas of the brain relevant to these kinds of decisions are continuing to mature through adolescence, and even into young adulthood. Next slide, please. So, knowing all of that, how does that inform how we're going to assess risk versus benefit for a given teen interacting with social media? So, first, we need to know what sites they're using, and how they're using them. What specifically are they viewing, and what's the content of that, and is the content something that we're worried about, and then what specifically are they posting, and is the nature of what they're posting something that we need to worry about, and so, you know, we can ask them to show us their social media activity, and many teens are willing to do that if you ask them and approach it with curiosity, but knowing the details is really important there, because the risk can be so variable from adolescent to adolescent, and this does require us to keep up with the landscape of what's going on recently, what are the sites that teens are typically using, and how do they function, and what are the, you know, the capabilities of each site, because that really will inform the risks that they might be taking, and we, you know, if you're not personally using a lot of social media, the teens in your lives can teach you about it, your patients can teach you about it. And many teen patients are gonna be more than willing to if you ask them. As an example, back in the early days of Snapchat, it was from a teen patient that I learned that even though the images disappear, there's a risk that someone can do a screenshot and keep it and send it on to other people. And I learned about that when a teen showed up in the emergency room because sexually explicit images had been screenshotted and sent out to a bunch of peers and she ended up in the emergency room with suicidal ideation. Next slide. I think it's a good place to start by assessing the positives of social media. And teens may be much more open to disclosing some of the risks if you acknowledge that, yeah, they do get a lot out of it. And it's not just a problem. And in many ways it can be helpful. And so is it facilitating social connections that they wouldn't otherwise be able to have? Is it facilitating in-person connections that are positive for the teen? And then are there positive impacts on mental health? And those can come through being a decreased sense of isolation, being able to connect with people with similar experiences that they might not have access to in their in-person lives. And that relationship with mental health is complicated and you have to think about it for the individual teen which is going to very much depend on the specifics of their use. Next slide. And then the risks. So are online connections replacing in-person connections? Are they being exposed to upsetting and traumatizing content? And are they having negative impacts on their mental health? And again, that's a complicated assessment that depends from teen to teen, but things like cyber bullying, of course, can negatively impact mental health. The phenomenon that they used to call Facebook depression where you see people presenting highly curated versions of their own lives and all their glamorous vacations and stuff, and then your own life looks pretty boring in comparison, that can have a mental impact on mental health. And then you need to assess for specific risky behaviors for the given teen. So are they meeting people that they met online in what's potentially a dangerous situation? Are they posting content that's likely to damage their reputation and that they won't want out there in a few years? Is it facilitating their use of substances? Are they being exposed to cyber bullying, cyber stalking, online predation? Is that person that they think is another teen that they're talking to online, is that even actually a teenager? And then sexting can have multiple implications, images being spread around to all of their classmates when they didn't want them to. They can be exposed to criminal liability because that may, depending on your state laws, be considered the trading of child pornography. A special note on sexting is you may need to be careful in how you assess that. Depending on your state law, you may be a mandated reporter of child pornography. For example, in California, we are mandated reporters if our patient is viewing or distributing child pornography. So have to be careful about how you're assessing and what you might learn and what you might need to do with the information. Next slide. And then as part of this assessment, we want to assess how we can be helpful to this teen in the risk that they're facing. So we can educate them about the risks and we might think that it doesn't really matter because they're not thinking about the risks when they're posting online, even if they know them. And to an extent, that's true. But again, back to the research that adolescents are able to make more mature decisions when they consult with expert adults and when they do them in a deliberative manner. Think about safety planning around the risks, both about in-person dangerous activities and about risks of self-harm when something goes wrong online. Think about how we could maybe help with damage control to their reputation if that occurs. Evaluating and treating related mental health symptoms, of course. And then recruiting parents to be part of this conversation too. Recent surveys show that most parents aren't highly aware of what their teens are doing online and their teens can be exposed to a number of really serious risks. And so we wanna really encourage parents to be in the loop there. And with that, I'll turn it over so we can talk about our case. So I'll be leading us through a case and throughout the case, we'll present the case and then we'll break up and have some discussion questions. And then towards the end, we'll kind of summarize the case and think about how we might wanna present this information to families. So we get this patient, we get a referral packet end of June, and this is our patient. So Carter is a 15 year old male. He's a high school sophomore in New York City and regular education classes. He lives with bio mom and dad and also a twin sister. He doesn't have a prior psychiatric history that we're aware of. And he was referred by dad for evaluation of what dad says is depression and social media addiction. When we get the intake packet, we find out in terms of past medical history, there really isn't anything. He's not on any meds. He has no allergies. There's been no surgeries in the past, no significant family history. And he met developmental milestones on time, had routine prenatal care, and it was a normal birth, normal pregnancy. Social history, he lives in Brooklyn. He was born and raised there. Both of his parents are black. Mom is from New York City and dad is from Puerto Rico. They actually met in college, have been together for a long time. They're both employed. Mom works a lot. She's a neurosurgeon. So dad is really at most of the appointments. Carter was born when they were really young. So in their early twenties, and they were struggling at that time economically, trying to get moms through med school. Carter grew up in affordable housing, what they describe as a rough neighborhood. And he witnessed gang-related violence. So they say there was gang violence that he saw and the building complex that they lived. There was also a lot of domestic violence outside of the home, but that he heard a small New York City apartment. So just a lot of exposure to violence in early childhood. Later, he moved to a more affluent neighborhood because the parents just wanted him to have a better start. And that was around when he was eight years old. School, he's recently completed 10th grade. School is virtual right now. He's usually an A, B student. Never repeated a grade. There's been no suspensions. He's involved in a lot. He loves computers. He loves video games. He's a video game club president, and he's also involved in Model United Nations. So he loves to debate. In terms of relationships, he gets along well with his twin sister. They have the occasional sibling rivalry, but overall, nothing serious. Very supportive relationship with parents. He's close to both. And he has a girlfriend, describes it as a healthy, supportive relationship, and they've been together for about one year. Psychiatric history, he has no prior diagnoses. There's been no inpatient treatment. Outpatient, he got short-term in-school counseling in middle school for a bullying incident. So when he moved, he was actually bullied for being a little bit darker. He was called a lot of names based on his appearance. He was told that he was too ghetto and that the way that he talked was odd. And he really took hard to this and went to in-school counseling. No suicide attempts or self-injury. And like we talked about, just that witness violence. Trauma, so for the bullying in middle school, he remembers being very tearful, very upset. Parents say it was hard on him, but he did get better with school counseling. They didn't seek outside help. Substance use, he tried marijuana twice. It wasn't really for him, doesn't use anything right now. And psychosocial consideration. So we said that our patient came to us the end of June. It's important to realize George Floyd was murdered four weeks ago. And even though Ahmaud Arbery and Breonna Taylor died before then, he only recently learned of their deaths through social media. So our first discussion question for Dr. Gibbs, are there any risk factors based on this case for the development of either race-based or collective trauma? So thank you so much, Asha and Stephanie for presenting this wonderful case and for Kaitlyn for presenting such a nice overview of social media. The question of are there any risk factors for development of race-based or collective trauma? So I would say yes. This case highlights several risk factors that we could inquire more about and be curious about with Carter and his family. You know, at the individual level, we consider Carter's own developmental level, right? So he's consolidating his identity and his place in the world. And when we think of his individual experience of racism, we can imagine that he will recall that episode of being bullied in middle school because of the color of his skin. There's also this topic of like, you know, his interaction with the internet and with social media, and that there's a lot of online hate speech and that comes up in comments and that comes up in images and especially during that time, so that he may have also encountered racism online that we should inquire about. At the level of like his vicarious trauma, like so that he's aware of these deaths at the hand of police or others. And he, you know, even though he wasn't there, there is that vicarious identification. I mean, he is a young man, a young black man who could identify very much with the victims. And so I think that would reinforce some of his own concerns, you know, about his own bodily integrity, his safety in what's a structurally racist society. And so I think the other risk factor I would think about is, you know, at the structural level, you know, he has this experience of moving from a rough neighborhood to what is described as more affluent neighborhood. And while we don't really know the makeup of either community in detail, often these are segregated spaces. The differences are probably not lost on Carter as he pertains to his own experience as a black American. So we also want to remember the experience of his parents. So I think overall, we can be curious about his prior exposures and his risk factors and about his protective factors as well, and the way that his family and community cope with the stress of racism. So the next question we wanted to sort of think about was why is the societal context important in this case? So what's happening in the world at the time of the presentation? I mean, really with the pandemic, kids being in virtual school, kids having more time with their family, there's been a drastic change in what's going on in the world. And, you know, because of the Black Lives Matter and all the protests and the concerns about police brutality, you know, our whole society is really being group traumatized. So for me, that brought up a lot of emotions and we're hearing the dad reach out for this evaluation and, you know, very concerned about Carter, but what's also going on for the parents? So high emotions, our whole society was in high emotions. Imagine, think of it, everyone's locked up for all these months and then all these terrible things happen and we get together as a group and we explode with feelings and emotions and the desire to do something and be out also. So in terms of the micro context, he's in New York City. It sounds like this family, you know, sort of has pushed to be upper middle class or middle class and, you know, move to a mixed race neighborhood, I'm assuming, where it's different than it was when he witnessed the violence. And so, you know, I think this is all very, very important to think about and also think about what developmental stage Carter's in. You know, if we want to talk about Erickson, it's identity versus role confusion. So, I mean, I think a lot of the stuff that we're hearing about or the concerns of the parents have to do with some of the developmental tasks that are normative at this age. All right. Thank you. Thank you. Let's move on to the patient and the family interview. So the patient tells us that he's been using social media for about seven hours per day for the past four weeks. He's been on Instagram, Twitter, Facebook, TikTok. He says he uses it to find out and promote protest and other events. He's also telling us that he's been posting a lot about systemic racism and ways in which to support the black community. He feels like it provides an outlet for him. He also says he has felt sad by the videos of the murders, but is able to disconnect most of the time. However, when we talked to his dad, dad says that Carter is glued to his phone and all posts related to Black Lives Matter. He has also even blocked and canceled some of his friends. So on our psychiatric review of systems, he denies any symptoms of depression, hopelessness, anhedonia, there's no changes in his energy, no suicidal ideations or homicidal ideations. We do know that he is having some difficulties falling asleep and he talks about fear for his safety as a black male teenager. No panic attacks, no history of psychotic or manic symptoms and no current substance use. So when we talk to Carter a little bit more to understand his perspective of what's been going on, he tells us that he feels sad at times spending a lot of time on social media. The protest gives him hope and gets him excited when he notices that some of his friends are talking about change. He does feel stressed and overwhelmed at times with balancing school and protests and his emotions, but his grades have not declined. He still feels that he's enjoying spending time with friends and feels that, or especially the friends that he feels that get what's going on. He thinks he could benefit from cutting back on social media but is afraid to miss out, thinks his parents, and he's afraid he'll miss out and he thinks that his parents might be blowing this out of proportion. So our mental status examination, so he, you know, overall he appears as stated age, he is dressed casual, he's cooperative, well-related, guarded at times, no abnormal movements, his affect, or his mood he describes as fine, I guess. And his affect is mood congruent, appropriate, euthymic, thought process is future oriented, linear, logical, thought content mainly on protest. And there are no acute safety concerns or paranoia or delusions. His perceptions, he's not internally preoccupied and his insight and judgment appear to be fair. All right, so let's get on to a discussion question. So how would we characterize Carter's social media use? Are there any red flags or maybe yellow flags that we might want to monitor a little bit more of? So at this point, I would say that we're more in yellow flag than red flag territory. So if we think about first the impact on Carter's mental health and his social media use, from his description, this does appear to be somewhat mixed. You know, so he's describing both that he gets upset by some of the content and that he feels hopeful by some of the content as well. And this is something that we probably wanna talk to him more to get more information about what that balance is, and to keep an eye on as time goes by as well. His father came to us with a concern about social media addiction, and Carter's certainly spending a lot of time on social media. So, you know, we can see why his father might be worried about that. You know, the DSM has not yet formalized social media addiction as a disorder, but if we think about, you know, sort of the general criteria for addictive disorders, it doesn't seem like from the information we have that Carter meets those criteria. You know, certainly he continues to function well in other aspects of his life. You know, again, something to monitor. And then in terms of specific risk-taking behaviors, so we know that he is using social media to facilitate in-person connections, and from his description so far, those sound mostly positive, you know, but we probably wanna talk to him more to get more information about whether any of those are riskier. And then again, we probably want more information about specifically what he's doing on social media to see if there are other risky behaviors that we don't yet know. Thank you, Dr. Costello. All right, so this is our next discussion question. How would we formulate the case? How can we deliver this information to dad who is concerned about addiction and depression? Yeah, so I think at this point, Carter's main symptoms include, you know, the sleep difficulty, some mild anxiety, and some specific fears about being a black teenager, but some stress, overwhelm. We already discussed some of the psychosocial factors related to the racial climate. He, at the same time, does have a lot of significant protective factors at this time. You know, he feels engaged, he feels hopeful, he's able to connect with his peers, he's learning more, and he's being an activist. And so he verbalizes that it's an helpful space. So his functioning is also pretty intact, it sounds like, though maybe some interpersonal functioning at home with his family, there is some struggle right now. But diagnostically, it seems like he might be in the category of an adjustment disorder with mixed mood, with the stressor and mood and anxiety symptoms, with the stressor being really, you know, the societal context, the police brutality, and sort of that engagement, that repeated engagement being somewhat stressful at this time. So I don't know if Gabrielle might wanna comment a little bit about the initial feedback to the family. Well, I wanted to do that, but I also wanted to, one question I keep on asking about this case is, did he actually get to go out and protest? And did the family, which often I know my family did, but did the family allow him to do that? And did they perhaps go with him? So again, in terms of how to deliver all this information to dad, first, I wanna just say that I think the social media, again, is giving him, Carter, a sense of belonging and connection, being part of something greater. And, you know, I think that's very age appropriate and developmentally appropriate for an adolescent to search for meaning through connection with a group. If we go back to different stories about adolescents and initiation rights, I mean, you know, if they don't have a strong sense of self, they often join gangs and other groups. So I think he's just really, really riding the wave of his generation here, and so that's pretty normative. And in terms of how do we speak to dad about this? You know, the other question I have had throughout this case is, where's mom? I'd like to deliver the information to both. But so what I would do as a clinician is I would meet with father and mom, if that's a possibility, maybe she's working. And I'd really try to sort of feel him out and discuss with him where he's coming from and why he's so worried and try to, you know, allay his fears because right now at this point in the case, I don't think that, you know, Carter is, you know, at risk or, you know, acutely a concern. So I would just add, yeah, that some initial feedback could be, again, this engagement and discussion, but maybe thinking about, you know, the symptom area. So regulating sleep, establishing some boundaries and discussing healthy social media use. That might help promote better sleep, sort of maybe keeping the phone outside of the bedroom at bedtime. And then the family, as Gabrielle was mentioning, really encouraging him to engage in processing collectively some of what's been going on, right? Those discussions that everyone participates in them, because that can also be protective as a family could participate jointly in activism. And that might involve some of what was mentioned, attending the protests together. In that case, I would also suggest that maybe a family media agreement, right? Like the one found on commonsense.org might help the family and Carter have this conversation about how to stay balanced and promote, you know, family communication about the use of social media, but how to promote like a healthier interaction so that Carter learns these boundaries so that he can help himself manage and regulate stress even as this time was so stressful for everyone. I also want to add that I want to find out why dad's so worried about addiction and depression. And so I would really try to establish a rapport with him and mom and find out what the family psychiatric history is. Is there someone that has an addiction issue with gambling or shopping or drugs or alcohol? And is there a history of depression? And I'd also want to kind of find out more if dad was open to it, you know, what his history of trauma was. And I know, you know, he's very concerned about his child. He's very invested. And I think that, you know, I think there's a part of him that's really worried about the fact that Carter is moving from being a child to sort of having feelings about being a young adult. So we might want to explore those further when we speak with dad. Yeah, I think just to piggyback on this idea of engaging dad, what was his experience with racial discrimination, right? And how is he responding? So many adults had to deal again with their own emotional reaction to the racial violence and the killing of George Floyd. And then also around the protests and activism, sort of how did dad engage with that? And did it also sort of trigger and worry him really? As many black parents were very worried about their children, you know, in their level of engagement with the protests, but also just their children's safety. And that heightened sense of worry might be also kind of coming through in this presentation as well. So thank you guys. Three weeks later, we actually get this electronic message from dad. So dad says, good morning, doctor. It's Carter's dad. I'm really concerned that he's taken a deep dive. He's consumed by social media and the protests. He seems so afraid. He's always on edge. He has also started having nightmares and I hear him yelling in his sleep. He talks about feeling so down by the weight of it all. This has aged him so much. I'm really worried and I just want my little boy back. So of course we bring Carter and we bring dad back to the office. We talked to Carter and dad about the social media use pattern. This time, he's still on Instagram, Twitter, Facebook, and TikTok, but now it's more than 12 hours per day. And this has been occurring for the past two weeks. He says, I just can't stop. The videos are everywhere. There's a new one every day. I go on one site, I'm clicking another thing and I just get stuck in a loop searching for the murders. And if there's been any justice, he says, even when I try to disconnect, I'll just be scrolling. And then there's another video. He's like, I can't escape it. He wants to disconnect, but he feels guilty. Like he's ignoring the real world and running away from the problem. His friends have told him, if he tries to disconnect, he's not woke. So he just feels like he needs to stay woke and stay involved. And he feels really selfish for trying to take a break from the internet and the protests. On site preview of systems, he says that he worries that he will be murdered or even die young. He's been feeling nervous and on edge when he's at stores, when he sees security and when he reads the news. So he's not been going out as much because when he goes shopping, he'll see a security guard and just feel so anxious and overwhelmed. He's sleeping less. He gets nightmares, intrusive thoughts, and he finds this disturbing. So he has mental images of the clips and the videos that he's watched and just nightmares of violent scenes that he's watched online. And sometimes he's even incorporated into these nightmares. Despite all of this, he feels like he's not involved enough with the protests. So he feels he's not involved, but he also knows, I want to recharge. He says he doesn't have any psychotic or manic symptoms. There's no substance use. And per dad, he's just more on guard. He seems burnt out, a little bit disconnected. At times he feels like he's spaced out. He's not really there. So dad is just really concerned for him. So then when we talked to Carter individually to get his perspective of what's going on, Carter tells us that he feels stressed. He's overwhelmed. He feels on edge most days. He has difficulty relaxing. He worries about his future. And if he will realistically make it into adulthood, he also worries about black peers and family members. He thinks his social media use is a problem since he is constantly seeing new videos every day and then gets lost in deep Google searches on racially motivated violence. He does not think he is depressed. He is not sure if things will improve. Every day seems beyond my control. So on mental status, he in generally appears stated age. He's dressed appropriately. His behavior, you know, he's cooperative, well-related. He's noted to yawn multiple times during the interview. And at times he is guarded. He is mildly fidgety and restless. His mood is described as stressed and his affect is mood congruent, dysphoric, and constricted, and constricted. And constricted. Thought content consists of his future orientation, no delusions, and no suicidal or homicidal ideations. Thought process is linear and logical. Perceptions, he denies auditory and visual hallucinations and he does not appear to be responding to internal stimuli. Insight and judgment, impulse control are fair. So this brings us to our next discussion question. How can we characterize Carter's current social media use? Well, we're definitely more worried about Carter's social media use now than we were before. He's spending a lot more time on social media. He's finding it hard to disengage. And it appears that he's on social media, you know, at the expense of doing other activities that he used to engage in. And so this is shaping up to be a concerning pattern of use. You know, to the extent that we wanna view social media addiction as a phenomenon, there are more red flags for that being a possibility right now. But beyond just the use itself of social media and the amount of his time it's taking up, you know, we're becoming increasingly worried about how much social media is exposing him to trauma. And he's, you know, describing a lot of symptoms suggestive of that effect. And then I would also just say that it's really hard to separate out what part social media is playing here because it's very much tied up in that, you know, in the fact that he has developed worsening of a number of psychiatric symptoms. And, you know, the causal relationship between social media use and the symptoms is gonna be complicated. I also think that, and I know Dr. Gibbs is gonna speak too, but I also was thinking that at this point, some of the symptoms he's describing are sort of, you know, flashbacks of the violence. So the criteria for acute stress disorder, you know, are definitely starting to rear their ugly head. The problems with sleep, the kind of disassociation and depersonalization or feeling of like being spaced out. And, you know, probably the ruminations and the intrusive thoughts in his mind about the images of the violence as well as some of the obsessive compulsive need to keep up. So I just wanted to mention that. Dr. Gibbs, yeah. I would just also wonder maybe some about what is he posting? I think that was a question we had all discussed. Would it be helpful now to take snapshots or ask him to take screenshots so that we could see whether in this more emotional state, whether he's even becoming more impulsive, right? With what he writes and the ways in which he makes decisions online, given some of what we heard earlier from Caitlin. I also feel like it's so important. I mean, we're really fixated, all of us and dad is on, oh, I'm worried about him. I just want, I would have established a rapport with him enough where we could find out what he's really feeling in his internal world, besides for like sort of worrying or focusing on his social media use. Just, I mean, give him an outlet to verbalize, not just be online typing and posting, but verbalize to another human being what he's feeling. Maybe he's scared to discuss it with his parents. Maybe some family therapy would help, but maybe they're kind of stuffing what their own adolescent experiences were as adolescents of color. And maybe just sort of letting the cat out of the bag and letting him have some talk therapy would be supportive for him as well as for the family. I think these are excellent points. Thank you for answering this question. Yeah, and I think along with that, I think it's, he's on social media. I think we also have to consider like the pandemic, it's a summertime, he can't go outside. So when you think about trying to make connections, I wonder how much the pandemic and just this isolation, not being in school or having structured activities is playing. So for our next discussion question, how would we characterize a patient's problems now? And what role did social media and the heightened attention to police shootings of unarmed blacks play in this presentation? Yeah, I think from a symptom perspective, we're seeing more trauma-related symptoms. We're seeing some hyper arousal, re-experiencing, this obsessive re-experiencing, the dysphoria, some negative cognitions, even a bit of that dissociating with what was mentioned about him sort of feeling a bit spaced out. And then that sense of a foreshortened future really kind of helping us to get a sense of just like how this repeated viewing of content related to people dying actively as victims of racialized violence really is permeating his sense of self and his own future. So, we don't really see a ton of symptoms related to avoidance, but this is sort of a picture of a trauma-related presentation and might fit under acute stress reaction, or again, something that we wanna pay attention to as we move forward, because these symptoms have been going on for a really long time. We also wanna make sure that we're continuing to screen for depression, a kind of burgeoning depression and just ongoing adjustment symptoms with the mood and anxiety. So, I think there are a lot of protective factors here still. He's very insightful. He's able to identify that this behavioral activity that he's engaged in is harming him, and he's able to verbalize some of his feelings, which is really awesome. And so, I do agree that his ongoing, repeated exposure to online, video, chat, social media related to the deaths of unarmed Blacks contributed to this traumatic reaction. And I agree that it's time for us to really think about how we can kind of help him have another space for processing that as he moves forward. So, next we'll move on to how we would take all of this information, consolidate it, and counsel the patient and the family. So, I'll begin if that's okay. So, again, we had talked about different things we might wanna ask the family and the patient, including the screenshots and stuff. But again, dad's concern worries me, and I would wanna find out from dad what his history is and why he's worried. I think his cry for help as a parent, I want my little boy back. Again, I think he's trying to protect his son and is worried about the fact that he's being exposed to so much hurt and pain that's generational and historical, and that'll have a huge impact on him, and he wants to preserve his childhood. So, I would spend some time with dad, and I'd empathize with his worry and concerns. His past experience with racism might inform his perspective and hopefully hope to get the mom involved. And I'd ask also, what would I wanna recommend for them? And I think keeping the avenue open for all of them to speak about their feelings, increasing communication and activities together as a family, having family, I guess I'd also just honor them for their openness and reaching out to have mental health counseling, which is hard and is stigmatized in their cultural group, and then make it a positive experience for them so they continue it. And I would also try to normalize as much as possible some of what we're seeing symptomologically. I don't, I mean, he is at risk and he may meet criteria for acute stress disorder right now, but I don't think we're in a very dangerous situation. I just think that keeping the lines of communication open, keeping him so he feels like he's actually doing something rather than needing to go online for everything. So again, engaging the family and he together as a group to perhaps participate safely in the protests would be some things that I would recommend. And I'm gonna let Dr. Gibbs continue. And I would just add again that Common Sense Media, that website is a really great resource for parents of young people at different, of all ages to kind of learn about various issues related to interaction of youth with social media and with the internet in general. And so I would really see if there are resources on there and try to see if the family can engage with that. The APA does have this resource on talking to patients and families about race and racism and racial discrimination. And some of the questions there are related to like, have you experienced racial discrimination? Have you felt like you were treated differently because of your race? And so that could be a resource for clinicians who are trying to really get into this, like have this conversation with the family and the parents with some language to go with it and to not be afraid of it. Because I think it's, as we've, I think elucidated here today, there's obviously also this intergenerational piece that is part of this family dynamic of the level of concern that dad has and also the level of response this child is having. So us being able to be comfortable asking those questions and asking for an inventory even of times, if that's appropriate and if the rapport is there, just an inventory of episodes that were triggering racially and the ways in which it may be impacting their mental health is another way of just like really building that alliance with this family for whom, we're not gonna make racial discrimination in America disappear in a conversation, but really opening that conversation up and allowing it to be part of treatment, I think really helps with providing this like culturally appropriate level of discourse in that relationship. So I would just add that as there is a resource for asking questions about this topic, aside from just a diagnostic issue, I think really looking at the societal piece as well. I wanna just say that all of the people involved in this presentation were authors of that resource through the APA. And so hopefully the viewers and people that are participating in our presentation, please go look online for it. It's excellent and a good training tool as well as a good tool to use for families. I guess my next question, I know as trainees right now, especially in the pandemic, there's little opportunities for outpatient shadowing or to hear from attendings on cases like this. So I'm just wondering if Carter's dad were in the room right now, like what might that sound like? I know we wanted to have a demo or like just a role play, but we couldn't do that because we're online. So what might that sound like? What might we hear if you're in the room with the patient and his family? Well, hi, how are you today? So glad you could come in or so glad we could meet. And I really want you to know and acknowledge your concern for Carter. And so Carter's not in the room, I just want to get the picture. Just the parents are in the room? Yeah, just the parents, sorry. So I wanted to meet today, I would say, to find out how are you feeling and what your concerns are other than what we've already discussed about Carter and our current situation. So I would listen, I would give open-ended questions. I'd try to be as empathic as possible. And often we see parents that are identifying their patient as, their child as the identified patient. And we later find out that really, they also could have be suffering from mental health issues and their own stress and trauma issues. So I would sort of open up an avenue to find out about that, reassure the dad, let the dad know that we really care and we're going to keep track of what's going on with Carter. I would give some tools and pearls for him, as we've already discussed, in terms of social media time. What would be a reasonable thing to have Carter do? Like, for instance, I wouldn't say, oh, take away his phone. This is a child that's a late adolescent who would find that pretty offensive. I would just say, Carter, I'm thinking that maybe you'd get a better night's sleep tonight if let's put all our phones away as a family, let's put them in a little basket until we wake up in the morning, or do something to join the family and join with Carter on treating some of the things that might be precipitating the acceleration or the increase in his symptoms. But I mean, I really would just try to really establish a good rapport with the family. I would add that one really helpful way of establishing that rapport, in addition to what has been said, is really saying, hey, what does your family do to manage stress? How does your family deal with stress? What kinds of activities help you all to feel more rejuvenated and balanced? And if there aren't any things, then you might suggest that they come up with some ideas together, recognizing the role of their own resilience, their own coping strategies that really they lean on or that have worked in the past. And I think that's a really validating way as well of recognizing that not every family is into clinical interventions, but that they do have their own recipe for what helps and what doesn't. And that obviously in this situation, the problem went outside of probably the level of resources that they had, or that the coping strategies that they had before kind of fell apart during the pandemic. Whether it's seeking spiritual support, attending their community center or their house of worship, that the family may have had all this stuff together before with the structure of school and those relationships. And that some of that might have become fragmented with the pandemic. And that that's why in this case, things kind of went out of the level that they typically would be able to manage. Thank you so much, Dr. Gibbs and Dr. Shapiro. And Dr. Costello, I love what you shared earlier about how you respond to parents when they ask you how much is too much social media. So I'm wondering if you might be able to share that really quickly before we end. So it's a particularly complicated question to try to answer right now, because any guidelines that have come out about number of hours for pre-pandemic and everything is so different now and there just aren't that many options besides social media for young people to connect with other people. And so it may very well be appropriate and not detrimental for them to be spending quite a bit more time right now on social media than in more typical times. So I would look at it more as not so much a function of the number of hours per day, but what's the effect on the rest of their life? What is the effect on their mental health, positive or negative? What is the effect on personal relationships, positive or negative? And is social media use coming at the expense of fulfilling their obligations at school and at home and of participating in other developmentally appropriate activities? So much, and I'll just turn to some of the talking points that we shared earlier, in case you guys wanna take a screenshot, love to discuss this more at the live presentation, which is going to be that Monday of the APA. So we're really hoping to see you there and looking forward to chatting more. Thank you. ♪♪

adolescent social media use

race-based trauma

structural racism

police brutality

awareness

benefits and risks

case study

mental health

support

family communication

pandemic