Thank you for joining us for this very interesting, important, and relevant session. I'm Raman Marwaha. I'm part of the APA Scientific Program Committee. So on behalf of the Scientific Program Committee, it is my pleasure to introduce this session, Stopping the Scroll, Navigating the Intersectionality of TikTok, Instagram, and Youth Social Media Addiction by Ashwin Sood and Mark Potenza. Dr. Sood is a board-certified child and adolescent psychiatrist in Fond du Lac, Wisconsin. Dr. Sood has written book chapters and op-eds on the intersectionality of youth, mental health, and social media, featured in both Psychology Today and the Psychiatric Times. He's a member of the ACAP Media Committee, having presented numerous topics pertaining to video games and social media. Dr. Sood also runs a grant-funded TikTok channel providing psychoeducation about navigating screen media safely to over 80,000 followers. Dr. Mark Potenza is a professor of psychiatry, child study, and neurosciences at the Yale University School of Medicine, where he's the director of the Division on Addictions Research at Yale, the Center of Excellence in Gambling Research, the Yale Research Program on Impulsivity and Impulse Control Disorders, and the Women and Addictive Disorders Corps of Women's Health Research at Yale. He's also a senior scientist at the Connecticut Council on Problem Gambling. So please join me in welcoming both of them. Thank you. Hi, all. Thank you so much for having us. If you haven't already, please point to your smartphones, if you've got them, right up there at that QR code, because I would like to personally get an inventory of your social media experience. I'll give you 15 seconds. Share it. No TikTok today for me. So we're going to go through these questions and hear what you have to say. So do you have a TikTok? 19 of you said yes. All right. Fellow TikTokers, 39 of you said no. Two of you said, what's a TikTok? And I think I accidentally wrote history when I wrote this question. Which one of you agreed to? So majority of the audience doesn't have a TikTok. That's helpful. All right. Let's answer this question. Do you have an Instagram? It should go to your phone on the next question. So 43 of you are saying yes to Instagram, which I think is important, right? So let's talk about generational age gaps here and the younger audiences and older audiences, which I think is important, because even my 17-year-old cousins have moved to Instagram from TikTok. In 2022, which app slash website had the highest percentage of U.S. teens visiting daily? Was it TikTok, Snapchat, Instagram, or YouTube? This poll is also getting a lot of likes on the right side of the page, which I didn't know you would get, which is affecting my self-esteem, so keep liking it. All right. So TikTok. That's important. And then finally, what does BSMAS stand for? Is it the Boyle Social Media Associate Sales Association, Beta Simulation Medical Addiction Scale, the Bergen Social Media Addiction Scale, or Option 4? As you can tell, I spent a lot of time on this pollster. Okay. So Bergen Social Media Addiction Scale, which we'll discuss more. Well, again, we invite you today to Stopping the Scroll, Navigating the Intersectionality of TikTok, Instagram, and Youth Social Media Addiction. My name is Dr. Ashwin Sood. I was already introduced earlier. Here's my QR code for TikTok. The slides will be up. You don't need to go to it right now. My disclosures is that I have a state grant from the Advancing the Health of Wisconsin grant, that pays for some of my time to produce TikToks. I am an external consultant for TikTok about youth mental health safety. I am a content creator, which I've made a total of $227 over the past four years, which I don't know how to access, so that's my benefit. My brother is an attorney for Meta, which basically the benefit there is intense family debates. So again, not sure if it's a benefit or not. But today, we're going to discuss the history demographics and functions of TikTok and Instagram. We're going to talk about the neurobiology of addiction and criteria for addiction via various models. We're going to assess risk factors for social media addiction, and then we're going to talk about how different clinicians implement clinical interviews when we're assessing social media addiction in youth and young adults. I'm going to pass it along to my colleague now. Thank you. We're going to be going back and forth between the computers, and they are operating as I'm hoped. So that was my biggest concern about today's set of presentations. So I'll be talking about TikTok, pros and cons, particularly for developing youth. I have a series of disclosures with respect to pharmaceutical, gambling, gaming, and legal entities. As I think most people know, the Internet has changed over the past several decades, and many people are engaging in many different activities on the Internet for many purposes. This has risen to the level of a national concern in many different ways. Diane Sawyer had a special on-screen time where she was covering this topic in the pre-pandemic era and it's probably only gotten more of a focus since that time. Youth in particular, and adolescents specifically, may be at particular risk for engaging in addictive behaviors. It's been proposed that adolescents have a brain system where pro-motivational drive networks subcortical brain regions mature more rapidly than the prefrontal cortical ones in terms of controlling behavior. So what do we know about children and adolescents and screen media activity? One study that I think is providing important data is the Adolescent Brain Cognition and Development Study, where an initial study by Martin Paulus found that there were four factors, principal components that linked to screen media activity with the high screen media activity usage group being associated with cortical thinning, or evidence of more rapid brain maturation. We've looked at the ABCD data, which is a longitudinal study, and we've looked at the first three waves. So beginning with the nine to 10-year-old children going up to ages 11-12, we've also looked at the human connectome project development data. When we did a factor analysis or machine learning-based approach of understanding screen media activity, we found a two-factor solution where slightly more than a quarter had this high screen media activity pattern and the remainder had a low screen media activity pattern. In the nine to 10-year-old children, that screen media activity was largely more passive viewing, video-based content, as well as video gaming. If we looked at the characteristics that were associated with this high-frequency video-centric screen media activity, we found that that group was more likely to show poorer cognitive performance, more total behavioral problems, more severe prodromal psychotic symptoms, higher impulsivity, and a number of other negative health measures. This group was more likely to be male, black, Hispanic, and of other race and ethnicity. If we looked at this in more fine detail, we see that that orange color is the high-frequency group and we see higher measures of impulsivity, behavioral inhibition, behavioral activation, lower measures of crystallized and fluid intelligence, lower reading scores, lower sequence memory and working memory scores, lower vocabulary scores associated with the high-frequency screen media activity. We also see higher measures of psychopathology with respect to externalizing behaviors, internalizing behaviors, conduct, ADHD, as well as other measures. So, what happens when the children mature into adolescence? One thing is that by the time individuals in the U.S. are in the high school range, age 13 to 17 years, nearly all have access to a smartphone. It's estimated that data from 2023, 95% of youth have access to a smartphone. Importantly, the proportion of teens who say that they are online almost constantly has doubled over the course of a decade, from 24% in 2014 to 2015 to 46% in 2023. And certain subgroups of individuals are more likely to be online almost constantly, particularly black and Hispanic youth as compared to white youth and older adolescents as compared to younger adolescents. Importantly, the types of screen media activity also change. So, data from the Human Connectome Project dataset, which included a larger age range, we found that among the younger group up to age 12 that this pattern of video-centric screen viewing was replicated, but in the group from ages 13 and older, shown in this lime green color, we see a more sociocommunication-centric pattern of screen media activity. So, things like social media engagement and texting. So, what are the pros and cons of social media? A number of them are listed here with how people may connect, but also there have been studies linking social media use and high-frequency social media use to loneliness. And this may relate to things like fear of missing out as compared to engaging with other individuals. Also, what people present on social media may not reflect real-life day-to-day activities and more like the highlight reels. And for developing youth as they're developing their identities, this may be concerning as there may be social comparisons where people feel inadequate. And then there are concerns about age-appropriate versus inappropriate content, privacy versus disclosure of information, and how youth may not be aware of some of these privacy concerns. And then there's also the algorithms and how this may influence free will. And one documentary that I think highlights this is The Social Dilemma, in which a number of individuals from the internet industry, if you will, who have left, cited their concerns with some of the ethics of some of the algorithms and how it was impacting individuals. So, going back to the Pew Research Centre data, there are a number of apps or platforms that are particularly popular among teens. And a number of these platforms are social media platforms. A number of them are listed here, and they each have somewhat unique features that I think, to get a more nuanced understanding, one needs to understand those aspects. But taking a step back as to the platforms that are frequently used by teens, YouTube is among the highest, going from 2022 to 2023. But TikTok is also very high, and we'll talk about the evolution of TikTok. And importantly, a majority of teens not only use TikTok, but the proportion of individuals who say that they use almost constantly is particularly high for TikTok as compared to some of the other platforms. And that's also represented here, where we can see that there's a relatively small percentage with respect to Facebook, which is often seen by younger individuals as an older person's platform as compared with some of the newer platforms that are used by younger individuals. And again, there may be particular groups of individuals who may be particularly vulnerable to high-frequency use, including Hispanic youth, about one-third say that they're almost constantly on TikTok. There are also gender-related differences, where the proportion of girls as compared to boys who say that they're on TikTok almost constantly is substantially greater, 22% versus 12%. And this may be a precursor or reflect some gender-related differences that are seen in adults. These are data from a meta-analysis looking at Internet gaming disorder, Internet addiction, and social-media addiction, where the higher the bar is, the more male-predominant. The lower the bar below the line is more female-predominant. So one can see that among adults across cultures, there is male-predominance for Internet gaming disorder, female-predominance for social-media addiction. So with respect to TikTok, what makes TikTok different? TikTok, one should realize, is a relatively new app. It was only developed in 2016 as Musical.ly, Musical.ly, introduced in China, owned by ByteDance, a Chinese entity. But its popularity in the U.S. seems to have particularly grown during the onset of the pandemic, and its short video format seems to be particularly engaging for a number of individuals. There are also aspects about the structural features, such as a For You page that is informed by algorithms that may promote engagement in particular aspects. And then there are also challenges that are put out that certain individuals may feel compelled to engage in the challenges, some of which may be physically or mentally concerning. So going back several years, Kristen Montag and colleagues asked questions about why do people use TikTok, who uses TikTok and who does not, how do people use TikTok, and provided this diagram, which thought about the business model and then the design of the platform with elements such as likes, endless scrolling, and other features perhaps related to more frequent engagement or more compulsive engagement. And then, you know, to think about who might be using, but also, importantly, why are people using? What are the motivations? And I think this ties into what one might think of when people are engaging problematically, how we might reduce the demand features, the motivations to engage. And particularly concerning may be engaging for negative reinforcement motivations to relieve stress or for emotional regulation. So what are some of, we've talked now a little bit about some of the potentially concerning features, what are some of the benefits of TikTok? There is a wide reach that TikTok has, and people can gain followings and have elements that are designed for them on the For You feature, the For You page feature of TikTok. And it may be for mental health, there may be both pros and cons with respect to certain groups, particularly minority groups who might have difficulties connecting, sexual minority groups, finding homes within either TikTok or other social media platforms. There may also be information on mental health, which comes with both pros and cons. Some of the pros mentioned the sense of community, tackling important topics like decreasing stigma, increasing awareness and access, but there also may be privacy considerations with respect to individuals sharing personal information and perhaps sharing unfounded advice that other people then implement in their own lives. So in this setting, recently last year, the US Surgeon General came out with an advisory, again, citing the high frequency of youth using social media platforms and a third saying that they use social media constantly and calling for different stakeholders to work together to address mental health concerns relating to social media use. We talked a bit about the reach of TikTok. This article, looking at mental health videos, looking at 100 mental health videos, identified that these 100 videos had received over 1 billion views, so 1,354,000,000 views, had received over 266,000,000 likes and over 2.5 million comments. Importantly, a large proportion, particularly of those that had received high viewership, included comments about other mental health issues and struggles. So there's a large reach that can have either positive or negative effects. Amnesty International has been looking into this and has raised concerns about the for you feed risks and harmful mental health, saying that the platform's algorithmic content recommender system, credited with enabling the rapid global rise of the platform, may expose children and young adults with pre-existing mental health challenges to serious risks of harm. They have a video about some of the research that they've been doing, and that's summarized here, that they have done manual research into the videos and receive on these accounts multiple recommended videos in a single hour, romanticizing, normalizing, or encouraging suicide, and feeling like going down these paths was somewhat like going down a rabbit hole. Others have purported that TikTok may be an important tool for getting appropriate empirically validated information out to individuals, particularly given the reach of TikTok. So there are these different opposing views, and we do need to be mindful of the quality of the information on TikTok and other social media platforms. But even the individuals who are purporting that this may be a powerful tool recognize that a number of the feeds on the platform contain misinformation, and that we should keep this in mind given that many TikTok, many people who use TikTok are adolescents or young adults who can be particularly impressionable. And with this impressionable consideration, there are the challenges aspect of TikTok. And so this recent piece highlights some of the most popular TikTok challenges of all time. Some of these were quite dangerous, like the blackout challenge to see how long someone could choke oneself without passing out. There are others like the milk crate challenge where you would stack milk crates and see how high you could climb up stacks of milk crates. And this was also stopped due to people injuring themselves. And some raised privacy concerns, like the don't rush challenge. And this is taken from the article where individuals would apply makeup and then speed up the video to fit into a TikTok length. But I found this image on the website concerning to have a young girl putting on her makeup in lingerie-esque type clothing going out onto the internet. So then it raises questions about what can people do and particularly what can families do. And this comes from the Center for Parent and Teen Communication written by a young adult. Learn to identify misinformation, check the author and speaker and their sources with the understanding that some websites may give more credible, reliable information. Check the URL. And then to try to understand whether this is satire or people being truthful because sometimes the individuals who are providing information can see this as a way to have elaborate jokes and to understand that platforms like The Onion are satirical in nature. So and then what can families do with respect to role modeling, self-care, with respect to taking time away from the computer, balancing this with online time, setting screen time limits, using a balanced parenting approach that is governed by love and supervision, but also being open, non-judgmental with respect to conversation and creating a dialogue where one can understand the platform is really important for maintaining a relationship when children and adolescents are developing and perhaps are moving towards independence to keep the door open for dialogue about important topics. Teaching teens how to cope with stress and not going to the computer as a means of stress management or emotional regulation is important. And then understanding and recognizing warning signs with respect to mental health concerns like depression or anxiety which are significant and associated with social media use. So I'm now at the intermission stage and we'll hand the computer back over. Thank you. I think it's a good discussion, but we'll just jump right in. All right, so we've talked about TikTok, let's talk about the OG, Instagram. Founded and made public on Apple App Store on October 6, 2010, Stanford graduates Mike Krieger and Kevin Sindstrom created Instagram for the sole purpose of sharing check-ins at locations similar to Foursquare, if anyone remembers that. It was initially aimed to be called Bourbon due to one of the founders' enjoyment of bourbon and whiskey, but the application was then renamed to Instagram for the purpose of shifting it to cell phones with images being featured with captions and that you could send it to someone like an instant telegram, Instagram. In essence, this got super, super popular. It was within 24 hours of launching, the social media application had over 25,000 users, and by mid-December of that year, it had over 1 million users. And by March 2012, the application had grown over to 27 million users. Due to its rising success, Instagram was courted and eventually purchased by Facebook, as now known as Meta, for roughly $1 billion in cash and stock, with Facebook going public one month after, in the winter of 2012. Since then, Instagram's success has been significant, and it has grown to about 1 billion followers or users by 2018. So who's actually using Instagram? Well, I think it's really important that they're currently, right now it has 2 billion active users globally, with 51.8% of the users being male and 48.2% being female, with gender demographics are nearly split on the platform. In terms of age, 60% of Instagram's population lies between the ages of 18 and 34 years old. What I want to point out is that roughly 13 to 17-year-old population is about 8%, and if we look closer, since 2014 to 2015, and this was shared earlier, there has been a rise in terms of total percentage use in this population, with about 10% increase in total teens using Instagram from 52% to 62% of teens. So what does it actually look like? Majority of you have an Instagram, so this shouldn't be new, but for those who don't, it's important to kind of get an idea of what your patient population might be looking at. So as you can see, there's this left-most panel. This is known as the home page. It's basically known as the feed, if you've heard of that before, and it's what drives kind of showing photos with captions that you can follow of people that you actively follow. The middle page is pretty much kind of like where the algorithm is derived. It's kind of a search page for you, but it's what you are looking at, and these are filled with photos and Instagram Reels, which is the equivalent of kind of like TikTok's For You page of showing you videos back over and over and over again. This is my quote-unquote search page. You can see pictures of medical content creators, cooking, which I'm not very good at, and Hamilton. So if anybody's seen Hamilton this week, I hope you enjoyed it. And finally, on the right hand is the profile page. This is where individuals see how many followers they have, who they're following, and what they've created. What I want to highlight about this is that every social media application that comes out typically follows a similar kind of format, and then they copy off each other. So anytime you see an application, know that it might look similar to Snapchat or TikTok or Instagram or Be Real or whatever comes out next year, right? It often copies each other. So this bottom panel that you see on this first panel, which is like a home, a search button, a plus button, that just changed. There used to be a shopping button on Instagram, which is gone now, which was just removed, I think, last year. So this will constantly change, and this is how social media works. And then also, you also have to talk about sliding into your DMs, right? This is a slang term for direct messaging. Direct messaging basically means if you can contact and talk to someone privately or in a group chat on Instagram, and it's like almost like a text message through Instagram. Instagram has added more features to this feature, because this is how a lot of people communicate, and that includes message editing for up to 15 minutes after sending a message. IG users are able to pin up to three chats right at the top. So if you think about the child and adolescent population that I treat, who's your best friend? They're pinned right at the top of my Instagram, right? So it's a good way to get a social history, if you think about it. And then additionally, you can have leave messages on read received, so that can irk some people if you read and then don't respond. So I'm telling you all of this in jest a lot, but it's important because we, as clinicians, have to take the ability to actually implement this in our interview, especially how things are changing so quickly. And as I see, I think, 80% of my patient population are children and adolescents. Often, the parents are rolling their eyes, and they come to us, and the children see us as another adult in the room who's probably going to do the same thing. And our whole point, when we talk to kids and teens and even young adults, is to build kind of an alliance right off the get-go. So my whole portion of it is to talk about kind of empathy, not eye rolls. This is incredibly important for identity. This is incredibly important for group and peer selection. And this, for the pandemic, for many young children and teens, was their only way they socialized. This was the only way they connected with others. So if you laugh at that or roll your eyes, you have to understand this was their identity for probably two-plus years. So it's important to also ask open-ended questions. Be dumb. Be curious. Let them teach you, because they will teach you so much, and you will learn so much very quickly. Curiosity, humility. You know, I often say, like, I don't know what a DM is. What is that? Kind of playing dumb in that fact. And they'll tell you so much more than you'll ever even imagine. And then slowly, bit by bit, session or two, even if you use it for the session or two to learn about, the alliance slowly gets built. And that gives you the entryway to talk about risk reduction. So this is a kind of building on what Dr. Penanzo had shared earlier, was how do we kind of move about interviewing? And how do we move about kind of gauging away in what is happening in the social media world? I can tell you, I thought I was hip and I knew social media. It changes. So there are new ones coming out that I know nothing of. So we created this kind of agenda or type of questions to ask for clinicians, which will be published in a journal later this year. And this is kind of how we format. So we go first with looking at the what, which is what is the platform? And the platform basically identifies right off the bat, what platforms do you primarily use, right? There are hundreds of platforms out there, and there will be hundreds more. And so they will change rapidly. And you want to ask, you know, what have you downloaded most? What do you spend the most time on? What's your favorite application to use? Why? What's the latest, coolest, newest platform to use? There's one called, I think, Lapse or Lens or something like that, which I just learned the other day. And I use this exact question, what's the newest platform that young teens are using? Then you go to functions. So, right, if you sit there and you say, okay, they use Snapchat. Now what? I don't have a Snapchat. I don't know what even a Snapchat is. Did I get Snapchat it? Right? Like, it's very hard, but you have to remember there are functions to every social media platform. And as I was saying before, they all copy and paste each other. So, what we tended to find out was that majority of these social media applications follow under similar functions. These include social networking. Who do you connect with? Image sharing, like photos. Video sharing, like video TikToks or Reels or anything like that. Messaging or direct messaging. And live streaming. Do any of you, raise your hand, does anybody know what Twitch is? Okay, good, right? That's live streaming. That's where people watch other content creators do stuff, like play video games and then give money to those people. And they make way more money than me. So, they're live streaming, right? So, these are all different functions of social media. And that's how a way you can kind of get into how do you use it. And so, then we jump into kind of like more of the what. These are some of the questions. And just for time's sake, I won't jump through and we will share the slides. And then I go into how, right? How do users go about using social media? Are they passively use it? Like are they mindlessly scrolling or doom scrolling, which is a term, right? Finding negative content and just watching negative content over and over and over again and they feel terrible about themselves afterwards. Or are they active users? Do they comment? Do they post? Are they content creators where this is where they display their expressive selves, right? Do they share? Do they react and like things? Or do they, again, lurk and are more passive? And these are just different questions you can ask, right? Like let's look at image sharing. How often do you look at images on a platform? How often do you react to them? If they say I react all the time, I like all the time, right? Well, that tells you a little bit more that they're very active on social media versus spending hours scrolling, right? Do you ever post pictures of yourself, your family, your friends? That can tell you an idea of privacy, right? Who are they sharing these photos with? Do they leave it to private users? Do they send it to private users? It gives you a good idea of where to focus on in the interview. And so for now, just kind of looking at time, I think we are going to, if I'm not mistaken, go back to Dr. Potenza, and we'll save our last breakout group for a similar type of question, and we'll break out and talk more about that. So, I'm going to now shift gears into the problems with TikTok with respect to excess screen time, and we talked a bit about how the short video element of TikTok is a central one that some people have described as being part of a perfect recipe for addiction-like behavior for another number of individuals, and this may be particularly true for vulnerable populations, specifically girls suffering from depression, who may be more inclined to feel addicted to TikTok than girls without. So how do we measure problematic use of social media, as was the QR code at the beginning, the Bergen Social Media Addiction Scale, which was initially the Bergen Facebook Addiction Scale, essentially has five questions that are rated along a five-point Likert scale that are listed here. There are other scales that have been developed and adapted to specifically look at TikTok, for example, modifying the Brown or the Griffith six-component models of addiction for TikTok. One that I think is very relevant for assessing Internet use behaviors and is very brief, relatively brief, and we're working on making it briefer, is the ACID-11, the Assessment of Criteria for Specific Internet Use Disorders, which is based on the ICD-11 criteria. One of the sample questions is here, and one can see that one looks at five different behaviors with respect to gaming, shopping, pornography use, social networks, and gambling. There are 11 questions that cover the three main domains of the ICD-11 criteria with respect to impaired control, increasing priority, and continued engagement despite adverse consequences, as well as a functional impairment question and a mental distress question. So covering the main ICD-11 domains. There are also, on the initial study, one looked at the factor structure, which a three-factor structure relating to those three domains was supported. There's also a problematic TikTok use scale that is a bit longer, includes 16 questions that factors into obsession, escape, and impaired control domains. Going back to the Montauk et al. article, going back several years, the TikTok use was noted to be, particularly problematic use, be associated with mental health concerns like depression, social anxiety, boredom proneness, and distress intolerance. There are also other features that may be relevant to functioning, like procrastination, and the relationship between procrastination and depression in young adults appeared to be mediated by problematic TikTok use. With some of these other domains in a longitudinal study, depression and social anxiety were assessed, as was boredom proneness and distress intolerance. And distress intolerance was particularly relevant with respect to mediating the relationship between these mental health concerns and problematic TikTok use. So understanding the interrelationship among these domains is going to be particularly important as more longitudinal data are collected. So COVID-19 changed the ways in which many people use the Internet. At the onset of the pandemic, a group of us generated consensus guidance as to how to reduce the likelihood of problematic use of the Internet. It included a number of general recommendations related to self-care, and then specific recommendations related to the use of digital technologies, including using analog technical tools like plug-into-the-wall clocks instead of your phone if one was having difficulty disconnecting from the digital devices. During the course of the pandemic, we came out with more refined recommendations, particularly focusing on mental health. And also, as part of a cost initiative, a cooperation in science and technology, we generated an e-booklet that can be downloaded for free at www.internetandme.eu. It's listed on this slide and the next few. It covers a broad range of different types of problematic use of the Internet, including problematic use of social media, but also topics like cyberbullying and cyberchondria, and cyberchondrias collecting health information in a way that may be distressing or interfering. And this e-booklet provides background information and practical tips. So some of the practical tips appear particularly relevant for parents and children, and are summarized on the next three slides with respect to considering the age-appropriateness with respect to content and duration of use, and how to introduce digital devices in an age-appropriate fashion, to balance screen and physical activity time, and particularly with respect to sleep concerns, not having digital devices in the bedroom, not using them immediately prior to bedtime, having screen-free mealtimes, as well as tech-free zones, importantly avoiding the use of digital devices for emotional regulation and stress reduction purposes, and to teach youth alternate ways to address those concerns and to be able to talk about them by keeping the dialogue open. Having clear, consistent rules that parents also follow, and then considering the roles of digital technologies, particularly with respect to developmental groups. So for example, gaming is a normative behavior, particularly among groups of boys, and recognizing this, having an interest in this, having an understanding of this as parents, and engaging in discussions about, and not judging or pathologizing regular use of gaming is, I think, important, holds true also for social media. But then there are a number of other online elements and etiquette that parents can help teach children in order to help keep them safe, keep an open space for children to talk with parents about cyberbullying aspect and other mal-intended use of digital technologies and harmful ways in which digital content may interfere with healthy identity formation. So getting back to TikTok and Instagram, there are, again, this article, which is a recent article that came out last month, focuses on the importance of identity development, critical thinking, and emotional regulation with respect to the use of the social media apps. So the algorithms and the ownership of information is also important to consider with respect to TikTok, and the debates about banning TikTok in the United States versus not. And these are two articles from The Hill, one that says it may not matter about a TikTok ban because it's going to be fought in the court for years, and another opinion piece raising national security risks and how the app may serve as an apparatus for psychological and asymmetric warfare. And it talks about some of the shared motivations for social media companies as well as some of the individual factors. But at the core of this debate, I think, is the balance of the protection of civil liberties and the promotion of public health. And where jurisdictions come down on this, it varies across different parts of the world. And it's also important to note the age regulation aspect, and this article touches upon this with respect to some of the public health rules that are in place in societies with respect to speed limits, ages for driving, smoking laws, and others, being accepted public health promotional aspects that do limit civil liberties, and where should our society fall on this is being debated. In the absence of good data or in the absence of complete data, the groups like the American Academy of Pediatrics have guidelines for screen media activity at different developmental stages that I imagine will continue to be refined as more information becomes available for integration. World Health Organization has also come out with some guidelines, and they tend to focus more on this physical activity versus sedentary behavior and sleep interference, particularly for young individuals. We've considered some of the prevention strategies with respect to online gambling and video gaming, some of which may translate over into problematic use of social media. There are age restriction considerations, age verification, even for things like pornography viewing are not implemented. There may be other approaches with respect to fines, warning labels, restricted access. With respect to the warning label considerations that are, for example, on some tobacco products within different jurisdictions, there are a number of considerations with respect to how these messages would be received. Some of these restrictions, for example, with respect to advertising restrictions, have been helpful for reducing tobacco use and alcohol use, but they may or may not apply equally for all online behaviors. That being said, in the United States, we're seeing a range of heavy advertising for sports gambling in the setting of that becoming legalized, so there's been bills introduced to try to limit the sports gambling advertisement. Now the U.S. Surgeon General Advisory on Social Media Use and Youth Mental Health does identify what different stakeholders might be able to do with respect to what parents and caregivers might do in their households, what children and adolescents can do with respect to adopting healthy practices, and what researchers can do with respect to prioritizing research in this area, which, of course, needs funding in order to be conducted, which is another challenge. And then policymakers and technology companies are also mentioned, and I think that this has a very important role. I've mentioned the Social Dilemma documentary, and some of the individuals from the digital technology company community have also gone to Congress to testify about how to address social media, and this seems to be a topic, particularly with respect to youth, that both Democrats and Republicans can support. Also in the testimony, she cited the misinformation that can be found on social media as being important to address. The EU has also taken approaches with respect to regulating internet platforms, and in the setting of data privacy acts have fined MEDA over a billion dollars for not following the act, and this is being played out in court presently. Also in Canada, there have been regulatory meetings with respect to internet pornography, keeping in mind childhood sexual abuse imagery, also known as child pornography, and how this might protect youth from such experiences. The Trudeau has laid out plans to target content on a number of platforms. These groups, including TikTok, YouTube, and others, have pushed back against this, but earlier, about a year ago, this regulatory act to govern online streaming made its way into a bill. But again, groups like MindGeek, the parent company of Pornhub, has said that they should be exempt from this because their platform doesn't have society or cultural value. So we'll see how that argument fares in court, but again, at the center of this is this balance between civil liberties and protecting the public health. Swanton and colleagues, I think, identified, like the U.S. Surgeon General, a number of key stakeholders and roles, including with respect to researchers, government, and industry. So last but not least, I would like to go through some of the work of the World Health Organization for how this has been considered from a clinical and diagnostic perspective. So in the road leading to ICD-11, a group of us had been meeting annually to discuss how Internet use and behavioral addictions might be considered in the ICD-11. In 2019, at the World Health Assembly, ICD-11 was adopted. Gambling and gaming disorders were included as formal clinical diagnoses. Hazardous gambling and hazardous gaming were entities to assess public health elements. And compulsive sexual behavior disorder, which can include problematic use of online pornography, was also included, but as an impulse control disorder rather than as a behavioral addiction. And this raises the question, what about problematic use of social media, problematic shopping and buying? Those were not included. It was felt that there were insufficient data at the time to have these diagnoses included. However, there is a diagnosis of other specified disorders due to addictive behaviors that can be used to diagnose individuals with problematic use of social media. And we have an article forthcoming in the American Journal of Addictions that focuses on these Internet use behaviors or behavioral addictions related to gambling, gaming, social media, shopping and buying, and pornography use. So we also have a handbook on digital technologies and mental health, but that was published now four years ago, and a lot has changed over the course of four years. And we do need to collect further information with respect to TikTok and other social media platforms so that we can best intervene, protect youth as they go through their development, and provide them the best opportunity for healthy lives as adults. So I'd like to thank a large number of individuals, funding agencies, and thank you all for your attention. Thank you. There we go. All right. So we covered a lot in the last 60 minutes. And what I'm going to try to do is just talk about some of the kind of topics that Dr. Patenza has covered incredibly well, but just looking a little bit more at some of the data from the neurobio standpoint and kind of like clinical examination as well. So what actually makes the adolescent brain and the young adult brain tick when it comes to viewing social media? For adolescent brains, they're in the process of maturation. We know that the prefrontal cortex, where working memory, shifting attention, and impulse control reside heavily, they have not reached their full potential. So with TikTok, Snapchat, Instagram Reels, the focus of swiping through videos relatively quickly and praise for attention grabbing material, it's no conundrum that the brain has difficulty with impulse control and kind of stopping scrolling and ultimately scrolling for hours and hours and hours. What's more interesting is how the nucleus accumbens works in the teenage and young adult brain. Sherman et al came up with a study looking at the child development and looking at the nucleus accumbens and how we, as teenagers, react to likes, quote unquote, received on a photo on Instagram. For those not aware, a like is a quantifiable social endorsement in which content, such as a photo, video, et cetera, is appreciated. And the public is notified that the content has been appreciated with a thumbs up on Meta or a heart emoji on Instagram. Both high school adolescents and young college adults viewing their own photos in the studies, and of those photos, they submitted it to the study. They also were given neutral photos to look at and risky photos, like somebody holding a marijuana joint, which might not be considered risky now, because that's a Schedule 3 substance potentially, as well as researchers then attributed a certain amount of likes to each photo. And in this feed, while they were looking, an fMRI was examining their brain and looking right at the nucleus accumbens. And results noted that both adolescents and young adults had higher activation of the nucleus accumbens when viewing popular photos, especially participants' own photos when they had higher likes. The study really highlighted how increased participation in social media is partially derived from the positive feedback from peers. So that's super important. And that's why I was saying at the beginning of the poll, y'all are liking my poll. This is helping my external sense of self-esteem, right? So this is a really important portion because this is the neuro bio of how social media can work. So when we look at risk factors associated with social media addiction, this was a study that was conducted in 2022 in China. Researchers had 520 college students complete the surveys based on the social media addiction scale, which was earlier referenced the Bergen Social Media Addiction Scale, and looked at also impulsiveness, anxiety, self-esteem, and attention for negative information. Gender and age were also controlled for. Notably, males appeared less likely to suffer from social media addiction compared to females, but the population size was pretty small. And the age did not seem to correlate with more or less addictive traits. Higher correlations between impulsive decision-making, lower self-esteem, anxiety, and attention to negative information correlated with higher use of social media. We also know socioeconomic status. We talked about race before, with black, Hispanic, people of color, how they will have a higher likelihood to be addicted to social media. We also know that those of lower socioeconomic status tend to have a higher daily use of social media. So this is what we call the intersectionality, where we want to be looking at these populations and thinking, you know, these are at-risk groups, how do we screen for these things as well? And I think this is really important because we talk about risk factors, we talk about social media, we talk about social media applications, but we don't talk about what happens in consequence, right? What happens when you're using too much social media? Well, this was done by Common Sense Media. That is a nonprofit organization that asked teens aged between 13 to 17 how they felt about social media. And they correlated their responses with a survey focusing on social emotional well-being. So the survey asked questions like, are you happy with your life? Do you like yourself? Et cetera. And those who scored higher had a higher social emotional well-being. Then they asked those same questions, same individuals about how they felt about social media. And those who scored lower, lower social emotional well-being scores tended to say things like, well, sometimes I feel more left out or excluded when using social media. I tend to delete my social media posts more because they get too few likes. I feel bad about myself if no one comments or likes about my posts, and I am more likely to be cyber bullied. So again, when I say at-risk groups, who for many clinicians in this audience do have at-risk groups, they tend to have a negative influence from social media. And we talked about this earlier, I won't jump into this, but this is the Bergen Social Media Addiction Scale. It's a great screener. It's something that I learned while I was creating this presentation, something that you can kind of just get a better idea. It follows, again, a lot of what we see with like alcohol use disorder or internet gaming disorder, like where the functionality happens with our patients when they're having difficulty with their social media use. So, would I take an approach, would I talk to a child with, who's say is on Instagram, right? I kind of, kind of again, we build that alliance through connection, right? Like getting a better understanding of how they operate in this world. So I kind of start with like, how long are you on Instagram? How many hours in a day? How many amount of times is Instagram opened? On average, for example, TikTok is opened right now 17 times a day per daily user. 17 times a day. So they might say like two or three times, might be a little higher than that in terms of when it comes to Instagram or TikTok or anything like that. And if they tell you, you know, yeah, four hours some on Instagram on average, which again is near the average in America of social media use. So it isn't a high number, right? It is the average. Then I start, you know, what are some of the pros behind the amount you scroll? So this is kind of the how questions, like what, how do you use social media? And they might tell you connection, right? Peer connection is incredibly important in terms of development at this stage. Creation, I'm a content creator. Now, a lot of the teens who don't, who do create content don't want to show me the content they create, but some say they do and they do show me. And then education, you know, print media is now moving to social media and digital media as a way to educate individuals. So in this example, they say, I like connecting with my friends. Okay. And then I kind of go on, what are some of the cons behind the amount you scroll? Sleep, right? What time do you get to bed? In my clinical interview, I get asked them always, before I even jump into psychiatric review of symptoms, I go, tell me your day to day. I want to know from hour to hour, what are you doing on a typical Tuesday besides seeing me? And they say, well, you know, they get everything. And then it's at six to midnight time, where it's like, I just hang out. And that's the perfect time to ask about, well, what do you do while you hang out? And they tell you social, well, I'm kind of on my phone. And then you get into the social media. Well, yeah, I'm up to like 11 or 12 on Instagram or TikTok. And then you start asking about sleep. You told me you wake up at 6.30 for school and you're going to bed at midnight. So you're only getting six and a half hours a night. And that's a good way to kind of start assessing about the cons of social media. Self-esteem, do you feel better when you follow these people on Instagram? How do you feel? To show me the people that you follow on TikTok or Instagram, tell me about this content creator. How do you feel after you watch their videos? It's funny, it's humorous. What about your friends who get a ton of likes? How do you feel compared to the likes you get? Ah, not as well, right? So it kind of, you can use these questions to kind of get a valuation. And obviously, grades, right? Parents will come in complaining about this. How has social media affected your grades or how much of your time? And here, this person says, I feel so tired all the time. I don't sleep too much. And then, you know, can you do the cons outweigh the pros? Do the pros outweigh the cons? Sometimes they'll say, I love social media. There's nothing wrong with it. Okay, right? You can kind of highlight, well, you brought this, this, and up. Or mom and dad have brought this, this, and up. Do you think we can modulate in some way, shape, or form? So parents always ask me, you know, what can I do? What do I do? And I think this is also applicable to young adults as well. Digital identity is super important. We kind of talked about this earlier, but people who use social media and who are in conflict regarding their digital use often have an issue also with their digital identity. Take our topic of social media addiction. They may find that they need to scroll to stay connected with friends or peers. That's their group. That's who they connect with. But it has degraded their self-esteem. It's getting in the way of their sleep, et cetera. So our job is to empower young adults to kind of take back control. We teach them how to use skills that promote wellbeing. An example could include, you know, who they follow, examining their screen time and asking if they feel better after their hours of use. Do you feel better after you scroll after six hours? I want you to journal. You don't have to look at how much time you use, but I want you to say, like, you know, on a mood journal, how do you feel after you've been on social media for six hours on a Sunday? And is it on a scale of one to 10, 10 being amazing, one being pretty bad? Tell me where you land, before and after, right? You can also role play, how to set a boundary with applications. When you notice your post doesn't get enough likes and you don't feel good about that, how do we set a boundary with the application that we're using? Collective agency is the idea of focusing on teaching teens how to rely on each other or how they can rely on their peers as a group. So for example, has anybody heard of Discord? Yeah, so you can create a safe study space on Discord, for example, to encourage others to complete their homework rather than scroll on social media and tell teens, hey, create a group with your friends where you can study together and make that group specifically like it. You do not go on social media while you're on this group and hold those teens accountable for each other. Parental interventions are incredibly important. You know, how many moms and dads have gotten like demanding to rip the phone in front of me and then they have a fight and they're like, doctor, solve this. And I'm like, we're in the firestorm now. But like when you speak with the parents, highlight the importance of learning the terminology, emphasizing that absolutely like curiosity and humility with social media while maintaining the boundaries. That does not mean have the teen or a child walk all over you, but it means that those boundaries are important because they have to remember that screen time, social media is a privilege to children. It can be taken away. And how do we do that without having a crisis situation of bringing the child to the ER because their phone got taken away and now they've thrown a punch against a wall or something like that or, you know. So I like to use choice language. For example, you know, have clear rules about when phones can and can't be used and what isn't appropriate. And if those rules are broken, highlighting to the child or teen, this was the choice you made. I just have to enforce them. These are the choices, right? This is your choice because you have control of the situation. And back up those rules consistently. And when a rule is broken, highlight that it was a teen's choice. Again, emphasizing agency and decide what that punishment is, right? Phone removed for 24 hours, but you can maintain that snap streak with a friend just for right now and then, you know, take that away. But we can talk about Snapchat later. Distress tolerance is key. Prepare the parent and child that there will be a conflict regarding phones even when everything is going well. Calm dinner Monday night. Let's go over talking about your technology use. Everything's great. You've been doing fine. What happens when things aren't fine? And everything is good right now. Let's prepare for that. You cannot do that in the midst of a fight. It's not gonna go well. So, you know, there's a whole kind of way we can go about this. Dr. Penanza had written about this. This is from healthychildren.org. It's from the American Academy of Pediatrics. Electronic contract. Has anybody implemented that before here? Kind of, okay. Lot of no's, some yes's. An electronic contract is the idea of sitting at the dinner table with a child writing out together what are the rules of using technology in the home, right? And then having them sign it and saying this is a living document. We are going to revisit this contract every week. Five minutes on a Sunday and see how you've been doing. And if you get two or three good check marks on your contract, meaning you're maintaining it, we can expand it a little, all right? It's a whole idea. And if they violate that contract, you say, hey, you violated it. We wrote this and you have your signature there. Set screen-free zones, right? The family room is where the PS5 and the Xbox and Nintendo Switch are, right? It's where the gaming computer of mine sits. I can't bring it to the bedroom because that's bad sleep hygiene. You know, get screen-free times. Dinner, breakfast, you know, right before bed, one to two hours, no screens. And then the most, and the hardest thing about this is model appropriately. I am a child and adolescent psychiatrist and I am board certified and I went to good schools. And how many times has my wife slapped my phone out of my hand in front of my infant because I am scrolling in front of them? Modeling appropriately is one of the hardest things for parents to do as well because we are a part of all of this too, right? Especially during the pandemic when daycare would be lost and we had to keep our wits together. So just looking at the time, we are about 15 to 20 minutes left for this kind of presentation. We could do a case or we can do an open Q&A. Would you guys like to run a case and have discussion or would you like to open to questions? Case? Case, all right, let's do case. So you got a 15-year-old female, single, domiciled with mother, father, and 13-year-old sibling, sophomore at a local high school with past psychiatric history of depression, treated with Sertraline 50. And if you're an adult psychiatrist, welcome you to try on this, all right? Just because they're below the age of 18, you've got this. No significant past medical history who presented for follow-up. She initially is terse, stating everything is okay, but is yawning throughout the interview. Her mother appears frustrated, stating that she is up late every night on her phone. She states all she does is scroll on Instagram and TikTok and I can't get her to stop. As a result, mom states that she has started to miss her classes in the morning, leading to concerned phone calls from the school. How do you approach the topic of social media addiction? How do you gauge interest in reduction of social media addiction? And what are some tangible solutions you can offer the family? Why don't we take five minutes? You guys can work within like two or three person groups or more, and then when you come back, I'll get your ideas. Does anybody have any, what's it called? Yeah, come to the mic, please, we'd love to hear it. Yeah. Hi, great presentation, by the way. So, yeah, so I've attended the Child and Adolescent Psychiatry Observership earlier last year, so yeah, these were very important and these questions were actually repeated all the time with the parents. So yeah, some of the answers that I would like to give with you is that how to approach the topic, first of all, would be to be very empathetic and patient with the child. Like whenever, obviously, first time when you tell them that, okay, you cannot get the phone now, or you have to switch off your tablet now, of course, they might throw a tantrum or cry, but yeah, you just be calm, do not lose your cool, and these were some solutions that we actually offered the parents, which kind of worked with them. And yeah, so instead of just nubbing off the child, just sit with them, make them understand, talk to them, listen to them, make them feel that they are being heard, and just offer them simple solutions like, okay, now you cannot get the tablet, but how about you read this book, or how about I read this out to you? This has similar kind of rhymes that you actually see in your tablet, or what you actually do with your electronics. These are similar, and these might interest you more. So yeah, these were some things that we actually offered to the parents at that time, and yeah, so, and how do you gauge the interest in reduction of social media? It's a slow process, like, of course, once you give the child a solution, they might start taking up interest in, you know, dividing their time between using social media or electronics, and like, doing something else, like maybe reading a book or going out to play. So yeah, that might take some time, but so developing of the interest might take some time, but yeah, these are some solutions and how to approach the topic. I guess this is what I learned from this, so yeah. Excellent, thank you so much. That is really, that's really it. We were talking earlier, somebody came up and talked about the electronic contract and how another talk was saying that it doesn't work, right? And I think, and I get into this talk with my colleague, Dr. Jeremy Chapman, who's also a child and adolescent psychiatrist, that consistency behind a lot of these things comes from consistently meeting with the provider, taking the time to speak with the parents, and making maybe individual sessions with the parents on how to implement these things. And then, you know, expecting that it might not be perfect, but if it reduces from like six hours a day to five, that's a win, right? Just reduce it initially and just trust the process slowly and slowly. Trust the process, yeah, thank you. Anybody, anybody else? Okay. Hello. Hello. I'm out of voice. Yeah, perfect, perfect. No, I was actually interested in asking about not just looking at the actual social media, but also looking at the vehicle where the social media is being accessed. Are there any sort of evaluations, investigations looking at not just how we access social media on our cell phones versus desktop, laptop? And is the actual device itself potentially having some addictive, you know, increasing the risk of addiction in that sense? Yeah, so I think this is an important question and one that has been debated among, for example, the DSM-5 Substance Use Disorder Committee that considered internet use behaviors as well as with respect to considering ICD-11. Historically, the groups have considered the internet and digital devices more as delivery mechanisms, kind of like a needle in intravenous drug use or a bottle in alcohol consumption and have advocated to focus on the behavior that is being conducted on the internet. However, over time there's been an appreciation of the accessibility of smartphones and the ease of using smartphones that people have looked at measures of, you know, in addition to early studies, in particular looking at internet addiction but still being assessed, looking at problematic use of smartphones, recognizing that certain behaviors may be more facilely done on smartphones rather than desktops. When we've looked at ABCD data, to look at the EARS data, which is a device usage data versus the self-report data of how much screen media activity the children are reporting using, we see a much greater concordance between the social media use of the perceived social media use and the actual device-related measures than we do for gaming, which we think reflects that gaming is often done on more complex desktop platforms as compared to social media, which tends to be on phones and these are phone-assessed screen media activity. So I do think it's important to understand the smartphones. This also holds for gambling, with sports gambling, because like with platforms like Twitch, which tend to be really, they seem to me to be very frenetic, like a lot going on at once where you're seeing the hands of the person gaming, having a stream of dialogue, the person talking, what's happening on screen, all happening simultaneously. If you go to a sports gambling app, you can bet on virtually anything rapidly. You can bet on the next play. So again, it's this fast-paced environment that certain individuals, particularly, for example, youth with ADHD, may find they're able to hyper-focus and engage in these domains, these areas, and they may be more vulnerable to developing problems relating to problematic usage of specific apps or technologies. Thank you. Hi, thank you so much for that. This is really interesting and definitely something we see a lot with our patients. I was wondering out of, kind of at the beginning, there was like a list of different questions about are the kids doing live streams? Are they DMing out of those? Are there any questions that are more high yield for problematic social media use versus others? So problematic social media use in the sense of like addiction or problematic social media use in terms of like how so? Like addiction. Like are there ones that are more indicative or more like high yield for kids who have addiction? I think it's really like, so when we will publish this article in the summer and we kind of give an example of like different situations, you have to risk stratify of who you see. Are they passively consuming data and they're passively consuming it for high amounts of time? Then your risks for that, those questions are gonna be like, have you seen sunlight today, right? Like when's the last time you attended class? Because a lot of schools are still hybrid. So a lot of my kids have moved to online schooling and the parents are like, well, they're getting their work done, but they have no social interaction whatsoever. So you have to risk stratify by asking, how exactly you're interacting with the media. And then that gives you an identity of, or a question direction of like, what am I looking for? For example, take the opposite, the content creator that is incredibly popular, but then their self esteem relies heavily on getting views and likes. So then that leads to burnout. That's gonna be a different questionnaire that you're gonna be asking. So it really comes down to how you stratify risk and then helping them modulate, is this really good for you? So that's how I'd answer that. Thank you. Of course. One app that I actually use now that one of my patients told me about was something, a study I think done at Berkeley where they, it's called OneSec and it's something you download and it gives you, you can attach it to anything. And I use it for my Facebook as an older person uses social media. Absolutely. Literally, it's just, the screen goes up and says, take a breath in, take a breath out. And then do you really want to enter the site? So it kind of gives you this pause and it's really nice. They're collecting data on that, it's a study, but a student told me about it, I use it. My question to you is, what have you seen in looking at these past 10 years of functional MRIs of cohorts of those who are using addictively and those who aren't in terms of what you would anticipate for normal trajectory with cognitive development in these areas that are lighting up? Is there a difference? And are the studies there really, I guess? Great question, I'm gonna defer to you, Dr. Pentz. So I do think there are very few longitudinal studies which is why I'm very excited by the Adolescent Brain Cognitive Development Study because they have embedded measures of problematic use of video games and problematic use of social media into the battery. So we should be able to, and their brain imaging measures every two years using a range of functional tasks, one widely used reward processing task, the monetary incentive delay task, a cognitive control task that involves aspects of emotional processing and a memory task. And resting state measures. So we should be able over time to get a better idea of these brain behavior relationships. And some of the studies that we have been conducting because right now we're still in the early part of that study or the people who are collecting the data are. So we've used cross-lag panel models to look at interrelationships between internalizing and externalizing concerns, screen media activity and sleep concerns. And have looked at the relationships over the first several years. And it seems like this impact, this operating through externalizing behaviors in the 11 to 12, the 10 to 11 year old seems to be a mediating factor for some of these relationships. All of this being said, I think there's a lot that we still need to learn because if we're looking at data from people with gambling problems, the prevalence estimate may be the same from wave to wave, but the people who have a problem at one wave may be different from those at another wave. And given some of the gender related differences and the changes in use of social media, I would suspect that we're going to see different individuals going from childhood to early adolescence who are having problems with different types of screen media activity. Another brain related finding that seems to be consistent through meta-analyses in adults is with respect to reward processing where using meta-analytic data from people with substance use disorders and people with gambling disorder, there is a shared blunted activation of the striatum, particularly the ventral striatum during the anticipatory phase of monetary reward processing fitting with this reward deficiency theory of addictive behaviors. We've also seen that in an independent study of people, young adults with internet gaming disorder and with the monetary incentive delay test data longitudinally in ABCD, I think we'll be able to get a better understanding of some types and patterns of internet use behaviors. One of the measures that I've been pushing for introduction into ABCD is internet pornography use because children and adolescents are viewing pornography on the internet. Data from Poland from an internet provider indicate that over one five year period as compared to the prior five year period, the proportion of seven to 12 year olds viewing internet pornography has statistically significantly increased. And if you read Gail Dines' work where she searches internet pornography websites and she kind of jokes that probably she's seen as an adolescent male viewing pornography, but she's also documented how more extreme forms of sexual behavior have become more normalized such that what was once gonzo pornography is now more mainstream. And talking with people in recovery from problematic pornography use, they talk about the nudges that they get to view more extreme forms of pornography and the extent to which youth may be learning about sexual relationships and going into their initial sexual context with certain expectations that are based on pornography, I think is concerning in many ways, both for females and for males in heterosexual relations. There's a literature on young adult males who are experiencing erectile dysfunction that they attribute to watching large amounts of internet pornography during their adolescence. So this raises many questions, but this is in some ways an elephant in the room with respect to the lack of implementation of age verification, with respect to viewing of internet pornography, and it raises questions about a generation of individuals or more who may be influenced in this manner in ways that are going to be complicated to understand precisely. We are also out of time, but we are happy to take more questions. I just wanted to let you know that. Thank you so much for attending. Thank you.

social media addiction

TikTok

Instagram

youth mental health

neurobiology

adolescent brain

screen time limits

digital literacy

privacy concerns

regulatory debates

Dr. Ashwin Sood

Dr. Mark Potenza